The Entropy of Emergency
Zaria Joyner writes about her chaotic shadowing experience in the UNC Emergency Department, touching on everything from the opiod crisis to life-or-death resuscitations.
UNC Emergency Medicine, Chapel Hill NC – Within white walls lie the victims of disease, trauma, and addiction. Nurses and doctors briskly tread the sterile halls accompanied by the hazy ambience of the light above. Keyboard clatter and indistinct chatter fill the spaces occupied by the medics and practitioners. Dark pools of caffeine complement each desk housed in paper, metal, or ceramic. Between the muffled dialogue of patients and prescriptions, a monitor pings in rhythm and pulses as the heartbeat of the UNC Emergency Department.
A scrambled array of wandering eyes occupy the patient beds waiting tentatively. Nursing their ailments and clinging to their company, patients await attention from their doctors. One elderly man lies alone on his bed in the hallway moaning helplessly with his mouth agape and his eyes on the ceiling. Another woman listens to advice from her doctor while a small child peeks around the corner of her hospital bed. A translator will later explain the doctor’s recommendations to her in her native tongue. Doctors calmly lean against the walls scanning their patients list in preparation to examine each of them. Occasionally, they discuss strategy and or treatment options for their respective patients.
These were the patterns of the evening:
This is the most tranquil process of the evening, as it is a recurring cycle that repeats several times a day. At this time, the current staff prepares to end their shift and be replaced by their respective counterparts. They call this time “signing out.” During signing out, all the nurses and doctors are centralized and focused on forming agreements and relaying the necessary information about patient care.
Signing out is a similar idea to having a timeout in a basketball game. A timeout is often used by a coach to inform the players entering the game on the strategies they will employ on the court and give the tired athletes a break. The “players” or nurses and doctors work collectively to formulate how they will approach the patients at hand.
A crowd of personnel stand behind the computer screen to scan the patient list. They explain each patient to their replacement in detail and discuss possible treatments and diagnosis. As all staff members are busy at this time, the patients are not tended to as it is imperative for the information to be relayed accurately and efficiently . Dr. Zhang explains, “This is a very dangerous time for patients, but it must be done.” Zhang is a Resident Doctor from China who came to the U.S. to practice medicine after completing high school and medical school abroad. Throughout the evening, he possesses a keen and eager attitude and gives many positive insights.
Dr. Kirk stands from his desk and begins his patient rounds. Passing the small psych space, there is a tall rectangular window that is covered by sheets of paper. The psychiatric patients who are considered dangerous stay in these quarters. Kirk explained that sometimes the patients would expose themselves, so they kept it covered. Inside a curtained space laid a middle-aged man with a severe illness; his malady had yet to be identified. He wore a beanie over his head to combat his low body temperature and grimaced in pain as the doctor examined him. Kirk and another doctor explain the spinal tap procedure to the patient. He seems shocked and in dismay but is kind and warm towards the doctors despite his affliction. He smiles with a grim disparity and eyes that sparkle despite being tired.
After a brief lull in action, Zhang stands from his desk and prepares to do his patient rounds. The first patient he visits struggles with diabetes and heart related issues. Dr. La Paz stepped into the room to consult the patient, she is in charge of teachings all the residents what they need to know and offering advice for patients when necessary. This patient ran the risk of having a heart attack and needs lab work done to detect the symptoms early. La Paz consoles the woman assuring that she will be completely fine and they just need to run a few more tests.
The woman laid on her bed and her daughter sat tentatively beside her on a green chair. They both seem relieved to hear that she would most likely be just fine. Before La Paz leaves she asks the patient to repeat back what she said about her heart. The elderly patient does her best to recall the science of what La Paz said, and although less eloquent, she relayed the general message back to her. After this, Dr. La Paz explains to Dr. Zhang the importance of communicating with patients. She reiterated several times that communication is extremely important especially when the patient does not speak English as their first language.
The phone rings to alert the doctors that a trauma case is going to arrive shortly. The doctors on the left side of the department begin to prepare the trauma room for the patient as the right side is entirely unaffected. The doctors preparing the trauma room work seamlessly together to get the room primed in no time. In the interim between preparing the room and the patient arriving, the tone quickly changed from intense and frantic to jovial and casual.
The comradery is stifled by the sound of medics busting through the entrance with a 70-year-old man on a stretcher. The gentlemen houses several broken ribs and a fractured arm. His body lies still on the table as the doctors begin running tests. One operative inquires test results, and the doctors relay back the information which he enters into the computer. It seems as though the doctors have done the exact examination a thousand times. They follow procedure and communicate quickly and precisely with respect for the patient.
The trauma patients have been released and things have began to revert back to normalcy. Things are relatively quiet again, and the sensation is much less intense. Distant chatter fills the room, along with the pulsing ding of the monitor system.
A man lies in the hallway across from where most nurses are stationed. Belonging to no room, it is strange that he lie in the open and is not sheltered by any curtains at least. He mumbles something every now and then and says that his feet are cold. His face is bewildered, as no one has come to help him. His eyes search to lock onto someone else’s.
Scattering about the hallways and bouncing between rooms, Zhang is growing irritated by one of the patients trying his best to obtain a pain medicine prescription which he seems to have no real claim to. He has no idea what is causing his pain causing him to seem untrustworthy.
Many patients claim illegitimate ailments in attempts to score medication to sell for profit or to use recreationally. Dr. Zhang explains that, “Many patients do not have legitimate ailments, but we cannot tell for sure. A big problem is patients getting drugs from hospitals and reselling them for cash. We are generally pretty conservative when it comes to this. Since we can’t tell if the ailments are legit or not, we usually only prescribe five tablets here in the hospital. That way they won’t make much profit if they try to sell them, and this way they are less likely to do it again.” He goes on to explain that they usually hand-off the patients to their primary care doctors if they wish to gain an extended amount of drugs.
Fittingly, the next patient complains of itching and pain in his entire body. Dr. Zhang says this patient may be a psych patient seeking drugs. He describes a burning sensation radiating through his entire body and says it has been happening for a long time. He keeps repeating the phrase, “I just want to know what’s wrong with me.” He has sat on his bed upright in the hallway for several hours. His tests have come back negative for any illnesses, and Dr. Zhang assured him that he is healthy aside from the burning.
Between patient reports, the entrance of the E.D. is flashing blue and red from the lights of the EMS vehicles. Several teenagers are rolled in with neck braces. Three out of the four of them seem to be fine, but another girl is clearly the main concern. She was immediately rolled into the trauma room where they began running tests on her.
Dr. Zhang stands in the back of the room and explains the procedure while other doctors tend to the patient. He describes the two different surveys they do to assess the patient. An EMS worker reports that an MVC Rollover had occurred and that the car the patient was driving had deployed the airbags and was so dented she had to be manually extracted. On the floor laid her clothes inside a dirty plastic bag.
As the commotion passes, the girl lies in her bed and looks around anxiously while the hallway outside begins to ease. She is young, around 16, and is resting on her bed still frightened and equally exhausted. A nurse comes in to give her an IV, and they have identified that nothing is wrong with her other than some minor bruising. The doctor says she will be alright after a few doses of pain medication. Her parents have arrived and although worried they seem to be in relatively high spirits despite her unfortunate circumstances.
Dr. Zhang is beginning to write a prescription and says that he has to sign it because the government is cracking down on opioid prescriptions. Since the Opioid Crisis is affecting many Americans, the regulations have become stricter as the government is monitoring the flow of drugs more closely than before.
In the middle of a relative lull, a 30-year-old female is rushed in with severe trauma to the head and doctors quickly begin analyzing the injuries. She has temporal and frontal lobe skull fractures caused by the impact of a tractor trailer that slammed into her vehicle at 45 mph . The doctors rush to prepare the trauma room (Fig.1.) As the doctors keep working, they find additional face fractures and that the patient is bleeding profusely. The plastics team from upstairs is consulted for the patient. Typically after traumas regarding the face area, plastic surgeons will be consulted to minimize scarring and permanent damage.
An IV bag hangs from the ceiling and the attending Dr. La Paz identifies that the patient needs more blood. At this point, all the trauma rooms are completely maxed out with patients. This is something that Dr. Kirk says, “rarely happens.” Outside of the trauma rooms, there is an elderly man being hurried through on a wheelchair with a severe eye contusion. The man seems disoriented and says, “I’m going to walk out of here!” in a frantic and distressed manner. To the right, on the less populated side of the E.D., there is a young boy around the age of five who seems sleepy and tranquil. He sits upright in a tall stretcher with a cast around his arm. He stares off into the short distance with a brand-new green and orange Tonka Truck on his lap; the tag was still attached.
Trauma continues bustling. Across the room, there are two feet visible poking through a narrow space in a blue set of curtains. These curtains are meant to isolate the people in the trauma room giving them privacy. Between the passing of scrubs and stretchers, the feet on the bed began to spasm uncontrollably.
Just as this happens, a loud beeping sound alarms from that side of the building. It is the monitor responding to the patient’s sudden drop in heart rate. Upon hearing the all familiar sound, several doctors jump out of their seats and rush into the trauma room. This is the first time that the staff are visually in a full on panic. Their typical behavior is extremely calm even in the presence of all the other serious cases that have been brought in during the evening.
It is a strange occurrence to see the entire left side of the department scrambling around and in a frenzy while the right side stays about their own business. There is a polarity to it, a dichotomy of the two sides. The patient is stabilized after receiving shocks from a defibrillator, which saved him from going into cardiac arrest.
Dr. Zhang prepares to end his shift after a long, eventful day in the E.D. The elderly man who struggled to receive attention is still in the hallway by himself. The lights flash intermittently and patients are rolled in and out the area every few minutes. EMS workers report quickly and return to the field; doctors rush in and out of the trauma rooms. It is going to be another long night.