White Cloud Over the UNC Main Emergency Department
Michelle Zheng runs through a standard four hour graveyard shift at the UNC E.D. She focuses on the relationship between the nurses in the Department, offering insight into how they pass the time and keep entertained.
CHAPEL HILL, N. C. — An ambulance cruises down a straight four-lane road until interrupted by an intersection. Turning right, the ambulance heads up to a rectangular building identified only by a broken backlit sign on the overhang: “gency.” Behind the double doors, in the Main Emergency Department of UNC Hospitals, activity winds down for the day as health professionals in blue, black and magenta attend to patients, deliberate treatments, and do paperwork. The scrub-clad are sometimes blessed with a calm night. Residents snack as they stare at their screens; steady beeping competes with the voices of doctors recalling stories of patients past; nurses tease and prank one another.
Another graveyard shift begins.
Night 1, Saturday, October 13th:
As UNC’s devastating loss against Virginia Tech comes to an end, the Main ED remains relatively calm as fans and staff process how the Hokies swiped victory from the Tar Heels. Chatter fills the room during a shift switch as those who caught the game gossip with those who had to work during it, only matched in volume by the steady beeping coming from the machines in the Acute rooms. Laughter erupts from fraternizing nurses gathered under a “Get Well” balloon. A banner proclaiming “Happy ER Day!” hangs next to a sign marking the “Clean Room,” which has cookies to commemorate the holiday. Three doctors stand around chatting, each with that iconic stethoscope around their necks.
The grey-clad one, Dr. Samuel Reilly*, has just arrived for his shift. With black coffee in his left hand and an Insomnia cookie in his right, he leans on the door and regales his co-workers with stories of previous nights in the ED. I arrive and unknowingly offer a redundant cup of coffee which he sheepishly accepts before giving a tour of the floor.
The Main ED is split into two sections: Side A and Side B. The right side, which Dr. Reilly worked at tonight, is Side A. As he walked around, he points out the rooms. Acute room 2 is the main trauma room, where a severe burn victim was evaluated just moments before our arrival. Reilly explains that they inserted a tube into the burned man’s lungs to help him breathe through the smoke in his body. As he brushes aside the curtain to exit Acute 2, an excited EMT interrupts the tour, “Great broken nose coming in!”
After the EMT finishes inundating Dr. Reilly with the flood of details concerning the broken nose, the doctor signing out asks Dr. Reilly to sign in for his shift. After signing in at his desk, he examines a list of patients, ranging from 20 to 118** years old, as a resident, Ian*, stands at his shoulder and gives an overview of each. Ian outlines the cases, stopping only once to look for a nearby EKG (electrocardiogram), and then grabs a pink sheet from a sloppy stack of heart electrical activity records. “Great EKG for a 30-year-old man,” Dr. Reilly agrees. One of the doctors signing off pops in and suggests the patient should still come in.
Although the cases would sound severe to a layman, they are rather routine, and the doctors are in an upbeat mood. Four men around two monitors discuss cases and decide what to prescribe. There are three residents under Reilly tonight, so he can relax and wait for them to make rounds and report back to him before he reviews each case individually. The conversation turns to joking around. With a smile plastered across his face, he says, “This is my serious face… and [this is] my joking face.” A nurse just laughs and points out that he had the same exact facial expression each time.
Reilly takes a breather, looking away from the patient chart. He remarks, “the frustrating thing is having to take in patients from other hospitals. We’re a tertiary hospital, so UNC takes patients smaller hospitals can’t, so we can get flooded and really busy with calls.”
His break lasts ten seconds before someone walks over to talk about a case. Immediately afterwards, one of his residents calls his attention, “Hey uh, someone disappeared from the list.” Dr. Reilly sits up and scours the patient list on the monitor.
Reilly gets up to visit the broken nose case after one of the residents report back to him. Pulling back a curtain, he greets the man who rolled by on a stretcher earlier. He has Virginia Tech gear on, a bag of Chick-fil-a by his side, and a smear of blood on his forehead from a fall after the game.
“Anything hurt?” Reilly asks as he pulls gloves out from a box attached to the wall.
“Just my pride,” muttered the man.
He grows quiet when Dr. Reilly feels around for injuries. Dr. Reilly starts asking questions about the incident and learns that the man blacked out and fell on concrete on his way back, but not on the stairs as believed. Reilly explains he broken nose situation, leaving out the uncertainty over the solution. In under 10 minutes, Dr. Reilly is done with the check-up.
Back at the desk, the residents under Reilly discuss the workload in the background. “I’ve seen so many people already, it’s, like, freaking crazy,” one resident groans. As if to make a point, a familiar patient on a gurney rolls by for the third time in an hour.
I ask to take a picture, and Dr. Reilly agrees. Resident Ian chuckles at his tenseness.
After checking up on a young 20-year-old, Reilly is back to his desk again, reviewing cases. Work seems to have cooled down again. He chats with the residents on the side and other nurses and residents from various teams stop by to ask for input. An EMT patiently waits for the conversation to end and then talks about one woman’s case. Eventually, they start bonding over the joy of realizing a call for a patient is not for them; it means no extra spreading of their limited resources. Reilly talks about how he cheers when he hears the radio call is for an 18-year-old or someone 20 weeks pregnant – 18-year-olds, classified as children, go to the pediatric department and people over 20 weeks pregnant go upstairs. The EMT laughs and offers her equivalent: “[the patient’s] heart rate, 99, is it? [Then it’s] not tachy (tachycardia), yes!”
They then discuss the game, which they agree the Tar Heels should have won. Other doctors passing by pipe in, “Come on, if you can run 30 yards, you did not suddenly get injured.”
Finally, a call comes in. The mood immediately picks up as excitement buzzes over the room. Clinicians from multiple rooms rush to dress up in red aprons and surgical masks with eye visors; in the midst of the chaos, someone mentions a Code Red: the case is so bad that the OR staff was already informed and told to get prepped. “Oh yeah, we have a trauma patient” cheers one of the residents as he slips on a blue gown and heads to Acute Room 2. Resident Ian stands at the head of the gurney; a nurse grabs the hook as another looks for a new IV bag.
The patient is taking longer than expected to arrive. As the doctors and staff on call watch the clock tick, the tense atmosphere casually melts back into normal chatter. They start talking about strangeness of the code name the patient has been given: Winter Catastrophe*. One of the more experienced doctors talks about how, in her day, patients were only referred to by number, causing a lot of confusion. It was “one of those stupid ‘that’s just how it was always done’ procedures. Thank god it isn’t like that anymore, I fought against it for years,” she remarks.
A gurney suddenly rolls in and a man wrapped in white sheets is carried onto the gurney prepared for one of the Acute rooms. Three clinicians turn him to his side in unison and examine him as the head doctor begins asking him questions. In the flurry of sheet adjustments and pain evaluation, the observers don’t see much except the occasional glimpse of the genitals. It was over very quickly.
Within 5 minutes of poking around, they are done evaluating. Doctors have already torn off the aprons and are trickling out as the others finish up. Where there once were 12 doctors, there are now 4, discussing the case as some scrubs clean up.
Dr. Reilly stares at the X-ray of the man’s neck he has just received. He and Ian pinpoint a pinched nerve and set it aside. Reilly apologizes that nothing interesting had occurred yet. He attributes it to being a so-called “white cloud”. White clouds often have easy nights and few bad things fall upon them. Some people are black clouds, those who seem to be inundated with lots of bad cases during their shifts. Of course, for doctors who crave action in the Emergency Department, bad cases aren’t always a bad thing.
Dr. Reilly then pulls up Pandora as he continues to transcribe cases. “Man of Constant Sorrow” starts playing.
Ian busts out giggling, as he remembers a video of a child concerned about a bleeding baby brother. He describes the baby as “probably an 18-month-old” and the child as “no more than a 3 year old kid, who, as you know for those at his age, does not have the full mental capacity to construct full sentences.” Ian mimicks the toddler, and eventually brings up the video to show the others. All four of the doctors take a break to watch the video. “Bluuhduh! Bluuduh! Not FUNNY!!!” A brief reprieve from the monotony of the job, grins fixated on all their faces.
They systematically go through the same procedure. Soon all are back at their desks, transcribing cases, joking around, and jamming to music. Dr. Reilly turns to me, asking yet again if I had questions. I ask about the balloon I saw lingering before. Ian pipes up and explains that someone left it there a few days prior. He was supposed to inhale the helium and nonchalantly report a case to Dr. North*, who was notoriously no-nonsense. To everyone’s disappointment, he had “chickened out”.
Another shift change goes by, though Dr. Reilly and his residents are not among them. As people take off their scrubs and pass by Reilly’s desk, they hear Pandora playing over the transcriber. Dr. Reilly won’t be done until 7 AM, but not much more is expected in these wee hours of the morning.
“No way… How did five people check in within the last hour?” Reilly and his residents sigh at the new records that needed to be filled.
October 22nd, Monday:
A chai latte arrives for Dr. Olivia Jones*, who displays her festiveness for Halloween with spider earrings, monster eye socks, and a bag of candy at her desk, same as the one Dr. Reilly used before. The nurses seem to be out in full force, as the room is a sea of Carolina blue this night. On the surface, this night seems much busier than the last, with nearly every room filled and many stretchers lining the halls. Yet, there are actually far fewer cases.
Against my hopes of a more eventful night, not one trauma case arrives in the Acute rooms the entire shift. When Jones returns to her desk, a host of people shoot finger guns and chirp hello. Some loiter about, joking as they prepare to end their shift. Before heading out with another nurse, one writes down the name of a domestic abuse patient she wants to be kept updated on.
“Have a nice shift, guys.”
The shift-switch eases in with the last few evening-shifters passing over cases. Those clocking in exchange banter with those clocking out. A nurse leans over the counter.
“I’m going to hand over bed 15 so I can go home.”
“What if I say no?” teases Dr. Jones.
“Then I’ll be very sad,” the nurse half-jokingly says.
With the last one headed home, only two residents remain with Dr. Jones: John*, a seasoned resident about to graduate, and Bo*, a visiting resident wishing to experience other hospital departments.
“Let’s head over and talk to Mr. Frank*,” Dr. Jones announces before heading over to a semi-enclosed area affectionately called the “A Hole.” She stops by a resident looking at a “newfangled iPad” that will translate Spanish and English to help communication between the resident and a patient. After exploring the strange new device, Dr. Jones walks to Mr. Frank’s bed on the far right and starts examining him. He rests with two family members by his side, groaning quietly that everything hurts, but mostly the area around the kidneys. In the background, you can hear the resident asking questions and the iPad repeating in monotonic Spanish.
Dr. Jones finishes the check-up and promises to bring him some padding to help with the pain. She stops by her desk and discusses the case with the resident. They both believe the patient has kidney stones but find it strange that Mr. Frank isn’t exhibiting the characteristic symptoms like the “itchy stone dance.”
“Thank you for this by the way,” Jones smiles after the discussion ends. She pulls out a piece of chocolate, turns around, then tosses it onto the lap of a nurse on the phone. He mouths thank you.
Back at the desk, a nurse drops by to hang out with the others in Side A. He asks if John was on the shift and groans when another nurse giddily responds yes. The other nurses continue to joke about the dismayed reaction to John’s arrival, to which he responds, “What? When have I made fun of you?” They all laugh over their friendly rivalry, and John goes back to business at his desk as the others keep chatting and exchanging stories from their day.
When Dr. Jones returns, she asks about a man who was waiting, and is surprised to learn that he decided to just leave. The case has left John perplexed about the paperwork and leads to a rant with Dr. Jones over patients who make themselves wait “unnecessarily for what we don’t offer” although they are explicitly told what the department can or can’t do for them.
Like Dr. Reilly, Jones finds paperwork the hardest and most tedious part of the job. Unlike the others, however, she doesn’t use the transcriber, opting to type everything out. As she types up Mr. Frank’s case (which concluded when he passed a kidney stone), Dr. Jones recalls earlier days when she wondered when she could do the “cool stuff.” She regrets that I came in on a boring night. After hearing that Dr. Reilly expressed the same sentiments, she jokes that I “really [was] a big, fluffy white cloud.”
Dr. Jones’ mouth opens wide as she looks at patient cases again. “Oh man I yawned, I shouldn’t be yawning,” she says, standing up to get the blood flowing. She heads to Acute room 7 to see an elderly patient and his wife. Checking his vitals, Dr. Jones asks the old lady how she is holding up. “Let’s put it this way: my tired is tired,” she sighs.
Afterwards, Dr. Jones visits Ian on the B side. She notes that he looks tired, but it is “great that [he] has a Team B night at the end of the string of nights.” It’s best when the shifts start busy and end uneventful, as B side graveyard shifts usually do. Dr. Jones brings up a related lecture she plans to deliver to residents on wellness on night shifts, studies on nocturnists, and strategies for sleeping schedules. Checking the time, she insists that Ian end his shift and I go home soon.
Dr. Jones is fuming. “Disk wasn’t even his, it was of a female’s…” The imaging department has messed up again; first they delivered the CT image several minutes late and, after a quick glance, Dr. Jones realized it wasn’t even the correct image she requested. Wasted time that could have been spent more efficiently helping a patient. Dr. Jones rants to her sympathetic friends. The frustration reminds one doctor of a talk between their father and his grandchild. After an incident, the grandfather reassured his grandkid: “Grownups have bad days too… Today, I almost pooped my pants on the way home from work.” The last line cracks the others up and they move onto more cheerful topics. The doctors and residents lean towards each other, exchanging stories of drunk costumed college kids. Tonight may not have been eventful, but there is plenty to look forward to with Halloween right around the corner.
*Names have been changed to protect identities.
**”118 years old” is what shows up for people who are pre-registered (i.e. trauma patients) and don’t have an actual date of birth entered in the system.
Fink, S. (2014, October 08). Life, Death and Grim Routine Fill the Day at a Liberian Ebola Clinic. Retrieved from https://www.nytimes.com/2014/10/08/world/life-death-and-careful-routine-fill-the-day-at-a-liberian-ebola-clinic.html.