Introduction by Croakey: Back in September, soon after National RUOK day prompted Australians to check in with each other’s mental health, Australasian College for Emergency Medicine President Dr Simon Judkins asked the same question of our public hospital Emergency Departments, via a post at Croakey.
The answer was ‘no’. Judkins evoked a system stretched beyond its limits, leading to “delays in critical care, increased risk of medical error, medication mistakes and other adverse events”.
The post below is an on-the-ground account from a clinician. It extends Judkins’ assessment, to the people who work in our overstretched EDs: the people who carry much of the burden of an inadequately resourced system.
The original article encouraged readers who were not OK with unsafe conditions in our EDs to register their disquiet with their State and Federal MPs. This post may give you a further reason to do so.
A clinician in an Emergency Department writes:
In some ways, I wish I hadn’t read Simon Judkins’ article, R U Ok? No, say our emergency departments and hospitals.
I don’t like conflict. I’m a leave-things-be type. Safety in silence. Writing a personal piece to highlight Dr Judkins’ claims is out of character to say the least. I want to talk about the patients, but I can’t. Patient confidentiality is too important. Since I can’t talk about patients’ experiences, I’ll uncomfortably have to write about my own.
This is not about any particular town or health service. As Dr Judkins points out, the dire situation in emergency departments (EDs) is a nationwide problem. So, in that spirit, I write my nameless, faceless experience that I suspect crosses all postcodes. I hope it resonates with other health care workers whatever their job descriptions.
I read Dr Judkins’ article whilst preparing dinner. I’d just woken up. In a few hours I’d be back in my ED working the night shift. As I read, I could feel the anger building. He’s right. We are not OK. With lap-top balanced on the kitchen bench, I scrolled down; ‘Overcrowding…hospitals bursting at the seams…mental health patients stuck in ED…the ‘corridoring’.
An angry squeak broke my concentration. I looked over my shoulder to find my four-year-old turning purple with rage in an effort to pull the lid off a container. Then came ‘the face’, which was followed by the whole-body shake. I wiped my garlic-stained fingers on my pyjamas and prepared my speech.
“Matey. Nothing is ever achieved by getting angry, try and use your words.”
Distraction was needed so we headed out to the park, me still in my pyjamas. A solid-coloured track pant is a shifter’s best friend. At the park, we had a running race. I usually let child win, but a ‘parenting moment’ took over and I decided to teach the bravery-in-defeat lesson. I took the lead at the exhaustive 10-meter mark and, as expected, child gave up.
Assuming the parental kneel, I said, “Buddy, it’s not about winning. Be brave!”
Using words and being brave
Walking home, I mulled over the article. My workplace is at breaking point. We’re constantly talking about the failures; failures that glow red at night. I’m burning out, but I say nothing.
I pride myself on putting my head down and getting on with it but now, as I look down at the little fingers intertwined with mine, it strikes me that daily I ignore the lessons I’m so desperate to teach. I get angry. I don’t use my words. I am certainly not brave.
I complain to my colleagues, yet do nothing to change it (except work harder). Departments aren’t the only thing at capacity, their staff are too. As I head out to my night shift, I promise myself that I will take the time to write my experiences down and share them.
People care when they see their own life in the story; their husband, son, friend. So, here’s a brief snippet of my last three night shifts. I hope they support Dr Judkins’s claim that Emergency departments are not OK.
The department is busy but at least the staff aren’t looking wide-eyed. Healthcare workers are trained not to panic, but there’s a certain whites-of-the-eyes gaze that we betray to each other when the department is getting out of hand. No one’s wearing it yet. Good start.
Throughout the night, the department ramps up. By 2.30am, we’re full. There are patients in the waiting room who desperately need a bed. I go to help a junior colleague. There are a number of us in the cubicle. Why? Because the patient is 140kg, drug-affected and becoming very aggressive.
When these situations occur, we do our upmost de-escalate and keep the individual, other patients and staff safe. But occasionally, despite all our combined experience, there are moments where the hairs on the back of my neck stand up. The fear rises with the realisation that someone is potentially about to get very hurt.
This is one of those moments.
Thankfully, the situation is diffused with no harm to patient or staff. Another near miss. We peel off back to our respective tasks. Realising later that the situation, while relatively routine to me, may have been very frightening for my junior colleague, I check in with them.
“Are you ok?”
The junior turns to me and says rather cheerfully, “I’m ok, but yeah wow, for a minute there I thought someone might…”
I can’t finish the sentence. It would sound sensationalist. In healthcare we are not sensationalist. We downplay and internalise. We do not alarm.
In a few hours, the staff members involved in the incident hand over to the morning staff. They of course ask, “Are you ok?”
The staff are wide-eyed. The department is bursting at the seams. Not enough beds and a waiting room out of control. Two senior doctors stay well past the end of their shift, ensuring the department is safe for patients. They leave in the early hours of the morning, sunken-eyed and exhausted.
There’s a situation again. The triage nurse has alerted the in-charge to a sick elderly patient in the waiting room. We can’t get them in, there is no bed. The seniors in the department gather around the computer. What about the patients in the corridor – the ones lying on ambulance stretchers, most of them frail and elderly, sick bags hovering under their mouths?
The staff do everything possible with the resources they have. They get the patient from the waiting room in to receive the care that he needs, but you can see the concern on their faces. Have they made the right decision? What about the elderly woman on the ambulance trolley? What if they made the wrong call? This to-and-froing, ball-juggling with patients’ lives continues all night.
I cannot even begin to understand how this feels for patients or families. But I can promise you, we carry it with us. Your loved one, who we didn’t get off the ambulance stretcher for hours, creeps into our bedroom when we are trying to fall asleep, appears when we’re pushing our kids on the swings, and may be the reason why we are staring blankly, lost in thought at the dinner table the next day.
A good start to my shift. The department is reasonable and I have time, so I relish the opportunity to talk with patients as I care for them. As I head to the pan room (if you don’t know what that is, ask a nurse), I meet the eye of a patient sitting in a cubicle, surrounded by police officers and paramedics.
The patient shouts at me, “What are you looking at you f***ing C#@t.”
A colleague enters the pan room behind me. “You ok?”
We take a moment to surreptitiously play the game, ‘Names the public have called me’. It ends in a brief fit of laughter that breaks the tension. A healthy coping mechanism? Maybe.
This is one area that Dr Judkins didn’t mention, but I hope he’ll agree it’s an important one. The drugs. The alcohol. The violence.
I remember once having to change my clothes within 10 minutes of starting my shift, after being spat-on by a drug-affected patient. As his saliva dripped down my face, I turned to find I was standing in front of a poster that read ‘VIOLENCE AGAINST HEALTHCARE WORKERS WILL NOT BE TOLERATED’.
Or the time I asked an intoxicated patient if they’d taken the drug ‘smack’, at which point, with frightening precision and speed, the patient lunged and slapped me across the face with some force. “There’s your smack”.
As I touched my stinging cheek, the overwhelming feeling was one of embarrassment and shame. I’m an ED professional. I should have seen that coming. The time taken to ice my cheek was time that I should have been using to help patients and co-workers.
A failing system is not OK for patients and staff
What’s interesting about the experiences I’ve highlighted? Nothing other than the fact that they are becoming the norm. Of course, there are wonderful aspects of working in the ED. It’s a great privilege to do our job.
However, as uncomfortable as it is, I’m here to talk about the system that is failing to allow us to be there for our patients. A situation that is causing exhaustion, burn-out and trauma.
The Judkins article reminded me that the ED culture of ‘we can cop anything’ has got to stop. It’s a maladaptive coping strategy that is harming patients and staff. We don’t like to admit we’re struggling. We don’t want anyone to think we’re not tough enough.
In our toughness, we fail to advocate for our patients. But in our defence, exhaustion also plays a part. You can’t scream for help when you’re gasping for air.
I sat on my story for days vacillating between wanting to be brave and wanting to leave it alone. Story-telling is for the big people. I don’t want to be unprofessional. I don’t want to do the wrong thing. I want the public to have confidence in us. I don’t want to be negative about systems I can’t pretend to know how to fix – it’s way above my pay-grade.
I put the story away. Then I walked into work one day and noticed the decorations.
“What’s with the balloons?” I asked.
“Its National Emergency Nurses Day!” a colleague shouted back over her shoulder.
What useful change will my three-night story achieve? Very little I suspect. I hope I have maintained professionalism while still sharing an experience. At the very least, I’m not as angry anymore. I used my words. I spoke about something important to me.
I didn’t just put my head down and coast on. I was brave enough to say, I am not OK.***
*** To all the emergency department workers who’ve missed birthdays, Christmases, bar mitzvahs and sorry business. To those who’ve fasted through 12 hour shifts during Ramadan, not made the school concert, missed that dinner, forgotten to walk the dog (and found the ramifications on the carpet the next morning), thank you. Thank you for being there. I could not be prouder to work alongside each and every one of you.
To the patients, I want you to know that no matter how bad it gets, we will keep turning up. We will find you when you are sickest and take care of you. When you really need us, no matter how many times we’ve been slapped, every staff member in every ED across this country will drop everything to keep you safe. ***
The anonymous author is a clinician in an Australian metropolitan public hospital emergency department.
Thank you for this.
I’ve worked as a doctor in the Victorian public hospital system for a little under a decade now and this is also my experience. The endless juggling of beds that do not exist, the waiting rooms with lines out the door, the patients who deserve better, the violence, the harassment. It is not OK. It really isn’t. Always remember (and this is hard for an empathetic person to do); this is not your fault.
In my opinion, this is a collective failure. A failure of the government to properly fund the social good of healthcare with its fetishisation of bureaucracy, information technology and market mechanisms. A failure of society to hold itself together, demand basic respect and decency from all individuals and institutions as a norm and call the government to account for its failure to show basic decency to public hospitals. Anomie is in the air and no one seems to be listening to the canaries in the coalmine. And us canaries still keep singing, keep caring and looking bright and kind because that’s who we are, but we are getting breathless. No-one is noticing our near collapsed state because we just keep singing.
Let me tell you a story though. I went on holiday to Japan recently. On the bus back from one of temples in Kyoto we happened to stop by one of Kyoto’s major hospitals for some lunch. There was a man out the front of the hospital who was directing the parking. He was neat, in his uniform and keeping the flow of traffic smooth,helping elderly people out of their cars, speaking to carers. I keep thinking about the number of times my hospital’s intercom has announced the licence plate of someone who has left their car in the wrong spot or the number of patients who have asked me where they can park. Or the number of patients angry about the lack of parking. Ot the number of patients and carers who called me something abusive for not being able to direct where they should park. I’m thinking; a better way is possible. I’ve seen it out the front of a Kyoto hospital. It should be possible here too. Why not?
Beautifully written article, and bravely written!
– thank you.
“The Judkins article reminded me that the ED culture of ‘we can cop anything’ has got to stop. It’s a maladaptive coping strategy that is harming patients and staff. We don’t like to admit we’re struggling. We don’t want anyone to think we’re not tough enough.
In our toughness, we fail to advocate for our patients. But in our defence, exhaustion also plays a part. You can’t scream for help when you’re gasping for air.”
the Judkins response article is also worth a read!
Perhaps it’s part of the “Let’s make our EDs Better” MOVEMENT, that so many of us are part of.
lets be brave!
PS – Here’s an old Poem I wrote after a locum night shift back in 2012 called “night shift No2” – your own recollection of some random shifts, reminded me of my own wellbeing strategy within EM as a registrar (which is a very challenging training and speciality, often not recognised enough) . Here, with this poet reflection on just 2 night shifts in some St Elsewhere’s hospital I was simply trying my best to focus on the positives, after what had been a challenging couple of night shifts (NB although they were challenging shifts, it is worth noting that they were also normal for ED in under-resourced settings, in a high income country -ie Australia. Also worth noting -despite many things having improved in EM in Australasia, i’m not sure if I can say the situation of being under resources in ED has improved even in 2019 – like Simon’s article says- we simply need better staffing with skilled and senior doctors in EDs … across the board )
NIGHTSHIFT No 2
After night shift number two,
You could have heard me say “PHEW!”
It wasn’t that the night was so bad, or particularly sad,
For good times by the staff all round were certainly had!
But rather it was just-so-packed!
And now I feel a little bit hacked…
There were emergencies of the brain,
And patients that kept flowing in like rain,
Radiology was called in through the night,
And the essential scans were given without fight,
Then there were the children who couldn’t sleep,
Breathing in ways that made mothers weep,
Men screaming in pain,
With injuries that wouldn’t wain,
And of course the worker who crushed his fingers at the start of the shift,
Whose injury was not to be taken so thrift,
Plastics advised, we sutured him wise,
And he left like he’d been given a prize!
But the thing that touched me most,
Was the caring effort of those manning the post,
For when all others were tucked away in their land of the dream,
This bunch were holding it together by the cloth and the seam,
And with kind advice from friends on the phone,
We didn’t feel so very alone,
Perhaps “team-work” was the winner of the day,
So “Thank you my awesome team! “ is what I have to say!