Behind the Curtain:
A morning in the Emergency Department
It’s 5 a.m. on a Tuesday morning. Most of the city is fast asleep, but for the night shift team in the Charlotte & Lewis Steinberg Emergency at North York General, they have two more hours until their shift is over. It was a busy night. These days, most are.
Staff are starting their early morning assessments when the ambulance dispatch phone rings. Everyone recognizes that ring — it’s paramedics calling to notify the team that they’re coming in with a critically ill patient. Charge Nurse Malissa picks up — she can hear the crackle of the radio and knows the paramedics are in the back of an ambulance. Sirens are blaring in the background.
They are bringing in a 55-year-old male who is vomiting blood. His blood pressure is extremely low, and he is in and out of consciousness. They are only a few minutes away. The notification is short and there is no chance to ask questions, but Malissa has enough information — she knows what needs to happen next.
Malissa notifies the resuscitation nurses and doctors and relays the brief information she has. They know exactly what they need to do. They start assembling equipment, staff and supplies as Malissa heads off to notify more members of the team. There isn’t a moment to waste.
Malissa notifies security. They will need to hold other patients from coming through to alleviate congestion and ensure there is an unobstructed path when the ambulance pulls up.
There are still over 100 patients in the Emergency Department (ED), so Malissa does a quick walk around to see if there are any urgent issues. The care of other patients can’t stop. She gives a heads up to the rest of the nurses, letting them know she is going to be occupied in the resuscitation room. She also identifies a few other nurses to stand by
in case they need to be called in to assist.
It has only been a few minutes, but by the time Malissa gets back to the resuscitation room, a large team has congregated. Everyone is in the process of donning their personal protective gear. Dr. K is giving an overview of what he anticipates the patient needing.
Respiratory therapist Irene is prepping airway equipment. Nurses Jen, Erica, and Hannah are identifying their roles and deciding who will look after drugs, who will chart, and who will assist with procedures.
Social Worker Alex is standing outside awaiting the ambulance’s arrival. There may be family or friends with the patient and Alex will be their primary support and contact person. The family will be allowed to stay in the room with the patient during the resuscitation and Alex will be at their side, explaining what’s happening at every step.
Team Attendant Anthony has had this kind of call hundreds of times. He knows that he needs to expect the unexpected. He has the role of runner and will get anything and everything that the team needs so that they can remain at the bedside with the patient.
Marta, the Patient Care Assistant, has come by. She knows she will be there to provide any comfort that the patient or family need. It’s often the simplest things — ice chips, warm blankets, a pillow — but they are so important to patients and families during a distressing time.
There is a quiet hum in the room as the team waits for the patient’s arrival. It will be any minute now.
The security team starts walking briskly from the ambulance bay towards the resuscitation room. Behind them is the patient being attended to by three paramedics. No one needs to say a word. A quick look at the patient and everyone knows — this is the real deal. This patient is very sick and it’s time to get to work.
The entire team moves into the resuscitation room as the patient rolls through the door. It’s all hands on deck as the patient is lifted gently from the ambulance stretcher onto the hospital bed.
The attending paramedic gives Dr. K the full patient report: history of stomach ulcers, has had bad stomach pain for days, started vomiting blood this morning, passed out in the bathroom where his partner found him on the floor. They estimate that he has lost a few litres of blood. The paramedics had given the patient some intravenous fluid but his blood pressure is still too low.
Nurses Hannah, Erica and Jen are also listening to the report. They have been nursing for many years and they know exactly what Dr. K is going to want to order based on the patient’s condition.
The second intravenous is in, followed by the third. Multiple tubes of blood need to be drawn. Within minutes the patient is on the cardiac monitor. Oxygen is flowing through a face mask.
There is an alarm coming from the cardiac monitor. A quick glance from the team confirms what they already knew: the patient’s heart rate is too fast, and his blood pressure is too low.
Social Worker Alex walks to the waiting room. He quickly locates a panicked woman running into the department. It’s the patient’s sister. Alex takes a deep breath. It doesn’t matter how many times he does it, it never gets easier. He explains the severity of her brother’s sickness while she pleads with Alex to save him. He assures her that the team is doing everything they can. He offers to bring her in the room so she can be with him.
Dr. K is standing at the foot of the bed overseeing all orders. He is the conductor of this highly co-ordinated medical orchestra. More fluid. An electrocardiogram. And next the patient needs intubation. The patient is also going to need a lot of blood and fast.
Dr. K calls a Code Omega, a hospital code that signals the need for a massive transfusion. Charge Nurse Malissa gets on the phone and moments later the code is announced on the hospital’s paging system.
Team Attendant Anthony has been standing by patiently. Code Omega is his cue to collect the blood that’s needed for this patient. He quickly runs off in the direction of the 4th floor lab. There’s no time to wait for the elevator, so he sprints up the four flights of stairs. He knows his colleagues in the lab will have heard the overhead page and will be building the transfusion box just as fast.
The medical team steps out of the room to prep the supplies and equipment to be able to administer the blood as fast as possible. Patient Care Assistant Marta knows this is the right time. She quietly places some fresh blankets on the patient to keep him warm, being careful not to disrupt the tubes or lines. She also gently wipes the dried blood away from his face and places a pillow under his head. He is hooked up to a breathing machine and is heavily sedated. She also provides some Kleenex and water for the patient’s sister.
Anthony is back — this time carrying a large box that contains units of blood. Lots of blood. He brings it to the nursing team who immediately start checking and confirming that it’s the right blood for the right patient. There’s no time to take a breath. Dr. K and Irene are asking for some more equipment and this time Anthony is going to need to get it from the Operating Room.
The Intensive Care Unit (ICU) team heard the Code Omega call overhead. They have come down to see if they can assist. After a quick discussion with Dr. K, they determine that the patient is going to need an urgent scope, a diagnostic test that will enable the doctors to look inside the stomach.
The ICU team heads back to their department to get ready for the patient, knowing it won’t be too long.
After two units of blood are administered, there’s no change. After the third goes through, nurse Erica starts to see some hope. For the first time in 45 minutes the patient’s blood pressure is strong. His heart rate has come down slightly. He is responding to the treatment and you can almost hear the collective sigh of relief from the team. Social Worker Alex squeezes the sister’s hand and whispers, ‘this is a good sign’.
Dr. K authorizes the transfer to the ICU as the patient is stable enough to be moved. Irene starts prepping the portable ventilator to accompany the patient on the short journey to the 6th floor. For Anthony this is the only time he doesn’t run. He will take his time as he transfers this critical patient. With all the tubes and lines, one missed step and it would be disastrous for the patient.
The team slowly starts to remove their soiled gowns, gloves and face shields. It has only been 75 minutes since the first notification and the team is exhausted. But heads are high and there are smiles behind the masks. Today there was a positive outcome. Some days there isn’t.
It will only be 30 minutes until the day shift arrives. There is some discussion about breakfast and what the day will bring — until silence fills the room. The paramedic dispatch phone has started to ring again.
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