Treating patients after midnight
In his new book, Life on the Ground Floor, Dr. James Maskalyk explores the humanity he has found while working in emergency rooms around the world — and at home, on a night shift at St. Michael’s Hospital
“Drug-wise, here at St. Mike’s . . . a lot of crystal these days for some reason. Some crack, but everything really. GHB, MDMA, heroin, fentanyl, OxyContin.” DR. JAMES MASKALYK TELLING A MEDICAL STUDENT WHAT TO EXPECT
Emergency Department. Authorized personnel only. I place my badge on the automatic door. Click. Major. Bright lights glare harshly from every corner. At the consultants’ desks, teams of residents pore over lab tests, scroll over screens looking for a pattern that would fit into a diagnosis. One takes off his glasses and puts his head on the desk. Beside him, a colleague, blinking sleepily, stares at an X-ray of a chest, white bones frozen on a computer screen.
That once was me, but since I graduated my residency, no one’s looking over my shoulder to catch mistakes, and I no longer work such long hours, but I do work a range of shifts. Christmas afternoon, midnight on a Sunday, if not me, someone like me.
In eight-hour intervals, we cover the clock. From dawn until midnight there are four or five of us scattered through the ER, another waiting by the phone for a serious trauma, but nights, no matter how special they seem at the start, no one wants to work them.
Eventually, research says, they make you sick, something you didn’t need science to tell you, so in the smallest hours, you work alone.
And quickly. As cities pile people downtown, as people live longer on more medicines that make more side effects, have more surgeries and more complications, as specialization break bodies into smaller and smaller parts, as our population spends more time on screens than outside and grows ever more anxious, there are more people in our ER every day.
Only a few years ago, it was rare to see 200 people register. Now, we rarely have fewer. Soon, we’ll need two of us at night. As it is now, we run all night and never get caught up.
Tom sits at the major desk, looking at a virtual map of the department on a computer screen. Each room is red, meaning full. I put my coffee mug beside him.
“How’s it goin’?” I ask, snatching a piece of paper from a printer’s tray.
“Living the dream,” he says, stretching his arms above him, and yawns.
A young woman in a white coat hovers five paces away.
“Are you the medical student on tonight?” She nods. “Well, gather close” I say, and flop into a chair.
“Bed 1,” says Tom, “is a 70-year-old man with a history of heart failure, came in about an hour ago, quite short of breath. Looked pretty bad at first, but he turned around with nitro and some diuretics. He doesn’t even need oxygen anymore.”
I nod. Nitroglycerine lets veins fatten, drops the load rushing into the heart such that it can beat more easily. Diuretics kick salt from our kidneys, and with it, the extra water from a failed heart that has leaked across the membrane of our lungs. “Chest X-rays . . . here.” He pulls up a silhouette of the man’s ribs, plump heart in the middle. The lungs, usually as invisible as the air they hold, are whiter where fluid has seeped from the pressures of a failing pump.
“Not bad,” I say, pointing out to the medical student where Tom and I are looking.
“Turns out he hasn’t been taking his pills, and we talked about that. Still waiting on blood work, but if he passes a walk test, I think he should be able to go with followup.”
These 10 minutes are the most dangerous ones in the ER. I haven’t seen any of the people Tom is talking about. I will if asked, but there are new people in beds, more every few minutes. You need to trust the person who is leaving that their plans are good, that they insert no false certainty.
Tom has the knack. And the account makes sense, the details tie into each other. If they didn’t, we would go over it again, or he would ask me to start anew.
“Bed 2 is a 35-year-old man . . .”
I scratch down15 short stories of people’s lives, into a line or two of worries, circle the ones with outstanding business.
“This your first night shift here . . . Zainab?” I ask the medical student, looking at her badge “Yes.” “Well, that’s exciting,” I say, standing up and walking around the nursing desk to the charts of the patients waiting to be seen. She follows.
“OK. So, quickly. All these beds” — I gesture to the semicircle of curtains around us — “are major.” She nods. “Sicker people. Heart attacks, or things that could be them. Strokes and overdoses. Traumas. Low blood pressures, hearts that are too fast or too slow. The unconscious. People who need constant monitoring, because they’re getting sicker, or because the information gathered over time helps us know whether it’s safer for them to stay in hospital or whether they can go home.
“If they have a home, that’s where we send them, if it’s safe to. If it’s not, or they need treatment only found in hospital, they’re admitted. There are more nurses here in major, like one for every two beds. That’s what makes the difference between here and intermediate. We take over those rooms at 1 a.m. People are on monitors there, but have fewer nurses to check on them, less time per sick person.”
A woman in a white coat comes out of bed 11 and joins us. I smile in greeting.
“Just orienting Zainab to the ER. In intermediate, we see abdominal pain, kidney stones. Vaginal bleeding. That type of thing. People with mostly normal vital signs, who can wait for an hour or two, though they often wait longer. We also have a security guard there at all times, so that’s where we put people who are psychotic, suicidal, or high on drugs. Drug-wise, here at St. Mike’s . . . a lot of crystal these days for some reason. Some crack, but everything really. GHB, MDMA, heroin, fentanyl, OxyContin.” I stop to think. “And booze. Lots of booze. People can be pretty agitated, so best to check with me or one of the nurses before you go into a room alone.”
Zainab follows my eyes, hangs off my words. I was the same. It was the most exciting place I had been.
“Last, minor. It’s the busiest. Only a couple nurses, little monitoring. Long waits, small problems. Well, to us. To the person, worst day of their life.” The senior resident smiles, nods. “Here’s how it will work. You” — I point to Zainab — “will see cases, do the history and physical exam, talk to me about what you think is going on, and we’ll come up with a treatment plan together. Make sense? And you” — I flip the senior resident’s badge the right way round, Ellen, visiting final-year resident, on a trauma rotation, maybe wants a job — “talk to me before you order any scans or discharge anybody home. We’ll connect every hour or so to see what’s going on. If any traumas come in, they’re all yours.
“Oh yeah, and if either of you hear ‘Dr. Maskalyk to wherever,’ meet me there. Something exciting is happening.” They nod, satisfied. “OK, break. We’ll work in major for a bit, then let the other docs go home.”
I look through the remaining charts. Confused, registered at 23:23 hours. Shortness of breath, 23:40. It’s best to not get picky about what you see, just go to whoever’s next.
A preference for the sickest, though. That’s what matters most, shuffles the order. The triage nurse makes a first fast pass, glancing at the vital signs, heart rate, blood pressure, temperature, but also how the body is held, the clothes, the worry, asks a few critical questions about chest pain, how suddenly the weakness started.
The inspection continues in finer detail when the patient moves into a room and another nurse spends more minutes on the story, pulling out details, sees them gasp as they change into a gown, what bruises are revealed, then comes back in 20 minutes to note what’s changed. The worst sicknesses don’t stay still. Short of breath then gulping for it, the confused turn unconscious.
Aperson tells the story a third time to me, about how they came to be hooked to all these machines. Some get frustrated, but I need to hear it myself. I must be forever suspicious, trust no previous information necessarily, at least not more than what I can gather. I have diagnosis and treatment in mind, decide who gets discharged or referred for admission, the middle and end of their emergency department story. In the eyes of the law, my mistakes matter most, so I ask two questions in enough different ways that the answers are as clear as possible: what exactly are you here for, and why, exactly, today?
Then I look at their shoes. In truth, I probably look at them first, and if they have none, their feet. It tells me how much money they have, what kind of care I can expect them to afford their body once they leave.
Regardless of which bed they start in, the sickest win their way to the front, and we see them first, then everyone else in the order they come, as fast as we can. I say that sentence so often to people frustrated at the wait, I want it flashing underneath the “Emergency” sign.
I drain the rest of my coffee. One of the nurses turns the lights down. Some of the patients Tom saw are numb, drowsing, morphine washing through their brains, waiting for admission orders to be written by the resident with his head on the desk. It’s quiet, at least for now, but you must never, ever say that word in this ER. It is our one superstition. Well, we haven’t a bed 13, so I suppose there are two.
I walk past the man in bed1. He breathes easily. A body in bed 6 clicks and whirs on a ventilator, paralyzed and unconscious. Space is being made for her in the intensive care unit. In the rare event there wasn’t some, she would be flown to another ICU by helicopter, maybe even wake up in a brand-new city once she could gather her own breaths again. What a surprise.
Around the ER, in major, intermediate, minor, in bright rooms, 20 families sit, anxious. For them, hours of waiting. For us, a series of five-minute encounters until morning.
I stand outside the bed of the confused man. I have seen so many people pass through this bed. Seizing ones. Bleeding ones. A man yelling, bug-eyed, high on amphetamines, while security strained to hold him down.
I glance at his chart. Eighty-six. I pull the curtain aside.
He looks older. He is alone, his eyes closed, mouth drawn over empty gums. His face is freshly shaven.
Who did it? I wonder. So careful. Not even a nick. I lean closer. The smell of aftershave. Maybe he did it himself. No stridor. Oxygen in his blood was good, at 98 per cent. His heart tracing is slow and regular on the black screen. He could wait minutes. I shuffle the next chart forward.
Bed 14. Shortness of breath. I draw its curtain back, and the face of a man I have seen half a dozen times looks up. He sits, shirtless, legs dangling, sharp shoulders rounded forward, heaving up and down. His nose flares as he draws in a breath, cheeks blow fat as he puffs it out past the edges of an oxygen mask connected from his face to the wall. “Hey . . . Doc . . .” “Saeed. Asthma again?” “Yeah.” “Still smoking?” “Cuttin’ . . . down . . . five . . . a day . . .” “Good.” I put the bell of my stethoscope on his back. Wheezes. “You coughing anything up? Fevers? Using your puffers?”
No’s. I scribble an order on his chart for inhaled medicines, a steroid pill to shrink the inflammation in his scarred lungs. In an hour, he will walk out of here with an inhaler in his pocket and a prescription for more. Same every time. He always says he needs more. He must have a hundred of the things. What’s happened to them all? I don’t ask.
I drop the orders off at the nursing station, walk back to the bed of the confused man.
“Sir!” I shout. He doesn’t blink. I move to his ear. “Sir!”
Nothing. I rap his chest. No response. More “unconscious” than “confused.” I rub my knuckles hard, back and forth, on his sternum. He grimaces, moves his hands to mine. Good. Something is infinitely better than nothing.
I feel for a pulse in the arm that clutches mine. The skin at his wrist is paper-thin. Skin does that as we age, fades, its fat and elastics grow loose. Sometimes older people come in after bumping their shins and the skin will just have peeled away. Putting it back together is like sewing wrapping paper; the threads just slide right through. I’ve learned to use tape.
I look more carefully at the chart. From nursing home. Alzheimer’s. History of stroke. Two-person transfer. Not eating, not drinking x 3 days. Blood sugar normal. No family. End-of-life form signed by public trustee: transfer to hospital, antibiotics OK. Do not resuscitate.
I’ve seen this man before too. Versions of him, I mean, so many I’ve lost count, all of them dead now.
I saw two roads when I noted his age and complaint. Review his medicines for sedatives, order blood work, chest X-ray, test for urinary tract infection, a CAT scan of the head to look for blood that, if seen, will cause me to stop the Aspirin he’s on.
Or let him die. He’s on his way. Whatever fear of death we’re treating by pretending to stave it off, this man isn’t feeling it. If I could talk to him, I don’t know if he would want to stretch this part of his life. But I can’t.
That’s the tension that pulls through this place. Not just how to call out the right medicine over a dozen other voices and have the right person hear it, or not to miss a tiny white patch of blood on a CAT scan when you’re blinking sleepily at 4 a.m., but how to mete out the great wealth to those who might profit in ways that matter. Admitting to intensive care all the people who will never again open their eyes would fill it in a day. Pour blood into people who won’t stop bleeding and you’ll run dry while they’ll still die. These decisions become more real in places like Ethiopia, where for a single person there may be two units of blood to spare, not 20.
I pull the man’s lower lids down. The pupils tighten briskly in a blue iris, clouded with cataracts from the sun’s rays.
Someone’s son, brother, father, husband, lover. Grandfather. One day, someone will bend to my wrinkled face, put a stethoscope on this chest, and listen to my heart pound down, their mind on their own private thoughts while mine dances with memories.
Or maybe I’ll be surrounded by people I love. Or be alone on the floor.
I swish the curtain aside and leave the room.
In minor, charts fall to the floor. I grab the clipboard of the next to be seen and work through the alphabet of rooms. A bug crawled into a man’s ear. A young couple share a common cold. A lady dropped a wine glass and tried to pick it up, cutting . . .
Hiss. “Dr. Maskalyk, please call triage. Dr. Maskalyk, call triage.” Click. I look at the clock. Three a.m. Bars closed. Probably a trauma.
“Excuse me, ma’am,” I say, wrapping the bandage back around her finger.
I walk out of the ER through the side door, to the ambulance bay.
Snow loops on the black pavement. An ambulance beeps as it backs quickly to our ramp, stops. A man leaps out, rushes to the back door, springs it open. In the back, another medic sits beside a stretcher, squeezing a bag. They push the bed from the truck’s boxed back and two legs click down, two more, and they rush up the ramp.
I hurry beside them, pull my surgical gown tight against the wind. The man’s face is swollen, his eyes just slits. Blood burbles out of his snoring mouth, spatters on the clear rubber mask. The medic squeezes the bag and starts to recite the story breathlessly.
“Twenty-something male . . . assaulted . . . to the face and neck. Unwitnessed. Heart rate 120, sat 80 per cent, blood pressure . . .”
(Ellen) intubates him. It is hard to stand back, but I manage. The surgery resident is beside the patient’s neck, ready with the scalpel, plastic shield over his eyes. Zainab stands, riveted, eyes wide, three paces back.
While the man is getting his broken face imaged a floor above, another hiss overhead. A woman dancing on her balcony, drunk, high, daring fate, slipped. She arrives in the trauma room, her neck craned behind her in a dull stare, already dead.
We tell her brother, an hour later, underneath white lights. He nods bravely. Behind him, his father strokes his daughter’s hair, whispers loving words into her cold ear.
At 5 a.m., a woman comes to the nursing station where Ellen and I sit looking at the man’s fractured face on a computer. Blood has seeped through her bandage. “I’ve been waiting for more than two hours, you know,” she says, angrily, thrusts her wound at me.
“Well, ma’am,” I say, “I’m the only doctor at night, and we see the sickest first.” So much misery in that one little finger. A half-hour later: “Sorry for the wait. Let’s see that hand.” I carefully unwrap the gauze. “It’ll come together nicely. There’ll hardly be a scar.”
She smiles, and in that square space, in the middle of the night, a bit of suffering disappears.
Or let him die. He’s on his way. Whatever fear of death we’re treating by pretending to stave it off, this man isn’t feeling it