A day – and an unexpected night – in the emergency ward

A woman stretched out on a wheeled gurney holds a towel to her head, her injury and how it happened unknowable as orderlies whisk her through the clamour of the emergency department.

Medical equipment beeps, long banks of headphone-equipped staff rattle keyboards and issue instructions, nurses and doctors – mostly young registrars – swap crucial information.

Paramedics wheel in patients from the ambulance bay, relaying details of trauma or illness.

A loudspeaker blares, requiring the urgent attention of a specialist team.

Resuscitation seems to be the major requirement this morning.

Say it quickly and it is just another word, shorthanded airily in the emergency department as “Resus”.

The Oxford dictionary puts you to the wise.

Resuscitation is “the action or process of reviving someone from unconsciousness or apparent death”.

It happens that within a few days – in a different emergency department – I will learn more than I might have wished about what resuscitation means, and how sweet it is to be revived.

Here, then, is the ultimate goal of all the relentless movement and noise and the brisk transport of the ailing on gurneys around the emergency department, spoken simply as the ED.

Beyond the easing of pain and distress, it is the saving of lives.

In a corner, a pair of police officers stand together, calmly taking notes.

The consequence of whatever crisis brought them there – a car smash, a vicious assault, something worse? – has been transferred to the care of doctors and nurses.

Police are a near constant presence in the ED, an intimation of tumultuous or tragic or complicated events way beyond the walls of the hospital.

Within cubicles along corridors, patients lie in beds. Some appear asleep or unconscious, others gaze at the passing parade, their eyes betraying bewilderment or something between acceptance and relief at having found sanctuary from pain or trouble.

It is a quiet morning, says Daniel Crompton.

Crompton is director of the emergency department at the Northern Hospital in Epping, a vast place serving Melbourne’s swiftly-growing north, where housing estates chew relentlessly into old grazing land.

Out there is what might be called modern Australia: a community born in more than 185 countries, speaking 107 different languages, and following more than 90 religions or spiritual beliefs.

The Northern Hospital, central to this cultural mosaic, houses Victoria’s busiest emergency department.

In the past year, close to 120,000 sick, injured, traumatised, wounded, nauseous, alarmed and otherwise indisposed men, women and children came through the doors seeking attention: an average of 330 every day.

The arrival of ambulances is relentless, too – 93 of them swing into the bay to disgorge patients on an average day. On the busiest day so far, 126 ambulances turned up.

Some days more than 400 people trek to the emergency department’s waiting room, and 160 cram through the treatment areas.

At such times things can become frenetic and loud, building the potential for the frustrated, anxious, claustrophobic – and especially the drug- and alcohol-affected – to topple into anger and even violence, says Crompton. There are always two security guards on duty, and eight available at the hospital.

And yet, despite all the hubbub that assaults the senses of the casual outsider, there is reassuring order within Epping’s ED.

Everyone clearly knows precisely what they are required to do, whether it be answering a telephone or working to save a torn life.

Once the visitor becomes accustomed to what initially seems turmoil, it becomes impossible to avoid a more arresting truth: there is a studied and reassuring efficiency about the way everyone here goes about their work. A focused, purposeful calm within a tempest.

It is no accident. Upstairs, the heads of the various emergency department units gather at 1am in a blessedly quiet room for what they call a huddle.

Crompton hands around a container of lollies. ED nurse unit manager Hannah Downie types up a scorecard that appears on a large screen.

It is a rundown on the “flow and capacity” of the various acronyms that constitute the department’s treatment arms – from the CPEU (Chest Pain Evaluation Unit) to the ICU (Intensive Care Unit) and numerous more.

It emerges there is no space left at all in the ICU.

No one seems fazed. Crompton says the department is capable of setting up a temporary intensive care operation if required.

This unflinching assessment of numbers and flows and likely demands is a critical quality in the ED environment.

All the pressure, rather than crushing the doctors, nurses, clerks, triage specialists and all the others who keep the place operating, has lit creative and innovative fires at Epping.

To give the community an alternative to physically visiting the emergency department, the hospital has developed an internet-driven telehealth system called Virtual ED.

It allows anyone with a device equipped with a video and linked to the internet to consult a specialist emergency nurse or doctor without leaving home.

Created at the Northern during the COVID-19 pandemic to assist people reluctant to be exposed to others in the hospital waiting room, virtual ED has grown to a 24-hour operation spanning Victoria.

The state’s entire system – Australia’s first – is now run from a wing of the hospital, and currently provides almost 1000 “virtual” consultations every day at the mere tapping of an internet address: vved.org.au.

Paramedics regularly use it, too, while attending patients at home. It means their patient often will not need to be transported by ambulance to the hospital for face-to-face assessment.

The hospital itself offers members of the public the chance to walk a few steps from the crowded ED waiting room to quiet booths similar to telephone boxes where they can consult an emergency nurse or get patched through to a doctor by video.

Specialist nurses answer calls in banks of booths at the virtual ED headquarters in its wing of the hospital. The ED doctors consulting through the video screens are themselves at their own homes.

There are about 250 of them across Victoria, rostered during their downtime from private or hospital practice. They issue medical advice and prescriptions, or in some cases suggest patients seek further assistance from a GP or at the physical ED.

To ensure communication is no barrier, the hospital and the virtual ED have interpreters on call of numerous tongues, from Arabic to Punjabi and everything between.

Northern Health’s executive director of public affairs, Pina Di Donato, points out the hospital’s own staff members reflect the community they serve. Most live in Melbourne’s northern areas, and represent a broad array of ethnic backgrounds.

Meanwhile, though the inventive virtual ED helps reduce some of the load, the public continues to pour in to the physical ED, seeking relief from numerous hurts or ills, their numbers swollen in part by a dearth of bulk-billing GPs.

And here, too, the hospital at Epping has developed its own method of dealing with the tide.

Hospital emergency departments everywhere operate on a series of code alerts: Code Blue, for instance, is for cardiac arrest or other medical emergency.

In June 2018, the hospital of the north introduced an extra Code, called Surge.

Code Surge involves marshalling the resources of the whole hospital to help the emergency department when, during peak demand, there grows a backlog of patients waiting for a bed or the waiting room becomes overcrowded.

A Code Surge means doctors are paged and senior staff across the hospital receive text and email alerts to put aside non-essential tasks and find beds and other resources urgently.

Within three months in 2018, this “whole of hospital” system was used successfully eight times, usually for periods of about two hours.

This year, says Crompton, the hospital has been on constant Code Surge since the start of winter.

An increase in respiratory diseases such as RSV (respiratory syncytial virus) and influenza on the back of COVID-19 is part of the reason, coupled with population growth.

A constant Code Surge might place unusual stresses on the big hospital, but Crompton says he is immensely proud of the result. “Of all patients arriving at emergency departments in the state, we treat the most within the recommended time,” he says.

But brisk attention doesn’t translate to the expectations of all those who turn up to the ED.

Urgency and timeliness descends through a series of categories laid out in guidelines of the Australasian College for Emergency Medicine and assessed by the ED’s triage specialists.

The system ensures that someone suffering a life-threatening crisis such as major heart attack or respiratory arrest – category one emergency – gets immediate treatment.

A patient suffering severe respiratory distress, chest pain of likely cardiac nature or acute stroke, right through to severe trauma, is judged to be Category 2 – imminently life-threatening – requiring treatment in 10 minutes.

Category 3 is assigned to those suffering potentially life-threatening conditions – moderately severe blood loss, moderate pain, persistent vomiting or a child considered at risk of abuse – and should be seen within 30 minutes.

Category 4 is classified non-urgent, and might include vomiting without dehydration, pain or difficulty swallowing without respiratory distress, or a sprained ankle. This group can hope to be seen in an hour.

Category 5 is for the “less urgent” experiencing minimal pain, minor symptoms of existing stable illnesses and small cuts not requiring stitches and the like.

They can hope to be seen within two hours. However, Crompton says the less urgent cases meet this goal only 50 or 55 per cent of the time, and at particularly busy periods, they might find themselves waiting for up to five hours or more.

Those virtual ED booths, thus, are clearly designed to look increasingly attractive to those in the non-urgent and less-urgent categories. Waiting time in a virtual booth is currently about 30 minutes.

The busiest ED in the state, however, needs something more than a small army of plain hard-working, efficient and skilled health workers backed by a team of nurses and doctors online.

It needs an underlying philosophy to hold the endeavour together.

“Safe, Kind, Together” is the hospital’s chosen ethos, its statement of its values.

The three simple words are designed to form the basis of everything that drives the operation.

“It is a program to support each other, all of us, whatever we have to face,” says Crompton.

The Northern Health website spells it out.

Safe: We provide safe, trusted care for our patients. We are inclusive and culturally safe, celebrating the diversity of our staff and community.

Kind: We treat everyone with kindness, respect and empathy.

Together: We work together with our staff, patients, consumers and health system partners.

Three days after I bid farewell to the Epping ED, I found myself in urgent need of medical assistance, and discovered that those concepts travel well across the emergency world.

Having contracted a lung infection, I was fast losing the ability to inhale a breath when my family sped me off to an emergency department, this one at The Alfred hospital.

The triage specialist recognised I was drowning and that my heart was dancing a panicked, painful stomp. I was hustled into the resuscitation unit and assailed with care and breathing apparatus and needles and other life-saving stuff by a small team of nurses and a doctor.

The ED was hectic all around, compounded by a failure of computers, with staff forced to resort to handwriting notes.

But when I finally grabbed a lungful of oxygen and the heart stopped jiving, I knew I was safe, among kind people who worked calmly together because that’s what they do.

Forty kilometres across the city, I reflected, people within the broad embrace of the Northern Hospital at Epping learn the same happy thing, every day, every night.

The Australian health system is a gift in a tough, increasingly inequitable world, and the people who work in it can’t be treasured enough.

It’d be a fine thing, I thought as I finished my little odyssey into the world of emergency departments, if those who draw up state budgets might have come along for the ride.

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