Yesterday's Emergency

The clinic where I work serves a remote town and an area of surrounding desert extending over two hundred kilometres to the east and the west. The nearest hospital is 500 kilometres away in Alice Springs.

Many of our patients are regulars who come for routine check-ups. But more often than we like, we find ourselves in an emergency scenario. Inflamed appendixes, snakes bites, heart attacks, cars rolled over. The team I work with has gotten good at this over the years and I’ve learned a thing or two, but sometimes there’s a moment.

A moment when I realise that the emergency won’t be deflected, that the patient’s pressing need — the threat to life or limb — won’t be met or rationalised away or quickly ameliorated. There’s a kind of steadying myself, at that moment, for the solid hard work ahead. I try to figure out, with help from the nurses, what the patient’s problem is. I assess my knowledge, or lack of it, about the problem. If there’s a lack, it’s time to look up a key concept and remind myself while the nurse makes a start on the fundamentals — keeping their airway open, gaining access to the patient’s veins. The Internet is good then, but if that fails I have my trusty books.

There’s a grimness to the moment when I realise that this person might die here today.

Blood Moon by  Jake Hills

Blood Moon by Jake Hills

It’s good to be with people I know then, people who know me. I am counting on my team at the clinic the way I would count on dear friends. Time working together blurs the borders between teamwork and friendship. We understand each others' style of communication. We know each others’ strengths and we know each other's weaknesses. This helps us step in for each other. We’re all ready to bring our best to this one. Again.

And then there are the friends at the end of the blessed telephone. The doctor in his or her home in the city or on a rainforest farm — in any case far away — listening to me. I try to organize the information I have into pictures and language we both understand. We talk numbers and if they are bad, the doctor at the other end shares my dread. Many of them know me, on the telephone at least, from many other conversations that felt like an emergency for the patient but were not really emergencies for us. On this critical day, though, the doctor at the end of the line hits the books between phone calls, phones a specialist for advice, looks at different evidence or guidelines and comes back at me with questions and suggestions. Another doctor in the hospital emergency department 500 kms away makes me feel, with a measured and thoughtful voice, as if I’m there, in a great big, strong building full of generous minds, big hearts, strong drugs and handy appliances. In a critical situation, she or he also turns from my call and discusses with colleagues the best way forward. Perhaps another worker at the end of the phone is negotiating a plane to get to us. The Royal Flying Doctor Service might have to re-direct one of its sturdy little planes away from another sick person towards my sick person. I feel grateful to the family, the nurses, the patient at that other remote place who may have to stay up all night managing their suffering now that we have taken their promise of help away.

My patient shows me what’s wrong in ways we have to figure out without a CT scan or a lab upstairs. My purpose is to prevent suffering or to get rid of it. The two are not always the same. Sometimes, often, usually, we have to use rough means to prevent the damage that would cause long-term suffering. We need to help the body quickly. People are frightened of us for a reason, I think, as I see my beautiful colleague seize an arm or a hand and push a huge needle firmly into my patient’s vein. My nurses know how to look after someone who is critically ill. We put plastic tubes into your nose or throat when you are not conscious enough to protect your airway. When you can no longer control the fluid coming out of you, we’ll put a plastic tube into your urethra to save you the indignity of wetting yourself and to make sure your kidneys are working.

We reassure ourselves by murmuring abc, like a nursery rhyme, “airway is clear, breathing spontaneously, circulation, we’ve got two cannulas in, fluid running.” Finish a task and think of another one. What else can we do to help protect our patient? How can we nourish this patient? Would a tube into his stomach or a needle drilled into her bone help keep this one alive? What medicines do we have that might help? If we don’t have that one, is there another that might work? How do we keep him alive until he has a chance to heal?

Perhaps he has seizures. As his eyes roll back and limbs jerk, I recall every other patient I knew who had seizures, perhaps even remember the first time I saw somebody’s body spasming and convulsing uncontrollably. There is a strange comfort in having seen it before. I’ve seen someone get better from this before. (I’ve also seen someone die with these signs before — every one of my patients teaches me.) I find a grand comfort in having a medication that will quiet these jagged waves. “Give him plenty,” says my colleague in the far away Emergency Department. We are all aware of the potential side effects and we watch the patient, like hawks surveying their territory. The machines measure meaningful numbers and we process them, adding up to a response, adding up towards a life.

Or my patient has had a head injury. The nurse shines his torch into her eyes, using her pupils as windows to a possibly injured brain. He asks her to lift her eyebrows, make a fake smile, stick out her tongue; hoping to find out that she is in the middle way, in that harmonious realm where all is lined up, body, mind and spirit. But perhaps she has skull fractures and we’re afraid her brain is swelling. Give mannitol, says a doctor at the end of the phone. She has the dosage at her fingertips.

Amidst this, I’ll hold the patient’s hand or whisper in his ear. “We’re looking after you. You’re doing well.” The nurses, working steadily, give me a few minutes to talk to another frightened person – the patient’s friend, spouse or child, their world circumscribed now to the narrow bed on which their loved one is fighting.

 “What do I tell his wife?” I asked my colleague on the phone yesterday as we formulated a treatment plan. My colleague helped me frame the words. “Tell her that people can get entirely better, but that he might die,” he said. I told our patient’s wife this, adding, “I would hang on to the idea that he could get entirely better, if I were you.”

That’s what I try to do. When the team from RFDS arrives it is always a great relief to see them. Another doctor is here — she’s in charge now. She and her nurse are checking the fluids, putting in a better airway, giving medicines or blood that they have especially brought. Life savers in the Outback, each one of us, from the receptionist who coordinates our phone calls and looks after re-booking the appointments of the people we can't see during an emergency, to the man who came to take the snake out of the clinic in the middle of a resuscitation yesterday, the cleaner who also keeps our clinic safe, to our drivers, who pick up the sick people or run quotidian errands that can help save lives — buy some salt, get some tape, pick up the team from the airport. Sometimes one person plays many roles. Everyday, each one of us does focused good work for health, life and enjoyment. During emergencies, that focus gets sharpened to an edge.

“I’m happy to see you so healthy,” I tell my patient on a routine clinic day. I’m not sure if they understand how sincerely I mean it.