Memorial Hospital's Emergency Department. Photography by Tamell Simons.

From one minute to the next, there's no telling what will come through the emergency room doors. The cases range from minor complaints - the nosebleeds, the earaches, the bumps and scratches - to the most severe - the stabbings, the multiple road traffic injuries and cardiac arrests. Many people working in emergency have had patients look them in the face and say they know they're going to die moments before it happens. In many ways, the things they have seen have hardened them, yet these people are more sensitive and caring than most.

The staff at the Emergency department of the King Edward VII Memorial Hospital have not had it easy in the past decade. Their jobs have become busier, with an increasing number of patients. They are seeing more violent injuries and more violence against hospital staff by patients, their relatives and friends.

And now the department, along with the rest of the hospital, is facing its worst crisis of confidence ever, largely the result of two highly publicised inquests in which the hospital was criticised for its "lack of professional care''. One of the inquests, into the death in 1990 of Wendy Wilkinson, has resulted in a $30 million lawsuit against the hospital.

The problems began in the 1970s, when a series of deaths prompted a Commission of Inquiry to investigate complaints made about the department. The Commission report, released in 1983, made several recommendations that would improve the standard of care in Emergency. Within five years, the hospital had implemented almost all of the recommendations. An Emergency director was hired to run the department on a full-time basis. The number of people working in the department was increased, and both doctors and nurses were required to have more emergency room experience. There are now seven doctors, 25 registered nurses, four receptionists, and 15 full and part-time ambulance drivers, all but two of whom are trained emergency medical technicians (EMTs).

One of the biggest improvements has been the physical plant itself, which in the late 1980s was moved to a bigger space next door to its old location.

Today the department centres around a large nursing desk. On one side are four cubicles where stable patients are examined, as well as a gynaecological room.

On the other side is a theatre, or suture room, a paediactrics room, a special treatment room for patients who may need more privacy, a cardiac area with three beds, plus a six bed observation area. Directly in front of the central nursing desk is a two bed resuscitation room, which also has direct access for in-coming ambulance patients. When patients arrive at the hospital, they are registered and then examined for the severity of their care in a walk-in triage room. The triage is manned by nurses and EMTs and on weekends by EMT volunteers from St. John Ambulance Brigade, the Fire Service, and other organisations.

"Yes, we have problems, there's no question of that, but I think our departmenthas improved a great deal - especially in the five years that I've been here,'' says Emergency director Dr. Ed Schultz, who took over from the department's first director Dr. Ian Cordon, after working in emergency medicine in a Miami hospital.

"There are going to be mistakes - these things always happen in medicine, and all we can do is try to stop them from happening. In a community of 55,000 people, where everyone knows everyone and everyone's inter-related, any complaint has a much greater impact. In a bigger city, the complaints and the mistakes get lost in the masses. In Bermuda, we will always be under scrutiny.

"It's very hard on the morale of the staff. It doesn't do anything. People come in and say it's a lousy department, that we don't care. Of course, the staff are going to react. I think this department is very, very good. It is superior to any community hospital of its size in the US. All the time we're compared to Johns Hopkins and Toronto General. That's not fair. We're a community hospital by North American standards.'' Despite the problems, there is one thing all the Emergency staff have in common. Not one of them would trade their jobs in Emergency to work in any other area of the hospital. What follows is a chronology of events that took place over two weekend nights in June. Names of patients have not been used except where consent has been given.

FRIDAY 6 p.m. The Emergency department is quiet, so quiet that nurses on duty say it's unusual for a Friday evening - one of the quietest in weeks, they say. Three people are sitting in the waiting room - two women, one with a young child. They are gone a few minutes later. The atmosphere seems different than you might expect. There isn't the craziness of a non-stop flow of patients. The staff are quiet, but the mood is upbeat. The nurses and the two doctors on duty, Dr. Phillip Jones and Dr. Derek Sage, are gathered around the department's nursing desk, waiting. Even the phone is quiet. "It's funny in here,'' one of the nurses says. "One minute it can be quiet with not one person in here, and the next it'll be full. Tonight is unusual. Fridays and Saturdays are usually a lot busier. People are out doing things, they're more active, there's more drinking going on, and people have more of a chance of hurting themselves.

6.40 p.m. The first call comes in. The ambulance is called out to pick up a woman with a back injury - she's had a prolapsed disc. The pick-up has already been arranged by the woman's doctor. It's not an emergency - she had to be brought in for surgery the following day. Twenty minutes later, the woman is wheeled in on a stretcher. She is kept in Emergency while a bed in one of the upstairs wards is prepared.

7.10 p.m. A young girl arrives with a muffler burn on her leg. She is taken into one of four cubicles, which are used for stable patients with smaller injuries. She is treated and released 10 minutes later.

7.30 p.m. A young man in his 20s comes in. The tip of one of his fingers has been sliced off. Dr. Sage says it's not too serious, but it will take several weeks to heal. The wound is cleaned and wrapped in a dressing. He is also given a tetanus shot. He is released a short time later.

8 p.m. There is a little activity as one shift ends and another begins. Dr.

Sage finishes after 12 hours on duty, and Dr. Carol Ferris begins a 12-hour shift. Dr. Jones will remain on duty until midnight. A few smaller cases come in for treatment during the next 10 minutes. A two-year-old boy is brought in with asthma - he is having trouble breathing. He is taken into one of the cubicles for treatment. A nine-year-old with a nose bleed arrives five minutes later, is treated and released. And a little boy comes in crying. He is suffering from an earache. He too is treated and released.

8.35 p.m. Again there is a discussion about how quiet the night has been. Dr.

Jones says it's "almost ominous'', while another adds: "It's sort of like the calm before the storm.'' They talk of a busy Friday night, when all beds and cubicles in the unit are full, and still more people are waiting to be seen. "One of the things that the public doesn't always understand is that when it's busy in here, some people are going to have to wait,'' one of the nurses says. "We have to help the sickest people first, but when people are out there in the waiting room, and they've been there for an hour, or even two hours, they start to get frustrated. But they don't know what's going on in here. We're trying to save someone's life and that's the priority. Usually the patients are fine. It's the family or the people with the patient who tend to get frustrated. They start complaining about how long they've had to wait, and once one person starts, others join in. They don't understand that when it's busy, the staff in here is working as hard and as fast as possible, and they are there complaining about the wait. It can become a very tense situation.'' 9.05 p.m. An hour after he is brought in, the two-year-old boy with asthma is released. Minutes later a man comes in complaining of chest pains. He says he's had them for a year. He's placed in one of the beds in the cardiac unit.

A short time later, he's taken down the hall for an X-ray. He's also given an electro-cardiogram (ECG) to monitor his heart. About three hours later he's released to go home.

9.45 p.m. A woman in her late 20s is brought in with a cut on her head. Her dog accidentally bumped her. She is taken into the theatre, also called the suture room or minor injuries room, where Dr. Jones stitches the cut. She is released a few minutes later. Out in the waiting room, Victoria Spenser holds her one-year-old son Jahki while they wait to see a doctor. Jahki's mother says he has a fever and was vomiting the day before. He's brought in and examined by one of the doctors. He begins to cry. An hour later, it is decided that he'll stay the night. One of the resident doctors, who is responsible for monitoring patients on the upper wards and for checking patients into the hospital, examines Jahki, and just before midnight, he's taken up to the children's ward.

10.35 p.m. A woman, about 30, arrives complaining of a sore finger. She is examined,treated and released. "One of the things about emergency here, more than other hospitals, is that people see it as a 24-hour clinic,'' says one nurse. "We get a lot of cases where people who are suffering from one thing or another, whether it's a pain or a minor cut, wait until after hours - late at night or early in the morning - to get it taken care of. They come here because doctors offices are closed. But they don't think to go to see their doctor during working hours when they've had the pain, or whatever, for many hours, days or even weeks.'' The unit is quiet. The atmosphere is calm, but the staff, doctors and nurses, are waiting. A half hour passes, and nothing ... then another half hour. Dr. Schultz later describes a busy weekend night when every bed and cubicle in the department is full, other patients are seated in the waiting room, and then two or three severe trauma cases arrive by ambulance needing immediate attention. "I remember one weekend night in November,'' he says. "The other doctor on duty had gone home sick. The department was full and we were really backed up. Then we got three unconscious patients from two different road traffic accidents. Two patients, they were tourists, remained unconscious, and the third, a local, had regained consciousness by the time he arrived here. He had broken the lower leg bones on one of his legs. Of the other two, one had a fractured thigh bone, and the other had a ruptured spleen and a bowel injury. I had to see both patients simultaneously. Basically what you do is work on one, whichever is in worse condition, while the nurses prepare the second. Then you work on the second patient. When something like this happens we call the anaesthetist down for help. If my memory serves me correctly, the two tourists never regained consciousness in Emergency. They were taken up to the Intensive Care Unit, and then air-vacced out of Bermuda for further medical attention. That was an outstandingly bad night, and it doesn't usually get that busy. "When it is busy and you get two or three really severe injuries, you do the best you can.'' 11.45 p.m. The first call comes in on the 911 line. It's a road traffic accident at Hog Bay Level in Somerset. The caller says a motor cyclist has serious head injuries. Two of the EMTs, along with a nurse, head out to the scene. They will call in from the scene if it is serious. No call comes. "You know, I've worked here for 13 years, the same shift 4 p.m. to midnight for 13 years, and I still find it tough,'' says Glen Woods, ambulance driver and EMT.

"It's a rough job. We see so much of everything - people who've been out partying on the weekends, the kids who are out on their bikes late at night ... it's hard sometimes. It's not an easy job. There's a lot of stress. But one of the things I've learned ... when your shift finishes and you go home, you leave your work here. You have to.'' 12 Midnight. Another shift ends. The staff is down to Dr. Ferris, the only doctor on duty, three nurses and ambulance staff.

12.20 a.m. A mother arrives and asks if her daughter is a patient. She says she was called by the Police and told that her daughter was in an accident. A nurse asks her daughter's name. She is not a patient, but the mother is told to wait in the waitingroom. Ten minutes later, the ambulance arrives. The daughter is wheeled into one of the two resuscitation rooms. She is conscious, but has cuts and bruises on her face. Dr. Ferris and two nurses are by her side.

12.30 a.m. Another 911 call. A 58-year-old St. Brendan's patient, with a history of congestive heart failure, is short of breath and staff there call for an ambulance.

12.35 a.m. A young boy is carried in by his grandfather. He is crying and wheezing. He is asthmatic. He is taken into the paediatrics room, where his grandfather holds him and tries to calm him down. The man is worried and is on edge himself. He is told to calm himself down or he will scare the child. The boy calms down. A few minutes later, Dr. Ferris comes in to examine him. 12.45 a.m. Police officer Andrew Hancock arrives to question the accident victim, her boyfriend and her mother.

12.55 a.m. The young boy is crying hysterically. Dr. Ferris is in with the patient from St. Brendan's. 1 a.m. The ambulance returns with the woman from St. Brendan's. The unit has come to life, but there is an obvious sense of order. Pc Hancock questions the accident victim's boyfriend and mother in one of the cubicles. The girl, about 20, is taken for a facial X-ray. Dr. Ferris says that this particular road traffic accident doesn't come under the heading of "serious''.

1.05 a.m. The mother and father of the young asthmatic boy arrive and are taken into the paediactrics room to see their son. A few minutes later the boy begins to scream again. He, too, is taken to the X-ray room. Thirty minutes later he is brought back to the paediatrics room with his mother and father.

It is decided that the little boy will stay overnight. 1.25 a.m. A 59-year-old man, complaining of pains in his chest, is brought in by his wife. He is taken to a bed in the cardiac area.

1.50 a.m. The accident victim returns from X-ray and is wheeled into the cardiac area. Her mother and boyfriend are with her. She begins to weep. Her mother is talking to her, calming her down. A few minutes later, after the patient from St. Brendan's is X-rayed, it is decided that she, too, will stay the night.

2 a.m. The accident victim calms down and is sitting up in bed. Five minutes later she is taken into the theatre for stitches to her chin. Every few seconds, she cries out in pain.

2.10 a.m. The little boy is taken up to the children's ward. He is asleep.

2.15 a.m. Two Police officers, followed by a third, bring in a man who's been involvedin a domestic fight. He's been hit over the head with a crutch and has cuts on his forehead. He appears agitated and not altogether coherent. He is taken into a cubicle, and the Police disappear to the waiting area. A few minutes later, when the nurses have their backs turned only for a second, the man walks out of the cubicle, and heads down the hall towards the Emergency exit. One of the nurses quickly notices, runs after him and brings him back, this time into the theatre for stitches. The girl from the road accident is wheeled back to the cardiac area. Her family doctor arrives just before 3 a.m.

and examines her. Her mother stays by her side for a few minutes, then leaves.

2.55 a.m. The woman from St. Brendan's is taken upstairs and admitted to one of the wards.

3.05 a.m. The man comes out of the theatre with a bandage wrapped around his forehead. He gives a loud chuckle. He stops at the reception desk. Dr. Ferris is filling out his medical report. He asks her how someone who has just had brain surgery would walk out. He laughs again and, escorted by the officers, walks out, dipping his head on each step. "It's those types of patients, the late night ones who come in from domestic fights or bar fights, that are unpredictable,'' says a nurse. "You just can't tell how they're going to react. They could reach out and hit someone at any time. You just don't know.'' Another adds: "You're dealing with attitudes. It can be very distressing. You get people in here who have been out all hours, they're loud and abrasive. They come in here in groups. They're impatient. They want to see a doctor and they want it now. They can terrorise other patients.'' 3.30 a.m. The girl from the accident is taken upstairs and admitted to one of the wards. The rest of the night is quiet.

SATURDAY 6 p.m. Another slow evening. There is nobody in the waiting room although there are a few patients in the unit. An elderly lady has been brought in with a fractured hip. She is with her family in the six-bed observation area. A two-year-old girl was rushed in by her mother after swallowing heart medication. She is resting in a bed in the cardiac area with her mother by her side. A large teddy bear has been placed next to the little girl. Another woman, about 28-years-old is also in an observation area bed.

Dr. Schultz and Dr. Martin Carey believe she has a chest infection, and they say she is jaundiced. She is undergoing tests. The two doctors talk quietly to each other. By the tone of their voices, and the look on their faces, this particular case is almost certainly a very serious one.

7.15 p.m. A few people with minor injuries have come and gone, and one asthmatic patient has been treated and released. The unit is quiet again.

7.48 p.m. The first ambulance call comes in. The caller says a man has fallen off a wall near the Modern Mart on South Shore Road in Paget. The ambulance leaves with twoEMTs two minutes later and arrives at the scene three minutes after that. Along the way, there is traffic and one car fails to pull over for several seconds despite the loud sirens. The ambulance eventually passes the car and the rest of the ride is clear. At the scene, the man, in his mid-50s to early-60s, is lying face down on the sidewalk across the street from the Modern Mart. He is not moving, although one of the EMTs says he's conscious.

He's had too much too drink. He's placed on the stretcher and lifted into the ambulance. The ambulance arrives back at the hospital nine minutes after it left. The man is examined. He has small cuts on his face and a bump on the side of his head. He has no identification with him, and Emergency staff refer to him as John Doe. He is monitored every half hour.

8.15 p.m. There has been a changeover of staff. Dr. Carey gets ready to leave after 12 hours on duty. There are a few more patients in the unit. A young child with a cough and cold is in the paediatrics room with her parents. She is waiting to go for a chest X-ray. Another young child, another asthmatic, is in one of the cardiac beds. Fifteen minutes later, an elderly man with a history of heart trouble, is wheeled into the unit in a wheelchair and placed in the third cardiac bed. The cardiac area is now full.

8.30 p.m. A young mother, frantic, carries her four-year-old son into the unit. He's been hit by a car. The boy is immediately placed in a bed in the observation area. His father arrives a short time later. The boy is examined by one of the doctors and about 30 minutes later is taken to the X-ray room.

His mother is upset - her hands are trembling.

9 p.m. The unit is busy. The nurses and two doctors on duty, Dr. Schultz and Dr. Ferris are rushing from patient to patient, out of one room and into another. There is a constant flow of friends and family members in an out of the department checking on patients. Both ambulances have been called out, one to Southampton, where a young girl has been hit on the head with a cricket bat, and the second for a woman, in her 50s, who is suffering from spasms and severe abdominal pains. Fifteen minutes later, both ambulances are back - the woman is placed in the observation area, and the girl is taken into one of the cubicles.

9.25 p.m. A young girl, maybe two-years-old, is brought in by her mother. She is asthmatic. She waits five minutes and is taken into one of the cubicles for treatment. The woman with the hip injury is waiting to be admitted to one of the hospital wards. The elderly man who is short of breath is sent for a chest X-ray. A woman 32-weeks pregnant comes in with her husband and child. She has been vomiting. She wonders whether she's about to go into labour - her last child was born eight weeks early at 32 weeks. She is examined by one of the doctors who learns that her husband and child have also been sick and vomiting in the past few days.

9.40 p.m. The young asthmatic girl who came in at about 8 p.m. is released.

She is cheerful, and runs and jumps into the arms of one of the ambulance drivers, calling him by name. She says thank you and waves goodbye to the staff. The four-year-old boy who was hit by a car returns from X-ray, and ten minutes later his parents aretold that he has broken both legs below the knee.

His mother makes a telephone call from the nursing desk. She has a look of obvious distress across her face. A few minutes later, another asthmatic woman walks in - the staff know her by her first name - she is a regular. She is taken to the only empty cardiac bed.

10 p.m. Another asthmatic comes in - this time 29-year-old Sinclair Smith. He is taken into the resuscitation room because there are no more beds available.

He's having trouble breathing and he is making wheezing sounds. He rushed himself to Emergency because his inhaler was empty. "You don't feel it in the daytime, but as soon as the sun goes down and the dampness sets in, it becomes terrible,'' he says. "All of a sudden you can't breathe and you start to panic.'' Smith was rushed into Emergency last October, when it was discovered after tests and X-rays that he was asthmatic. "Nothing was ever wrong with me, and then out of nowhere I had asthma. I just woke up one morning and I couldn't breathe. I can tell you, it's changed my life, slowed me down.'' It's nights like this night, when the temperature drops and the air is moist, that bring on attacks. Treatment in the hospital can take between one and three hours, he says, adding that it increases his heart beat and makes his whole body shake. Dr. Schultz later says the department is seeing increasing numbers of asthmatics who come in for treatment and stop breathing altogether. "There have been more cases of respiratory failure with asthmatics than there have been in the past. It's a trend in North America, where the rate of mortality and morbidity in asthmatics has increased 30 percent in the last 10 years.'' 10.10 p.m. The young girl who accidentally swallowed heart medication is allowed to go home. Her mother picks up the sleeping child and carries her out of the department. A few minutes later, the little asthmatic girl who was treated in the cubicle is released. And 10 minutes after that, the elderly woman with the hip injury is taken upstairs to one of the wards. The little four-year-old boy is having casts put on his legs. His mother and father are at his side. A few minutes later, the girl hit in the head with a cricket bat is taken to X-ray. John Doe wakes up. He gives his name and says he's hungry.

He's given toast, soup and a chicken leg.

10.45 p.m. The unit is gradually quietening down. The only sounds are of the young child, whose screams fill the department. She is still in with the paediatrician. The waiting room is empty. The young girl hit with the cricket bat is released. She has a bump and bruise on her forehead, nothing serious. A half-hour passes, and then another. The department is still quiet. A few minutes later, the young child is allowed to go home. Sinclair Smith is released, and the four-year-old with the two broken legs is taken up to the children's ward where he will stay for the night. A few minutes later, the elderly man with the chest pains is also taken upstairs where he is admitted to one of the hospital's wards.

11.30 p.m. There appears to be more of a sense of order, the nurses are replacing stock. The doctors are writing up their medical reports. The commotion of visitors comingto see family has just about stopped. At midnight, all patients are resting quietly in their beds. Another shift is over. Dr.

Schultz and two nurses leave for the night. The staff is down to Dr. Ferris and three nurses. It is decided that John Doe will stay overnight in the special treatment room, monitored every half hour. An hour passes without any emergency calls. The woman who came in with spasms and abdominal pain is taken to the operating room for emergency surgery. It is thought she may have a hernia. Another hour passes. The 28-year-old woman with the chest infection is taken upstairs to one of the wards. It is later discovered that the woman had a cancerous tumour. She dies five days later.

2.20 a.m. There is not a sound in the department. Out of nowhere, a man, about 28, appears at the nursing desk. He is bare-chested, wearing a gold chain with a large gold medallion around his neck. His left arm is bleeding heavily. He's used his shirt to contain the blood, but it is now saturated. There is a trail of blood from the entrance to the reception desk, where he is standing. He says he's been stabbed. He had been at a concert at the Clay House Inn, and was standing outside afterwards when another man stabbed him. One of the nurses leads him into the theatre, while another retraces his steps, cleaning the blood off the floor. Dr. Ferris cleans his arm. The wound runs about half the length of his forearm. A bandage is wrapped around the cut. A few minutes later he walks out of the theatre to use the washroom. On his way back he quietly slips behind the reception desk and picks up the telephone. One of the nurses turns, sees him behind the desk, and orders him to get back on the other side of the desk and to ask if he wants to use the telephone. He makes his call and returns to the theatre. Dr. Ferris begins stitching his arm.

3.25 a.m. The man is allowed to leave. The department is quiet again.

Photography by Tamell Simons.

Below, Dr. Carol Ferris (right) and nurse Cindy Currie treat a late night accident victim. Inset, Emergency Department staff (from left) Dr. Carol Ferris, Dr. Edward Schultz, nurses Louisa Micell, Cindy Currie, and Sue Drake, and EMT Curtis Place.

Mother Victoria Spenser holds her one-year-old son Jahki while they wati to see a doctor.

Emergency nurses Cindy Currie (left) and Sue Drake (right) work with Dr. Carol Ferris to treat a late night accident victim.

P.C. Andrew Hancock fills out a report in the Emergency Department following a late night road traffic accident.

Volunteer EMT Veronic DeSilva assesses an in-coming patient in the triage area.

Ambulance staff lift a patient from the ambulance after arriving back at the hospital. A mother waits beside her young daughter who hours earlier swallowed heart medication.

AUGUST 1993 RG MAGAZINE