Inside The ER

It's 6:00pm in the real world, on a Friday night in St. Bernard's emergency room. Already the moon rises, since daylight savings ended a week ago, and traffic in the ER waiting room slowly begins to build. Dr. George Dengler is the ER attending physician today, and he's in the final 60 minutes of a twelve hour shift. He stands in the hall near an ever-present security guard, talking quietly with the house chaplain. What they discuss doesn't seem pleasant, and perhaps that's a bad omen as we begin a six hour stretch observing the dynamics of the St. Bernard ER.

The conversation ends quickly, and Dr. Dengler easily morphs into a lighter and brighter mood, heading back to the busy nurses station that serves as the nucleus of the ER. It must be a prerequisite of the job - an ability to shift gears in a matter of seconds from serious, focused health care provider to relaxed, casual conversationalist. In the course of five minutes, Dengler talks to a Chicago Police officer about stapling a patient's wounds, clicks through medical information on a computer screen, and opines on the chances of Kyle Orton earning Rookie of the Year honors for the Bears. This is not uncommon among everyone working the ER tonight - at one moment a sense of urgency, then a burst of comic relief. Intertwined between terms of morphine drips and radiological jargon one might overhear a review of the city's finest Chinese cuisine, a convincing argument that "Sling Blade" is a life-affirming motion picture, or the query, "Were there any color episodes of Andy Griffith?" This is a good thing, of course, as a 12-hour unobstructed adrenaline rush would result in inevitable burnout. It's these mental breaks that keep everyone sane.

A flurry of activity surrounds the attending doc, a supporting cast that traditionally includes a resident physician, up to seven registered nurses, and a couple medical students. At 6:15pm, the Nurse Manager Troy Repuszka is calling out each of their names, scribbling them on a pad of paper, and diligent in her effort to be sure she accounts for everyone. For now, it is unclear why the poll is taken.

The Emergency Room is categorized as "Bypass" at this hour, which essentially means that the ER is full and not accepting ambulance deliveries. An influx of psychiatric patients causes the crowd, lining the halls on gurneys. Being the first Friday of the month, the hospital staff expected a potential traffic jam, a recurrent event often caused by the arrival of paychecks which patients use in less self-productive and more self-destructive ways. The psych crowd swells to a dozen, and they sleep or stare at the ceiling in search of ways to pass the time. One man in particular, with a chatty disposition and a penchant for requesting cups of water, is most challenging for the CNA (Certified Nurses Assistant) assigned to monitor the row of gurneys.

Around 6:30pm, Troy Repuszka talks to Infection Control's Nurse Manager Mary Santine on the telephone, and the reason behind her earlier staff tally becomes apparent. Many of them had come in contact with a patient found to suffer from bacterial meningitis, contagious at a distance of three feet or less. Repuszka double-checks the protocol for post exposure, which involves identifying every person in contact with the patient, providing them with a precautionary prescription of Ciprofloxacin, an antibiotic. She then needs to hunt down the hospital pharmacist to issue the prescriptions.

Despite the ER's bypass status, an ambulance arrives at 6:35pm carrying a 14 year old boy. His left leg has been stabilized after being struck bar a car while playing in the street. The boy slumps back on a stretcher, with an expression combining awe and shock. He'd rather not be here. Fortunately for him, only his leg appears injured.

Just before 7:00pm, medical students arrive and gather rather obediently behind Dr. Dengler. The nighttime attending Dr. Ed Correa also comes on board, and together they begin rounds promptly at the top of the hour. The students, eager to listen and learn, shadow Dengler and Correa closely. They meet the struck boy, a girl with breathing problems, and the man with meningitis. We learn that the latter is also suffering late stages of HIV and has declared himself Do-Not-Resuscitate.

When rounds end, everyone returns to the nucleus again. By now, the shift change is in full gear. The room grows busier, increasingly loud with almost twenty people inside. Daytime staff share information with the person who will assume responsibility, and most of the day crew won't actually leave the ER until almost an hour later. By 7:15pm, Dengler has officially handed the reigns to Dr. Correa, and it takes little time to realize the vast difference in their respective dynamics. Correa's emits a very serene aura, always engaged by charts or x-rays, constantly mobile, and unlikely to deliver Billy Bob Thornton's movie dialogue any time soon.

At 7:20pm, resident Dr. Dave Hunnius and his medical student Matthew Pflieger examine the boy struck by a car. The young man plays it cool until Dr. Hunnius reaches his ankle, and then the pain takes over. An x-ray will determine the extent of his injury. Meanwhile, Pflieger gets back to the books, alternating between real-time medicine and long-term studying. By 8:00pm he digs deep into a chapter on lower extremity injuries, not coincidentally the same problem his last patient incurred. "It's pretty much see the patient, do some reading," he says of his shift routine. Today is Pflieger's fourth day at St. Bernard, and in a month he heads west to Colorado where he and his wife plan to build promising medical careers.

A team effort is necessary at 8:10pm, where an animated gentleman needs a blood test but adamantly states, "I have the right to refuse treatment!" Making matters worse, he takes an immediate disliking to the first RN he encounters. Security is consulted. Troy Repuszka tries to reason with the man. Finally, he agrees to the tests, but in general the man remains no more agreeable.

The prognosis on the boy vs. auto yields expected results. His ankle is fractured, and he will leave the ER with a cast and crutches. Sitting with the boy, his mother worries that he'll miss school, because that in turn causes her to miss work. She's not thrilled about either possibility.

By 9:20pm there is a calm setting over the ER. Some of the psychiatric patients have been moved elsewhere. Night shift nurses and doctors have caught up with the charts given by their predecessors, and some quietly chat about travel plans and the upcoming weekend. But the ER has lifted its bypass status, and the calm could become a storm at any moment.

A 10 year old girl sits in triage with her mother, and she suffers from severe cold symptoms and some difficulty breathing. Med student Pflieger examines the little girl at 9:25pm, and quizzes her mother about medical history. Once finished he reports back to resident Dr. Hunnius. To the doctor, her symptoms ring of athsma - a condition not part of the student's initial diagnosis. Hunnius visits the girl shortly afterwards, and his initial questions find that, in fact, the little girl has a history of athsma. Pfleiger stands back, novice in hiding, as if he's missed something critical. But Dr. Hunnius won't allow it, calling his apprentice back into the room to sit next to the little girl. This will be a learning experience for the medical student. Finally, Hunnius and Pflieger leave, and the little girl stares at her mom, seeking a big hug. Touchingly, it seems like mom has been eagerly waiting to give one. Within an hour a nebulizer treatment will ease the girl's breathing, and she'll be full of life again.

At 10:00pm, Troy Repuszka counsels a CNA named Amere on how to deal with the irritable man who refused blood tests earlier in the night. Amere would prefer if security dealt with the difficult man, but Troy has faith in her CNA. By 10:30pm, Amere has successfully engaged the man in conversation far less animated than before. Their chat is most certainly quieter than the 4 year old boy down the hall, receiving stitches on his forehead.

Then, following the old adage "When it rains, it pours," the clock struck 10:48pm. A man in his early 20s arrives in the ER with cloth wrapped over his arm, blood seeping through. He has left work and was talking with friends near a street corner when he was shot twice, one bullet through his left hand, the other lodged into his arm and protruding against the skin. Based on the angle and placement of the wounds, Dr. Hunnius guesses the man's hand was in his pocket when struck. Only minutes pass before three police officers arrive to question the man.

While doctors and nurses oversee the gunshot wound, Troy Repuszka turns to find a man in a trenchcoat behind her. He's just strolled in though the ambulance bay entrance, carrying a crate full of disheveled clothes and shoes. Over his right eye, a deep gash looks painful. He explains that he had somehow been hit by a brick. Only after he is sent to triage does anyone notice that a second crate of clothes is left outside in the ambulance bay. Someone is sent to retrieve it.

Two more ambulances arrive at 11:00pm with two more patients, but the scope of their conditions is unknown. All but the gunshot victim are headed to triage, where Marlowe Gujil is the RN on duty. Like many other staff in the ER and throughout St. Bernard, Marlowe hails from the Philippines, and soon he'll mark a one year anniversary in the ER working 12 hour shifts from 7am to 7pm. With a nearly full house in triage, Marlowe conducts blood tests behind one curtain, administers antibiotics in the next. At one point he's updating a dry erase board that lists the on duty staff, asking who is due for breaks. When an ambulance arrives, he climbs down and shifts his focus again. Marlowe barely has time to chit chat, and when he does, you get the sense he has somewhere to be, and in the blink of an eye he's gone.

Soon the clock strikes 12:00am, the end of a six hour stretch in the ER. The gunshot victim sees a steady flow of friends and family stop by to check his well being, while police detectives continue asking questions. Mostly he seems disappointed that his Friday night is ruined. Across the hall, the girl with asthma breathes easier, napping in her mother's arms. They could both use a night's sleep. Dr. Correa scans more charts, flipping page by page through a clipboard. Dr. Hunnius does the same, waiting for Matthew Pflieger to return from examining yet another new face in the ER.

For all intents, this is just another night in St. Bernard's emergency room - families dealt everyday problems with complicated solutions, an array of accidents and mishaps, a man in the wrong place at the wrong time when violence struck. The dedicated, prepared ER staff somehow manages to get them all through the aches and pains and tears. It is, after all, what they do best.

Originally published in the St. Bernard Viewpoint newsletter