‘So how do you like our little hospital?’ I asked Russell on a rare, quiet afternoon in the emergency room.
‘Ach, she’s grand, mate. Plenty of action, if ya know what I mean.’
Dr Russell McDonald was our local Scottish import. He had come to New Zealand with one stated purpose.
‘I’m gonna fook me way around the world,’ Russell had been known to confess to the lads when he’d had a bit too much to drink. ‘The lasses here are different to home. At home, if a lass likes ya she’ll shag ya, but over here, even if they don’t like ya, they’ll shag ya anyway. It’s great.’
Needless to say, Russell was great for company whenever social occasions arose. And it was probably because he was such a laugh that whenever he fooked up at work, he rarely got in as much trouble as he should have.
Russell had mainly worked in medical wards, where things tend to be slower and more predictable; the things Russell was used to dealing with were the typical problems that make up the bulk of hospital medical admissions, such as the elderly and the difficulties that go along with ageing, from failing lungs, failing hearts, to strokes. It’s not exactly exciting like the emergency room, but general medicine like this makes up the backbone of any junior doctor’s experience.
Russell also had some experience working in the other areas. All doctors, in both New Zealand and the UK, have to spend some time in each of the main areas of specialisation. The common areas are surgery, paediatrics, obstetrics & gynaecology and orthopaedics. Of course, each of these general fields has many subcategories.
Russell had been working in our hospital for just over a year, six months in general surgery, six months in general medicine, and now the emergency department.
As entertaining as his remarks about wanting to sleep his way around the world were, I wanted a serious answer.
‘I’m glad you like the women here, Russ, but how do you like our department so far? How do you find the emergency room?’
‘Ach, it’s a bit worrying at times, but hey, I’ve always got you around to keep me out of trouble, eh?’ Russell said jokingly as he gave me a wink.
As Russell and I sat around sharing stories, Mrs Reid was brought through to the minor injuries area, clutching her left hand to her chest.
‘Can ya check that out for me, mate?’ Russell asked me. ‘It doesn’t look too serious.’
In the two weeks Russell had been in our department, I had discovered that he was the master of delegation, but no one seemed to mind, not even the person getting the instruction.
I sat Mrs Reid down on a bed, and began to undo the towel she had wrapped around her hand.
‘What happened?’ I asked.
‘The bloody kitchen knife,’ she replied, holding out her hand. She had a pretty nasty laceration running the length of her finger.
‘We bought one of those new ever-sharp kitchen knives; the ones that sharpen every time you put them away in their sleeves,’ Mrs Reid began to explain. ‘The damn thing has cut us all. My husband, my son and my daughter.’
I nodded my head in understanding. Generally we try not to suture up fingers. They can heal very well without stitches, often we can get by with paper strips to hold the wound together, but in Mrs Reid’s case it was too big a cut.
‘It looks like you’re going to need a few stitches; I’ll get the doctor to take a look.’
Russell didn’t mind dealing with anything to do with fingers and toes; they were usually easy to treat.
‘Won’t take long, Mrs Reid,’ Russell began to explain, once he’d taken a look at her injury. ‘A few stitches and you’ll be on your way home. I’ll pop in a bit of local anaesthetic and you won’t feel a thing.’
With this, Russell began to get things ready.
I watched as Russell grabbed the wrong vial from a cupboard, and briefly debated whether I should say something. Just because I know how to fix a particular injury one way, doesn’t mean it’s the only way. I wanted to give him the benefit of the doubt because maybe he knew something I didn’t, and I also didn’t want to make him look incompetent in front of a patient.
However, I eventually had to step in.
‘Um, Russ, here’s some different anaesthetic,’ I said, opening a second cupboard, ‘without adrenaline. Which one do you want?’
If you use adrenaline-laced anaesthetic on a finger, it can cut off the blood supply. Russell took a second look at the vial he was holding, before quickly exchanging it for the right kind.
‘I think I’ll take the one without adrenaline this time, no need to go overboard,’ he said with a smile and a wink as if he had things completely under control, even though Mrs Reid could have lost her finger if he’d gone ahead.
‘Just a little sting, then you won’t feel a thing,’ Russell said to Mrs Reid. ‘It will go numb pretty quick.’
Russell held Mrs Reid’s hand in his, with her palm facing down, and began to inject the anaesthetic into the base of her finger.
‘Nearly done, Mrs Reid,’ Russ said. ‘Can you just turn your hand over and I’ll numb the other side of the finger?’
Like the good and trusting patient she was, Mrs Reid did as she was instructed. Russell began to inject the other side of the finger.
Something didn’t look right. Again, I wanted to say something, but hesitated because I didn’t want him to look foolish. Surely Russell couldn’t be that stupid. I felt it must have been a technique I didn’t know. I knew he’d be pissed if I interrupted again.
‘Interesting technique, Russ,’ I said, trying to prod him into explaining himself.
‘Ach, it’s nothing, pretty basic really,’ he explained. ‘It’s the sort of thing anyone could do. You can’t go wrong, laddie.’
He touched the tip of the third finger from the thumb.
‘You shouldn’t be feeling a thing, Mrs Reid,’ he said as if he had casually performed a small miracle.
‘Well, I don’t feel a thing, but what about my middle finger? It’s still pretty sore.’
The triumphant look faded from Russell’s face. He looked at me accusingly.
‘How could you let me do the wrong finger? You watched me do it and said nothing.’
There wasn’t a lot I could say. I should have spoken up, but it was his bloody fault, not mine.
‘I’m terribly sorry, Mrs Reid,’ Russell said. ‘I feel a bit of a fool. Give me a moment and I’ll fix it up.’ Luckily for Russell, Mrs Reid wasn’t upset, in fact she laughed. It was the Russell charm at work. No one could resist it.
Two days later, Russell still hadn’t completely forgiven me.
‘Ya stood and watched me fook things up. Fookin’ lot of good you were.’
He said it jokingly, but the Dr Russell McDonald charm was wearing a tad thin on me.
‘Get over it, Russ. You screwed up, not me.’
Later that afternoon, Miss Hope was brought in by ambulance.
‘She fell off her horse. She’s a race horse trainer. The horse stood on her thigh. It looks pretty bad,’ the paramedic explained to Russell as we all helped transfer her from the stretcher on to the emergency room trolley, ‘but I don’t think she’s ruptured an artery.’
Miss Hope chose that moment to scream out in pain.
‘Arrrgh, hell, oh bloody hell.’ She then began to weep.
‘We’ve given her ten milligrams of morphine, but when we move her she screams in agony,’ explained the paramedic.
There were muffled gasps of horror when the extent of Miss Hope’s injury was revealed. Her right thigh was most definitely U-shaped. I glanced briefly at Russell to gauge how he was coping. I’ll give him credit, he looked calm and in control.
‘What next?’ I asked Russell.
I knew what to do, as did the nurses around me, so we got to work monitoring her pulse and blood pressure. Someone put in another IV line and took blood for a cross-match, another got a bag of fluids ready.
‘Let’s leave her leg briefly. I need to check her out,’ Russell said as he began at Miss Hope’s head and worked his way down, checking for any other injury.
Thank goodness he said the right thing, because after his last screw-up, I needed to be reassured that he knew what he was doing.
Whenever a serious admission comes into hospital with an obvious injury, it’s easy to focus on that one injury because it’s so glaringly obvious. But what mustn’t be forgotten is a check of the rest of the body, to make sure there are no other injuries. For all we knew, Miss Hope could have been briefly knocked unconscious when she fell. It would be pretty awful if we fixed her leg up, and missed a small but lethal bleed in the brain.
Once Russell was satisfied that Miss Hope had no other injury, he began to deal with her pain.
‘What do you think, Dr McDonald?’ I asked, not really sure what would be best for Miss Hope as the intravenous morphine wasn’t as effective as I had hoped.
‘Femoral block, that’ll do the trick, then off to theatre.’
A femoral block is an injection of pain killer into the groin on the affected side. The anaesthetic is extremely effective as it completely blocks the pain. It’s short lasting, only an hour or two, but it would be enough to keep Miss Hope comfortable until she was taken to theatre.
Russell really seemed to be doing a good job. The calm and correct way he was dealing with things was putting not just me at ease, but the patient as well.
‘I’ll leave you to it,’ I said to Russell, having got the equipment he needed to perform the procedure. ‘But I’ll be at the bed opposite if you need me. Just sing out and I’ll be right there.’
Ten minutes passed and Russell hadn’t reached out for help. All must have gone well. I poked my head through the curtain.
‘You shouldn’t be feeling a thing,’ Russell was saying to Miss Hope while gently touching her left foot.
I couldn’t believe what I was hearing.
‘I can’t feel a thing,’ she replied, ‘but my right leg is still bloody agony.’
Russell looked up at me, an expression of horror on his face.
‘When will it help my right leg? It had better be bloody well soon. It’s unbearable.’
How would Russell charm his way out of this one?
‘I think you need a bit more,’ Russell began, ‘just another small injection, and then you’ll be fine.’
I couldn’t speak up in front of the patient. The damage had been done but at least with another injection the patient would still get some relief. But in the interests of future patient safety and my own liability, I had to do something.
Once Miss Hope was wheeled off to theatre, Russell approached me, a big, albeit forced, smile on his face. But there was no Russell wink, and he wouldn’t look me in the eye.
‘Fookin’ great,’ he said. ‘Have ya told the boss yet?’
I didn’t like to be the one to turn my friend in, but this was serious.
‘Sorry, Russ, but you really messed up. At least he doesn’t know about the finger episode. It’s your first screw-up as far as he is concerned,’ I said, trying to look on the bright side.
‘Well, thanks anyway.’
Russell was taking this better than I expected.
‘I can’t believe I got the wrong leg. What is wrong with me?’
I didn’t say anything; we both knew that this could be the end of his time in the emergency room.
The senior doctor of the emergency room reacted reasonably well, with only a little shouting, and some mild threats to end Russell’s career.
Nevertheless, the following week, Russell went to work in the medical ward where he would be in familiar territory. The emergency room is not for everyone, and it’s not a place where you can bluff your way through. The emergency room is often the home of the most experienced doctors and nurses, who have spent plenty of time in the core areas of medicine. People like this don’t accept egos or incompetence. They can’t afford to when people’s lives are at stake.
‘Where’re my boots? You’ve stolen my bloody boots,’ Mr Crump shouted as he was wheeled past. ‘Did you hear me? Where’re my fucking boots?’
Tom the paramedic stood at the head of the trolley. He’d heard it all before and was now impervious to Mr Crump’s tirades. In fact, as an experienced paramedic, he’d heard a lot worse. Mr Crump was just being his normal self, a miserable old drunken sod.
‘Let me guess, the garden again?’ I asked Tom as we transferred Mr Crump from the trolley to the bed.
‘How’d you guess? Oh, that’s right it’s raining. This is the third time in two months, isn’t it, Mr Crump?’ Tom replied, with a wry smile.
‘I didn’t bloody well ask to come here. You’ve no bloody right. Where’s my boots, ya thief?’
‘Just doing my job.’ Tom shrugged his shoulders, and turned to me. ‘His neighbours found him unconscious in the garden; said they could hear him partying all night. At around eight o’clock next morning, he headed out to the garden and began digging.’
Mr Crump was freezing to touch; he was lucky to be alive. It may have been late summer, but there was a nip in the air and the rain coming down outside was torrential.
‘Mr Crump, your neighbours probably saved your life. If they hadn’t kept an eye on you, you’d probably be dead on your lawn.’ I paused briefly, wondering why I bothered to explain, but it was my nature to give Mr Crump a chance to redeem himself.
‘Bah! What bullshit. I’m not soft like you. I’ve been doing this for 50 years and I’m as tough as nails. A little rain won’t hurt me. Just get me my boots and I’ll be outta here,’ Mr Crump said in disgust.
‘The only reason you’re still here, is because every time you’ve passed out in the garden, in bad weather, your neighbours have called the ambulance. It’s not our fault you can’t handle your booze.’
Of course, I was well aware the old boy could outdrink any of us. He had all the visible signs of a serious long-term drinker: rheumy eyes that could still see, but no longer cared what they saw; a huge, red, bulbous mass that once was a nose; a wiry body, grotesquely distorted by his protruding beer belly; and worst of all, the overwhelming smell of rotten teeth, mixed with blood from his bleeding gums, combined again with spirits and beer. When people regularly drink too much the alcohol affects every organ in the body. At the levels Mr Crump drank, he was constantly poisoning himself, from his brain to the tiniest blood vessel. Long-term heavy drinkers develop swollen noses due to the damage caused by and dilatory effect of alcohol on the blood vessels. Over time, it’s the liver that takes the brunt of alcohol abuse. It keeps on getting bigger, as it has to work overtime to remove the toxins from the body. It’s not unusual to see people with a liver twice the size of a normal one, hence the swollen stomach.
Then, of course, there is the effect on the brain. I’ve seen some middle-aged men showing signs of dementia. It’s not reversible.
Mr Crump sat up in bed and looked at me expectantly.
‘Well, I’m here now so you might as well make yourself useful.’
His tone had softened a little. I felt the corners of my mouth forming a smile – I knew the routine well.
‘One or two sugars?’ I asked.
‘Two, and don’t forget the sandwiches; I’m starving.’
Tom looked at me and rolled his eyes. He too was familiar with the process.
Mr Crump inhaled the sandwiches.
‘Any more?’ he asked, picking crumbs off the plate.
Four ham and cheese sandwiches, four slices of toast dripping with butter and honey, and a cup of coffee later, Mr Crump sat back on his bed rubbing his belly, a contented look on his face.
‘Where’s me boots? Be a good lad and get me boots would ya, I’d better be on my way.’
I half-heartedly tried to dissuade Mr Crump from leaving, as he technically needed to see a doctor.
‘I don’t need to see a flaming doctor. I need to get home, back to me garden. I’m as fit as a fiddle,’ he protested.
From past experience, I knew the battle was never going to be won and I made sure that Mr Crump signed the self-discharge form, just in case he dropped dead when he walked out the door.
Sometimes it felt like nearly all my time and energy was spent dealing with the consequences of alcohol misuse. From Thursday through to Sunday night, I would have been willing to bet my monthly salary that every shift would bring in an alcohol-related patient, whether they were drunk themselves, or the victim of someone else’s drunkenness. Maybe they were all victims in one way or another, they just didn’t know it.
My experiences were sometimes amusing, tragic, horrible, or even scary, but never boring. The people affected by alcohol came from all walks of life, and from all corners of the world.
Whether it is the Mr Crumps of the world, or a first-time drinker, I’ve found patients come in two main categories: there are your nice drunks and then there are your mean drunks.
In fact it’s amazing how much Brits and Kiwis have in common when it comes to alcohol-related presentations to the emergency room. Here’s a sample of some of the colourful characters, and the typical types of patients and problems.