The Emergency Room: ‘Limping, Screaming, Bleeding’ Comes First

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By Neil Marks

“Anybody troubling with nose, ears, throat and rash on the skin?”

It’s about eight the morning, November 20, at the West Demerara Regional Hospital, located at Best Village, West Coast Demerara, giving it the common name “Best” Hospital.

The security guard gets no response to his initial inquiry; he tries again, addressing the 23 persons sitting on the wooden benches awaiting their turn to see the nurse.

“I am saying it again, listen carefully! Anybody troubling with nose, ears, throat and rash on the skin?”

There is no response; the security guard retreats to the entrance of the Accident and Emergency Department and takes a seat near a group of men dressed in cream shirts and black pants.

Why is a security guard questioning patients?

“Because we are a hospital and the security guards are part of the system,” says Dr Angela Ramlall, who heads the Accident and Emergency Department at the hospital.

“They help; we function as a unit.”

She assures that it in no way compromises the attention given to those who walk through the doors of the Emergency Department and patients should not be shocked.

What happens as soon as a person enters an Emergency Department could literally mean life or death.

“Many of the health programmes internationally are disease oriented and diagnose oriented, and there has been a failure to disseminate very basic lifesaving services to the frontlines of that system,” says Dr Teri Reynolds, a scientist with the World Health Organization (WHO) in Geneva, Switzerland.

One of her responsibilities is emergency and trauma care systems development

At the 13th World Conference on Injury Prevention and Safety Promotion held from November 5-7 in Bangkok, Thailand, Dr Reynolds participated in the launch of an Emergency Care Systems toolkit for Government ministries and policy makers.

It includes a workbook in basic emergency care, which details a practical and systemic approach to four acute and potentially life-threatening cases, namely trauma, difficulty breathing, shock and altered mental status.

“Patients have problems like difficulty breathing, or dizziness, or pain.

“They don’t know necessarily that they have this disease or that disease; they don’t know if they need surgery or medicine,” Dr Reynolds says in an interview with the News Room.

The toolkit being rolled out worldwide can help fill the gaps in emergency care that do not cost more resources.

Inside the Emergency Room by Dre Jacobus

“The great thing about emergency care is that there are enormous impacts; many, many lives you can save by simple process changes that do not require new input of material resources,” Dr Reynolds asserts.

While Guyana is not yet rolling out the course from WHO on basic emergency care as yet, there are changes already being undertaken in hospitals locally.

At the Best hospital, there has been a shift in the way persons are seen when they first enter the Department. Previously, the triage section, where patients are seen to determine whether they need urgent care, was located inside the Department, but now, they have been placed outside where patients are seated as soon as they enter.

There are usually two nurses in this section; they are trained to recognise emergency and non-emergency cases.

How does the nurse know if it is an emergency?

“They would come limping, screaming, bleeding – those are emergencies,” says Dr Ramlall.

The nurse would observe if the patient must be assisted out of the vehicle and would need the help of the attendants – the men in the cream shits and black pants – to take them in using either a wheelchair or a stretcher.

If that’s the case, the nurses would see the person right away and once they recognise it is an urgent case, they would take them to the doctors who then take over management of the patient.

A similar change has occurred at the Emergency Department at the Georgetown Public Hospital Corporation (GPHC), the country’s main hospital.

Previously, there were only triage nurses at the front responding to patients who come in.

If there are an emergency, she should have to take the patient inside to be seen by the doctor.

During that time, new emergency cases would come in, possibly denying patients the urgent care they require.

“That has definitely changed,” says Dr Tracey Bovell, the Emergency Medicine Specialist and Senior Registrar & Trauma Coordinator at the Accident & Emergency Department at GPHC.

“With the development of emergency medicine, we now have nurses and a doctor at the front line,” she told the News Room.

Even with this development, the Emergency Department continues to face criticism in the way it handles cases and is sometimes a scene of chaos.

On November 28 last, Anjali Persaud took her mother to the Emergency Department. They arrived at about 7: 30 in the morning.
Three hours later, she was still waiting for her mother to be processed.

She was “put to sit on the bench.”

“What’s wrong with your mother?”

“Shortness of breath, trembling, hot fever.”

“Did you talk to the nurse?”

“Yes, they said she is not emergency, she got to wait, they got people in wheelchair and stretcher and so.”

Dr Bovell says the situation is not unusual.

“We do not see patients as they come in; we prioritise,” she states.

Emergency cases would include those who have difficulty breathing, those with chest pains and those who have multiple injuries, such as a chest injury with leg injury.

“It’s not just what you come and say that determines if we take you in. There are some people who say all sorts of things,” she says.

She related a recent case in which a patient was being seen by a doctor who realised that his case was not just urgent.

“I just say that so I could get to see the doctor fast,” the patient admitted, recalls Dr Bovell.

Once a person arrives at the Emergency Department, basic checks are made, such as their blood pressure, heart rate, oxygen level in body, blood sugar level.

“These things will determine whether you will have to wait or whether you will be seen immediately by the doctors,” Dr Bovell points out.

For those who do not require emergency care, there is a system to refer them to the appropriate department or their nearby health centre.

That was the case with Anjali; her mother was referred to the health centre in the area she lives.

“We have to sort out the life-threatening cases first; if you have an abscess or you fell and have a laceration, those most likely can be taken care of in the area where you live.”

Dr Reynolds says this approach works best.

“If you see the most acute ones, the sickest people first and then you see the other people, by the end of the day you’ve saved all the lives that could be saved.

“If you see the people in the order by which they arrive, you’ll take care of some of the ones; the ones that weren’t seriously sick will be taken care of by the end of the day – but they ones that were very sick, some of them would have died by the end of the day.”

(This story was made possible with support from the ICFJ-WHO Safety 2018 Reporting Fellowship Program and Bloomberg Philanthropies)

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