It is just before 7pm on Saturday night and there are 19 people sitting on the hard blue chairs in the emergency department of St James’s Hospital in Dublin in various states of distress. Everyone’s anxious but only some are in pain. A man in a blue tracksuit is slumped in the back row snoring loudly. His phone rings but not loud enough to rouse him.
Heads turn as two young men burst through the double doors and scan the room urgently. They don't look sick – or concerned for anyone who might be – they look angry. As they walk between the chairs one takes a phone from his pocket and answers it. "He's where? Is he running? Right." He hangs up. "They seen him, he's in Rialto." They leave, with menace in their eyes, like pasty-faced extras from Love/Hate.
This mysterious mini-drama over, the room goes back to waiting. I am the lucky one. I don’t have to wait long and minutes later Patrick Plunkett, head of emergency medicine, picks me up and takes me on a tour of his department. He grew up in nearby Ballyfermot and is more deeply embedded in the community, one of the most social disadvantaged in the State, than his consultant peers.
He’s not one for sugar coatings and he talks openly of the intolerable delays patients under his care tonight will face and the violence that will constantly simmer in the hostile waiting room. He tells me my night in A&E will not be easy. But I know he’s wrong. Of all the people here, my night will be the easiest.
At the doctors’ station Plunkett points to a computer screen that has given all the patients seen so far a number based on the severity of their condition. The Ones are very seriously ill and will be treated by doctors within minutes. Right now, an elderly woman with a swollen leg has been waiting longest to be seen. She has been here for nearly 10 hours and keeps getting bumped down the list because she’s only a Three. There are lots of Twos. The drunks tend to be Twos.
Triage is separated from the waiting room by three blue doors and behind it is the clinical care section of the department. This is where the handover from day to night staff starts at 8pm. Medics crowd round a white board and discuss patients already admitted. The registrar on duty tonight is Úna Nic Iomháin. Plunkett is on call but is heading home soon. Before he leaves he highlights the complexity of the bed management system. “If someone is to be moved from here to ICU then someone has to be moved out of ICU to high dependency and then someone has to be moved to a ward. It is like one of those little plastic puzzles which have a piece missing and until you get it just right the clear picture doesn’t emerge.” Often moves can’t be made – particularly overnight – so patients are left on trolleys or on the hard blue chairs outside.
An emaciated man in his 20s is sitting alone in one of the “quiet rooms” reserved for patients with psychiatric conditions. He has been admitted as a potential suicide risk. The last few weeks have been tough for him. He has been moving from hostel to hostel and has been denied access to his children. He also has HIV. “Where’s he going to sleep tonight?” asks Plunkett. “I’ll take care of it,” Nic Iomháin says.
She is specialising in emergency medicine largely because of Plunkett. “I worked here as an intern and he became a role model. He kind of inspired me,” she says as soon as he has left the building. “The beauty and the hell of this job is you never know what is going to come through those doors. You might be working for 12 hours straight and struggle to get something to eat or drink and you are constantly putting out fires and worrying that you are not seeing enough patients or spending enough time with them. ”
It is 8.30pm and Gabrielle Dunne, the advanced nurse practitioner’s shift has ended. “I have been here a long time but I still get shocked by the stories,” she tells. “A mother might come in having lost two kids to drugs and then there is the domestic violence. We get a lot of domestic violence. But the single biggest problem is alcohol. If we could just reduce the amount of alcohol consumed.”
She walks me to reception and points to the two women taking patient details. Colette Hartigan and Anne Ryan are “often forgotten about but they take a lot of grief”, she says. They shrug off the praise. “People are waiting so long,” says Ryan. “And often they are with an elderly relative who is in pain. That is very hard for them, particularly when they see some drink-related cases of coming in and apparently being given a higher priority.”
The security guards sit behind a thick glass window watching the waiting room. They would rather not be named. “It is always likely to kick off out there,” one says. “Saturday nights are bad but the worst things are the shootings. You never know what is going to happen when there is a shooting,” he says. “Especially if they’re not dead.”
Aoife Pedreschi has been a nurse here for four years. “The waiting times are horrendous,” she says. “Last night was particularly bad. I went out at one point and was surrounded by desperate people wanting to find out what was going on. I just wanted to tell them that I was on their side.” Her attention is diverted by the arrival of an ambulance. A very drunk man is wheeled in. He fell out of his wheelchair and then passed out, the ambulance man says. He is hoisted on to a trolley where he starts snoring loudly.
A man wearing a smart shirt and tie is wide awake and pacing the corridors. He doesn’t look sick but one of his shirt sleeves has been cut clean off at the shoulder. He is a security guard and hours earlier was bitten by an IV drug user. The bite is barely noticeable now but he is at risk of HIV or Hepatitis. All he can do now is wait for the results of blood tests. “He has a long few months ahead of him before he gets the all-clear,” says Majella Kilmartin, the triage nurse on duty tonight
She has been here since 1999 – “so long that the drama doesn’t impact on me any more”, she says. She is still affected by the sadness though. “A lot of patients’ self worth is nothing, absolutely nothing. I see a lot of second- and third-generation drug problems coming in and too much long-term alcohol abuse problems. As a triage nurse I would sometimes like to delve a bit deeper and go past the superficial problems but I just don’t have the time.”
It is 10pm and the man with suicidal tendencies has just been seen by an on-call psychiatrist and moved from the “quiet room” to the loud corridor. He is staring straight ahead, barely blinking. He looks utterly lost and terribly sad. It is a heartbreaking sight.
Helen Schuster, the senior nurse on duty, walks past him and notices the man who fell out of the wheelchair has pulled a blanket over his head to block out the fluorescent lights. “Don’t pull the blanket over yourself,” she says to him. “You’ll end up in the mortuary.” She laughs. He doesn’t. He is still dead to the world.
“Security to the waiting room. Security to the waiting room.”
The hospital PA comes to life. At the front desk, a very drunk and barely coherent woman in her 50s is shouting the place down. Kilmartin immediately takes her into triage. “I’m not drunk, I’m just tormented,” she says. The nurse is calm and firm and tries to establish if she should be concerned about anything more than the reek of booze from her new patient. “When am I going to lie down? When am I going to lie down? I’m a very bad case I am, ” the new admission slurs. She is given a trolley and she passes out in seconds. I marvel at the nurse’s calmness in the face of such belligerence. “When you are dealing with someone who is really hostile you can’t confront them,” she explains. “Once you do, the problem can get a lot worse very quickly.”
It is just before midnight and the number of people in the waiting room has fallen to 14. Critical Care One is empty but the beds in the other units are full and there are 11 people on trolleys in the corridors. An earthy fog of booze and body odour hangs over the place.
A man in his 40s comes in wearing only jeans and a leather jacket. He has his mother-in-law with him. His head is covered in blood and her arm is in a sling. A family event has just turned nasty “after a few drinks” and he was hit on the head with a bottle. She was pushed to the ground in the commotion. Triage nurse Kilmartin bandages his wound and tells him he will need stitches. The mother-on-law needs an x-ray. He wants to go home. “I am a very fast healer,” he assures her. She’s not buying it. He stays.
The first one through the doors first thing on Sunday morning is an ashen-faced man who can walk and talk unaided. He looks inconsolable but physically fine. “The ambulance men told me to come in,” he says in a quiet voice. He gives Hartigan his personal details at reception and when Kilmartin takes over, he admits to having overdosed on heroin. “I’ve smoked it a few times and it was grand but this was the first time I injected it and I collapsed,” he says. “I feel like such a scumbag.” He wants to go home but Kilmartin explains that the ambulance staff have given him drugs to counter the effect of the heroin but warns that they will soon wear off. “It’s a short-acting drug and once it wears off you will need to be here,” she says. He is assigned a gurney. “You’re on a very dangerous path,” she tells him in a very non-judgemental way.
Just minutes pass before the next drug victim comes in. An man in his 20s is unconscious as he is wheeled through the doors by Dublin Fire Brigade. They picked him up after he fell down at a house party. “We were told he had two ecstasy, a naggin of vodka and some Budweiser,” one of the ambulance men tells Schuster, the nurse who meets them. “There was a load of them at the party and they were all out of it,” the ambulance man tells me. “We asked them what he had taken and they all say ‘nothing’ and there they are with their eyes like portholes. We don’t know how much he took. They eventually said two but it could have been eight.”
Kilmartin takes a roll-call of the waiting room. There are now eight people waiting to be seen. Hugh Laurie's House is on the muted TV. Nobody is watching the medical drama unfold – they have their own dramas to be concerned about.
After 1am a very well-spoken man walks up to the reception desk. “Nurse, I think I am banjaxed. I think I am finished,” he says before adding that he just had “a few drinks”. Apparently he fell and hurt his back. “But I wasn’t under the influence,” he insists. “I’m not a messer, I’m not a troublemaker. You’re a magnificent lady and I am sorry to be like this.” He seems more lonely than any thing else. He is given a trolley and he falls asleep.
The man admitted on ecstasy is nolonger unconscious. He is roaring. He has wet himself and is wandering the ward unsteadily, looking for his mates. He has no idea where he is. Nurses get him back to bed and remove his soiled clothes. He passes out again.
An old lady is brought in after collapsing at home. She is the first person admitted with a non-drink related condition in more than five hours. She is sober and sorry. “I am an awful nuisance,” she says in a quiet voice. “I don’t want to be bothering anyone.” She is seen quickly and given another trolley.
Half an hour passes and ecstasy man wakes up again and goes for another walk. A naked one. He approaches the elderly woman’s bed. She looks terrified. Within seconds medical staff surround him. Despite the intense provocation and his aggressive stance, they remain calm and take him back to his bed. Security men hover nearby but aren’t needed.
At 2am a burns victim is rushed into the high dependency section. His face, hands and knees are black with soot. Eight medical staff, including the senior doctor and senior nurse, attend to him. He is shaken but coherent. “I lit a candle for my mother. Her anniversary is tomorrow,” he says. The candle set some plastic bags on fire and he tried to extinguish the blaze with a damp tea towel which caught fire too, as did his flat. He got out alive. Jokingly staff tell him he looks like Al Jolsen and he starts singing. “How I love ya, how I love ya Mammy!” Everyone laughs. Then he is given a chest x-ray because, while the staff make light of his condition, they are concerned soot inhalation may have done serious damage to his lungs and airways.
Minutes later an elderly man with a long white beard is wheeled in. His nephew says “he had a few drinks” but collapsed and the left side of his face started drooping.
“We’re just not winning on the list tonight,” says registrar Nic Iomháin. “Sometimes you get the drunks trumping the others in the waiting room. It is sad but there is not a whole lot that we can do about it. We can’t ignore someone because they may have been drinking.”
Ecstasy Man is back on the ward still naked. He is returned to his bed and a stoney-faced hospital orderly stationed by his bedside. “We can’t send him home,” says Pedreschi. “His heart rate is elevated and he is still very confused and there is no-one to take care of him. This can be a bit of a baby-sitting service sometimes.” A very, very expensive one.
Next through the doors is a man in his 30s who seems confused. Another drunk? No. He was struggling to focus or keep his balance when he got up for work an hour earlier. He is the second sober person to come through the doors. There is concern about his condition and he is scheduled for a CT scan just in case he is suffering from a brain bleed or worse.
The bearded man admitted with the suspected stroke has made a miraculous recovery and is getting dressed despite not having seen a doctor. Pedreschi advises him to stay where he is but he gets agitated. “This place is too noisy. It is like being in f**king Afghanistan with all the beeping and banging. I came in here for treatment not torment,” he shouts. “Now, what I need is a smoke to clear my head.” She tells him to go for a smoke and promises to move his bed to a quieter spot.
There is high drama at 6.30am when a catatonic man is rushed through the doors by ambulance men. Three guards are not far behind. He had wandered into a station drunk a couple of hours earlier, keen to discuss a murder dating back to 1994. The garda on duty refused to take his statement while he was so unhinged by alcohol so he got aggressive and was arrested. Then he had a seizure. Nic Iomháin revives him by running a thumb hard along the base of his foot. He sits up, looks in the direction of the arresting guard and shouts “ya baldy c**t. I’m going to get you, you bald pr**k.” He tries to get past the medical team but they are having none of it.
While they attend to him, the burns victim takes a turn for the worst. His airways have swollen and he needs intubation quickly or he’ll stop breathing. An anaesthetist is called and the procedure done in minutes.
It is done to the strains of Raglan Road which waft in from the corridor nearby. The suspected stroke man has agreed to stay and is singing. He has a good voice which carries through the unit.
Not far away a woman in her 70s struggles to keep her eyes open. The song reaches her and she smile the smallest of smiles. She is clutching tightly the hand of her husband, admitted more than 12 hours earlier. He is sleeping fitfully but she is bolt upright. She won't go home until he has a bed. It will be hours yet. A few feet away, on the other side of locked doors and a thick glass window is a room where patients already seen and those still to be seen are waiting. Their number has dwindled to just five. Then an ambulance pulls up and the cycle of sadness and suffering starts up again.
To see more of Alan Betson's photographs, go to irishtimes.com
