The Emergency Room

 After 3-weeks in the ICU, I entered the Emergency Room for the first time. No more air-conditioning, single-occupancy beds out of the window and one-to-one nursing a dream. It was replaced by multiple people per bed (the most I witnessed was six) and families rushing to buy supplies, IVs, medications, syringes, needles, giving sets and more from the pharmacy. Within the ER there are three zones: green, yellow and red (resus). At triage patients are allocated to one of these dependant on the severity of their illness. Over the next week I got the opportunity to work in all three areas and triage itself.

In the green zone there was a range of people, mainly young with acute illness, who have come in and are receiving antibiotics and/or fluids. The process worked that a doctor would attend to the patient, write up a plan including all the medication to be given, and give this to the family to take to the pharmacy so they can collect and pay for the medications required. Once purchased, the relatives would bring back all the equipment to us and we would start to get to work.

Whilst cannulating we drew blood, and gave those samples to the relatives to pay for them to be run in the lab, and held the cannula in place with a little tape. We then drew up the drugs, gave them and then the patient would be re-reviewed by a doctor to see if they required a hospital bed. There were a few things I found during my day in the green zone that intrigued me. Everyone, and I mean EVERYONE, received IV pantoprazole whether they liked it or not, and when I asked medical staff about this apparently this is just "how it is done" in Nepal. Several people were on multiple antibiotics without any proof or sometimes evidence of infection, and led to me believe some people were being massively over-treated. I again spoke to medical staff about this who said as many people come from villages several hours away by the time they get into the ER some infections could be rampant so they give stat antibiotics at the slightest suggestion of infection. During my time in green I looked after over 60 patients and the flow was remarkable, I felt for even cannula I was inserting I was removing one straight after.

Next was the yellow zone, for people with more acute illness or exacerbations of chronic conditions such as COPD. Oxygen was hissing, monitors were beeping and again there were multiple people to a bed. Most of these patients were waiting for inpatient beds whilst receiving more intense treatment. There were people on CPAP/BiPAP sat in a bed with other people, families assisting in the personal care of their relative without any curtains or privacy and overshadowing everything was the importance of finance for people receiving care. I didn't spend long in this area, but it was interesting all the same and some of the ways COPD was managed differed to the UK including steroid use and lack of nebuliser use.

The final zone was red, where the most unwell patients including cardiac arrests go. There are 8 beds, no crash trolley, one defibrillator and one ventilator to go around. During my day here septic, seizure and severe cardiac arrhythmia patients came through. Doctors were available immediately and patients were under close observation by medical and nursing staff. Although nursing and medical care was similar to what you would find in a resuscitation room back home, the equipment availability and bedside provision certainly proved a barrier in several situations. Where patients with extremely severe hypotension were requiring fluids, we would have to wait until family returned with fluids, medication and more to start treatment. At times it felt surreal knowing there was something that could be done, but all you could do was wait as you watch a patient deteriorate rapidly in front of you.

Triage proved extremely interesting and consisted of a desk, two chairs and a cardiac monitor. Patients would come in with their relatives, take a seat, and between myself and a RN we would decide whether they go to the green, yellow or red areas. This would be based on physical appearance, physiological measurements and relevant history leading to the attendance.