Running out of patience: a long night in the emergency department

The emergency department of Mid-Western Regional Hospital, in Limerick, is a window into Ireland's social ills: drug and  alcohol abuse, violence and a creaking health system. ROSITA BOLANDspent last Saturday night at the hospital

Saturday, 6pm

38 people waiting

The first thing you see when you walk into the dimly lit waiting room of the emergency department at Mid-Western Regional Hospital, in Limerick, is a television screen. It faces the entrance, and carries the message “Due to exceptional circumstances, the current waiting time is five hours.”

The waiting room, chilly from the perpetually opening automatic doors, is utterly functional. It has three recycling bins, a hot-drinks machine that is already out of sugar, a vending machine for chocolate, crisps and soft drinks, a payphone and a few rows of unforgiving plastic seats.

Among the 38 people waiting last Saturday are Anne Wallace, who is 89, and her son Pat. “My balance is not as good as it was,” she says, turning around to show the back of her head: there is a dramatic red stain in the middle of her white hair. She fell over that afternoon on to paving stones, while weeding, and lay there, unable to get up, until a neighbour’s child spotted her.

Under the HSE’s emergency-department system, you register at reception and are then taken to a triage area to be assessed and stabilised. Depending on the severity of your case, and on the medical staff available, your wait will almost certainly extend to several hours. Patients admitted by ambulance usually take priority, as do young children.

So unless your condition is critical, after being assessed – like Anne, who was given two paracetamol for pain – you have to wait for further treatment.

“I thought, because of my age, I might be seen earlier,” she says. Is it sore? “Very.”

The catchment area of Mid-Western Regional Hospital now includes Co Clare and north Co Tipperary, as neither Ennis nor Nenagh hospital now has an emergency department that is open after 8pm.

Pat and Karen Breen have travelled from Feakle, in Co Clare. They have been here since 2.15pm, referred by a GP who saw Pat this morning, and are waiting for Pat to have an X-ray. “I’m never sick, but I’ve had terrible chest pains all day since waking up. It’s sore when I walk,” Pat says, pressing his hand gingerly to his chest. He looks like a man trying hard not to show how frightened he is.

Saturday, 7pm

32 people waiting

The Kenny brothers, John, Henry and Ger, are commuting between the emergency department and the main hospital, where their father has been since having a stroke, six weeks ago.

“I came home from Perth because it looked like we might lose him,” John says. The hospital wants to discharge him, as it needs the bed, but their elderly mother is not up to the long-term nursing he will need, and, despite looking in Cos Limerick and Clare, they have not yet found a spare bed in a nursing home.

They’re in the emergency department now because Henry’s young son, David, fell off a bouncy castle at a birthday party earlier and broke his leg. John, who had come to the hospital to visit his father before leaving for Australia the next day, is also waiting to visit his nephew. They are all stressed and fretting about finding alternative care for their father. “I haven’t been back to Ireland in four years, and I can’t believe nothing in the health service has been upgraded,” says John, bitterly. “The staff are excellent, but they are under so much pressure.”

Saturday, 8pm

26 people waiting

A man with crutches who has been here since 6pm broke his leg when a chair collapsed under him as he was painting. He holds out magnolia-stained hands. He would rather not give his name.

“I suppose I was lucky I wasn’t standing at the top of the stairs,” he says cheerily, then admits with a grimace that his leg is really very painful. He delayed coming in, hoping the pain would go away, and because he dreaded the wait he knew from experience he would face, but his wife persuaded him to let her drive them in.

Saturday, 9pm

29 people waiting

Our access is limited to the public waiting room, so neither I nor my photographer colleague can enter any of the clinical areas. There are glass panels in the door between the waiting room and the area beyond it, however, and whenever I look through them I see an ever-changing configuration of trolleys with people on them in varying states of distress. Lack of space means only one person may join a patient at a time. Earlier in the evening, there is room for one chair between trolleys, but as time passes, the chairs are taken away so that the trolleys can be pushed alongside each other to maximise the space.

One of the people lying on a trolley is the 21-year-old future son-in-law of the distracted woman who sits beside me when she comes back from the coffee machine. “You wait in here, you wait out there, you’re waiting wherever you are in AE,” she says. “In any other country there would be riots, but the Irish don’t complain.”

Her daughter’s fiance was admitted by ambulance, passed out in an alcoholic stupor, having threatened suicide before he started drinking. “It’s the second time he’s been taken in for threatened suicide. The poor lad has his reasons. His father died by suicide two years ago. I think he’s making a cry for help.”

Saturday, 10pm

37 people waiting

There is consternation when several members of a family rush through the doors in panic, following a man supporting a vacant-faced young girl who cannot stand up. She has taken an overdose, but it appears that she was found by her family, who brought her in. She vanishes through the doors to the clinical area, leaving nine people who huddle in a corner and sob periodically.

At 10.30pm, Anne and Pat Wallace leave, after Anne has been X-rayed and discharged, although she must return on Monday. “This was a warning to us,” Pat murmurs as they depart. “There’s no point having a panic button if you leave it on the kitchen table when you have a fall outside.”

The previous day, Margaret and Paddy Moniyhan’s daughter had got married in Tipperary. “Everything had gone so well,” Margaret says with a sigh. “We were coming home afterwards on a bus we’d booked for the guests, and there were two lads on it who weren’t supposed to be on it,” says Paddy. He got up to ask them to get off the bus, and was punched in the face. “In the 36 years I’ve known him, it’s the first time he’s ever got a belt,” says Margaret, mortified.

Paddy’s left eye and cheek are bloody, bruised and swollen, with broken blood vessels in the eye. They have been in the emergency department since 4pm, waiting for an X-ray. “I’d go home, only I can’t see right. There’s spots in front of my eye, and a kind of a black cloud keeps coming and going. I’m kind of worried,” Paddy says. Already tired from the wedding, and a drive from Thurles, they look more exhausted each time I pass.

Saturday, 11pm

35 people waiting

“They have a policy of trying to get children out before midnight, so let’s hope we’ll be gone by then,” says Rose Cleary. Her 10-year-old son, Hugh Cleary-Ward, pale and quiet beside her, fell off his mountain bike at 3pm, and his right knee has a deep cut that needs stitches.

Like many other people waiting, their first call was to the Shannondoc GP service, which referred them to the hospital. According to Shannondoc, because there is dirt in the wound, it needs to be deep cleaned. This requires a referral to the emergency department, where they have been since 7.30pm. “Why is it that you have to go to AE for cleaning a wound and getting stitches?” Cleary asks. “Why isnt there a designated person for small things like this? I asked to see a nurse, but apparently he has to be seen by a doctor. Why?”

Shortly after this, a nurse in blue scrubs emerges for the first of several briefing sessions that continue through the night. She has a sheaf of paperwork in her hand, and goes from patient to patient, explaining how long more they might have to wait. For virtually everyone, the waiting time has increased.

Midnight

25 people waiting

After the psychological threshold of midnight, the atmosphere in the room changes perceptibly. People who have not yet been seen now realise they are likely to be there until at least the middle of the night, or very early morning. The feeling in the room is resignation mixed with exhaustion and low-level anger.

There’s also a sense of people looking at their watches and wondering when and if a drunken cohort might start arriving. There is a low, intermittent hum of talk, but people mostly sit silently, staring ahead. Few are reading, and nobody is asleep.

Now and then, people get up and go out for a cigarette. Smoking is supposedly permitted only in a designated sheltered area some way from the entrance, but nobody appears to be using it, despite the constant tannoy announcements saying smoking is forbidden outside hospital entrances. People simply walk out of the waiting room and light up. It’s a small act of defiance. People have no choice about how long they wait to be seen, but they can choose to break a rule by smoking where they shouldn’t.

At 12.40am, Pat and Karen Breen emerge from the clinical area after the X-ray results. Pat is beaming. He is almost skipping. “Muscle strain,” he reports, explaining that he had been using a chainsaw in the previous days, which must have caused it. “I’m fine.” He admits he had feared the onset of a heart attack.

Sunday, 1am

23 people waiting

At 1.15am, Rose Cleary and her son Hugh leave. His wound has been cleaned and stitched by a nurse. “Why couldn’t a nurse have done it when we arrived?” Cleary asks rhetorically, rolling her eyes.

Five minutes after they depart, the notice on the television screen changes. It now reads, “Due to exceptional circumstances, the current waiting time is six hours.” People stare at it. Some have now been waiting here more than 12 hours. Time is elastic in the emergency-department waiting rooms. The nurse in scrubs does another walk-around with her paperwork. “Are ye all exhausted?” she asks sympathetically. Nobody replies.

At 1.25 am, Paddy Moynihan is called in to have his eye X-rayed.

Bridie McCarthy’s left hand is wrapped in a temporary bandage. Before Mass at St John’s Cathedral the previous evening, she had hurt it while trying to light a candle at one of the church’s large brass stands. A piece of metal dislodged and fell, trapping her hand, which is now badly skinned and lacerated. She has been here with her son Peter since 8pm. “I was only going to Mass, and look what happened to me.”

Sunday, 2am

12 people waiting

Two young women and a man arrive from a nightclub. The front of the man’s blue-and-white checked shirt is stained with blood. “There were bouncers; there was a fight; he was fighting to protect someone else; it wasn’t his fault,” his girlfriend says defensively. The man thinks his nose is broken. It looks red and very swollen. But when he’s told by reception how long he will have to wait – indefinitely – the three of them decide to leave. “We shouldn’t have sent the taxi away,” his girlfriend grumbles.

Gardaí appear, for the first time. Margaret, who has come out for a cigarette, and says Paddy is still awaiting an X-ray, says a man inside on a trolley is yelling abuse, trying to hit staff and attempting to pull out his drip.

Soon after, two gardaí escort a verbally aggressive man out of the clinical area. He’s leaving barefoot, because he was brought in by ambulance barefoot, having been found by his mother after he passed out from drink and drugs. He has no money, so the gardaí will bring him home.

“We see the same thing, night after night,” the security guard says grimly. “And we’re on first-name terms with some.”

Sunday, 3am

17 people waiting

A young barefoot girl limps in with her father. After triage, she comes out in a wheelchair to await the result of an X-ray. She says she got drunk on Jägerbombs – “Jägermeister and Red Bull” – fell down three steps when someone pushed her, and passed out in a nightclub. She thinks she has either broken a toe or sprained an ankle. “I fell over only because I was wearing high heels,” she says.

A short time later, another young girl, also barefoot and drunk, arrives with her boyfriend. Her left foot is bloodstained and cut. She puts her foot on a chair and looks at it as if she’s never seen it before.

“How did you do that?” the girl in the wheelchair asks.

“Honestly? I can’t remember,” the other girl says, giggling.

The girl in the wheelchair is triumphant. “At least I can remember that I fell,” she announces with pride.

About half an hour later, the girl with the cut foot puts her stilettoes back on over the bloody wound and marches off with her boyfriend, saying she won’t wait any more. The girl in the wheelchair is asleep on her father’s shoulder.

Sunday, 4am

12 people waiting

Bridie McCarthy and her son are called in. The man in crutches who fell off the chair emerges from the clinical area to tell his wife he is still waiting for an X-ray. He has been managing wry, resigned smiles all night, but now he is in pain, frustrated and furious. He’s telling her he wants to go home. She listens. They both know he cannot leave without having his leg seen to. After a while, he goes back inside.

Six women in pyjamas and dressing gowns keen through the doors, accompanied by a man who soon vanishes outside for a cigarette and does not return. This is the only point in the night that anyone raises their voice. One woman screams at the others, “These f***ing house parties have to come to an end. They’ll f***ing kill someone, I’m after telling you. If she f***ing dies, it’s your f***ing fault.”

The person already inside the emergency department is this woman’s sister, who was found unconscious on her kitchen floor at 3am. I step outside for air, and to keep awake. Coming back in again from the sharp, icy night, what’s immediately noticeable in the waiting room is the distinctive smell of alcohol. When you sit there for hours, you don’t notice it build up slowly over the night.

Sunday, 5am

15 people waiting

Margaret, red-eyed from exhaustion, and looking as if she has been crying, emerges from the clinical area. “Paddy still hasn’t been X-rayed. He’s still just sitting there outside the door,” she whispers. They have now been here for 13 hours, and after her husband is treated, Margaret will still have to drive home to Tipperary without having slept.

Four gardaí come and go several times from the clinical areas. A phone call to the Garda station on Henry Street reveals they are investigating a report from a patient of an alleged sexual assault.

We leave just before 6am. Paddy is still inside, as is the man who has broken his leg when painting, and Bridie, who injured her hand trying to light candles before Mass.

I don’t know how much longer they will have to wait.

All I know is that I am so bleary, after spending 12 hours there myself, that my colleague has to remind me to turn on my lights before I drive out of the car park.

LATER, THE hospital’s communications officer asks me if patients came in with gunshot wounds or stab wounds, which suggests that these are routine. The hospital cannot give me a breakdown of the number of people who attended the emergency department during Saturday night and Sunday morning, saying it no longer has the personnel who can make them “readily available”.

It confirms that at 8am on Saturday, 23 adults who came to the emergency department were awaiting a bed, and the department’s predicted activity was 68 people. By 8am on Sunday, 16 people were waiting for a bed, and the predicted activity was 64. Mid-Western Regional Hospital could not clarify these figures, nor give a breakdown of what medical needs people arrived with during those hours.

Medical history Work stoppages at Limerick

The emergency department at Mid-Western Regional Hospital in Limerick was the scene of a number of work stoppages in recent weeks by staff protesting at overcrowding in the unit and at cutbacks in the health service.

Nurses at the emergency department, who are members of the Irish Nurses and Midwives Organisation and Siptu, held three separate stoppages last month in moves that saw some services postponed by management.

The industrial action, which lasted for a number of hours on each occasion, was strongly criticised by Minister for Health James Reilly, who claimed unions had broken the Croke Park agreement on public-service pay and reform.

However, the dispute also led to the Minister sending his new special delivery unit, set up to tackle problems in emergency departments, to Limerick to assess the situation and draw up recommendations.

The nurses maintained overcrowding at the emergency department at Mid-Western Regional Hospital was posing a threat to patient safety.

The HSE has argued that the unions would not agree to roster changes for staff in the hospital that could alleviate much of the pressure on the emergency department.

Following the recent work stoppages, agreement was reached at the Labour Relations Commission. Under this agreement, industrial action was suspended for a period of four weeks, which expires later this month. This was to allow time to undertake a number of actions: a full review of rosters and resources across all hospitals in the mid-west to support the patient safety concerns of nurses at the hospital in Limerick; to carry out a review of all day work that could be transferred to other acute hospitals in the region and thus free up beds for emergency admissions; and the introduction of structured ward rounds and improved access for consultants to diagnostic procedures, such as X-rays, at weekends.- MARTIN WALL