A state of emergency...

Long waiting times at the Accident and Emergency Department is Mater Dei’s millstone. Kristina Chetcuti puts on her scrubs and joins the A&E staff for a day.

Every day some 350 patients make it through the doors of Mater Dei’s Emergency Department. That is an average of 50 patients a day more than the former St Luke’s Hospital.

Users often complain that the waiting time is atrocious, that the staff are slow and inefficient and that urgent cases are sometimes left unattended for hours on end. How much of this is true? The Sunday Times checked in, not as a patient but as an observer.

We follow a few of the 80-plus nurses staffing the department, and observe the different priority areas to find out if the nurses pass the time sitting around with a mug of tea permanently in hand and flicking through magazines.

For the day we are tagged to Vicky Rausi, 37, Practice Development Nurse, stationed at the A&E for 14 years. She is petite, soft spoken, with emerald, reassuring eyes. Her tiny hands feel so strong that instantly you know that no pair of hands would feel safer than hers in a critical situation. She is wearing a blue, zipped-up boiler suit, one of the nurses’ uniform at the A&E.

“It allows for practicality. Easy to wipe clean,” she says. And you know immediately that she is referring to blood, not to tea-stains.

First stop is the ‘Triage Room’ – derived from the French word ‘trier’ which means ‘sorting out’. The priority of patients’ treatments is based on the severity of their condition: urgent cases are seen to immediately ; semi-urgent patients receive care by a doctor in Area 2; and the least urgent cases – those which could have easily been treated at the Health Centres or family doctors – are the ones tackled last.

It has been raining heavily this morning. “When it’s raining, people tend to stay away, but now they’re flowing in,” Ms Rausi says. Rain, football and elections are the only lull in an otherwise inundation of the sick and not-so-sick.

She calls in the first patient on her list: he’s in his 30s, somewhat overweight and slightly short of breath.

“He’s asthmatic,” says his wife. He is asked if he has called at his community health centre before going to the A&E – he has not.

Others come in: chest pains, head injuries, stomach aches, even ankle sprains. In an hour, Ms Rausi sees more than 30 patients. She checks their pulse, takes their blood pressure, temperature and submits them for an electrocardiogram (a test that measures the electrical activity of the heart) if need be.

She asks for symptoms, and if they are taking any medication. Most say yes but cannot recall the names: “I’m taking those blue pills three times a day and a brown one in the morning,” is a typical reply.

Some, you can tell are either hypochondriacs or just playing truant, like the patient who comes in claiming that for weeks he has been feeling a lump on his back. My untrained eye cannot see anything, nor can the nurse.

That’s when he says: “I went to the GP. He told me it’s nothing. So I came here. I want to make sure.” He is asked to wait to see the doctor in the so-called Area 3, but is warned that the wait is going to be a long one. Because these are not life-threatening conditions, people can be here for several hours.

Police and private security cover A&E mainly to support frontline staff who at times are subject to verbal or physical abuse.

“The most demanding attendees, ironically, are the most non-urgent cases. They have to keep in mind that this is not a first-come-first serve service but one dependent on urgency,” Ms Rausi says.

Other ailments are not so minor. A woman comes in at 11 a.m. with a sudden onset of Bells’ Palsy (facial paralysis). Her husband is anxious, but politely asks how long they have to wait till they can see the doctor. The nurse reassures him that it would not be too long. At noon they are ushered in to see the doctor in Area 2. Waiting time for semi-urgent cases is usually from one to two hours.

The majority come in without any referrals from family or health centre GPs. The most common condition during The Sunday Times visit is chest pain – with sufferers ranging from teenagers to septuagenarians. Only three are urgent cases.

Ms Rausi is constantly taking decisions, sorting, prioritising. She is efficient, confident, but above all sympathetic: “We’ll take it step by step”; “Don’t worry, we’ll do whatever needs to be done.”

It is not for my benefit: her attitude, her compassion is clearly automatic. “My job is to reassure them that they are going to be seen by the relevant doctor.”

A&E attendances can only be reduced by encouraging people to seek treatment for any non-urgent conditions, in their communities to ease the pressure on the already stretched-thin staff. Some vulnerable patients, for cultural, personal and socio-economic reasons, will almost always turn to the Emergency Department for their care. “We cannot turn away anyone,” the nurse says.

The Traige session is over. We step into the actual hospital emergency zone which is buzzing with overwhelming activity. It feels like stepping straight into the set of Scrubs, the sitcom. Nurses and doctors mill around the patients, their body language is saying “Go! Go!” No chair is in sight, let alone anyone sitting down.

There is a children’s emergency section, for the treatment of medicinal cases. It’s hectic. A little boy is sleeping on his mother’s lap; the mother’s head resting against the wall, her eyes closed as a result of exhaustion and worry.

In Area 1 all the eight cubicles are occupied. So are the six cubicles in Area 2. And so are the corridors. Surely these patients – more than 20 of them in stretchers, lining the area corridors – shouldn’t be there?

“These are all priority cases which we would have seen to immediately but they have to wait for a ward bed to vacate,” Ms Rausi explains.

Sometimes patients wait in the ‘hot zone’ corridors for several hours. The A&E staff has to administer the patients’ medicine and to provide food – it’s like a temporary ward, eating into their already tight schedules. There doesn’t seem to be any imminent solution to it: it’s the result of a patient inflow bigger than the outflow.

Next stop is the ambulance control room – where the 112 emergency line is directed from the police control room. There are about 70 ambulance calls per day – roughly half of them are emergency calls, the other half are requests for ambulatory transport to hospital.

“Unfortunately some people think that because they turn up in an ambulance they are given priority. They are not: unless it’s a major trauma, they still have to go through the triage system,” says Mary Bezzina, 48, the Nursing Officer in charge of the Emergency Ambulance Service.

We witness a live call: a man has been injured. The nurse manning the control room, Josvic Galea, asks about the accident as well as the address and location details. By the time he hangs up, a nurse and a porter are already rushing to the waiting ambulance outside.

These nurses are Malta’s equivalent of paramedics – the pre-hospital nursing team. Here, they come in contact on a daily basis with gushing blood, undiagnosed conditions, people on the verge of death. The stress levels are enormous like no other section in the hospital: there are lives constantly on the line. To work here, day in day out, you must be strong physically, morally and psychologically.

All the nurses say that they wouldn’t change their job for the world – helping a patient in the most crucial stages gives them an adrenaline rush. However, it takes its toll: “Working here changes you. It changes your attitude to life. You appreciate life more,” says Michelle Gove 24, a nurse at the department for two years.

It is extremely difficult for them to break the news to parents and relatives that despite lengthy medical efforts, their child or loved one failed to make it. The feeling of helplessness is overwhelming, and all they can do is offer support.

“When you work in the A&E, what matters is that you’re healthy,” says Lucienne Brincat, 37, Deputy Nursing Officer, who has been working at the A&E for 17 years. Roberta Tonna, 29, still cannot get over the time she went out on an emergency call to find her father in the throes of a heart attack.

The place can be emotionally draining. Some nurses still recall patients they attended to more than 10 years ago. Some relatives of victims call on them every now and then. The intensity of the nightmarish moments they share creates a lifelong bond.

All nurses claim their job has turned them into proactive decision-makers. They do have clashes, but then their teamwork is like clockwork, and in their 12-hour shifts, they offer each other the best kind of support.

And their tea, when they make it, gets cold.