Mention ER and you’re likely to associate it with the popular hit series starring George Clooney that lasted 15 years and scored a whopping 124 Emmy nominations.

Or it might remind you of the eccentric Dr House engaging the audience with solutions to baffling medical cases in House.

Or the ensemble cast of Grey’s Anatomy, Night Shift or Code Black.

Drama series and interesting characters aside, have you ever wondered what happens in the emergency room in real life?

A night like any other

It was drizzling lightly at midnight when 28-year-old James cruised down the Federal Highway in Kuala Lumpur. He stepped on the accelerator, eager to reach his destination to meet a good friend.

All of a sudden, he hit a puddle on the road, losing control as his car spun into the side railings. He hit his chest against the steering wheel, knocking the breath out of him for a moment, and blacked out.

The next moment he woke up groggy, gasping, in the Emergency Room, barely aware of being examined.

“Low BP, mild tachycardia and peripheral pulses at low volume. PR at 102/min, BP 92/54mmHg. ECG stat done,” said the medical officer on duty as he updated the physician in attendance – usually referred to as Doc by his colleagues – handing him some data from the ECG.

Seeing the low voltage recordings on the ECG, Doc zeroed in on the observations he thought were the most significant.

“Distended neck veins. Muffled heart sounds. Low Blood pressure. Seems like a classical Beck’s triad.”

To confirm his suspicions, Doc performed an echocardiogram, using ultrasound to visually display what was happening in the patient’s heart.

It was immediately evident that the problem was a pericardial effusion, possibly from internal bleeding into the pericardial space around the heart.

He immediately called the nurses to assist, preparing to extract the blood to relieve the pressure with a pericardiocentesis procedure guided by the ultrasound display.

James’ vital signs improved immediately as 30cc of blood was drained from his chest, allowing the doctor to do a CT scan of the region and another surgical incision to arrest the bleeding.

Just when Doc thought it was over for the night, a nurse called him for another case.

Forty-eight-year-old Kamala was rushed into the Emergency Department with complaints of experiencing shortness of breath and restlessness.

Nurses already noted that her oxygen saturation was critically low at 80%.

At this level, brain and heart functions would be affected, with the possibility of respiratory or cardiac arrest.

Even with additional high flow oxygen, the medical team could not achieve 90% oxygen saturation.

Observing the patient and the data charts, Doc saw that she was morbidly obese, diabetic and hypertensive, with high sugar levels and an arterial blood gas pH of 7.14, bicarbonate 8 and potassium at 7.2.

Speaking to the critical care physician (intensivist) on duty, Doc shared his working diagnosis: diabetic ketoacidosis with impending collapse.

“She’s diabetic and not getting enough insulin. It’s going to be very difficult, but we need to intubate her and maybe induce a coma.

“Get me an ultrasound on her, she might need an emergency surgical airway. Let’s try an awake intubation first.”

The intensivist gave Kamala a mild sedative to calm her down, and quickly attempted to insert a breathing tube down her throat, but to no avail.

“Doc, I can’t get a clear visual of the vocal cords. We need that surgical airway.”

Luckily, the cricothyroid membrane was identified earlier with the help of the ultrasound. Doc proceeded to create a small incision to insert an airway branula and connected it to a jet insufflator, an apparatus to help her breathe.

Averting a life-threatening situation, they transferred her to the ICU for further care and observation.

Doc stretched his shoulders and took a short break, relieved that clinical acumen, timely intervention and the right instruments at hand saved these patients tonight.

Emergency medicine today

Emergency medicine has come a long way and is now a highly sophisticated, evidence-based practice.

Primarily associated with obstetrics and gynaecology at one point in time, ultrasound has become a useful tool in the area of emergency medicine and critical care.

Focused Assessment of Sonography in Trauma (FAST) uses ultrasound to effectively assess trauma patients for major bleeds and other conditions that could be life-threatening if not addressed at the earliest opportunity.

In recent years, most emergency rooms have been equipped with an ultrasound machine, proving again and again to be a game changer in saving lives.

In its infancy, ultrasound was used to detect intra abdominal fluid collection, which in the context of trauma, is blood until proven otherwise.

It later evolved to include the lungs and heart as part of Extended FAST (EFAST).

Major life-threatening conditions can now be diagnosed within the first few minutes of patients arriving at the Emergency Department.

With the array of medical equipment available, medical officers, or in certain specialised hospitals, an emergency physician on duty, can channel their knowledge and expertise to instantly arrive at a conclusive diagnosis to save lives, just like in reel life.


Dr Paranthaman Kaneson is a consultant emergency physician. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.