The Four R Rule

It would be fascinating to run a fly-on-the-wall documentary on life at trolley level in a local Emergency Department. When you’ve been there, done it and survived to watch TV again, the dramatised version served up in your average medical soap is about as true to life as Harry Potter. Someone will just have to come up with ED-trolleycam. The MicroGnome was left under no illusions when struck down with a travel-related infection following a week with the Lab Without Walls in East Timor. He became a victim of the Four R Rule:

1. Review


Having walked into a nearby ED asking to speak to the on-call consultant [05:30. You’ve got to be kidding. Any properly organised consultant will be tucked up in bed or, if worried about their BMI, might be starting their cycle ride into work], your Gnome was taken in hand by the triage nurse, a short history taken and found a ‘bed’ – the infamous trolley. A registrar, clearly worried that the on-call infectious diseases resource had just rocked up for admission during his shift, swallowed hard and got on with the primary review. By this time the ability to form a considered MicroGnosis was failing fast. A few key tests were suggested rather weakly, then the Gnome lay back and let it happen.

2. Referral

The registrar passed his case up the line, but not before he’d outlined his plan of action, got his baseline bloods off to the lab and plugged in a drip. The cannula went in without a squeak from the patient, who was relieved to feel fluid coursing into his parched body. A sample for urinalysis? You must be joking; the MicroGnome was dry.  The view from the trolley took in a vertical strip through which you could see nurses busy with other patients and doctors conspiring. The patient next door complained of dizziness following ‘a touch of the flu’. The Gnome wanted to prompt the intern on labyrinthitis before she got to the end of the structured interview, but she got there under her own steam. An ED consultant gazed vaguely in my direction, obviously wondering why the patient in E20 looked so familiar. Then the physicians arrived. Gone were the jokey comments about what the MicroGnome was doing there. Instead the MicroGnome got a generous dose of differential diagnosis, supplemented with presumptive therapy and cogent explanation. The Gnome was relived to refer his own case to the care of another specialist. But even more relieved to be able to hand over the out-of-hours duty to a colleague, who also came in to review progress and pronounce on antibiotic choice. One of the ED consultants came over for a chat about the initial lab results. The MicroGnome may have said something coherent. On the other hand, he could have been completely out of it by that stage. However, there is a good chance he may have tried to persuade the ED colleague to run a series of quantitative blood cultures on him.

3. Restoration

The fluids started to work their magic within a couple of hours. The exact duration is a bit vague. For all he cared, the MicroGnome could have been floating in a hydrotherapy pool on the trolley mattress. In fact, he was moved to X-ray for a standard set of views. When traffic picks up, this entails a wait on the ED trolley immediately under the door-release button for the ED exit. Staff lean over the patient to activate the doors. It is surprising how many staff didn’t recognise the deathly pale Gnome under a hospital blanket, despite having seen him one or two days previously. They say recognition is all about context. The MicroGnome was then moved to the observation ward and put in a quiet corner to lick his wounds. The other thing running into his venous circulation was an antibiotic. Each pulse of liquid could be felt. Before long each pulse was painful, then a burning sensation started working its way up his arm. The drip was working fine, but the solution was getting seriously irritating. The ED consultant deftly slipped another cannula in on the other side and relocated the drip. Despite running it at half the speed, the same burning sensation started up. The Gnome heard an elderly patient next door cooly recount her motor vehicle accident and made a mental note to toughen up. OBS was full of bright, cheerful and optimistic staff. It felt like a conspiracy to make people feel better, even if it was the last thing they wanted. No, the MicroGnome didn’t want to be ill and though improving measurably by then, couldn’t muster the mental energy to go through a list of requirements for discharge. Phone calls and SMS started to trickle in from concerned colleagues who’d started to notice how quiet the workplace had become. These were a mixed blessing: a reminder of how essential Gnomic wisdom is and at the same time, how much work has backed up in the Gnomes’ short absence.

4. Recovery.

The name of one of Runrig’s earliest albums [code below]. By the time the MicroGnome had the mental energy to plug in his iPod, he knew he was on the road to recovery and could think about discharge. This happened before leaving the OBS ward. It must have been due to the pathologically cheerful disposition of the staff and the bed they rolled him into from the trolley. The porter who pushed MicroGnome’s bed to the medical wards seemed seriously small for the task but made light work of it, dispensing more hospital cheer along the route. By now the Gnome was almost fully back on the planet and ready for intelligent conversation. Small chance: the ward staff chose to follow the rules and put up the Contact Precautions sign, restricting access to my room. The only company he had for the next 12 hours was a relay team who passed the cheerfulness baton from nurse to nurse at each handover. Otherwise, it was Gnome alone. Perth at night can be an incredible sight, but even this view gets a bit dull after a few hours in a hospital room. The iPod ran out of juice. At the 24 hour mark, perilously close to terminal boredom, the medical team decided to fire me. By then it was clear that the Gnome should go back to his day job.

Let it go down on the record that the MicroGnome cleared his own hospital room, took down the Contact Precautions sign and moved back to the dark side to wait in the doctors’ room for his lift home.


BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

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