Lights, Endoscope, Action!

This week we're taking a step back from the human body and instead looking at the medical environments that surround it.

In this article we'll look at the Accident and Emergency Department, and in the following weeks we'll cover Consulting Rooms, Intensive Care Units and Operating Theatres.

The Accident and Emergency Department

Across the world emergency departments have slightly different names and characteristics - an Emergency Room in the US has very different appearances to an unstocked shack in Ulaanbaatar. For today, I'm going to stick to describing the environment that is most familiar to me - an A&E department in the UK.

Overview

A typical UK A&E department opens onto the front of the hospital, with separate doors to the main entrance. There'll be a main reception area, where patients and visitors can come in, and an ambulance door through which emergencies are rushed. The ambulance door will also be used by junior doctors and nurses taking short cuts, so they don't have to walk past all the patients in the waiting area when they enter and leave the building.

Inside, beyond the waiting area, there will be found the following areas: Triage, Minors, Majors and Resus. Between these four areas is an unnamed central area and out to one side will be the X-Ray Department. Most departments will also have a separate Paediatric Resus and some will also have Paediatric consulting rooms in Majors and Minors. There'll also be a few other rooms on the corridors nearby - consultant offices, secretary offices, a training room, a staff room, store cupboards, staff toilets, patient toilets and a relatives room (where doctors can speak quietly to people to tell them that their loved ones are seriously ill or have passed away).

As your players approach the A&E department from the outside bear in mind the mood you are trying to evoke. If you are trying to set a feeling of frantic pace, you will likely want to have people in surgical scrubs or white coats rushing back and forth. On the other hand, if you are going for quiet despair, consider painting the area in a grimy grey light, and filling the seats of the waiting room with extras who are near-death and silent save for the odd hacking cough.

If in doubt, consider the time of day, the weather and of the year. Every A&E department in the country will be filled to bursting on a Friday night, full of drunk kids and people with head injuries from street fights. Conversely, if it is four in the morning on a Tuesday, then expect to see the department mostly empty, save for doctors and nurses lounging around taking a much needed break, and little noise save for the occasional beep of a cardiac monitor on patients who are too unwell to go to the wards yet.

If there is a storm outside with lightning enough to ionise the air, then expect to see dozens of wheezing asthmatics with nebuliser masks on, filling every available seating space in the main department. If there is heavy snow, then the place will be mostly empty, as most people won't bother coming in with smaller complaints, but there will inevitably be at least motorcycle accident and a few elderly people who have fallen over and broken their hips. If it is a cold winter's day there will be endless ranks of the elderly and infirm suffering from pneumonia and urinary tract infections, filling the place with the rotten smell of infection and death.

Triage

Soon after a patient books themselves in through reception they are brought to a nurse for triage. The nurse will then decide whether the patient is for minors or majors.

There won't be many props in this part of A+E. The desk and a couple of chairs are all the nurse really needs to make an assessment, though likely he or she will have a blood pressure cuff and a wall-mounted opthalmoscope.

Minors

The Minors department is for problems which can be dealt with quickly and easily. Coughs and colds, small superficial injuries and other minor ailments will all end up here. Patients in minors aren't being considered for admission to hospital, nor do they normally receive any blood tests or investigations.

Majors and the Main Area

This is where player characters will mostly end up in most games, of they don't land in resus instead. majors will be divided into cubicles, sometimes with a separate side room for each patient, but more commonly with nothing but a curtain on rails dividing each bed space. Each cubicle will be numbered, and in larger departments will be broken down into different bays as well.

Most majors cubicles will not have much in them, save for a patient couch. In the UK at least, there is rarely enough equipment for every cubicle to be fully tooled up.

Instead most equipment will be kept in the main area, with trolleys and drawers full of medications, needles, swabs an other tools. There'll be an ECG machine or three in the department as well. Doctors, nurses and receptionists will communicate with each other via a loudspeaker system - by pressing a button on the wall and speaking into the microphone you can have everyone in A&E hear what you saying. Convention demands that everything gets repeated once (for example "Doctor Blythe to resus, Doctor Blythe to resus") . Common phrases you might hear include:

• "ECG machine to Majors Room 4, please..." As noted, equipment is in short supply, and because people don't tend to put things back, the only way to find something is to ask everybody where it is.
• "Red keys to Majors, please." Most drugs are easily accessed, by just opening the right cupboard. Controlled drugs (like morphine) are kept under lock and key, and only one person will carry the bunch of keys in majors, and one in resus. A few other items are also kept under lock and key, such as pregnancy test kits ("PT keys to main desk please...").
• "Dr. Blythe to Resus, please." Mostly if someone wants to get hold of an A+E doctor, they will search around for them first. Only in an emergency do doctors get called for over the tannoys. Generally this announcement will be followed by a junior doctor springing from whatever he is doing and running (or briskly walking, once he is a bit more experienced) through to the resus department.

Another feature of Majors cubicles is that there may be one or two cubicles fitted for specific purposes. For example, in the last A+E I worked in, Cubicle 12 was a plain empty room with undecorated walls, a plastic-covered mattress on the floor and a drain set into the corner. The room was used alternately for lice-ridden tramps and addicts who would otherwise have covered a cleaner cubicle and faeces, or for violent patients brought in police custody who needed to be kept away from anything they could to inflict injury.

The Resus Room

When television shows and movies depict emergency departments, they almost always focuses on the Resus room. In actuality the Resus room will normally comprise less than a third of the floor space of the department as a whole. The Resus room will be empty for at least half the day, as its purpose is to stabilise unwell patients then move them on elsewhere. A medium sized department in the UK might have just three or four Resus beds, compared to twenty or so Majors beds.

Each Resus bay will be fully equipped with a monitoring station that will be attached to the patient as soon as they are on the couch. This makes threatening beeping noises and has a lot of confusing information on it, but if you're going for realistic depiction the following details might help:

• An alarm going off normally means nothing. Almost always an alarm sounding means little more than monitoring leads not being connected, or having slipped off the patient. The docs will normally hit the "silence" button to quiet the alarm.
• Sick patients sweat... and this makes sticky pads fall off. Which then makes alarms fall off.
• Doctors and nurses don't sweat. Resus work is everyday for A+E doctors, so they don't run around shouting "stat!" and "we're going to lose him dammit!". In real life, they'll most likely talk about something calmly and loosely, as in "shall we try some amiodarone, do you think?"

The exception to the above is in a Trauma Call or Cardiac Arrest call. In this circumstance the team will rush in, arriving one at a time over the course of a few minutes, and there will be medical drama aplenty as they try to keep the patient alive. Even then, of course, some people are so clearly DOA that efforts can be half hearted. We'll come back to the Cardiac Arrest in a later article, because its fun enough to deserve its own discussion.

Using A&E in your games

Any story which involves physical conflict in a modern setting will sooner or later end in A+E. Rather than brushing this over and skipping straight to recovery, consider setting a portion of the session in the A&E department. With the details above you ought to be able to conjure a fairly good mental image of the environment and of what goes on inside it.

Attending A&E in real life can be a dramatic event, so there's no reason why you can't use it as such in a game. You need not limit A&E environments to modern day settings either: Consider the Ariel scenes in Firefly - the hospitals depicted have modern trappings and a 20th century feel to them, with only a few tweaks to fit the science fiction setting.

A&E as a mood-setter

As any good film director knows, good use of sets and stages can set the feel for scene. The same is true of GMing in roleplaying games, and medical environments can be used in many different ways to affect mood in your storytelling. Think of the bustle and chaos of ER and compare it to the clean lines of a Star Trek medbay. Its not just their caseloads that are different - the environments and sets used conjure entirely different atmospheres.

Like any environment, A&E can be described in different ways by a skilled GM to effect his players' moods and perceptions.

A&E as a stage for drama

Like a battlefield, an A&E department stands at the borders between life and death, so is a natural stage for scenes about conflict. Unimaginative GMs may think that the only drama that you can find in A&E is resuscitation scenes, but watching any TV medical drama should provide many more ideas than this.

A&E as a big bag of props

Different environments also allow for different props, and medical environments tend to be especially rich in props. Whether you're playing Feng Shui and looking for objects to stunt off, or playing D+D and are interested in the GP value of esoteric goods, a medical environment gives the GM and the players a lot of scope for introducing unusual items. Consider the following items:

• A patient trolley is a classic prop, both in Carry On films and in the Hong Kong Action Theatre genre. You can ride it like a giant Back to the Future skateboard, send it flying into standing mooks with your super-strength/telekinesis, or simply swing them around as giant clubs. And remember, any Carry-On trolley-based special effect that is funny is twice as funny if there is a granny on the trolley at the time.
• A hypodermic syringe full of infected blood is, in its own way, a far more frightening weapon than a dagger could ever be.
• Fighting in a Majors area divided up by closed curtains could be the modern day equivalent of the classic scene of samurai cutting through paper-walls.
• A defibrillator could be charged up and used as a weapon - just don't forget (as Die Another Day did) that you need to touch someone with both paddles to properly pass a current through them.
• If a simple telephone is a useful dramatic prop in films, then multiple phones must be even better. A&E is filled with phones, from the red-emergency phone, to the dozens of phone extensions scattered around the department. The natural backdrop of sound in a busy A&E department is not the bleep of cardiac monitors, but the ringing of a dozen unanswered phones.

Hopefully this article has painted a picture for you of what an Accident and Emergency department looks and feels like, and has given you some ideas for original scenes of your own. In a fortnight we continue the theme of medical environments by examining the Consulting Room.

Till then, I hope you end up in Accident and Emergency! In character, that is...