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In conversation, I just said:

Il s’est passé tellement de choses, et les membres de la direction l’envoient travailler dans les salles d’urgence sans arrêt, {comma} il doit être épuisé.

{Instead of}: Il s’est passé tellement de choses, et les membres de la direction l’envoient travailler dans les salles d’urgence sans arrêt, qu'il doit être épuisé.

Normally, the expected structure takes the form of "tellement X que Y", but when another clause is interposed like this, do you place a comma (rather than "que") to introduce the subordinate clause "il doit être épuisé"?

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I don't think the interposed clause matters.

You can simply say:

Il s’est passé tellement de choses, il doit être épuisé.

Tellement doesn't always require que, here the juxtaposition is enough to express the causality.

Il a tellement plu que je suis trempé.

Il a tellement plu, je suis trempé.

Il a beaucoup plu, je suis trempé.

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The logic of the second construction is wanting on the count of a missing parallel; for the sake of seeing that more easily a simple example is used;

Il est tellement tôt et le temps est si mauvais, ils sont sans courage. (1)
Il est tellement tôt et le temps est si mauvais qu'ils sont sans courage. (2)

Il est tellement tôt et le temps est mauvais, ils sont sans courage. (3)
Il est tellement tôt et le temps est mauvais qu'ils sont sans courage. (4)

The comma is not used in simple coordinations with "et"; the first set of sentences is correct because the intensities associated with the assertions (est tôt, temps mauvais) are both evaluated at a critical point, which is sufficient for satisfying to the estate introduced by "que"; this evaluation at a critical point is effected by means of "tellement" and "si". The assertions are in the sentence on an equal footing, that is to say you can suppress one and the other shouldn't be affected, nor should this suppression affect the sentence as a whole; so let's suppress the first part of the coordinated assertions in the first set;

Le temps est mauvais, ils sont sans courage. (5)
Le temps est mauvais, qu'ils sont sans courage. (6)

Only the first sentence (5) is correct because, two independent clauses can be coordinated by a comma (equivalent Le temps est mauvais et ils sont sans courage.); the cause and effect relationship is sometimes expressed that way, but it's by no means always to be decoded into a coordination. However we see now that there is no more a question of intensity, the statment is general. That's in fact what we have in "(1)" the cause and effect relationship, in that case being indicated by a degree of intensity (tellement, si). So, (6) is not correct.

In the second set only (3) is correct and that is on the count of not containing "que"; there is no need then for both coordinated clauses to be constructed in a parallel manner with respect to a conjunction; as that is the pattern of the first sentence in your question, that first sentence is correct.

The answer, as I understand the problem in these sentences, is that interposition is not a possibility and that the matter remains in the domain of coordination and preserving to coordinated parts a parallel nature. Thus, the first one is correct and the second one becomes so if modified as follows;

Il s’est passé tellement de choses, et les membres de la direction l’envoient travailler dans les salles d’urgence si souvent, qu'il doit être épuisé.

For a short sentence I wouldn't use a comma before "que"; in a long sentence it would improve reading and then, using it is a good idea.

I don't see a way to let the idea in the interposed clause imply the condition that "que" introduces as a consequence; let's consider this;

  • Il s’est passé tellement de choses qu'il doit être épuisé et avec ça les membres de la direction l’envoient travailler dans les salles d’urgence sans arrêt.

In this scheme it is clear that the idea in the coordinated clause has nothing to do in the way of justifying that in "qu'il doit être épuisé".

In this other solution an interposition (simpler) of a different sort will make everything right but at the price of a little more complexity;

Il s’est passé tellement de choses et les membres de la direction l’envoient travailler dans les salles d’urgence si souvent, en fait sans arrêt , qu'il doit être épuisé.

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