Useful information about working in Emergency Medicine
There is a Consultant in the Adult Emergency Department (AED) daily from 0800-0200h. On most days there is a Consultant in AED 24/7. If there is no consultant there will be a Fellow on night shift. They should be the first port of call for enquiries or advice related to AED. The AED Charge nurse can also be contacted.
The ED Consultant and ED/CDU Charge Nurses are always available for clinical and administrative advice for patients in AED.
All staff wear distinctive scrubs which helps with identification; ED SMO in-charge (light blue), ED SMO (black), ED/CDU Charge Nurse (red) and ED/CDU Flow Nurse (green).
Junior RMOs are expected to discuss all patients they see with more senior ED doctors, both for their own and their patients' protection. There are no exceptions to this rule. You will be assigned a senior at the start of your shift to discuss all your cases prior to discharging anyone.
Emergency medicine pearls
The Emergency Department may be one of the first clinical attachments in which a junior RMO may see and treat a patient entirely on their own.
There are ample opportunities for you to expand your procedural skills, such as ultrasound guided IV access, suturing, joint manipulation and fracture reduction, and Epley manoeuvre. As these opportunities may be sporadic and not offered to junior staff due to acuity, it is useful if you show initiative and interest in learning these skills early so that you can be taught and supervised safely for your benefit.
Certain presentations such as abdominal pain, chest pain, headache and syncope are common, but carry a high risk of a dangerous diagnosis, such as ischaemic gut, aortic dissection, and subarachnoid haemorrhage.
Ensure that you have a broad differential diagnosis, while considering the worst-case scenario: what is the worst, most serious possible cause of this particular presentation? e.g. headache − could this be meningitis/SAH?
Diagnoses that can easily be missed if not considered include:
Aortic dissections – ripping/tearing/severe pain, radiates to back, patient looks very unwell with hyper- or hypotension
Pulmonary embolism – pleuritic chest pain, SOB, hypoxia, unexplained tachycardia, risk factors – use Well’s Score and PERC score
Severe sepsis and septic shock – be wary of tachycardic/hypotensive/tachypnoeic patients with a raised lactate in the context of fever/sepsis
SAH and subdural haematomas – sudden-onset severe headaches, head injury in elderly patients, altered level of consciousness or meningism
Ectopic pregnancy – abdominal pain +/- PV bleeding +/- tachycardia/hypotension in ANY woman of reproductive age, make sure to do a B-HCG early
Cauda equina syndrome – lower back pain with urinary retention/incontinence, saddle anaesthesia, lax anal tone, or bowel incontinence.
When things go wrong, the clinical record is your strongest ally and best defence. Therefore, your records should be comprehensive: include details of your thought processes (e.g. differential diagnosis and justifications for actions taken), any clinical discussion you have had (both ED and non-ED) and their advice, and your clinical plan and advice to the patient. If you are unsure, ASK.
Please debrief the whole team after resuscitations. Debriefs are used to create a shared understanding of what has happened in critical events, and the aim is to explore what happened, what went well and what we can do better for our patients. The hot debrief form is under AED CDU webpage, which provides a framework for debriefing, including the ‘how to’ information.
CDU and Adult ED: Guidance for all Specialty Doctors
The Adult Emergency Department (AED) and Clinical Decision Unit (CDU) aim to provide an effective, efficient and safe front door service to acute adult patients presenting to the hospital.
Long delays to ward admission from ED are associated with increased mortality for both the patient being admitted and new patients arriving at ED. Best practice is that acute referrals are seen within an hour of the referral. If your team is not resourced appropriately to achieve timely review of acute patients, you should escalate this to your Registrar or SMO on call.
Acute referrals are made because either the patient needs your help, or the referring team need your help. The first specialty to be referred the patient should see the patient. It is not appropriate to decline or deflect referrals over the phone. After you’ve assessed the patient, if you think another specialty would be better suited to care for the patient, you should document your rationale for this decision in the clinical notes and refer the patient to that team. It is not appropriate to ‘bounce’ referrals back to Emergency Medicine.
Please refer to Working Collaboratively for better Patient Care document on Hippo to help you navigate patient level 2 patient care. This document also provides detail on
Patient Triage Process
Referrals from Primary Care to inpatient specialities
Types of referral process from Emergency Medicine to inpatient teams
After Assessment by EM
Failed discharge process
Inter-hospital transfers
CDU serves as both an in-patient assessment ward for patients referred in from the community and from AED, as well as an in-patient Short Stay Unit for patients waiting for a bed on the wards.
See Hippo guideline: Clinical Decision Unit (CDU) Purpose, Operating Principles and Criteria Guideline For a trauma emergency when massive transfusion is required call Code Crimson.
Please see your patients, make clinical and disposition decisions as soon as possible. Early decision making allows for good patient care and good patient flow. Patients that do not require a bed will be placed in the Ambulatory care area. To facilitate timely and efficient patient care, it is important that we all work together.