Emergency Medicine Survival Guide: Emergency Medicine Survival Guide for New Doctors

By Bensson V Samuel, MD;MSc;PG Dip

Emergency Medicine Survival Guide is a book that is very informative and gives a practical approach to medical personnel in the emergency room setting. It is aimed at medical students, advanced nurse practitioners, new physicians, and junior medical staff. It contains information that cannot be found in the books. It emphasizes safe practice of medicine, general day-to-day workings of an emergency department, and an overall guidance that could help one transition to an emergency room work setting without any difficulty.

• Language: English
• Publisher: Xlibris US
• Release date: Jun 27, 2016
• ISBN: 9781514487730

Bensson V Samuel, MD;MSc;PG Dip

Dr. Bensson Samuel completed his undergraduate degree at University of Connecticut in the field allied health, cytotechnology. He was later board certified by American Society of Clinical Pathology. He completed his medical degree at Karol Marcinkowskiego University of Medicine, Poznan, Poland. After medical school, Dr. Samuel completed his foundation training at Wirral Hospital, during which he spent of the time in acute and emergency medicine. Dr. Samuel completed to work as an SHO at Macclesfield hospital, Royal Blackburn hospital. After gaining significant exposure, he went on to work as Specialty Associate in Macclesfield and Weston Super Mare district general hospitals. Dr. Samuel completed a Post Graduate certificate in Emergency Medicine during his time there. In addition to the above, he completed his training in Internal Medicine at St. Luke’s Hospital, Bethlehem, Pennsylvania. Dr.Samuel also has completed a postgraduate diploma in gastroenterology from Queen Mary University, London. The book is a summation of cumulative experience gained from his time in the emergency department and contains insights that are not usually found in a regular textbook. The book was written over a span of five years and references Royal College and NICE guidelines written at that time. The book could be a supplementary reading and not to be used as the sole source of information. Dr. Samuel is currently employed as an ER physician at Williamsport Regional Hospital, Pennsylvania, and War Memorial Hospital, Sault Ste. Marie, Michigan.

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Copyright © 2016 by Bensson Samuel. 740883

ISBN:      EBook      978-1-5144-8773-0

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Rev. date: 06/23/2016

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Table of Contents

Introduction

Organizational Issues

Communications and Records

Discharging patients into police custody

Admissions

Hand Injuries and Referral to Other Hospitals

Observation Ward

Follow-Up from the Emergency Department

Other Clinics Including Medicine and Surgery

Pathology Services

Blood Transfusion

Domestic Violence

Major Incidents

Road Accident Medical Team

Clinical Standards

Clinical Governance Standards

NICE Standards

College of Emergency Medicine Standards

Infection Control

Resuscitation - Adult

Advanced (Cardiac) Life Support (ALS)

Bradycardia

Tachycardia Algorithm

Torsades de Point

Post-Resuscitation Care

Trauma Resuscitation

Trauma System Protocol

Resuscitation of the Traumatised Patient

Paediatrics

Pediatric Resuscitation

Non-Accidental Injury of Children (NAI.)

Anaphylaxis in Children - See Adult Page

The Child With Fever

Management by a non-pediatric practitioner

Traffic light system for identifying likelihood of serious illness

Symptoms And Signs Of Specific Diseases

Swallowed and Inhaled Foreign Bodies

Ingestion of Small Batteries

Toxic Ingestion

Unexpected Infant Deaths

Acute Asthma in Children

Convulsions in Children

Status Epilepticus

Clinical Presentations of Meningitis and/or Meningococcal Septicaemia

Diarrhea

Anesthesia in Children

Radiology Guidelines

Use of X-Rays

Indications for Radiological Examinations in Trauma

Indications for CT Head Scan in Trauma

Non-Trauma Radiology

Head Injury

The Management of Head Injured Children

Thoracic Injury

Abdominal Injury

Urologic Injury

Dressings

General Wound Care

Tetanus Prophylaxis

Bites

Soft Tissue Injuries

Spinal Cord Injury

Clinical Presentations

Anaphylaxis

Chest pain

Acute Coronary Syndromes

Acute Asthma in Adults

Chronic Obstructive Pulmonary Disease – Acute Exacerbations

Spontaneous Pneumothorax

Self Poisoning (Overdoses)

Carbon Monoxide Poisoning

Neurological Conditions

Epilepsy (Adults)

Drowning and Immersion

Abdominal pain

Acute Back pain

Breathlessness

Pneumonia (Community Acquired)

Venous Thromboembolism

Pulmonary Embolism

Ruling out Pulmonary Embolism in ED

Massive Pulmonary Embolism

Coma and Confusion

Headache

Red Flags for Headache Disorders

Accidental Exposure to Blood and Body Fluids

Serum Hepatitis Hazard

Upper Gastrointestinal Bleeding

Septicemia

Alcohol Abuse

Mini-Mental State Examination

Geriatric Depression Scale

ICD-10 symptom list for depression

Sedation

Overdose and threats of self-harm

Ear

Nose

Epistaxis

Throat

Sexual Assault and Rape

Patients Leaving Department Before Completion of Treatment

The Mental Health Act l983

The Mental Capacity Act

Under Age Contraception

Local Anaesthetic Techniques

Procedural Sedation and Analgesia

Rapid Tranquillization - Adults

Rapid Traquilization - Children

Drugs of Abuse

Packers and Stuffers

Incidents involving Radiation

Hospital Hoppers

The Difficult Dozen (some common pitfalls in Emergency Medicine practice)

Clinical Conditions Sometimes Missed or Mismanaged

Introduction

Disclosure: This book is written by Dr. Samuel over a period of five years. It is a cumulative summation based on experience and current day guidelines. The purpose of this document is to inform and advise about the day-to-day working policies in an Emergency Department. The content contains established national guidelines, guidance from Royal Societies, NICE guidelines and Oxford Hand Book of Clinical Medicine. The dosage used in this book is with reference to British National Formulary. The handbook is not intended to be a comprehensive textbook and can not be exhaustive. The cardiac guidelines used in this book are from British Guidelines.

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Other Sources of Information

Oxford Handbook of Clinical Medicine

Oxford Handbook of Emergency Medicine

British National Formulary

Dedicated to the loving memory of my grandmother

Mariamma Varghese, a source of inspiration.

Organizational Issues

Communications and Records

These are very important for safe clinical practice.

Every page of clinical notes should have the Patient’s name, number, the date and time. Every clinical record should have a signature and printed name. These are audited.

For the sake of the clinician at least it is important that the writing is legible.

It is important to complete the back summary page of the ED notes for use by reception and others.

When ending a shift it is essential to hand the care of patients to another doctor and not to leave the patient adrift in the department. This is potential source of serious error.

Writing to the GP/PCP

If you wish a note to go to the GP, write a brief, readable message in the box on the front of the Emergency Department record card and sign it or if electronic send a copy of the ER record. It will later be photocopied and sent off by the Reception staff/clerk.

A letter is advised for the following:

if you prescribe

if the GP has written to you.

if you have issued a certificate of incapacity to work.

if the Emergency Department attendance will affect the G.P.’s future management of the patient (x-ray result, allergy, etc.)

Discharging patients into police custody

Usually require medical clearance. Highlight the discharge area in your ER records that patient was discharged into police custody.

It is essential that the attending doctor assess these patients very carefully. Disruptive behaviour may be a consequence of serious pathology, or drugs, including alcohol which can mask serious underlying pathology. When it is unclear whether there is serious injury or illness the patient should be further investigated and / or observed.

When a patient is discharged into police custody, clear instructions need to be provided for the custody officer regarding further management, including when to return the patient if needed. A statement needs to be made that the patient is considered fit for detention.

It is vital that a letter is written to the forensic medical examiner (police surgeon) outlining the diagnoses, any investigation results, and advised further management if needed.

Senior doctors should be involved in cases discharged into police custody.

A zero tolerance policy does not mean that potential serious pathology can be overlooked.

Admissions

Rapid Response Team

This is a team of nurses,ER doctors and +/- internist who attend the MEW’s calls and medical emergency calls on the floor. The purpose of this call is to prevent patient deterioration.

Social Worker

Every hospital has a social worker, find their availability. They come in handy in handling patients without insurance, placement, children and adult abuse cases.

Referral to Specialties

This is usually made to the on call SHO for that specialty. There should be no arguing between the specialists through the ED staff. The team considered the most appropriate placement for the patient should be the first contacted by the ED and that team will see the patient. If they feel care under a different specialty is preferred, they are at liberty to make the referral. This is a clinical governance standard and is a unsaid working rule in most hospitals.

Tertiary Referral Centers

Patients with head injury, chest injury, or burns, where referral to the Regional Specialist Unit may seem appropriate, the assistance of the Emergency Department middle grade or consultants should normally be sought before arranging referral. Find out who your hospital has an agreement with to speed up the process.

Orthopedic Cases/DME Admission

When an elderly patient requires admission to hospital because a minor injury has rendered them incapable to managing safely in their own home, it is agreed that the most appropriate placement is in a rehabilitation bed in the Department of Medicine for the Elderly (DME).

Examples of such injuries include minor pelvic fractures, Colles’ fractures, and fractures of the proximal humerus in which there is no intention to operate. The Orthopedic SHO or resident should always see the patient first, confirm the diagnosis, ensure that any casts or bandages are correctly applied, write instructions for continuing care. Care, including the arrangement of admission, is then transferred to the admitting medical team.

Sometimes medical beds might not be available, in these circumstances the patient should be admitted to an Orthopedic bed and the medical team should be consulted so that the patient’s other medical needs are managed. In general, it is the Orthopedic resident responsibility to arrange the admission, but this may vary in your hospital. It is not appropriate that the on-call general medical team be asked to admit the patient unless there is a coincidental acute medical problem, e.g. unexplained collapse causing the injury, which itself merits the patient’s admission to a medical ward.

Hand Injuries and Referral to Other Hospitals

Patients with vascular deficit to the hand or nerve injury should first be referred to the duty orthopedic team. If they are not able to manage the patient the following arrangements are in place for referral to the Plastic surgeons or tertiary centers

Observation Ward

Prior to admission on the Observation Ward, SHOs should always discuss the admission with a senior Emergency Department doctor by day and with the sister in charge of the department at night. Record the discussion in the notes.

The Observation Ward is for the following categories of adult patients:-

Self-poisoned patients, who require no specific treatment (except parvolex) and no cardiac monitoring and who are not likely to be in danger of toxic complications. Patients with depressed conscious level GCS less than 14 require should not go to the observation ward. Patients