Mater Misericordiae University Hospital

Emergency Medicine (EM) Attachment Jan- March 2015

Emergency Department (ED) Handbook

and

Logbook for Assessment

Introduction.

Welcome to your Emergency Medicine attachment in Mater Misericordiae University Hospital, a department which sees approximately 50,000 new patient attendances per year. There are 3 Consultants, 6 registrars, 12 SHOs, 2 Interns, and 6 Emergency Nurse Practitioners. Emergency Medicine is defined as “a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioral disorders; it further encompasses an understanding of the development of prehospital and in-hospital emergency medical systems and the skills necessary for this development”.

As a student in the department, you will see a vast array of patients presenting with medical, surgical, social, psychiatric, and also gynaecological conditions. Patients are typically in the acute phase of their illness, very often with clinical signs that may disappear when the patient is stabilsed. You have the opportunity to be the first to assess these patients and develop the invaluable skills of initial assessment, diagnosis and emergent management. The paediatric hospital in Temple street will see patients up until the age of 16, we will see over 16’s only.

Unique to the ED is the concept of dealing with the “undifferentiated” patient, ie the patient does not have a diagnosis, or a “label” when they come through the door. Therefore we emphasise a symptoms-based approach, working through differentials with focused examinations and readily accessible tests. Patients do not present to EDs with “acute anterior myocardial infarctions”, or “abdominal aortic dissection”, but rather with “a bad bout of indigestion” or “ terrible back pain”. The key skill in emergency medicine lies in translating the patients’ presenting signs and symptoms to a definitive diagnosis, or alternatively outruling a serious life threatening cause.

Accessibility to patients and teaching is round the clock as we have 24 hour registrar presence on the shop floor and patients presenting with extreme conditions at all hours of the day and night. In the resuscitation area, you will observe and be encouraged to participate in management of patients presenting with cardiac arrest, trauma, and sepsis by staff, many of whom are instructors on life support courses. At the other extreme you will gain a unique exposure to minor injuries managed by our Advanced nurse practitioners and medical staff.

You will also be expected to perform baseline observations (temperature, pulse, blood pressure, respiratory rate, GCS (glasgow coma scale) and bedside blood glucose) and 12 lead ECGs. You will receive ample opportunity for development of your practical skills such as phlebotomy, intravenous cannulation and suturing. You will gain experience in communication skills through dealing with patients with clinical uncertainty, breaking bad news, conflict resolution, management of acutely disturbed behaviour, and patients and relatives in extreme distress. You will also gain exposure to internationally accepted clinical decision rules or diagnostic aids in the assesment of trauma and acute medical problems, eg Canadian C-Spine rules, Ottowa knee and ankle rules, Well’s score for Deep Vein Thrombosis and Pulmonary Embolism and NICE head injury guidelines.

Effective communication and co-operation with the multidisciplinary team is fundamental to effective functioning in the ED and this will be key to your success in this attachment also. If you have little or no prior experience, we will be happy to demonstrate and facilitate you in learning these skills. This will enable you to initiate your patient assesment, and establish rapport. It will also bond you with both medical and nursing staff as there is often an interdisciplinary crossover in who does many of these tasks. This will allow staff to facilitate your learning, in a positively biased learning environment for you as you will be more easily accepted as “team members”. As we work in a “hands on” specialty you benefit from the attachment in proportion to what you contribute.

Emergency Medicine Placement

1. Lectures

We are fortunate to have Andy Neil as one of our registrars who has an excellent emergency medicine website: www.emergencymedicineireland.com and he has also created podcasts on a variety of topics.

Our main induction to the department is available on the dedicated student webpage on:

materemeducation.wordpress.comPassword: medstudent

You will be expected to watch the tutorials before the lunchtime teaching sessions in order to partake in an informed discussion. The Friday session will allow students to discuss interesting cases they have seen and feedback on the placement.

2. Tutorials

There will be a tutorial every day at 12pm (except Wednesday) in the reg room in the ED delivered by Consultant or SpR/Registrar.

3. Case Presentations

It is mandatory to complete a case presentation based from the cases you have seen during your placement. These should include history and examination findings, differential diagnosis, investigations with data interpretation and management plan. The Consultant or Registrar in Emergency Medicine will complete the signoff, and this will be recorded in the log-book section at the end of this handbook.

4. Procedural Skills

Apart from experience in performing baseline observations, GCS, BM, and ECGs, it is also mandatory to undertake the following procedures, under the supervision of an ED nurse or doctor: phlebotomy, IV cannulation, arterial blood gas sampling. You are encouraged to perform urinary catheterisation, suturing, and POP application as the opportunity arises. Satisfactory completion of these procedures should be signed off in the log book section at the end of this document.

5. ‘Shop Floor” Clinical teaching

All students are assigned to the ED attachment for 1 week and we encourage you to attend all sessions as it is a short period of time.

Students assigned to ED will be expected to do 9 sessions on the shop floor over the week period. Handover takes place in the registrar room at 8am and students are expected to attend.

There is registrar teaching on a Monday morning, but students are scheduled in to attend SHO teaching on a Friday morning (there is a free breakfast!!) Once a month we have radiology teaching on a Tuesday morning, and the first Friday of the month there is a joint ED/ICU teaching session at 07:30- students are expected to attend if on placement during that week.

You should attend these when you are scheduled to be here. You may do a late shift as outlined in the timetable but these are not mandatory.

All students will be expected to spend a morning in triage, where you will perform baseline observations, +/- bloods and iv cannulation.

Students will be expected to become part of the team for the attachment. Their time should be divided between performing the initial assessment of stable patients (including history, physical, and blood tests if necessary), and shadowing ED staff during the assessment of unstable patients and observing procedures. Students will be encouraged to document notes on the ED card however this must be read and countersigned by an ED middle grade.

Students are expected to shadow doctors or ANPs, and towards the end of the week, take new patients on their own, work them up, and present the case to an ED registrar. This will include focusing on abnormal findings in the history examination and basic tests (ECG/ABG etc). Occasionally it may be appropriate for two or even three students to attend one case if it is exceptionally interesting or involves resuscitation. However it is important to be mindful of the sensitivities of staff, patients, and families. We encourage you to be as “hands on” as possible, to avoid shadowing staff when they are writing notes or making phone calls, and instead use the time to look at ECGs , Internet based learning resources such as “Up to Date” etc. You are encouraged to seek out teachers who suit your learning style, to be flexible, and identify interesting cases, at the same time as incorporating yourself into the team by helping out with practical tasks.

6. Assessment

Clinical cases and basic skills will be signed off in the log book at the end of this booklet. Students will be expected to observe a code of conduct and their overall communication skills, attitude, and empathy will be signed off in their log- book as “satisfactory” or “training needs identified”.

Safety

You will encounter a significant number of patients who have blood borne viruses such as HIV, Hepatitis B, and C in this department. Wearing of gloves is mandatory for performing all blood tests and cannulation on all patients, and wearing a visor or eye protection is recommended for suturing. Many patients also need isolation for other infectious diseases (eg TB, Gastroenteritis). You should not contact an isolated patient without the direct supervision/approval of an ED doctor or nurse. Before performing any procedure, ensure that both you and the patient are physically comfortable and behind a curtain with adequate space to perform the task, in order to minimise risk and maximise your effectiveness. If you are uncomfortable performing a task do not proceed - you will not be criticised for this. You should only see patients or take blood samples after first checking with a member of the ED staff that this is appropriate. You should explain to each patient you see that you are a medical student and obtain their verbal consent for you to proceed with taking a clinical history, examining them or undertaking any procedures.

If you sustain a needlestick injury, or blood splash to the eye inform the most senior doctor available immediately in order that the risk of the donor can be assessed, and appropriate management can be initiated immediately.

Many patients presenting to the ED may be intoxicated, agitated, aggressive or even violent, and you should not engage with such patients without the presence of a senior ED doctor. You may encounter extreme cases or scenarios which are potentially stressful or traumatic; we encourage you talk to staff about this as we are aware that the environment we work in can be very different to other areas you have worked in previously.

Orientation

The department is divided into: Triage/Reception, Resus with 5 bed spaces Majors area-all monitored including 1 negative pressure isolation room, an interview room and

the main nurses station Obs area- patients seated whilst receiving nursing care awaiting admission or review Minors- 10 bed review area including gynae room and ANP room. Back corridor includes minor theatre room, plaster room and eye room.

For your placement in the ED your group will be divided into pairs and provided zones to attend during the day. This includes sessions in our minor injuries unit at Smithfield clinc at The Forge, Smithfield Market, Dublin 7.

MON TUES WED THURS FRI0830-1130 A Triage Resus Minors Majors

SHO teaching/ smithfield

BSmithfield triage resus minors

SHO teaching/ majors

C Majorssmithfield triage resus

SHO teaching/ minors

D minors majorssmithfield triage

SHO teaching/resus

E Resus minors majorssmithfield

SHO teaching/ triage

1200-1300

Group Tutorial

1400-1700 A minors majors

Afternoon triage smithfield

Bsmithfield minors Teaching resus triage

C triagesmithfield All majors resus

D resus triage Students minors majors

E majors resus To attendsmithfield minors

1700-2000 A resus majors

B resus majorsC resus majorsD majors resusE resus majors

Mater ED student programme clinical activities

Procedure Observed Performed SupervisorVenepuncture -IV cannulation -ECG -CPRUrethral CatheterisationNG tubesuturing

Patient Presentations

Presentation Observed Own SupervisorChest painShort of breathCollapseAbdominal painHeadache/ injury

Attendance to lectures

Lecture AttendedMonday InductionTuesdayThursdaySHO teachingICU teaching (if applicable)Friday case presentations

Attendance at Wednesday teaching session

Session AttendanceSimulation sessionUltrasoundOther

Overall professionalism:

Consultant signoff for placement:

Logbook of cases/ procedures

Date M/F Age Notes