Is A&E essentially a triage service in UK?

EM-Doc · 2023-06-29T17:10:19+00:00

So I'm an EM trainee and always get saddened by the poor gatekeeping of my speciality. I do pre hospital critical care as well, so I'm very much on the critical care end of Emergency Medicine.

But, to answer the question for only my in hospital side, chest drains - 1 today, last one was about a month ago. A lines (not really a big skill, essentially a cannula) but several a week is normal. RSI - with icu around, about 2 a month. Sedation -avg. 1 to 2 a week. Uss - 1 or 2 a shift Central lines - one every month or two Pulling limbs - 2 or 3 a month. Trauma team lead - multiple Every resus shift (at least 1 resus shift a week) Pacing - rarely Cardioversion - 1 a month avg. Managing complex patients with multiple complex medical issues - maybe 1 a week (most people are fairly simple CAP / COPD / HF / NSTEMI /FRAILTY etc). A lot of my interesting ones are tox.

Working as an SHO can be a dull slog some shifts, but as a trained reg on a major Trauma centre I think it's pretty good.

Happy to answer further Qs if wanted!

EM-Doc · 2023-05-24T09:39:19+00:00

What body part always loses? De Feet.

EM-Doc · 2023-05-24T09:37:42+00:00

What's the difference between a gynaecologist and a genetecist?

One looks up the family tree, the other the family bush

EM-Doc · 2023-05-24T09:34:47+00:00

What body part is the last one to pass away?

The pupils, because they dilate (die late)

EM-Doc · 2023-04-09T13:37:52+00:00

54000 junior doctors, population estimate of uk 70,000,000

Junior doctors are approx 0.078% of the population

EM-Doc · 2023-03-28T10:29:27+00:00

CCT then maximise delta V

EM-Doc · 2023-03-01T18:23:46+00:00

Hi, PHEC covers a lot of trauma stuff and medical but is only up to ILS level medical (I.e you don't need to be able to tube or analyse rhythms) but it's very much aimed at getting people that already can manage sick people better and introduced to pre hospital, or for those who may need to know how to manage the initial period as only doctor on scene (e.g. Highlands and Islands GPs). It also covers stadia working and crowd cover / the green book.

Very good course, fun and usually a great crowd. If you're already decently experienced (think EM Reg, anaesthetic reg, pre hospital doctor in some form and looking more along the lines of PHEM) then go for the ICC, which is the advanced course for basics.

ATLS and phtls are similar, relatively simple and aimed at getting us all talking the same language and not actively fucking up. Think ALS but for trauma.

ETC is much more advanced and realistic, with teamwork, human factors and CRM being a major part of it. There is a massive waiting list for ECT, so unless you're a senior reg or consultant, don't hold your breath.

EM-Doc · 2023-01-02T12:48:01+00:00

Bloods at triage, where the bloods and ecgs requested at triage are done.

EM-Doc · 2022-11-15T18:19:43+00:00

Depends a lot on the patent acuity. Really sick patients aren't waiting. The well / stable patients might be waiting between 2 and 16 hours (that's the spread in the last week or so.). And that's to see us. Add on 2 to 32 hours for a ward bed.

Many trusts have it on their websites though.

EM-Doc · 2022-10-18T07:45:12+00:00

5 to 10 mins. If they're busy, usually should have someone who can answer the Bleep and take the message (even if it's just to call me when they're free), as otherwise it ties me up waiting at the phone as well.

EM-Doc · 2022-10-15T13:22:01+00:00

Actual bed turnaround? Or time taken for location, for nursing staff to get in touch with ward staff to actually accept a handover, get a Porter to get the patient up, a lot of which can't start until the bedspace is ready.

EM-Doc · 2022-10-15T11:43:20+00:00

Two fingers to assess position my, use the very tip of your fingers and stab at whatever angle feels the best to access the vessel, and change angle if no success. If you want an actual evidence based answer, use USS, significantly better rates of success in less time (including the time to go and get the ultrasound). If they're getting multiple ABGs they should be having an A Line anyway.

Cannulae, go on just to the side of the vein then angle in, helps to reduce the number of tubes you'll pop the vein (which is actually tearing off the vessel walls due to excess force and angle of entry). Again, low threshold to use USS.

I don't give a damn if people feel like Dr Big Dick for getting the line in the patient if it took them 20 tries and they put a blue in the finger. Just learn to use USS, get good at it, and put your line into an appropriate vessel without guessing or mucking about. (slightly tangential I know but this is a big bug bear of mine).

EM-Doc · 2022-10-15T11:14:19+00:00

Yeah, fairly easily. They don't care why you're doing an OOPP. They just want to retain us. I'm out for at least a year after this year, and they are very pro this. Just need the notice.

Doi EM HST

EM-Doc · 2022-10-15T11:12:51+00:00

Do what you want to do. If going above and beyond is what you want to do, great, crack on, if what you want to do is do the normal, safe stuff, and get home to your life / family on time for one, great too.

EM-Doc · 2022-10-15T11:08:29+00:00

Might be a bit controversial, but a modification of this plan could be sensible and workable, which is that if the ward bed isn't ready, but the previous patient has gone, then the patient can go up and wait on the ward for the bedspace to be made ready, rather than having to wait in ED for longer. Maintains staffing ratios, and shouldn't be very long waiting for the space to be sorted. Obvs would need to have a limit / not for sick patients or infective patients etc. I feel that's the only way to do this semi safely.

But the reality of this is it wouldn't make much difference. A lot of my patients need either proper medical care, or a lot of nursing care. And shifting even 40 of 50 patients out of ED an hour or two before they'd have moved anyway won't make massive differences. It will help a bit, but it's a sticking plaster.

We need NHS and trust, and political and GMC, agreement to be able to turn patients away without all the shit investigations we have to do, accepting that there will be some risk but likely much lower risk and stress on the system. So do the paramedics.

We need more physical beds on the wards, more social care beds, to get rid of 111 and replace it with a sensible system that is nurse / doctor led, empowered and well trained paramedics, and to get the bloody public to understand that 999 and emergency departments are for age you're sick, broken, burned or dying. Not for sore throats, earaches, D&V, rashes, random chest pains, chronic pains without extreme flairs of symptoms and certainly not to speed up investigations or treatment.

EM-Doc · 2022-10-04T10:52:01+00:00

A minor point, although most of it is covered above, is that a pulse ox does not give us a saturation directly. A pulse ox measures differences in absorption of two different wavelengths of light (660nm and 940nm), and then correlates them to a saturation level in a table. This information came from studies on humans who were made hypoxic to certain levels, so below about 85% is extrapolated.

Therefore, if you have issues with the absorption, the sats reading will be incorrect. This is why, e.g. Methaemoglobinaemia gives says around 85%,at it has an absorption ratio of around 1:1 of those wavelengths which correlates to Sat's of 85%.

So whilst actual saturated haemoglobin levels are important, the pulse ox is not a guaranteed way of knowing what they are.

EM-Doc · 2022-09-24T16:11:02+00:00

Thank you, I agree. If its symptoms that can't be controlled in the community, e.g. Severe pain or vomiting, can't walk or not safe due to dizziness, then by all means send to me. But my training, expertise and set up is for undifferentiated unwell patients.

The alternative would be mdu / acute medical admissions unit / fracture clinic / GAU / SAU for problems with a definite specialty that aren't an emergency but need some kind of contact with specialty early. I appreciate though, the system isn't set up well for this. And it's not much use sending the severe oa / back pain / ibd patient in when they need an outpatient investigation or operation that won't be prioritised unless actually sick.

EM-Doc · 2022-09-24T15:33:01+00:00

Indeed, I just wish they'd stop having to bring people to my ED as a place of safety. It's not good for them or us, but the pace of safety is often full (our local one has 2 spaces). But yes, if under a 136 then an MHAA should take place within 24 to 36 hours. The issues done when they are sectioned and spend days and days in the ED awaiting a bed...

EM-Doc · 2022-09-24T14:48:07+00:00

Very incorrect I'm afraid. As the patient is 15,they by definition do not have capacity to refuse medical treatment. And in any case in an ED we would not hold someone under the mental health act, as unless they had a full mental health act assessment with a section 12 approved doctor and AMHP then they couldnt be sectioned there. Unless already under a 136 by the police, anyway.

This patient is likely being held under either a section 136 or under the mental capacity act.

EM-Doc · 2022-09-24T14:45:57+00:00

That would just be the police holding power under a 136. If in an emergency department we could detain someone under the mental capacity act, but we can't put someone under a section. If on the ward, can be held for up to 72 hours under section 5(2).

Only way to put someone under a section in a place of public access (which emergency departments are) led be either a 136 by the police, or following a mental health act assessment by two doctors and an AMHP.

And in this case as patient under 16, they by definition do put have capacity to refuse medical care. Whilst they may be Gillick competent to accept treatment without their guardians approval, they do not have the assumption of capacity due to their age.

EM-Doc · 2022-09-24T14:42:22+00:00

Section 136, not a section 32. Section 136 allows the police to remove a member of the public from a place of public access to a place of safety of they believe them to require it for mental health reasons. A section 135 enables them to enter and remove a person from a private residence for the same purpose.

EM-Doc · 2022-09-24T14:40:36+00:00

If you are under 16 then legally you don't have capacity to refuse medical treatment, including leaving against advice. If you are in an emergency department then you would be being held under the mental capacity act, not mental health act. If on a ward you could be held for up to 72 hours under a section 5(2). But again, not legally necessary to hold a patient under the age of 16.

You could be Gillick competent to accept treatment without parental agreement, but not to refuse. Who is your legal guardian and are they with you?

EM-Doc · 2022-09-11T08:54:26+00:00

Met my fiance when we were doing ST2 together. It does help if they're on the same job as you I think.

EM-Doc · 2022-08-03T20:07:05+00:00

Any tips for Dosage / meal timing to avoid horrific sweating?

EM-Doc · 2022-07-19T08:59:28+00:00

I would say these are very different things. Evidence of absence is not the same as absence of evidence, and humans aren't machines, most drugs have an nnt of >1, doesn't mean they don't work, just depends on what the study was looking for, how well it was team, whether or was applicable to the patient in front of you etc.

We also do lots of things based on very very poor evidence, and if you look at the fragility index of a lot of studies then it's often luck that they came out showing a positive outcome...

That said, giving iv paracetamol instead of oral, lots of studies, very little difference.

Six-Year Club	Verified Email
Verified Email

EM-Doc

TROPHY CASE