Your First Day

Welcome to the Emergency Department! Patients are waiting hours to see a doctor, everything is beeping and… something smells funny.

This blog post aims to help you navigate your first few shifts, understand what other people are thinking and help you prioritise what you do so that you can make the most of your shift and, ideally, get out of here on time.

Priorities

How we do things in Emergency is often a world away from the wards or an outpatient clinic and our priorities are also very different. I find this is generally poorly explained in medical school and leads to anxiety and confusion in junior doctors. When seeing a patient in Emergency, we often start management long before finishing our assessment. We treat symptoms and address our patient’s vitals sometimes hours before we come to a unifying diagnosis. In fact, I would argue that diagnosis is not our primary role in Emergency at all.

You will treat and discharge many patients who do not have a clear diagnosis. This is normal and ok.

Our role in Emergency is to:

1. Stop patients dying (resuscitation)

2. Catch life-threatening illnesses

3. Treat people’s symptoms

To do this effectively in an emergency department we also need to prioritise patient’s disposition and movement from one place to another. When we don’t do this well, people have heart attacks in the waiting room.

For anyone interested in understanding this in more depth I highly recommend this lecture by Dr Reuben Strayer, I’ve recommended it to countless colleagues and it continues to impress:

What is an Intern's Role in Emergency?

I think it’s important to acknowledge that an intern’s main job in Emergency is not to see lots of patients or single-handedly diagnose rare diseases or be a team leader in a resuscitation. The intern in Emergency is mostly there to learn. There are certainly ways that you can be very helpful but you will also be assessing undifferentiated patients for the very first time. You’re allowed to be bad at it! That’s how we all began.

The most important thing I want to say is this – if you are unsure about something, please ask for help. When junior doctors feel too embarrassed to ask, that’s when mistakes happen and when people can get hurt. If your patient is getting sicker and you don’t know what to do, get some help. If you don’t know how to complete a task, like charting a heparin infusion for the first time, get some help. If a well-meaning nurse asks you for something you don’t understand, like marking a yellow doctor arrow on Firstnet, please ask someone for help. 

Your boss expects you to discuss every patient with them and will probably also see all of them again until you gain more experience and confidence. This is normal! Do not expect yourself to know what to do! That’s what internship is for.

What does Emergency look like?

In most large Emergency departments in Australia and New Zealand the medical shifts are split into Day, Evening and Night shifts with some exceptions. There is an area for resus patients (with severe illness requiring immediate care), acute patients (in beds), “fast track” or ambulatory patients (in a waiting room with some adjacent consult rooms), sometimes a separate Paediatrics area and a Short Stay area which is like a mini ward where Emergency patients can stay for a few extra hours if needed. Resus patients are usually cared for by the acute team. Each shift, you’ll be designated an area and a senior to supervise you.

Your First Shift

You arrive on your first shift, slightly nervous and well-caffeinated. You will likely be on a team with other junior doctors, registrars and a consultant (or FACEM). What do you do first?

Introduce yourself

Let your consultant know who you are and your level of training. If you have particular things you’d like to see or learn then this is a great time to bring it up. If you are an intern, your work should be directly overseen i.e. you need to talk to a senior about every patient and, ideally, they should be reviewed by a senior as well.

Ask how they would like you to work

Usually you will be looking at the list of patients and will be asked to see the longest waiting in your area (10 hours!?). Sometimes there’s a specific patient your boss would like you to see. Sometimes they will get you to do some documentation for them to save time or pop in a cannula for a patient needing bloods or waiting on a CT scan. Emergency is always changing. Try to stay flexible and add value where you can. Every boss also works differently.

Before you see your patient

I recommend looking at the triage note (ignore this at your peril), their vital signs and any relevant medical history just for a few moments. This can save you a huge amount of time and stops you going down any rabbit holes. You can also get an idea of whether your patient is sick and likely to get worse anytime soon.

Front load investigations

Most acute patients need blood tests. If these haven’t been done already then take a 2 minute history before sending the bloods. This can save you an hour of waiting. Similarly, if they obviously need a CT brain or a chest xray then order this early to save some time. You will get better at anticipating what people need the more patients you see. It starts off hard. It does get easier!

Reporting back

Talk to one senior doctor about each one of your patients. There are many ways to skin a cat – ask three consultants, you’ll get three different answers. If your patient changes, go and speak to the same person who made their initial plan. This saves time, keeps patients safe, stops doubling up on work and stops people treading on each other’s toes. When you have an admitting team for your patient also let the NUM know to facilitate bed movement.

A word on cherry-picking

Sometimes a senior will ask you to see a specific patient out of waiting time order – that’s normal and helps the flow of the department. But sometimes junior doctors will look at the list and choose an interesting case, skipping the longest people waiting. Sometimes many people will skip a patient with back pain or an elderly fall. It’s always noticed and it’s not a great look. If you have an interest in something particular and would like to pick them up just ask the boss. The exception is trying to see something simple quickly near the end of your shift so you can finish before home time. 

Referrals

Many people will tell you how to make a referral. My one piece of advice is to put all the spoilers at the start. “Hi Dr Thidwick, my name is Josh, I’m one of the registrars in Emergency at The Lord’s Work hospital. I’d like to talk to you about a patient for admission under Respiratory with Pneumonia. Would you like the patient details or the story first?” In three sentences I try to tell them the who, where, what and why of my call. The answer to my last question depends on the person you’re talking to and stops them interrupting you halfway through your spiel.

The pace of the day changes depending on the time and if it’s in-hours or out of hours.

Referrals in-hours can take a long time – generally, you page a registrar who will see the patient in person. There are often delays to that registrar seeing your patient and then delays in their admission (while they talk to their own boss), so have that conversation as soon as you can and move on to the next patient. This contrasts with after-hours where you call someone directly instead of paging. Here, you should have the information you need for the other person on the phone to get a clear picture of your patient. They can then help guide your management if they want anything specific.

There’s a crunch time around 11pm. Here, you will be trying to wrap up your patients, and the night team will be starting. If you delay your phone call too long, then it will be too late to admit your patient and you may need to hand this job over to the night team. Where possible, you should try to avoid this. When a phone call is handed over, the night doctor often doubles up your work and has a harder conversation later. If you’re able to make an earlier call and a plan for your patient before you go home, you’ll be doing the night team a massive solid. 

Night shifts work differently. Non-urgent phone calls are left until the morning, and you make them all together before you leave your shift. This is different in every hospital and the senior on at night can help you organise this.

There are exceptions – most hospitals will have 24-hour cover from general surgery, O+G and sometimes psychiatry. Here, paging is still the best way to contact them, and you can discuss a patient for admission at 2am.

The shift is done!

Good job! There are a few things you should make sure are finished before you head home.

• Finish all of your documentation including prepping any discharges for the patients who will probably go home

• Chart all your patients’ regular medications. Do they need VTE prophylaxis?

• Make sure all your patients are handed over including the admitted ones (they will still probably stay in ED for a while)

• Update your patients (and/or their family) about the plan so they know what to expect next

I like to save patients I want to follow-up. Checking on their progress helps me learn what I should have done differently and of course if my diagnosis was right.

Emergency can be pretty taxing. We see a lot. Take a moment to breathe. I like to think about a few things I did well and a few things I’m grateful for. Get home safe and do it all again tomorrow.