Your Second Day

You’ve made it through your first whirlwind tour of Emergency and are kind of getting a feel for the place. There are still so many unanswered questions – who are all these different people working here? How do I juggle my workload? Why is everything always beeping?

Who's Who?

Doctors

Doctor in charge - The senior will either be a consultant (FACEM) in Emergency Medicine or a senior trainee. You should discuss each of your patients with them. They oversee their entire area, including all the patients waiting, and make sure patients are getting what they need. 

Registrars - Some doctors in the middle, like SRMOs and junior registrars, can also be helpful people for advice. They may be able to get that tricky cannula for you, know how to order a particular test or point you in the right direction if the boss is stuck in resus. You should still make a plan for each of your patients with a senior doctor. 

Nurses

NUM - The Nurse Unit Manager - There are only a handful of these senior nurses on staff in any emergency department. They run the show. While they take a hands-off role they oversee every bed and clinical space in the department. They’re the person to talk to when your patient is admitted, if they’re being discharged or if they’re getting sicker and need to move to resus. 

Triage nurse - Somewhat unintuitively these nurses have very high levels of training and experience. Triage is a high risk area where a wrong assessment can delay care for critically unwell patients. These nurses quickly get to the heart of the matter and will put all of the important information for a patient in just a couple of sentences. The triage note is a goldmine. It should never be ignored. 

Resus nurses - These nurses are generally very experienced and are able to manage critically unwell patients, often preparing vasopressors from memory and quickly drawing up medications prior to a patient’s arrival. They know how to set up non-invasive ventilation, how to assist in intubating a patient and can anticipate if a patient is becoming more unwell. 

CNEs - Clinical Nurse Educators - Senior nurses who take an education lead for the nursing body. They teach me new things every day especially about processes or equipment. I have worked with CNEs who have accessed a patient’s port, helped place a difficult IDC, started peritoneal dialysis in resus, taught me about paramedic intubation equipment and helped upskill junior nurses on when to escalate. Their skills are diverse and their knowledge deep.

CIN - Clinical Initiatives Nurse - The Clinical Initiatives Nurse are senior nursing staff who will assess and start investigation and management for patients before they’re seen by a doctor, often while in the waiting room. In a busy department this can sometimes save hours of time for a patient waiting. They sometimes pop out to ask a doctor if they should order anything specific up front for an atypical patient. 

NPs - Nurse Practitioners - These nurses act autonomously as care providers in the fast-track space. They behave more like a doctor than a nurse when on shift, picking up patients and assessing burns, limb injuries and lacerations. The nurse pracs I have worked with have been the best learning source for plastering, lacerations and burns dressings. They are often teaching me about different orthopaedic injuries and the best follow-up for these. They’re really masters at what they do and are well worth learning from. 

Acute nurses - A mix of nursing experience is often seen in the acute halls but when nurses are new to Emergency they often start here. 

Allied Health

Physios - Emergency physiotherapists are experts at plastering and can help teach you the best tips and tricks to put on a good cast. They often work as part of the ASET team to assess a patient’s mobility and they may also help someone with back pain, providing exercises for recovery (if you ask nicely). 

ASET - Aged Care Services Emergency Team - This team is available in many Emergency departments to help assess the elderly and make sure they’re suitable for discharge home. They asses mobility and safety at home including what services are in place and what they’re eligible to receive. They can put in referrals for things like MyAgedCare assessments and can sometimes also refer on to community nursing teams to follow-up with them at home. 

GFS - Geriatric Flying Squad - Some hospitals have community nurses that visit nursing homes and complete a patient’s treatment there instead of in hospital. If a nursing home patient would be treated adequately with daily IV antibiotics, GFS could arrange this (for example to treat pneumonia). This pathway helps save bed space and may be more appropriate for many nursing home patients. 

How to Space Your Day

Unlike the wards, a day in Emergency is less predictable. It makes it hard to know when to eat, caffeinate or use the bathroom.

In my experience, a Day shift is usually from 8am to 6pm, Evening from 2pm to midnight and Night shift from 11pm until after handover. When on a Day shift, try to eat after 2pm when the cavalry arrives. Try to take a break in Evening when you reach a natural lull. Sometimes your patients are waiting on scans or blood results to make the next decision. Try not to leave when it will create more dead time for your patients. Ditto with night shift. Let your senior know when you’re going to eat. Don’t skip food. Eating is essential for life.

Do use the bathroom. Stay hydrated.

Near the end of your shift, you may be tempted to pick up one last patient. Beware. When you put your name next to a patient you want to complete their workup, make a referral to the admitting team and complete all your documentation and medication charting including VTE prophylaxis too. It’s unlikely you can do this in less than two hours (depending on how complex they are). You run the risk of either making more work for the night team or getting home very late or both.

If you have an hour left of your shift, then try to finish off all your documentation and medication charting for your existing patients instead. You could also put in cannulas and take bloods from patients who need it. Or you could cherry-pick a quick and simple patient like someone with a small laceration – this type of cherry-picking is very helpful! Ask your senior what would be best if you’re not sure. They want you to get home on time too.

How Many Patients Do I Need to See?

An inevitable question and one that I think is super unhelpful. There was once an expectation that doctors would see around 10 patients a shift. This goal post is utterly unrealistic, especially for a junior doctor. Patients are becoming more complex in an aging population. Emergency doctors are also expected to complete the workup for any patients admitted to hospital, not just begin it. And good medicine takes time.

The more time you spend in Emergency the more efficient you will be. You will be able to anticipate what needs to happen next, whether your patient needs admission or not and under which team. All these things mean you will treat the patient more thoroughly and you will also see more patients.

The goal is safe care, not high patient numbers. If you try to see more patients beyond your comfort level you will instead just do a crappy job with all of them. Focus on doing good work and safe work. Then watch your efficiency improve over time.

This Patient is Really Tricky

Every patient comes to Emergency for a reason. Sometimes they just don’t tell the triage nurse. The most challenging patients in Emergency are not those with difficult medical problems. Some patients want shelter when they’re homeless. Some patients want a solution to their chronic pain or illness that we may not have. Some want a shortcut in navigating through the public health system. And some people want a medical certificate.

Understanding and empathising with the desires of your patient is the best way to learn how to help them. Sometimes the priorities between doctors and patients are very different.

If you’re getting stuck when treating a patient like this and don’t know what they need, I would ask your senior for help early. They’ve probably navigated this before, sometimes with the very same patient.

Resus

If you feel confident getting involved in resus you can definitely be a help! Pop in a cannula, learn to run a blood gas and send off the blood tubes. Stick around to help order scans or document for the team. The more you’re involved in resus doing the simple things the more comfortable you are responding in an emergency.

Following up

I think that one of the best learning opportunities I have is to see what happens to my patients. The eMR system we use allows me to save the patient details of everyone I assess. A few days later, I click through and see if my diagnosis and management was right or if there was anything I missed. Sometimes I discover something very surprising. This helps me refine my history taking and examination skills as I gain further experience. Over many years I have found patients to be some of the most wonderful teachers.