Introduction and background

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Welcome to the Cork Emergency Departments

We hope your time here will be enjoyable and valuable to you.

The primary purpose of the Emergency Department is to treat patients suffering from a recent injury or patients who are taken suddenly or seriously ill, and these patients take priority. Work in the Emergency Department is multi-disciplinary. All departments function as a team with very close liaison with the nursing staff. In many areas of emergency management their experience and knowledge will be invaluable to you, particularly when you first start.

All patients who attend the department and who have booked in at reception have a right to see a doctor. If the attendance is quite obviously inappropriate the patient should be advised accordingly and then recommended that they see their GP. This should be recorded on the ED card and a clinical assessment should be undertaken if there is any doubt. Persistent offenders should be notified to the Consultants.

Particularly difficult or belligerent patients are usually best dealt with by involving medical and nursing staff  as soon as possible. Do remember that at night and at weekends it is more difficult for patients to contact their GPs and General Dental Practitioner.

Children should be seen as soon as possible and they take priority over adults unless the adult requires urgent attention.

Please encourage all patients who are not registered with a GP to do so.

Please remember, at all times, to be polite and courteous.

Information on SHO rotas and annual / study leave rules are in admin section

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Ten commandments of Emergency Medicine

1. Your first duty is to minimise the danger of death or deterioration in your patient's health, to relieve their distress and to arrange for their appropriate disposal. Worry about distress and deterioration, not diagnosis.
2. Be meticulous, legible and logical in your clinical notes. This will help everyone else involved in the patient's care, initially and later.
3. Wash your hands before every patient contact. This is the simplest way of reducing disease transmission.
4. only undertake investigations in the ED if they are going to alter the immediate management of your patient. You may need to justify your actions (e.g. ordering x-rays or blood tests) to the individual patient (and family), in a clinical governance setting and in a court of law.
5. Be evidence-based, logical and cost-effective in your prescribing. Don't prescribe adverse reactions and unnecessary expense.
6. Follow the WHO recommended "analgesic step ladder" in relieving pain, i.e. (i) paracetamol; (ii) ibuprofen, (iii) codeine-paracetamol combinations (iv) opioids. Only in unusual circumstances should alternative medication be provided (e.g. novel NSAIDs, tramadol or pethidine).
7. Only undertake procedures whose benefit to the patient outweighs the hazard: e.g. Plaster of Paris should not be badly applied when a simple splint might do. And don't give medication intravenously when normal gastrointestinal function exists, unless there are special indications.
8. Get advice or a review whenever in doubt: this means asking senior medical and nursing colleagues.
9. Arrange follow-up for every patient: e.g. by their GP, at an AED Review Clinic, by admission, outpatient clinic, or at another hospital. The easiest way to reduce error is to ensure that all patients who come to an AED are reviewed medically at least once thereafter.
10. Treat the patient, not the test. 

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Communications

Good and effective communications are vital (risk management)

• The majority of mistakes and complaints derive from poor communication.
• Write clearly on the ED card the treatment required so that nursing staff and receptionists can continue the patient's care.
• When going off duty a clear and complete handover of patients (and responsibility for that patient) must be arranged between staff.
• Unfortunately the so called computer systems at CUH are not designed to collect any clinically helpful data. The new system, due to be in use Spring 2004, will be little better.
• Please use the IM&T systems in the Mercy University Hospital (they collect diagnostic and investigative results) to help communicate with in-patients and community colleagues.
• Despite these restrictions, please try to manually complete patients records and code appropriately, particularly in the following cases.
  • Significant illness or injury likely to need GP follow-up, including sick notes or prescriptions.
  • Patients referred to the Emergency Department by their GPs.
  • All children under 16.
  • Frequent attenders.
  • Attendees associated with drug and alcohol abuse.
  • An injury likely to have medico-legal implications, e.g. Road Traffic Crashes

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Please see the note keeping section

 

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ACCESS Translations

Supply all the local hospitals with interpreters on a 24 hour basis. They are also included in the National Emergency Plan, as well the Mountain Rescue. For details please contact Cathy Goode, 13 Bruach na Laoi, Union Quay, Cork.   (021) 4316 022. Link

The NHS in the UK have prepared Emergency multilingual phrase books that are available for download. Please note that the information they produce is under Crown copyright, which is administered by Her Majesty's Stationery Office.

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Admission policy

Accepted cases are seen by the accepting team but the ED staff are responsible for the patient until a member of that team arrives and we may need to give urgent treatment.

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Sickness benefit claim forms

Please note that only registered patients can be considered eligible. Memo.

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Professional secrecy

In any communication to any bodies whatsoever the patient's right to confidentiality must always be respected. It is quite indefensible for any member of the Emergency Department staff to give information either verbally or by telephone to any person such as managers at work, school, etc., without the patient's written permission. The only people who have a right to know the nature of the patient's condition are the patient himself, and/or the next of kin, parents if the patient is under 16 and the patient's own General Practitioner.

These comments relating to professional secrecy are to safeguard the confidentiality of any information the patient may give to us and the same rules apply even if information is requested by the Gardai. No information, under any circumstances, should be divulged to the Gardai without the patient's consent. The Gardai do not have the right to see case sheets, with the exception of serious crime such as homicide, etc., in which circumstances it is expected that the SHO will:

a. consult with his senior immediately and having done so,

b. give the Gardai all reasonable help if he/she is advised to do so.

NB: Even if the patient concerned is in Garda custody or a prisoner it is still necessary to obtain their written consent before divulging any information.

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Blood samples

Use the vacutainer system for your safety and that of others.

The accurate labeling of all blood samples is of paramount importance, especially requests for transfusion.

Specimens for cross-matching must be labeled by hand

Addressograph labels must not be used

The indications for clotting screen out of hours should include:

• haemorrhage unrelated to trauma
• history of a known or suspected bleeding disorder
• known or suspected liver disease
• paracetamol OD with a delay in seeking medical advice
• after massive rapid transfusion
• suspected disseminated intravascular coagulation

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X-ray commandments

1. Treat the patient, not the x-ray: the diagnosis of many important conditions depends mainly on clinical findings (e.g. fractured base of skull, scaphoid fracture, Salter-Harris Type I injuries to the paediatric epiphysis, a pulled elbow in a toddler).
2. Take a history and examine the patient before requesting an x-ray: a clear understanding of the mechanism of injury may prompt the discovery of a second injury (typical "paired injuries" include a cervical spinal injury in the significantly head injured patient, fracture of the radial head with Colle's fracture, a fracture of the styloid process of the 5th metatarsal and an ankle fracture, a fractured calcaneus and fractured thoraco-lumbar junction).
3. Only request a radiograph when necessary: imminent European legislation will penalise clinicians who unnecessarily irradiate patients (e.g. x-rays are rarely required in cases of a fractured coccyx, fractured nose, head injury undergoing CT scanning or isolated rib fracture).
4. Never look at an x-ray without seeing the patient first, and never see a patient without looking at their x-ray.
5. Look at every x-ray, the whole x-ray and the x-ray as a whole: remember the ABC's of x-ray interpretation (A = Adequacy and Alignment; B = Bone; C = Cartilage and joints; S = Soft tissues).
6. Re-examine the patient when there is an incongruity between the x-ray and the expected findings.
7. Apply the Rule of Twos: i.e. get two views (at right angle to each other), include two joints (above and below the injury site), x-ray two sides (when necessary, e.g. with subtle epiphyseal injuries in children), on two occasions, (e.g. for stress or scaphoid fractures), and where possible get two x-rays (reference and abnormal).
8. Take x-rays before and after procedures: e.g. removal of foreign bodies or reduction of dislocations and fractures.
9. If an x-ray does not look quite right, ask and listen: there probably is something wrong.
10. Try to ensure that you are protected by a variety of "fail-safe" mechanisms: e.g. a green and red label system for prioritising radiology reporting.

X-rays requests

The x-ray request should contain, at a minimum, mechanism of injury and the site of focal tenderness.

Do not send seriously ill or injured patients to the x-ray department until they have been resuscitated.

It is almost always necessary to obtain an x-ray if the patient returns with the same problem.

Do not be afraid to discuss with the radiographer any problem you have because the films are not of diagnostic quality or the required views have not been taken. Do not accept single views of the hip, lateral views of the cervical spine which do not include C7/T1, views of the leg or forearm which do not include the joints at each end, etc.

The only portable X-rays considered appropriate are chest, lateral cervical spine and pelvis.

 

Abdominal pain - "When not to X-ray":

• non-specific abdo pain
• acute peptic ulceration
• pancreatitis
• acute appendicitis
• biliary disease (Ultrasound)
• urinary retention
• acute UTI
• haematemesis/melena
• constipation

 

Patients who are receiving Metformin are at risk if given intravenous contrast medium. Patients must have a full assessment of renal function before IVU or CT scan in such patients

 

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Consent to treatment;

Please also see mental health section.     Extracts from the MDU Booklet:-

Emergency situations: "A practitioner may be faced with a patient requiring immediate treatment which is itself associated with serious risks but which must be undertaken if his life is to be saved. He must advise the patient to the best of his ability and endeavour to secure his consent before his rendering such treatment as is immediately necessary. If the condition of the patient does not permit of this, the practitioner should if possible, discuss with a near relative the treatment proposed, but in any event the patient should be given whatever treatment is immediately necessary".

Minors: 

Under Sixteen: "Except in an emergency the consent of a parent should be obtained before any operation is performed on a person under the age of sixteen. The recommended form is Form II. The health or life of a minor must not, however, be jeopardised by waiting for formal parental consent. If, in an emergency, it is impossible to obtain the consent of a relative the practitioner should render all such treatment as is reasonable and necessary".

Sixteen and over: "Section 8 of the Family Law Reform Act 1969 provides that the consent to a medical or surgical or dental treatment of a minor who has attained the age of sixteen years shall be effective consent from the parent or guardian".

Consent CUH

Patient in CUH should be informed about relevant procedures and the relevant admission consent form, consent for a photograph to be taken, consent for surgery and consent for tissue retention.

Consent at CUH - Patient Information (beware large document), Staff Information

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Ref 1. Touquet R, Driscoll P, Nicholson D. Teaching in A&E medicine: 10 commandments of accident and emergency radiology. BMJ 1995;310:642-5

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Content by Dr  Íomhar O' Sullivan on 02/03/2004.   Reviewed by Dr ÍOS 17/01/2005, 14/01/2007.   Next review 14/01/2008.