Life in the Emergency Department
This chapter describes the way the Emergency Department operates, and some of the unwritten rules. The prevalence of Emergency Department-based drama generates plenty of misconceptions about what occurs in the Emergency Department. For instance, it is generally inadvisable to say ‘stat’ at the end of one’s sentences, and neither of the authors has been mistaken for George Clooney!
What happens when a patient arrives at the Emergency Department?
Also known as the ‘red phone’ or sometimes ‘the Bat-phone’, this is the dedicated phone line that the ambulance service uses to prewarn the Emergency Department of incoming patients likely to need resuscitation.
The concept of triage comes from military medicine – doing the most good for the most people. This ensures the most effective use of limited resources, and that the most unwell patients are seen first.
Nurses rather than doctors are usually used to perform the triage because doctors tend to start treating patients. Systems of rapid assessment and early treatment by senior medical staff can be effective, but risk diverting attention from the most ill patients.
The reception staff are essential to the function of the Emergency Department: they register patients on the hospital computer system, source old notes and keep an eye on the waiting room. They have to deal with difficult and demanding patients, and are good at spotting the sick or deteriorating patient in the waiting room.
Adult and paediatric patients should have separate waiting rooms, and some sort of entertainment is a good idea. Aggression and dissatisfaction in waiting patients has been largely eliminated in the UK by the 4-hour standard of care: all patients must be seen and discharged from the Emergency Department within 4 hours.
Treatment areas in the Emergency Department Resuscitation bays
Resuscitation bays are used for critically ill and unstable patients with potentially life-threatening illness. They have advanced monitoring facilities, and plenty of space around the patient for clinical staff to perform procedures. X-rays can be performed within this area.
High acuity area
This is the area where patients who are unwell or injured, but who do not need a resuscitation bay, are managed. Medical conditions and elderly patients with falls are common presentations in this area.
Low acuity area
The ‘walking wounded’ – patients with non-life-threatening wounds and limb injuries – are seen here. Patients with minor illness are discouraged from coming to the Emergency Department, but continue to do so for a variety of reasons.
There is a common misconception that patients in this area are similar to general practice or family medicine patients. Numerous studies have found that there is an admission rate of about 5% and an appreciable mortality in low acuity patients, whereas only about 1% of GP consultations result in immediate hospital admission.
Imaging, such as X-rays and ultrasound, are integral to Emergency Department function. Larger Emergency Departments have their own CT scanner.
When dealing with the relatives of a critically ill patient and breaking bad news, doctors and relatives need a quiet area where information is communicated and digested. This room needs to be close to the resuscitation area.
Observation/short stay ward
This is a ward area close to the Emergency Department, run by Emergency Department staff. This unit treats patients who would otherwise need hospital admission for a short time, to enable them to be fully stabilised and assessed. The function of these units is described in Chapter 28.
Hospital in the home
Some hospitals run a ‘hospital in the home’ programme for patients who do not need to be in hospital but who need certain therapy, e.g. intravenous antibiotics, anticoagulation. The Emergency Department is the natural interface between home and hospital.
Culture of the Emergency Department
There is a much flatter (less hierarchical) organisational structure in the Emergency Department than most other areas in the hospital. This occurs because all levels of medical, nursing and other staff work together all the time, and the department cannot function without their cooperation. Ensuring good teamwork requires good leadership, an atmosphere of mutual respect and a bit of patience and understanding.
The resulting atmosphere can be one of the most enjoyable and satisfying places to work in a hospital. A feature of this less hierarchical culture that surprises junior doctors is that nurses will question their decisions; this is a sign of a healthy culture in which errors are less likely to occur, and is actively encouraged.
Emergency Department rules
Being a doctor in the Emergency Department is different from elsewhere in the hospital. There is nowhere to hide and, for the first time in most medical careers, you are responsible for making the decisions. On the positive side, there are plenty of people around to help you, who have all been through the same process.
Some basic advice:
• Write legible, timed, dated notes.
• Show respect for other professional groups and be prepared to learn from them.
• Do not be late for your shifts; do not call in sick less than 6 hours before a shift.
• Patients who re-present are high risk and need senior review.
• Take your breaks. You need them.
• Keep calm.
• If in doubt, ask.
• Do not pick up so many patients that you cannot keep track of them.
• Do not avoid work or avoid seeing difficult patients. We do notice.
• The nurse in charge is usually right.
With so many people working closely together in a stressful atmosphere, it is inevitable that conflicts will occur. Do not let them fester; some ground rules for resolving such conflicts are:
• Resolve it now.
• Do it in private.
• Do it face to face.
• Focus on facts.
• Criticise action, not person.
• Agree why it is important.
• Agree on a remedy.
• Finish on a positive.