bangor ed news spring 2012

THE EMERGENCY DEPT TECHNICAL UPDATE (+ ADDED EXTRAS TO MAKE IT MORE INTERESTING) Spring 2012

Compiled by Dr Linda Dykes - email [email protected] VOL 4; NO 1 - SPRING 2012 PAGE 1

Spring is here, the clocks have gone forward, and the tourists have started to arrive!

Hmmmm. Maybe that last bit is not so good: the ED is in the midst of very challenging times, and a few hundred thousand extra people staying in our catchment area, whom we will look after

when they manage to fall over/ get ill/ crash cars/ slip on Snowdon means the impending tourist season is being viewed with some trepidation by the ED staff !

On the other hand, there is much to celebrate:

Our trainees have given us spectacular feedback in the GMC survey; plans for the

ED rebuild (a two-storey wraparound-extension) are progressing very nicely with work due to start early in 2013; recruitment to the Clinical Fellow scheme (middle grade doctors) for August 2012 is

going brilliantly; and we will soon have an isolation resus/sedation room up and running (in Room 3, the one that was a “Major Treatment Room” years ago) which means we can make more use of important modern ED techniques such as ketamine sedation in kids.

So, Mr “SAPhTE Red” Gridlock, you haven’t beaten us yet!

BEDLESS BANGOREMERGENCY DEPARTMENT LOCAL EDUCATION &SOCIAL STUFF

You couldn’t make this one up……

We promise this isn’t an April Fool (and warnings have been circulating for a few months now) but how’s this for a tale?

Thousands of potentially deadly bracelets have been sold in the UK by unwitting retailers, including 2800 from Cornwall’s Eden Project…. until one of their own horticultural experts happened to notice that the bracelets were made from Jequirity Beans (the seeds of the deadly abrus precatorious plant) which contain a toxin called abrin, chemically related to ricin.

An ingestion of 3 micrograms can be lethal. Isn’t that just smashing? A WMD on a child’s wrist!

IT’S SPRING IN YG ED! Incorporating News

mailto:[email protected]




From the editorWelcome to Bangor ED’s BEDLESS - the first of 2012!

AWSEM News is back too - material relevant to all Welsh Emergency Departments is incorporated within both Bangor (and Bridgend’s!) BEDLESS, but made available separately to those Welsh EDs who don’t have their own newsletter.

This is a strange and challenging time for Ysbyty Gwynedd ED. A shortage of medical beds and “access block” (AKA “Gridlock”) have crippled our performance in many ways for many months now, and all ED staff are deeply concerned that we cannot maintain quality of care when we regularly have a dozen medical patients to look after for very long periods, leaving no resources, staff or space for incoming new ED patients.

We can only hope that BCUHB management can find a way out of current quagmire that is completely outside the control of the ED, and take heart from the thought that we will survive these trials, and every change we manage to undertake to optimise our performance despite these challenging times should mean that, when when patient flow returns, we may well have become be the slickest hottest most fabulous ED in Wales.

We’re certainly one of the most desirable EDs to work in Wales: our Clinical Fellow scheme will begin its second year in August 2012 and we have some absolutely fabulous doctors appointed for these innovative posts. We have, as mentioned on the front page, been singled out for praise from the Deanery for our fabulous feedback scores from our trainees - an accolade that must largely belong to the nursing staff and middle-grade doctors who look after our young doctors at the coal face around the clock. And we continue to be a very popular medical student placement, with students from inside (and outside) the rest of the UK booking electives with us - our first booking for Spring 2013 was recently confirmed. Oh yes, and did we mention we are interviewing for a new consultant (“locum-with-a-view”) later this month?

More news in the Summer issue of BEDLESS - please, please send in your contributions!

Linda Dykes, Consultant in Emergency Medicine

WHAT’S IN THIS ISSUE?Front Cover% Self explanatory, one hopes!%% Editor’s Note & ContentsPage 3%% Learning Points & RemindersPage 4%% New developments Page 5%% Pathway Update: Infective diarrhoeaPage 6%% Pathway Update: HIV testing in the EDPage 7%% Pathway Update: Referrals to psychyPage 8%% Pathway Update: Sedation checklist

Page 9 % Pathway Update: Walton SAHPage 10 % TIA referralsPage 11% Pathway Update: Haemaphilia/vWDPage 12% Reflections on GridlockPage 13% Local CPD: TA hospital talkPage 14% Chemical Suicides and % % % % metamphetamine lab trainingPage 15% New Occ Health contact details Page 16% The Bangor ED Hello magazine!

Have you visited our website yet? If you haven’t, you really should: www.mountainmedicine.co.uk

Have a delve around and you’ll find everything from a Rogues Gallery of ED staff to a guide to Leisure Activities in North West Wales! And we do stress - it is a tota#y unofficial website, which is run and maintained by the ED Consultants on a purely

voluntary basis! We have a blog on there - do check in regularly!



http://www.mountainmedicine.co.uk




Peak Flows

There’s a magic bit of kit that needs to see the light of day when assessing or treating anyone with a possible asthma attack… yes, the peak flow meter.

And we’re not getting it out as often as we should be!

PEF is a basic part of the essential observations of anyone who may be having an asthma attack. And yet it is hardly ever being done - recent example would be a 13 year old girl, known asthmatic, brought to ED following SOB & chest tightness on a gorge walking trip.

No evidence of PEF being checked (and there wasn’t even a proper chest examination detailed, for that matter)

Metal Detectors in the ED...

We are still x-raying kids who have swallowed coins - despite other units having been happily using metal detectors as a screening tool for years. It seem immoral (and is probably illegal under IRME) to be subjecting young kids to an unnecessary dose of radiation, so we’d like to switch to using a metal detector too: has anyone got a nice one they don’t use anymore?

Escitalopram, citalopram & dose-dependant QT prolongation

In the last issue of BEDLESS we included the MHRA-triggered alert about larger doses of citalopram carrying a risk of QT prolongation - not a drug we normally prescribe, but we do prescribe some other drugs that

could act synergistically to prolong the QT interval (e.g. some antibiotics).

The MHRA have now extended their alert to include escitalapram… so the take home message is evolving as “if it ends in PRAM, think QT”!

Altitude Sickness

Despite what some anxious patients may try to tell you, altitude sickness is not a problem anywhere in Wales. Not even on the top of Snowdon. Honestly, truly….

Snowdon is only 1085m (3560 feet) above sea level.. altitude sickness does not 0ccur below 5000 feet (and most people are fine up to 8000 feet, which is the pressure on board commercial airliners!)

Large scalp wounds...

Some scalp wounds are too large to be effectively cleaned and sutured in the ED, largely because the volume of local anaesthetic required would be too large (total maximum dose of lidocaine is 3mg/kg, increased to 7mg/kg for lidocaine + adrenaline. Sedation after a head injury isn’t

usually a very good idea (it may be sometimes be acceptable after a normal CT brain) so a delayed toilet & suture under GA may be the only option.

If this is necessary, the local agreement is that the orthopods will accept the patient… this was confirmed in a letter dated 10th December 2010 from Glynne Andrew. Current orthopaedic junior doctors may not be aware of this agreement and should be politely made aware of it if required.

Pelvic ultrasounds in women

Our radiology colleagues have asked us to warn women we are referring for pelvic US that a transvaginal scan may be required to visualise the uterus and ovaries. If the patient is pre-alerted this may be necessary it can avoid awkwardness when they are asked to consent to this when in the scanning room if they have not previously considered the possibility.

LEARNING POINTS & REMINDERS….

Percentage Calculations...

Do these put your head in a spin? You’re not alone - many people are confused by them. Your starting point is that 1ml of 1% solution of any drug contains 10mg of the drug. Two ED examples:• 10ml of 2% lidocaine contains 200mg of the drug… the maximum dose for a 66kg adult (unless you use lidocaine with adrenaline/epinephrine!).• 50ml of 50% dextrose contains 25g of dextrose…. we don’t use 50% dex any more (it rogers veins) so instead we have to use a larger volume of more dilute solutions of dextrose to give the same dose for emergency treatment of severe hypoglyaemia, e.g. 250ml of 10% dexrose.





Marvellous NAC calculator

Hands up anyone whose never managed to make a mistake writing up Parvolex (N-acetyl-cysteine). No one? Thought so.

Well, in an unexpected benefit (possibly the only benefit so far identified!) of belonging to

BCUHB [stop right there, you’# have us a# shot - Ed] a little delving into the intranet revealed that Glan Clwyd have a nifty NAC calculator/ precription app.

And we love it. To find it, get onto the intranet in Explorer. Choose Pharmacy Resources from the short-cuts> Central Area pharmacy resources> Parvolex Treatment Chart.

You need the patient’s name, weight (kg) and D number handy and then as if by magic, et voila, up pops a personalised prescription chart.

We’re getting some 1000ml bags of 5% Dextrose for EDOU to make it easier and reduce the risk of error when preparing the 3rd bag in the sequence.

Amazing Mersey Burns App

Got an iPhone? Then download the Mersey Burns App - free. Designed by the Mersey region Plastics service, the app calculates burn size in % and if you tap in the patients age/weight and time of burn it will also work out fluid requirements for you.

We have had incidents where ED docs have got the fluid formulae and the fluids to give muddled up, and this app should help enormously.

Bladder Scanners

The urology nurses are, understandably, getting very fed up with ED staff repeatedly borrowing their bladder scanner so we are getting out own. Until they arrive, however, don’t forget that all the ED seniors and most of the middle grades are perfectly capable of using our own ultrasound machine to tell you if a bladder is full/moderate ore empty, if you’re really not sure!

Don’t forget stroke thrombolysis!

If a patient arrives in the ED in office hours within about 3.5 hours of onset of stroke symptoms, summon the ED middle grade or senior doctor immediately (triage orange) - only a very small proportion of stroke patients are eligible for lysis but it would be a tragedy to miss one because of inappropriately low prioritisation on arrival. We recently lost 20 minutes of precious brain time as nobody had flagged up to the shop floor supervising doctor that such a patient was in the ED.

Remember: if you can’t see the Shop Floor Supervisor, they’# be on the 999 bleep! (unless Mark has taken it home again by mistake!)

Trauma or cardiac arrest? Book in as unknown

When a critically ill or injured patient is brought to the ED, we need a D-number - immediately. Waiting for the patient to arrive to “get them booked in” wastes precious moment of time and distracts the clinical staff & paramedics during vital early minutes of a resus room situation. Also, details obtained in a hurry like this are often wrong.

It’s much better to book such patients in as “unknown male/female” initially. This will give them a D-number that is a unique identifier. Their name, address and GP can be obtained later; and if a local patient has ended up with two D-numbers they can be merged later, too.

Also, please bear in mind that the paramedic of winchman bringing in a confused head-injured patient with no informants may have no idea what their casualty is actually called: it is not helpful for ED staff to harangue them in this situation!

WATCH THIS SPACE:WHAT’S NEW OR COMING SOON TO BANGOR ED!

Did you know?

Colchicine - better known as a treatment for acute gout in patient intolerant of NSAIDS - can be used to treat recurrent pericarditis, and may well become a first line treatment (in addition to NSAIDs) for initial attacks for pericarditis too…..





NEW/REVISED PATHWAYS - I

?Infective diarrhoeaPatient presents with diarrhoea

Ysbyty Gwynedd Emergency Department

Q1 - Any suspicion that the diarrhoea is infectious?

• Do not give antibiotics• Admit if severe abdo pain• Consider admitting very young or very old patients• All children with suspected E Coli infection should be referred to/discussed with Paediatrics (even if they are not seriously unwell)• Beware Haemolytic Uraemic Syndrome (HUS) which can lead to renal failure

YES• Treat as normal: keep up fluids and rest.• Always advise re infection control procedures (see below)• Anti-diarrhoeal drugs are not recommended

Draft 3 - Jan 2012Dr Linda Dykes (Consultant EM, YG) & Dr Chris Whiteside (Consultant PH, North Wales)

NO

Includes: Associated fever

Recent foreign travelBloody diarrhoea

Known outbreak of infective diarrhoeaOthers in household affected

Other contact with affected individuals

If “Yes” to any, send stool sample to lab

Q2 - Is there any possibility of E Coli infection?

Consider E Coli if:

• Stools grossly bloody or uniformly blood stained (the

diarrhoea itself may range from mild to severe)

• There has been contact with farm animals or a known outbreak/contact

• Fever is not usually a feature of E Coli infection.

Check the patient is passing urine normally and check U&E if any concerns

FOR ADVICE ON INFECTIVE DIARRHOEA OF PUBLIC HEALTH IMPORTANCE (E.G. E COLI O157):

Contact Public Health: in hours (01352) 803234, out of hours ring Ambulance Control and ask for Public Health On-call.

Don’t forget: infectious bloody diarrhoea, “food poisoning” and enteric fever are notifiable by law (no need to wait for microbiological confirmation)

Diarrhoea: INFECTION CONTROL

• Stay off work/school/college for 48 hours after the diarrhoea stops• Everyone in the household should pay attention to hand-washing, after visiting the toilet & before preparing/eating food. Children will need supervision! • If hospitalised, use side room, barrier nurse & ensure all medical and nursing staff are aware.

Diarrhoea & the Septic Patient

Dr Stuart Darcy, one of our Consultant Microbiologists, asked us to flag up the following key points:• Don’t treat gastroenteritis with antibiotics unless you have a septic patient.• If you do have a septic patient, use ciprofloxacin (until cultures prove otherwise, which will be info available after the patient has left the ED). • If the stool is bloodstained, be very sure that the patient is indeed septic (not just run down and debilitated secondary to dehydration) before giving cipro, so as not to precipitate HUS in a possible E. Coli O:157 case.

Infective Diarrhoea New Jan 2012

• Prepared in conjunction with Public Health colleagues…. Dr Chris Whiteside and Linda Dykes drafted this over a working lunch….. which is a bit gross….

• Contains reminders about E Coli, esp. E Coli O157.

• The “pooping cow” caused some controversy at a regional infection control meeting. It’s actually there to provide a “visual anchor” to help make the association between infectious diarrhoea, farm animals, and E Coli O157.

• Plus, it’s funny…. Which means that people might actually talk about this protocol, which means they are more likely to remember that the protocol actually exists, which sadly is more than can be said of most public health memos….





NEW/REVISED PATHWAYS - II

HIV Testing in the ED

• Atypical meningitis/encephalitis• Cerebral Abscess• Intra-cranial SOL of unknown cause• Multi-dermatomal/recurrent Shingles• Glandular fever-like illness


The ED is moving towards implementing the recommendations of the UK National Guidelines for HIV Testing (2008).

All ED doctors should offer HIV tests to patients presenting with the following:

1 - Consent Verbal Consent, documented on the form. You must also obtain and document permission to share result with their GP.

v1.0 - Jan 2012 LKD/NG/UA/SDReview date - by Jan 2013

2 - Contact details

Example: a student from a sub-saharan African country with an atypical chest infection

In addition, be alert for patients with risk factors (either who are from areas of the world where HIV is very common, or, who have lifestyle risk factors)

as we must offer an HIV test whenever it is clinically indicated.

This is not everyone with a

viral illness and fever: but if you are intending to send a monospot,

you should probably send an HIV test too.

Check name & address - ensure GP is documented.Obtain up to date contact phone number(s).

3 - Do the test Yellow bottle, microbiology form. Don’t forget to include reason for the test & GP details on request form.

5 - Put in the file Check that you have filled in the HIV Testing Sheet completely, and left a copy in the Immunodeficiency Testing File.

Remember!Always get permission to leave phone message/

voicemail “in case of any queries”

4 - Book results appt Book an appointment in Academic F2’s results clinic (Monday morning >1 week away) - see “HIV testing file”

Important: This protocol does not include all the conditions in the 2008 guideline:

We have included those conditions that are both likely to be been in the ED and where a clinical/radiographic diagnosis is possible. We have not

included “bacterial pneumonia”: our microbiology colleagues have advised this should be confined to patients with bacteriologically confirmed lung

infections, and will therefore fall under the remit of inpatient specialties, not ED. We are working with GUM, Microbiology & Acute Medicine & the

eligible groups for HIV testing from the ED may be expanded.

Started on 1st Feb 2012:See the last issue of BEDLESS (the “Whole of 2011 issue”) for a full discussion of the rational behind HIV testing in the ED.

HIV Testing FormYsbyty Gwynedd Emergency Department

Photocopy this form when completed:

Original stapled to ED card + photocopy to Immunodeficiency Testing File.

v1.0 - Jan 2012 LKD/NG/BH Review date - by Jan 2013

! Sticky Label here

Indication for HIV test in EDAtypical meningitis/encephalitis ! ! ❒Cerebral Abscess! ! ! ! ! ❒Intracranial SOL ?cause! ! ! ! ❒Multi-dermatomal or recurrent shingles! ❒Glandular Fever-like illness! ! ! ❒Clinically indicated in high-risk patient! ! ❒

• State details:

Date of ED visit:

ED Doctor:

Discharged from ED! ❒Admitted from ED! ❒If admitted...Under which team? (circle)

Medics!! SurgeonsO&G! Walton Centre

Other:

Date of Results Appointment:

Contact Details - GPIs GP correct on ED card? Yes ❒ No ❒

If no, obtain correct details & tell ED Reception

Contact Details - PatientIs address on ED card correct? Yes ❒ No ❒Obtain at least one contact phone number:

Can we leave a voicemail message if necessary? Yes ❒ No ❒Offer of HIV test accepted - Record of Verbal Consent: I have explained to this patient why I have offered an HIV test. The patient has accepted the offer of an

HIV test and understands that the result of the HIV test will be available to his/her GP.

Signed: …………………………….…… PRINT NAME/GRADE: ……………………………Offer of HIV test declined:I have explained to this patient why I have offered an HIV test but s/he has declined to accept the offer of

HIV testing, or, is unwilling to allow an HIV test result to be shared with his/her GP.

Signed: …………………………….…… PRINT NAME/GRADE: ……………………………

If patient states reason(s) why they have declined, record here:

Just follow

the form!

The proforma and

the pathway (above)

provide step-by-step

instructions what to

do. Just find the

“Immunodeficiency

folder” (red, lever

arch file) and it’s all

right there!





NEW/REVISED PATHWAYS - III

Referrals to Psychiatry - new Feb 2012

• Prepared in partnership with the psychiatric team, we hope this pathway will remind ED staff to refer to psychiatry early….. and remind psychiatric SHOs that they can come and assess patients as soon as they can hold a sensible conversation….. which is not necessarily the same as being “medically fit for discharge”. • Inappropriate insistence upon the latter is a major source of breaches, and frustration within the ED team, so we very much welcome the clarification.• We are hoping that the existence of this document will make referrals to psychiatry out of hours as painless as those in-hours…. when we have our fabulous psych liaison team to call upon.

Referrals to Psychiatry

Delays in Psychiatric referral and assessment are one of the leading causes of avoidable Emergency Department 4-hour breaches – please refer as early as possible to avoid delays.


Patients presenting following deliberate self harm or overdose with suicidal intent, or otherwise requiring psychiatric assessment,

must be referred promptly to the appropriate Psychiatric Services

Patient fit for psychiatric assessment, and probable discharge from ED

Patient not yet fit for psychiatric assessment or is likely to be admitted (e.g. to Medicine or EDOU/Beuno)

0900-1700 daily (inc weekends)

Refer to Psychiatric Liaison Service. No need to wait for blood tests/results.

Inform Psychiatric Liaison Service. Provide an estimate of when patient expected to be

medically fit for assessment.

Our of Hours(1700-0900)

Refer to Psychiatric On-Call Service. No need to wait for blood tests/results.

Inform Psychiatric On-Call Service. Provide an estimate of when patient expected to be

medically fit for assessment.

Is this patient fit for psychiatric assessment? “Fit for psychiatric assessment” is not necessarily the same as “Medically fit for discharge”.

Patients who are comatose or heavily intoxicated will not be fit for psychiatric assessment, but mild/moderate intoxication does not necessarily preclude psychiatric assessment.

(Ref: Council Report 118: Psychiatric services to accident and emergency departments, Royal College of Psychiatrists; 2004, P18)

Please note: patients referred to Psychiatric Services remain under the medical care and responsibility of the Emergency Department until “medically fit for discharge”.

How to contact the right person:

Via Switchboard(long range bleep)

1630-0100 Bleep 108 (SHO)

0100-0900 Bleep 089 (Hergest bleep-holder)

v1.0%%Feb%2012% %Developed%by%Dr%Ben%Hall,%ST4%EM%&%rati>ied%by%EM%Consultants%(LD/RP/MA),%Psychiatric%Liaison%Team%&%Dr%TatineniReview%by%February%2014.%

When you don’t see for looking: Corneal Foreign Bodies and the gorilla in the

baseball game…..

Many people will be aware of the now-classic video of a basketball game with a gorilla walking across the pitch: almost half of people watching that video for the first time fail to notice the gorilla if they’re concentrating hard on counting the ball-passes between human players.

Similar things can happen in medicine. An ED doctor saw a patient c/o FB in eye after walking past a grinding machine 3 days before, and examined the eye expecting to find a FB in upper or lower fornix, but saw nothing, including on carefully everted the eyelid. On staining with fluorescein, no green appeared. Puzzled, the ED doc referred to the Eye team who instantly spotted a central corneal FB. How?

Firstly, the patient was, by then, more tolerant of light on his pupil which had hampered earlier slit lamp exam. Secondly, fluorescein may take a few minutes to get a fix on disrupted corneal cells. And thirdly, the ED doc had started out with an expectation of finding a FB in the more usual position of

under and eyelid and overlooked the obvious.





NEW/REVISED PATHWAYS - IV

Sedation “Pre-flight checks” - new March 2012We have recently had an incident where a patient undergoing procedural sedation ended up with an oxygen mask attached to medical air, instead of oxygen, as the measures we have previously taken to try to eliminate this risk (i.e. medical air flowmeter is meant to be removed and clipped flat onto the wall when not in use rather than being left in situ; the colour coded signs at the oxygen/air outlets) failed.

Luckily the patient came to no harm, but this is an easy mistake to make: equivalent to putting petrol into a diesel car…. which hundreds of people do it every day, despite pumps being colour coded!

There are a number of other aspects relating to procedural sedation that we could do with tightening up on, particularly in these difficult days when staffing is so stretched and the sedation bay in the resus room may only be available for a limited period.

So, we are setting up an “ED Safer Sedation” group to enable us to raise our standards of sedation across the board, but especially as propofol and ketamine use starts to become more common: any volunteers?

And we have introduced this aviation-style checklist: there’s a copy in the sedation bay in resus.


Sedation ChecklistTo be used before any ED sedation procedure

v1.0! Feb 2012! Linda Dykes

1 - Patient ID Has the patient got an ID bracelet on?

2 - Consent Is the consent form completed, signed & present?

3 - IV access Is venflon working, checked, flushed and secure?

4 - Allergies Are any allergies noted on ED Card & Sedation Form?

Has the sedating doctor checked the Airway? (e.g. loose teeth, caps/crowns, restricted neck movement, time last ate/drank)5 - Airway

6 - Oxygen Is the oxygen mask/nasal cannulae definitely connected to oxygen and not the Medical Air outlet?

Is ECG/Pulse oximeter connected & BP set to cycle q3min?

Is Capnography set up and working? Use either the monitoring nasal cannulae or cut end off standard monitoring line.

Is the suction checked, working and ready to use?

Is there an ambu bag and face mask to hand?

7 - Monitoring

8 - Capnography

9 - Suction

10 - Airway kit

Are today’s x-rays displayed on PACS?11 - X-raysAre the minimum numbers of sedation-trained staff present? 2 ALS providers - absolute minimum one doctor, one nurse12 - PeopleAre the minimum numbers of authorised, trained staff present? Minimum 1 x middle grade/senior authorised to use these drugs in Ysbyty Gwynedd ED in addition to all the requirements above.

13 - ketamine & propofol only

Sedation may only proceed if the answer to all these checklist questions is “YES”





NEW/REVISED PATHWAYS: V

Sub Arachnoid Haemorrhage:New North Wales pathway - Feb 2012Following on from the excellent guide to Head Injury management, this new document provides a comprehensive guide to the immediate and ongoing management of SAH.

It’s a fairly beefy document - 12 pages - but there’s a useful two-page summary/checklist (right) that we suspect will be of great

use as a quick reference guide… we will place a copy in the new ED Protocol File that should be up and running by the time you read this.

Take-home messages for ED staff include the three-step Care Bundle for optimising outcome after SAH: • Control of ICP (which may rise due to hydrocephalus

and global cerebral oedema)• Optimisation of cerebral perfusion and oxygenation• Prevention of anuerysm re-bleeding: control of blood

pressure & seizure prophylaxis.

The bundle includes instructions on frequency of Obs (for example, pupils should be checked frequently: minimum half-hourly for first 12 hours).. other than that it is very similar to the head injury protocol (SAH is after all just another kind of brain injury….) which we’re not bad at following, but things like 20-30 degrees head up tilt (if SBP allows) do sometimes get forgotten.

There’s also a checklist/referral form to use at the time of phone referral (it’s very similar to the Head Injury one we have used for some time) and a reminder of the World Federation of Neurological Surgeons SAH Grading:

North Wales Critical Care Network [APPROVED] January 2012.

1

North Wales Crit ical Care Network

SUBARACHNOID HAEMORRHAGE

PATHWAY &

CARE BUNDLE (for Adult patients requiring Crit ical

Care)

Quick Guide for Subarachnoid Haemorrhage (SAH) Care Bundle

Bundle Element Aims Rationale Exclusion Compliance Audit Point Pupillary reflexes performed minimum ½ hourly for 12 hours. Hourly for 24 hours, then 2 hourly thereafter.

Pupillary reactions will provide prognostic information. Prompt detection of changes in size, shape and/or reaction of pupils any indicate swelling/an expanding lesion and increasing ICP.

Avoid venous congestion • Head tilt 20-300, preferably 300 • Neutral head position • Avoid external compression (consider use adhesive

or loose ETT tapes) • Avoid high thoracic pressures (adhere to bowel

protocol).

Head elevation will reduce oedema (and thus ICP) but >300 may reduce MAP and therefore CPP. Head rotation and neck flexion can increase ICP by impeding cerebral venous drainage. Tight ETT tapes will impede venous return. Straining will increase abdominal and thoracic pressures. Avoid ‘clustering’ care – stagger interventions giving time for ICP to settle in between.

Element 1: Control of Intracranial Pressure (ICP)

Control agitation/maintain adequate analgesia and sedation • Analgesia and sedation. • (If required) muscle relaxant with neuromuscular

monitoring.

Sedation will help dampen the effect of any stimuli that might increase ICP. NB Beware of hypotensive effects of sedation, especially boluses.

Neuromuscular blockade may need to be considered if patient movement or ventilation remains problematic despite full sedation. It will also help to avoid rises in ICP due to coughing, straining etc.

Terminal care. EOL Care Pathway. Patient does not require neuromuscular blockade

Are there attempts to control ICP? Do all patients with a GCS less than 15 have Neurological observations performed as described? Are all patients nursed • Head elevated • In a neutral position Are all patients adequately sedated and analgesed?

Administer Nimodipine to all SAH patients • 60mg orally/NG every 4 hours, continued for 21

days. If enteral route is not possible, consider IV infusion via CVP as per BNF; 0.05mg/ml at 5-10mls/hr.

Administration of oral Nimodipine improves outcome after SAH. The oral (or NG) route has been shown to be just as effective as intravenous administration, but is associated with less hypotension.

Element 2: Optimisation of cerebral perfusion and oxygenation

Adequate circulating volume • Capillary refill <2 seconds • CVP minimum 8mmHg (zero at mid-axilla) using

isotonic crystalloids 0.9% NaCl at 1.0-1.5 mls/kg/hr. • Consider hypertonic saline where hyponatraemia

present • If u/o >4mls/kg consider Rx for D.I.

Maintenance of cerebral perfusion pressure (the variable which defines the pressure gradient driving cerebral blood flow) can be achieved with fluid replacement and inotropes (see below).

Hyponatraemia occurs in 20-40% SAH patients as result of the syndrome of inappropriate excretion of anti-diuretic hormone (SIADH).

Terminal care. EOL Care Pathway.

Are there attempts to optimise cerebral perfusion and oxygenation? Do all patients have • Nimodipine • CVP minimum 8mmHg • pO2 >13kPa • MAP >80mmHg • pCO2 4.5-5.0kPa

Adequate perfusion pressure • Systolic <160mmHg, diastolic <110mmHg • MAP >80mmHg

o adequate filling (as above) • Vasopressors as necessary • Antihypertensives as necessary • Adequately filled (as above)

Hypotension will result in a reduction in cerebral blood flow thus causing tissue hypoxia. Hypotension has been uniformly identified as the predominant factor in secondary brain injury and has highest correlation with morbidity and mortality. Hypertension

Adequately oxygenated • SaO2 >93% • PaO2 >13kPa

Hypoxia is the second most influential cause of secondary brain injury after hypotension and worsens outcome. Hypoxia causes vasodilation which will increase ICP.

Avoid hyperaemia • pCO2 4.5-5.0kPa

Hypercapnia causes vasodilation which increases cerebral blood flow and volume and therefore ICP. NB Beware low VT (e.g. Ventilator bundle causing an increase in PaCO2)

Hypocarbia causes vasoconstriction which may exacerbate the risk of ischaemia.

Control pyrexia • Maintain normothermia < 37.00C

For every 10C increase in temperature there is a 10-13% increase in metabolic rate. Therefore pyrexia will exacerbate ischaemia. Shivering markedly increases ICP

Control hyperglycaemia • Maintain blood glucose or 6-10mmol-1 • (Avoid hypoglycaemia at all costs)

Hyperglycaemia may worsen cerebral ischaemia by decreasing cerebral blood flow. NB Beware of hypoglycaemia – the injured brain cannot tolerate it

Control of blood pressure (see also f – adequate perfusion pressure) • Systolic <160mmHg, diastolic <110mmHg

• adequate filling (as above) • Vasopressors as necessary • Antihypertensives as necessary

A labile BP is common in high-grade SAH. Hypertension increases the risk of re-bleeding however hypotension must be avoided at all costs as it causes a reduction in cerebral blow flow resulting in cerebral ischaemia.

Element 3: Prevention of rebleeding; control of blood pressure, seizure prophylaxis. Control fitting

• Consider the context and requirement for induction of anaesthesia/intubation and ventilation

• If indicated; load with Phenytoin 20mg/kg IV bolus followed by 300mg/day* (adjust dose according to plasma levels corrected for serum albumin); not exceeding 1.5grams/24hrs.

Seizure activity may cause rebleeding. It may also cause secondary brain injury as a result of increased metabolic demands, raised ICP and excess neurotransmitter release.

Patient does not require antiepileptics. Terminal care

Steps taken to reduce the risk of re-bleeding? Are all patients with SAH • Normotensive • Adequate control of

fitting (where necessary)

Or is there an attempt to achieve these parameters?

Grade Descriptor GCS

I Mild headache with or without meningeal irritation 15

II Severe headache but no focal deficit 13 or14

III Severe headache WITH focal neurological deficit 13 or 14

IV Depressed level of consciousness with or without focal deficit 7 to 12 inclusive

V Unconscious patient 3 to 6

Email Sue O’Keefe on Sue.O’[email protected] to request a copy of the fu# guide or check out the North Wales Critical care Network website at www.wales.nhs.uk/nwcriticalcare

Caution!

The first version of this document contained an error regarding the dose of IV nimodipine: a revision was issued in early March.

If you are using a printed-out version, please do check you are using the right one!







NEW/REVISED PATHWAYS: VI

New TIA referral arrangements The Acute Stroke Team have now got their TIA Clinic system up and running. We no longer need to routinely automatically admit high-risk patients with TIA, which are patients with:• ABCD2 score 4-7 or• More than one TIA in past 7 days or • TIA despite being on warfarin already.

Instead, for high-risk TIA patients, during office hours we will bleep the Acute Stroke Team on 082, and out of hours we will fax a complete copy of the new TIA Clinical Referral Form (right) to 01248 384722. Low-risk patients just need to be referred by faxing a copy of the same form. Please fax over, or pop a copy of the ED notes in the post to the TIA clinic, too.

The TIA Clinic referral forms live in the same drawer at the hub as the double-sided ED “TIA and ABCD2 checklist” and “ROSIER: ?Stroke” forms (pictured below) which are there for anyone to use, nursing staff and students as well as doctors… in fact, ROSIER was developed and validated for use by UK ED triage nurses.

TIA and ABCD2 ChecklistYsbyty Gwynedd Emergency Department

! Sticky Label here

ED tasks:1) Check contact details ❒2) ECG ❒3) Check risk factors3) Bloods (U&E, FBC, Gluc) ❒Request on form that a copy is sent to both the Acute Stroke Unit and the patient’s GP.

Signs & Symptoms which may suggest TIA:• Sudden unilateral weakness or numbness of face, arm or leg• Difficulty with speaking or being understood• Visual loss in one eye• Loss of balance & co-ordination + weakness • More than one of dysarthria, vertigo, double vision, ataxia or

dysphagia.

ADCD2 Risk Stratification ScoreADCD2 Risk Stratification ScoreADCD2 Risk Stratification Score Score

A Age >60 years 1

B BP Systolic >140 and/or Diastolic >80 1

C Clinical Features

Limb weakness 1Clinical Features

Speech difficulty 1

Clinical Features

Both of the above 2

D Duration of symptoms

>60 mins 2D Duration of symptoms 10-59 mins 1

D Duration of symptoms

<10 mins 0

D

Diabetes 1

Total of ABCD2 =Total of ABCD2 =Total of ABCD2 =

Start aspirin 300mg for 2 weeks (unless CI or on warfarin) then reduce to 75mg OD

ADCD2 Score 1-3: low risk

Routine referral to TIA clinicFax a “TIA Clinic Referral Form” to 01248 384722.

Referral sent ❒

Signed: …………………….

ADCD2 Score 4-7 or >1 TIA in 7 days or TIA despite warfarin

Fast Track TIA assessment

0900-1700 M-F: Bleep 082

Out of hours: fax a “TIA Clinic Referral Form” to 01248 384722.

All patients:• Warn patient to expect the following:! Smoking Cessation! ! Increase exercise! Reduce alcohol intake! ! Health eating programme! GP may start statin; commence treatment for hypertension if ! resent; and may consider dipyridamole or (if patient is in AF), ! warfarin. • Tell patient they cannot drive for four weeks after a ?TIA• Return to ED if symptoms recur• Instruct patient to contact 01248 384677 if they have not been

contacted within 2 working days with an appointment date for the TIA clinic.

Sign to confirm patient informed of this ………………………………..

v2.0 LKD Adapted from ASU “TIA Pathway” for ED use Jan 2012 & updated March 2012 with new TIA clinic details

Use ROSIER on other side of this form if symptoms still present

New TIA Clinic Referral

Form

Symptoms/Signs not suggestive of TIA:

One or more of loss of consciousness, light-headedness/ faintness/ dizziness. total body weakness or fatigue, drop attacks or amnesia = not likely to be a TIA.

Consider referral to Medicine or neurology.

D D M M Y Y H H M M

Assessment Date: Time: D D M M Y Y H H M M

Symptom Onset Date: Time:

GCS E = M = V =

BP *BM * if BM <3.5mmol/l, treat urgently and reassess once blood glucose normal Yes No Has there been loss of consciousness or syncope? -1 0

Has there been seizure activity? -1 0

Is there a NEW ACUTE onset (or on wakening from sleep) of: i. Asymmetric facial weakness +1 0 ii. Asymmetric arm weakness +1 0 iii. Asymmetric leg weakness +1 0 iv. Speech disturbance +1 0 v. Visual field defect +1 0

**Total Score (-2 to +5) ** Stroke is likely if total scores are >0. Scores of <0 have a low

possibility of stroke, but not completely excluded

Provisional Diagnosis: Stroke Non-stroke (specify)

Stroke Instrument Guideline: 1. If total score > 0 (1 to 5) a diagnosis of acute stroke is likely and should be admitted to the

Stroke Unit (Prysor) during the hours of 9-5 Monday to Friday, or the Acute Medical Admissions Unit (Tryfan) out of hours.

2. If total scores 0, -1 or -2 stroke unlikely but is not excluded and patient should be discussed with the Stroke Team, or Acute Medical Admissions Unit on call Doctor.

3. Patients with a score of 0, -1 or -2 should be admitted to Tryfan FIRST

PLEASE FILE COMPLETED FORM IN PATIENTS MEDICAL CASENOTES Appendix A- SOP 009 - Use of the ROSIER Scale Author: Rachael Barlow, Patient Pathways Facilitator Nursing and Healthcare Governance Directorate, Ysbyty Gwynedd Tel. 01248 385094 / Email: [email protected]

Reference: Nor AM, Davis J, Sen B, et al., 2005, ‘The Recognition of Stroke in the Emergency Room (ROSIER) scale:

development and validation of a stroke recognition instrument’, Lancet Neurology 4(11), 727–34

Patient ID Label ROSIER Scale Stroke Assessment Tool

The aim of this assessment tool is to enable medical and nursing staff to differentiate with stroke and stroke mimics.

TIA protocol Ysbyty Gwynedd Emergency Department Use ABCD2 on other side of this form

if symptoms have resolved

ROSIER: ?Stroke

v2.0 LKD Adapted from ASU “TIA Pathway” for ED use Jan 2012 & updated March 2012 with new TIA





NEW/REVISED PATHWAYS: VII

This pathway has been produced in conjunction with the haematology team in response to a series of incidents where patients with haemophilia or vWD have presented to the ED and not had their clotting factor treatment for several hours.

In one case, this led to a serious haemarthrosis and another patient was greatly distressed by the apparent inability or unwillingness of ED staff to prescribe and administer clotting factor treatment.

The root cause is, of course, lack of confidence in managing a problem that is very simple to clinicians who do it all the time, but jolly terrifying to those who don’t.

The gist of the new protocol is to try to give ED staff the confidence to get on and give the necessary treatment to these patients: and, if advice is required, not to build in unnecessary delay by phoning the medical registrar (who will probably have to phone for advice too).

So - ask the patient; ring the lab; and don’t hesitate to call the Consultant Haematologist on call for advice if required.

Haemophilia & Von Willebrand’s:What to do in the Emergency Department

Examples:• Epistaxis• Bleeding from mouth/tongue• Haemetemesis• Melaena• Haematuria


Is the patient obviously bleeding?

Head Injuries: Treat like warfarinised patients (and be alert to the possibility of intracranial haemorrhage):• Low threshold for urgent CT scan• Consider Clotting Factor replacement after any HI

Immediate treatment required• Any delay may have serious consequences• Most haemophiliac/vWD patients will need factor

replacement immediately*: check with patient/lab • If advice is needed, ED staff must contact

haematology urgently: do not cause additional delays by expecting medical registrar to do this.

v1.0 - March 2012 - From protocol supplied by haematology team - LKD/MH/NB

DO….• Hurry up! Untreated bleeding will

progress rapidly if treatment if delayed.

• Listen: haemophilia patients and their relatives are trained to recognise bleeding episodes, so listen to their opinions. They are likely to know more than you do!

How do I know what factor to give?

• Patient may tell you and/or bring a supply of their coagulation factor.• If not, contact blood bank/on-call haematology biomedical scientists

(bleep 043) - they have access to treatment records of local patients. • If further advice needed, contact on-call consultant haematologist.

How do I give clotting factors?

Who to call if you need advice Office hours: ! Haemophilia Specialist Nurse: Bleep 958/ext 5172 ! ! or Alaw Unit: 4008/4945/4331Out of hours: ! 1st - Haematology biomedical scientists (Bleep 043)! ! 2nd - Consultant haematologist on-call

Could there be an occult bleed?Consider in any patient with haemophilia/vWD

No

Muscle or joint bleeds: • Beware haemarthroses and muscle bleeds - either

may occur spontaneously.

Intra-abdominal & retroperitoneal bleeds: • May simulate a variety of abdominal emergencies. • Bleeding into psoas muscle or sheath is typified by

groin pain and loss of mobility.

Yes

Yes

• Just reconstitute and give them like any other IV drug!

• Modern clotting factor preparations are easy to mix

DON’T….• Give any IM injections:

immunisations (e.g. tetanus or Hep B) are to be given subcutaneously.

• Give NSAIDS or aspirin: to any patient with haemophilia, vWD or other bleeding tendency.

Give clotting factor ASAP to patients who need it!

Typical doses:Minor bleed - 25 units/kgMajor bleed - 50 units/kg

* NB: Some patients are on DDAVP and may not need clotting factors; others will get by with tranexamic acid.

Haematology biomedical scientists can access their records in lab and advise.

Call consultant haematologist if still uncertain.

Refer to relevant specialty

• Inform medical team if patient admitted to ward other than Tryfan.

Haemophilia and von Willebrand’s patients in the EDNew April 2012





Gridlock…..the challenge of working in an ED under pressureANYONE WHO WORKS IN, OR REGULARLY VISITS, THE EMERGENCY DEPARTMENT IN BANGOR WILL HAVE BEEN SHOCKED TO WITNESS THE NOW-REGULAR STATE OF GRIDLOCK .

'.":;...•.


SAPHTE SummaryInsert sticker for the highest SAPHTEapplicable for the relevant time period

WEEK COMMENCING: 120'lH ~7S 2oi2,

Day of week Monday Tuesday Wednesday Thursday Friday Saturday SundayMorning 'j.,.~\.J(.H-,s w. • • 0• .)((>~ •0800-1300 rj.. '"l fc{j()it .

Afternoon ••;;~• ~ • • •1300-1800 • ~) 011.- • •'l- ~'-tb CtHEvening

1800-0100 • • • • ••••Night • 0 0~~ • 00100-0800

-::9~ ,



WEEK COMMENCING: ;)1-~Fe'orUCAv~ ~Ol~Day of week Monday Tuesday Wednesday Thursday FridayMorning •0800-1300

i :z.., D.,. • • •Afternoon

1300-1800 • •I~OOEvening 2;000 • ••1800-0100 ). ,::>00' •Night - 020-0 •0100-0800 oXCO

SundaySaturday

•• lb,eD

• LQ--01)- •J;'

• •)



WEEK COMMENCING: IstL March

.;' ... ,

Day of weekMorning

0800-1300

Monday Tuesday Wednesday Thursday Friday

4 • •Saturday Sunday

Afternoon

1300-1800 •Evening

1800~0100

Night

0100-0800

• •

• ••,

• • •••

)

,


SAPHTE Summary ~"'.

Insert sticker for the highest SAPHTEapplicable for the relevant time period

WEEKCOMMENCING:

I19 MJ:1k?CH 20 \ 2..

Day of week Monday Tuesday Wednesday Thursday Friday Saturday SundayMorning • • 0• •0800-1300

Afternoon • • • •1300-1800

Evening • • 01800-0100

Night

0 00100-0800 • •

{{ ,(\, I f



WEEK COMMENCING: Il1-- 3 - .z..Day of week Monday Tuesday Wednesday Thursday Friday Saturday Sunday ,Morning • ~ •• •0800-1300

Afternoon • • • •1300-1800 •Evening • • •• • • •1800-0100

Night • • •0100-0800 •

The charts below were compiled contemporaneously by ED staff over a five-week period, with the peak SAPhTE score recored for each time period of 0800-1300, 1300-1800, 1800-0100 and 0100-0800.

• The ED has an “acceptable level of risk” (green) for only about 5% of the hours in this 5-week time period.

• On 100% of days in the 5-week study period the ED reached “dangerous” or “critical”….. sometimes for periods of 4-5 days at a time

Tested by fire….

Our ED is a very stressful environment at the moment, as the status charts to the left reveal. The pressure upon ED staff is is causing many (if not all) staff to display stress-related behaviours, ranging from tears to anger, helplessness and frustration, which threatens our much-cherished team dynamic.

Any slight weaknesses in our procedures are highlighted by the heat in the system. There are many examples, ranging from manag ing flow, handl ing queuing ambulances, keeping minors going - but let’s take one example that is easy to understand for anyone reading this outside the ED: triage.

We’ve known for a while that we aren’t always utilising the Manchester Triage Score accurately, but we didn’t have any funding to send nurses on the official MTS course to tackle this. Now, this used to be a relatively minor area for improvement: it didn’t really matter if someone was triaged yellow instead of orange if they were seen within a few minutes anyway. But when there are long delays in the system it can blow safety to smithereens: patients accidentally undertriaged may inappropriately wait hours to be seen, but if over-triaging occurs, it is impossible to effectively prioritise cases.

Unfortunately, now that it’s really, really important that triage nurses are supported in making accurate, defendable prioritisation decisions there’s even less money available for external study leave and our triage nurses are, understandably, anxious. Which makes it more likely that feedback from (equally worried!) doctors will be interpreted as criticism, further reducing confidence and making triage errors more - not less - likely.

There are many other examples of the current strains in the system thwarting our departmental development: we are ready to start “RATS” (Rapid Assessment & Triage Service) - the much-needed “senior doc at the front door” - but it’ll only work when we have somewhere to decant patients after they leave the RATS bay, which is impossible much of the time at present. We are trying to make more use of “See & Treat” with a doctor working alongside the triage nurse (contrary to popular belief it doesn’t slow down triage - we can prove it!) but are hampered by our archaic IT… although we have been told Symphony (a purpose designed ED IT system) will be ordered for us in 2012. These are difficult times and the ED consultants & senior nurses are working very hard to flag up safety concerns at every possible opportunity.

But we all need to be aware of the effect that stress is having both on ourselves and our colleagues, and try to be aware of the Human Factors issues involved to reduce risk to patients.





LOCAL CPD EVENTS

FRONTLINE TRAUMA IN AFGHANISTAN:STUDY DAY

203 (Welsh) Field Hospital (Volunteers)

Friday 11th May 2012 0930-1700Lecture Theatre, Education Centre, Ysbyty Gwynedd, Bangor

0930-0945 Opening Address: Commanding Officer Col Tina Donnelly0945-1000 Benefits of the TA to the NHS Capt H Wiliams1000-1100 Trauma Teams Maj K Smith1100-1200 Surgery in a Frontline Hospital Maj J Woolgar

1200-1300 Lunch

1300-1400 Case Presentation:Catastrophic Hemorrhage Control Maj A Jones

1400-1500 Life in Theatre Maj Levett & Capt Thomas

1500-1530 Coffee

1530-1630 MERT - Afghanistan's airborne ED Maj A Jones1630-1700 Closing Address Col Donnelly

Many ED staff wi# be aware of Eirian Davies’(Trauma Orthopaedic Practitioner) involvement with the TA Field Hospital - along with our own Steve Ga#agher and Andrew Parry. This event should be a fascinating insight into what they get up to when they disappear off to the desert for a few months!





LOCAL CPD EVENTS

WALES JOINT EMERGENCY SERVICES GROUP

Chemical Suicides and Methamphetamine Labs: Safety Awareness for Staff

Date: 30th April 2012 at 1330hrs

Aim: To provide awareness of the actions to take on discovery of a chemical suicide or a methamphetamine lab to ensure the health safety and welfare of those present and responding. Who Should Attend: This event is aimed at those who have a role which requires them to work outdoors and/or in the community or providing advice to those that carry out such roles. The Learning Outcomes You will learn

o what a methamphetamine lab is o the current increase in chemical suicides o what steps to take to protect yourself and others on discovery of either

situation Details The event is a presentation from experts in the field. Venue: Conference Room 1, North Wales Police Headquarters, Colwyn Bay, LL29

8AW Delegate Numbers: Places will be allocated on a first come first served bases. The maximum number of delegates for the session is 30. Event Fee: Free of charge To reserve a place please contact: PC Andrea Pashley by email: [email protected] Closing date for applications: 5th April 2012

… and for something tota#y different! Probably more relevant to any ED staff involved in Pre Hospital EM, or just plain curious…. methamphetamine hasn’t hit the UK the way it has the USA, and we rea#y don’t want it to. Nasty, nasty stuff. But if you’re interested in learning how it’s made, this study day should be fascinating.





HOW TO CONTACT

New Occ Health contact details

The phone number for the Occupational Health and Wellbeing Service has been changed to: 01745 448277 or 1815 8277 This replaces all former phone numbers for the service across the region, and will allow for your call to be filtered accordingly to the appropriate adviser or regional service as necessary. The system will allow calls to be filtered to: • Reporting needle stick

injuries • Access to emotional /

musculoskeletal support / CARE

• Returning calls or arranging an appointment at a host site

• General Occupational Health advice / manager enquiries

RHONWEN’S NOTES!

Gwasanaeth Iechyd a Lles Galwedigaethol

Sylwer, o hyn ymlaen, un rhif ffôn fydd gan

Gwasanaeth Iechyd a Lles y Bwrdd Iechyd.

01745 448277 or 1815 8277

Occupational Health and Wellbeing Service

Please note, with immediate effect, there will be

one phone number for the BCUHB Occupational

Health and Wellbeing Service

Mae’r rhif hwn yn disodli’r holl rifau ffôn blaenorol ar

gyfer y gwasanaeth ar draws yr ardal

This replaces all former phone numbers for the service across

the region

ENP Rhonwen Lewis has been busy again!

1)Whiston have requested that we please use their Burns Proforma when transferring patients, which has their preferred fluid calculator. We are assuming this is the same as the fabulous iPhone Mersey Burns App.

2) Keeping streaming going at a# times is absolutely vital to departmental flow: even if majors is crazy busy, we know that keeping Minors running reduces waiting time for all patients, major and minor - but the logistics with our layout is tricky! It is clear that HCAs can help. Rhonwen will be commencing training them in wound closure, issuing crutches etc etc soon.

Minor Injuries Training Day

Thursday May 17th

Rolling programme all day: wound care, aseptic technique, burns dressings, wound closure.

All welcome, including paramedics and medical students.

Book with Eleri: ext 4003





ED WEDDINGS, BABIES & RETIREMENTS

The ultimate ED wedding has got to be two of our nurses getting married to each other!

Here at last (photos kept disappearing into spam filters!) is Steve & Nia Gallacher’s wedding which took place on 9th April 2011 (Nia’s birthday) at Llanbeblig Church, Caernarfon, fo#owed by a honeymoon in Mexico.

Night Sister for many years, Silvana Esposito, retired late in 2011: here she is pictured at her (at-work) retirement celebration. There’s a group pic on our website, www.mountainmedicine.co.uk

Silvana is skilled at needlecraft and she actually made the ED a wonderful leaving gift: a large bespoke tapestry chronicalling our development from a small “accident unit” through to today’s ED.

Weddings!Babies!!

…. and Retirements!

Staff Nurse Anita Loxton and husband Dan welcomed Lorelei Maree on 2nd Feb 2012 weighing in at 8lbs. Mum and baby are doing great!Dan (an RAF Sea

King pilot) appeared in several episodes of the recent BBC Wales TV series “ Helicopter Rescue”, and is also training in Sports Massage.

and for next time…...We shall not be short of photos BEDLESS later in the year, with two ED weddings coming up - Julie Williams and Dr Ben Hall (not to each other, though….!!!!!) plus two ED babies…. S/N Nicola & Dr Bethan Owen are having a baby race with due dates only 6 days apart!

Consultant Mark Anderton and his wife Pippa welcomed their second daughter, a sister for Emily, on 6th March.

Baby Daisy weighted in at 3.42kg: surely a sign of a thoroughly modern medical couple (Pippa is a GP) to insist on using kg instead of lbs!

Ever-cheerful S/N Gwen Sandiford gave birth to Christie Mari Johnson at 04.34 on 4th Jan…. all rather eventful with a C-section 4 weeks early - Christie weighed in at 4lb 6oz - isn’t she cute?! Congrats to Gwen and James!





bangor ed news spring 2012

Documents

ed staff

interesting spring

incoming new ed patients

challenging times

bangor eds bedless

dr linda dykes email

welsh emergency departments

deadly bracelets