EmergencyMedicine

7e

THE PRINCIPALS OF PRACTICE

SASCHA FULDE GORDIAN FULDE

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SEVENTH EDITION

Edited by

Sascha FuldeMBBS, BSc (Med), FACEM

Emergency Specialist, St Vincent’s Hospital, Sutherland Hospital, Sydney, NSW

Royal North Shore Hospital, St Leonards, NSW Senior Lecturer, University of New South Wales

Gordian FuldeAO, MBBS, FRACS, FRCS (Edin), FRCS/RCP (A&E) (Edin), FACEM

Director of Emergency The Sydney Hospital, Sydney, NSWStream Director, Critical Care, South Eastern Sydney Local

Health Care DistrictProfessor, Emergency Medicine, Notre Dame and

New South Wales UniversitiesFormer Director, Emergency, St. Vincent's Hospital,

Sydney, NSW

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Elsevier Australia. ACN 001 002 357(a division of Reed International Books Australia Pty Ltd)Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

Copyright 2020 Elsevier Australia. 6th edition © 2014; 5th edition © 2009; 4th edition © 2004; 3rd edition © 1998; 2nd edition © 1992; 1st edition © 1988 Elsevier Australia.

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ISBN: 978-0-7295-4301-9

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NoticePractitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verifi cation of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

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Preface

Since the fi rst edition of this book in 1988 and following editions in 1992, 1998, 2004, 2009 and 2014, emergency medicine has—fortunately—continued to advance. In this edition much new information, many new approaches and extensive refi nements of existing clinical management have been incorporated. Again, current and respected practising clinicians have been chosen as authors for their clinical expertise and experience, so that they can compact their knowledge into the pocket-sized format. As healthcare resources continue to be stretched, the fi rst hours of a patient’s illness or initial contact with healthcare providers, outside and inside a hospital, are even more critical to the outcome. It is also very pertinent given the challenge of re-engineering patient fl ow (e.g. COVID-19, the ‘4-hour rule’), the many key performance indicators (KPIs) and expeditious competent care which can be coupled to funding. Th is book aims to help with this initial contact. Any suggestions for improving this will be much appreciated.

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Acknowledgments

Once again I am very grateful to the busy clinician authors for their excellent contributions. Also, the support and stimulation from many doctors, nurses, students and other professionals who use this book and have helped with ideas are greatly appreciated.

How do I adequately thank my wife, Lesley, for her unfailing encouragement and support?

Sophia Espinosa, with the help of her daughter Sierra and son Emilio, typed, collated, chased up details and much more; I most sincerely thank her.

Also to all the fabulous staff of the emergency departments and back up who are so great to work with—not only are the patients lucky to have such people care for them, but also the way they support and care for each other is wonderful.

Disclaimer:

Every eff ort has been made to ensure that all the information contained in this book is correct and accurate. However, the publisher, editor and authors accept no responsibility for the clinical decisions, management or dosages given. Th e fi nal responsibility rests with the treating doctor.

Gordian and Sascha Fulde

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Contents

Quick reference QR1Abbreviations A88Preface vAcknowledgments viEditors' note on COVID-19 xixContributors xx

1 Cardiopulmonary resuscitation 1Melinda Berry and Gordian WO FuldeBasic life support • Advanced life support • Paediatric advanced life support • Newborn resuscitation • Choking

2 The airway, ventilation and procedural sedation 16Melinda Berry and Judy AlfordThe airway • Airway assessment • Ventilators • Non-invasive ventilation • Procedural sedation

3 Resuscitation procedures 42Drew RichardsonOverview • Introduction • Intravenous access techniques • Ultrasound guidance • Arterial access techniques • Chest drainage procedures • Pericardiocentesis • Urinary catheterisation • Suprapubic cystostomy • Cricothyroidotomy • Lumbar puncture • Emergency department thoracotomy

4 Trauma 66Judy AlfordAcknowledgment • Defi nition of major injury • Pre-hospital triage • Preparation • Systematic assessment and management • Primary survey • Management of life-threatening conditions • History • Secondary survey • Specifi c injuries • Defi nitive care • Trauma service performance improvement • Conclusion

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5 Shock 106Stephen Macdonald and Steve DunjeyCauses and effects • Overview of management • Hypovolaemic shock • Cardiogenic shock • Distributive shock • Anaphylactic shock • Neurogenic shock • Obstructive shock • Pericardial tamponade • Tension pneumothorax • Pulmonary embolism • Summary

6 Major haemorrhage 120Marian LeeResponse to haemorrhage • Clinical assessment • Management of haemorrhage • Putting it together • Summary

7 Burns 128Ania SmialkowskiOverview • Basic burn fi rst aid • Assessment of burn depth and injury • Management of minor burns • Emergency management of the severe burn • Burns unit retrieval and referral guidelines

8 Patient transport, retrieval and pre-hospital care 137Neil BallardIndications for retrieval • The retrieval team • Equipment • The retrieval environment • Retrieval vehicles • Preparing a patient for retrieval • In transit • Hand-over • Pre-hospital care

9 The seriously ill patient: tips and traps 146Gordian WO FuldeWarning—red lights—beware • Decision-making tips • Emergency department ‘laws’ • Do not feed the lawyers • The fun bits

10 The approach to the patient with chest pain or dyspnoea 157Patricia Saccasan and Anthony J WhelanChest pain • Dyspnoea • Haemoptysis

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11 Acute coronary syndromes 176Kevin MarunoAcknowledgment • Safe assessment • Management of STEMI • Stratifying ACS without diagnostic STEMI ECG changes: NSTEACS patients • Management of NSTEACS • Additional management (STEMI and NSTEACS) • Cocaine-induced chest pain • Patient transfer

12 Clinical electrocardiography and arrhythmia management 189Kevin MarunoAcknowledgment • Indications • ECG interpretation

13 Respiratory emergencies: the acutely breathless patient 216Bronwyn Orr and John RobertsAcknowledgment • General principles • Oxygen therapy • Investigations in respiratory emergencies • Life-threatening conditions presenting with breathlessness

14 Haemoptysis 239Rahul Santram

15 Acute pulmonary oedema 242Anthony FT BrownOverview • Pathophysiology • Clinical features • Differential diagnosis • Investigations • Management of APO • Disposal

16 Venous thromboembolic disease: deep venous thrombosis and pulmonary embolism 251Tim Green Acknowledgment • Introduction • Pathophysiology • Clinical features • Diagnostic approach and clinical decision rules • Investigations • Treatment • Disposition

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17 Neurological emergencies 262Gonzalo AguirrebarrenaAcknowledgment • Altered mental status • Management • Seizures • Prolonged or frequent fi tting (status epilepticus) • Cerebrovascular disease • Ischaemic stroke • Transient ischaemic attack (TIA) • Spontaneous intracerebral haemorrhage • Subarachnoid haemorrhage (SAH) • Headache • Meningitis • Lumbar puncture (LP) • Encephalitis • Investigations • Treatment • Migraine • Giant cell arteritis (temporal arteritis) • Trigeminal neuralgia • Other causes of headache • Neuro-muscular disorders • Periodic paralysis

18 Poisoning and overdose 285Kate SellorsAcknowledgment • Overview • Resuscitation • Risk assessment • Decontamination • Enhanced elimination • Toxidromes • Specifi c toxins

19 Drugs and alcohol 320Kate SellorsAcknowledgment • Introduction • Alcohol • Nicotine • Cannabis • Injecting drug users • Opioids • Benzodiazepines • Drug-seeking behaviour

20 Endocrine emergencies 335Glenn ArendtsEmergencies in patients with diabetes • Adrenal emergencies • Thyroid emergencies

21 Acid–base and electrolyte disorders 352Derek Louey Acknowledgment • Electrolyte emergencies • Urine electrolytes • Hyper-osmolarity • Hypo-osmolarity (see Hyponatraemia) • Hyponatraemia • Hypernatraemia • Disorders of serum potassium • Disorders of calcium • Disorders of phosphate • Disorders of magnesium • Disorders of acid–base balance • Acute kidney injury (AKI)Sample

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22 Geriatric care 386Shahrzad Jahromi and David MurphyOverview • Falls • Confusion • Syncope • Abdominal pain • Carer stress • Disposition

23 Infectious diseases 401Emma Spencer and Richard SullivanAcknowledgment • Antibiotic prescribing • CNS infections • Gastrointestinal infections • Viral hepatitis • Genitourinary infections • Sexually transmitted infection (STI) • Needle-stick injuries and body fl uids exposures • Respiratory tract infection • Tuberculosis (TB) • Severe sepsis • Meningococcal infection • Skin infections • Wound infections • Water-related infections • Herpes zoster (shingles) • Tetanus prophylaxis • The overseas traveller

24 The immunosuppressed patient 431Sarah C Sasson, Judy Alford and Anthony KelleherOverview • Immune system failure • Cancer patients • Malignancy in HIV/AIDS • Immune reconstitution infl ammatory syndrome (IRIS) • Antiretroviral drugs • Pre-exposure prophylaxis (PrEP) in HIV • Post-exposure prophylaxis in HIV • Solid-organ transplants • Immunosuppression for non-malignant disease • Newer biological therapy • Asplenia • Summary

25 Emergency department haematology 464FX Luis Winoto, Rebecca WalshAcknowledgment • Common haematological emergencies • The anaemic patient • The patient with abnormal bleeding • Anticoagulant therapy • Blood transfusion • Inappropriate use of blood components

26 Gastrointestinal emergencies 477Greg McDonald, Nadine Huddle and Christopher WongAcute abdomen • Specifi c surgical conditions • Gastrointestinal bleeding • Acute pancreatitis • Gastro-oesophageal refl ux disease (GORD)—oesophagitis • Mesenteric ischaemia/infarction • Vomiting • Constipation • Hepatic failure—portosystemic encephalopathySam

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27 Neurosurgical emergencies 503Rob EdwardsGeneral concepts • Traumatic neurosurgical emergencies • Blunt cerebrovascular injury (BCVI) • Subdural haematoma • Cervical spine and spinal cord injuries • Lower back pain • Non-traumatic neurosurgical emergencies

28 Aortic and vascular emergencies 530Mark GillettAcute aortic dissection: thoracic • Ruptured abdominal aortic aneurysm • Non-aortic abdominal aneurysms • Acute arterial insuffi ciency • Atheroembolism • Chronic arterial insuffi ciency

29 Orthopaedic emergencies 537John RaftosAcknowledgment • General principles • Upper limb injuries • Pelvic fractures • Lower limb injuries • Hip joint dislocation

30 Urological emergencies 582Daniel Gaetani and Edmond ParkAcknowledgment • Balanitis • Common post-procedural problems • Epididymo-orchitis • Fournier’s gangrene • Hydrocele • Paraphimosis • Phimosis • Priapism • Prostate disease • Renal/ureteric calculus • Testicular torsion • Urinary tract infections (UTIs) • Urine retention • Urological trauma • Varicocele

31 Wounds 618Ania SmialkowskiWound assessment • Wound debridement • Basic dressings • Basics of wound closure • Lacerations, abrasions and bites • Skin tears • Pressure ulcers

32 Pain management in the emergency department 626Jennifer Stevens and Tiffany FuldeOverview • Analgesia • Opioids • Non-specifi c back pain • Dental pain • Renal colic • Migraine pain • Cancer painSample

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33 Paediatric emergencies 647Melinda Berry and Arjun RaoRecognition of the sick child • The sick baby • The child with stridor • The child with respiratory distress • The child with fever • The child with abdominal pain • The child with vomiting • The child with diabetic ketoacidosis (DKA) • The child with seizure • The child with a rash • The limping child • The baby with jaundice • The unsettled crying baby • Trauma in children • Non-accidental injury • Pain management in children • Vaccination schedule

34 Gynaecological emergencies 690Nikki WoodsAcknowledgment • General principles • Common presentations • Other complications of later pregnancy (� 20 weeks’ gestation) • Prescribing in pregnancy • Anti-D prophylaxis • Postcoital contraception: morning-after pill

35 Sexual assault and domestic violence 704Nikki Woods and Sophie Blake(Adult) sexual assault • Domestic violence

36 Surprise! The baby is coming 726Jessica GreenAcknowledgment • Preparation and assessment • Management • Transfer • Emergency delivery • When the baby has already arrived • Resuscitation of the newborn

37 Hand injuries and care 743Bill CrokerAssessment • Examination • Treatment • Soft-tissue injuries • Nails • Tendons • Nerve injuries • Vascular injuries • Bony injuries • Specifi c conditions

38 Ophthalmic emergencies 757Michael R Delaney and Gordian FuldeAcknowledgment • Principles of examination • Use of the slit lamp • Trauma • The painful red eye • Sudden painless monocular Sam

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visual loss • Postoperative problems • Ophthalmic conditions needing referral • Common ophthalmic medications

39 Ear, nose and throat (ENT) emergencies 774Shalini ArunanthyEar emergencies • Nose emergencies • Throat emergencies • Epiglottitis

40 Management of dental emergencies 796Peter FoltynToothache • Infected gums • Impacted teeth • Mouth sores and ulceration • Neoplasia • Facial swellings • Heart disease and dental care • Post-extraction instructions • Dry socket • Oral bleeding • Traumatic injuries to teeth • Trismus and temporomandibular joint (TMJ) dysfunction • Dental nomenclature

41 Psychiatric, mental health presentations 812Jackie Huber and Tad TietzeAcknowledgment • Working in the emergency setting • The ED mental health assessment • Suicidality and self-harm • Acute severe behavioural disturbance (ASBD) • Acute psychosis and mania • Drugs and their consequences • Confusion and delirium • Anxiety • Iatrogenic emergencies • Malingering and factitious presentations • Frequent attenders

42 Dermatological emergencies 836Kevin Phan, Alicia O’Connor and Deshan SebaratnamAcknowledgment • General approach to acute dermatological presentations • Dermatological diseases by morphology

43 Drowning 861Kent RobinsonIntroduction • Pathophysiology • Precipitating events • Pre-hospital • Emergency department • Inpatient management • Outcome

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44 Envenomation 870Andrew OrrAcknowledgement • Introduction • Snakebite • Spider bites • Marine envenomation • Centipedes and scorpions • Additional resources

45 Electrical injuries 886Chris Mobbs and Gordian FuldeOverview • Low- and high-voltage electrical injury • Tasers

46 Hypothermia and hyperthermia 897Gordian FuldeAcknowledgment • Physiology • Hypothermia • Hyperthermia • Controversies

47 Mass-casualty incidents, chemical, biological and radiological hazard contingencies 911Iromi SamarasingheIntroduction • Phases of a disaster • Administrative and legislative mandates • Medical emergency response plans and agencies • Pre-hospital medical coordination and disaster scene control • Triage • Communication • Code Brown: hospital external disaster or emergency response plan • Stages of response • Chemical, biological and radiological (CBR) hazards

48 Diagnostic imaging in emergency patients 955E S SeelanImaging modalities • Intravenous contrast reaction • Imaging of the head • Emergencies in the neck • Emergencies in thoracic and lumbar spine • Chest emergencies • Radiology in abdominal emergencies • Some obstetric emergencies • Fractures of pelvis and limbs • Radiation issues

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49 Ultrasound in emergency medicine 1004Julie LeungAcknowledgment • Basic physical principles • Ultrasound equipment • Common applications in the ED • Other applications • Training, credentialling and quality review

50 X-ray and CT common misses 1018John RaftosX-ray • CT

51 Test ordering: blood results, CSF analysis, pleural fl uid analysis, ascitic fl uid analysis and joint fl uid analysis, choosing wisely 1023Farzad JazayeriBlood results • CSF analysis • Pleural fl uid analysis • Ascitic fl uid analysis • Joint fl uid analysis • Choosing tests wisely

52 Nursing and allied health advanced practice and adjunct roles 1039Wayne Varndell and Julie GawthorneAcknowledgement • The triage nurse

53 Emergency medicine in a rural setting 1051Alan TankelDefi nitions • Challenges • Education • Stabilisation for retrieval • Managing expectations • Rewards

54 Caring for Indigenous patients 1056Pauline Deweerd, Mark Byrne and Bonita Byrne Providing practical health services to Aboriginal people • Relationship with family and community • Relationship with the home • Communication styles • Indigenous patients • Communication • Alcohol and substance abuse

55 Students’ guide to the emergency department 1062Sascha Fulde and Tiffany FuldeAdvantages of the ED • Use it as a light at the end of the tunnel • How do you get the most out of it? • SummarySample

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56 A guide for interns, residents, medical offi cers working in emergency medicine 1070Tiffany Fulde and Richard SullivanIntroduction • Day 1—getting started • Working up a patient • Further into the term/learning opportunities • Miscellaneous • Quick/general tips

57 So it’s your fi rst night shift ‘in charge’—how to manage the department 1089Sascha FuldeReprioritise your responsibilities • Keys to success • Other tips and tricks

58 So you had a bad shift . . . 1093Sascha Fulde

59 Useful resources: FOAM resources, podcasts and online emergency medicine material 1095Sascha FuldeFOAM Podcasts

60 Career, lifestyle and success 1098Gordian Fulde and Sascha FuldeCareer • Lifestyle

61 Career in emergency medicine: workplace-based assessment 1105Sascha Fulde and Marian LeeChoosing emergency medicine • The different facets of workplace based assessment

62 Administration and governance in the ED 1111John VinenOverview • Managing the emergency department • Business plan • Administration • Administrative structure • Governance • Clinical risk management (CRM) • Emergency department models

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of care (applicable to EDs that are level 3 and above) • Teams and teamwork • Patient care process (PCP) • After-hours management • Project and change management • Teaching, training and skills acquisition • The future • How to write a Clinical Practice Guideline

63 Rules, confi dentiality, legal matters 1124John Raftos, Lesley Forster and Gordian FuldeGeneral principles • Codes • Confi dentiality • Requests for information • Medical certifi cates • Police statements • Patient care incidents • Root cause analysis • Physical examination/intimate examination • Personal appearance, behaviour and deportment • Results of investigations • Notifi able diseases • Public Health Act 2010 notifi able diseases • Mandatory blood alcohol and drug testing • Sexual assault forensic testing • Coroner’s investigations • How to avoid a lawsuit • Personal care • Consent • Procedural mistakes • Reports and records • Going to court • Doctors out-of-hours or away from their workplace • Standards of behaviour out-of-hours/mandatory reporting • Duty of care: patients who refuse treatment • Insurance • Media • Complaints

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Editors note on COVID-19Dear fellow healthcare workers,

First and foremost, THANK YOU to you and your family, loved ones and friends who support you.

This is not an update on COVID-19, nor is it an excuse for the delay of this 7th edition appearing.

The world is being devastated by the pandemic; it is global war. We still know very little about the virus. For example: What medications will be effective? When will a vaccine bring up the ‘herd immunity’ across the world?

Much more is unknown. We are responding, adapting and changing, and making difficult decisions on the spot while facing shortages to keep healthcare staff and the population protected.

Among the main enemy is anxiety and fear of death or loss, which is very much exacerbated by all the unknown.

Emergency medicine workers, responders and all those car-ing for others are in the frontline and you are amazing to be putting yourselves first while at definite risk to yourselves and those around you. This is especially amazing with the risk that in the line of duty you face the possibility of exposure to infected COVID-19 people who may be, although asymptomatic, infectious for days. Let alone caring for the full spectrum of sick patients up to full resuscitation, with the high risk of aerosol-generating procedures such as intubation.

Sadly, besides so many really good deeds and behaviours, this crisis also brings out the worst in some.

COVID-19 will pass with unimaginable consequences at so many levels. Healthcare workers will be among the unfathomable statistics. We all know the true toll will be incalculable. It is defi-nitely not just dollars and deaths, but also the stress and scars to the mind, body and soul over generations.

Please keep well, safe and sane because what you do really matters and makes such a difference. We all owe you and need you! Thank you again.

Sincerest best wishes,Gordian and Sascha Fulde

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Chapter 55 Students’ guide to the emergency department

Sascha Fulde and Tiffany Fulde

Th e emergency department (ED) can be the highlight of a student’s day or the place where you feel most out of place, or both at the same time. Hopefully, this chapter will outline some practical tips for getting the most out of this wonderful resource.

Advantages of the ED As the place where almost all patients enter the hospital, the ED is a short-case heaven. In addition, you can see patients before they’ve been overrun by a thousand other students and doctors. Just think: by the time a patient gets up to a ward, they’ve most likely had the same questions asked and been poked in the sore spot by the ED intern, ED registrar, the intern on the admitting team and then the registrar, plus at least one nurse. Th ey’ve had a stressful time, feel unwell and, ultimately, probably just want to be left alone; whereas in the ED they haven’t been examined that many times. Th ey’re pre-pared to be undressed, poked and prodded because they recognise that that is what happens when they come to an emergency depart-ment. A student can often be useful: either confi rming examination fi ndings, sometimes fi nding something someone missed, either on history or examination; or just alleviating some of the patient’s worry by spending some time with them while they’re waiting for the results of investigations. Even if you’re only doing an examina-tion, it makes the patient feel that something is happening and that they’re being taken care of. Th e patient is also in the mind-set where they really want to talk about their story and those niggly details of symptoms as it’s pretty much all they can think about. Th us the ED is a fantastic resource for a medical student.Sample

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When patients present to the ED, they’re much more likely to present in a way that is useful to a student. First, as no one knows what is wrong with them, you actually get a chance to test your clinical and diagnostic skills. Second, they present in the same way that short and long cases are often presented in exams. Th e complaints are also often at a level which you will be expected to know. For example, you are much more likely to see a patient with chest pain than one with a phaeochromocytoma.

LEARN TO HANDLE EMERGENCIES As a student my biggest fear was that I would actually kill some-one! My second biggest fear was failing exams. And the third was, how do I actually save someone’s life? I’m not just talking about the big trauma cases, but also the smaller practical proce-dures. Th is is one of the greatest things the ED can teach you. By spending time there and talking to the doctors, you learn how to actually prioritise management and the basic couple of things that you need to do right now before you stop and work out the clinical management guidelines. You can also learn how to actu-ally do them.

FIND PATIENTS FOR TUTORIALS, CASE HISTORIES AND PRESENTATIONS Although the hospital is full of patients, it can often be hard to fi nd patients that fi t the requirements of the task you’re trying to do—for instance, fi nding an interesting surgical case to present in a surgical tutorial or even for a bedside tutorial. As staff in the ED have seen all the patients that have entered the hospital, they are wonderful at knowing what patients are around and worth chasing up.

FITS WELL WITH PROBLEM-BASED LEARNING (PBL) COURSES At the beginning of a PBL course it can often be diffi cult to ap-proach medicine on the wards, as you have only learnt informa-tion on certain specifi c disorders or systems. Th is can make it overwhelming to approach a general medical or surgical term. However, in the ED the patients present in the same way as a case Sample

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in a scenario, and this allows you to approach things you haven’t seen before.

One of the strengths of PBL, which is that you focus on indi-vidual areas, can sometimes be slightly frustrating. By only focus-ing on one clinical vignette, you can sometimes feel like you don’t know much about broader medicine. By hanging around the ED for even only a short period of time, you can very quickly start to counteract that and learn a lot across a broad range of areas.

PROVIDES A PLACE TO INTEGRATE A LOT OF KNOWLEDGE Whatever level you’re at in your training, the ED provides a great place to pull both your clinical skills and your esoteric knowledge together and practise what you’ve been learning. It’s always easier to remember something when you’ve seen a patient with it and seen how they were managed.

GET A WIDE RANGE OF CLINICAL MATERIAL With increasing specialisation of medicine and increasing num-bers of students, often you only get to experience a limited number of diff erent departments. For instance, you may never have had the opportunity to do a cardiology term. Th e ED is the place where you can compensate for this defi cit. All the acute cardiology patients will come through the ED, so you can see how they are managed.

SEE MILD PATIENTS THAT GET DISCHARGED Th e ED also has a range of severity of patients, so you get to see the simple sprains, cuts and bruises before they are discharged.

SEE GREAT SIGNS BEFORE THEY ARE TREATED Often you trail around the hospital trying to fi nd a patient to prac-tise your examination signs on, only to fi nd that while many people are unwell, they’ve already been treated (e.g. ‘Mrs X had shifting dullness but we tapped it last night’).

In the ED you can see these signs often when they are at their peak before the arrhythmia is treated or the blood pressure lowered.Sample

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AVOIDING BEING BARRED As a student, you’re always going to be refused by some patients. Even though you know it’s not personal, this is often demoralis-ing. In contrast, it’s always exciting to go and visit a patient you saw when they fi rst presented in the ED and have them recognise you and happily let you repeat your examination to see their improvement.

Th e ED also provides an excellent opportunity to learn about the unspoken professional etiquette between diff erent doctors. At some stage all doctors, whether interns or the most senior con-sultants, come to and interact in the ED. Th is allows you to learn a lot about the fi ner negotiations; for instance, of getting staff up late at night.

Use it as a light at the end of the tunnel Little encounters that you can have in the ED allow you to pretend to be a real doctor, even if only for a few seconds—not just a nurse or a cannulating technician doing a cannula or a blood pressure, but a real doctor. Th is not only reminds you what you’re working for, but why you’re working so hard. It really allows you to put all the hard decisions you’re making into perspective. It can be even more important to remind yourself that there is a light at the end of the tunnel. Th is can be really motivating, either because being a doctor is exciting or because it makes you realise you’re not quite knowledgeable enough yet.

How do you get the most out of it? SO HOW DO YOU ACCESS THIS GEM? First you must get access either by your swipe card or the keypad access code. Th is is crucial. Emergency department staff are usu-ally very happy to have you there, but it’s much easier if you just appear at the doctor’s desk. If you have to constantly ask to come and go, you’re probably much less likely to be there regularly.

Go to the ED regularly. If you become a familiar face to staff , they very quickly go out of their way to help you meet your learn-ing goals or just to be friendly. A good tip is to leave the hospital via the ED. Th is forces you to see whether there are any interesting patients when you know you’ve got nowhere better to be. Even if Sample

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you only see one patient a day, you’ll start to become part of the hospital team.

Th e ED can get very busy. When this happens, people often get stressed. If you are around, do not automatically skulk back to the student room or ask if you can intubate the patient! Ideally, fi nd a way to be involved while getting in as few people’s way as possible. Th is can involve standing at the outer edge as resuscitation is going on, or going and seeing one of the low-triage-category patients by yourself to start with.

ATTACH YOURSELF TO A REGISTRAR As the ED is usually very busy, you can also get a lot out of it by attaching yourself to a consultant or registrar and becoming their assistant. By doing the little tasks like chasing results, you can re-ally help them out. Th is often engenders a lot of goodwill, which means that you get good teaching along the way and opportunities to do practical procedures if you’re interested.

FOLLOW YOUR PATIENTS UP When you have seen a patient in the ED, make sure you take the opportunity to follow them to the next step in their treatment. For instance, watch their surgery or check on them in the medi-cal ward in a few days’ time. Most teams are more than happy for you to be included in care when you explain that you saw the patient in the ED. Th us, you get to see many aspects of medicine and surgery.

DON’T COME IN HORDES Although it’s often less confronting to come in a group or with a partner, it’ll be easier to get accepted by staff and patients if you come by yourself. It’s also better to come alone, as this is how you’re ultimately going to be in exams and it really allows you to realise your strengths and weaknesses and work on them.

ASK THE NURSES FIRST Before doing anything, fi rst ask a nurse. Th is is very important. Even if you have a doctor’s permission and the nurse is busy, wait until they are fi nished and then ask their permission. Nurses often end up coordinating care, so they know whether they’ve had time

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to give the pain relief that the doctor has prescribed so that the patient can handle talking to you.

FIND THE THINGS THAT ARE USEFUL TO YOU AS A STUDENT BUT THAT NO ONE ELSE CARES ABOUT Th ere are many things happening in a hospital that are common-place, barely thought-about activities but that can be really useful to a student. For instance, most people who come into the ED get an ECG and some blood tests. If you regularly look up the results and try to interpret them, whether you know the patient’s history or not, you can become very good at interpreting results. Th is is easy to do and doesn’t need any doctor’s or nurse’s help—you sim-ply look them up and then check how the doctor interpreted them.

Another useful skill you can learn is to practise writing up notes. After seeing a patient, if you practise putting the salient points down on paper you can then compare your notes with the registrar’s and see how good you were at getting all the points and putting them down in a clear format.

ASK ABOUT TEACHING Most EDs have compulsory teaching sessions for interns, RMOs (residents) and registrars. Th ey are often more than happy for a few students to attend. Th ese sessions are usually fi lled with teaching on diseases that are of interest to you and will often make it into exams. So just ask some of the registrars and interns who organise the tutorials, if and when they’re on and whether you can attend.

PRACTISE PROCEDURES—ALWAYS TAKE A BLUEY Th e ED is a really good place in which to practise the basic proce-dures that you’re expected to be able to do as an intern. Th ere is always someone who needs bloods taken or a cannula or catheter, and people are usually happy to oversee you doing one. One im-portant thing is to always check that you have all the equipment you need before you start a procedure. When you’re doing any-thing you’re a bit unfamiliar with, always take a bluey (a plastic protective sheet) so you don’t make a mess of the sheets—this alienates the patient and makes the nurses cross. Also, always take a set of cotton balls and tape just in case something goes wrong—you can patch almost anything up.

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If you have the chance, practise procedures on models. Many EDs have simulation centres or plastic models to practise proce-dures on. Th ese can be fantastic for your fi rst couple of times or if it’s been a while since you’ve done one.

HAVE A SLIGHTLY THICK SKIN Unfortunately, at some point as a student you’re likely to get in trouble for something. While it’s important to be considerate and do your best to avoid it, at some point you will get on someone’s bad side. When this happens, just apologise and try to make it right. Th en don’t let it get to you. It happens to everyone.

FIND A FRIENDLY FACE AND TAKE ADVANTAGE OF THEM! In every department there are a few really incredibly nice people. When you fi nd them, make friends and then ask them about all those niggly things you need help with. Th ey understand how hard it can be to be a student and they’re more than happy to help, but you need to ask them. Th e worst they can say is ‘no’.

TAKE MORE RESPONSIBILITY When you’re in more senior years, take more responsibility. You can use time in the ED as a pre-intern term. Go in at nights and help out. You can see some of the most interesting, diverse patients after dark. Plus, people appreciate your dedication and usually try to help you get the most out of it. You can even clerk patients from beginning to investigations and then take the write-up, just needing a signature, to your supervising doctor. Th is will help you, and hopefully save them a little time even if they then go back and check it.

Summary Ultimately, make sure you enjoy both being a medical student and your life outside of medicine. Don’t let the stress of medicine or all the advice above distract you from enjoying your time as a student. We hope that you learn a lot from this book and that this chapter has helped to inspire you to head into the ED.Sample

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Editorial Comment

It is our responsibility, privilege and delight to help and supervise our future colleagues, especially senior students who quickly and enthusiastically take up a workload. A very good system is to ‘buddy’ them with a doctor—even nights and weekend shifts; they love it. Also remember that you

will be asked questions and that demonstration and teaching really improves and keeps your practice up-to-date.

The ED is often the most desired term, as students sense the joy and terror of being the fi rst to deal with unknown, unexpected and potentially very ill patients—all this

among a great gang of healthcare professionals. It is usually fi nal-year students that are attached to the ED.

They are going to be interns in months—maybe at your hospital! So, even more so, time spent teaching them

intern skills is very worthwhile.

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Chapter 60 Career, lifestyle and success

Gordian Fulde and Sascha Fulde

Career What do you want to be?

A question disliked the more you grow up! Once you have graduated in medicine, it is normal to not really

know where you want to go next.

SOME HINTS Th e most important is HAVE NO REGRETS—that is, if after a good term or an interest is kindled, go for it! It doesn’t matter if the exams are hard or if lots of others have the same interest and so on. • If you try and it does not work out, you will not be bitter; but

if you don’t try, later it can lead to massive regrets. • It is okay to change choices, especially when a new, good

opportunity presents itself.

HOW TO GET YOUR NOSE IN FRONT • Talk to people—bosses, registrars who are in that fi eld—to

ask their advice and show you are interested. When possible, attend unit education and other meetings, off er to help with audits and so on.

• Get the information and start plans regarding college requirements and exams (you want these for any career interview).

• Choose and ask one or two people to be your mentor/role model. Keep in contact!

PUBLISH OR PERISH Yes, publishing is valuable. Some hospitals and colleges will not give you a job if you do not have publications. • Try to choose a project you fi nd interesting.

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• Try to choose co-investigators who have a track record of success.

• Try to be the fi rst or second author. • Check it is doable (around your time/commitments) and

can be written up in a reasonable timeframe (i.e. has a good hypothesis).

• Do not get disheartened if it gets rejected or needs rewrites. • Try to make sure it is a reputable peer-reviewed journal. • Consider specialist journals. • It allows you to discuss in detail your research, a common

interview question.

EXAMS: HOW TO PASS—FIRST TIME • Allow 12 months of serious study. • Data—old papers, trial exams—is a must. • Talk to and get notes/tutorials from recent successful

candidates. • If possible, talk to examiners. • You MUST form study groups and have at least one study

buddy that you meet regularly (if you study alone, you will do poorly).

• Go to as many courses and tutorials as you can. • Practise—practise each part of multiple-choice questions

(MCQs), Vivas, essays, objective structured clinical examination (OSCE) and so on (e.g. each shift get quizzed by each registrar, consultant).

• Bug them—you only really learn and retain by practising, especially things you do not think you know well.

JOBS Do your homework. Find out, ask about a possible role, possible new hospital/department. It is essential for the questions: What do you do? Why this job? Make an appointment to visit the depart-ment; it is a really smart thing to do for both you and them.

INTERVIEWS Again, do your homework, practise interview questions and be prepared for the ‘left-fi eld questions’ which are now common in all industries (e.g. Who is your favourite action hero and why?)

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Try to relax, smile and be yourself. Try to think that if you were the interviewer, what would you be looking for?

Daily stuff to stay out of hassles and do well! • Mistakes—we all make them.

— University, job orientation and common sense have taught you the fundamentals, but even a good doctor makes mistakes and has a bad day!

— Manage it how you would advise a friend to sort it. Get advice. But always be honest, do not be afraid to apologise and have open disclosure (with admin, medical defence advice when necessary). Never try to cover up—in general life the cover-up gets people in more trouble than the original event.

• Getting consults and arranging tests. — Yes, it is mostly online now but we mainly are still dealing

with humans. So take every opportunity to talk on the phone, go around to X-ray and explain what you think the patient needs. Even better, ask their advice regarding tests, apologise for hassling/urgency, tell them why and so on.

— It works, and say thank you especially to this invisible army of nurses, radiographers, clerical support, allied health, secretaries and so many more who make it all happen.

TRIBALISM AND TEAMS • Humans tend to group and not be nice to other groups (e.g.

professionals, sport clubs, nations). • So they have to keep neutral. Remember the old saying, if you

cannot say anything nice, do not say anything at all—it works. • As part of a team, you are there to work well, learn and gain

experience. Even if that term is not exciting/sexy, it probably has a lot to off er and probably represents a big slice of overall general patient care—get the most out of it.

• Also be aware that high-profi le, very clever specialities can breed arrogance. Again, learn and ask questions.

• Sometimes in a term the workload and hours become excessive (e.g. other staff on leave, no relief person for their exams, sick leave).

• Once again, use a structural approach.Sam

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• Keep a record of the workload and overtime. Is there a simple solution? First, talk to your senior. If you are worried it may cast a shadow on your term assessment, it can be diffi cult. However, if there is a group of you (especially if there are straightforward solutions such as a better roster) maybe go to administration as a group.

• As an admin tip, it is often cheaper to employ another staff member than to pay lots of overtime.

BULLYING, HARASSMENT AND DISCRIMINATION Bullying is repeated, unreasonable behaviour directed towards someone that creates a risk to their health and safety. It also im-pairs their ability to do their job.

If bullying occurs document: • repetitive verbal abuse, threats or yelling • unjustifi ed criticism • physical or mental intimidation • behaviour such as excluding, ignoring, isolating or belittling • giving people impossible tasks or timeframes • deliberately withholding information that is vital for eff ective

work performance • spreading false rumours or lies or backstabbing.

See www.fwc.gov.au/documents/documents/factsheets/guide_antibullying.pdf

Sadly bullying, harassment, discrimination as well as the bad eff ects on any individual are quite prevalent and often complex.

Very early • Talk to someone! • Seek help and advice! • You are not alone! • It is not acceptable!

Help is available at: • Doctor’s Health Advisory Service ( http://dhas.org.au ): • NSW and ACT–02 9437 6552 • NT and SA–08 8366 0250 • Queensland–07 3833 4352 • Tasmania and Victoria–03 9280 8712 http://www.vdhp.org.au • WA–08 9321 3098

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• New Zealand–0800 471 2654 • Medical Benevolent Society ( http://www.mbansw.org.au/ ) • AMA lists of GPs willing to see junior doctors

( http://www.doctorportal.com.au/doctorshealth/ ) • Lifeline on 13 11 14 • beyondblue on 1300 224 636 • beyondblue Doctors’ health website: https://www.beyondblue.

org.au/about-us/our-work-in-improving-workplace-mental-health/health-services-program

Lifestyle It is very important. Medicine and hospital life can break you.

It is essential to pick up warning signs early. For example: • always exhausted • no time for friends • no time to do fun things • saying no to many things you used to do • grumpy, cynical • depressed • sleep disturbances • dangerous ‘escapes’ such as alcohol and drugs (these do not

fi x anything but just make it a lot worse) • your pot plants all die • patients, consults, tasks become irritations/problems • becoming unpleasant to others (e.g. nurses, allied health) • grizzling all the time.

PREVENTION AND REMEDIES Have and keep a good routine (the hospital will always be there). • Exercise (e.g. walking, short morning exercise routines). • Healthy diet (avoid overeating, unhealthy food—too easy if

time poor or tired for night shifts). • Sleep—enough is a MUST! Nights, late and early shifts. Your

mind and body need any defi cit paid back! Batteries all need recharging.

• Fun—make the eff ort, set a day, a time, it is a priority to know what you like. Do not let ages go by, procrastinating this includes hobbies, interests (e.g. a dog), time with a friend.Sample

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• Friendships and family are vital, essential. Yes, they take time and can be inconvenient but without talking to and spending time with them, you will struggle more with your work and be at risk of mental or physical health issues. Th ese are the ones who you can turn to and will support you.

• If you are in trouble, talk to your mentor or GP, or seek professional help (you are not alone or the only one).

• All hospitals have access to free confi dential counselling. • In the end it is about healthy, rational self-esteem, not feeling

worthless. • You are a doctor! Really cool! • Wow, how lucky are you to be able to help people, be listened

to, be trusted and even respected. Whose shoes would you really rather be in? People want your advice.

• Your patients are worse off than you. • What you do really matters, even the annoying little tasks like

chasing results, somebody else’s discharge summary, dealing with so many people—some will be annoying so recognise this quickly and always be professional—it is a passing parade.

• Healthcare/medicine is one of the industries that is not threatened by robots and artifi cial intelligence—it is a future growth area for employment.

SUCCESS Th e key to success! • Appreciate how fortunate you are. • Be positive. • Be nice to those around you (e.g. smile, say g’day, learn their

names, defi nitely say thank you, praise, say well done, if someone swaps a bad shift for you—coff ee or chocolates are in order not just be prepared to pay back).

• Treat other people as loved ones. • Mind games—yes, quiet ones are the best. • Shit happens! • Th ink it, do NOT say it! • Do not whinge all the time—it is too easy to do this.Sample

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• Have some mantras in your head so you do not feel guilty to say no (e.g. ‘a lack of planning on your behalf does not constitute an emergency on mine’).

• If you come to me with a problem and have not thought of possible solutions, you really have a problem.

• Corollary—you yourself are in a good position to off er solutions. When dealing with administrative duties and so on, discuss them—it really works.

• In clinical situations (I call it the social work approach—it is excellent), ask the patient (or others) their thoughts on issues . . . and listen!

• Always be honest (e.g. explain to patients you do not know—medicine is full of uncertainty—but discuss strategy; choices—make sure they ask questions; shared decision-making).

• It is okay to ‘bail’ and walk away (politely) if not comfortable, and get assistance, advice (e.g. aggressive patients, feeling harassed [including sexual], bullied or just beyond your capabilities to easily cope with). Remember the action of holding your hand up with your palm facing away—‘Stop’. It works, so use it! Do not stay and fi ght, always keep notes and always go and talk to someone even outside of the workplace. All hospitals have access for free confi dential counselling.

• Develop areas of special interests, get involved, study, keep updated, take opportunities to give a tutorial and talk to others (medical, nurse, students etc.).

• If you can, advocate it (e.g. basic life support, become an instructor and teach it to community groups or how to use an AED).

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