Emergency MedicineDR. HOSSAM HASSAN

What is Emergency MEDICINE?

Acute and life threatening aspect of medical care

Recognition, evaluation, care and disposition of patients with acute

illnesses and injures.

Chaotic workload 24/7

Undifferentiated symptoms and completely new patients

On the spot decision despite uncertainty

Challenges of Emergency Medicine

All sorts of patients could come in at any time

Any combination of cases may present together

Task

Set priorities

Organize activities flexibly

Handle several cases at a time (multi-tasking)

Adjust speed and style of evaluation and treatment

Quality & safety despite chaotic workload

Challenges of Emergency Medicine

Undifferentiated symptoms and completely new patients

Task

Good interpersonal communication skill

Clinical acumen for a focused approach to clinical evaluation

Challenges of Emergency Medicine

On the spot decision despite uncertainty

Task

An ED Doctor needs to be able

To tolerate uncertainty, to make reasonable

decision out of uncertainty

To assess probability of serious pathology,

and hence appropriate referral.

Demonstrate the principles of initial evaluation, stabilization and differential diagnosis management of patients with the following symptoms:

Shortness of breath

Chest pain

Shock

Altered mental status and coma

Headache

Syncope

Abdominal Pain

Fever

The 'unwell' patient

GI Bleeding

Vaginal bleeding

Abnormal behaviour

seizure

Approaches in the management of patients in ED

Performs an accurate and concise history and physical examinations of the undifferentiated patient presenting to the emergency department

Formulates an appropriate plan for the initial investigation, treatment, and disposition of undifferentiated patient presenting to the emergency department

Approaches in the management of patients in ED

Does the patient have a

life/limb/sight threatening process?

Primary Survey of

Airway

Breathing

Circulation

What must be done to stabilize the patient

Approaches in the management of patients in ED

Evaluate for potentially serious conditions

that are compatible with the patient’s presentation?

For example:

Chest pain: AMI, dissecting aneurysm,ruptured oesophagus, tension pneumothorax, pericarditis with tamponade

Dizziness: GI bleeding

Headache: SAH, Meningitis,pseudotumour cerebri,ICH

PV bleeding: Ectopic Pregnancy

Rash + fever: Meningococcemia

Approaches in the management of patients in ED

Reaching a working diagnosis for the complaints

Clinical picture, investigations and probability

Initial Management at ED

Does the patient require admission?

Discharge the patient with adequate information

+/- referral

Approaches in the management of patients in ED

Does the documentation reflect

your evaluation and treatment?

Results of physical examination

investigations, e.g. X-ray, ECG,

should be documented and

interpreted.

Make sure your chart support your

diagnosis and management of the patient

Approaches in the management of patients in ED

Have the patient’s expectations,

voiced and unvoiced, been met?

Do you understand patient’s

concern?

Psychosocial needs

Psychosis

Suicide Attempt

Alcohol / drug abuse

Social Problems

Home help e.g. elderly living alone

Financial assistance

Temporary accommodation

Battered spouse

Child abuse / elderly abuse

Pitfalls to Avoid

Dizziness in the elderly

Epigastric pain in elderly

Flank/Loin pain in elderly

Backache in elderly

Elderly lady walk-in after a

fall c/o hip pain

GIB

Inferior wall AMI

Leaking AAA

Impacted fracture

Trauma

Neck trauma

Cut by broken glass

Hand laceration

Injury of thumb

Sprained ankle

Fall from height + fracture calcaneum

Missed C7 fracture due to inadequate film

Failed to X-ray / explored for FB

Trauma

Missed partial tendon cut, nerve injury

Missed fracture base of 5thMT with ankle film

Missed fracture upper end of fibula

Missed spinal fracture, mesenteric tear, aortic tear

Medical complaints

Chest pain with normal ECG

Headache of recent onset

Acute confusion / combativeness Confused alcoholic

Dissecting aneurysm, AMI

SAH

Hypoxia, hypoglycemia

Hypoglycemia, intracranial hemorrhage, Wernicke encephalopathy

Eye, ENT complaints

Nose injury

Hammer & chisel injury to eye

FB in eyes

Missed septal hematoma

Failed to X-ray for IO FB

Failed to stain for corneal abrasions

Miscellaneous

PV bleeding ? Reliable LMP

DAMA

Failed to order preg. test

Failed to document risk / explanation

Failed to get second opinion

Clinical Pearls

Respect is earned

Be friend, through a show of respect, to your

nursing staff, your colleagues – TEAM work

Listen closely to the suggestions of patients and

their families – this is why you are employed or trained.

Clinical Pearls

Learn how to tell a patient you don’t know what is wrong

Never say: “There is nothing wrong with you.”

Beware of the patient you do not like or e.g. drunk, aggressive, etc.

If the patient can’t walk as before, he can’t go home.

Clinical Pearls

If you don’t know what to do - do nothing; do no harm & consult your senior.

Abnormal vital signs must be re-checked and explained.

A printed form never saves anyone e.g. DAMA form.

Always verify patient’s personal data before seeing the patient, doing XR, cross- matching, taking any specimens, signing and issuing documents.

Good documentation

not written down = not done

Clinical Pearls

Ask for allergic history and check in medication history before prescribing any medications

appropriate sick leave and discharge advise helps to decrease unscheduled re-attendance and complaints.

Be aware of “Privacy Ordinance” and “Data Confidentiality” .

Do not download patient’s identifiable data without prior approval.

Not only soft copies but also hard copies with patients’ identifiable data need to be protected and they should not be brought out of hospital without prior approval.

Clinical Pearls

Recognize that certain groups of patients require a high index of suspicion for serious illness.

Immuno compromized

Chronic renal failure

Transplant

Extremes of Age, i.e. elderly and neonates

Intoxicated

Diabetes

Clinical Pearls

Develops an approach to patient resuscitation including

Initial management of the patient with a compromised airway

Indications for intubation of a patient and recognition of possible complications of this procedure

Exposure to the use of various airway adjuncts, ventilation devices, and oxygen administration devices

Initial assessment and treatment of the patient with common cardiac dysrhythmias: supraventricular tachycardias

ventricular fibrillation, ventricular tachycardia, asystole,

Initial assessment and management of the patient in shock

Thank you ?