Working in the Emergency Department

Introduction

Starting work in the emergency department (ED) as a doctor can be a daunting prospect. It is a high-octane environment where multidisciplinary team members move briskly amidst the noise of beeping monitors and disgruntled patients.

Imagine an ED as an inverse swan: on the surface, you see the chaotic activity of a bustling department like the frenzied paddling of a swan’s legs. However, underneath the surface lies a methodical system, which keeps the department gliding smoothly through the challenges (although admittedly not as gracefully as a swan).

In this article, we will introduce you to the emergency department so that you can better understand the environment and the people who work there. With this knowledge, you will be able to approach your first job in the ED with confidence and benefit from the wealth of clinical experience working in emergency medicine offers. 

The front door and patient flow

The emergency department is the front door of the hospital, accommodating walk-ins, GP referrals and ambulance arrivals.

As patients arrive, they are triaged by a senior nurse and directed to the relevant part of the department (majors, minors, resus) or an alternative off-site location.

There has to be a smooth flow of patients from triage to discharge. This concept is referred to as patient flow, and is crucial to ensuring the department doesn’t become overcrowded. 

Triage, RATing and pre-alerts

Triage

Triage refers to the quick clinical process of assessing a patient to determine the urgency of their need for treatment. This should be done by an experienced nurse within 15 minutes of arrival. Many triage systems exist, such as the Manchester triage system and the emergency severity index.

Rapid assessment and treatment (RAT)

Rapid assessment and treatment (RAT) involves initiating investigations and treatment at, or soon after, triage. A senior doctor normally performs this, and RAT can improve patient flow by ensuring appropriate investigations and treatments are initiated early.  

Ambulance pre-alerts

Pre-hospital crews will call in advance to inform the ED if they are bringing in a patient who is unwell and requires immediate treatment.

This call will go through to a red phone located in the main doctor’s hub or resuscitation room. The harsh, metallic ring of the pre-alert phone is designed to stand out from the background noise of a busy department. 

Pre-hospital crews typically use the ASHICE or ATMISTER structure to hand over their patients. The pre-alert phone should be answered immediately, and the relevant details should be taken down on a designated sheet of paper and passed to the consultant in charge.

The ED layout

The resuscitation room

The resuscitation room (“resus”) is reserved for the sickest patients in the department. Here, you will find patients with life-threatening emergencies such as anaphylaxis, septic shock, severe asthma and more.  

Patients may be transferred to resus directly from triage, brought in as pre-alerts by the paramedics or escalated from another part of the department due to clinical concern.  

Features of a resuscitation room include:

• High level of nursing care
• Cardiac monitoring
• Defibrillation machine
• Cardiac arrest drugs
• Difficult airway trolley
• Specialised equipment (e.g. splints, chest drains and thoracotomy kits)
• Controlled medication (e.g. opioid analgesia and rapid sequence intubation drugs)

Majors

Majors is the business end of the ED, where you will find most of your medical and surgical patients. Patients may be moved to majors directly from triage, escalated from minors or stepped down from resus. 

Typically, the main doctors’ ‘hub’ will be located in majors with the patients visible. 

All emergency departments will have several majors cubicles with basic bedside monitoring equipment. 

There may be one nurse looking after several patients. It is essential to know which nurse is looking after your patient and to hand over any jobs that need doing. 

If the nurses or healthcare assistants are very busy, you can help by doing bedside investigations yourself, such as blood tests and urine dips.  

The corridor

As emergency departments become busier, it is an unfortunate reality that more and more patients overflow from majors’ cubicles into non-clinical areas such as the corridor. This is a consequence of poor flow, where not enough patients are being discharged from the hospital to keep up with the demand for beds. 

The corridor is inherently unsafe, and patients’ risk should be mitigated by bringing on extra nursing and healthcare support to cover these areas.

Minors

This part of the department is for minor injuries and minor medical or surgical conditions. 

Typical cases you will see here include sprains, fractures, small wounds, coughs, colds and other minor ailments. However, there may also be sicker patients sitting in the waiting room who have been triaged to minors. 

If you are seeing a patient in minors who you are concerned about, then discuss with a senior to advise if escalation to majors or resus is appropriate.

Staffing in minors is varied, and you may find doctors, nurse practitioners and physician associates working side by side. Knowing your colleagues and being familiar with each other’s roles is vital to teamwork and will make your shift run much more smoothly.

Managing minor injuries is like an apprenticeship. You will learn how to buddy strap fingers, close wounds, remove foreign bodies, apply splints, and reduce fractures. Much of this isn’t taught at medical school, and a lot can be learned by spending time with clinicians with experience working in minors.

Clinical decisions unit

Most EDs will have some version of a clinical decision unit (CDU). These units are intended for patients not expected to require hospital admission. This is a place for patients to wait for investigations and treatment to be completed before discharge. 

Paediatric emergency department

You may be working in an adult, paediatric or mixed ED. If you work in a mixed ED, there will be a designated part of the department where children are seen. 

Paediatric emergency departments are staffed by specialist paediatric nurses who are knowledgeable and experienced in caring for children of all age groups. 

The doctors working here will be a mixture of paediatricians with an interest in emergency medicine or emergency medicine doctors with an interest in paediatrics. 

Urgent treatment centre

Some hospitals may have an urgent treatment centre (UTC) inside or adjacent to the emergency department. These are GP-led treatment centres which operate independently from the ED. 

People and their roles

Health care assistants

Health care assistants (HCAs) have training in a wide range of tasks and are key players in the emergency department. They can help with monitoring vital signs, ECGs, assisting with personal care, chaperoning intimate examinations, taking blood tests and cannulation. 

Nurses

Emergency department nurses are some of the most skilled in the hospital. They may come from different nursing backgrounds, and it is a good idea to get to know the skill mix of the staff you are working with.

Emergency nurse practitioners (ENPs) have undertaken additional postgraduate training in emergency medicine. They work independently, often seeing and treating minor injuries.

Advanced clinical practitioners

Advanced clinical practitioners (ACPs) are healthcare professionals who come from a variety of backgrounds, including nursing, paramedic and physiotherapy. They hold a master’s degree in advanced practice and can work as independent practitioners, seeing a range of patient presentations. 

Physician associates

Physician associates (PAs) are starting to play an increasingly important role in the delivery of emergency care in the UK. They are healthcare professionals with a master’s degree in physician associate studies. PAs work alongside doctors in the emergency department. As with doctors, their skills vary depending on the level of experience they have in the specialty.

Hospital specialties

Specialties such as the on-call medical and surgical teams will work alongside you in the department, either clerking patients, reviewing patients or giving advice on management. Remember that you are not alone and there is an entire hospital here to help you. Don’t be afraid to ask other specialties for advice.

Therapy teams

Therapy teams made up of physiotherapists and occupational therapists work in the ED to facilitate early discharge of patients who are medically fit but require further support (e.g. mobility aids or a package of care).

These teams come by various names and acronyms, such as integrated discharge team (IDT) or hospital rapid discharge team (HRDT). 

Police

Police may bring patients in who are under arrest but require medical attention. They will stay with the patient if he or she is under arrest. 

Police may also bring someone in under section 135 or section 136:

• Section 135: patient brought in from their home to a place of safety
• Section 136: patient brought in from a public place to a place of safety 

The police will stay with these patients for the duration of the section (initially 24 hours).

Mental health liaison 

Mental health liaison services are on-call to review patients who are suicidal or suffering from an acute mental illness. You will work closely with these professionals due to the high volume of mental health-related presentations.

Other team members

Other members of the multidisciplinary team include porters, housekeeping, alcohol liaison service and speech and language therapists (SALT). Some of these may not be available out of hours. 

Liaising with other healthcare professionals

Referral to a specialty

Using a structured approach such as the SBAR communication tool when speaking to on-call teams can help you structure your referral.

The medical and surgical on-call teams will be busy and fielding a lot of queries. When speaking with them, it is important to be clear about:

• Who you are
• Why you are calling them
• What you would like them to do

For example, “My name is Michael, I am a foundation doctor in the emergency department, and I am calling to refer a patient who I think requires a medical admission….“.

Not all referrals involve a hospital admission. You may be asking for advice on management, treatment, or follow-up. Being clear at the start of the conversation about the purpose of the call will help steer the discussion in the right direction. 

Ambulatory pathways

Ambulatory pathways exist to avoid hospital admissions in clinically well patients.

Check your local guidelines to see which pathways are in place and how to book your patients into them.

A common example is a DVT pathway for patients with a suspected DVT who present out of hours and cannot have a Doppler ultrasound scan until the next working day. Most departments will have a pathway whereby these patients are given an initial (STAT) treatment dose of low molecular weight heparin and asked to return for a review in clinic after their scan. 

GP follow up

When discharging a patient home who requires follow-up in the community, you should state clearly in the discharge letter what you would like the GP or community teams to do.

Keep the clinical information relevant (the GP will not want to read an essay!) and be specific about the follow-up required. For example. “Right forearm wound closed with 5 x non-absorbable sutures. Tetanus booster and wound care advice given. Please remove sutures in 7-10 days”.

Discharge letters will be sent either electronically or through the post to the patient’s GP. If possible, it is good practice to print a copy of the discharge letter and give it to the patient.

Your first day in ED

Empty your bucket

Imagine your brain as a big bucket of ideas. If your bucket is full of worries and distractions, then you won’t have the capacity to take on new information. Before you enter the emergency department, try to mentally empty your bucket. Put those mental distractions to one side so you can fully engage with, and enjoy, the day ahead. 

Tour of the department

You should start your first day with a tour of the department. Familiarise yourself with the layout. It may initially feel like a maze, but you will soon be able to walk around with your eyes closed!

IT access

Every ED has its own IT systems, including a digital whiteboard or patient tracking system. Ask someone familiar with these to show you how they work.

Updating the patient location and referral status on the tracking system is key so that the doctor and nurse in charge can maintain an overview of the department. 

Do what you’ve been trained to do

At the start of your shift, you will be allocated to a specific part of the ED. Your seniors will explain how to identify the next patient to be seen on the patient tracking system. 

Pick up your first patient and do what you’ve been trained to do: take a history, perform a relevant clinical examination, formulate a differential diagnosis, make a management plan and discuss with a senior. Repeat. 

The art and the science of medicine are built on the back of individual patient encounters. By the end of your rotation, you will have gained an enormous amount of clinical experience, fine-tuned your clinical reasoning and become confident in new procedures.

Discuss with your senior

Aim to discuss your management plan with a registrar or consultant early in the patient journey.

This is to ensure that the relevant investigations and treatment are initiated promptly. You shouldn’t hold onto a patient for hours without a clear management plan.

Some departments have a policy where all patients must be discussed during the first few weeks of your rotation. However, as you gain experience, you will start to act more autonomously as a decision-maker. 

High-risk presentations such as chest pains, re-attenders or elderly people with abdominal pain should always be discussed. 

The Royal College of Emergency Medicine (RCEM) advises that the following presentations should have a consultant sign-off before discharge:

• Atraumatic chest pain in those aged 30 years and over
• Fever in children under 1 year of age
• Patients returning within 72 hours of discharge with the same complaint
• Abdominal pain in patients aged 70 years and over 

Check your department’s policy on consultant sign-offs and senior review during your induction as they may have additional presentations which require sign-off by a consultant.

Referrals

Patients who have been referred to a specialty team are officially under the care of that team. However, you still have a responsibility for that patient while they remain in the department. You should follow up on pending investigations and escalate your concerns if there is a clinical deterioration.

Escalate

You may start seeing a patient and immediately realise they are not well. They might have a high NEWS score or a clinically concerning presentation.

If you think the patient needs immediate treatment and you are unsure what to do, let a registrar or consultant know before getting stuck into a full history and examination.

Look after yourself

Make sure you take a break during the day to rest your legs and refuel. Knowing where to find the staff room and kettle is the second priority after locating the defibrillator and difficult airway trolley!

Look after your physical and mental health. The anti-social hours associated with working in the emergency department can be challenging. Debriefing with your colleagues after a difficult day and finding time to unwind is important.