Author: Charlotte Davies / Editor: Liz Herrievan / Codes: / Published: 01/07/2025
This blog is another pilot blog to see what you think! Its a day in the life of the Emergency Department (ED) problem buster. I wrote a list of what I did every day, and researched it for a blog. If you think this is great, please let us know – especially if youd like to research your day.
Incident Reports
An incident today around a patient with myasthenia being prescribed gentamicin made me think about how to stop this from happening again, and also about what other long term conditions we need to be careful of prescribing in. We know about drug interactions, and exacerbation of toxidromes, and potentially (probably dogma) problems with beta blockers in asthma, but what about the rare conditions we forget?
I came up with Myasthenia and Parkinsons. X platform helped me come up with G6PD deficiency and long QT syndrome. Further review of the incident forms and discussions with the pharmacist made me think of mastocytosis and clarithromycin.
As for actioning the incident report, reflect back on our risk and safety blog.
Risk and Safety – RCEMLearning
Can they Walk? – Louisa Brooks
Walking patients, who have attended after a fall, particularly elderly patients, is essential, yet never covered in medical school! Our physio and OT colleagues are excellent at doing this, but out of hours, or even during the day, we need to review our own patients to make sure they can get home safely.
Similar safety tips should be utilised when performing a lying and standing blood pressure.
Here are my tips for doing this safely:
- Provide analgesia for the patient and ensure theyve had their Parkinsons medication.
- Ensure appropriate footwear, whether thats well-fitting shoes or anti-slip socks.
- Remove as many tubes as possible – IV fluids, BP cuff etc.
- Check expected function – if they walk with a frame normally, get a frame.
- Check their blood pressure.
- Sit the patient up first, and check no symptoms.
- Slowly get them to stand up.
- Recheck their blood pressure.
- Position your feet in front of theirs as a buffer to stop their feet sliding.
- When the patient feels ready, encourage them to take some steps.
- If the patient feels unwell at any point, sit them back down.
- After 3 minutes check their BP again, then pat yourself on the back for doing a proper Lying and standing BP. Measurement of lying and standing blood pressure: A brief guide for clinical staff | RCP London
- Be positive, and reassuring, remember fear of falls can be limiting, but with support and reassurance can be alleviated.
- Sit the patient in a chair instead of a trolley, if possible. Mobility and falls The Hearing Aid Podcasts
Fitting a Miami J collar
Weve talked about how to fit hard c-spine collars previously here: C-spine skills – RCEMLearning. A soft Miami J collar follows similar principles, but is much better for the patient, as the risk of pressure ulcers is lower. The Miami J has a front piece, and a back piece, and is sized according to the silhouette chart with the kits. OSSUR MIAMI J INSTRUCTIONS FOR USE MANUAL Pdf Download | ManualsLib
Im sick, and going home
I think if a clinician has made the decision they are too unwell to continue working, that decision needs to be respected. I like to first review their current patients, and check they have all been appropriately handed over. If the clinician is sick, their patient care may be compromised so if possible, these need to be handed over to a senior to ensure nothing is missed.
I then check how the doctor is getting home, encouraging them to call a taxi if theyre too unsafe to drive, and I check who will be at home. If theyre going to an empty house, I ask them to let me know when theyre home – I always worry there will be a poorly clinician found on the tube somewhere that no-one was aware of! I then assess why they are going home, and whether they will be back for their next few shifts, and if they need any support. Its easy to assume physical illness has worsened leading to absence, but sometimes, a patient has caused upset, and a quick debrief is actually all that is needed.
I then ensure the rota coordinator is aware theyve gone home, so it can be logged in case extra sickness support is needed.
Surgeons say no, gynae say no
Weve all been there – its a woman with right iliac fossa pain, and neither team think it’s their responsibility. This is such a common problem, hopefully your department already has a solution. You might request the imaging – although thats difficult, as surgery is often CT and gynae is often USS – but we dont in our department.
Our strategy is the ED senior makes the call whether it’s gynae or surgeons – and the specialty has to see. If ED arent sure, we refer to both, and they liaise amongst themselves. The last case I saw I was convinced was surgical, but turned out to be a large fibroid causing vomiting – but the patient got the right management in the end!
Whilst the patient is waiting, they need appropriate analgesia, and maybe antibiotics – ED may not be surgical or gynae specialists, but managing pain should be our forte.
How do you manage this in your ED?
I hope you enjoyed the collection of ED snippets. Please send us your feedback, and why not get in touch with your own day in EM?