F2 Teaching Day (Aug)

This week we held the first F2 teaching day for our newest rotation of junior doctors at Leicester Royal Infirmary’s ED. We had a smörgåsbord of topics from mental health, through to minor injuries and managing head injuries.

Here's a summary of some of the key learning points from the day…

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Mental Health

Primary Assessment

Physical health needs:

• Observe the patient, look for any injuries or evidence of self-harm

• Assess their cognition

Environment:

• Is the environment safe for you?

• Is the environment safe for the patient?

Personal possessions:

• Does the patient have any potential weapons on them?

• Remove anything that could be used to harm themselves

Intent:

• Any thoughts to harm self or others

• Any desire to leave

Assessment of Risk

Suicidal thoughts:

• What were they thinking at time of episode?

• Did they want to die?

Lethality of episode:

• Would it have resulted in death?

• Made efforts not to be found

Intent now:

• Any current thoughts to self-harm

• Do they have any regrets?

Protective or Adverse factors:

• Aspects can be protective and/or adverse…

  • Jobs, relationships, friends and family

  • Criminal charges

Risk factors and past/current mental health problems.

Capacity

A person is presumed to have capacity and can refuse treatment…

• Person must understand the information given to them

• Retain the information

• Weigh up the information to come to a decision

• Communicate that decision

If refusing, explore why they are refusing and consequences of refusing.

Resources

• RCEM Learning: Psychiatric Emergencies for the Adult Patient (module)
• RCEM: Mental Health Toolkit
• Emergency Medicine Cases: Medical Clearance of the Psychiatric Patient (podcast)

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Toxicology

Intentional and Non-Intentional overdoses are managed in the same way at the start.

Find out…

• What was taken?

  • Consider activated charcoal if within 60 minutes

• How much was taken?

• When was it taken?

• Was anything else taken with it? (e.g. alcohol or other drugs)

Check on Toxbase.org for investigations…

• Bloods (FBC, U&E, LFT, CK, Clotting, VBG)

• ECG (rate, rhythm, QTc)

Once treated get Mental Health assessment (if indicated)

Resources

• TOXBASE®
• Core EM: Toxicology-related articles
• RCEM Learning: Toxicology-related modules (#CAP27)
• Emergency Medicine Cases: Salicylate Poisoning & Low and Slow Poisoning (podcasts)

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Head Injury

Why? How? When? Are they on anticoagulation? Consider and know the CT Head NICE Guidance (see below).

When examining head injuries in patients always check…

• Eyes and CNs

• Ears – haemotympanum?

• Have a good feel at the lumps and bumps → if boggy, large or unsure get a senior to have a feel.

• Any evidence of seizure? Wet themselves or bitten their tongue?

Resources

• NICE Guidance: Head Injury: Assessment and Early Management
• The Resus Room: Head Injury – Roadside to Resus & Devastating Brain Injury (podcasts)

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Palliative Care

““Compassion. Compassion. Compassion!””

CPR is not a treatment for #ordinarydying. Every instance of futile CPR - which is what will happen if nobody has sorted out the protection of a DNACPR for someone whose life is coming to an end - is a tragedy. Please, doctors, nurses, patients, families - #havetheconversation. pic.twitter.com/t7yp6qm8Jd

— Linda Dykes (@DrLindaDykes) February 11, 2018

With too many health care professionals (and families) ducking #havetheconversation because it’s “too difficult” (actually, it usually isn’t) we need to empower individuals to demand the protection of a DNACPR. pic.twitter.com/8ShSXcjOni

— Linda Dykes (@DrLindaDykes) July 21, 2018

Resources

• St. Emlyns: Have a bit of ReSPECT for End of Life care
• RCEM Learning: Palliative Care in the ED
• Emergency Medicine Cases: End of Life Care in Emergency Medicine (podcast)