Do nothing, and nothing happens. Life is about decisions. You either make them or they’re made for you, but you can’t avoid them.
— Mhairi McFarlane, You Had Me At Hello

Patients in the Emergency Decisions Unit remain under the ED team, and whilst there are strict criteria for who can be admitted occasionally things can and do go wrong...

In preparation for this and in part because new doctors have rotated into EDU we ran three "live fire" in situ sims based on real adverse incidents. Staff were directed to perform their roles and to use equipment including the crash trolley if they needed it.

We will cover all three scenarios below, along with some links for further reading. There were also tweets going out during the sims, and we would like to say thank you to those who followed along on twitter.

Scenario 1: Seizures

30 year old man admitted on the alcohol pathway has now started seizing...

Positive Feedback:

  • Good closed loop communication.

  • Appropriate use of PPE.

  • Worked through algorithm for management of status.

  • Consider the reason for a seizure - patients with alcohol intoxication and head injuries are frequently admitted for observation.

Learning Outcomes:

  1. It is important to identify a team leader to maintain an overview when managing the critically ill patient.

  2. Consider the dose of lorazepam relative to the size of the patient (be aware that a 4mg bolus should be given over 2 mins - Lockey 2002).

Ref - AS Locky, Emergency department drug therapy for status epilepticus in adults Emerg Med J 2002;19:96-100 doi:10.1136/emj.19.2.96

Further Reading:

Scenario 2: VF Arrest

A middle aged man on the NSTEMI rule out pathway has developed chest pain...

Positive Feedback:

  • Clearly established a team leader.
  • Clear allocation of tasks to team members.

  • Minimal interruptions to chest compressions.

Learning Outcomes:

  1. To get help to EDU quickly tannoy: "DR and Nurse in Charge to EDU STAT".

  2. When needing to ventilate the patient move the bed so you can access the head of the bed.

  3. When attaching defib to a patient change the display to paddles, as it defaults to lead II ECG.

Further Reading:

Scenario 3: Opiate Overdose

Betty has been admitted on the MDT pathway after a fall, she has had a lot of pain in her back. She has had some painkillers and gone for a lie down...

Positive Feedback:

  • Quickly recognised unwell patient and called for help (as well as putting the lights on!).

  • Identified low GCS and respiratory depression. Also examined drug chart and realised possible opiate toxicity.

Learning Outcomes:

  1. A-E assessment is important in order to avoid missing things.

  2. Simple interventions can buy you time, for example opening airway and applying oxygen.

  3. It is important to be familiar with equipment in the crash trolley as you will often need them in a hurry.

  4. Remember that opiates are excreted by the kidneys so think about renal function once the immediate emergency is over and don't forget to check for opiate patches!

  5. Opiate overdose is a Never Event (see references below).

Edit & Peer Review by Jamie Sillett and Rebecca Prest