Psychiatry

It is estimated that 1 in 4 people in a year will have some kind of mental health problem, and that mixed anxiety and depression is the most common disorder in the UK. There is an increasing number of mental health patients attending the ED, and a new FY doctor in the ED will encounter such patients from their first shift onwards. The approach to a mental health patient is only marginally different from the approach to those presenting under other specialties. The assessment largely depends on careful history taking and attentively listening to the patient’s narrative. There are only a few situations in psychiatry in which a physical examination and investigations are required in the ED to make a diagnosis. As it would not be possible to cover all the areas of psychiatry which come through the doors of the ED in one chapter, only a few questions have been included here to provide a flavour of the common psychiatric situations that FY1/2s may come across in their early training period. The UK has the highest rate of self-harm in Europe and so one of the most important points is to recognize suicidal patients who can harm themselves seriously and manage them appropriately. If such patients are discharged following an inadequate assessment, they may go on to commit suicide and the attending doctors would have missed the opportunity to support and save them. In this category of patients, when they present to the ED, no matter how minimal is the level of their self-mutilation, it is a serious ‘cry’ for help. Our job is to listen to the patient and support them with the maximum help we can provide. As it may be difficult to occasionally get to the bottom of the problem, particularly within the time constraints in the ED, a low level of suspicion should be kept to ask for the assistance of the mental health expert. Self-harm and depression go almost hand in hand. The suicidal rate is higher in depressed patients than in the general population.

Ophthalmology

Approximately 2% of ED attendances comprise patients with eye complaints. Most of the time this group of patients is seen by a junior doctor with very little training in thorough and relevant history taking and examination. The majority of such eye problems can be treated in the ED without requiring any intervention from an ophthalmologist. But a few may require immediate action and subsequent referral to the on-call ophthalmologist. Most of the emergencies require a standard approach to history taking followed by an examination, although some (acid or alkali burns) may need immediate treatment, which is given while the assessment is being done. In ophthalmology, the history will help indicate the part of the eyes to focus on during the physical examination. The following points should be covered in the history: • Associated trauma • Pain versus irritation • Photophobia • Discharge—colour, quantity and consistency • Loss of vision • Pattern and speed of onset of symptoms • Any past eye problems in the same or the other eye. During the physical examination always measure VA separately for each eye by using Snellen’s chart and document your findings. If the patient wears glasses, these should be kept on during the test. The examination should also include a good look at the eyelids (both from outside and inside), conjunctivae, cornea, pupils and their size and reaction, visual fields, eye movements, and ophthalmoscopy. Do not forget to evert the upper eyelid with the help of a cotton bud as tiny foreign bodies often hide underneath it and their removal will immediate relieve the symptoms—the patient will be very grateful! Patients with potentially serious pathology requiring immediate ophthalmology referral include those with: • Sudden loss of vision • New reduction in VA • Acute red and painful eye (suspect acute glaucoma) • Penetrating eye injuries • Chemical burns to the eye • Suspected iritis, herpes zoster infection, and orbital cellulitis (referral on the same day). The questions in this chapter cover the common eye emergencies and a few uncommon but serious pathologies.

Wounds, Fractures, Orthopaedics

A significant number of patients attending the ED are those who are often referred to as ‘minors’, ‘streamers’, ‘walking wounded’, etc. These include patients with minor injuries, wounds, fractures or other soft tissue injuries. Therefore, a basic knowledge of anatomy and its application in various circumstances is mandatory. The injuries mentioned above are rarely life-threatening, but they may be limb-threatening and severely disabling. So it is extremely important to avoid errors in diagnosis and management, and to know when to ask for help at the appropriate time. By following the key principles listed below, you will be able to avoid many problems with such patients: • In the history, a detailed description of the mechanism of injury and the patient’s complaint will help in predicting the type of injury sustained. • A careful and thorough physical examination can point to the site and type of injury, on the basis of which appropriate radiological images can then be requested. • A neurovascular examination must be completed and documented in every limb injury, before and after any reductions, and before and after immobilization. • Appropriate radiological imaging, accompanied by a thorough physical examination, can pick up injuries with a high degree of accuracy. Inadequate radiographic films should not be accepted. • Immobilize the patient if a fracture is clinically suspected even if the X-rays are negative. • In cases of dislocations or subluxations, X-rays should be done before and after reductions, except when a delay could be potentially harmful to the patient (for example, when a severe traumatic deformity of a joint threatens to jeopardize the viability of the overlying skin). • The patient should be able to mobilize safely before being discharged from the ED. • Patients should be given proper aftercare instructions before leaving the ED, including how to look after themselves and to recognize limb-threatening features, the follow-up arrangement, and to return if things go wrong. • Ask for senior help if you are not sure about an injury or its management.

Analgesia and Anaesthesia

Seventy per cent of patients who present to the ED have pain as their main complaint—and most of the time as a sign of injury or inflammation. Therefore, early assessment by scoring at the point of triage and offering the appropriate analgesia are the first steps towards the management of such patients. The College of Emergency Medicine guidelines suggest that at least 98% of patients in severe pain (pain score of 7–10) should be offered appropriate analgesia within 60min of arrival, or triage, whichever is earlier. In 90% of these patients, the status of pain should be re-evaluated within 60min of receiving the first dose of the analgesic. Despite this clear-cut standard and the availability of a wide variety of analgesics, achieving such a target remains, occasionally, elusive. It must also be realized that a positive experience for the patient largely depends on relief of pain as early as possible. Consequently, one of the primary areas for a new FY1 to focus on is the pain management. Remember it is simple and straightforward in most circumstances. GA may be required in the ED for various clinical indications, for example, cardioversion, facial trauma or burns, and acute respiratory failure (such as in asthma). In an emergency situation it may be a challenging procedure even for an experienced anaesthetist and could be dangerous for the patients. An FY1/2 will never be expected to perform this, but it is important to know when to call for help when the situation demands. Local anaesthesia is widely used in the ED, and is one of the skills foundation trainees learn in the early days. It is comparatively safe if the doctor is aware of how to perform the procedure and the upper limit of the dose for a particular patient. Finally, conscious sedation is also widely used in the ED for reducing fractures and/or dislocations and minor operations. However, it carries the same risks as GA and should be carried out by a doctor who is trained in the procedure as well as in resuscitation. A risk assessment should be performed as a patient with high risks (previous cardiac or respiratory diseases) must be sedated with extreme caution.

Surgery

Among surgical patients presenting to the ED, abdominal pain is the most common complaint, comprising 10% of ED visits. Evaluation of such patients in the ED is often challenging for a variety of reasons, such as the variability in the description of the perception of pain in individual patients, variable and changing physical findings with time, and life-threatening conditions presenting as seemingly benign symptoms. I always advise inexperienced doctors working in the ED to bear in mind seven time bombs that may be ‘sitting inside’ every adult patient’s abdomen who presents with abdominal pain. Patients who are discharged, but in whom one of these diagnoses was missed, will be blue-lighted back to the department dead. Therefore, before discharging a patient presenting with acute abdomen pain, all such conditions as listed below must be excluded beyond reasonable doubt. These conditions are: • Ruptured AAA • Hollow viscus perforation • Mesenteric ischaemia • Ruptured ectopic pregnancy • Acute pancreatitis • Intestinal obstruction • Acute myocardial infarction. Acute (inferior) myocardial infarction may present as upper abdominal pain and cannot afford to be missed. Patients >50 years presenting with abdominal pain must have an ECG in the ED, not only for detecting acute myocardial infarction, but for other associated cardiac problems precipitating an abdominal catastrophe. Elderly patients are more likely to have life-threatening conditions such as a ruptured AAA, mesenteric ischaemia, peptic perforation, and diverticulitis. Atypical presentations and rapid progression of these diseases, coupled with decreased diagnostic accuracy, may increase the risk of mortality in elderly patients. The only way to avoid the above is, as importantly as in other parts of medicine, by taking an accurate history, performing a thorough full clinical examination, arranging appropriate investigations rapidly, and making the correct decisions as to whether or not urgent surgery is required. Even with advanced imaging techniques, a good understanding of background clinical information is of utmost importance for accurate interpretation of imaging findings. This chapter includes questions on acute abdominal emergencies to give the reader an insight into the latest management strategies for these situations.

Paediatric Emergencies

It is normal in the early days of one’s medical career to feel apprehensive on seeing a seriously ill child in the resuscitation room. The effect is compounded by the fact that children of different age groups have different normal clinical parameters and require different drug dosages, volumes of fluids to be transfused, equipment of variable sizes, etc. To deal with the situation safely, various formulae have been developed to calculate the approximate weight of the child, size of the endotracheal tube, etc. The BNF for Children should be consulted when there is time to address it; otherwise, use the standard chart of common drug dosages according to the child’s body weight, which is freely available in almost every ED in the UK. It should cover most of your concerns when seeing and treating the acutely sick child. Children compensate well with any underlying serious illness, but there are some subtle symptoms and signs they will usually have in such circumstances. If these are missed, and appropriate management is not given or delayed, a child can suddenly decompensate and go into cardiorespiratory arrest unlike adults, who show gradual deterioration before an arrest. The success rate of return of spontaneous circulation from this situation is poor in children in comparison with adults. Therefore, for clinicians treating children, it is highly rewarding to identify those subtle symptoms and signs and institute the required treatment early on to avoid a catastrophe or a poorer outcome. There are high-quality videos available at the website www.spottingthesickchild.com for junior doctors on how to diagnose a sick child. ‘Be gentle with the young’ (Juvenal, Roman poet) is a well-known saying. Yet, for various socioeconomic or personal reasons, children sometimes become victims of adults trying to find an outlet for their anger. The ED is the place where such children are then brought to, with complaints that may raise suspicion of abuse. It is our primary duty to safeguard vulnerable young children and provide them the opportunity and support they require to grow up like every other child. A few questions in this chapter aim to stimulate the thinking of the reader in this area.

Ear, Nose, and Throat

A variety of ENT disorders present to the ED on a regular basis and are seen by the ED junior doctors. The majority of these are benign, but a few may be life-threatening conditions that require immediate recognition, rapid assessment, management, and involvement of the ENT specialist, for example, severe epistaxis (especially posterior type), acute epiglottitis, angio-oedema, and Ludwig’s angina. Therefore a basic knowledge and an understanding of the diagnostic features of the common ENT conditions are vital. It would be impossible to cover the large extent of ENT conditions presenting to the ED within a small space, hence this chapter will focus on a few common ENT emergencies that a newly starting ED doctor would have to deal with on a regular basis. There is a wide variety of ENT symptoms depending on the region affected. However, it is important to keep in mind the red flag symptoms that signal urgent help of an ENT specialist is required. Some examples are: sudden unexplained sensorineural deafness, facial nerve palsy, CSF leak, difficulty swallowing with toxic appearance, and drooling saliva. The ENT physical examination is different from other systems as its components are largely inaccessible, particularly in the ED. A good headlight, an auroscope, and correct patient positioning are all important accessories. Although rod lens and flexible fibreoptic scopes for nasoendoscopy and laryngoscopy are routine investigative aids, they are outside the realm of emergency medicine. Most of the diagnosis and management, however, of ENT emergencies can be achieved by following simple rules and using basic equipment. If any patient requires more than an auroscope or standard nasal speculum for a thorough examination, they should be referred to the ENT specialist. All sorts of foreign bodies may become lodged in the ears, nose, or throat. Most of them cause discomfort but are not life-threatening. A foreign body in the throat may have the potential to compromise the airway—a fact to be borne in mind. A lot of them can be removed in the ED, particularly in adults, but children sometimes may require attention of the ENT specialist depending on their age and the capacity to cooperate.

Medicine

This chapter encompasses questions on acute and subacute clinical situations spread over the various branches of general medicine, which include cardiology, gastroenterology, respiratory system, etc. The questions cover common presentations and anyone who starts practising emergency medicine will encounter such cases right from the beginning. Some of these may be brought by blue light ambulance in an acute stage (acute hypoxia, acute asthma, acute exacerbation of COPD, GI haemorrhage, myocardial infarction, arrhythmias, and many others). Therefore, it is important to have a good grasp of the fundamentals of common ailments so that timely intervention can avoid development of life-threatening complications. A variety of ECGs and chest X-rays have been included in this chapter to cover the common emergencies encountered in regular practice, both in the resuscitation room and in the trolley area. The aim is not necessarily to make you an expert in these areas, but to be able to recognize the patterns of important diseases in their acute stages, to expand your horizons further through seeing and treating more cases, by means of which vital confidence can be gained. There is always an inclination that any patient presenting with chest pain has to have an ACS and the aim is to prove or disprove that it is so. Even after admission to a ward and further tests, the patient is often discharged without the reason of the chest pain being found out. So it is important to consider several other causes of chest pain. Once ACS becomes unlikely, pulmonary embolism should also be considered as an important differential. With regard to the respiratory system, a severe or life-threatening asthma attack can be a daunting experience for the new doctor. Ask for help if you find the presentation is beyond your competence. In such a situation, you would need help from other specialties anyway. Timely intervention by an intensivist may save a young life. Anticipating airway obstruction in smoke inhalation is difficult most of the time, particularly when the patient appears to be talking normally, so it is important to recognize the importance of asking for senior help for further assessment.

Major Trauma

In the UK, trauma is currently the commonest cause of death in people <40 years and its incidence is predicted to rise over the next 20 years. So you have an important role in the assessment and management of this group of patients. Doctors of the ED perform a vital role in the early stages of management of trauma patients. In patients with multiple injuries, the care is delivered by a trauma team constituted by middle-grade doctors from various specialties. A senior doctor, usually from the ED and with training in dealing with trauma, leads the team. The trauma team is often requested by the prehospital ambulance personnel, but this is not always the case. Although in your first few days you would not be expected to manage such situations on your own, you may come across a patient with serious trauma behind the curtains in a cubicle. Recognizing the seriousness of the situation and calling for help in the form of a trauma team may make all the difference to that patient in terms of recovery. The principles of assessment and management of trauma patients are discussed in the first answer of this chapter. The ATLS course introduces you to the principles of early management of trauma victims and this can be applied to any trauma patient whom you will see in the ED. The skills you learn on the ATLS course are applicable in many situations. It is advisable to attend this training course while you are working in the ED. You should suspect major trauma in the following situations: • Related to vehicles: high-speed collisions, victim’s ejection from the vehicle (partial or total), rollover, prolonged extrication, etc. • Death of a co-passenger • Pedestrians run over or thrown away to a distance, or with a significant impact (>20mph/32kph) • Falls from a height of >6m in adults and >3m in children or two to three times the height of the child. Resuscitation in the first hour in the resuscitation room has been proved to reduce mortality and morbidity among trauma patients, and so it might be you who will have saved the life of an individual.

Infectious Diseases

An infectious disease, as the name implies, is caused by pathogenic microorganisms such as bacteria, viruses, parasites, and fungi, and it spreads from one person to another through various ways, directly or indirectly. Most, but not all, of such diseases present to the ED with fever. Septic shock, respiratory failure, or central nervous system involvement may occur following an infection and threaten life. Such a situation presenting with tachycardia, reduced BP, tachypnoea, or depressed GCS requires immediate assessment and resuscitation. Following the principles of ABCDE, promptly carry out airway protection, oxygenation, and IV access with collection of blood samples for investigations, and fluid resuscitation. The aetiology of fever may be wide ranging, but a careful history and a detailed physical examination should help in determining the cause in majority of cases presenting to the ED. In addition to this, the initial investigations may help further in establishing the diagnosis. In elderly patients, the source of such infections may be the respiratory system, the genitourinary system or the involvement of the soft tissues, and they are often serious. In the otherwise healthy younger patient, one must keep in mind the other systems such as the central nervous system, as well as abdominal and soft tissue infections. Patients may often present in septic shock. Even if the cause of a fever may not be evident at the outset, the best ‘guestimate’ often helps in determining which antibiotics to start with, which should be given as soon as the culture samples have been collected. One must make every effort to collect appropriate samples of body fluids (blood, urine, stool, sputum, etc.) to find the source of infection so that targeted antimicrobial therapy may be started if the empirical treatment has not worked. A discussion with the on-call microbiologist to properly direct the empirical antibiotic therapy is often most rewarding. A patient with an infectious disease may put others at risk as well, resulting in devastating effects, particularly in hospitals.