JMO SURVIVAL

GUIDE
Sameer Al-Ameen, BMDH JRMO
FIRST SHIFT IN ED
Starting your shift

■ Be on time for the shift!

■ Find your consultant or registrar when you arrive
■ Day shift: Get handover from the night shift first
■ Evening shift: Teaching on Tuesday and Thursday at 2pm, otherwise pick up a patient
■ Night shift: Pick up a patient if they aren’t handing over already
Handover

■ Taking handover
– The previous shift’s patients will be split between the new shift Mos
– Make sure you note down briefly who they are and what needs to be done
■ Giving handover
– If you’re giving handover, the important things are:
■ Name, age, sex, location in the ED
■ What diagnosis they have and/or what they came in with
■ Already admitted under a team? What with?
■ What we’ve done for them
■ What we still need to do for them
Picking up a patient (on team A or team B)
1. Sort FirstNet by LOS (length of stay)
2. Find the person waiting the longest without an MO assigned and without a green arrow next to their name (fast track patients)
3. Put your name on them! (Right click in the MO column, assign provider)
4. Open the triage notes (the mouseover text is usually only half the info you have!)
5. Take a quick look at their previous discharge to get an idea of their background
6. Take the patient into a free room (if in the waiting room)
7. Get a quick HPC, examine the relevant system – don’t sit and write a beautiful summary yet!
8. Get a cannula in (unless they REALLY don’t need it) and take bloods from it before you flush it (EUC, FBC, LFT, CMP + specific
bloods they need)
9. Order imaging if they need it
10. Chart fluids, meds and analgesia if they need it – let the nurse know what they need
11. Talk to your reg/consultant about the patient! Do this early. It’s okay to miss things or not be sure about what to do, your seniors
are there to help, you’re not meant to be fully independent and comfortable with all specialities yet.
12. Do the jobs you and your senior came up with
13. Now sit and write a beautiful summary
14. Patient admitted? Type “ADMIT – CONSULTANT NAME // DIAGNOSIS” in all caps in the firstnet comment column, let your
senior know the team’s accepted, let the CNUM know so she can organise their departure!
Picking up a patient (on PIT/Front of House/Team C)
1. Find the next waiting patient that’s not fast tracked (green upward arrow)
2. Get their file (loose notes in a clear sleeve) from the triage area
3. Call for the patient in the waiting room
4. Take them to the PIT room with their file
5. Your registrar/consultant will get a brief history and exam
6. Get a cannula in + collect blood (Aseptic technique. Please document if aseptic technique
used as cannula can stay in for 3days as opposed to non aseptic technique only 24h)
– I prefer collecting a 10mL syringe full, 20mL if they’ll need blood cultures too
– This way you can just full whatever tubes are needed after they’re ordered
7. Your senior may ask you to order the scans/bloods as well
8. This is the mainstay of team C/PIT/FOH. Some consultants will pick up very straightforward
cases, but they’ll let you know if you need to do anything for them.
General ED survival
■ If you’re not sure or if you’re worried, ask your senior!! If they’re not there, ask whoever’s in
charge. This is THE most important rule of internship.
■ Communicate. Pt. needs meds? Let the nurse know after you chart it. Team accepted your patient?
Let your senior and the CNUM know. New plans/delays/admission? Let your patient know too.
■ The ED nurses are all lovely, especially if you treat them like you’d want to be treated.
■ Just because you’re a doctor doesn’t mean you can’t do “nurse’s jobs”, being able to do/help with
certain things can really speed things up and make people like you.
– See the next slide for examples!
■ Don’t expect to perfectly diagnose and package up a patient before calling a team!
– ED is there to make sure they’re safe, stable, and get them under the appropriate team for
complete diagnosis and treatment
■ Read Marshall & Ruedy’s “On Call” – This is brilliant for both ED and afterhours ward shifts
“Non-doctor jobs” that you can do
■ Doing obs
– Sometimes not all obs are done at triage, a HR/Sat/BP/Temp takes 2 minutes at most and saves waiting for
someone to come and do it for you. Ask a nurse how to record it on the file
■ Doing a UA/urine HCG
– Ask a nurse to show you when your patient gives a sample. It takes 1 minute and it can save 10 minutes of
looking for/waiting for a busy nurse
■ “Checking” drugs/fluids for a nurse
– IV fluids and IV or S8 meds need two people to check and sign them before they’re given. That means the nurse
needs to get your chart, get the meds then find ANOTHER nurse that’s free to give the stuff your patient needs
– Checking involves confirming the drug, the dose and the expiry date, then countersigning. Takes 5 seconds. Can
save 5 minutes and a lot of hassle
■ Helping to push a bed/wheel a patient to imaging
– If the wardies busy and your patient needs this scan NOW, think about getting them to imaging yourself. Saves
the patient time, saves the wardies time, and most importantly can get the patient sorted out and discharge
■ This is just the beginning! You’ll do all sorts of things you never thought you could/would during this term.
MISCELLANEOUS
TASKS
Paging
■ Normal paging
– Dial *2
– “Enter the pager number followed by the hash key”
– “Your page has been sent”
– Hang up
■ Text paging
– Go to services -> Emergency Department -> Blacktown
– Click on the big pager on the right!
Ordering imaging

■ Step 1: Order it on powerchart

■ Steps 2-5: Depends on the scan!
– X-ray: Page the wardsman to take them down
– Plain CT: Call CT directly (48244) and request the scan
– IV Contrast CT: Make sure they’re cannulated, call CT, they may ask you to get approval from the
radiologist if the pt. is in renal failure/on metformin etc.
– Oral Contrast CT: Call CT. They’ll send the contrast sachets and instructions to the ward. Chart the
contrast as per the instructions when it arrives!
– MRI: Fill out the paper imaging form as well. Fill out the MRI questionnaire. Take the imaging form to
the radiologist and ask for approval – they’ll want justification for the MRI.
– Ultrasound: Call the ultrasound department (No need to call unless urgent if you are in ED)
■ Final step: Let the nursing staff know!
Adding on pathology

■ Forgot to order a CRP? Already sent a green tube down?

■ Don’t fret, you don’t need to get more blood!
■ Get a paper pathology request form
■ Write “ADD ON (insert test here) PLEASE” in the requested tests section
■ Fill in the patient’s details, brief clinical note, sign and date
■ Send it in a canister to pathology
■ You can do this for just about any test for which you’ve already collected the tube that
day
COMMON CALLS
“Doctor, your patient needs more fluids charted!”
■ Step 1: Are they eating and drinking well? Are they old/at risk of overload?
– See if they need it
■ Step 2: Check if they have electrolyte abnormalities
– Low K+? Low Mg++? Think about replacing these orally or with minibags if NBM.
– High Cl? Don’t give too much NaCl
■ Step 3: Commonly prescribed fluids
– 1L 0.9% NaCl
– 1L 0.9% NaCl + 30mmol KCl
– 1L Hartmann’s
– 1L 4% dextrose + 0.18% NaCl (4% and a fifth)
– 1L 5% dextrose
– “Minibags” - Common fluids for electrolyte replacement (give over an hour generally)
■ 100mL 0.9% NaCl + 10mmol MgSO4
■ 100mL 0.29% NaCl + 10mmol KCl (If your patient can drink it, PO chlorvescent replaces more and doesn’t take up a line!)
■ Step 4: Let the nursing staff know it’s charted
“Doctor, your patient is in pain!”
■ Step 1: Make sure you know why they’re in pain!
– Unless you already know them and it’s ongoing, it’s best to see the patient
– Check how much analgesia they’ve had already. If 5mg IV/SC morphine isn’t cutting it, think
about calling the pain CNC or anaesthetics reg if after-hours
■ Step 2: Remember your WHO pain ladder
– Paracetamol + NSAID + opioid
■ Step 3: Check allergies!
■ Step 4: Common analgesics
– 1g PO/IV Paracetamol TDS PRN (avoid in liver failure)
– 400mg PO ibuprofen TDS PRN (avoid in kidney failure and peptic ulcers)
– 5mg PO endone Q3H PRN, max 30mg/day (careful with elderly patients)
– 2.5-5mg SC/IV morphine Q3H PRN, max 30mg/day (Check step 1!)
“Doctor, your patient needs a new cannula!”
■ Step 1: Are they on IV medications? Are they NBM? Are they likely to need IV medications or
fluids soon?
– If not, check why they still need a cannula
■ Step 2: Sterile technique!
– This is the difference between the patient needing a new cannula every 3 days and the
patient needing a new cannula every day
■ Step 3: Don’t cannulate fistula arms/post lymph node dissection arms
■ Step 4: You will fail many many times
– Nobody is born being able to cannulate well, keep trying. I went from a 90% fail rate to a
90% success rate over my first year.
– Failed twice on the same patient? Ask your friendly resident/reg/anaesthetics reg for help!