How to get the most out of your placement in the emergency department
Working in an emergency department is a great opportunity to learn how acutely unwell patients are managed and to practise your clinical skills
The fast paced nature of the emergency department might seem an intimidating environment, with an average of 40 people presenting to these departments every minute across the United Kingdom.
A placement in an emergency department provides a unique opportunity to see patients at what is often the first presentation of their pathology, which is as yet undiagnosed and unmanaged. It is also an ideal place to build your clinical confidence by practising your history taking and examination skills and to see how the wider hospital works together. This article gives an overview of how the department operates and provides advice on how to prepare so that you have a productive and enjoyable placement.
What to expect in the emergency department
The set-up of each emergency department differs slightly between hospitals, but generally patients are allocated to different areas by a senior nurse, depending on their clinical presentation. The most common areas in most emergency departments are resuscitation (resus), majors, and minors.
In 2004, the government introduced a four hour waiting target for emergency departments, which means that patients must be seen, treated, admitted, or discharged within this time limit. This target, along with the high volume of incoming patients, means that emergency doctors often need to make rapid decisions about the management of their patients’ care.
The role of the emergency doctor is primarily to assess and manage acute pathology but also to have one eye on where the patient should go next: either admitted to the hospital under the medical or surgical teams or discharged home.
The emergency department team deals with the acute phase of a patient’s presentation with initial investigations and management, but more specialist investigations will be carried out by teams in the relevant specialty. About 18% of all attendances at emergency departments in England result in admission to hospital.
A good emergency doctor will enjoy hearing a patient’s story, making sense of the initial presentation of a pathology, and pulling the threads together into a working diagnosis.
Before you start your placement you should practise a systematic approach to history taking and performing examinations, including a general systems review. If your emergency department uses a clerking proforma, pick up a copy to get to grips with the information you will need to collect if you are asked to clerk a patient.
Box 1: Tips for surviving your emergency department placement
- Familiarise yourself with how each area of the emergency department works and what opportunities are available to practise your clinical skills.
- Introduce yourself to key members of staff to understand their roles and what they contribute to the team. Let them know your skill level and that you are keen to help and be involved. If you are unsure about anything, ask early on and stay within your competence.
- Check at the start of each day who is covering the different areas of the department, so you know whom to approach to present patients you’ve clerked
- Consider wearing a pair of scrubs—it will make you feel more part of the team and stop your own clothes from getting messy.
- Ask to be notified if an acute case is coming into resus, and ask the doctor receiving the patient if you can be involved. Have a fresh pair of disposable gloves ready in case you are called on at short notice.
- Carry an emergency medicine textbook (such as the Oxford Handbook of Emergency Medicine) to look up management recommendations.
Areas of the emergency department
Alongside gaining clinical knowledge, you can also find out how different professional groups work together and how to communicate well in stressful situations. You can learn more about how the ABCDE approach is applied in practice by reading this article: http://student.bmj.com/student/view-article.html?id=sbmj.i4512.
As a student, you may think you are getting in the way of the team, particularly if you do not have a designated role. Before you start your placement ask where the best place is to observe. If you would like to get involved, introduce yourself to the doctors running the resuscitation area at the start of the day and ask them to let you know when major cases are coming in. Tell them about your skills and your level of competency—for example, if you are happy to take blood and put in cannulas.
If it’s appropriate, you may be asked to assist with the initial stabilisation of a patient using the ABCDE approach, and with urgent investigations such as taking blood tests.
Patients who are likely to need comprehensive assessment and investigation before treatment and possible admission are sent to majors. Common presentations include the acute abdomen, headaches, and pneumonias.
Spending time here can be rewarding and you can help speed up the assessment and management of a patient by offering to clerk patients. This can be a rare opportunity for you to practise coming up with a differential diagnosis on the basis of only the information you have elicited, without being influenced by previous assessments.
Each emergency department has a system for tracking patients in “majors.” Find out where this information is, where triage notes are kept, and how to locate a patient. You can then identify new patients who may be suitable for you to clerk. Always ask your seniors if it is appropriate and safe for you to see a patient first. Leaving a sticky note on the patient’s notes is a good way to let staff know that a student has seen the patient. Write your clerking on a spare proforma or history sheet which you can add to the notes later.
If it seems likely that a patient needs simple investigations, such as blood tests, check with the medical staff that they are happy for you to do these before you start a lengthy clerking. Always stay within your competency level, and make sure you have appropriate supervision.
When presenting your clerking to your supervising doctor, include a differential diagnosis, further investigations, and a management plan. The Oxford Handbook of Emergency Medicine is a helpful resource that can help you suggest the most appropriate management.
Minors is for patients who may need treatment but do not need to be admitted to hospital.
The case mix includes minor trauma such as ankle or hand fractures, lacerations, and less severe medical cases. Musculoskeletal problems are common, so this is a good opportunity to practise your musculoskeletal histories and examinations.
Patients may be seen by emergency doctors and advanced nurse practitioners. Talk to them about what sort of cases you would like to see. They may involve you with more complex procedures, such as fracture relocations.
In minors you can gain experience of practical procedures, including suturing and giving subcutaneous and intramuscular injections. Practise these in the clinical skills laboratory so that you’re comfortable and competent performing them when you are on your placement.
Box 2: Five tips from a consultant on how to make the most of your time on an emergency medicine placement
Katy Guy, emergency medicine consultant, Morriston Hospital, Swansea
- Get to know the team. Introductions are really important. You may have a named supervisor but it is likely you may shadow a variety of different doctors and other staff members.
- Get involved. If there is anything in particular you would like to see or practise, let your supervisor know (specific presentations, clerking opportunities, or practising clinical skills such as cannulation or suturing).
- Understand the structure of the day. Most emergency departments do a round at least twice a day (morning and evening) where patients currently in the department are discussed; some doctors will have review clinics, but the remainder of the day will depend on what patients present.
- Don’t take offence. If the department is busy, senior doctors may be tied up trying to sort out management issues, so don’t take offence if the day doesn’t go as you’d planned. Seeing the management side of running a department can provide valuable non-clinical experience..
- Keep a list of what you see during your day and read around that subject after your shift. Being able to “hang” a condition on a real patient can help you consolidate your knowledge.
1Abertawe Bro Morgannwg University Health Board, UK, 2Aintree University Hospitals NHS Foundation Trust, UK
- QualityWatch. Focus on: A&E attendances. Why are patients waiting longer? 2016. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/140724_focus_on_ae_attendances.pdf.
- Coates WC. An educator’s guide to teaching emergency medicine to medical students. Acad Emerg Med 2004;11:300-6. doi:10.1111/j.1553-2712.2004.tb02215.x pmid:15001414.
- Mason S, O’Keeffe C, Carter A, et al. A longitudinal study of well-being, confidence and competence in junior doctors and the impact of emergency medicine placements. Emerg Med J 2016;33:91-8. doi:10.1136/emermed-2014-204514.
- Kings Fund. What’s going on in A&E? The key questions answered www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-and-emergency-care-mythbusters#hospital-bed.
- Wyatt J, Clancy M, Robertson C. Oxford handbook of emergency medicine. 4th ed. Oxford University Press, 2012 doi:10.1093/med/9780199589562.001.0001.