Friday, August 30, 2013

The Emergency Medicine Posting


The Emergency Medicine posting is the last piece to the whole housemanship experience.

HoSHAS Emergency Dept a.k.a the de facto hospital information counter.

During this posting, one will learn, experience and manage the whole spectrum of medical diseases as a preparation for MOship. When I say 'spectrum', I mean all diseases and conditions covered during the five previous major postings, from the mundane outpatient cases to the adrenaline-inducing emergency cases. 

Think oneself as a junior MO instead of a final-posting HO to get the brain firing up in preparation for the wild world of district posting.

So, that's why it's important to familiarize oneself with the common cases, procedures and drugs during each posting. Alas, that epiphany only comes the first time you see a patient in the consultation room and wonder what the heck you should do with such cases. Before you experience that regret, I'm telling you now: jot down important notes in a small notebook during each posting. By the time you come to A&E, you'll avoid significant anguish when you have five notebooks readily available all the time.

I prefer to use the abbreviation A&E which stands for Accidents & Emergencies (it unofficially stands for Anything & Everything as evidenced by the retarded number of unnecessary green zone cases). ED which stands for Emergency Department sounds impotent. 

The A&E is divided into red, yellow and green zones plus an observation ward. Patients who come to A&E are triaged accordingly. Triaging is one of the basic principles of Emergency Medicine. All A&E staff can and will do it anytime/anywhere. Its purpose is to determine who deserves prompt treatment and who doesn't

For example, a 40-year old smoker presenting with chest pain:
  • If he were breathless and clutched his chest, the triage MA will, without asking a question, automatically think of myocardial infarction, grab a wheelchair and rush him straight to the RED zone. 
  • If the same patient comes walking in and complains of chest pain, then he will be sent to the procedure room first for ECG then re-triaged depending on the ECG (or sudden deterioration depending on your luck). If the ECG is mildly abnormal or vital signs are not stable (e.g. very high BP or tachycardia), then he/she will be sent to the YELLOW zone for further workup.
  • If the ECG is normal and the vital signs are normal, he/she will be sent back to the GREEN zone for proper consultation.
That means if you come with fever, cough and sneezing, please shut up and wait while we attend to guy with the broken neck or the lady with excessive menstrual blood loss. 

Empathic pain - can you feel it?

There are other red flags signs and symptoms that warrant immediate management e.g. unconsciousness, fitting, or very rapid breathing. Pregnant ladies in late pregnancies involved in non-obstetrics conditions are also sent to the A&E. Referrals from KK and smaller hospitals also get the same triaging; they are usually referred for further workup or further management.

The UK NHS Choose Well campaign aims to reduce unnecessary A&E cases and hence, the posters above. But can such campaigns work in Malaysia? Can people recognize simple URTI, AGE or allergic reactions? Do they know what medications they need and are usually prescribed? The answer is no, yes, yes. People will still flock to the A&E because they want the best treatment for such ailments which is a government MC.

Typical day in the green zone.

As for my 4-month HO experience, I found that each zone has its own learning curve. The red zone is a place for immediate diagnosis and management; the patients have clear-cut symptoms and signs; treatment usually follows guidelines e.g. ACLS for heart cases, EGDT for septicaemic shock and primary/secondary survey for trauma. The yellow zone patients are usually stable and have masked or less dramatic symptoms; it's a place for thorough examination and investigations; if you miss something, it will come back to haunt you. The green zone is where the drama takes place; patients who don't understand triaging and complain about the long waiting time mentally write their complaint letter in the green zone waiting hall.

Once a life-threatening condition has been ruled out or unstable patients have been treated and stabilized, the A&E team will refer the case to a primary team. While most cases are usually accepted and admitted, there are times when cases are rejected or asked to refer to another team first. Sometimes, argument ensues between teams when both teams don't want to accept a case. When that happens, we sit back and enjoy the show.

The end of Emergency Medicine posting signals the separation of friends, the trial of the bonds forged during hardship and stress, the pursuit of further career advancement, the end of the gauntlet of clinical life and the beginning of a life filled with responsibilities.

Last day in HoSHAS. Will be back as paeds trainee lecturer at USIM.
Good bye and good luck, peeps!