During this attachment, you will encounter patients who have overdosed on various drugs. As such, revising toxicology would certainly be worthwhile. Know how to assess and treat the most common overdoses, including:

• Paracetamol
• Benzodiazepines
• Anti-depressants

TOXBASE is a vital resource which you will use a lot

Handover is at 08:00 in Resus and starts promptly. Arrive on time wearing the doctor scrubs located in the cupboard on the right as you walk into A&E from the main hospital

CDU is also known as EAU2 and is just outside of A&E. There are 8 beds and 8 chairs for patients awaiting investigation results or specialty reviews. CDU chairs are often used for ambulatory patients in ED to avoid breeches.

As an FY1 you are treated the same as the other SHOs and junior trainees apart from the fact you are not allowed to discharge patients of your own accord. The ED team works coherently and you are very well supported. As you must discuss all patients with seniors, take each patient as an educational opportunity. The consultants are all approachable and would be more than willing to help in the interest of patient safety and education.

As the most junior of the SHOs you will usually be allocated to Majors (Areas A, B & C) or Minors & Paeds. You may on occasion get asked to go to Resus if it is busy or when there is less cover. As an FY1, you are super-numery on the rota and upon completing CDU duties, the ED consultants are happy for you to go to any area in the department which you would like to experience – following permission from the Emergency Physician In Charge (EPIC).

CDU shifts are 08.00 – 17:00 and you will normally finish on time. You also get to choose your own annual leave rather than being allocated it. The slight drawback is working 1:3 weekends.

For FY2s, shifts are 08:00 - 18:00, 13:00 - 23:00, 17:00 - 03:00 and 22:00 - 08:00. This works out as roughly a 1:2 weekend pattern. You often work a few weekends consecutively followed by a few off. FY2s have allocated annual leave though swaps are possible but often difficult to organise given the shift pattern.

It usually depends on your rota but roughly follows:

Every morning: teaching bite after handover based on the theme of the week

Weekly “Wednesday Work-out” 08:15 – 08:30 in Resus. Usually an ED SpR or ACCS trainee is asked to run a simulation and the other juniors make up the other members of the team.

ED Weekly Teaching: Thursday 13:00 – 15:00 in the ED Seminar Room on Level 1. This involves a mixture of lecture-based sessions, practical skills and case presentations.

FY1 on CDU: The A&E consultants take it in turns to do the CDU morning ward round - the do's, don'ts, and length of ward round vary between consultants. Most like to read each patient’s notes then review the patient before moving onto the next. However you should ensure that all patients’ results are reviewed (ECGs, urinalysis, bloods and imaging). Ensure that all patients have a completed drug chart and VTE. Patients who are alcohol-dependent should have the “alcohol withdrawal orderset” prescribed on EPIC to ensure they do not develop withdrawal. The pharmacist who covers CDU is often present on the ward round and can help with verifying patients' medications (eg from the GP record on SystmOne) and organising TTOs. There is usually a pharmacist covering ED and CDU who carries a bleep.

You are responsible for discharging, or referring onwards, the patients you see on the morning WR. All other patients that come from ED during the day are the responsibility of the doctor who clerked them so they should do any hobs required for them. In reality, sometimes it is easier to do some of these jobs yourself. If you have discharged all your patients from the morning WR and completed the discharge letters, then you can go to ED to see new patients (all of these should be senior reviewed by a registrar/consultant).

For Major trauma that comes into Resus, the FY1 will be called as part of the trauma team to scribe. This is a great learning opportunity to see how trauma is managed real-time. Unfortunately there is no “EPIC playground” for the “Trauma Narrator” tab as yet so have someone familiar with it observe you once to speed your learning.

The Emergency Physician In Charge (EPIC) will be the main port of call for any general advice during your shift. Report to EPIC at the start of your shift so they can allocate you to Majors, Minors or Resus. During the day until roughly 22:00, there are other consultants on shift and are available for advice. From 02:00 until 08:00 the on-call consultant is no longer on-site so you will need to discuss with the registrar should you need advice.

As an FY2 you will generally be allocated to Majors (Areas A, B & C). Patients in these areas vary from ambulant to quite sick. The ED SpRs/Consultants are around for general advice and are always happy to help.

CDU patients (FY1):

• Intentional drug overdoses (Check TOXBASE)
• Alcohol Dependents (Alcohol withdrawal orderset)
• Other psychiatric presentations awaiting liaison psychiatry review (who will often only review the patient once medically fit for discharge)
• Falls - Usually elderly patients needing START (Physio/Occupational Therapy) review before safely discharging
• Unordered List ItemOften there are issues with whether or not a patient has capacity; it is one of the first questions security ask when called to CDU. Always remember that capacity can change, especially in intoxicated patients. Reassess as regularly as necessary. Capacity is the ability to understand, retain and weigh up information in addition to being able to communicate their decision. The Psych Liaison nurses / Consultant Psychiatrists will always be around for assistance in this area and the nurses on CDU are very used to dealing with these issues. Use and learn from their experience.

A&E patients (FY2) - Anything and everything

CDU: No patient should ideally stay in CDU >24hrs. This generates a lot of paperwork - which unfortunately you are responsible for. Though the many discharge summaries can get tedious, the Trust gets fined per discharge summary that is not completed and sent to the GP within 24 hours. The same is true for VTEs not completed within 24 hours of admission. You can take a small amount of pride knowing you are saving the Trust a lot of money by being organised and timely with your paperwork.

If you get a child with a psychiatry presentation (<17yrs), a CAMH referral is your top priority. Contact them as soon as possible, as these are often the patients who end up in CDU >24hrs because the CAMH services are oversubscribed. It is also important to recognise that CDU is not an ideal ward for any child, so limiting the exposure is in your patient’s best interests. These patients also have to go in bed 2 (isolated bed) in order to be isolated from the adult bay.

A&E: As expected

Discharge letters are usually succinct and do not take as long as compiling those from a main ward reflecting the patient’s short length of stay in CDU. Try to give your GP as much information as possible. If you have not seen the patient yourself, this can be very difficult. Therefore clearly state in the discharge letter that you compiled the letter from the patient’s medical notes and that you did not see the patient during their admission.

EPIC is very different in A&E to the wards. Once signed in as an Emergency Doctor, you are taken to the track board - a list of all the patients in the department. It can be sorted by area, speciality, patients waiting to be seen and patients that you have allocated yourself to.

Once you have assigned yourself a patient, they will disappear from the waiting screen so make sure you see them. If not, you need to unallocate yourself and return them to the waiting screen. There plenty of PAs for bloods and most patients will have had bloods by the time you see them. The nursing staff are excellent and getting people to scans is managed timely.

For medical referrals locate the Medical Registrar on-call for the day, who will normally be in Area A or Resus. Other specialities are bleeped and are normally reliable. When discharging someone, they need to be given a diagnosis coding.

FY1 - Lots of senior support and no out of hours work besides weekends. Handovers occur at 08:00 in Resus, then 16:00 in CDU to the consultant on call.

FY2 - It can sometimes be daunting deciding who is well enough to go home, as it is often the first time you have had to make autonomous decisions. If you have any doubt, always ask a senior. Additionally certain presentations always need a consultant review prior to discharge, for which an alert on EPIC will appear, including:

• Febrile child <1 year old
• Non-traumatic chest pain in adults (>16 yrs)
• Unordered List ItemUnplanned re-attendance – Patients returning < 72hrs after previous visit with the same problem

The “Induction” app has an up-to-date list of all the bleep numbers in the hospital. In addition there is Rotawatch for the on-call bleeps and switchboard (100) if you need to get through to mobile phone numbers

Under the new contract, banding no longer exists. As such you will receive an additional supplement, on top of your basic salary, based on the amount of out of hours work you do.

Naomi Cooper is in charge of the rota. She is very friendly and easily contactable via email.

CDU- Clinical Decisions Unit

TOXBASE - Online toxicology resource

START - Team of physiotherapists and occupational therapists in A&E

CAMH - Child and Adolescent Mental Health

There is plenty of time as an FY1 on CDU to do an audit. Take this opportunity as during busier rotations you may find it difficult to do so.

If you are interested in ED and would like to do Locum shifts, the consultants and Naomi (in charge of the ED rotas) would be delighted to give you shifts you can make.

There are a lot of useful documents on Connect regarding referral pathways and investigation guidelines which can be very helpful.

It is worthwhile organising access to SystmOne via the NHS Smart Cards so that you can access GP prescription records for patients out of hours when pharmacy are not in ED.