Lessons Try to rule our bad stuff first Don’t assume Trust no one Comprehensive Subjective - Ask appropriate questions Exact mechanism (if present) Recollection of events (eg fall vs collapse) PMHx, Meds, Allergies SHx Smoking, ETOH, Drugs Fasting status Comprehensive Objective Assess the LIMB, not the reported injury Observation is important – see the limb and look for irregularities (inc red, hot) Distal NV function is very important CMWS, capillary return, pulses, distal neural function (eg median / radial / ulnar nerves) If it is remotely fishy, clear other potential problems Know what your clearing tests are for different regions Cx, Lx, Orthopaedic Neurological Exam vs Neuro Neurological Exam Palpate above and below reported injury If there is something bad, or it doesn’t add up, ESCALATE If you find something and don’t do something about it, that is BAD

Lessons from Day 1 Diagnostic Imaging Does anything need to be done at all? Evidence based guidelines for requesting of images Knee, Ankle, Cx, DVT, Lx What needs to be done TODAY? For interpretation of films taken Have a systematic approach to interpretation (seek more training) Are they appropriate? Right person, region Picture (ie are they rotated / poor quality) – need to repeat if not Bony changes Cortical disruption Trabeculae Soft tissue signs Elbow – posterior fat pad sign Knee - lipohaemarthrosis Is it enough to rule something out to just have x-rays? Eg Scaphoid If something else needs to be done, when should it get done?

Lessons from Day 1 Particular pathologies Often there is no one particular answer Justify why you would choose a particular management plan for a condition, rather then just rote memorising what you do for an injury Know commonly presenting problems well Complete a more comprehensive investigation for each region than what we did yesterday Use appropriate resources – online, articles / reviews, books, people, local policy Upper Limb Clavicle Fractures Proximal Humeral Fractures AC joint injuries Shoulder dislocations Metacarpal fractures IP jt dislocations Scaphoid fractures (or suspected) Distal Radial fractures

Lessons from Day 1 Particular pathologies Know commonly presenting problems well Lower Limb Ankle Fractures 5 th MT #s Lis Franc injury Ankle sprain / small avulsion #s Achilles / Quads rupture Avulsion #s (esp kids around the pelvis) Back Pain Neck Pain When you are not sure, ASK SOMEONE ELSE who has better knowledge (should always discuss everyone when you are starting out) This is a fantastic way to learn (and also show the other stuff that you know what you are doing and get respect) !!! If you don’t know what you are doing and you don’t ask and do something wrong – it is on YOU!

Lessons from Day 1 Pain Relief / Medications Consider non-drug options Splinting / Slings / Ice / Elevation / Counterirritants (linaments) Know what you are allowed to do Restricted medications = cannot suggest Unrestricted medications Even if suggesting something that is freely available, you still need to know how that is going to sit with the patient Scope Doesn’t matter if it is # management, splint application, assessment of particular problems or advice given regarding medications, you need to be competent to do so How you may be competent may be tricky to prove Evidence of Training / Competency Testing Logs of procedures eg casting, patient types, radiology interpretation, reductions etc can be helpful to show breadth of practice. If you are not competent to do something or manage a particular condition, you need to seek further advice, or hand the patient over to someone else with further expertise.