1. Emergency Medicine DR. HOSSAM HASSAN

3. What is Emergency MEDICINE?  Acute and life threatening aspect of medical care  Recognition, evaluation, care and disposition of patients with acute illnesses and injures.  Chaotic workload 24/7  Undifferentiated symptoms and completely new patients  On the spot decision despite uncertainty

4. Challenges of Emergency Medicine  All sorts of patients could come in at any time  Any combination of cases may present together  Task  Set priorities  Organize activities flexibly  Handle several cases at a time (multi-tasking)  Adjust speed and style of evaluation and treatment  Quality & safety despite chaotic workload

5. Challenges of Emergency Medicine  Undifferentiated symptoms and completely new patients  Task  Good interpersonal communication skill  Clinical acumen for a focused approach to clinical evaluation

6. Challenges of Emergency Medicine  On the spot decision despite uncertainty  Task  An ED Doctor needs to be able  To tolerate uncertainty, to make reasonable  decision out of uncertainty  To assess probability of serious pathology,  and hence appropriate referral.

7.  Demonstrate the principles of initial evaluation, stabilization and differential diagnosis management of patients with the following symptoms:  Shortness of breath  Chest pain  Shock  Altered mental status and coma  Headache

8.  Syncope  Abdominal Pain  Fever  The 'unwell' patient  GI Bleeding  Vaginal bleeding  Abnormal behaviour  seizure

9. Approaches in the management of patients in ED  Performs an accurate and concise history and physical examinations of the undifferentiated patient presenting to the emergency department  Formulates an appropriate plan for the initial investigation, treatment, and disposition of undifferentiated patient presenting to the emergency department

10. Approaches in the management of patients in ED  Does the patient have a  life/limb/sight threatening process?  Primary Survey of  Airway  Breathing  Circulation  What must be done to stabilize the patient

11. Approaches in the management of patients in ED  Evaluate for potentially serious conditions  that are compatible with the patient’s presentation?  For example:  Chest pain: AMI, dissecting aneurysm,ruptured oesophagus, tension pneumothorax, pericarditis with tamponade  Dizziness: GI bleeding  Headache: SAH, Meningitis,pseudotumour cerebri,ICH  PV bleeding: Ectopic Pregnancy  Rash + fever: Meningococcemia

12. Approaches in the management of patients in ED  Reaching a working diagnosis for the complaints  Clinical picture, investigations and probability  Initial Management at ED  Does the patient require admission?  Discharge the patient with adequate information  +/- referral

13. Approaches in the management of patients in ED  Does the documentation reflect  your evaluation and treatment?  Results of physical examination  investigations, e.g. X-ray, ECG,  should be documented and  interpreted.  Make sure your chart support your  diagnosis and management of the patient

14. Approaches in the management of patients in ED  Have the patient’s expectations,  voiced and unvoiced, been met?  Do you understand patient’s  concern?

15. Psychosocial needs  Psychosis  Suicide Attempt  Alcohol / drug abuse  Social Problems  Home help e.g. elderly living alone  Financial assistance  Temporary accommodation  Battered spouse  Child abuse / elderly abuse

16. Pitfalls to Avoid  Dizziness in the elderly  Epigastric pain in elderly  Flank/Loin pain in elderly  Backache in elderly  Elderly lady walk-in after a  fall c/o hip pain  GIB  Inferior wall AMI  Leaking AAA  Impacted fracture

17. Trauma  Neck trauma  Cut by broken glass  Hand laceration  Injury of thumb  Sprained ankle  Fall from height + fracture calcaneum  Missed C7 fracture due to inadequate film  Failed to X-ray / explored for FB

18. Trauma  Missed partial tendon cut, nerve injury  Missed fracture base of 5thMT with ankle film  Missed fracture upper end of fibula  Missed spinal fracture, mesenteric tear, aortic tear

19. Medical complaints  Chest pain with normal ECG  Headache of recent onset  Acute confusion / combativeness Confused alcoholic  Dissecting aneurysm, AMI  SAH  Hypoxia, hypoglycemia  Hypoglycemia, intracranial hemorrhage, Wernicke encephalopathy

20. Eye, ENT complaints  Nose injury  Hammer & chisel injury to eye  FB in eyes  Missed septal hematoma  Failed to X-ray for IO FB  Failed to stain for corneal abrasions

21. Miscellaneous  PV bleeding ? Reliable LMP  DAMA  Failed to order preg. test  Failed to document risk / explanation  Failed to get second opinion

22. Clinical Pearls  Respect is earned  Be friend, through a show of respect, to your  nursing staff, your colleagues – TEAM work  Listen closely to the suggestions of patients and  their families – this is why you are employed or trained.

23. Clinical Pearls  Learn how to tell a patient you don’t know what is wrong  Never say: “There is nothing wrong with you.”  Beware of the patient you do not like or e.g. drunk, aggressive, etc.  If the patient can’t walk as before, he can’t go home.

24. Clinical Pearls  If you don’t know what to do - do nothing; do no harm & consult your senior.  Abnormal vital signs must be re-checked and explained.  A printed form never saves anyone e.g. DAMA form.  Always verify patient’s personal data before seeing the patient, doing XR, cross- matching, taking any specimens, signing and issuing documents.  Good documentation  not written down = not done

25. Clinical Pearls  Ask for allergic history and check in medication history before prescribing any medications  appropriate sick leave and discharge advise helps to decrease unscheduled re-attendance and complaints.  Be aware of “Privacy Ordinance” and “Data Confidentiality”.  Do not download patient’s identifiable data without prior approval.  Not only soft copies but also hard copies with patients’ identifiable data need to be protected and they should not be brought out of hospital without prior approval.

26. Clinical Pearls  Recognize that certain groups of patients require a high index of suspicion for serious illness.  Immuno compromized  Chronic renal failure  Transplant  Extremes of Age, i.e. elderly and neonates  Intoxicated  Diabetes

27. Clinical Pearls  Develops an approach to patient resuscitation including  Initial management of the patient with a compromised airway  Indications for intubation of a patient and recognition of possible complications of this procedure  Exposure to the use of various airway adjuncts, ventilation devices, and oxygen administration devices  Initial assessment and treatment of the patient with common cardiac dysrhythmias: supraventricular tachycardias ventricular fibrillation, ventricular tachycardia, asystole,  Initial assessment and management of the patient in shock

28. Thank you ?