Nelson Hospital Critical Care

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Trainee Intern Critical Care Run

 

Overview

The critical care run is broken into 2 weeks of anaesthesia followed by 2 weeks of emergency medicine. Intensive care experience is included throughout the run, and you are expected to come to the ICU daily to participate in the ward round.

During the anaesthetic component, it is suggested that you go to OT at 8 am, to get a chance to be involved in any airway procedures at the start of the operating list. You should then go to the ICU & report to the ICU consultant of the day. If there isn’t much happening, you can return to OT. It is however strongly suggested that during the 4 weeks you participate in several ICU outreach visits of potentially critically ill patients on the wards, as this skill of assessing sick patients  & communicating with seniors about this will be examined in the end of run viva (and  more importantly is a key skill in beginning your career as an RMO). Email Katie ben (Katie.ben@nmhs.govt.nz) or Alastaire Mark (alastair.mark@nmhs.govt.nz) the week before your run begins to get assignments for OT lists for the 2 weeks

During the ED component, you should report to ICU at 8am & participate in the ward round (if suitable patients are in the unit). You should then go to  ED. If you are on an ED evening shift, then obviously don’t worry about going to ICU in the morning (similarly if you are on a day off). Email Tom Jerram (tom.jerram@nmhs.govt.nz) or Mark Reeves (Mark.Reeves@nmhs.govt.nz) the week before your ED component starts to get a roster for the 2 weeks

If there are any problems or questions, please contact Dr Tom Jerram or Dr Mark Reeves in the Emergency Department in the first instance

tom.jerram@nmhs.govt.nz

mark.reeves@nmhs.govt.nz

Emergency Department

Introduction

Welcome to the Nelson Hospital Emergency Department, (ED). We are the interface between the hospital and the community, and this creates unique opportunities for learning and experience. This attachment is designed to prepare you for practice in acute and undifferentiated medicine.

The ED sees approximately 26,000 patients per annum and has an admission rate of approximately 28%. Nelson Hospital serves a wide catchment area at the top of the South Island and you can expect to see and manage patients that cross all the major disciplines. As a regional hospital we do not staff all subspecialties and from time to time patients will be retrieved to larger tertiary institutions or more specialised facilities (e.g. Burwood spinal unit, Wellington Hospital neurosurgical unit, Hutt Hospital plastics and maxillofacial service)

You will join a cohesive team of Emergency Specialists, experienced senior medical officers (SMO’s) and emergency nurses.

** On the first day of your ED placement**

Email Dr Tom Jerram or Dr Mark Reeves the week before you start for a schedule for the next 2 weeks. You will do between 7 and 8 shifts, including the weekend between the first and second weeks (this is often a great time to get some practical procedures & a different experience). You will do a mix of morning (0800-1630) and evening (1600-0000) shifts. The more you immerse yourself in the ED team for the duration of your placement, the more you will get out of it.

Staff

Senior Medical Officers

– Dr Andrew Munro (FACEM) Clinical director

– Dr Chris Abbott (FACEM)

– Dr Alex Browne (FACEM FCICM )

– Dr Tom Jerram (FACEM)

– Dr Tom Morton (FACEM)

– Dr Marc Guttenstein (FACEM)

– Dr Clive Garlick

– Dr Fran Halford

– Dr Kanishka Jayasena

– Dr Mark Reeves

-Dr Jane Hopgood

Clinical Nurse Leader – Sharon Scott

House Surgeons & Registrars: There are a total of 10 House Surgeons and Registrars attached to the ED. All undertake a shift work pattern that includes nights.

Shifts

Emergency Medicine is by its very nature is a 24 hour specialty. All of the staff members you will work with are shift workers.  This means that you will be overseen by different doctors on a day by day basis.  It is very important that you introduce yourself to both the senior doctor and other team members who will be working alongside with you on your nominated shifts.You will in general be allocated to a RMO (registrar or SHO) , & will present your cases to them. Sometimes you will be working directly with a consultant.

As the case mix varies according to the time of time , you will be expected to do a mix of shifts (some 0800-1630, some 1600-2400) to a total of 8 shifts in your 2 weeks with us.It is important that you are there at handover time (0800 and 1600) at the start of your shift

It is important to ensure that you take meal breaks during the day. If leaving the ED for any reason, please make sure that you have discussed any patients you are seeing with one of the doctors first.

Procedures

The ED is great for procedures. We expect students to perform the following procedures (with guidance where necessary):

  1. Blood drawing
  2. Cannula insertion
  3. Suturing
  4. Arterial Blood Gas
  5. Dislocation manipulation
  6. Foreign body extraction
  7. Plaster and splint application
  8. Indwelling catheterisation
  9. Other procedures are at the discretion of the senior doctor e.g. nerve blocks, fracture manipulation, basic airway maintenance, lumbar punctures and cardioversion

Students are not to perform vaginal examinations on any woman unless they are accompanied by a senior doctor and have written consent.

Seeing Patients, Writing Notes and Ordering Investigations

The ED is a chance to see patients yourself, and come up with assessment and management plans under the supervision of one of our doctors. You should check with one of the senior doctors before seeing a patient, and get them to enter their name on the computer system (EDAAG). If you think the patient needs something urgently (especially pain relief), you should immediately let your supervising doctor know. Please do not get your own EDAAG login as a doctor, as this can lead to issues with patients being lost on the system.

In general you should spend no more than 10 – 15 minutes in assessing your patient checking back with  the medical staff. It is expected that you document your history and examination findings on Concerto (using your own login), and this record must then be finalised by the senior who is overseeing that patient.

Should you think that investigations are warranted, then these must be discussed with more senior staff first, and any forms signed by them. Likewise with specific therapy – any medication must be signed for by a doctor before it is given.

Once the patient has left the department, please note the time they departed  on EDAAG

Teaching

The Department has its own CME session from 8.30 to 10.00 each Tuesday morning. All students are very welcome to attend. This session takes the format of an x-ray case review session, and a seminar or case presentation on alternate weeks.

Your attachment in the ED will be based around:

  1. The topics covered in the podcasts/webpages below
  2. Tutorials and “on the floor teaching” by emergency physicians and SMO’s during your term
  3. Clinical exposure to conditions within the emergency department

You will see most of the subjects covered in your attachment. The success of your stay in the department will be dependent upon you getting to know the staff and your willingness to be involved in its everyday functioning. You need not be reminded that the emergency department is a busy, sensitive and often unpredictable area of the hospital. You must respect the directions of the nursing, clerical and medical staff at all times.

The principles of management you develop here will be of benefit to you regardless of what field of medicine you choose to pursue. Some of the issues you should consider are:

  • If in doubt, ASK! You are never alone
  • Seek assistance early if you are concerned about a patient
  • Think about what tests you might request – ask yourself how will a certain investigation alter management? Also, don’t wait for all of the results to be back before discussing a patient with someone
  • Be proficient with time management practices – don’t see patients one by one; organize yourself to be seeing another patient whilst waiting for another to come back from X-ray, etc
  • Communication is essential – with medical colleagues in the department, nursing staff, inpatient teams, general practitioners in the community, and allied health professionals. Here, you function as a member of a team
  • Pain is one of the main reasons people present to the ED and addressing this issue early in your consultation benefits all parties. Think about what you would expect if you were in pain…
  • Assessment and management often occur in parallel – we often have to commence life-saving treatment before we have a complete diagnosis

Assessment 

Assessment will be based upon attendance, satisfactory completion of this workbook, and your overall aptitude. We will discuss these components at the beginning of your term. You will also be formally assessed with a viva during the last week of the run

The links below constitute your formal Emergency Medicine teaching for this run. They are a mix of podcasts and webpages. You WILL be examined on these topics, so make sure you listen to/read  them all.

how-to-refer-a-patient-a-must-have-skill-for-the-emergency-physician/

core-analgesia-in-the-ed-induction-podcast/

induction-podcast-back-pain-in-the-ed/

asthma-induction-podcast-stemlyns/

problems-in-early-pregnancy-induction-podcast-with-nat-and-iain-at-stemlyns/

chest-pain-in-the-emergency-department-induction-podcast-at-stemlyns/

syncope-induction-podcast-with-stemlyns/

shortness-of-breath-induction-series/

an-approach-to-headache-in-the-ed-induction-series/

induction-to-em-staying-safe-in-your-first-job/

http://www.heftemcast.co.uk/sepsis-in-the-ed/

local-anaesthetic/

own-the-airway/

Ensure that you have received appropriate orientation to the department prior to commencing your term – this can be provided on the first day.

Enjoy your stay in an exciting and interesting area of medicine

Dr Tom Jerram

Anaesthesia

Welcome to Anaesthesia at Nelson Hospital – we look forward to having you as part of our team.

Theatres at Nelson Hospital

There are six operating theatres (five general plus one obstetric) which are located on level 3.

Start time 0800, for commencement of case at 0830

Lunch 1230-1330

Afternoon lists 1330-1730.

Specialities covered:

  • General Surgery, including Upper GI , Breast & Endocrine, Endoscopy and Colorectal
  • Vascular Surgery
  • Urology
  • Orthopaedics
  • Ophthalmology
  • ENT
  • Dental
  • Obstetrics & Gynaecology
  • Visiting Plastics, Maxillofacial and Paediatrics

Anaesthetic Department

There are twelve consultants, one registrar (rotating from Wellington for 12 months), and we have four SHO positions of 3 months each.

Consultants Dr Katie Ben, Dr Rodger Fitzgerald, Dr Allan Grant , Dr Gareth Harris, Dr Fou Lim, Dr Steve Low, Dr Joe MacIntyre, Dr Alastair Mark, Dr Philip Palmer, Dr Prue Pullar, Dr Matt Scott, Dr James Tuckett

Registrar:

 

Anaesthetic subspecialty interests are covered including Paediatric, Obstetric, Regional, Acute & Chronic Pain, and ICU.

Daily Plan

Start at 8am by contacting Alastair Mark or Katie Ben who will allocate you to a list (although you should have emailed them the week before!!). Theatre lists are pinned up in the dictation bay along the main theatre corridor. You should be present for the start of the list, then go to ICU once the first patient is anaesthetised.

If there isn’t much happening in ICU, you should return to OT

 

If there are interesting cases happening in another theatre you are welcome to shift around to gain more experience, but liaise with the Anaesthetist you have been allocated to primarily as to whether this is possible. If there is an interesting acute case happening after hours you can head home early in the afternoon and come back if you wish.

Skills to acquire

Anaesthesia is a very practical, ‘hands-on’ speciality, and is a useful as a TI to help acquire important skills you will need as an RMO. Below is a list of suggested skills and topics which you should aim to cover during your two weeks with us.

  • Airway management – assessment of the airway, manual airway manoeuvres, bag-mask ventilation, adjuncts such as oropharyngeal and nasopharyngeal airways, LMA insertion, Endotracheal intubation. Understanding of difficult airway management including the role of fibreoptic intubation
  • Vascular access – perfect your IV insertion technique; understand the role of Midlines & PICC lines, Central Venous Catheters, Rapid Infusion devices
  • Pharmacology – much of anaesthesia is applied pharmacology (and physiology), so it’s useful to revise the following topics which are important to know as a House Surgeon:
    • Analgesics – The analgesic pyramid, PCAs, co-analgesics
    • Anti-emetics
    • Antibiotics
    • Anaesthetic induction drugs & volatile agents
    • Muscle relaxants
    • IV fluids including crystalloids, colloids, blood products. Bolus vs. maintenance
    • Basic understanding of vasopressors & inotropes
    • Emergency drugs – such as adrenaline, atropine, amiodarone, adenosine, calcium
  • Anaesthesia pre-assessment
  • Understanding of alternatives to General Anaesthesia (spinal, epidural, nerve blocks)

We hope you enjoy your time with us, and value any feedback you can provide to help to continue to improve this attachment.

Critical Care objectives

Critical care/ ICU is woven throughout the run, & is very much opportunistic, due to the size of Nelson. If there is anything of interest in ICU, it is strongly suggested that you make yourself involved. There is an Intensive Care consultant on every weekday from 0800-1800.

The ICU consultants are

  • Dr Alex Browne (clinical director)
  • Dr John Foy
  • Dr Tom Jerram
  • Dr Megan Coltman

 

 It is strongly suggested that you should go on at least 3 outreach visits with the ICU consultant, as this is an ideal opportunity to practice assessing and handing over the deteriorating patient on the ward. These outreach visits happen most days- Ask the ICU consultant.

The following topics are seen as “core” critical care topics

  • Recognition of the unwell patient, including communication/handover
  • SIRS/Sepsis/MODS (see ED section for resources)
  • Resuscitation fluids
  • Oxygen delivery systems and non invasive ventilation
  • Blood gases
  • Altered level of consciousness
  • Shock

ALL trainee interns should have a good overview of these concepts by the end of the attachement,these will be tested in your end of run viva. Please read around these topics, as well as specifically asking for “mini” tutorials from your supervising doctors during the run if possible. You will be examined on this

 

Assessment

There is a clinical viva & log book assessment during the last week of your run. This encompasses all aspects of the run. Please use the excel logbook template on this site rather than hand in the paper logbook

Your Viva will be on the last Wednesday of the run unless otherwise notified.

 

 

Most importantly, enjoy your time with us.

Dr Tom Jerram

Specialist Emergency Physician & Senior Clinical Lecturer, Convenor Critical Care run

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