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.firstname.lastname@example.org) or Alastair Mark (email@example.com) 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 (firstname.lastname@example.org) 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
- The main objective of this run is to gain familiarity with the assessment and initial management of the critically unwell/ deteriorating patient.
- You should also gain basic airway skills, and an understanding of the process of anaesthesia including pre and post operative assessment.
- You should also gain some idea of the Emergency Medicine approach to key presenting complaints including chest pain, syncope, headache, abdominal pain, and fever.
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 29,000 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.
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 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.
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.
The ED is great for procedures. You will hopefully get the opportunity to perform the following procedures (with guidance where necessary):
- Blood drawing
- Cannula insertion
- Arterial Blood Gas
- Dislocation manipulation
- Foreign body extraction
- Plaster and splint application
- Urinary catheterisation
- Other procedures are at the discretion of the senior doctor e.g. nerve blocks, fracture manipulation, basic airway maintenance, lumbar punctures and cardioversion
You should make a real effort to learn to start IV fluids, draw up drugs, and do other tasks usually performed by the nursing staff. You will look and feel silly if you are asked to start a bag of IV fluid during a resuscitation in your first week as an RMO & can’t do it!.
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. Do not leave without clearly handing over/discussing any patients still in the department
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:
- The topics covered in the podcasts/webpages below
- Tutorials and “on the floor teaching” by emergency physicians and SMO’s during your term
- 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 will be based upon attendance, satisfactory completion of a logbook (there is a logbook pro forma on this site- please do your logbook electronically) 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.
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
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
Afternoon lists 1330-1730.
- General Surgery, including Upper GI , Breast & Endocrine, Endoscopy and Colorectal
- Vascular Surgery
- Obstetrics & Gynaecology
- Visiting Plastics, Maxillofacial and Paediatrics
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
Anaesthetic subspecialty interests are covered including Paediatric, Obstetric, Regional, Acute & Chronic Pain, and ICU.
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
- 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. YOU SHOULD SPEND ONE FULL DAY HELPING THE ICU NURSE CARE FOR A VENTILATED PATIENT. This is an incredibly important opportunity to understand what goes into looking after a critically ill patient. Many of the insights you get during this day can’t be gained by simply tagging along on the ICU ward round. Please ensure you do this.
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
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
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, intensivist & Senior Clinical Lecturer, Convenor Critical Care run