• Medical Orientation

Layout, Staff and Services

Introduction

The Bendigo Emergency Department sees approximately 50000 patients per year and this number increases annually. It includes around 12000 children. There is no ambulance bypass and we are the only ED for our community including private patients.  We are the referral centre for an area that stretches from Kyneton to Southern NSW. Bendigo is a regional trauma centre and while our area is within helicopter range of the Melbourne major trauma centres, helicopters are frequently unavailable due to weather or other reasons meaning Bendigo also receives major trauma at these times.   The hospital moved into its $1 billion new facility on the 24th January 2017.

Services Provided

We are committed to serving our community and our region.  This means being the regional referral centre where we make every effort to accommodate patients from hospitals in our catchment requiring higher level care. The Duty consultant also provides telephone advice to GPs and smaller hospitals throughout our referral area.

Unit Layout

You should receive a tour of the department and a verbal orientation on arrival.

There are 5 main clinical areas which you will work in

Short Stay Observation Unit (SSOU)

This area acts as a high turnover ward for patients staying up to 24 hours and is run by Emergency Phyisicians.  Its capacity is12 beds with its own staff station, werd clerk and drug room.  SSOU is located 6A, which is the 6th floor of the main hospital tower.  It receives patients from all areas of the emergency department and also directly from the waiting room/ambulance stretchers. Beds are numbered  12 - 21 (with rooms 20 and 21 being double rooms, Room 19 has the ability for negative pressure as well . We aim to put 24 patients a day through SSOU.

Ambulatory Care (AC - Previously known as fast track)

This area has 6 treatment rooms, its own drug and equipment room and its own internal waiting room.  It is located adjacent to short stay and nearest the main hospital foyer.  There is a plaster room, eye room, and 2 procedure rooms in the corridors adjacent to Fast Track making a total of 10 spaces.  This area is for anyone patient who is walking - if patients subsequently need a bed/admission, then alert the Main area ANUM and Consultant.  Please do not keep patients in the rooms while waiting for tests - get them to wait in the AC waiting area or in the waiting room.

Main Cubicle Area

This area is centred on the "flight deck" where the ANUM and Consultant in charge of the shift are located in the pointy corner.

There are 20 cubicles however Cubilces 1-4 and 19-20 are dependant on Nursing staff numbers and as such not always used, cubicle 11 is only used for ECAT reviews at present.  It includes 2 isolation rooms in the ambulance corridor and a behavioural assessment room.

Paediatric Hub

This area is currently cubicles 1-3 for children under the age of 17 years or younger.  Preference is given to Main area children but Ambulatory care patients may use this area.

Reuscitation

There are 4 resucitation cubicles located at the extreme east end of the department furthest away from the main hospital foyer.  Most neonatal and paediatric resucitations will occur in Resus 2 where the resuscitaire is stored just outside.  The 4th cubicle also contains the blood gas machine, video laryngoscopes, difficult aireay trolley and US machines.  A registrar is rostered in the resuscitation area but must also be flexible enough to see their fair share of main cubicle patients.

The resuscitation area also contains the main drug room, ultrasound machines and portable Xray machine (which has an inbuilt instant viewer).

The "Hot Lifts" in the resuscitation area provide direct access to Theatre Level 1, ICU Level 2, and Deleivery level 3.  They will also provide access to the helipad in the near future.

Triage, Administration Area

This area is where triage and reception HIS staff are located and where patient labels on clip boards for patients are found.  It has 2 assessment rooms which are used by triage staff, rapid assessment team (RAT) nurse and doctor.   The area fronts onto the main waiting room and separate paediatric waiting room.  There are separate doors opening from the main waiting area to the fast track waiting room and short stay corridor.

Ambulance Corridor - The corridor from triage to resus has an ambulance triage/waiting area, a quiet room (to be solely used for distressed families and not as a treatment or psychiatric interview room), the main sterile store room, the psychiatric seclusion room and the 2 isolation rooms.

 Administration Area/Toilets/Staff Change Area/Tea Room/Education Room

These spaces are all located at the extreme East of the building near Arnold Street and are beyond the resuscitation area if walking from the direction of the main hospital foyer.  A Kronos clock is also located just outside the toilets.

If working in Fast Track, the public toilets in the main foyer of the hospital may be just as close.

It is important to have a break – let the consultant know you are having your meal break and enjoy the space in the Tea Room or the outside BBQ area shared with radiology staff.

Equipment

The ED has a lot of toys and people need to take care of their toys and put them away when they are finished with them or they will be in trouble.

Ultrasound machines

These live in the resuscitation area. Keep them clean, keep them plugged in.  Junior staff are requested not to use the US machines (even for peripheral IV access) without supervision unless they have done basic ED US training or a specific course.  Interns and residents should not be relying on ultrasound to achieve IV access other than in exceptional cases where they have asked for help.

Ventilators

There are 4 Hamilton Ventilators

Defibrillators

Manual defibrillators are in each resus cubicle.

AED’s are in various locations around the department including in the resus drug room on top of the fridges where they form part of the transport bag resources.

Telemedicine Machine

The telemedicine machine lives in the resuscitation area and is used for videoconferencing with local sites or to central retrieval services.  It is also used for the Victorian Stroke Telemedicine (VST) project for neurologist to teleconference as part of a stroke call.  Essentially plug it in and ring the number you want following the prompts.

Head Lamp

This is expensive, portable and very useful. Make sure it never leaves the ED. It is kept plugged in the Ambulatory Care Eye room when not in use.

Nasal Endoscope

This was donated by ED Consultants for the use of senior staff in the ED only.  It must be sent to CSSD after use that there is a reasonable turn around time.   It lives in the main resus drug room on one of the top shelves in the same aisle as the after hours pharmacy.

ENT Trolley

There is a red ENT trolley box with all your ENT needs that is housed the Ambulatory Care drug room.

Dental Kit

Emergency first aid dentail equipment is stored in the main resus drug room on the top shelf opposite the after hours pharmacy supplies.  Get a registrar or consultant to help you with this.

Eye Equipment

Dental Burrs for rust rings (after the metal foreign body has been removed by lifting it off with a needle) are in the eye room drawers.

The tonopen lives in the eye room and the condom covers are also on the shelves.

The panoptic ophthalmoscope also lives in the eye room.

 

Key Personnel 

Simon Smith Director Emergency Medicine
Richard Smith Deputy Director Emergency Medicine (Quality)
Mazdak Mansoury Satff Specialist / Rostering
Kate Fuller Nurse Unit Manager
Di Price Department Secretary and EMET Project Officer
Aaron Monro Department Secretary Assistant
Ruth Young Administration Officer / Data integrity
Kiran Veera Co-Director of Emergency Medicine Training
Yemin Swe Acting Co-Director of Emergency Medicine Training
Ian Staples Acting Co-Director Emergency Medicine Training / Medical Student Supervisor
Wolfgang Merl Staff Specialist / HMO Supervisor
Kent Hoi Staff Specialist
Deborah Maher Staff Specialist / Intern Supervisor
Debra Wood Staff Specialist / Mentoring Supervisor
Nathan Bushby Staff Specialist
Yvonne Higgott Staff Specialist / WBA Coordinator
Sanneeil Mathias Staff Specialist / Supervisor Intern Training
Dhruv Mori Staff Specialist / EPR
Khiem Ngo Staff Specialist
Vicky Kim Staff Specialist / Intern Supervisor
Fahad Yousif Staff Specialist / POCUS
Keith Nallaratnam Staff Specialist / EMET
Gabby O'Connor Staff Specialist
Scott Taylor Staff Specialist
Yit Leang Staff Specialist
Yvette Bassin Staff Specialist
Emma Paterson Staff Specialist
Shaun Greene Staff Specialist

Intern/HMO/Registrar Responsibilities & Report Lines

There is consultant cover in the ED from 0800 to 2400 every day and consultants are on call from 2400 to 0800 every night. On day and evening shifts there are 3 consultants on, one with responsibility for SSOU, AC and Main (the latter with overall responsibility for the main department, the admitting officer phone, flow, safety and so on).

There is a nurse in charge (ANUM) for each shift who allocates patients to cubicles, arranges inpatient beds and ensures the nursing staff are on top of their duties among innumerable other duties. It is vital that the ANUM and the duty consultant are kept well informed of what is happening with every patient.  The plan for each patient is recorded on EPR Floor plan by the ANUM and Duty Consultant which is visible to the whole hospital.

Interns and Residents are allocated on their shift to either

1) Short Stay

2) Ambulatory Care

3) Main Cubicles/Resuscitation

Registrars are allocated to resuscitation (but still see main patients) or main cubicles.  Senior registrars are allocated the consultant in charge or short stay shifts as part of training.

We do not formally police which junior staff have had a particular amount of each shift and this requires flexibility amongst all staff to ensure that each doctor has a fair spread of case mix exposure.  If you have done 3 Short Stay shifts in a row, make sure you dont do it on your 4th shift and swap at the beginning of the shift with someone else.  We have found that rigidly rostering people creates difficulties and some unhappiness and as such the daily roster/findmyshift is a guide only with regard to duty areas.

Interns should discuss all their patients in detail with a consultant.  SSOU and AC patients should be discussed with the consultant on for those areas. Other junior medical staff should discuss all but the most simple cases with a consultant or registrar and should seek immediate senior input for any cases where a patient breaches MET criteria (see below), is expressing dissatisfaction with treatment, is threatening to leave against advice or is outside the scope of experience of the junior doctor.

Registrars are expected to keep in contact with the consultant regarding their patients and to discuss complex or critically ill patients early.

Consulant On Call

There is a consultant on call overnight who should be called by the senior doctor overnight or nurse in charge overnight when either feel they are out of their depth or the department is out of control.

Other Clinical Staff

Physiotherapists

Physiotherapists fulfill 2 roles in the ED – As a primary contact clinician who consult patients from the waiting room (same as you do) seeing patients with musculoskeletal disorders: eg fractures, sprains etc.  They have no prescribing rights and are supervised by the ED Consultant.  They are a vital resource for all medical staff as they are often they experts in managing conditions within their scope of practice.  It is also vital that all medical staff support the physiotherapists when there is a request to precribe analgesia or there is a request for medical input.

They also fulfill a traditional role such as gait assessments and are an invaluable resource in this regard also.

Nurse Practitioners

Nurse practitioners consult patients (same as you do) within their scope of practice and have limited prescribing rights.  Nurse Practitioner Candidates also see patients but are still in the accreditation process.

ECAT

The Emergency Crisis Assessment Team are responsible for all psychiatric assessments in the ED.  You should ring them (47870) once you have confirmed that your patient is medically clear and to discuss what the psychiatric management plan is.   Medical staff in Bendigo ED do NOT perform psychaitric risk assessments but there is ample opportunity to understand this area by liaising closely with the ECAT team.

Nursing Staff

We are a team in ED and work closely with our nursing colleagues. They are an excellent source of information, help and practical advice.  Most tasks in ED can be performed by either medical or nursing staff whether it be getting a urine bottle for a patient, getting water for a patient or taking blood.  We do ask that junior medical staff take blood and insert cannulas themselves rather than delegating this to a busy nurse in which case the task is often delayed.

Plaster Technician

Jason our plaster tech is a valuable asset to teach you how to do slabs and plasters - find him and ask you to give you some tips...

Drug and Alcohol Coordinator

Daniel Eltringham is the drug and alcohol coordinator who works business hours but can followup patients the next day if you contact him about them.

Emergency Procedures

Code Blue

Code Blues are called in the ED for all arrests as they are in all other parts of the hospital - The number to call in an emergency is 7777.

MET criteria - Make A Call!!! - MAC Codes

MAC Codes are the EDs internal response to MET criteria.   All ED obs charts (on the EPR) have age specific MET criteria highlighted in red.  If any of your patients vital signs fall within the shaded area of the obs chart, or you are worried about your patient, you should immediately notify the duty consultant.  All staff are encouraged to "Make A Call" and flag any patient with vital signs in the shaded area.  Consultants and registrars are expected to respond in a reasonable to timefram to the concerns raised.

Helicopter arrival - Helicopter arrival team

Batphone advises of helicopter arrival

Call 7777 with HAT Call ETA.  Call hospital coordinator with ETA.

Doctor and Nurse meet helicopter and ring destination (cathlab/ICU/ED to confirm readiness for arrival).

Ambulance Victoria paramedics will manage the patient - your role is to phone ahead and make sure Bendigo Health staff are ready with the necessary resources.

Trauma Calls

Trauma calls, particularly level 1 trauma calls should be made as soon as the ED is alerted by the ambulance service. Click here for the criteria.

Level 1 Trauma – Non ED staff attending: Consultant surgeon, Surgical Registrar, Anaesthetics, ICU

Level 2 Trauma – Non ED staff attending: Surgical Registrar, Anaesthetics Registrar, ICU aware.

Level 3 Trauma – Emergency Consultant aware, ED staff only involved, no overhead announcement.

Code AAA

If an unstable ruptured AAA is suspected, a code AAA is called (phone 7777) which alerts the surgeons, theatre and blood bank.

Code STEMI

We currently have a 24/7 Cathlab on call for any STEMI's arriving to the hospital and are the defined Cardiology referral centre for a large area of Loddon Mallee.  STEMI codes are called by the ED senor in charge by calling the Cardiology Reg that is on call - or the interventional cardiologist on-call.  STEMIs may be identified by the ambulance bat phone with a subsequent fax, or from the ambulance service using the Pulsara App (passcode is postcode 3550), or by ECGs taken in the ED for patients already physically present.

Blood Code

There is a massive transfusion policy on PROMPT.  To activate a blood code call blood bank on 46300.  If you cannot get through or cant remember that number, call 7777 and ask to be put through to blood bank for a blood code.  Activating a blood code will automatically trigger 4 units of O-ve blood to be delivered to ED.  It will also trigeer FFP to start to be thawed for the second delivery of products.

Successful management and request of blood products in massive transfusion requires one clinician to be in contact and liaise closely with blood bank from the outset and our policy explicitly states that this should occur.