• Medical Orientation

Special Patient Groups

Staff Occupational Exposures (Needle sticks and so on)

See this entry in Bendigo Referral Options

Deaths

Find a handout about how to handle deaths in Bendigo ED here

Reportable Deaths - Coroners Cases

Is this death coroner's case?

Death certificates should only be completed when there is a clear diagnosis and the death is expected.  Death certificates are NOT written for Coroners cases.  Any case that is not clear or there is any doubt, should be referred to the coroner – our department has a low threshold.  The coroner’s clerk can give further advice regarding whether or not to refer a case if there is doubt.  They can be contacted via the Coronial Admissions and Enquires number on 1300 309 519.  If they indicate it is a coroners case you will be asked to complete a medical depostion online using an access code they will give you.

Click here for coroners information on which deaths are reportable and the link to the medical depsotion page.

Non Coroners Deaths

Step 1

DOCTOR to write a death certificate (Medical Certificate Cause of Death - MCCD) and PRINT 3 copies.  From March 2019 this is done via Registry Information Online.  To use this you must have registered personally for it here.  You do not need to sign the print outs.  The hospital can access the cetificate via their account if they need to print more.

Step 2

NURSES to fill out ED Death Notification Form.  One copy goes to morgue with body, one copy to ED Director/Administration Assistant, one copy to ED NUM.

Step 3

DOCTOR to fill out mortality screening tool form (online version hereprint and fill out version here) and send to ED Director/Administration Assistant.

Step 4

Write a discharge summary and fax it to the GP notifying them of the death.

Paediatric Category 1 and 2 Patients

These patients are high risk and are to be seen by a consultant or registrar if a consultant is unavailable.  They are not to be treated by interns or HMOs unless in the direct presence of a senior medical staff member.

Interns and Paediatric Patients

All children under the age of 2 seen by interns must also be seen by a supervising consultant or registrar.  The amount of time spent with the family by supervising staff will depend on how much of the presentation the supervising senior knows from other sources and the type of presentation.

Non Accidental injury

Kids who have catastrophic NAI (murdered, disabled from subdurals etc) often have a string of  presentations to the ED or GP prior to the event. Daniel Valerio (below) was murdered when he was 2 and is a classic example of this.  Bendigo has its own examples.  Some states have mandatory forms to make sure there has been senior doctor review of minor injuries and review of the past medical record. Bendigo has its own procedure that must be followed.

NAI should be considered with any injury to a child, even if trivial.

daniel-valerio

Daniel Valerio

Bendigo has the following procedure to target the highest risk group (children under 4) so that MINOR injuries DO trigger consultant review and review of the old notes.  However NAI should still be considered in children of all ages.

Bendigo Procedure:
1) All injuries in children under 4 years MUST be discussed with a consultant (or registrar overnight)
2) The past history of presentations (the hospital record) must be reviewed and presented to the consultant when the discussion process occurs.

The following documentation is expected in ALL cases of child injury in under 4 year olds:

Source of history - i.e. mum, dad, ambulance, triage nurse notes
Consistency between history sources -did Mum, Dad and Auntie all give the same story? Did the same story get given to ambulance, triage and you?
Correlation between history and clinical findings- do the injuries make sense with the history given?
Documented discussion with a senior ED doctor - we have last names and this is a good place to use them.
Comment on general developmental stage- does the injury correlate with the developmental age? (rolling, toddling, running. climbing?)
Past medical history and review of previous notes- you must see the notes for all injured kids. Multiple minor injuries in small children or admissions for social problems should trigger further investigation.
Comment on whether the doctor is satisfied that it is an accident

This need not be onerous. For example: "3yo boy, runs and climbs, Mum says he fell while running and hit head on pot plant, Step-Dad says same, O/E well kid, burise and abrasion on forehead with no other sign of injury on body (correlates with history), good rapport between parents and kid. D/W Dr Putland. Old history- one URTI only. Dx Accidental minor head injury."

Clues pointing to NAI in the Bendigo medical history are previous minor injuries, any allied health input including social work, including when the child was born/neonatal period.  Most childrens histories are wafer thin and anything else should prompt further consideration.

The paediatric consultant should be contacted directly at any time if there is any concern or a second opinion is required.

More general considerations for NAI of a child of any age: Although little kids are often covered in bruises the following things about bruises are important to note: accidental bruises are almost invariably on the front of the body, accidental bruises are mostly over hard bony surfaces, accidental bruises are rarely on ears, genitals, buttocks or soft surfaces, kids who are not yet walking very rarely if ever get accidental bruises and kids that are walking but not running get very few accidental bruises (picture the way an 18 month old toddler topples over onto their knees, hands and forehead- knees and forehead are the spots that bruises can be expected in this age group with the forehead taking the majority of them as the knees don't hit the ground with much force from standing height).

For a summary of the Bendigo joint Paediatric and Emergency teaching session on NAI click here.

Further information is contained on the RCH Clinical Practice Guideline for Child Abuse

Further information about mandatory reporting of suspicion of child abuse in Victoria can be reviewed here.

Blood Alcohol testing in motor vehicle collision.

In Victoria, by law, all persons over the age of 15 years involved in a motor vehicle accident must allow a registered medical practitioner to take a blood sample.  A Doctor or RN may take the sample but in Bendigo it is a doctor duty.  Although the legislation provides for blood to be taken from ALL persons, the currently accepted Code of Practice (as approved by the Victoria Police, Traffic Alcohol Section) provides that samples need only be taken from drivers who present to hospital following a motor vehicle collision must be tested.  In situations where there is uncertainty about who the driver is, then all those involved must be tested.

Representations

Patients who represent to the ED with the same or related complaints are high risk. High risk for complications, complaints and death.
Classic examples are the back pain patient who has a spinal abscess or the epistaxis patient who is never packed with a nasal tampon and admitted but instead almost bleeds to death after being sent home repeatedly when the bleeding stops in ED. Or endocarditis when the patient represents with muliple vague symptoms.
Serious complications may arise from seemingly benign representations.
If a patient represents:
1) You MUST discuss with and get senior staff to lay eyes on the patient
2) Escalate investigations, opinions or management to a standard expected by the community and your colleagues.
3) Think very hard before discharging them again.

Frequent Attenders/HARP patients

Frequent attenders with chronic problems feature not infrequently in our mortality meeting.
We recommend that you look for
1) Management plans - these are signed by the Director and live in a folder in the fishbowl.
2) The Alert on the tracking system - use the letter "A" to access it.  There is an alert if there is an exclamation mark next to the patients name on the tracking system.
3) Take some extra time to sift through the medical record
If you have a patient that is frequently attending then they should be referred to HARP by phone or by internal referral form.

Blunt Chest Trauma

Early multidisciplinary response can improve outcomes in patients with blunt chest trauma. These patients run into trouble from respiratory embarrassment due to pain, contusion progression, atelectasis and effects of opiates.  A blunt chest truma call should be made at the earliest opportunity for all admitted patients with confirmed or suspected chest wall injury and any of the following risk factors

·≥ 65 years old

·≥ 45 years old and current smoker

·≥ 3 rib fractures

  • Sternal fracture
  • Intercostal Catheter (ICC) in situ
  • Respiratory comorbidities: Chronic Obstructive Pulmonary Disease (COPD), Steroid-dependent asthma, Bronchiectasis, Cystic fibrosis, and/or Pulmonary Fibrosis
  • Chest wall deformity (eg; Kyphoscoliosis)
To activiate, contact switchboard on 2222 and state " Blunt Chest Trauma Call" and give patients location and UR number.  Switch will page the Anaesthetics Reg (for Acute Pain Services), ICU Reg and Surg Reg who will reivew the patient within 2 hours.

Pregnant Patients

Every time you see a pregant patient consider the foetus and check its well being with a foetal doppler (hand held doppler or US by consultants/registrars). If you can't achieve this yourself then ask maternity services to come and do it for you.
Any patient greater than 20 weeks gestation MUST be assessed by maternity services - in ED if a clinical problem needs ED help, or straight upstairs from triage if abdopain/bleeding/labour etc. There is a PROMPT policy on this.

Psychiatric Patients - Medical Clearance

All psychiatric patients must have a medical assessment documented.  This includes a set of observations and a varying assessment depending on circumstances.  There is a policy regarding this that can be viewed here. Here is an excerpt:

All psychiatric conditions are clinical syndromes for which there is no diagnostic test and every acute psychiatric presentation can be mimicked by any number of underlying general medical or susbtance-related conditions.  Therefore a psychiatric diagnosis is always a diagnosis of exclusion, and so it is particularly important that non-psychiatric conditions have been considered and where practicable, excluded.

Complications of treatment, complications of illness, injuries / self harm and coincidental medical illnesses all need to be considered.

Renal + Peritoneal Dialysis Patient (underappreciated time critical condition)

All renal units (and Bendigo is no exception) take ownership of their patients and you should call them promptly when a dialysis or transplant patient arrives in ED. Peritoneal dialysis patients need a thin healthy peritoneum to keep them alive.  Spontaneous peritonitis is a  complication that must be treated rapidly to avoid a thickened useless peritoneum.  It is time criticial and dialysate must be sent promptly. All PD patients require the renal consultant to be called on arrival immediately and before workup. Make sure a ward nurse is on the way to change the bag so it can be sent for microscopy.

Glass injuries and other cutting injuries

This has been a common source of junior doctors receiving complaints about missed diagnosis of damage to underlying tendons or missed foreign body. Make sure injuries are evaluated by direct inspection using local anaesthetic to facilitate adequate examination. Get an Xray or US if there is a strong suspicion of retained foreign bodies which can travel some way under the skin.

  • Special Patient Groups

    Staff Occupational Exposures (Needle sticks and so on)

    See this entry in Bendigo Referral Options

    Deaths

    Find a handout about how to handle deaths in Bendigo ED here.

    Reportable Deaths - Coroners Cases

    Is this death coroner's case?

    Death certificates should only be completed when there is a clear diagnosis and the death is expected.  Death certificates are NOT written for Coroners cases.  Any case that is not clear or there is any doubt, should be referred to the coroner – our department has a low threshold.  The coroner’s clerk can give further advice regarding whether or not to refer a case if there is doubt.  They can be contacted via the Coronial Admissions and Enquires number on 1300 309 519.  If they indicate it is a coroners case you will be asked to complete a medical depostion online using an access code they will give you.

    Click here for coroners information on which deaths are reportable and the link to the medical depsotion page.

     

    Non Coroners Deaths

    Step 1

    DOCTOR to write a death certificate (Medical Certificate Cause of Death - MCCD) and PRINT 3 copies.  From March 2019 this is done via Registry Information Online.  To use this you must have registered personally for it here.  You do not need to sign the print outs.  The hospital can access the cetificate via their account if they need to print more. 

    Step 2

    NURSES to fill out ED Death Notification Form.  One copy goes to morgue with body, one copy to ED Director/Administration Assistant, one copy to ED NUM.

    Step 3

    DOCTOR to fill out mortality screening tool form  (online version hereprint and fill out version here) and send to ED Director/Administration Assistant.

    Step 4

    Write a discharge summary and fax it to the GP notifying them of the death.

     

    Paediatric Category 1 and 2 Patients

    These patients are high risk and are to be seen by a consultant or registrar if a consultant is unavailable.  They are not to be treated by interns or HMOs unless in the direct presence of a senior medical staff member.

    Interns and Paediatric Patients

    All children under the age of 2 seen by interns must also be seen by a supervising consultant or registrar.  The amount of time spent with the family by supervising staff will depend on how much of the presentation the supervising senior knows from other sources and the type of presentation.

    Non Accidental injury

    Kids who have catastrophic NAI (murdered, disabled from subdurals etc) often have a string of  presentations to the ED or GP prior to the event.  Daniel Valerio (below) was murdered when he was 2 and is a classic example of this.  Bendigo has its own examples.  Some states have mandatory forms to make sure there has been senior doctor review of minor injuries and review of the past medical record. Bendigo has its own procedure that must be followed.

    NAI should be considered with any injury to a child, even if trivial.

    daniel-valerioDaniel Valerio

     
    Bendigo has the following procedure to target the highest risk group (children under 4) so that MINOR injuries DO trigger consultant review and review of the old notes.  However NAI should still be considered in children of all ages.
     

    Bendigo Procedure:
    1) All injuries in children under 4 years MUST be discussed with a consultant (or registrar overnight)
    2) The past history of presentations (the hospital record) must be reviewed and presented to the consultant when the discussion process occurs.

    The following documentation is expected in ALL cases of child injury in under 4 year olds:

    Source of history - i.e. mum, dad, ambulance, triage nurse notes
    Consistency between history sources -did Mum, Dad and Auntie all give the same story? Did the same story get given to ambulance, triage and you?
    Correlation between history and clinical findings- do the injuries make sense with the history given?
    Documented discussion with a senior ED doctor - we have last names and this is a good place to use them.
    Comment on general developmental stage- does the injury correlate with the developmental age? (rolling, toddling, running. climbing?)
    Past medical history and review of previous notes- you must see the notes for all injured kids. Multiple minor injuries in small children or admissions for social problems should trigger further investigation.
    Comment on whether the doctor is satisfied that it is an accident

    This need not be onerous. For example: "3yo boy, runs and climbs, Mum says he fell while running and hit head on pot plant, Step-Dad says same, O/E well kid, burise and abrasion on forehead with no other sign of injury on body (correlates with history), good rapport between parents and kid. D/W Dr Putland. Old history- one URTI only. Dx Accidental minor head injury."

     
    Clues pointing to NAI in the Bendigo medical history are previous minor injuries, any allied health input including social work, including when the child was born/neonatal period.  Most childrens histories are wafer thin and anything else should prompt further consideration.

    The paediatric consultant should be contacted directly at any time if there is any concern or a second opinion is required.

    More general considerations for NAI of a child of any age: Although little kids are often covered in bruises the following things about bruises are important to note: accidental bruises are almost invariably on the front of the body, accidental bruises are mostly over hard bony surfaces, accidental bruises are rarely on ears, genitals, buttocks or soft surfaces, kids who are not yet walking very rarely if ever get accidental bruises and kids that are walking but not running get very few accidental bruises (picture the way an 18 month old toddler topples over onto their knees, hands and forehead- knees and forehead are the spots that bruises can be expected in this age group with the forehead taking the majority of them as the knees don't hit the ground with much force from standing height).

    For a summary of the Bendigo joint Paediatric and Emergency teaching session on NAI click here.

    Further information is contained on the RCH Clinical Practice Guideline for Child Abuse

    Further information about mandatory reporting of suspicion of child abuse in Victoria can be reviewed here.

    Blood Alcohol testing in motor vehicle collision.

    In Victoria, by law, all persons over the age of 15 years involved in a motor vehicle accident must allow a registered medical practitioner to take a blood sample.  A Doctor or RN may take the sample but in Bendigo it is a doctor duty.  Although the legislation provides for blood to be taken from ALL persons, the currently accepted Code of Practice (as approved by the Victoria Police, Traffic Alcohol Section) provides that samples need only be taken from drivers who present to hospital following a motor vehicle collision must be tested.  In situations where there is uncertainty about who the driver is, then all those involved must be tested.

     

    Representations

    Patients who represent to the ED with the same or related complaints are high risk. High risk for complications, complaints and death.
     
    Classic examples are the back pain patient who has a spinal abscess or the epistaxis patient who is never packed with a nasal tampon and admitted but instead almost bleeds to death after being sent home repeatedly when the bleeding stops in ED.  Or endocarditis when the patient represents with muliple vague symptoms.
    Serious complications may arise from seemingly benign representations.
     
    If a patient represents:
    1) You MUST discuss with and get senior staff to lay eyes on the patient
    2) Escalate investigations, opinions or management to a standard expected by the community and your colleagues.
    3) Think very hard before discharging them again.
     

    Frequent Attenders/HARP patients

    Frequent attenders with chronic problems feature not infrequently in our mortality meeting.  
    We recommend that you look for
    1) Management plans - these are signed by the Director and live in a folder in the fishbowl.
    2) The Alert on the tracking system - use the letter "A" to access it.  There is an alert if there is an exclamation mark next to the patients name on the tracking system.
    3) Take some extra time to sift through the medical record
    If you have a patient that is frequently attending then they should be referred to HARP by phone or by internal referral form.
     

    Blunt Chest Trauma

    Early multidisciplinary response can improve outcomes in patients with blunt chest trauma.  These patients run into trouble from respiratory embarrassment due to pain, contusion progression, atelectasis and effects of opiates.  A blunt chest truma call should be made at the earliest opportunity for all admitted patients with confirmed or suspected chest wall injury and any of the following risk factors

    ·≥ 65 years old

    ·≥ 45 years old and current smoker

    ·≥ 3 rib fractures

    ·Sternal fracture

    ·Intercostal Catheter (ICC) in situ

    ·Respiratory comorbidities: Chronic Obstructive Pulmonary Disease (COPD), Steroid-dependent asthma, Bronchiectasis, Cystic fibrosis, and/or Pulmonary Fibrosis

    ·Chest wall deformity (eg; Kyphoscoliosis)  

    To activiate, contact switchboard on 7777 and state " Blunt Chest Trauma Call" and give patients location and UR number.  Switch will page the Anaesthetics Reg (for Acute Pain Services), ICU Reg and Surg Reg who will reivew the patient within 2 hours.
     
     

    Pregnant Patients

    Every time you see a pregant patient consider the foetus and check its well being with a foetal doppler (hand held doppler or US by consultants/registrars).  If you can't achieve this yourself then ask maternity services to come and do it for you.  
    Any patient greater than 20 weeks gestation MUST be assessed by maternity services - in ED if a clinical problem needs ED help, or straight upstairs from triage if abdopain/bleeding/labour etc.  There is a PROMPT policy on this.
     

    Psychiatric Patients - Medical Clearance

    All psychiatric patients must have a medical assessment documented.  This includes a set of observations and a varying assessment depending on circumstances.  There is a policy regarding this that can be viewed here.  Here is an excerpt:

    All psychiatric conditions are clinical syndromes for which there is no diagnostic test and every acute psychiatric presentation can be mimicked by any number of underlying general medical or susbtance-related conditions.  Therefore a psychiatric diagnosis is always a diagnosis of exclusion, and so it is particularly important that non-psychiatric conditions have been considered and where practicable, excluded.

    Complications of treatment, comlications of illness, injuries/self harm and coincidental medical illnesses all need to be considered.

    Renal + Peritoneal Dialysis Patient (underappreciated time critical condition)

    All renal units (and Bendigo is no exception) take ownership of their patients and you should call them promptly when a dialysis or transplant patient arrives in ED.  Peritoneal dialysis patients need a thin healthy peritoneum to keep them alive.  Spontaneous peritonitis is a  complication that must be treated rapidly to avoid a thickened useless peritoneum.  It is time criticial and dialysate must be sent promptly.  All PD patients require the renal consultant to be called on arrival immediately and before workup.  Make sure a ward nurse is on the way to change the bag so it can be sent for microscopy.

    Glass injuries and other cutting injuries

    This has been a common source of junior doctors receiving complaints about missed diagnosis of damage to underlying tendons or missed foreign body.  Make sure injuries are evaluated by direct inspection using local anaesthetic to facilitate adequate examination. Get an Xray or US if there is a strong suspicion of retained foreign bodies which can travel some way under the skin.