Registrar Orientation Supplement
Welcome to Bendigo Emergency Department
Bendigo is a fantastic place to work with varied pathology that will allow you to rapidly grow your clinical experience. The consultant group would like to welcome you. We look forward to sharing with you the adventure that is a busy clinical shift and helping you develop your emergency medicine skills. Below is some information that you should know from day 1 and if there is something missing, or you are unsure of something, contact one of the DEMTs. Good luck and have fun!
Generally once the roster has been put out, you are responsible for making your own roster swaps. Di Price the ED Secretary and Consultant Dr Kent Hoi currently oversee rostering of medical staff in ED. Please note the process for roster swapping for all levels includes emailing both of them and the person you are swapping with. The process is clearly outlined HERE.
You will be paid for shifts on the original roster - if you arrange your own swaps and do more than 76 hours in a fortnight you will not be paid overtime. This is in contrast to extra shifts you pick up when the roster is short, in which case you will be paid overtime where it is due and is greatly appreciated by all of us.
You can only swap with someone at the same level as you.
Annual leave and study leave should be applied for at the beginning of the year – as early as you have an idea when you want. If you know you are having a baby, getting married, doing exams or any other important life event then book your leave ASAP! The process for doing this is filling out a leave form (HR6) either from the hospital intranet or from the ED secretary and submitting it to the ED secretary for the director to sign.
Your needs and request will be balanced against the needs of others and the department. Not everyone can have leave at the same time and this goes for both study leave and annual leave. We have a well staffed department, but this means you must cover each other which generally means no more than one registrar can be a way at any one time except under exceptional circumstances. The ED Director (or roster delegate) has the final say on allocating leave and also signs your leave form. The sooner you fill out the leave forms the more chance you have of getting what you want. Please also be aware that if you are taking leave from different departments this will be an additional factor to be considered.
The leave will then appear on findmyshift once it is approved – it is essential that you check that this has occurred once your leave is approved to avoid any confusion.
You MUST call 5454 8104 and inform Senior/Consultant in charge 24/7 AND send an email to Di Price. Give as much notice as possible, especially for night shift. Consider the sick leave section in the main orientation when considering your personal threshold for calling in sick.
We have a mentoring program for our registrars based on the framework of ACEM's mentoring initiative. We will pair you with one of the senior doctors with the aim of you meeting with your mentor early in the term. We try to avoid paired mentors and trainees having to do WBAs together and we also exclude the DEMTs from the mentoring system. It is a great opportunity to touch base, feel connected, debrief and have an additional support option during your term.
You are paid to come to Thursday morning teaching and are expected to attend and contribute.
It is important that you can discuss one or two of your cases from the previous week as a way of consolidating your own clinical experience, sharing it with others as an opportunity to teach, and gaining others perspectives as an opportunity to learn.
You will be required to conduct the ED morbidity and mortality meeting roughly once every 6 months (see separate guide on how to do this on ED Central).
You will also be required to present discrete topics or case presentations as directed by the DEMTs.
Use your own initiative. If you have a case or topic you want to present then you will always be given the opportunity. If you want to get involved with a new project in the ED as quality improvement then there are always opportunities. The benefit of being in a place like Bendigo is that you can help shape and lead the department as it grows.
Primary exam preparation should be discussed with your DEMT and you should carefully go through the excellent resources provided on the ACEM website. There is also a resource being accumulated by recent successful candidates to assist you. We expect you to approach consultants and DEMTs to ask for viva practice after your MCQs.
Fellowship Exam Preparation
This is integrated into Thursday teaching and otherwise tailored to individuals needs.
There are always ways to improve the quality of care and delivery of service. If you are keen to perform an audit or become involved in a small study then please raise this with DEMT or Director. They will have suggestions to help you get involved or direct you accordingly if you have ideas of your own.
We will cover how to formally go about all common emergency medicine procedures in the formal Thursday teaching program. We expect you to be exposed to and be able to do (supervised or unsupervised depending on your experience) most common procedures during your term. If you are lacking or want more experience in a certain area ask and we will endeavour to help you.
We expect you to be able to gown and glove (without putting your hands through the sleeve cuffs) prior to starting your term with us. If you don’t know how to, please ask!
You should complete the specific ED procedural sedation form for every sedation. You should either keep a copy of this record or UR numbers to be able to retrieve the histories later. Your ability to keep these episodes logged will enable you to convince your next employer you are capable and will allow us to credential you to sedate people at night. You must be specifically credentialed to perform procedural sedation at night. Whether or not you are given the green light for night time procedural sedation depends on:
- Your previous experience especially anaesthetics
- Whether or not you have completed the paediatric procedural sedation module (to complete this see Di Price or Nurse Educator Kate Roulston.)
- The number of procedural sedations you have completed in Bendigo. (The number we require you to do is based heavily on your experience and ability to manage an airway).
You should sit down with your DEMT early in the term to establish your goals in this area.
Please note you may use nitrous at night without specific credentialing if you have completed the paediatric sedation module.
Admitting Officer Phone
We all hold a view that we should fulfil our role as a regional referral hospital and take pride in having a leading role in supporting our region. If there is someone with a #NOF in Cohuna, there is only one place they should go, regardless of bed availability and we accept them into our ED. If you are holding the phone at any time (you should ask to hold it sometimes during the day as well as at night) be courteous, supportive and generally say “yes”. Sometimes there may be opportunity to advise of an alternative option such as transfer in the morning, transfer to a Melbourne hospital if a specialist service is not available in Bendigo or referral to ARV/PETS if you ascertain the patient is unstable or has a time critical problem. Remember you are a specialist in training - your role is to contribute to problem solving and advice rather than to provide any barrier to patient care.
Night shift presents its own challenges for ED registrars. You have to deal with the mental and physical stresses of working a night shift while working with less resources than are usually immediately available. The consultants have all been there before and understand the difficulties – do not be put off by 20 questions in the morning at handover time – its all part of a process. If there are difficulties or issues overnight please pull aside the day consultant and have a chat to them, they are there to support you.
Night Shift Radiology
The radiographer is oncall after 11pm. You should not hesitate to call them in if there is imaging that you require that will change your management. Morbidity and Mortality meetings frequently feature patients where night shift conditions create a bias in decsion making (delay in or decision not not to image) and our threshold for recalling radiographers overnight is decreasing as the department gets busier.
Night Shift Referrals
A common cause of anxiety amongst ED registrars is disturbing on call doctors sleep and the sometimes difficult interaction that can follow. To minimise this, please group your phone calls so they have the least interruptions– scan the board, make sure the staff you are supervising do not have any patients or issues to discuss with the registrar before you call.
If you get a response from an inpatient (IP) registrar that you believe will not deliver quality care and you have been unable to convince the referring team to attend to your request then the admitting consultant would want to know- This is best clarified with the on-call ED Consultant prior to involving the consultant and it is courteous to inform the IP registrar that you will be following this course of action.
Unit specific referrals overnight
There is an Emergency Department Admissions to Inpatient Units Protocol on PROMPT (hospital intranet)
There is a night shift med reg doing a night shift like you. Refer all medical cases as usual. In addition you should refer hospice or potential rehab or GEM patients if there is no bed immediately available to be allocated to these patients. The medical unit will decanter these patients to the appropriate destinations during daytimehours if appropriate. Leaving these patients in ED unadmitted is not reasonable as there may or may not be a bed at the required destination in the morning.
There is a surgical registrar doing night shift just like you – refer all surgical cases early as usual.
There is an oncall orthopaedic registrar on overnight who has also usually worked during the day. This often means they are tired. However they are on call to provide 24 hour orthopaedic cover and should be called for all admissions regardless of time of day. They may or may not come and see the patient, and if they intend not to, interim orders should be agreed to and the conversation documented. As with any out of hours referral, please group your phone calls so they have the least interruptions. – scan the board, make sure the staff you are supervising do not have anything other patient or issues to discuss with the registrar before you call.
If you are not sure what to do with an orthopaedic problem and cannot get the answer from guidelines, the orthopaedic registrar should also be rung.
There is a cardiology consultant on call but there is generally no need for you to call them. If you need help with a critical cardiology decision eg whether to thrombolyse someone or not, or help in managing malignant arrhythmias then call the ED consultant on call.
STEMIs, NSTEMIs, Unstable angina, arrhythmias all get admitted under the Cardiology bed card at Bendigo. Medical registrar will facilitate the admission process during the weekends and afterhours..
There is an oncall system shared by the consultants and registrars - contact them via switch. The general surgical regsitrar may assist in the admission if requested by the urology team. This is an opportunity to remind you that suspected testicular torsion is managed by the general surgeons in Bendigo - call the surgical regsitrar.
Currently there are no ENT surgeons on-call for Bendigo hospital. All public ENT cases are referred to Melbourne hospitals
Private patients of ENT surgeons should be discussed with them anytime of the day or night especially post tonsillectomy bleeds. All post tonsillectomy bleeds require admission overnight. If this cannot be achieved with the surgical unit for public patients and the patient is stable then leave the patient in ED for day staff to sort out.
Packed epistaxis should be admitted to SSOU on the appropriate pathway. We generally drain our own quinsies and the ED Consultant can sort this out in the morning.
Life threatening ENT emergencies require the ED consultant oncall to be contacted.
There is an oncall oncology consultant (sometimes registrar) overnight. All patients requiring admission should have the oncology unit contacted regardless of hour. The conversation should be documented (as with all phone call referrals) and the medical registrar completes the admission. If a case is not straightforward, engaging the med reg to help problem solve before you call the oncology consultant may make for a more meaningful oncology referral and advice. Looking up the patient on Medtrack (oncology unit database) will give you up to date letters and chemo treatments.
If radiation oncology patients need admission, the consultant radiation oncologist oncall should be contacted and then admitted by the med reg. The bed card will actually be medical oncology as the Peter Mac radiation oncologists do not have admitting rights at Bendigo Health and the 2 units will liaise with each other in the morning.
Oncology patients managed at other hospitals should be discussed with that hospital first.
You can look up any Peter Mac (even Melbourne ones) patient records on a system called Verdi. https://raportal.petermac.org/Citrix/CAG/site/default.aspx
There is an oncall renal consultant (sometimes registrar) and they should be contacted about all renal transplant and dialysis patients regardless of hour. If a case is not straightforward, engaging the med reg to help problem solve before you call the renal consultant may make for a more meaningful renal referral and advice.
Peritoneal dialysis patients are a special group where spontaneous peritonitis is a time critical problem and should be discussed with the renal consultant on arrival and not after work up.
There is a paediatric registrar covering paediatric admissions overnight with a consultant paediatrician oncall. If a paediatric patient needs admission and the case is straightforward then the registrar should be contacted in the first instance who will then call the consultant. If there is doubt or difficulty then the paediatrician should be contacted directly. Often getting the Paediatric registrar to be part of the team caring for the patient before you call the paediatric consultant will lead to better outcomes and less communication problems.
Remember there are 2 patients to consider when assessing a pregnant patient. Always document foetal heart rate.
All patients > 20 weeks gestation MUST be reviewed by labour ward staff - in ED if there are problems for ED to sort out - in delivery if the problem is clearly actively obstetric.
All private pregnant patients must have their private obstetrician contacted regardless of hour and presentation type (unless it really is just a splinter in a finger or rolled ankle).
Otherwise contact the O+G reg who is doing night shift like you. Have a low threshold for facilitating an US the next day if there are abdominal or vaginal symptoms.
Night Shift - When to call The ED consultant
In general you should contact the ED consultant oncall when you feel out of your depth and there is a critical management or decision required. Having insight into your own level of experience is an essential ability for you to be a safe doctor regardless of seniority.
Ideally you will anticipate when you will be out of your depth and call us before things deteriorate! Of course this is not always possible.
Most of the times you will need to call is when someone needs a critical intervention or you are making a critical decision. Some examples are:
- Transferring a patient to another hospital using a specialised service such as NETS, PETS or ARV.
- Intubating someone.
- Another inpatient consultant is present managing a sick patient.
- Directly calling in an inpatient consultant outside what is common practice spelled out above.
- About to palliate someone where there may be controversy.
One of the keys to safety is a team approach. We encourage ANUMs to call the ED consultant directly if they are not comfortable with a situation. If this happens on your shift you should not take offence as it is the sign of an ED being safe, and something you will want to happen when you are a consultant in the near future.
Night Shift - SSOU
You are allowed to admit patients to SSOU under the emergency consultant bed card if pathways are strictly adhered to. This admission must be accompanied by an appropriate discussion and handover during the morning board round.
There can be no deviation from the pathways and patients who do not meet pathway criteria must be admitted to other inpatient units.
Under no circumstances should elderly patients with abdominal pain be admitted to SSOU - they usually have surgical pathology even though not immediately apparent.
Night Shift - Other Critical Care Support for sick patients or MAC Calls
If you are faced with a sick patient and need assistance, the oncall consultant is the best person to contact.
However do not forget that there is an anaesthetic and intensive care registrar in hourse 24 hours a day to assist you if you require. You can contact them by direct phone from the daily oncall list, or they will respond if a code blue is called.
Overnight you are still required to respond to the Emergency Department internal MET syste, which is called a MAC Call (Make A Call). Utilising the inpatient registrar, anaesthetics or ICU to assist you will help cognitively offload some decision, enhance patient care, and alert appropriate units who will be involved in the patients care.
Night Shift - Old patients and patients from out of town
Do not discharge elderly patients after 11pm unless there is family concretely supporting and facilitating the discharge.
Do not discharge patients from neighbouring towns unless they have supportive families, a way of getting home, a way of returning to ED if you get it wrong, and are clearly not going to deteriorate on discharge. If a patient is ready for discharge and all the scripts and paperwork is done, it is appropriate to put them in short stay for “bed and breakfast” to allow safe and socially acceptable discharge in the morning. The current pathway to use for this is the “psychosocial crisis” pathway.
ED doctors do not attend code blues. Designated nursing staff from ED attend codes.