ED GovCast - Episode 5
Emergency Medicine Learning Points from Datixes
Learning points from Datixes:
1. Time-Critical Medications (TCM) in the Emergency Department
M – Movement disorder (e.g., Parkinson’s, myasthenia medications)
I – Immunosuppressants (e.g., HIV medications)
S – Sugar (diabetes medications)
S – Steroids (Addison’s disease, adrenal insufficiency)
E – Epilepsy (anticonvulsants)
D – DOACs and warfarin
2. Staff Safety and Assaults in the ED
Behavioural disturbance is often linked to alcohol, substance misuse, or severe mental health problems.
Section 136 patients (brought in with police) must undergo a risk assessment on arrival, including risk of violence and absconding.
Risk assessment should be completed by the nurse in charge and senior clinician in charge.
Hospitals operate under a zero-tolerance policy for violence against staff.
Case Discussions
Case 1 – Body Stuffers
Patient suspected of concealing drugs rectally.
Police observed cling film protruding; full body search powers rest with police, not clinicians.
Internal concealment carries significant mortality risk (43 deaths in police custody between 1997–2002, 16 related to internal concealment).
Options:
Observation (8 hours to monitor for wrapping dissolution).
Low-density CT scan for foreign body detection.
This patient’s CT was negative and he was discharged back to police.
Other concealment methods: swallowing packets or hiding in the mouth for later retrieval.
Case 2 – NSTEMI and Refusal of PCI
- Patient with NSTEMI refused PCI but could not clearly explain reasoning.
- Capacity assessment was challenging.
- Alternatives: thrombolysis versus PCI.
- Involving senior clinicians, cardiology, psychiatry, and possibly the legal team is appropriate.
- Important principle: patients with capacity can make unwise decisions—that alone does not mean they lack capacity.
- Ultimately, thrombolysis was given with good outcome.
Case 3 – Marfan’s and Aortic Dissection
- Patient in 60s with Marfan’s presented with mild chest pain and atrial flutter.
- Think Aorta Campaign: thinkaorta.net
- Red flags: abrupt, thunderclap pain, radiation to the back, neurological symptoms, syncope.
- Risk factors: hypertension, bicuspid aortic valve, family history, Marfan’s.
- CT aortogram confirmed extensive aortic dissection (aortic root to iliac).
- Use ADDRS scoring (MDCalc app) to support risk assessment.
Case 4 – Trauma and Missed Bowel Perforation
- 18-year-old after high-speed RTC.
- Initial trauma CT normal; discharged after analgesia.
- Returned the next day with ongoing abdominal pain.
- Repeat CT showed bowel perforation; underwent surgery with no adverse outcome.
- Learning point: persistent pain should not be dismissed even with a normal trauma CT.
Paediatric Case – Bacterial Meningitis
- 4-month-old presented with vague history of fever.
- No fever in department, some mottling, brief pauses in breathing but not described as apnoeic.
- Examined by SHO and registrar, thought viral illness, discharged with safety netting.
- Re-presented 8–9 hours later looking unwell, swollen fontanelle noted.
- LP confirmed bacterial meningitis.
Learning Points:
Always undress babies and perform a head-to-toe exam.
Look for subtle infection sources: fontanelles, throat, ENT, mastoid, neck, chest, abdomen.
Babies cannot give reliable history; examination is crucial.
Children under 1 year with concerning features should always be discussed with the ED consultant.
Always undress babies and perform a head-to-toe exam.
Look for subtle infection sources: fontanelles, throat, ENT, mastoid, neck, chest, abdomen.
Babies cannot give reliable history; examination is crucial.
Children under 1 year with concerning features should always be discussed with the ED consultant.