1 General approach

The emergency department (ED) occupies a key position in terms of the interface between primary and secondary care. It has a high public profile. Many patients attend without referral, but some are referred by NHS Direct, minor injury units, general practitioners (GPs), and other medical practitioners. The ED manages patients with a huge variety of medical problems. Many of the patients who attend have painful and/or distressing disorders of recent origin.

are:

ED staff work as a team. Traditional roles are often blurred, with the important issue being what clinical skills a member of staff is capable of.

include:

A principal focus of the ED is to provide immediate resuscitation for patients who present with emergency conditions. In terms of sheer numbers, more patients attend with minor conditions and injuries, often presenting quite a challenge for them to be seen and treated in a timely fashion. Different departments have systems to suit their own particular needs, but most have a resuscitation room, an area for patients on trolleys, and an area for ambulant patients with less serious problems or injuries. Paediatric patients are seen in a separate area from adults. In addition, every ED requires facilities for applying casts, exploring and suturing wounds, obtaining X-rays, and examining patients with eye problems.

To work efficiently, the overall hospital system needs to enable easy flow of patients out of the ED. Options available for continuing care of patients who leave the ED, include:

In addition to their roles in providing direct clinical care in their departments, many ED staff provide related clinical care in other settings and ways:

As the delivery of emergency care continues to develop, patients with emergency problems are now receiving assessment and treatment in a variety of settings. These include minor injury units, acute medical assessment units and walk-in centres. Traditional distinctions between emergency medicine, acute medicine, and primary care have become blurred.

It is impossible to over-emphasize the importance of note keeping. Doctors and nurse practitioners each treat hundreds of patients every month. With the passage of time, it is impossible to remember all aspects relating to these cases, yet it may be necessary to give evidence in court about them years after the event. The only reference will be the notes made much earlier. Medicolegally, the ED record is the prime source of evidence in negligence cases. If the notes are deficient, it may not be feasible to defend a claim even if negligence has not occurred. A court may consider that the standard of the notes reflects the general standard of care. Sloppy, illegible, or incomplete notes reflect badly on the individual. In contrast, if notes are neat, legible, appropriate, and detailed, those reviewing the case will naturally expect the general standards of care, in terms of history taking, examination, and level of knowledge, to be competent.

The Data Protection and Access to Medical Records Acts give patients right of access to their medical notes. Remember, whenever writing notes, that the patient may in the future read exactly what has been written. Follow the basic general rules listed below.

Follow a standard outline:

Indicate from whom the history has been obtained (eg the patient, a relative, or ambulance personnel). Avoid attributing events to certain individuals (eg patient was struck by ‘Joe Bloggs’).

Note recent ED attendances. Include family and social history. An elderly woman with a Colles’ fracture of her dominant hand may be able to manage at home with routine follow-up provided she is normally in good health, and has good family or other support, but if she lives alone in precarious social conditions without such support, then admission on ‘social grounds’ may be required.

Remember to ask about non-prescribed drugs (including recreational, herbal, and homeopathic). Women may not volunteer the oral contraceptive pill (OCP) as ‘medication’ unless specifically asked. Enquire about allergies to medications and document the nature of this reaction.

As well as +ve features, document relevant –ve findings (eg the absence of neck stiffness in a patient with headache and pyrexia). Always document the side of the patient which has been injured. For upper limb injuries, note whether the patient is left or right handed. Use ‘left’ and ‘right’, not ‘L’ and ‘R’. Document if a patient is abusive or aggressive, but avoid non-medical, judgemental terms (eg ‘drunk’).

Record clearly.

For patients being admitted, this may be a differential diagnostic list. Sometimes a problem list can help.

Document drugs, including dose, time, and route of administration (see current British National Formulary (BNF) for guidance). Include medications given in the ED, as well as therapy to be continued (eg course of antibiotics). Note the number and type of sutures or staples used for wound closure (eg ‘5 × 6/0 nylon sutures’).

Document if the patient and/or relative is given preprinted instructions (eg ‘POP care’). Indicate when/if the patient needs to be reviewed (eg ‘see GP in 5 days for suture removal’) or other arrangement (eg ‘Fracture clinic in one week’).

Record advice about when/why the patient should return for review, especially if there is a risk of a rare but serious complication (eg for low back pain ‘see GP if not better in 1 week. Return to the ED at once if bladder/bowel problem or numb groin/bottom’ that might be features of cauda equina syndrome).

Increasing emphasis on evidence-based guidelines and protocols has been associated with the introduction of protocols for many patient presentations and conditions. Bear in mind the fact that, for some patients, satisfactory completion of a pro forma may not adequately capture all of the information required.

In an electronic age, there has been an understandable move towards trying to introduce electronic patient records. The potential advantages are obvious, particularly in relation to rapidly ascertaining past medical history. When completing electronic records, practitioners need to follow the same principles as those outlined above for written records.

can make a huge contribution to decision making. One potential advantage of electronic records is that they can be accessed rapidly (compared with older systems requiring a porter to search through the medical records store and retrieve paper-based notes).

‘I am glad to say that in this country there is no need to carry out unnecessary tests as a form of insurance. It is not in this country desirable, or indeed necessary, that over protective and over examination work should be done, merely and purely and simply as I say to protect oneself against possible litigation’—Judge Fallon, quoted by Oscar Craig, Chairman Cases Committee, Medical Protection Society.

The Royal College of Radiologists’ booklet ‘Making the Best Use of a Department of Clinical Radiology: Guidelines for Doctors’ (6th edn, London, RCR, 2007) contains very useful information and is strongly recommended.

Many hospitals have systems so that all ED X-rays are reported by a specialist within 24hr. Reports of any missed abnormalities are returned with the X-rays to the ED for the attention of senior staff, so that appropriate action can be taken.

In addition to the formal reporting system described above, a system is commonly used whereby the radiographer taking the films applies a sticky ‘red dot’ to hard copy X-ray films and/or request card or to the equivalent electronic image if they identify an abnormality. This alerts other clinical staff to the possibility of abnormal findings.

The nature of ED work means that a sorting system is required to ensure that patients with the most immediately life-threatening conditions are seen first. A triage process aims to categorize patients based on their medical need and the available departmental resources. One most commonly used process in the UK is the National Triage Scale (Table 1.1).

As soon as a patient arrives in the ED he/she should be assessed by a dedicated triage nurse (a senior, experienced individual with considerable common sense). This nurse should provide any immediate interventions needed (eg elevating injured limbs, applying ice packs or splints, and giving analgesia) and initiate investigations to speed the patient's journey through the department (eg ordering appropriate X-rays). Patients should not have to wait to be triaged. It is a brief assessment which should take no more than a few minutes.

Three points require emphasis:

Most patients seen in the ED are examined, investigated, treated, and discharged home, either with no follow-up, or advice to see their GP (for suture removal, wound checks, etc.). Give these patients (and/or attending relative/friend) clear instructions on when to attend the GP's surgery and an indication of the likely course of events, as well as any features that they should look out for to prompt them to seek medical help prior to this. Formal written instructions are particularly useful for patients with minor head injury (  p.367) and those with limbs in POP or other forms of cast immobilization ( Casts and their problems, p.424).

The referral of patients to an inpatient team can cause considerable anxiety, misunderstanding, and potential conflict between ED staff and other disciplines. Before making the referral the following should be considered.

Usually, this will be obvious. For example, a middle-aged man with a history of crushing chest pain and an ECG showing an acute MI clearly requires urgent management in the ED, and rapid admission for further investigation and treatment. Similarly, an elderly lady who has fallen, is unable to weight-bear and has a fractured neck of femur will require analgesia, inpatient care and surgery.

However, difficult situations occur where the clinical situation is less clear; for example, if a man experienced 4–5min of atypical chest pain, has a normal ECG and chest X-ray (CXR), and is anxious to go home. Or a lady has no apparent fracture on X-ray, but cannot weight-bear.

This requires a balance between availability, time, and appropriateness. In general, simple investigations which rapidly give the diagnosis, or clues to it, are all that are needed. These include electrocardiogram (ECGs), arterial blood gas (ABG), and plain X-rays. It is relatively unusual to have to wait for the results of investigations such as full blood count (FBC), urea & electrolytes (U&E), and liver function tests (LFTs) before referring a patient, since these rarely alter the immediate management. Simple trolley-side investigations are often of great value, for example, stix estimations of blood glucose (BMG) and urinalysis. If complicated investigations are needed, then referral for inpatient or outpatient specialist care is often required.

Do not forget, or delay, analgesia. Treat every patient in pain appropriately as soon as possible. A patient does not have to ‘earn’ analgesia. Never delay analgesia to allow further examination or investigation. Concern regarding masking of signs or symptoms (for example, in a patient with an acute abdomen) is inhumane and incorrect.

Referral is often by telephone, and this can create problems:

Handing over a patient to a colleague, because your shift has ended and you are going home, is fraught with danger. It is easy for patients to be neglected, or receive sub-optimal or delayed treatment. It is safest to complete to the point of discharge or referral to an inpatient team every patient that you are seeing at the end of a shift. Occasionally this may not be possible (eg if there is a delay in obtaining an X-ray or other investigation). In these situations, hand over the patient carefully to the doctor who is taking over and inform the nursing staff of this.

Include in the handover relevant aspects of history and examination performed, the investigation results, and the treatment undertaken. Sign and aim to complete records on the patient as soon as possible. Note the time of hand over, and the name of the doctor or nurse handed over to. When accepting a ‘handed-over patient’ at the start of a shift, spend time establishing exactly what has happened so far. Finally, it is courteous (and will prevent problems) to tell the patient that their further care will be performed by another doctor or nurse.

Despite changes in the way that care (particularly out of hours) is delivered, GPs still have a pivotal role in co-ordinating medical care. Often the GP will know more than anyone about the past history, social and family situation, and recent events of their patient's management. Therefore, contact the GP when these aspects are relevant to the patient's ED attendance, or where considerations of admission or discharge are concerned.

Every attendance is followed routinely by a letter to the GP detailing the reason(s) for presentation, clinical findings and relevant investigations, treatment given, and follow-up arrangements.

If a patient dies, contact the GP without delay—to provide a medical contact and assistance to the bereaved family, to prevent embarrassing experiences (eg letters requesting clinic attendances), and out of courtesy, because the GP is the patient's primary medical attendant. Finally, the GP may be asked to issue a death certificate by the Coroner (in Scotland, the Procurator Fiscal) following further enquiries.

Always contact the GP prior to the discharge of a patient where early follow-up (ie within the next 24–72hr) is required. This may occur with elderly patients where there is uncertainty about the home situation and their ability to manage. A typical example is an elderly lady with a Colles’ fracture of her dominant wrist who lives alone. The ED management of this patient is relatively simple (  p.444). However, merely manipulating a Colles’ fracture into a good position, supporting it in an adequate cast, and providing analgesia, is only one facet of care. The GP may know that the lady has supportive relatives or neighbours who will help with shopping and cooking, and will help her to bath and dress. The GP and the primary care team may be able to supplement existing support and check that the patient is coping. Equally, the GP may indicate that with additional home support (eg home helps, meals, district nurses), the patient could manage. Alternatively, the GP may indicate that the Colles’ fracture merely represents the final event in an increasingly fragile home situation and that the patient will require hospital admission, at least in the short-term.

For the same reasons, a GP who refers a patient to the ED and indicates that the patient requires admission does so in the full knowledge of that patient's circumstances. Always contact the GP if it is contemplated that the patient is to be discharged—preferably after senior medical consultation.

Finally, remember that GPs are also under considerable pressure. Some situations may appear to reflect the fact that a patient has been referred inappropriately or the patient may report that they have tried to contact their GP unsuccessfully. Rather than irately ringing the practice and antagonizing them, inform the ED consultant who can raise this constructively and appropriately in a suitable environment.

Many departments receive calls from patients, parents, and other carers for advice. Approach these calls in exactly the same way as a face-to-face consultation. Formally document details of the call, including:

As with all notes, date, time, and sign these notes.

In England and Wales NHS Direct provides a 24-hr, 7-day a week telephone service providing information and advice on health matters. It is staffed by nurses who respond according to protocols.

The telephone number for NHS Direct is 0845 4647.

The equivalent service in Scotland is NHS24 tel. 08454 242424.

These services have internet websites at www.nhsdirect.nhs.uk and www.nhs24.com

Occasionally, other health professionals request advice regarding the management of patients in their care. Such advice should be given by experienced ED staff.

Increasingly, emergency health care is provided by integrated networks, which include EDs, minor injuries units, radiology departments, and GP surgeries connected by telemedicine links. This has advantages in remote or rural settings, enabling a wide range of injuries and other emergencies to be diagnosed and treated locally. The combination of video and teleradiology may allow a decision to be made and explained directly to the patient. A typical example is whether a patient with an isolated Colles’ fracture needs to have a manipulation of the fracture. Expertise is required to undertake telemedicine consultations safely. This specialist advice should be given by senior ED staff, and careful documentation is crucial.

Paramedics and ED staff have a close professional relationship. Paramedics and ambulance staff are professionals who work in conditions that are often difficult and sometimes dangerous. It is worth taking an off-duty day to accompany a crew during their shift to see the problems they face.

A benefit of paramedic training has been to bring ambulance staff into the ED to work with medical and nursing staff, and to foster the communication and rapport essential for good patient management.

In the UK, a patient brought to an ED by ambulance will routinely have a patient report form (PRF) (see Fig. 1.1). This is completed by the crew at the scene and in transit, and given to reception or nursing staff on arrival. The information on these forms can be invaluable. In particular, the time intervals between the receipt of the 999 call, and arrival at the scene and at hospital, provide a time framework within which changes in the patient's clinical condition can be placed and interpreted.

The initial at-scene assessment will include details of the use of seat belts, airbags, crash helmets, etc., and is particularly valuable when amplified by specifically asking the crew about their interpretation of the event, likely speeds involved, types of vehicle, etc.

The clinical features of the Glasgow Coma Score (GCS), pulse rate, blood pressure (BP), and respiratory rate form baseline values from which trends and response to treatment can be judged. Useful aspects in the history/comments section include previous complaints, current medications, etc., which the crew may have obtained from the patient, relatives, or friends. The PRF will also contain important information about oxygen, drugs, IV fluids administered, and the response to these interventions. Before the crew leave the department, confirm that they have provided all relevant information.

Do not be judgemental about the crew's performance. Remember the constraints under which they operate. Without the benefits of a warm environment, good lighting, and sophisticated equipment, it can be exceedingly difficult to make accurate assessments of illness or injury severity, or to perform otherwise simple tasks (eg airway management and intravenous (IV) cannulation).

Do not dismiss the overall assessment of a patient made by an experienced crew. While the ultimate diagnosis may not be clear (a situation which pertains equally in the ED), their evaluation of the potential for life-threatening events is often extremely perceptive. Equally, take heed of their description of crash scenes. They will have seen far more than most ED staff, so accept their greater experience.

Most ambulance staff are keen to obtain feedback, both about specific cases and general aspects of medical care. Like everyone, they are interested in their patients. A few words as to what happened to Mrs Smith who was brought in last week and her subsequent clinical course is a friendly and easy way of providing informal feedback, and helps to cement the professional relationship between the ambulance service and the ED.

Although many junior doctors coming to the ED have completed more than 12 months of work since qualification, the prospect of working at the ‘sharp end’ can be accompanied by trepidation. As with many potentially worrying situations in life, reality is not as terrifying as its anticipation. The number of hours worked may not appear long in comparison with other posts, but do not assume that this makes an ED job ‘easy’. Being on duty inevitably involves much time standing, walking, working, thinking, and making decisions. It is unusual to come off-shift without feeling physically tired.

Active young doctors can usually cope with these physical demands, but a demanding professional life and demanding social life are rarely compatible. Make the most of time off and try to relax from the pressures of the job. One function of relaxation is to enable you to face work refreshed and invigorated. You are mistaken if you believe that you can stay out all night and then work unimpaired the next day. Tired doctors make mistakes. They also tend to have less patience and, as a consequence, interpersonal conflicts are more likely.

A greater problem is the mental aspect of the job. Doctors often find that the ED is the first time in their careers when they have to make unequivocal decisions based on their own assessment and investigations. This is one of the great challenges and excitements of emergency medicine. It is also a worry. Decision-making is central to ED practice and, with experience, the process becomes easier. Developing a structured approach can pre-empt many problems and simplify your life. After taking an appropriate history and completing the relevant clinical examination of a patient, ask yourself a series of questions such as:

The wide spectrum of problems with which ED patients can present means that no individual can be expert in every possible condition. It is therefore as important to recognize and accept when you are out of your depth as it is to make decisions and treat patients whom you know you can manage. Seek help appropriately and do not just try to muddle through. Help may be readily available from senior ED staff, but in some departments direct contact with a specialist team is required. One of the most difficult situations is where a specialist either refuses to come to see the patient or gives telephone advice that is clearly inappropriate. You must always act as the patient's advocate. If you refer a patient with a fractured neck of femur, and the telephone message from the inpatient team is ‘bring him back to the Fracture Clinic in one week’, it is clearly wrong to carry this out. First, check that the doctor has understood the details of the patient's condition and your concerns. More conflict and aggravation is caused by communication errors (usually involving second-hand telephone messages) than by anything else. If the situation remains unresolved, consult senior ED staff. Whatever happens, never lose your cool in public and always put your patient's interests first.

Try to learn something new every day. Keep a note of patients with interesting or unusual problems, and later check what happened to them. Ask senior staff for advice. Use the ED reference books. Try to note all new conditions seen during a shift and read about them later.

The nature of the job, the patients, and the diversity of staff involved means that a considerable degree of camaraderie exists. For an outsider, this can initially be daunting. Junior medical staff are likely to work for 4−12 months in the department. Other staff may have spent a lifetime there with long-established friendships (or sometimes animosities). Respect their position and experience, learn from them.

The nub of this is an understanding that the role of one individual and that of other individuals in the department are inextricably linked. Any junior (or senior) doctor who feels that they are the most important individual in their working environment will have an extremely uncomfortable professional existence. In the ED, every member of staff has a role. Your professionalism should dictate that you respect this. Only in this way will you gain reciprocal respect from other staff members.

Never consider any job ‘beneath you’ or someone else's responsibility. Patients come before pride. So, if portering staff are rushed off their feet and you are unoccupied, wheel a patient to X-ray yourself—it will improve your standing with your colleagues and help the patient.

Never be late for your shift.

If, for whatever reason, you are unable to work a shift, let the senior staff in the ED know as soon as possible.

Ensure that you take a break. Two or three short breaks in an 8-hr shift are better than one long one. Remember to eat and maintain your fluid intake. Shift working may mean that you will work sometimes with familiar faces and perhaps occasionally with individuals with whom you find social contact uncomfortable. Put these considerations aside while you are at work, for the sake of the patients and your peace of mind.

Finally, if you feel that you are unable to manage or that the pressure of the job is too great—tell someone. Don't bottle it up, try to ignore it, or assume that it reflects inadequacy. It doesn't. Everyone, at some time, has feelings of inability to cope. Trying to disguise or deny the situation is unfair to yourself, your colleagues, and your patients. You need to tell someone and discuss things. Do it now. Talk to your consultant. If you cannot face him or her, talk to your GP or another senior member of staff—but talk to someone who can help you.

The BMA Counselling Service for Doctors (tel: 08459 200169) provides a confidential counselling service 24 hr a day, 365 days of the year to discuss personal, emotional, and work-related problems. The Doctors’ Support Network (www.dsn.org.uk) and Doctors’ Support Line (tel: 0844 395 3010) are also useful resources.

This is an emotive and ill-defined term. Depending upon the department, such patients could comprise 4–20% of attendances.

The perception as to whether it is appropriate to go to an ED or attend a GP will vary between the patient, GP, and ED staff. Appropriateness is not simply related to the symptoms, diagnosis, or the time interval involved. It may not necessarily be related to the need for investigation. For example, not all patients who require an X-ray necessarily have to attend an ED. Further blurring of ‘appropriate’ and ‘inappropriate’ groups relates to the geographical location of the ED. In rural areas, GPs frequently perform procedures such as suturing. In urban areas, these arrangements are less common. For ill-defined reasons, patients often perceive that they should only contact their GP during ‘office’ hours, and outside these times may attend an ED with primary care complaints.

It is clearly inappropriate to come to an ED simply because of a real or perceived difficulty in accessing primary care. Nevertheless, the term ‘inappropriate attendance’ is a pejorative one—it is better to use the phrase ‘primary care patients’. It must be recognized that primary care problems are best dealt with by GPs. Many departments try to prevent this primary care workload presenting to the ED. Some departments tackle the problem by having GPs working alongside ED staff.

Only through a continual process of patient education will these problems be resolved. Initiatives include nurse practitioner minor injury units and hospital-based primary care services. Evaluations are underway but, to function effectively, such services require adequate funding and staffing.

It can sometimes be difficult to deal with primary care problems in the ED. After an appropriate history and examination, it may be necessary to explain to patients that they will have to attend their own GP. This may need direct contact between the ED and the practice to facilitate this.

Sometimes, it may appear that another health professional (eg GP, emergency nurse practitioner, nurse at NHS Direct) has referred a patient to the ED inappropriately. Avoid making such judgements. Treat patients on their merits, but mention the issue to your consultant. Remember that the information available to the referring clinician at the time of the prehospital consultation is likely to have been different to that available at the time of ED attendance.

Some patients will have been referred by another medical practitioner, usually a GP. The accompanying letter may include a presumptive diagnosis. The details in the letter are often extremely helpful, but do not assume the diagnosis is necessarily correct. Take particular care with patients who re-attend following an earlier attendance. The situation may have changed since the previous doctor saw the patient. Clinical signs may have developed or regressed. The patient may have not given the referring doctor and ED staff the same history. Do not pre-judge the problem: start with an open mind. Apply common sense, however. Keep any previous history in mind. For example, assume that a patient with a known abdominal aortic aneurysm who collapses with sudden, severe, abdominal pain, signs of hypovolaemic shock, and a tender pulsatile mass in the abdomen, to have a ruptured abdominal aortic aneurysm, rather than intestinal obstruction. The patient's previous ED and hospital case notes are invaluable and will often give useful information and allow, for example, ECG comparisons, aiding the diagnostic process. A call to the GP can also provide useful background, which they may not have had time to include in their referral letter or may have excluded for confidentiality or other reasons.

Take care with patients who label themselves. Those with chronic or unusual diseases often know significantly more about their conditions than ED staff! In such situations, take special notice of comments and advice from the patient and/or their relatives. Do not resent this or see it as a professional affront—rapport with the patient will increase markedly and management will usually be easier.

Every ED has a group of ‘regular’ patients who, with time, become physically and sometimes emotionally attached to the department. Some have underlying psychiatric illnesses, often with ‘inadequate’ personalities. Some are homeless. Regular attenders frequently use the ED as a source of primary care. As outlined above, make attempts to direct them to appropriate facilities, because the ED is unsuited to the management of chronic illness, and is unable to provide the continuing medical and nursing support that these patients require.

Repeated presentations with apparently trivial complaints or with the same complaint often tax the patience of ED staff. This is heightened if the presentations are provoked or aggravated by alcohol intake. Remember, however, that these patients can and do suffer from the same acute events as everyone else. Keep an open mind, diagnostically and in attitude to the patient. Just because he/she has returned for the third time in as many days complaining of chest pain, does not mean that on this occasion he does not have an acute MI! Maintain adequate documentation for each attendance. Occasionally, especially with intractable re-attenders, a joint meeting between the social work team, GP, ED consultant and psychiatric services is required to provide a definitive framework for both the patient and the medical services. For some patients, it will be possible to follow a plan of action for ED presentations with a particular complaint.

Accept the patient as he or she is, regardless of behaviour, class, religion, social lifestyle, or colour. Given human nature, there will inevitably be some patients whom you immediately dislike or find difficult. The feeling is often mutual. Many factors that cause patients to present to the ED may aggravate the situation. These include their current medical condition, their past experiences in hospitals, their social situation, and any concurrent use of alcohol and/or other drugs. Your approach and state of mind during the consultation play a major role. This will be influenced by whether the department is busy, how much sleep you have had recently, and when you last had a break for coffee or food.

Given the nature of ED workload and turnover, conflict slows down the process and makes it more likely that you will make clinical errors. Many potential conflicts can be avoided by an open, pleasant approach. Introduce yourself politely to the patient. Use body language to reduce a potentially aggressive response.

Put yourself in the patient's position. Any patient marched up to by a doctor who has their hands on hips, a glaring expression, and the demand ‘Well, what's wrong with you now?’ will retort aggressively.

Most complaints and aggression occur when the department is busy and waiting times are long. Patients understand the pressures medical and nursing staff have to work under, and a simple, ‘I am sorry you have had to wait so long, but we have had a number of emergencies elsewhere in the department’, does much to diffuse potential conflict and will often mean that the patient starts to sympathize with you as a young, overworked practitioner!

There is never any excuse for rude, abusive, or aggressive behaviour to a patient. If you are rude, complaints will invariably follow and more importantly, the patient will not have received the appropriate treatment for their condition. It may be necessary to hand care of a patient to a colleague if an unresolvable conflict has arisen.

Management of the violent patient is considered in detail on  p.610.

Attending the ED is difficult enough, but can be even more so for certain ‘special’ patient groups. It is important that ED staff are sensitive to the needs of these groups and that there are systems in place to help them in what may be regarded as an intimidating atmosphere. The following list is far from exhaustive, but includes some important groups who require particular consideration:

Taken at face value, the concept that certain groups of patients are ‘special’ and so require special attention does not meet with universal approval. There is a good argument that every patient deserves the best possible care. Whilst this is true, it is also obvious that certain patients do have additional needs that need to be considered. Many of these additional needs relate to effective communication. There are some tremendous resources available that can help practitioners to overcome communication difficulties (eg www.communicationpeople.co.uk).

There are no set predisposing factors that determine patients most at risk following discharge. Those that affect the chance of difficulties at home include the current medical problem, underlying functional and social factors.

Multiple pathologies and atypical symptoms render this group more vulnerable to the physical, functional, and social effects of acute illness. Past medical history and pre-admission status are especially important determinants for patients with dementia or psychiatric illness. There may be evidence of recently changed circumstances, a recent bereavement, a change in medical or physical condition, increasing confusion, or unusual behaviour. The patient may not be able to afford adequate food or heating. Community services may not be aware that support is needed or help may have been offered, but refused.

Other important indicators are:

Look for evidence of self-neglect that suggests that the elderly person is having difficulty coping at home (eg poor personal hygiene, unclean or unsuitable clothing). Evidence of recent weight loss may suggest difficulties with food preparation or eating, unavailability of food, or may be due to serious pathology, such as a malignancy or tuberculosis. Signs of old bruising or other minor injuries may be consistent with frequent falls. Shortness of breath and any condition producing impaired mobility are important factors.

are a common problem of old age and require careful analysis, perhaps at a special ‘Falls’ clinic. Correctable factors include damaged walking aids, loose rugs, poor lighting, or unsuitable footwear or glasses. Common medical causes include cerebrovascular disease, arthritis, and side-effects of drugs.

Many elderly people claim that they can cope at home when they are unable to do so. If in doubt, ask relatives, the GP, and community support agencies. They may give helpful insight into the patient's mental state, which can be investigated/assessed further, whether it be a cognitive or reactive condition.

Hospital admission for an elderly person is a frightening experience and can lead to confusion and disorientation. If circumstances allow, discharge home is often a more appropriate outcome. If there are concerns regarding their functional ability and mobility, ask for an occupational therapy and/or physiotherapy assessment with, if appropriate, a home assessment. The elderly person is best seen in their home environment with familiar surroundings, especially if there is evidence of cognitive deficit. The provision of equipment and recommendations for adaptations can be made at this point if required. A wide range of community services including district nurse, health visitor, home help, crisis care, social work, hospital discharge, and rapid response therapy teams can be contacted to provide immediate follow-up and support and play a crucial role in preventing later breakdowns in home circumstances and unnecessary admissions for social reasons.

Patients with learning difficulties use the healthcare system more than the general population. Unfortunately, many healthcare professionals have little experience with these patients. However, understanding common illness patterns and using different techniques in communication can result in a successful consultation. Patients with learning difficulties often have complex health needs. There are many barriers to assessing health care, which may lead to later presentations of illness. Patients may have a high tolerance of pain—take this into consideration when examining them.

Patients with learning difficulties have a higher incidence of certain problems:

These include pneumonia (relating to reflux, aspiration, swallowing, and feeding problems) and congenital heart disease.

Past experiences of hospital are likely to have a big impact on the patient's reaction to his/her current situation. Most patients have problems with expression, comprehension, and social communication. They find it difficult to describe symptoms—behavioural change may the best indication that something is wrong.

When patients have problems that exceed the capabilities of a hospital and/or its personnel, transfer to another hospital may be needed.

Do not commence any transfer until life-threatening problems have been identified and managed, and a secondary survey has been completed. Once the decision to transfer has been made, do not waste time performing non-essential diagnostic procedures that do not change the immediate plan of care. First, secure the airway (with tracheal intubation if necessary). Ensure that patients with pneumothoraces and chest injuries likely to be associated with pneumothoraces have intercostal drains inserted prior to transfer. This is particularly important before sending a patient by helicopter or fixed wing transfer. Consider the need to insert a urinary catheter and a gastric tube.

Speak directly to the doctor at the receiving hospital. Provide the following details by telephone or telemedicine link:

Write down the name of the doctor responsible for the initial reception of the patient after transfer. Establish precisely where within the receiving hospital the patient is to be taken. Where possible, prepare the receiving unit by sending details ahead by fax/email. Pre-printed forms can help in structuring the relevant details and avoiding omissions.

If the patient to be transferred may require advanced airway care, ensure they are accompanied by a doctor who can provide this. The accompanying nurse should be trained in resuscitation with a good knowledge of the equipment used during transfer.

‘Transfer cases’ containing a standardized list of equipment must be immediately available and regularly checked. Take all the emergency equipment and drugs that might prove necessary to maintain the ‘Airway’, ‘Breathing’ and ‘Circulation’ (ABC) during transfer. In particular, take at least twice the amount of O₂ estimated to be necessary (a standard ‘F’ cylinder contains 1360 L of O₂ and will therefore last <3hr running at 10L/min). Before leaving, ensure that the patient and stretcher are well-secured within the ambulance. Send all cross-matched blood (in a suitably insulated container) with the patient.

Minimum monitoring during transfer includes ECG monitoring, pulse oximetry, and non-invasive BP measurement. If the patient is intubated and ventilated, end-tidal carbon dioxide (CO₂) monitoring is mandatory. An intra-arterial line is recommended, to monitor BP during the journey. Make allowances for limited battery life on long transfers: spare batteries may be needed. Plug monitors and other equipment into the mains supply whenever possible.

Include the following:

Some departments use standard forms to ensure that important information is complete.

Keep the patient's relatives informed throughout. Explain where and why the patient is going. Document what they have been told. Arrange transport for relatives to the receiving hospital.

Prior to transfer, re-examine the patient. Check that the airway is protected, ventilation is satisfactory, chest drains are working, IV cannulae patent and well secured, and that the spine is appropriately immobilized, but pressure areas protected. Ensure that the patient is well-covered to prevent heat loss. Inform the receiving hospital when the patient has left and give an estimated time of arrival.

Communicate to the receiving hospital the results of any investigations that become available after the patient has left. Contact the receiving doctor afterwards to confirm that the transfer was completed satisfactorily and to obtain feedback.

In many respects, the only difference between intra- and inter-hospital transfers is the distance. The principles involved in organizing a transfer are the same, whether the patient is to be conveyed to the computed tomography (CT) scanner down the corridor, or to the regional neurosurgical unit miles away.

A proportion of patients presenting to the ED have life-threatening conditions and some will die in the department. Often, the event will be sudden and unexpected by family and friends. It may already involve other family members (eg in the context of a road traffic collision). In contrast to hospital inpatients or those in general practice, an opportunity to forewarn relatives as to what has happened or the eventual outcome is unlikely. The relatives may already be distressed after witnessing the incident or collapse, and may have been directly involved in providing first aid.

It is inappropriate for junior hospital staff without suitable experience to speak with distressed or bereaved relatives. The task must be undertaken by someone with sufficient seniority and authority, who also has the skills of communication and empathy. The most important component is time.

Relatives usually arrive separately and after the patient. Anticipate this by designating a member of staff to meet them and show them to a relatives’ room, which should afford privacy, comfortable seating, an outside telephone line, tea, coffee, and toilet facilities. Paper tissues, some magazines, and toys for small children are useful.

While the relatives are waiting, a designated nurse should stay with them to act as a link with the department and the team caring for the patient. This nurse can pre-warn relatives of the life-threatening nature of the patient's condition and assist in building (an albeit short) relationship between staff and relatives. The link nurse should also check that important details have been recorded correctly, eg the patient's name, address, date of birth, religion (in case last rites are required), next of kin (name, relationship to patient, address and phone no.), and the patient's GP. This information should be collected as soon as possible, since later the relatives may be too upset to remember all these details or it may be difficult to ask for them.

Irrespective of who performs this task, remember a number of points. If you are the person who informs the relatives, ensure the link nurse is with you. After leaving the resuscitation room or clinical area, allow a minute or two of preparation to make yourself presentable, checking clothing for bloodstains, etc. Confirm that you know the patient's name. Enter the room, introduce yourself, and sit or kneel by the relatives so that you are at their physical level. Ensure that you speak with the correct relatives and identify who is who. Speak slowly, keep your sentences short and non-technical. Do not hedge around the subject. In their emotional turmoil, relatives very often misconstrue information. Therefore, you may need to re-emphasize the important aspects.

For many critically ill patients, their ultimate prognosis cannot be determined in the ED. In these situations, do not raise unrealistic expectations or false hopes, but be honest and direct with the relatives and the patients.

If the patient has died, then use the words ‘death’ or ‘dead’. Do not use euphemisms such as ‘passed away’, or ‘gone to a better place’.

After giving the news, allow relatives a few minutes to collect their thoughts and ask questions. In some cases, these may be unanswerable. It is better to say ‘we don't yet know’, rather than confuse or give platitudinous answers.

Common responses to bad news or bereavement include emotional distress, denial, guilt, and aggression. The feelings of guilt and anger can be particularly difficult to come to terms with, and relatives may torture themselves with the idea that if only their actions had been different, the situation would never have arisen, or the clinical outcome would have been different.

Many relatives wish to see or touch their loved ones, however briefly. Television and cinema have prepared much of the population for the sights and sounds in the ED. In some departments, relatives are encouraged to be present in the resuscitation room. In selected situations the stratagem has benefits. If the relatives are present during resuscitation, it is essential that the link nurse is present with the relatives to provide support, explain what is happening, and accompany them if they wish to leave.

More frequently, the relatives can see the patient in the resuscitation room briefly or while they are leaving the ED (eg to go to CT scan room or theatre). Even a few seconds, a few words, and a cuddle can be immensely rewarding for both relative and patient. The link nurse can give guidance beforehand as to the presence of injuries (especially those involving the face), monitors, drips, and equipment, to diminish any threatening impact that these may have.

Even before death has occurred, involvement of religious leaders is valuable. As early as possible, inform the hospital chaplain, who can provide invaluable help to relatives and staff.

When a patient has died, offer the relatives the opportunity to see the body. This contact, which should be in a private quiet room, can greatly assist in the grieving process. With careful preparation, most patients who have died from multiple injuries can be seen by relatives in this fashion.

Remember that followers of some faiths, such as Muslims and Hindus, have important procedures and rituals to be followed after death, although these may not always be feasible after a sudden death, especially from trauma. In such situations, discuss the matter with the Coroner's or Procurator Fiscal's officer, and obtain help from an appropriate religious leader to look after the bereaved relatives.

Any suspicious death must be immediately reported to the Police who will liaise directly with the Coroner or Procurator Fiscal (in Scotland).

Following all deaths in the ED, a number of important contacts must be made as soon as possible:

Ensure deceased's relatives are given information about the process for death certification and registration, and how to organize funeral arrangements. Most EDs have useful leaflets that cover these matters and can answer many questions. Some departments have formal arrangements for counselling after bereavement. Often the GP is the best individual to co-ordinate bereavement care, but in any event, give the relatives a telephone number for the ED so they can speak to a senior nurse or doctor if they need further information or help.

Report sudden deaths as soon as possible to the Coroner (in Scotland the Procurator Fiscal). It is helpful to give the following information if it is available:

The death of a patient or the management of patients with critical illness inevitably affects the ED staff. This is particularly so when some aspect of the event reminds staff of their own situation or relatives. These episodes often occur at the busiest times and when everyone in the ED is working under pressure.

One of the most difficult situations is to have to inform parents of the death of their child and help them in the initial grieving process, and then return to the busy department where many people are waiting with increasingly strident demands. It would be easy to respond that such individuals, with injuries or illnesses that are minor or present for days or weeks, are time-wasting. However, this approach will lead to conflict and is unfair to all concerned. Instead, take 5−10min for a break in the staff room before returning to the fray. Remember that in these circumstances you too are a patient. Even senior and experienced staff may be distressed after difficult resuscitation situations and may require support.

There is considerable potential to assist with the process of organ/tissue donation in the ED. However, the possibility of organ donation is sadly often overlooked in the ED. Many patients who die after unexpected cardiac arrest are potential donors of corneal tissue and heart valves. Kidneys may also be retrieved from some patients who have died in the ED, if a protocol for this has been arranged with the transplant team and the local Coroner or Procurator Fiscal. Many other patients who are moribund, intubated and ventilated (eg following massive subarachnoid haemorrhage) may be identifi ed as potential donors of other tissues also. Consider the possibility of organ donation in patients who die in the ED or who are moribund with no hope of survival. Most hospitals have specialist organ donation nurses (previously known as ‘donor transplant coordinators’) who will educate, advise and assist with the process of organ donation. Useful information about organ/tissue transplantation is available on the website of the British Transplantation Society (www.bts.org.uk).

Medicolegal problems are relatively common in the ED. Many of these problems may be avoided by adopting the correct approach.

Be polite and open with patients. Try to establish a good rapport. Be as honest as possible in explaining delays/errors.

(see General Medical Council guidance)

Use the consent form liberally for anything that is complex, risky, or involves sedation or general anaesthetic (GA). Ensure that the patient understands what is involved in the procedure, together with its potential benefits and risks. Whenever possible, attempt to obtain consent from parent/guardian in minors, but do not delay life-saving treatment in order to obtain consent.

Good notes imply good practice. Keep careful notes, using simple, clear, unambiguous language. Write your name legibly and document the time that you saw the patient. Remember that successful defence of a medical negligence claim may depend upon accurate, legible, comprehensive, contemporaneous notes. Try to avoid abbreviations, particularly where there is room for confusion. In particular, name the digits of the hand (thumb, index, middle, ring, and little fingers) and specify right or left by writing it in full.

Be meticulous in documenting the nature, size, and position of any wounds (  p.402). Write down a diagnosis, together with a full interpretation of any investigations. Ensure that all attached documents (nursing observations, blood results, ECG) are labelled. Document all instructions and advice given to the patient, together with any follow-up arrangements made.

Always seek senior help or refer those patients with problems beyond your knowledge or expertise. Record any referral made, together with the name and grade of the doctor referred to, the time it was made, and a summary of the facts communicated. After referral, be cautious about accepting telephone advice alone—an expert cannot usually provide an accurate opinion without seeing the patient.

Take special care with any patient who returns to ED with the same presenting complaint, because it is no better, has deteriorated, or the patient is simply dissatisfied. Do not automatically rely upon previous diagnosis and X-ray interpretations as being correct—treat the patient as if they were attending for the first time. Try to involve the consultant in these cases.

Always attempt to persuade the patient to accept the treatment offered, but if this is refused, or the patient leaves before being seen, ask the patient to sign an appropriate form. Patients not deemed competent (see Mental Capacity Act below) to make this decision may need to be held against their wishes—seek senior help with this. Write full notes explaining what happened.

The Mental Capacity Act 2005 outlines how a person is unable to make a decision for himself if he/she is unable to:

A patient lacks capacity if at the time he/she is unable to make a decision for himself/herself in relation to the matter because of an impairment or a disturbance in the functioning of the mind or brain.

All ED staff should bear in mind that patients may gain access to their medical records and read what has been written about them. Patients in the UK have a statutory right of access to information about themselves (set out in the Data Protection Act 1998) and this includes medical records. Competent patients may apply for access to, and copies of, their own records. Applications are usually made in writing via the hospital's legal department.

Join a medical defence organization. The Medical Defence Union (MDU), MDDUS, and Medical Protection Society provide professional indemnity cover for emergencies outside hospital, and advice and support for all sorts of medicolegal matters that are not necessarily covered by NHS trusts, eg statements to the Coroner or Procurator Fiscal, support at inquests or fatal accident inquiries, allegations of negligence, legal actions, and problems with the GMC. They also provide members with useful information and booklets about consent, confidentiality and other issues.

www.the-mdu.com/hospital

www.mddus.com

www.medicalprotection.org

Medical information about every patient is confidential and should not be disclosed without the patient's consent. In the UK the police do not have routine access to clinical information, but some information may be divulged in certain specific circumstances:

A patient's ability to drive may be impaired by injury (especially limb or eye), by drugs (eg after GA, opiates, alcohol) or medical conditions (eg TIAs, epilepsy, arrhythmias). In each case, warn the patient not to drive and ensure that this warning is documented in the notes. It may be prudent to provide this warning in the presence of a close relative.

For further information on medical aspects of fitness to drive see: www.dft.gov.uk/dvla/medical/ataglance.aspx

In the UK, the police may request a blood or urine sample under Section 5 of the Road Traffic Act (1988) from a patient they suspect to have been in charge of a motor vehicle with an illegal blood alcohol level (>80mg/100mL). In such circumstances, specimens should only be taken if they do not prejudice the proper care and treatment of the patient. The relevant specimens should only be taken by a police surgeon (clinical forensic physician) and with the patient's consent.

A change in the law (Police Reform Act 2002) also allows a police surgeon to take a blood sample from an unconscious patient who is suspected of having been the driver of a motor vehicle while under the influence of alcohol and/or drugs. The blood sample is retained and tested later, depending upon the patient later giving consent. Again, only permit the police surgeon access to the patient if this will not delay or prejudice proper care and treatment of the patient.

Many deaths that occur in (or in transit to) the ED are sudden and unexpected, and/or follow trauma. The exact cause of death is seldom immediately apparent. Accordingly, do not be tempted to sign death certificates. Instead, report all deaths to the Coroner (the Procurator Fiscal in Scotland). See  p.26 for details of the information required.

Do not provide information to the police until patient consent has been obtained. Writing a police statement requires thought and care. Write the statement yourself. Keep statements brief and try to avoid hearsay, conjecture, or opinion on the likely outcome. List injuries using both medical and non-medical language, explaining terminology in detail as necessary. State the investigations and treatment provided as accurately as possible (eg what sutures and how many were used). Having written the statement, ask your consultant to read it and comment on it. Get the statement typed (a friendly ED secretary may help if you cannot type yourself, and will also know how you can claim the relevant fee). Having checked it, sign and date the statement, and give it to the officer concerned. Always keep a copy of the statement and the ED notes, so that they are easily available if you are called to court.

Discuss the case with your consultant, and review the notes, the questions that you might be asked, and the likely court procedures. Get a good copy of the notes and any investigations. Ask whether you should take the original records to court.

Dress smartly, arrive early, and behave professionally. Be prepared for a long wait, so take a book to read. Turn off your mobile phone. Once in court, you have the option of taking an oath before God or affirming without religious connotation. You are equally bound to tell the truth whichever you choose. Use the same form of address that others have already used (eg ‘My Lord’, ‘Your Honour’). Answer directly and simply. Use comprehensible language, free of medical jargon. Remember that you are a professional witness, not an expert. Therefore, confine the expression of opinion to within the limits of your knowledge and experience—if asked something outside this, say so!

If you are called to give evidence at an inquest (in Scotland, a fatal accident inquiry), discuss the case with your consultant and also with your medical defence society.

The medical defence organizations (  p.29) have useful advice sheets for their members about writing reports and appearing in court.

Staff in the ED have an important role in preventing and controlling infection, which can be a serious risk to patients, relatives, and staff.

Organisms such as Staph. aureus, including MRSA (  p.235), can readily be transmitted by contaminated hands or equipment, causing infection of wounds, fractures, and in-dwelling devices (eg catheters or chest drains). Infected blood can transmit many infections, including hepatitis B and C (  p.239) and human immunodeficiency virus (HIV;  p.242). Viral gastroenteritis is usually spread by the faecal-oral route, but vomiting may cause widespread viral contamination of the surroundings and equipment, with a risk of transmission to other patients and staff.

Coughing and sneezing produces small droplets of infected secretions, which could involve viruses such as influenza ( Influenza pandemics, avian flu, and swine flu, p.252), severe acute respiratory syndrome (SARS;  p.251), and respiratory syncytial virus (RSV;  p.682). A nebulizer used on an infected patient may spread respiratory viruses widely, as occurred in the outbreak of SARS in Hong Kong in 2003 which involved many ED staff.

Standard precautions (also known as ‘universal precautions’) should be used at all times and with all patients to reduce the risks of infection. Blood and body fluids from all patients should be treated as infected. These standard precautions include:

Planning to cope with an outbreak of a serious infectious disease such as SARS or pandemic flu (  p.252) is a considerable challenge for ED staff and for the whole community. The ED must be organized so that patients can be assessed properly with a minimum risk of infecting staff or other patients. If possible, patients with serious airborne diseases should be treated in negative pressure isolation rooms by staff in appropriate PPE who are fully trained to minimize the risks of spreading and acquiring the infection. In high risk situations a ‘buddy’ system for staff may be helpful, with each doctor or nurse being watched closely by another person to check that full safety precautions are maintained.

Hospitals in Hong Kong with experience of SARS use the FTOCC criteria when assessing febrile patients for potentially serious infectious diseases:

Similar criteria are used in the UK Health Protection Agency's algorithm: www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/AvianInfluenza/

www.rcn.org.uk/downloads/publications/public_pub/002725.pdf

www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SevereAcuteRespiratorySyndrome/Guidelines/sars040Facemasksand respiratorsFAQ/

Influenza pandemic, avian flu, and swine flu, p.252.

SARS, p.251.

If you are interested in out of hospital work, join the British Association for Immediate Care (BASICS: www.basics.org.uk), which is a valuable source of information and expertise. It can give advice on clothing, medical and protective equipment and their suppliers, and Immediate Care courses.

The equipment that could be carried is extensive. In the UK, except in the most remote situations, it is likely that an ambulance will be on scene quickly. Emergency ambulances carry many items of equipment, eg for intubation, volume infusion and splintage, and also some drugs. There is a risk of carrying too much equipment in your car and getting diverted from the primary aims of pre-hospital care, which are to perform only relevant life-saving techniques, and to transfer the patient rapidly and safely to the nearest appropriate hospital.

The equipment listed below is a personal choice based on experience attending out-of-hospital calls over the past 20 years:

The equipment listed is only of value if you know how to use it, it is secure (ie locked in a case in a locked vehicle), and it is in date:

It is easy in an emergency to forget the simplest, most life-saving procedures. At worst, an individual trying to help can aggravate the situation, slow the process of care, and even become a casualty themselves.

Do not approach a chemical incident until declared safe by the Fire Service. Lorries carrying hazardous chemicals must display a ‘Hazchem’ board (see Fig. 1.2). This has:

contains only the UN product number (bottom) and a numerical hazard code (top)—a repeated number means intensified hazard. Mixed loads <500kg may only be identified by a plain orange square at the front and rear of the vehicle.

carried in the driver's cab gives information about the chemical for use at the scene of a crash. The fire tender may be equipped with CHEMDATA—a direct link with the National Chemical Information Centre at Harwell. Alternatively, contact a Poisons Information Centre or the transport company.

If helicopters are used for transport/evacuation, remember:

A major incident involves a lot of people. The casualties may have multiple injuries, minor injuries/burns, or other emergencies such as food poisoning or chemical inhalation. Every hospital accepting emergencies has a Major Incident plan to use when the normal resources are unable to cope and special arrangements are needed. There will be action cards for key staff detailing their duties. All staff need to familiarize themselves with their roles in advance.

Call-in lists

must be up to date and available at all times.

Major incident practices

must be held regularly to check arrangements and contact details and to remind staff what they should do.

The ambulance service or the police should warn the hospital of a possible or definite major incident. Initial messages are often inaccurate because they are based on confused and incomplete information from the scene. Occasionally, patients arrive without warning from a major incident near the hospital.

Ensure that the ED consultant on duty is informed immediately of any suspected major incident, enabling them to participate in the decision to start the major incident procedure. Senior medical, nursing, and administrative staff will set up the hospital's Control Centre and prepare for action. If the major incident is confirmed, the full hospital response is initiated, following the procedures in the plan.

Communications are vital, but switchboards rapidly become overloaded. Staff should therefore be called in using non-switchboard phones if possible. All staff should wear their identification badges.

Beds must be cleared to receive patients, preferably on 1 or 2 wards, rather than many different wards. A senior surgeon should triage patients needing operations and co-ordinate theatre work.

Relatives and friends of casualties should be looked after by social workers and chaplaincy staff in an area near to, but separate from, the ED, perhaps in the outpatient department. Keep relatives informed as soon and as much as possible. Security staff at each entrance to the ED should direct relatives and friends of casualties to the appropriate area and not allow them into the ED.

Journalists and television crews will arrive rapidly after a major incident. Keep them out of the ED—direct them to a pre-arranged room to be briefed by a press officer and senior staff.

The police are in overall command. The fire service take control of the immediate area if there is a fire or chemical risk. The police, fire, and ambulance services will each have a control vehicle, with an Incident Officer to co-ordinate their staff and the rescue work.

There may be a Medical Incident Officer (MIO) and also a Mobile Medical Team of doctors and nurses, who should if possible be sent from a supporting hospital, rather than the hospital receiving the first casualties. These staff must be properly clothed (yellow and green high-visibility jacket marked ‘Doctor’ or ‘Nurse’, over trousers, green helmet with visor and chin strap, safety boots, gloves, knee pads, torch, ID badge), and must be trained and equipped with suitable medical supplies and action cards.

The mobile medical team must report to the MIO, who is in charge of all medical and nursing staff on site and works closely with the Ambulance Incident Officer (AIO). The MIO should record the names of the mobile medical team and brief them about their duties and the site hazards and safety arrangements. The MIO is responsible for supervising the team, arranging any necessary equipment and supplies, and making sure that the team are relieved when necessary. The MIO and AIO relay information to the hospitals and distribute casualties appropriately.

Debriefing is important after a major incident, so that staff can discuss what happened and express their feelings. Mutual support of the team is essential. Counselling may be required. Senior staff should prepare a report on the incident and review the major incident plan.

www.dh.gov.uk/en/Managingyourorganisation/Emergencyplanning/index.htm

Decontamination of patients, p.211.