Blog a Day – A&E (9am-5pm Weekday)

So the first “typical day blog” is from A&E. Our department here has two x-ray rooms and ceiling mounted x-ray equipment in Resus (which you’ll see on Channel 4 this Autumn, no doubt!). On a normal weekday we have (ideally) two radiographers and a receptionist, and we work from 8:45 until 17:15. The areas we cover are Resus, Majors, and the Urgent Care Centre.

The day starts relatively slowly; a few walking patients from urgent care with minor injuries to their arms and legs, a couple of chest x-rays from Majors. Things remain calm until 10:15 when the trauma bleep goes off “Adult trauma team to A&E Resus…” I go to Resus to find out the details. On paper it’s a 40ish year old cyclist who’s been knocked off his bike by a bus. Open tibia fracture, but other than that all other obs are fine (he’s breathing, his blood pressure’s ok, and he’s fully responsive and coherent). He arrives fairly quickly; sometimes we get loads of notice before a trauma physically arrives, at other time the bleep is sent out when the patient is already here. When he’s wheeled in, he’s assigned a Resus bay and the paramedics give us a handover. He’s had morphine and his leg’s in a vacuum splint but the injury is easy to spot. Once on the Resus trolley the team begin the primary survey and everyone rushes round doing their jobs. It turns out that the patient was cycling along a blue cycle lane when a bus decided to squeeze between him and a car turning right. The cyclist slammed his brakes on and probably saved his own life, but the car behind the bus hit him and sent him flying over the bonnet. I’m asked to do chest and pelvis x-rays straight away to make sure he has no other serious injuries which are being masked by the pain in his leg. His pelvis is ok, but there’s a small pneumothorax at the top of his right lung. He’s taken to CT to check the blood flow to his leg, as well as the nature of the open fracture.

Back round in X-ray a queue has formed. Two chest pain patients are outside on trolleys, and there are three patients in the waiting area who haven’t been seen yet. Before I’ve had a chance to pick up the form for the next patient I hear the red phone ringing over in Resus. We get through the queue of patients just as the bleep goes off in response. “Adult trauma team to A&E Resus…” My colleague (who I’ll call Mark) goes round this time; similar story to the previous one, cyclist vs large vehicle, only this one’s much worse. The van that hit him went right over him, so he’s taken straight to CT after the handover and has extensive internal injuries including a spinal fracture (C4/5) and multiple pelvic fractures.

Meanwhile in X-ray a very unhappy paediatric patient has arrived with a very bent forearm. You can always tell it’s sunny outside when the trampolining injuries start arriving. She’s in agony, but is very cooperative (the seriously hurt ones usually are) and we get some perfect x-rays showing the greenstick fractures of her radius and ulna.

Then we get four stroke patients in a row (we “routinely” do chest X-rays for stroke patients in case of underlying chest pathology, or in case they aspirated fluid during the stroke, the usefulness of the X-rays is debatable, however).

The 5 year old with the broken arm comes back, this time in plaster, and lot less upset. She proudly tells me that she knows exactly what to do this time, and she definitely won’t cry. True to her word, we get perfect x-rays without me even touching her arm, and dad takes a photo of her giving the thumbs-up next to the x-ray machine.

The next child to come in is a bit different- “Paediatric trauma team to A&E Resus…” a two year old who was found, unresponsive and not breathing in his cot. Mum was absolutely inconsolable, screaming and crying (understandable, really) while the team attempted to resuscitate her child. He had a pulse, but his breathing was infrequent and shallow, so I did a chest x-ray, after he was intubated and it looked like he’d inhaled fluid (possibly vomit).

Things went quiet over lunchtime, with only a few chest x-rays coming in from Majors, and a psychiatric patient who had told her carer that she’d swallowed razorblades. It turns out from the abdomen x-ray that she’d actually swallowed parts from a pen, which was a relief.

As I escorted her back to her cubicle in Majors, a mortuary box was wheeled past me towards Resus for the second cyclist. Another unsurprising and unnecessary death on London’s roads.

Just as Mark made a comment about how calm things had been for the past couple of hours, the helipad response team sprinted past; the helipad had only recently opened and we were still in early double figures for patients visiting us via the roof so it was still very much a novelty. I dashed outside to see if I could watch it land, but it had already touched down by the time I got to a vantage point.

This was a straight-to-CT trauma patient who had fallen from a height of about 20 feet onto concrete. After his CT scan and on his way up to ITU we did some x-rays of his arms as it turned out that on top of the extensive lower leg injuries he’d sustained, he’d also broken his thumb…

We had a few more weather-related injuries (mostly sports, but two more trampolines), and a motorbike rider who broke his wrist in an altercation with a pothole. And then to finish the shift off, a woman came in who had sat on a wine glass and had shards embedded in her buttock- an accident which happens more often than you’d think, often enough for me to have perfected the tangential buttock projection

At 17:15 the long day people (who work until 20:00) arrive to take over for the evening. Looking at the worklist at the end of the day, I’d say we’d had at least 60 patients during the shift, fairly unremarkable for our usual workload.

6 Comments on Blog a Day – A&E (9am-5pm Weekday)

  1. Suzanne
    October, 17th 2014 at 1:42 pm

    Really interesting to see a typical day for our A&E radiology teams. Where I work, we tend to see less cyclist trauma but soooo much more chest/abdo pain patients. My typical day as a band 5 staff nurse goes like this: arrive 0800 for handover, get allocated to either majors or resus (only band 6’s and 7’s get to work in minors). I’m usually in majors unless they have no other ILS/ALS trained staff in resus. We get allocated 5 or 6 patients between 2 nurses. When a patient comes in, we have to do an A-E assessment, document it, take physiological and neuro obs, bloods, blood sugar and venous blood gas, site a cannula, take an ecg, maybe a bladder scan, assess mobility, undertake a falls and pressure sore rusk assessment which may include checking a patient’s sacrum. That is often difficult if they are immobile in a narrow trolley or need to be log rolled. The dr will see them then we have to give iv fluids, meds, take them to CT or x-ray, assist them to the toilet and test their urine. Then we might need to give further iv/oral meds/nebs and continue to monitor observations. Often other patients with greater needs such as chest pain or sepsis will come in and we will need to attend to them too. Lots of prioritising involved. It’s a constant balancing act. We also have to transfer patients to the wards, give phone handovers and handover on the ward. Transfers can be problematic as often the wards are not quite ready but we have to get our patients out of our dept in a certain time. This often leaves our colleagues short of staff, as we cannot leave our transferred patients until they’ve been put onto the wardb ed and we’ve handed over. I come back from a transfer and all of a sudden, 2 or 3 new patients have arrived. I usually get my first 30 min break around 4pm. Very lucky if I can make a second break by 2030, which is the end of our shift. If our handovers are more complex, or we are stuck in a transfer, we get out later.

  2. Suzanne
    October, 17th 2014 at 1:44 pm

    *risk assessment! Not rusk. I sounded like a kiwi there 😉

  3. Cherry Black
    October, 17th 2014 at 2:18 pm

    I love a good rusk assessment. They go very well with milk.

    Your post outlines the exact reasons why I could never be a nurse. Especially an A&E nurse. You’ve got too much going on all at once, and even that’s not enough. The fact that a lot of your woes are caused by targets and breaching just makes it even more frustrating.

  4. Suzanne
    October, 17th 2014 at 3:19 pm

    Indeed. It’s the targets and breaching times that get in the way of me getting time to actually care and speak to my patients. It feels so task based instead of person centred. I can’t wait to start in ITU!

  5. Kate
    October, 22nd 2014 at 8:23 pm

    Great post! Really interesting. I’m a radiographer with very little experience in a proper trauma A&E hospital (I graduated a few years ago but have worked mainly in a small private hospital with only a minor A&E). I’m due to start a job soon in a major teaching hospital and am a little nervous about working in A&E and doing nights etc. Any advice for a newbie?

  6. Cherry Black
    October, 22nd 2014 at 9:56 pm

    -Don’t be afraid to ask for help, don’t struggle on and get stuck!
    -2 views at 90 degrees to each other, don’t spend ages trying to get a textbook image, sometimes it’s not possible and not in the best interests of the patient.
    -Pain relief! Make sure they’ve had it BEFORE coming to x-ray, sometimes the medical team forget, or the porters collect the patient too early, don’t attempt to move or manipulate a patient if they’re screaming in agony.
    -Earplugs
    -Experiment with sleep patterns, some people function well without a pre-night nap, others need at least 6 hours during the day.
    -Bring sunglasses for the journey home after a night shift, even during winter.
    -If you’re in any doubt about your capabilities, DON’T DRIVE HOME!

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