Chapter 4

With contributions from Dr Kimberly Ashton

Working in accident and emergency (A&E) is likely to be the rotation in which you learn the most and have the greatest opportunity to put your skills into practice. You will almost certainly feel unprepared and out of your depth when you start. This chapter aims to provide some advice on surviving and thriving in A&E as well as guidance on coping with the more common medical and surgical conditions that you will treat.

General advice

Whilst there is an enormous variety of pathology to be encountered in A&E, you will soon realize that you see the same handful of conditions repeatedly most of the time.

A&E operates on a shift system. There will always be a consultant in charge for the day. Depending on whether you are working in a hospital that takes emergency medicine trainees, there may also be registrars or ACCS trainees.

As a junior doctor, you will be expected to see patients and initiate appropriate investigations and treatment, before referring to the appropriate specialty, or considering sending them home. If you have any problems, there should be someone in your own department to ask for advice, but if this is not the case, then you should phone someone senior from an appropriate specialty. Generally, if you plan on sending a patient home, you should discuss with someone senior before doing so to check that there is nothing you have missed. This is particularly important at the beginning of the rotation, when you may not have much experience of how things work.

Structure of A&E

A&Es have a majors and a minors or ‘injuries’ department. When a patient arrives, a relatively senior nurse or doctor will triage the person to the section they think suitable.

The minors department will see patients with a variety of problems. People may have fractures, cuts or other minor injuries. If you feel a patient has been inappropriately triaged as ‘minor’, you should arrange to have them transferred to majors as they will receive more urgent and thorough attention. You should make clear with your colleagues at this point whether you will see them, or whether someone else will, to avoid patients ‘falling through the cracks’.

Majors will have a section called ‘resus’ (short for resuscitation) where the most unwell patients go. This area can get quite full of people from different departments and can occasionally become noisy and chaotic. If you have started seeing a patient, you should make sure that you know who everyone is and what their role in the situation is. It may be that someone more senior than you takes over, but until this happens, try to maintain an overview of the situation to avoid confusion and inefficiency. Again, if it turns out that a patient is more unwell than first thought, they can be moved from majors or minors to the resus area:

  • Do not be afraid to ask nurses for advice. They have generally seen it all before and they know the regular patients. Senior nurses or advanced nurse practitioners can be a goldmine of information and are often particularly skilled at managing minor injuries.
  • You can waste a lot of time looking for equipment. Ensure that you know where important items are kept, including where IV fluids and giving sets are stored as you may need to put these up yourself.
  • There is likely to be a shortage of metal trollies, so make sure you clear up after yourself to leave them free for others. It makes life much easier if you have a reasonable space for working from rather than depositing everything on a nearby chair or bin lid.
  • A small yellow sharps bin is ideal if you can find one. If not, dispose of your sharps as you go. It may take time, but it’s the safest way to avoid a needlestick injury.
  • If you are on-take for a specialty and are seeing patients in A&E, tape two or three sheets of paper to an available desk. Use these to note down accepted patients, so as not to lose track of expected (and received) patients. These sheets can also be used to document tentative and confirmed diagnoses, the results of initial tests and the ward to which the patient is sent from casualty. You can then remove and use this information for handover or post-take rounds. Sticking patient labels on the list is a good way to get all the relevant details for your patient in one place legible. Remember to dispose of this in the confidential waste bin at the end of handover.
  • Dehydration is a real problem if you work without a break in A&E (or anywhere else for that matter). Drink as much fluid as you can! Otherwise, always take a bottle of water onto the ‘shop floor’ with you. Keep it in a non-clinical area, and label it clearly with your name.
  • Take meal breaks ruthlessly. Hold the fort for your colleagues and have them do the same for you. No one works efficiently with hypoglycaemia. You should find out when you come on shift whether the person on the shift before has taken their break. If not, encourage them to organize a suitable time, and then plan to take yours when the next person is due to arrive. Most A&E departments allow you the equivalent of 30 minutes break per 6 hours of work, either in one go or as two split breaks. Make sure you take them! Rest, recuperate, eat, and if you can then try and mental switch off from work for a few minutes.

Admitting and allocating patients

  1. If you are working in A&E on-take for a specialty, ask medical and nursing colleagues about the local routine for admitting and allocating patients during take. If anyone in particular needs to be informed, such as the bed manager, make sure you make a note of how to contact them. Remember that referral from the emergency team is generally a one-way street. Once you have agreed to see a patient, you have ‘accepted them’ and are then responsible for their care. If it turns out that they should have been referred to a different specialty, you cannot then ask the emergency team to do this – you will have to make that further referral.
  2. When a general practitioner (GP) telephones you to admit a patient:

    • Be polite. Remember that the GP almost certainly has more experience than you, and it is not respectful to take the attitude that you know more than they do because they are referring to you.
    • Have paper and pen ready.
    • Listen first. This will provide less frustration for both parties.
    • Take down the name, age, problem (in as much detail as is feasible), hospital number, GP name and number and when to expect the patient’s arrival.
    • Phone A&E or the ward with the patient’s details, and if necessary, inform the site manager.
    • Let your senior know that the patient is coming in and what their main complaint is.

  3. If you accept a patient from a GP, then you are obliged to review them, even if it is obvious that they need to be transferred to another specialty. Try, therefore, to obtain as much information as you can during the referral and triage if you can to the right speciality, or you will end up seeing the patient, however, inappropriately.
  4. In many hospitals nearly all patients will be shipped to an ‘Acute or Medical Assessment Unit’ from where they will be either discharged home or, if their stay is likely to be more than a few days, to a more long-term ward elsewhere in the hospital. If a patient is admitted directly to a normal ward, investigations and the instigation of treatment can take much longer than if they are seen in A&E. If you think someone is likely to be very unwell, try to insist that you can at least review them in A&E first. This makes obtaining tests such as portable CXRs much easier.

Keeping track of patients

  • Try keeping a sheet of paper with patient stickers down one side with results of baseline tests and diagnosis next to each sticker. This is invaluable for handing over to colleagues and ensuring nothing important is missed. It is easy to get overwhelmed when you have seen three or four patients and are waiting for multiple tests to come back before referring to the appropriate specialty or discharging. It is vital to keep a record of what has and has not been done.

If you are missing results, be conscientious in checking them before going home. It is better to spot an unexpected abnormal result late and when you are looking forward to leaving rather than when you return the next day and something tragic has happened. Alternatively, make sure you have handed over to someone else to check. If at all possible, it is better to check it yourself as you will know the story better and be in a better position to deal efficiently with the results. If you have handed over results to someone else to review, you should document who you spoke to, what you asked them to check and the plan of action. Remember that taking responsibility is absolutely central to being a good doctor, and if you do not follow up investigations and results, it is unlikely that anyone else will. It is your diligence in such a situation that will determine the type of doctor you become.

  • If you urgently need a result out of hours, you may need to phone the laboratory technician on call. This can be particularly important for tests like lumbar punctures, where the samples can otherwise sit unnoticed on the microbiology desk until the next morning. Likewise, there is usually a duty biochemist or haematologist on call.


On admission, complete for each medical patient:

  1. A focused history and examination
  2. Baseline tests:

    • Bloods: FBC, U&E, glucose, ESR and CRP (consider clotting screen and LFT)
    • Urine: MSU and dipstick
    • ECG
    • Radiology: CXR

  3. IV access
  4. IV fluid
  5. Drug charts

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