Lessons from Emergency Departments

Things I (and others) have learnt from working in Emergency Departments:

First published 31/3/2012, please email me with more suggestions/additions. Last updated 25/09/2012.

  • If a dog is trapped, it doesn’t matter who you are to them. It will bite the you on the hand or arm needing stitches and some antibiotics
  • There are more nasty bacteria from a human bite than from a dog or cat. In addition, if that bite is from your new partner…its best to find a new one.
  • Windy day + kids + local town show = busy A&E
  • Fever, tummy pain and vomiting in a toddler. Clear chest, ears and throat, no cough, runny nose: think UTI.
  • There is no such thing as an urgent repeat script, just lazy people
  • The Noarlunga Triad:

1) Tattoo on lower back,

2) piercings (usually belly button) and

3) shaved nether regions

Female with abdo pain and above triad = high degree of suspicion for PID

  • Guesstimate a kids weight: (age + 4) x 2…then add on 1-2 kgs in this day and age
  • If you are seeing someone with a sub acute problem who is being demanding, you are entitled to ask nicely: “so why haven’t you seen your GP for this in the past 4 weeks?”
  • Some nurses are fixated on saturation levels and not signs of increased work of breathing. You should never be happy with a respiratory rate of 60 and a head bob even though the machine says 98%.
  • The patients most likely to complain about having a needle are men covered with tattoos. When you say “but look you’ve had heaps of needles for your tatts” the answer is usually “its different then” Oh what, this time I won’t be giving you Hep C?!?
  • A nurse was wondering the other day if there was a word for someone that was rude to nurse, like equivalent of misogynist. There already is a word: doctor.
  • The Sunglass Rule: If someone is wearing sunglasses inside (usually middle aged female), they are crazy.
  • When it comes to children, all vomiting is described as ‘projectile’
  • The Centrelink Reverse Acuity Scale (CRAS). The more times a patient complains or mentions their failed DSP application, the less concerned a doctor should be about whatever somatic complaint they have. This scale is increased in the early hours of the morning in ED.
  • When you ask for a sample and hand the patient a urine pot, make sure you ask them for a ‘urine specimen’. You might be surprised what comes back after 15 mins in the toilet.
  • The Westell Triad

1) Unusually spelt/hyphenated first name

2) Stuffed toy (or furry slippers)

3) Packed suitcase

= Borderline PD (if diagnosis is uncertain, weigh case notes and divide by age. Higher number, higher certainty)

  • Patients that present between 2 and 5am are either genuinely very ill, or crazy.
  • Other doctors pretend to do work in order to avoid psych and/or gynae presentations
  • If you ask a nurse ‘are you looking after this patient?’ The answer will be ‘no’ or ‘I’m going on break’
  • If you personally know a patient who presents to ED, you can say “they asked me to see the malingerer first”
  • Lewis’ First Law: everyone is stupid until proven otherwise.
  • Everyone gets a prize. Patients shouldn’t leave ED without something: script, referral, take home meds, imaging request, specimen jar, extra dressings, plaster, kick up the bum.
  • When your registrar lets you know that the psych registrar is here to see your patient, make sure they don’t say “Gerry, the psychiatrist is here for you” in front of the other patient you are seeing
  • For all of the long days and annoying patients, it only takes one thank you email or letter to make it all worthwhile.
  • Some patient think that dress shoes and scrub tops are unacceptable for doctors to wear because they think you are actually wearing cowboy boots and a bonds top.
  • Positive name sign: if a child under the age of 15 has a different sounding or spelt name, they are from a low socio-enconmic background. Current list: Linkin, Olisha, Blayze, Cursty, Scarlett Hoare, Jedediah.
  • If your admission to the general medicine registrar is for a social reason. Be upfront and tell them. Don’t try and conjure up a UTI to get them in, interns are shocking for trying to window dress patients.
  • Considine’s Pain Rule: a patients actual pain threshold is inversely proportional to the amount of times they say “…..I usually have a very high pain threshold”
  • Never assume families are caring. Bringing grandma to ED two days before Christmas with vague symptoms of dizziness is still a ‘Granny Dump’
  • If there are more than four ambulances and any number of police cars out the front of ED, its going to be a crap shift.
  • You can smell what sort of booze the patient had been drinking when taking bloods for alcohol testing.
  • Always take extra blood tubes for crossmatch and clotting on oldies, O&G, trauma and chest pain. You’ll never know when you might need a transfusion or when your consultant wants a D-dimer.
  • Ex or current nurses, doctors and paramedics can’t help using jargon when helping to explain a friends symptoms. “Ive noticed that they have been a touch diaphoretic lately” Makes them very easy to pick.
  • Some people are INTENSELY phobic of cotton wool on their skin after blood is taken.
  • Tooth to tattoo ratio. If less than 1, then patient either has pancreatitis, hepatic encephalopathy or barracks for Collingwood.
  • One of Dr Tim’s Pearls of Wisdom. If there are more than 2 rings on 2 or more fingers, your patient will be barking mad


Filed under Emergency Medicine, Humour

10 responses to “Lessons from Emergency Departments

  1. James Bonello

    Love them ALL. Totally true. Except for the Collingwood comment you bum

  2. Excellent precis Gerry

    I reckon you missed only one sign – people who wear more than 2 rings on more than 2 fingers of any hand = barking unless proven otherwise

    AOGP used to have a PDF called ‘DrTim’s Pearls’ (a more realistic version than Murtagh’s Pearls)….it caused quite a furore and was banned, but you may be able to get a copy (Ben Abbott may have one). This was one of the facrors leading to my resignation as AOGP emergency medicine director.

    Anyway, maintain the passion…and let me know if you need a copy of the classic subversive GP reg text….

    • gerryconsidine

      Tim, you’ll be happy to know that Ben handed a copy of the Pearls to me after 2 weeks in Jamestown (did my 4th year and intern terms there). Evidently 2 weeks was enough for him to work out that my humour was suitable tuned! I still have that copy sitting in my bookshelf next to Murtagh’s here in Wudinna. Thanks for the message and keep em honest!

      PS have already seen your 2 ring, 2 finger sign in clinic this term. Classic


  4. Big B

    The Westell triad:
    unusually spelt and/or hyphenated first name +
    stuffed toy (or fluffy animal slippers) +
    packed suitcase =
    Borderline PD
    Diagnotic uncertainty? – weigh the case notes and divide by patients age. The higher the number the more certain you can be.

  5. Hildy

    Gerry, don’t you barrack for Collingwood?

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