Tasty Morsels of EM 134 – #FRCEM An RCEM Potpourri & the Guidelines

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

This one covers a variety of RCEM produced position statements, guidance and guideline summaries from the main college repository. Many of them weren’t big enough to deserve their own post so I’ve collected them here. I’ve also included links to many of the external guidelines I’ve covered for the FRCEM.

RCEM clinical responsibilty

• if a specialty sees them they have responsibility (including onward referral)
• poor referrals to be directed to ED consultant
• if patient changes while awaiting specialty then it is our problem (inc blood results)

RCEM Frequent attenders

• have a means of identifying them
• bespoke management plans are good

RCEM 50 guidance some highlights (or things that didn’t seem immediately obvious)

• messages on the ceiling tiles for those lying flat (you are in xxx ED)
• joint nursing medical hand over
• statutory duty of candor
• comfort rounding
• delirious offered distraction therapy

RCEM Female genital mutilation

• always document it
• for over 18s offer support and consider other younger household children
• report of FGM by under 18 or clinical findings of same then involve police and safeguarding protocols

RCEM Domestic violence

• no need to screen routinely but access simple direct questions if suspicion

RCEM Chaperones

• offer to all patients with sensitive area examinations
• “sensitive area examinations” = below clavicles and above mid thigh

RCEM Concealed Drugs

• police or UK border authority deal with these
• remember our role in confidentiality and drug smuggling itself is not a reason to break confidentiality
• imaging only undertaken with patients consent and request by rank of inspector or equivalent
• intimate examination – presumably PR or PV requires a similar standard and should be done by forensic doctor but in a hospital able to deal with consequences rather than a police station
• we should not handle the packages
• don’t use urine tox screens – what a surprise
• stuffers should be admitted for 6-8 hours obs
• AXR is reasonable as a screening tool in packers. If negative or inconclusive then a CT would be next
• Indications for urgent removal
  • obstruction
  • cocain/amhetamine toxicity
  • suggests opiates can be managed with naloxone infusion and consideration of surgery
• proven packers that are asymptomatic can be discharged to UK boarder authority force who have specialised suites and systems for observation (basic but more than a cell)

RCEM/Vasc society AAA

• those previously decided not for surgery should still be discussed consultant to consultant if they present with rupture (though they note if consultant is off site then senior to senior trainee is OK)
• alert with systolic 70 is the aim
• only contraindications to transfer here are cardiac arrest as part of this episode
• no essential investigations prior to transfer
• CT etc should not delay transfer
• transfer within 30 mins of diagnosis

RCEM 2010 C spine

• all roads point to CT….
• you can get an xray if you can’t get the collar off with nexus/canadian and there’s no indication for immediate CT
• they include 7/10 pain as an indication for CT by most routes in the algorithm
• they also include MRI if normal CT but unable to do 45 degrees or in severe pain

RCEM Summary of NICE CG88 (LBP)

• don’t X-ray
• consider MRI in red flags
• movement and exercise is good
• offer exercise, consider manual therapy or acupuncture
• paracetamol then NSAID and/or weak opioid (strong opioids for short term also an option)

The Guidelines

These are loosely organised by topic. The links should take you direct to PDF in most cases