but includes some important groups who require particular consideration: \200 Children : they are such an \200\230obvious \200\231 and large \200\230minority \200\231 group that they receive special attention to suit their particular needs (see b Pediatric emergencies, p.630). Pregnant women : see b Obstetrics and gynecology, p.563. \200 Those with mental health pr oblems : see b Psychiatry, p.601. \200 The elderly : who often have multiple medical prob lems and live in socially precarious circumstances. Patients with Alzheimer \200\231s disease and other states associated with chronic confusion. Those with learning dif \201 culties : b p.21. \200 Patients with hearing problems. \200 The visually impaired. \200 Those who do not speak or understand English : arrangem ents should be in place to enable the use of interpreters. Patients with certain cultural or religious beliefs (particularly amongst \200\230minority groups \200\231) : these can impact signi \201 cantly upon a variety of situations (eg af ter unsuccessful resuscitation for cardiac arrest \200\224 b Breaking bad news, p.24). Those who are homeless or are away from home, friends, and family (eg holiday makers). Those who have drug/alcohol dependency. Isn \200\231t everyone special? Taken at face value, the concept that certain groups of pat ients are \200\230special \200\231 and so require special attention does not meet with uni versal approval. There is a good argument that every patient deserves the best possible car e. Whilst this is true, it is also obvious that certain patients do have additional needs t hat 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 com munication dif \201 culties (eg www.communicationpeople.co.uk ). 20 CHAPTER 1 General approach Discharging the elderly patient There are no set predisposing factors that determine patien ts most at risk following discharge. Those that affect the chance of dif \201 culties at h ome include the current medical problem, underlying functional and social factors. Risk ind icators 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-ad mission status are especially important determinants for patients with dementia or psychiat ric illness. There may be evidence of recently changed circumstances, a recent bereavement, a change in medical or physical condition, increasing confusion, or unusual behavior. The patient may not be able to afford adequate food or heating. Community services may not be a ware that support is needed or help may have been offered, but refused. Other important ind icators are: \200 Those living alone. \200 Absence of close family support or community services. \200 Unsuitable home circumstances (eg external or internal stairs). \200 Di f \201 culty with mobility. Determining those unable to cope Look for evidence of self-neg lect that suggests that the elderly person is having dif \201 culty coping at home (eg poo r personal hygiene, unclean or unsuitable clothing). Evidence of recent weight loss may sug gest dif \201 culties with food preparation or eating, unavailability of food, or may be d ue to serious pathology, such as a malignancy or tuberculosis. Signs of old bruising or oth er minor injuries may be consistent with frequent falls. Shortness of breath and any condit ion producing impaired mobility are important factors. Falls are a common problem of old ag e and require careful analysis, perhaps at a special \200\230Falls \200\231 clinic. Correc table factors include damaged walking aids, loose rugs, poor lighting, or unsuitable footwe ar or glasses. Common medical causes include cerebrovascular disease, arthritis, and side-e ffects 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 \200\231s mental state, which can be investigated/assesse d further, whether it be a cognitive or reactive condition. The decision to discharge Hospital admission for an elderly person is a frightening experie nce 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 ap propriate, a home assessment. The elderly person is best seen in their home environment wit h familiar surroundings, especially if there is evidence of cognitive de \201 cit. The pro vision of equipment and recommendations for adaptations can be made at this point if requir ed. 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 cont acted to provide immediate follow-up and support and play a crucial role in preventing late r breakdowns in home circumstances and unnecessary admissions for social reasons. 21 THE PATIENT WITH LEARNING DIFFICULTIES The patient with learning dif \201 culties Patients with learning dif \201 culties use th e healthcare system more than the general population. Unfortunately, many healthcare profes sionals have little experience with these patients. However, understanding common illness p atterns and using different techniques in communication can result in a successful consulta tion. Patients with learning dif \201 culties often have complex health needs. There are m any barriers to assessing health care, which may lead to later presentations of illness. Pa tients may have a high tolerance of pain \200\224 take this into consideration when examin ing them. Associated health problems Patients with learning dif \201 culties have a higher incidence of certain problems: \200 Visual and hearing impairment. \200 Poor dental health. \200 Swallowing problems. \200 Gastro-oesophageal re \202 ux disease. \200 Constipati on. \200 Urinary tract and other infections. \200 Epilepsy. \200 Mental health proble ms ( i incidence of depression, anxiety disorders, schizophrenia, delirium, and dementia), with speci \201 c syndromes having their own particular associations (eg Down \200\231s is associated with depression and dementia; Prader \200\223Willi with affective psychosis). Behavioral problems (eg Prader \200\223Willi, Angelman syndrome). Leading causes of death T hese include pneumonia (relating to re \202 ux, aspiration, swallowing, and feeding proble ms) and congenital heart disease. The patient \200\231s perspective Past experiences of hospital are likely to have a big imp act on the patient \200\231s reaction to his/her current situation. Most patients have prob lems with expression, comprehension, and social communication. They \201 nd it dif \201 cult to describe symptoms \200\224 behavioral change may the best indication that somethin g is wrong. Tips for communication \200 Explain the consultation process before starting. \200 Spea k \201 rst to the patient, then to the carer. \200 Use open questions, then re-phrase t o check again. \200 Aim to use language that the patient understands, modifying this according to comprehension. Patients may have dif \201 culties with time, so try to relate symptoms to real life temporal events (eg \200\230did the pain start before lunch? \200\231) They may not make a connection between something that they have done and feeling ill (eg se veral questions may be required in order to establish that they have ingested something). Take particular note of what the carer has to say \200\224 information from someone who knows the patient well is invaluable. 22 CHAPTER 1 General approach Patient transfer The need to transfer When patients have problems that exceed the capabilit ies of a hospital and/or its personnel, transfer to another hospital may be needed. Timing the transfer Do not commence any transfer until life-threatening problems have been identi \201 ed and managed, and a secondary survey has been completed. Once the decision t o 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 intu bation 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 \201 xed wing transf er. Consider the need to insert a urinary catheter and a gastric tube. Arranging the transfer Speak directly to the doctor at the receiving hospital. Provide the following details by telephone or telemedicine link: \200 Details of the patient (full na me, age, and date of birth). \200 A brief history of the onset of symptoms/injury. \200 The pre-hospital \201 ndings and treatment. \200 The initial \201 ndings, diagnosis, and treatment in the ED and the response to treatment. Write down the name of the doctor responsible for the initial reception of the patient afte r transfer. Establish precisely where within the receiving hospital the patient is to be ta ken. 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. Preparing for transfer Transfer team 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 durin g transfer. Equipment \200\230Transfer cases \200\231 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 \200\230Airway \200\231, \200\230Breathing \200\231 and \200\230Circulation \200\231 (ABC) during transfer. In particular, take at le ast twice the amount of O 2 estimated to be necessary (a standard \200\230F \200\231 cylin der contains 1360 L of O 2 and will therefore last <3hr running at 10L/ min). Before leavin g, ensure that the patient and stretcher are well-secured within the ambulance. Send all cr oss-matched blood (in a suitably insulated container) with the patient. 23 PATIENT TRANSFER Monitoring during transfer Minimum monitoring during transfer includes ECG monitoring, puls e oximetry, and non-invasive BP measurement. If the patient is intubated and ventilated, en d-tidal carbon dioxide (CO 2 ) monitoring is mandatory. An intra-arterial line is recommend ed, to monitor BP during the journey. Make allowances for limited battery life on long tran sfers: spare batteries may be needed. Plug monitors and other equipment into the mains supp ly whenever possible. Accompanying documentation Include the following: \200 Patient details : name, date of bi rth, address, next of kin, telephone numbers, hospital number, GP. History, examination \201 ndings, and results of investigations (including X-ray \201 lms). Type and volume of all \202 uids infused (including pre-hospital). \200 Management including drugs given (type, route, and time of administration), practical procedures performed. Response to treatment, including serial measurements of vital signs. \200 Name of referri ng and receiving doctors, their hospitals, and telephone numbers. Some departments use standard forms to ensure that important information is complete. The relatives Keep the patient \200\231s relatives informed throughout. Explain where and w hy the patient is going. Document what they have been told. Arrange transportation for rela tives to the receiving hospital. Before leaving Prior to transfer, re-examine the patient. Check that the airway is protecte d, ventilation is satisfactory, chest drains are working, IV cannulae patent and well secur ed, and that the spine is appropriately immobilized, but pressure areas protected. Ensure t hat the patient is well-covered to prevent heat loss. Inform the receiving hospital when th e patient has left and give an estimated time of arrival. After leaving Communicate to the receiving hospital the results of any investigations that become available after the patient has left. Contact the receiving doctor afterwards to con \201 rm that the transfer was completed satisfactorily and to obtain feedback. Intra-hospital transfers In many respects, the only difference between intra- and inter-hos pital transfers is the distance. The principles involved in organizing a transfer are the s ame, whether the patient is to be conveyed to the computed tomography (CT) scanner down the corridor, or to the regional neurosurgical unit miles away. 24 CHAPTER 1 General approach Breaking bad news A proportion of patients presenting to the ED have life-threatening condi tions and some will die in the department. Often, the event will be sudden and unexpected b y family and friends. It may already involve other family members (eg in the context of a r oad traf \201 c collision). In contrast to hospital inpatients or those in general practic e, 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 \201 rst aid. It is inappropriate for junior hospital staff without suitable experience to speak with dis tressed or bereaved relatives. The task must be undertaken by someone with suf \201 cient seniority and authority, who also has the skills of communication and empathy. The most imp ortant component is time. Reception Relatives usually arrive separately and after the patient. Anticipate this by des ignating a member of staff to meet them and show them to a relatives \200\231 room, which s hould afford privacy, comfortable seating, an outside telephone line, tea, coffee, and toil et 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 \200\231s condition and assist in building (a n albeit short) relationship between staff and relatives. The link nurse should also check that important details have been recorded correctly, eg the patient \200\231s name, address , date of birth, religion (in case last rites are required), next of kin (name, relationshi p to patient, address and phone no.), and the patient \200\231s GP. This information should be collected as soon as possible, since later the relatives may be too upset to remember a ll these details or it may be dif \201 cult to ask for them. Breaking the news Irrespective of who performs this task, remember a number of points. If y ou are the person who informs the relatives, ensure the link nurse is with you. After leavi ng the resuscitation room or clinical area, allow a minute or two of preparation to make yo urself presentable, checking clothing for bloodstains, etc. Con \201 rm that you know the patient \200\231s name. Enter the room, introduce yourself, and sit or kneel by the relativ es so that you are at their physical level. Ensure that you speak with the correct relative s and identify who is who. Speak slowly, keep your sentences short and non- technical. Do n ot hedge around the subject. In their emotional turmoil, relatives very often misconstrue i nformation. Therefore, you may need to re-emphasize the important aspects. For many critically ill patients, their ultimate prognosis cannot be deter- mined 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. 25 BREAKING BAD NEWS If the patient has died, then use the words \200\230death \200\231 or \200\230dead \200 \231. Do not use euphemisms such as \200\230passed away \200\231, or \200\230gone to a be tter place \200\231. After giving the news, allow relatives a few minutes to collect their thoughts and ask ques tions. In some cases, these may be unanswerable. It is better to say \200\230we don \200 \231t yet know \200\231, 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 dif \201 cult to come to t erms with, and relatives may torture themselves with the idea that if only their actions ha d been different, the situation would never have arisen, or the clinical outcome would have been different. Relatives seeing patients Many relatives wish to see or touch their loved ones, however bri e \202 y. Television and cinema have prepared much of the population for the sights and so unds in the ED. In some departments, relatives are encouraged to be present in the resuscit ation room. In selected situations the stratagem has bene \201 ts. If the relatives are pr esent during resuscitation, it is essential that the link nurse is present with the relativ es 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 brie \202 y o r while they are leaving the ED (eg to go to CT scan room or theater). Even a few seconds, a few words, and a cuddle can be immensely rewarding for both relative and patient. The lin k nurse can give guidance beforehand as to the presence of injuries (especially those invol ving the face), monitors, drips, and equipment, to diminish any threatening impact that the se may have. When death occurs Even before death has occurred, involvement of religious leaders is valua ble. 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 rela tives in this fashion. Remember that followers of some faiths, such as Muslims and Hindus, have important procedur es 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 Cor oner \200\231s or Procurator Fiscal \200\231s of \201 cer, and obtain help from an appropr iate religious leader to look after the bereaved relatives. 26 CHAPTER 1 General approach What to do after a death Who to contact Any suspicious death must be immediately reported t o 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 poss ible: \200 Informing the next of kin : if the relatives are not already present in ED, it may be necessary to ask the Police for assistance. \200 Notifying the Coroner (Procurator Fiscal in Scotland). \200 Informing the patient \200\231s GP. \200 Canceling hospital outpatient appointments. \200 Informing social work and health visitor teams as appropria te. Ensure deceased \200\231s relatives are given information about the process for death c erti \201 cation and registration, and how to organize funeral arrangements. Most EDs have useful lea \202 ets that cover these matters and can answer many questions. Some departme nts have formal arrangements for counseling after bereavement. Often the GP is the best ind ividual to co-ordinate bereavement care, but in any event, give the relatives a telephone n umber for the ED so they can speak to a senior nurse or doctor if they need further informa tion or help. Information for the Coroner or Procurator Fiscal Report sudden deaths as soon as possible t o the Coroner (in Scotland the Procurator Fiscal). It is helpful to give the following info rmation if it is available: \200 Patient \200\231s name, address, date of birth. \200 N ext of kin (name, relationship, address, phone no.). \200 Patient \200\231s GP. \200 Da te and time of patient \200\231s arrival in the ED. \200 Date and time of patient \200 \231s death. \200 Name and job title of doctor who pronounced death. \200 Details of th e incident, injuries, or illness. \200 Relevant past medical history. \200 When the pat ient last saw a doctor (the Coroner may be happy for a GP or hospital doctor to write a dea th certi \201 cate if they saw the patient recently for the condition that caused death, e g a patient with known terminal cancer). The patient \200\231s religion : some faiths may wish to arrange burial before the next sunset, but this may not be feasible after a sudden death. Anything else that is important, eg dif \201 culties in communication with the next of kin due to language or deafness. 27 WHAT TO DO AFTER A DEATH Looking after the staff 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 ev ent reminds staff of their own situation or relatives. These episodes often occur at the bu siest times and when everyone in the ED is working under pressure. One of the most dif \201 cult situations is to have to inform parents of the death of thei r child and help them in the initial grieving process, and then return to the busy departme nt where many people are waiting with increasingly strident demands. It would be easy to re spond 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 con \202 ict and is unfair to all concerned. Instead, take 5 \210\222 10min for a break in the staff room before ret urning to the fray. Remember that in these circumstances you too are a patient. Even senior and experienced staff may be distressed after dif \201 cult resuscitation situations and may require support. Organ donation There is considerable potential to assist with the process of organ/tissue d onation 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 corne al 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 ventilate d (eg following massive subarachnoid hemorrhage) may be identi \201 ed as potential donors of other tissues also. Consider the possibility of organ donation in patients who die in t he ED or who are moribund with no hope of survival. Most hospitals have specialist organ do nation nurses (previously known as \200\230donor transplant coordinators \200\231) who wil l educate, advise and assist with the process of organ donation. Useful information about o rgan/tissue transplantation is available on the website of the British Transplantation Soci ety (www.bts. org.uk). 28 CHAPTER 1 General approach Medicolegal aspects: avoiding trouble Medicolegal problems are relatively common in the ED. Many of these problems may be avoided by adopting the correct approach. Attitude Be polite and open with patients. Try to establish a good rapport. Be as honest as possible in explaining delays/errors. Consent (see General Medical Council guidance) Use the consent form liberally for anything that is complex, risky, or involves sedation or general anesthetic (GA). Ensure that the patient understands what is involved in the proce dure, together with its potential bene \201 ts and risks. Whenever possible, attempt to ob tain consent from parent/guardian in minors, but do not delay life-saving treatment in orde r to obtain consent. Documentation ( b Note keeping, p.4) Good notes imply good practice. K eep careful notes, using simple, clear, unambiguous language. Write your name legibly and d ocument the time that you saw the patient. Remember that successful defense of a medical ne gligence claim may depend upon accurate, legible, comprehensive, contemporaneous notes. Try to avoid abbreviations, particularly where there is room for confusion. In particular, nam e the digits of the hand (thumb, index, middle, ring, and little \201 ngers) and specify right or left by writing it in full. Be meticulous in documenting the nature, size, and position of any wounds ( b p.402). Write down a diagnosis, together with a full interpretation of any investigations. Ensure that a ll attached documents (nursing observations, blood results, ECG) are labeled. Document all instructions and advice given to the patient, together with any follow-up arrangements made . Referral ( b Discharge, referral, and handover, p.8) Always seek senior help or refer tho se patients with problems beyond your knowledge or expertise. Record any referral made, tog ether with the name and grade of the doctor referred to, the time it was made, and a summar y of the facts communicated. After referral, be cautious about accepting telephone advice a lone \200\224 an expert cannot usually provide an accurate opinion without seeing the pati ent. Return visits 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 dissatis \201 ed. Do not automatically rely upon previous diagnosis and X-ray interpretations as bei ng correct \200\224 treat the patient as if they were attending for the \201 rst time. T ry to involve the consultant in these cases. 29 MEDICOLEGAL ASPECTS: AVOIDING TROUBLE Discharge against advice Always attempt to persuade the patient to accept the treatment off ered, but if this is refused, or the patient leaves before being seen, ask the patient to s ign an appropriate form. Patients not deemed competent (see Mental Capacity Act below) to m ake this decision may need to be held against their wishes \200\224 seek senior help with this. Write full notes explaining what happened. Mental Capacity Act (b p.629) The Mental C apacity Act 2005 outlines how a person is unable to make a decision for himself if he/she i s unable to: \200 Understand the information relevant to the decision. \200 Retain the information. \200 Use or weight that information as part of the process of making the decision. Communicate his/her decision. A patient lacks capacity if at the time he/she is unable to m ake 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. Access to records All ED staff should bear in mind that patients may gain access to their m edical records and read what has been written about them. Patients in the UK have a statuto ry 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 \200\231s legal department. Medical defense organization Join a medical defense organization. The Medical Defense Union (MDU), MDDUS, and Medical Protection Society provide professional indemnity cover for emer gencies 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 Fisca l, support at inquests or fatal accident inquiries, allegations of negligence, legal action s, and problems with the GMC. They also provide members with useful information and booklet s about consent, con \201 dentiality and other issues. Further information www.the-mdu.com/hospital www.mddus.com www.medicalprotection.org 30 CHAPTER 1 General approach Medicolegal aspects: the law Con \201 dentiality Medical information about every patient i s con \201 dential and should not be disclosed without the patient \200\231s consent. In t he UK the police do not have routine access to clinical information, but some information m ay be divulged in certain speci \201 c circumstances: \200 The Road Traf \201 c Act (19 72) places a duty on any person to provide the police, if requested, with information that might lead to the identi \201 cation of a vehicle driver who is suspected of an offense un der the Act. The doctor is obliged to supply the person \200\231s name and address, but not clinical information. \200 Suspicion of terrorist activity. \200 Gunshot wounds (see w ww.gmc-uk.org ). \200 Disclosure in the public interest. The General Medical Council advi ses that this might include situations where someone may be exposed to death or serious inj ury (eg murder, rape, armed robbery, child abuse). Although this may provide ethical permis sion for the doctor to reveal details without consent, it does not place him/her under any legal duty to do so. Discuss these cases with your consultant and/or your medical defense o rganization. (General Medical Council (GMC) advice: www.gmc-uk.org ). Ability to drive A patient \200\231s ability to drive may be impaired by injury (especially limb or eye), by drugs (eg after GA, opiates, alcohol) or medical conditions (eg TIAs, epi lepsy, arrhythmias). In each case, warn the patient not to drive and ensure that this warni ng 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 \201 tness to drive see: www.dft.gov.uk/dvl a/medical/ataglance.aspx Police requests for blood alcohol In the UK, the police may request a blood or urine sample under Section 5 of the Road Traf \201 c Act (1988) from a patient they suspect to have be en in charge of a motor vehicle with an illegal blood alcohol level ( > 80mg/100mL). In suc h circumstances, specimens should only be taken if they do not prejudice the proper care an d treatment of the patient. The relevant specimens should only be taken by a police surgeon (clinical forensic physician) and with the patient \200\231s consent. A change in the law (Police Reform Act 2002) also allows a police surgeon to take a blood s ample from an unconscious patient who is suspected of having been the driver of a motor veh icle while under the in \202 uence of alcohol and/or drugs. The blood sample is retained a nd tested later, depending upon the patient later giving consent. Again, only permit the po lice surgeon access to the patient if this will not delay or prejudice proper care and trea tment of the patient. 31 MEDICOLEGAL ASPECTS: THE LAW Reporting deaths to the Coroner (or Procurator Fiscal) Many deaths that occur in (or in tra nsit to) the ED are sudden and unexpected, and/or follow trauma. The exact cause of death i s seldom immediately apparent. Accordingly, do not be tempted to sign death certi \201 cat es. Instead, report all deaths to the Coroner (the Procurator Fiscal in Scotland). See b p. 26 for details of the information required. Police statements Do not provide information to the police until patient consent has been o btained. 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 outc ome. List injuries using both medical and non-medical language, explaining terminology in d etail as necessary. State the investigations and treatment provided as accurately as possib le (eg what sutures and how many were used). Having written the statement, ask your consult ant 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). Havin g checked it, sign and date the statement, and give it to the of \201 cer concerned. Alway s keep a copy of the statement and the ED notes, so that they are easily available if you a re called to court. Court appearances In advance Discuss the case with your consultant, and review the notes, t he questions that you might be asked, and the likely court procedures. Get a good copy of t he notes and any investigations. Ask whether you should take the original records to court. On the day Dress smartly, arrive early, and behave professionally. Be prepared for a long w ait, 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 af \201 rming without religious connotation. You are equa lly bound to tell the truth whichever you choose. Use the same form of address that others have already used (eg \200\230My Lord \200\231, \200\230Your Honor \200\231). Answer dire ctly and simply. Use comprehensible language, free of medical jargon. Remember that you are a professional witness, not an expert. Therefore, con \201 ne the expression of opinion t o within the limits of your knowledge and experience \200\224 if asked something outside t his, say so! Inquest/fatal accident inquiry If you are called to give evidence at an inquest (in Scotlan d, a fatal accident inquiry), discuss the case with your consultant and also with your medi cal defense society. Further information and advice about reports and appearing in court The medical defense org anizations ( b p.29) have useful advice sheets for their members about writing reports and appearing in court. 32 CHAPTER 1 General approach Infection control and prevention Staff in the ED have an important role in preventing and c ontrolling infection, which can be a serious risk to patients, relatives, and staff. Organi sms such as Staph. aureus , including MRSA ( b p.235), can readily be transmitted by contam inated hands or equipment, causing infection of wounds, fractures, and in-dwelling devices (eg catheters or chest drains). Infected blood can transmit many infections, including hepa titis B and C ( b p.239) and human immunode \201 ciency virus (HIV; b p.242). Viral gas- t roenteritis is usually spread by the fecal-oral route, but vomiting may cause widespread vi ral contamination of the surroundings and equipment, with a risk of transmission to other p atients and staff. Coughing and sneezing produces small droplets of infected secretions, which could involve v iruses such as in \202 uenza ( b In \202 uenza pandemics, avian \202 u, and swine \202 u, p.252), severe acute respiratory syndrome (SARS; b p.251), and respiratory syncytia l virus (RSV; b p.682). A nebulizer used on an infected patient may spread respiratory viru ses widely, as occurred in the outbreak of SARS in Hong Kong in 2003 which involved many ED staff. Standard precautions for preventing infection Standard precautions (also known as \200\230 universal precautions \200\231) should be used at all times and with all patients to reduce the risks of infection. Blood and body \202 uids from all patients should be treated as infected. These standard precautions include: \200 Hand hygiene Essential, but often negl ected. Decontaminate your hands before and after every patient contact, and after any activ ity that might contaminate hands, including removing gloves. Hands that are visibly dirty o r possibly grossly contaminated must be washed with soap and water, and dried thoroughly. A lcohol hand gel can be used if the hands look clean. Cover broken skin with a waterproof dr essing. Personal protective equipment (PPE) Wear suitable disposable gloves for any contact with bl ood, body \202 uids, mucous membranes, or non- intact skin. Latex gloves are widely used, but cause allergic reactions in some patients and staff, who need special nitrile gloves. Use a disposable plastic apron if there is a risk of blood or body \202 uids contaminatin g clothing. After use, dispose of it and wash your hands. Impervious gowns are needed if th ere is a high risk of contamination. Use a mask , face shield, and eye protection if blood or body \202 uids might splash in your eyes or mouth. Protection against respiratory viru ses, eg SARS or in \202 uenza requires special masks or respirators (eg FFP3), which must be \201 tted and used properly. Powered air-purifying respirators should be used for high -risk procedures such as intubating patients with serious viral infections. Safe handling and disposal of sharps Avoid handling needles directly or using hand-held nee dles. Never re-sheathe needles. Place used needles and blades immediately into a \200\230s harps bin \200\231. If possible, use safety needles and cannulae, which reduce the risk of needlestick injury. If, despite all precautions, a needlestick injury does occur follow loc al approved 33 INFECTION CONTROL AND PREVENTION procedures to minimize the risk of infection and look after the people involved (see b Need lestick injury, p.418). Managing blood and bodily \202 uids Samples of blood or other body \202 uids must be ha ndled safely, with care not to contaminate request forms or the outside of the container. F ollow local approved procedures for dealing with spillages of blood or body \202 uids: we ar suitable PPE (usually a disposable apron and gloves) and disinfect the spillage with an appropriate agent such as diluted bleach. Planning for outbreaks of infectious diseases Planning to cope with an outbreak of a seriou s infectious disease such as SARS or pandemic \202 u ( b p.252) is a considerable challen ge 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 r ooms by staff in appropriate PPE who are fully trained to minimize the risks of spreading a nd acquiring the infection. In high risk situations a \200\230buddy \200\231 system for st aff may be helpful, with each doctor or nurse being watched closely by another person to ch eck that full safety precautions are maintained. Assessment of febrile patients Hospitals in Hong Kong with experience of SARS use the FTOCC criteria when assessing febrile patients for potentially serious infectious diseases: \200 F \200\224 fever ( > 38 C). \200 T \200\224 travel history. \200 O \200\224 occupational history. \200 C \200\224 clustering of cases. \200 C \200\224 contact h istory (eg someone with SARS or avian \202 u). Similar criteria are used in the UK Health Protection Agency \200\231s algorithm: www.hpa.org.uk/Topics/InfectiousDiseases/Infections AZ/AvianIn \202 uenza/ Further information Standard precautions www.rcn.org.uk/downloads/publications/public_pub/0 02725.pdf Masks and respirators www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/SevereAcute Res piratorySyndrome/Guidelines/sars040Facemasksand respiratorsFAQ/ Pandemic in \202 uenza/avian \202 u b In \202 uenza pandemic, avian \202 u, and swine \202 u, p.252. SARS b SARS, p.251. 34 CHAPTER 1 General approach