Emergency medicine intern survival guide

The ED is where you’ll first see undifferentiated patients on your own: people who arrive with a symptom, not a diagnosis. It’s the steepest learning curve of the year, and for many juniors one of the best.

What the ED does

The ED is the hospital’s front door. People arrive by ambulance, on foot and with letters from their GP. Your job is to work out what’s wrong, start treatment, and decide where they go next: home, a short stay, an inpatient bed, or another hospital. The ED decides where people go. It doesn’t keep them.

Since 2024, an ED term hasn’t been compulsory for interns, but it’s a common way to cover undifferentiated illness patient care, one of the four clinical experiences every first-year doctor needs. Terms last at least 10 weeks.

The areas: resus, acute and fast track

The board is the department’s brain. It shows who’s waiting, how long they’ve waited, their triage category and who’s looking after them. Most EDs are split into areas, and you’ll work in several of them over a term:

• Resuscitation: the sickest patients. You’ll help here, with a senior leading.
• Acute or cubicles: most adult patients on trolleys. Much of your work is here.
• Fast track: walking patients with injuries and simpler problems.
• Paediatrics: children, often in their own area with their own team.
• Short stay unit: patients who need a few more hours of treatment or observation before a decision.

Picking up your next patient

When you’re free, take the next patient in your area by triage category, then by waiting time. Don’t pick the one with the most interesting complaint. Put your name on the board before you walk to the bedside. An unclaimed patient is an unseen patient.

Read the triage note and check the observations, then go and look at the patient. In the ED, how someone looks from the end of the bed often tells you more than the referral letter.

When you call your senior or refer to another team, use ISBAR: there are worked examples here.

Working with the nurses

The nurse in charge runs the floor and the flow. Tell them every disposition decision. The triage nurse decides who’s seen first, and your patients’ bedside nurses see them far more than you do.

You earn their confidence in the ED by telling them the plan before you leave the cubicle, and saying what you’re waiting for.

Where will this patient go?

You propose the disposition; your senior agrees it. Prepare for each option before you present. For home, have a safety-net and follow-up ready. For short stay, know what you’re waiting for and when you’ll decide. A short stay unit is for problems likely to settle within about 24 hours, usually in a patient with one active problem rather than several. For admission, have a clear reason for admission and a plan. For a referral, have a clear question for the inpatient team.

Your department will have rules about which discharges need a senior review. Learn them in your first week.

Your first week, by shift

First shift: get oriented. Do the department orientation, and get every login working. Seeing patients is the best way to orient yourself, so see your first ones alongside a senior and present each one. Don’t be afraid to ask peers and seniors how the mechanics work, such as ordering tests and making referrals.

Shifts 2 and 3: work alone, with a safety net. Pick up lower-acuity patients on your own, and present every one before they leave. Watch how your seniors present, document and refer.

Shifts 4 and 5: take the full mix. Pick up patients in triage order, whatever the complaint. Aim to finish your last hour with a clean handover.

Your first night shift: fewer seniors are on the floor, and you’ll be more tired. Find out who’s in charge overnight, and speak to them early. Plan your sleep and your trip home before you start.

Results that come back after the patient has left

It’s normal for formal imaging reports and some pathology results to come back after a patient has gone home. Sometimes they show something new. That isn’t always a miss: it’s part of how the system works, and part of the conversation with the patient is explaining that.

You can prepare patients for it. Before they leave, tell them: “A formal report will come back later, and you’ll get a call if it shows anything different.”

When a result does change things:

1. Tell your senior straight away.
2. Contact the patient through your department’s recall process, and arrange what they need.
3. Document what happened and what you did, factually.
4. Be open with the patient. Explain what the result shows and what happens next. If something was missed, patients have a right to an honest explanation and an apology. This is called open disclosure, and your senior will usually lead it.
5. Report it through the incident system if care fell short, and learn from it.

Signs you’ve found your feet

• You pick up the next patient without scanning the board for an easy one.
• You present with a plan, and your senior mostly agrees with it.
• You know who to call for what.
• Your handovers are short, and nothing comes back to you.