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How to survive a placement in A&E: A student ...

How to survive a placement in A&E: A student nurse’s guide

So you want the grit and gore of A&E on your student CV? Fancy a go at CPR? Want to get involved in crash calls? Well, it’s sorta not like that. At all, really.

What’s A&E like for a student nurse?

Accident and Emergency departments (or ER/emergency room for our friends across the pond) are usually made up of several different areas:

Triage

This is where walk-in patients are assessed by a nurse, usually someone who has undergone additional training to spot warning clinical signs, and their priority is worked out. We use the Manchester Triage system, where someone coming in with radiating chest pain scored a 1 and needs to be immediately assessed, and someone else with the sniffles is given a 5 and a leaflet on how a pharmacy and monetary trade for pharmacological items works.

If needed, bloods, ECGs, pregnancy and urinalysis will be ordered.

Ambulance bay

Here, a nurse will assess patients BIBA (brought in by ambulance). For patients where the hospital has been pre-alerted – think the red phone ringing and everyone getting ready – they go straight through the resus. For everyone else, they are assessed. Sometimes they can go straight into the waiting room, sometimes they require closer observation and may head over to another observation area before their care plan is decided.

Minors

After being triaged, patients will head to minors for, well, minor illnesses. Here they may see a health care assistant, a nurse, a junior doctor or consultant, or a specially trained emergency practitioner. This is where patients will have their wounds sutured, plasters fitted, and other medical examinations too. Most patients will either head to a ward for further treatment, for example, if they require IVABX, or go home for referral to a GP or the community.

Majors

This is where patients who need closer monitoring will go. They’ll often be attached to a three lead heart monitor (Ride, Your, Green, there is no Bike), BP cuff and O2/CO2 monitor. Everything will be fed to a monitor at the nurse’s station so they can check on patients as they work.

Resus

Think septic shock, MI, pneumothorax, etc. Anything that is life-critical will go to resus.

What area’s best for a student nurse

A&E is one of those placements where even student nurses with the community in their heart can learn. If your interest is in long-term conditions, then majors is ideal. You’ll see cardio issues, so much respiratory, and lots of patients brought in from smaller cottage hospitals who don’t have the resources to manage more complex conditions. If you’re like me, and you like excitement, chaos, and being rushed off your feet, then minors is great. But wait, you say, shouldn’t I be more interested in heading to resus? Well, sure. But when there’s a 2222 call it’s busy with medical teams, and once patients are stable they’re moved fairly quickly.

Minors is a constant stream of patients with a variety of illnesses. One moment you’re assessing a patient who had no idea she was pregnant and may be experiencing a miscarriage, the next you’re holding a wound pad on someone’s lacerated arm. Nurses here are also often able to prescribe basic analgesia.

How involved can I get?

Hardly at all, actually. I’ve been more hands-off here than I’ve been in any placement area. But holy hell have the nurses I’ve worked with been incredible tutors. A good nurse, whether they’re your mentor or not, will make every patient a learning experience.

So, for example, imagine a 23-year-old patient comes into minors after a mechanical fall with a laceration to their hand. Their obs are all within range, except they were hypoxic, with their sats at a meagre 91%. This patient has no respiratory issues and has never smoked. For our non-clinical readers sats should always be above 96%, especially in someone young. You ask them to sit up, because half the time positioning is key in effective ventilation, and they do so. But they really wince when they use their left arm. You ask if they have pain and they say their ribs ache. Then it all makes sense. Can you see why their saturations are low? While the patient is breathing at a normal rate of 19-20 breaths per minute, each breath is much shallower than normal. As that’s the case, their sats are low. Think now about the complications that can arise from hypoxia. What might have happened to their lungs in the fall?

In this case, the patient actually had a pneumothorax.

See how interesting a seemingly simple case can become?

My thoughts on A&E as a student nurse

I thought I always wanted a career in emergency healthcare. But after spending four weeks in A&E, with another four to go, I don’t think it’s for me. Sure I love the fast pace. I love the team I’m working with. And the opportunity for progression and learning is incredible. But here’s where I see the impact of the closure of community hospitals. The impact of stretched district nurses and mental health crisis teams. The impact of Monday to Friday GP services with no appointments to spare.

I find it also quite difficult, and a personal challenge, when patients abuse the precious resources the already-stretched NHS has to offer. I don’t believe privatisation is the cure to these issues, but I do think there needs to be a radical change of emergency services, in some way. I feel like while learning as an NQN in A&E might be invaluable, I would suffer burnout pretty quickly.

My placement has been amazing so far. And the fact I’m writing this on the afternoon of my upcoming night shift, absolutely thrilled to guess at what I might experience and learn overnight, should show just how buzzing I am. But as for a career? I think I’ll stick to surgery.

Tips for a placement on A&E

Your mentor might be excellent but ensure you work with as many other nurses as you can, especially those trained in Italy, Spain, Portugal and the Phillippines. They are trained to a far, far higher standard than we are and often trained to an FY2 level.

Observe observe observe. Every patient is a learning opportunity.

Nail your ECGs. Understand why the leads are placed where they are, and how important a good ECG is to the medical team.

ABG is not the same as VBG. Make sure you read up on both.

A-E will be your life on placement. As will GCS. Know these. Know them.

Ask to help. Ask to get involved. I've loved taking handovers from ambulance crews and SBAR transfers. There's always something to help with, if you're willing.

Images via Shutterstock.


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