Yuen’s yap 5/4/17 – Decision-making, dyspnoea, paediatrics, virtual fracture clinic

Summary of registrar teaching 5/4/2017
For DEMTs Ruth Hew and Terence Yuen


To Lucy Selleck and Alyza Gossat for passing the primary exam and Steven Lee and Deb Maher for passing the fellowship exam written component.


To DEMT Terence and Jenny Yuen for arrival of their son Archer.


Decision making under pressure

Registrar Amar Winayak presented a case of inferior STEMI with cardiogenic shock and discussed its time critical decision points. Of note:

  1. there are numerous means to gain circulatory access (peripheral IV, intra-osseous, central venous), each with pros and cons – be familiar with all modes as you may need to try all
  2. don’t forget external jugular veins for peripheral access
  3. ED must initiate STEMI calls to cardiology early and advocate appropriately for each individual patient

Dyspnoea in ED

Consultant Keith Nallaratnam presented a few cases of dyspnoea in ED which highlighted:

  1. thrombolysis in submassive PE is a thorny and complex issue without clear scientific consensus, but thrombolysis probably has minimal major risk and should be considered
  2. a new anticoagulation treatment protocol for PE is likely to appear for Western health soon which will suggest unfractionated heparin rather than low-molecular weight heparin (clexane/enoxaparin)
  3. bedside ECHO is a very useful test in ED for diagnosis of PE (right ventricular distension/strain) and pericardial effusion

Virtual fracture clinic

Senior physiotherapist Narelle Watson presented on the incoming Virtual Fracture Clinic which begins April 18th and is a new intermediary triage process between ED and the orthopaedic fracture clinic.

  1. Ward clerks are still to make fracture clinic appointments but patients will now receive a phone call from the virtual fracture clinic practitioners informing them of the next clinical step
  2. Clinical practice should not change because of this new process
  3. Please ensure notes are complete including patient social information like occupation, handedness, primary language and correct phone number as well as any discussions with orthopaedic teams
  4. patients should be given an information sheet abou the fracture clinic which will be available


Consultant David Krieser presented a series of excellent cases highlighting, amongst other things, fixation error, open disclosure and cannulation in children.

His tips for cannulation include

  1. remove the end of the cannula and flush with saline as it reduces the pressure differential and makes it more likely for you to see venous flashback
  2. veins are better felt than seen
  3. consider the use of butterfly or broken needles in venepuncture

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