Iatrogenic Complications of Compulsory Treatment in a Patient Presenting with an Emotionally Unstable Personality Disorder and Self-Harm.

Attempted suicide and deliberate self-harm are common and challenging presentations in the emergency department. A proportion of these patients refuse interventions and this presents the clinical, legal, and ethical dilemma as to whether treatment should be provided against their will. Multiple factors influence this decision. It is difficult to foresee the multitude and magnitude of complications that can arise once it has been decided to treat individuals who do not consent. This case illustrates a particularly complex chain of events that occurred after treating someone against their will who presented with self-harm and suicidal ideation. These consequences are contrasted with those of not intervening when similar situations arose with the same patient.

A comparison of emergency department presentations for medically unexplained symptoms in frequent attenders during COVID-19.

Medically unexplained symptoms (MUS) are those with no identified organic aetiology. Our emergency department (ED) perceived an increase in MUS frequency during COVID-19. The primary aim was to compare MUS incidence in frequent attenders (FAs) during COVID-19 and a control period.A retrospective list of FA-MUS presenting to our ED from March to June 2019 (control) and March to June 2020 (during COVID-19) was compared. Fisher's exact test was used to compare binomial proportions; this presented as relative risk (RR) with 95% confidence intervals (95%CI).During COVID-19, ED attendances reduced by 32.7%, with a significant increase in the incidence of FA-MUS and FA-MUS ED visits compared to control; RR 1.5 (95%CI 1.1-1.8) p=0.0006, and RR 1.8 (95%CI 1.6-2.0), p<0.0001, respectively.Despite reduced ED attendances during COVID-19, there was a significant increase in the incidence of FA-MUS patients and corresponding ED visits by this cohort. This presents a challenge to ED clinicians who may feel underprepared to manage these patients effectively.

Designing services for frequent attenders to the emergency department: a characterisation of this population to inform service design.

Frequent attendance to the emergency department (ED) is a growing public health concern. Designing services for frequent attenders poses challenges, given the heterogeneous nature of this group. This was a two-part observational study identifying frequent attenders from ED records. The first stage studied trends and developed personas with emphasis on differentiating moderate frequent attenders (attending between 5 and 20 times per year) and extreme frequent attenders (attending more than 20 times). Stage 2 included a case note review of 100 consecutive frequent attenders. Results showed an increase in frequent attendance from 2.59% to 4.12% over 8 years. Moderate frequent attenders accounted for 97%. Of the 100 frequent attenders studied, 45% had medically unexplained symptoms (MUS), associated with younger age (p<0.001) but not with gender (p>0.05). In conclusion, the ED is a useful hub for identifying frequent attenders with MUS, particularly among moderate frequent attenders; service design for this group should consider a 'whole-systems approach' with integration between primary and secondary care, including specialist liaison psychiatry services where appropriate.

The East Anglian specialist registrar assessment tool.

BACKGROUND: In our region, it was acknowledged that the process of assessment needed to be improved, but before developing a system for this, there was a need to define the "competent or satisfactory trainee". OBJECTIVE: To outline the process by which a consensus was achieved on this standard, and how a system for formally assessing competency across a wide range of knowledge skills and attitudes was subsequently agreed on, thus enabling increased opportunities for training and feedback and improving the accuracy of assessment in the region. METHODS: The opinions of trainees and trainers from across the region were collated, and a consensus was achieved with regard to the minimum acceptable standard for a trainee in emergency medicine, thus defining a competent trainee. The group that set the standard then focused on identifying the assessment methods most appropriate for the evaluation of the knowledge, skills and attitudes required of an emergency medicine trainee. The tool was subsequently trialled for a period of 6 months, and opinion evaluated by use of a questionnaire. RESULTS: The use of the tool was reviewed from both the trainers' and trainees' perspectives. 42% (n = 11) of trainers and 31% (n = 8) trainees responded to the questionnaire. In the region, there were 26 trainers and 26 trainees. Five trainees and nine trainers had used the tool. 93% (14/15) of respondents thought that the descriptors used to describe the satisfactory trainee were acceptable; 89% (8/9) of trainers thought that it helped them assess trainees more accurately. 60% (3/5) of trainees thought that, as a result, they had a better understanding of their weak areas. CONCLUSION: We believe that we achieved a consensus across our region as to what defined a satisfactory trainee and set the standard against which all our trainees would subsequently be evaluated. The use of this tool to assess trainees during the pilot period was disappointing; however, we were encouraged that most of those using the tool thought that it allowed an objective assessment of trainees and feedback on areas requiring further work. Those who used the tool identified important reasons that may have hindered widespread use of the assessment tool.