A clerk or nurse usually calls, who will connect you with an emergency room physician. Over the years I have noticed that the more sophisticated our communications systems become, the longer it takes to track down the emergency room physician involved. So, the first thing you want to do as soon as you are paged and answer the call, is to look for a chair.

The emergency room physician will provide his or her assessment of the problem and any out of the ordinary details, such as behavior problems from alcohol or drugs or other unusual circumstances. It is important to bear in mind that the situation you encounter on arrival may differ considerably from the description of the wound or wounds and general status of the patient. You should regard the physician’s call more as a request for assistance rather than an accurate appraisal of the defect or defects. This observation is stated not as a criticism but rather as an acceptance of the fact that we all cannot be experts in every specialty.

If you are paged in the middle of the night, it is prudent to inquire whether the patient is intoxicated. If he or she is, it is usually appropriate to let them sleep while you do the same. In the meantime, have the nurse elevate the wound, cover it with a cool, moist compress, start and IV and antibiotic and also tetanus immunization, if the latter is indicated.

If the patient is under the legal age of consent and unaccompanied by a parent or guardian, inquire how things are going as far as obtaining consent to treat.

Excessive bleeding is usually managed by the ER personnel by clamping and tying or by a pressure dressing. Bleeding from the head and neck area of oozing nature, can often be significantly ameliorated or even stopped by elevation, sedation and cool compresses. Elevation decreases venous pressure; sedation usually lower systolic pressure and cool compresses provide some vasoconstriction and pain relief.

Elevation of the injured part is critical when it comes to paper thin flaps. Patients routinely sit in the emergency waiting room for hours with the injured area dependent. The resulting edema not only complicates primary wound closure but occasionally makes it impossible. Your strongly emphasizing elevation of the wound higher than the heart, as soon as you are contacted, can significantly affect the closure process.

Airway problems are routinely managed by the ER physician or trauma surgeon. Your knowing how to expeditiously perform a cricothyroidotomy is a valuable skill in case intubation fails and time is of the essence. In a true airway emergency, tracheostomy is not the procedure of choice.

Appropriate x-rays often will have been ordered or taken by the time you are contacted. Most emergency room physicians and trauma surgeons are not aware of the fact that nasal fractures do not ossify. In the absence of signs and symptoms of recent nasal trauma, radiographic evidence of nasal bone disruption is indicative of an old fracture.

The cervical spine often is cleared by the ER personnel before you arrive. If clearance is delayed, frequently by a question of interpretation of the films, sandbag stabilization of the head following removal of the cervical collar may provide the exposure needed. In instances of lower lip and chin wounds, trimming of the upper anterior part of the collar may suffice for adequate exposure. If an unstable cervical fracture is suspected, it is prudent to delay your repair until a halo or similar surgical fixation has been done.

If the wound involves the lips or mouth, order a mouthwash of ½% hydrogen peroxide.  0.3% hydrogen peroxide is helpful in removing blood from hair but should be kept out of wounds as much as possible.

I routinely sedate patients in the ER trauma bay and prefer IV morphine unless contraindicated by history. Adults and older children can safely be sedated prior to your arrival. For patients younger than eight, I delay the sedation until I arrive. For the latter patients, it is time-saving to have the anticipated dose of morphine drawn up in advance so it can be given promptly when you arrive.

I order an IV for every patient but limit unsuccessful attempts to obtain IV access in children to two or the most three. Reverting to an IM route may involve multiple doses but one often will do the trick. The obvious advantage of an IV is that it enables one to titrate the sedation painlessly, after the IV is in place, thus avoiding repetitive IM injections. The IV also provides immediate access in case of an emergency.

When calling in orders on pediatric patients with head or neck lacerations, assuming you plan to stand during the repair, it is helpful to have the ER personnel obtain two pillows and a roll of 2-inch adhesive tape. Most gurneys are too low to make wound repair on pediatric patients convenient for the surgeon’s back. By flattening the gurney, placing the child’s head at the top of the gurney and two pillows under the patient’s thighs followed by taping of the pillows to the gurney, elevating the head of the gurney will provide reasonable elevation of the wounded area.

If instruments other than routine ones, drains or out of the ordinary dressing materials will be needed, request the emergency room to obtain them from central supply or the operating room when you are first contacted. It is important that the clerk or nurse send someone to the OR central supply to pick up the required items. Otherwise they will not arrive on time.

When ordering a moist, cool compress for a wound, it is imperative to add “no ice bag.” Otherwise, some well-meaning soul will apply an ice bag. The latter fails to keep the wound moist, often is uncomfortable because of its weight and can lead to freezing of the tissue if not applied properly. A clean washcloth or one or two 4 x 4 gauzes will usually suffice for a compress and these items will not add to the patient’s bill. A compress softens up dried blood about the wound in addition to the other advantages it provides.

Most ERs these days are family practice clinics rather than being devoted solely to the care of emergencies. Waiting times are almost routinely a matter of hours. Your appearing within a reasonable time after being contacted helps to provide evidence that the system is not completely broken. If you are tied up in another emergency room, give an estimate of the time you will arrive. Prior to leaving the other ER, it is courteous to phone the facility waiting to let them know that you are on your way.