Welcome to the Emergency Department

Loma Linda University Medical Center

What should you get out of this Rotation?✤ See something cool that you won’t deal with everyday in

your chosen specialty.

✤ Learn about how Emergency Medicine interacts with the other specialty services.

✤ Appreciate some of the unique challenges and opportunities inherent to the acute care setting.

✤ Practice forming and risk-stratifying differential diagnoses.

✤ Appropriately apply diagnostic strategies to the acute workup of patients.

Why an Emergency Medicine rotation is for everybodyAlmost regardless of which specialty you are entering, you will

interact extensively with the emergency department throughout your career. This experience offers a valuable chance to learn what goes into our medical care, and understand how we can all work together to help our patients in the best way possible.

Plus, it’s really fun...

Our Expectations

Teamwork

✤ Although we see our patients in parallel, rather than in the traditional inpatient team model, you are still part of the team.

✤ Get involved in resuscitations and traumas that “belong” to the senior residents.

✤ If you hear about a procedure that you’re interested in, ask to be involved.

✤ Your patient flow and your attitude affect everyone else.

Our Expectations

Own your patients

✤ The patient is your responsibility from the time you pick up the chart until they physically leave the ED.

✤ Reexamine the patient as often as needed.

✤ Be proactive in following up on test results.

✤ If something is delayed, find out why and try to fix it.

✤ Get discharge materials ready as soon as everything else is finished.

Our Expectations

Productivity✤ You expected to see a minimum of 10-15 patients/shift depending on

your level of training (i.e., PGY-1 vs PGY-3).

✤ At times, the RIC (Resident-in-Charge) may assign you charts out of the rack to help with department flow.

✤ Expect to carry up to 4-5 undifferentiated or undispositioned patients at a time.

✤ Plan on one brief meal break per shift, and coordinate the timing with the RIC or attending physician. Due to the fluctuating number of critically ill patients that present to the ED, the timing of breaks are coordinated to optimize patient care needs.

✤ Check in with the RIC any time you need to step out of the department.

Our Expectations

Professionalism

✤ Be on time and work hard until your shift is over. Then relax.

✤ If you need to call in sick or have other issues with a scheduled shift, please contact the chief as early as possible. Our contact information is on the last slide.

✤ If you have questions about the sick policy, please ask.

Our Expectations

Patient Care

✤ Nurses may ask you too "clear this patient off a backboard"; Do not clear spines unless directly supervised by an attending.

✤ If you have a patient who is crashing or unstable, grab a senior or attending right away.

Orientation to the DepartmentWhen you arrive for your first shift, find the senior resident on duty

and ask them for a tour. They should show you:

✤ Different treatment areas/designations

✤ Supply locations, including carts and storage rooms

✤ Ultrasound machine

✤ The rack (new patients)

✤ The charge nurse and unit secretary

✤ Where to find paperwork

✤ FirstNet, including the tracking board, notes, and discharge instructions

Important People

✤ Resident in Charge

✤ Charge Nurse (55070)

✤ Techs / Unit Secretary

✤ ED Pharmacist

When you pick up a new patient✤ Take the chart highest on the rack

(do not go out of order or cherry pick!)

✤ The location is written on the colored dot

✤ Colored dots = acuity✤ Red: Dying/Critical✤ Orange: Emergent or high pain

level✤ Yellow: Urgent✤ Green: Low acuity✤ Blue: Stable

1: Assign Yourself to the Patient✤ Be sure to sign up for the patient as soon as you pick up the

chart. The associated times are logged and evaluated. If you forget and need to adjust it later, we can show you how.

2: Sign the Chart

✤ Put a provisional diagnosis at the top (ex. abdominal pain)

✤ Sign and print your name

✤ Date and time the orders

✤ Place a patient sticker at the bottom

3: See the Patient

✤ You may want to spend up to 5 minutes looking up the patient in the system.

✤ Doing the H&P interview should take no more than 15-20 minutes.

✤ Be intelligently detail-oriented. Form your list of differentials as you go, and ask the questions that pertain.

4: Present to the Attending

✤ Give them a patient sticker

✤ Tell the room number and the patient’s basic information

✤ Be concise and organized in your presentation

✤ Formulate a differential and plan together

✤ Try to be proactive with your decision making. Don’t just ask what they want you to do.

✤ Order labs and imaging as agreed upon with the attending

5: Communicate

✤ Give orders to the tech in the patient’s area to be placed in the computer.

✤ Contact Radiology if necessary (usually nights and weekends)

✤ Discuss the plan with the patient and with their nurse.

✤ Keep the patient's nurse and the charge nurse informed about pending admissions and discharges.

6: Disposition

✤ Once you have all your data back, and you have reassessed the patient, recheck with the attending regarding a consult or discharge.

✤ For Admissions: Click the ‘ED MD Admit’ box to log the time as soon as you decide the patient warrants admission. Note that this isn’t necessarily the same as the time you actually call a consult.

6: Disposition

For consults:

✤ Ask the unit secretary to send the page. When they do, they should also start the appropriate timer. It’s still your responsibility to double-check that it happens.

✤ For MOD admissions, have the attending send a page, and mark the consult timer yourself.

6: Disposition

For consults:

✤ Be concise and specific.

✤ Every call should involve a clear question or reason why the patient requires their care.

✤ Provide them with the pertinent details to frame your question.

✤ Decide with the attending before calling as to who the appropriate consulting service will be.

6: Disposition

For discharges:

✤ You write discharge instructions by accessing ‘Patient Education’ in the tracking board.

✤ Select the most appropriate one(s) using the search boxes. Make sure you include an "ED Transition of Care Record."

✤ On the first line, type in whatever instructions you specifically want them to follow. This includes when to follow up, phone numbers to call, pending results, and precautions.

✤ Print the instructions, a work or school note if needed, write and attach any prescriptions, and have the attending sign them.

6: Disposition

6: Disposition

For discharges:

✤ When discharging a patient, avoid open ended instructions (return if you’re not feeling better). Instead, always give a specific date, place, and reason to follow up (Call your primary doctor in 2 days if you’re still vomiting). Leave it to them to decide if they actually want to follow the instructions.

Supervision

✤ You may write orders for pain meds as appropriate before chiefing with an attending.

✤ Present to the attending before ordering all other labs, imaging, etc. Some standard order sets may be started by the nurses before you get the chart.

✤ Avoid seeing a new patient until the previous one is staffed and in progress (at least for the beginning of the month)

✤ A senior resident or the attending is always available to supervise any procedure which you aren’t comfortable doing on your own.

Charting

✤ If there is no scribe, you are responsible for the full note. Choose “ED H&P” as the note type, and remember to send it to the attending for a signature.

✤ If there is a scribe present, choose “ED Resident” as your note type. These do not need to be sent to the attending for a signature unless they specifically ask you to.

✤ The addendum should focus on your medical decision making. It is your chance to summarize the pertinent details of the patient’s history, mention the differential diagnoses you considered, and explain how the course of the workup led you to your final diagnosis and/or disposition. Tell the story and make your case.

Medical Students

✤ Although medical students will chief their patients only to EM senior residents, they are still encouraged to learn from your patients as well. Please keep them in mind if you have any interesting cases, exam findings, imaging, etc.

Signout

✤ Signouts are a high risk time for emergency medicine, and giving good signout is a skill that takes practice. You may experience a bit of a learning curve; that’s normal. (And if the senior residents seem picky, it’s just because they’ve learned from previous mistakes)

✤ To help minimize those risks, we have a formal signout checklist on the program website, which we are asking you to use.

✤ Here are some of the highlights…

Signout

During the last hour of your shift, you should:

✤ Finish all minor procedures

✤ As a rule LPs, lac repairs, reductions, disimpactions, I and Ds, rectal exams, pelvic exams, etc., should not be signed out.

✤ Check for recommendations or admission orders for all patients awaiting consultation. Call the consultants again if necessary.

Signout

During the last hour of your shift, you should:

✤ Update all your patients and their nurses about the current plan, and tell them which doctor will be taking over for you when you leave.

✤ Take some time to work on your notes.

✤ For patients awaiting transfer to an outside facility (Kaiser, BMC…) you must complete the note before you leave.

✤ All notes must be completed within 24 hours.

Signout

During the last hour of your shift, you should:

✤ Formulate a final plan with the attending

✤ If [blank] is positive, then …

✤ If [blank] is negative, then …

✤ If patient will be admitted regardless of pending tests, go ahead and call the admitting team (even if all the labs/test aren't back)

✤ Prepare discharge and prescriptions for patients who will likely be discharged

Signout

✤ Print out a list of your patients for the oncoming resident.

✤ At the end of your shift, sign out to the senior resident who started most recently.

✤ Your sign out must include every patient still physically in the department, even if they are admitted, discharged, or have a consult pending.

✤ Bedside rounds are at the oncoming resident’s discretion, and recommended for potentially unstable patients.

Signout

✤ Use the following template to review each patient:

✤ D isposition (Admit/discharge/pending and sick/not sick)

✤ A ssessment (Brief history with a working diagnosis and relevant findings)

✤ D iagnostics pending (Labs, Imaging)

✤ S pecial Concerns (any potential issues that may arise with a specific patient)

✤ If you sign out pending diagnostics, be sure to communicate what to do in case of the various foreseeable potential outcomes.

✤ i.e., it’s not enough to say “if the CT looks normal, the patient can go.” Which kinds of abnormal are you worried about? If it’s abnormal, what’s your plan for the next steps?

How We Think

✤ Depending on your background and level of experience, you probably have developed your own way of thinking about each medical encounter that works for your specialty.

✤ There are some unique aspects of Emergency Medicine that affect our cognitive approach, which we expect you to appreciate during this rotation.

✤ Here are some of the most essential points:

How We Think

Emergency Medicine Treatment and Active Labor Act (EMTALA)

✤ Places a responsibility on hospitals to stabilize anyone with a potential ‘emergent medical condition’ regardless of ability to pay before other transfer or discharge can be considered. This is a big factor behind our ‘worst first’ mindset.

✤ The exception is a transfer for “higher level of care.” This means that although an emergent medical condition still exists, the sending facility is not capable of appropriately stabilizing it.

✤ You could fill entire legal libraries with what has been written about EMTALA attempting to define its’ intricacies. You only need to come away from this rotation with a basic understanding of it.

✤ The bottom line: the ED is the front line for all things EMTALA

How We Think

Tests: the intelligent approach

✤ What are the pros/cons/sensitivity/specificity of each test I’m ordering?

✤ What are the risks of the tests?

✤ How will the results (either positive or negative) affect my subsequent management?

✤ Are there any tools that can potentially help me avoid performing the test?

How We Think

✤ Although we commonly talk about “ruling out” and “diagnosing” diseases, it’s not really that simple. Every decision is really a matter of risk stratifying within the limits of the information and testing that we have available.

✤ As an example, do we ever “rule out” a PE? No, we just reach a point when the likelihood falls below the ability of our tests to further evaluate it.

✤ In Emergency Medicine it’s not always possible to make the final diagnosis due to the limitations of available studies that can be performed within a short timeframe. Other patients are waiting to be seen, many with potentially life threatening pathology.

✤ Our primary goal in EM is to evaluate and treat the immediately life threatening or disabling diseases and disposition the patient for further care.

How We Think

When we first see a patient, here are the basic questions that we have to address:

✤ Is this patient sick or not sick?

✤ Is this someone who obviously warrants admission, obviously will go home, or isn’t clear?

✤ What are the high mortality/morbidity diagnoses that COULD account for the patient’s presentation? Remember to think “worst first,” rather than by most likely.

✤ If the patient doesn’t end up having any of those, what will their follow up arrangement be? What are the next steps that you should anticipate?

How We Think

✤ When you see a patient, use your gestalt assessment to help you form a broad differential

✤ Direct your questioning towards those possibilities

✤ Refine and reprioritize that list as information comes back...

✤ ...until the patient is appropriately risk stratified and dispositioned accordingly.

Other Rules of Thumb

✤ Here are a few more random things that will help make your month go more smoothly:

RME (Rapid Medical Evaluation)✤ You’ll notice that some charts already have orders marked

and in progress, even though you just picked the chart up out of the rack

✤ Sometimes nurses work off of protocols (chest pain, abdominal pain)

✤ Other times a PA, NP, Senior Resident, or Attending may start a basic workup from triage to help expedite their care

✤ You still are responsible for that patient the same as for any other chart you pick up

ED Observation Unit

✤ Ideal for patients who need up to 24 hours to make a dispo decision

✤ You must have a specific end-point in mind. Examples include:

✤ A patient the needs some time to declare themselves (dehydration, allergic reaction)

✤ A patient waiting on a specific therapy (Clindamycin IV x3 prior to discharge, or low risk chest pain waiting on enzymes)

✤ There are three forms that you need to fill out:

✤ Order forms (specific to the observation diagnosis)

✤ Abbreviated History & Physical

✤ Discharge Form (you only have to fill out the first section)

✤ Give the forms to the unit secretary after the attending has signed them. Don’t forget to mark the ED/MD Admit box on FirstNet.

Checking Order Status

✤ A magnifying glass on the tracking board means that everything you ordered is back.

✤ To check the status of individual orders, right click on the corresponding box on tracking screen:

✤ Dispatched: sample not in lab. Check with the nurse to see what problem may be

✤ In-lab: lab has sample and running sample

✤ Complete: sample done

Checking Order Status

Radiology

✤ Read all your own X-rays and CTs, even if you don’t trust yourself without the radiology report. (at least LOOK at them)

✤ For any studies besides X-ray and CT, you need to page the radiology resident covering that service to finalize the order. Their call list is posted.

✤ This doesn’t apply to ultrasounds on weekdays from 8a-5p.

Resources

✤ LLUMC Chief Resident: Matt Barden, MBarden-9126

✤ RCRMC Chief (LLUMC Backup): Michelle Iwaki,miwaki/9420

✤ Scheduling: Sha Brennon SBrennan@llu.edu

✤ EM Department Office: Kathy Haimson and Ruby Navarro

✤ 558-4344, 558-4085