alina tsyrulnik md clinical instructor assistant residency program director off-service resident...
TRANSCRIPT
ALINA TSYRULNIK MDCLINICAL INSTRUCTOR
ASSISTANT RESIDENCY PROGRAM DIRECTOROFF-SERVICE RESIDENT DIRECTOR
DEPARTMENT OF EMERGENCY MEDICINEYALE UNIVERSITY SCHOOL OF MEDICINE
Welcome to ED Orientation
PREPARE OUR OFF-SERVICE ROTATORS FOR PATIENT CARE IN THE ED FROM THE
MOMENT THEY START THEIR ROTATION
Goal of this Orientation
Objectives of this Orientation
Logistics of working in the ED Your ED team Observations vs. Admission EPIC details
Admission/ Discharge Note completion
High- Yield Emergency Medicine Topics Cardiac Chest Pain
ACS: STEMI vs. NSTEMI Low/ Moderate risk CP
Anaphylaxis Trauma
Backboard clearance C-spine precautions and clearance E-FAST exam
Intoxicated Patient Psychiatric Patient
Medical Clearance
LOGISTICS OF WORKING IN THE ED
ED Layout
Section A: Highest Acuity- open 24/7 2 resident teams
Green: 9 beds +2 resuscitation bays Purple: 10 beds + 2 resuscitation bays
Staffing: 2 attendings 9am-1am (1 attending 1am-9am) Senior Resident Supervision
Trauma: All trauma patients that go to resuscitation bays are designated as “full” or “modified” trauma Off-service residents are not responsible for taking care of “modified” or “full” trauma Off-service residents are responsible for trauma patients that don’t meet “modified” or “full”
trauma criteria
Section B+C: Lower Acuity- open 24/7 (as of July 1 2014) May still get trauma patients that are not “full” or “modified” traumas Staffing
At least 3 resident/PA teams in each section during the day (down to 3 total teams overnight) supervised by an attending+/- senior resident
Senior resident present at high volume times
TRIAGE IS NOT A PERFECT SCIENCE- APPROACH EACH PATIENT AS IF THEY COULD BE VERY SICK
ED Layout- Other areas of Interest
Patient entrances/ triage/ registration areas: Ambulance Waiting Room
Central Communications Desk (a.k.a. “the bubble”) Located at the ambulance entrance All calls/ faxes Location of Medtronic Pacemaker interrogation equipment
Intoxication Observation Unit (IOU) Located in hallway behind Section C Staffed by an ED tech
Crisis Intervention Unit (CIU) = Psychiatric ED Separate unit staffed by psychiatry residents, attendings, nurses,
techs Chest Pain Center (CPC)
Separate ED observation unit for low/moderate chest pain patients Staffed by B-side attending, PA (during working hours), nurse, tech
Your team:
Attendings Supervise multiple teams simultaneously 24/7 in-house coverage for every section of ED
Senior ED Resident Not available on every shift
ED Nurse ED Technician Business Associate (BA)
Your ED shift: Arrival and Sign-out
Arrival: at least 5 min. prior to scheduled time B+ C sides: divide patient beds among providers
Sign-out: 2-part process Off-going senior resident or attending presents patients in bed-
order to the in-coming team Part one: at the computer- all the details (including labs, social
issues, Ddx) Part two: at the bedside- off-going attending introduces the in-
coming team Patient is made aware of the work-up progress, pending studies
and reason for why s/he is still in the ED, and approximate timeline
After sign-out See all new patients Introduce self to old patients
Your ED shift: Seeing patients
All patients assigned to your bed assignment are YOUR patients See them within the first 5 min. of arrival in section A or
20min. in section B&C See patients in parallel: essential EM skill
Present your patients as soon as you saw them To senior and/or attending Do not pile up patients to present in bulks
Enter all lab orders ASAP Notify your nurse of the plan as soon as you know it
Charts must be completed by the time patient leaves the department
Your ED shift: Disposition
Important to notify the patient and nurse as soon as the decision is made
NEVER discharge the patient prior to making the ATTENDING AWARE that the patient is being discharged
All PMDs need to be notified that their patient was in the ED Especially for high-risk CC: HA, CP, AP, BP Document all communication in chart
AMA discharge: ALWAYS alert the attending ASAP Document capacity to make decision
Can not be: intoxicated, mentally retarded, cognitively impaired Give appropriate discharge instructions and prescriptions Encourage return to the ED
Your ED shift: Admission vs. Observation
Reasoning: patients who have normal vital signs, normal lab results, normal imaging may not meet criteria by insurance companies to pay for a full hospital admission These patients may still require medical care not
reflected by these numbersLogistics: most of the time, the ED attending
will be able to determine admit vs. obs Care Coordinators are specially trained in making the
decision Will sometimes ask you to change the admitobs or
obsadmit booking Always make the attending aware of the change
The attending makes the final decision
Your ED Shift: Medical Admission
Enter order in EPIC: “ED Admit” Observation vs. Admission Medical vs. Non-medical
For medical, pick team: Hospitalist =patient’s PMD is on hospitalist team All other medical admits =no PMD or PMD doesn’t admit to hospitalist YED attending= CPC PCC/ generalist= patient goes to PCC Goodyear =cardiology complaint without Cardiologist or University
Cardiology General cardiology =cardiology complaint with private (non-
university) Cardiologist Klatsin =ESLD ESRD Donaldson = HIV/AIDS
Fill out the rest of the booking (specify tele vs. floor, etc)
Your ED Shift: Admission to an ICU
Step 1: notify Bed ManagerStep 2: Call appropriate team for sign-out. Get
name of admitting attending. CCU: page CCU fellow MICU: page MICU admission team SDU: page SDU resident SICU: the surgical team is responsible for getting SICU
attending aproval NICU: don’t need to page anyone b/c you are admitting to a team
that should already be involved in patient care
Step 3: Attending- to- attending sign-out.YNHH admission policy: the ED attending makes the final decision where a patient is admitted
Please let your senior resident and/or attending aware of any push-back you get from the admitting team.
Your ED shift: Admission to CPC
CPC or in-hospital ROMI Both:
low/ moderate risk chest pain patients who need a ROMI Observation, telemetry admission Not for ACS patients
No nitro drips, no heparin drips CPC: patient will get Stress Test at the end of their admission
Your role Place appropriate EPIC order:
• Order Sets: “ED Chest Pain Observation” EPIC Note:
• Smartphrase: “.edobsadmit” Order all out-patient medications
In-Hospital ROMI: most will NOT get a stress test Patient had a stress in the past year Patient with other diagnoses possible (other than CAD) Patient needs isolation Patient morbidly obese (will not fit stress table) Patient can not self-transfer (onto stress table)
Your ED shift: Admission of hip fractures
For isolated hip fractures No other traumatic injuries Mechanical cause (i.e. not syncope that needs to be
worked-up)Orthopedic team evaluates patient (as all other
ortho consultations)Computer orders:
Admit to: Hospitalist Service: Medicine Unit type: free-text ortho/ hospitalist 7-7
Page hospitalist at 766-7416 to give verbal sign-out
Other ED Pearls
COMMUNICATION IS CRITICAL Team-work is essential to surviving in the ED (both
patient and resident): greatest off-service resident pitfall is not communicating with the nurses and attending/senior
Let your senior/ attending know: Patient seems to be sicker…
than triaged than last time seen than signed out
You are feeling overwhelmed and are falling behind You need a break (nourishment/ bodily functions)
Navigating EPIC in the ED
Log in and pick correct environment
Sign inPick your work area
Navigating EPIC in the ED
Typical day in ED
ED Notes in EPIC
Double click patient name My note TAB is open
Pick My Note buttonYou are responsible for…
HPI: add chief complain ROS PE
If you did procedures (e.g. EKG) EKG: change provider
ED Notes in EPIC
To view your full note click on NotesBellow PE and above Proceduresfree-text Assessment and Plan
MDM What was done/ found in ED Disposition
Also, free-text PMD/ consultants called (name and time)
DO NOT WRITE IN THE ED COURSE SECTION
ED Notes in EPIC
When finished documenting: ShareWhen an attending has signed the note, the
system will only let you Sign Pick your attending to Co-sign Do not start 2 separate notes
Admitting Patient in EPIC
Double click to open patient chart Open Admit Tab
Navigate through sections Clinical Impression= diagnosis Manage Orders= “ED admit”… Disposition= admit
Discharging Patient in EPIC
Double click to open patient chart Open Discharge Tab
Navigate through sections Disposition= discharge Follow-up= pick appropriate MD/ interval of follow-up Clinical Impression= diagnosis Orders= Discharge prescriptions Discharge instructions= diagnosis/ symptoms
Discharging Patient in EPIC
When ready to discharge, open Discharge Tab
Pick Preview/ Print SectionClick PrintHand Instructions to nursewith signed prescriptions
QUESTIONS
THE ED PATIENT WITH CHEST PAIN
Background
5% of all ED visits = 5 million visits per year in the US
One of the highest-risk chief complaints For patient morbidity/ mortality For MD litigation
Wide differential- most is high mortalityIN THE ED, WE MUST THINK OF WHAT WILL KILL THE PATIENT Acute Coronary Syndrome Pulmonary Embolism Aortic Dissection Pneumonia Pneumothorax Pericarditis Esophageal Rupture
ACS: STEMI=CATH LAB ACTIVATION
National guidelines for STEMI cath lab activations: Door-to-EKG: 5 minutes Door-to-balloon: 90 minutes
All EKGs seen and interpreted by an attending immediately “Cath Lab activation” is done by ED attending
Cath lab personnel are assembled (if not in-house overnight) Cath lab attending gives a call to the ED attending to get quick story
NO role for: Cardiac enzyme results Cardiology Fellow consult Chest x-ray results
Patient needs to be rolling to the cath lab within 25 minutes from arrival at ED triage, having gotten: ASA 325mg Oxygen Plavix Heparin 5000U +/- morphine +/- nitroglycerin +/- Beta-blocker
ACTIVATION IS BASED PURELY ON EKG and PATIENT’S PRESENTATION
ACS: STEMI=CATH LAB ACTIVATION
What does the attending look for to activate cath lab? Activation Criteria
ST elevations of >1mm in 2 consecutive (anatomical) leads New LBBB
Other signs that may be present Dysrhythmia Reciprocal changes Dynamic changes
Why should you care? As an MD (doesn’t matter what specialty), you must
know what to do with acute chest pain!
ACS: “good story”
What if the EKG is not clear-cut, but the patient is giving a “classic MI story” No immediate cath lab activation: role of cardiology consult
Resident calls fellow Attending calls attending
Instruct the nurse to do q5min. EKGs Dynamic EKG changes activate cath lab
Possibilities for ACS: all should get heparin Good story – EKG changes – troponins = unstable angina/ ACS Good story – EKG changes + troponins = NSTEMI/ACS Good story + EKG changes +/- troponins = STEMI/ACS
Especially if came in first few hours (<6hr)
Bad story/ no CP – EKG + troponins= NOT ACS Look for other causes of troponins
ESRD Tachycardia/ Sepsis Myocarditis
Low/ Moderate Risk CP High Risk CP
Need a ROMI EKG and enzymes q3-
6hrs x 3 times +/- stress
In-hospital ROMI vs. CPC Decision made by ED
attending in consultation with cardiologist and PMD
ACSHeparin gttunstable vital signs
Cardiology team Goodyer / General
Cardiology telemetry
CCU/CSDU
Chest Pain Patient Disposition
Cocaine Use Chest Pain
Rule in approx. 6% of timeAvoid Beta-BlockadeTreat chest pain and/or tachycardia with benzodiazepines
QUESTIONS
THE ED PATIENT WITH ANAPHYLAXIS
Anaphylaxis/ Angioedema
Immediate Medications Epinephrine:
Mild- moderate: 0.3mL of 1:1000 dilution IM in thigh May repeat q5min. Up to max 3 doses
Severe: 1-5mL of 1:10,000 IV drip over 10min…continuous Solu-Medrol 125mg IV Benadryl 50mg IV Pepcid 20mg IV Fluids Albuterol PRN
Why should you care? Anaphylaxis happens on every in-hospital unit Will NOT have time to look up treatment
QUESTIONS
THE ED TRAUMA PATIENT
The Trauma Patient
There are triage criteria for activating “trauma alerts” for patients: “full trauma” vs. “modified trauma” You are responsible for those who didn’t meet criteriaTHIS DOES NOT MEAN THAT THEY ARE NOT SERIOUSLY INJURED
Most are on back-boards and with c-spine collars Back-boards must be removed within 15 min. of arrival
To prevent pressure ulcers To prevent agitation Spinal precautions maintained at all times
Never remove a c-collar, never allow a patient to remove a c-collar
Backboard Clearance
4 person job: need 3 other people One holding C-spine stability (with collar in place) Two holding torso One (you) palpating spine and rectal tone
Tenderness at midline Bruising Lacerations Stepoffs Rectal Tone Gross blood on rectal exam
Clearing a C-collar
Done by senior resident/ attending ONLYClinical Rules for clearing C-collars
Canadian Nexus
Midline tenderness Focal neurological deficits Altered level of consciousness Intoxication Distracting Injury
Trauma ABCDE’s
AirwayBreathingCirculationDisability (GCS)Exposure
Document all injuries and formulate a plan for intervention/ imaging if necessary
FAST exam
Focused Assessment by Sonography for Trauma Ultrasound exam looking for free fluid
Abdomen RUQ/ LUQ
Pelvis Pericardial Effusion
E-FAST: extended FAST Examines for pneumothorax More sensitive than supine x-ray
Validated in unstable patients Can not be used to exclude intra-abdominal trauma
“Pan-Scan”
“Pan-scan”= CT scan Head (no contrast) C-spine (no contrast) Chest/ Abdomen/ Pelvis (contrast x2) T-/L- Spine reconstructions
Contrast: IV and PO PO contrast given by the tech immediately prior to the
scan Evaluates duodenal injury
Protocol MUCH different from usual PO contrast Must specify this when ordering the study and make
nurse aware Usual protocol: wait 2hrs. after PO contrast complete
More Trauma Pearls
Laceration/ Abrasion Tetanus Contaminated wound: ?Antibiotics
Beware ICH
Old people: subdural/ intraparenchymal splenic lacerations
Immediately alert the attending for any vital sign abnormalities or changes in mental status
Vital Signs Narrow pulse pressures Mild tachycardia
Cause of trauma: mechanical vs. medical
QUESTIONS
The Intoxicated ED Patient
Intoxication
Need to be screened for other causes of their altered mental status Hypoglycemia Head trauma other toxic ingestions
At minimum: vital signs FSG +/- Breathalyzer
Consider whether any further testing would change management or disposition Most cases will not need serum overdose/ urine tox
Document SI/ HIRe-evaluate after clinical sobriety
Intoxicated Patients
Clinical sobriety is the bar- many patients will go into withdrawal if you wait for their breathalyzer to go below .08
Alcohol levels decrease by ~ .025/ hourLook over all documents in patient’s chart
Police “paper” Requires “physician clearance”
Nursing/ triage/ call-in sheets If medical evaluation is negative, and patient
is only intoxicated Enter “ED Sobriety Hold” order Patient will be placed in IOU until sobriety
Overdose: Physical Exam
Vital SignsPupilsPulmonary EdemaSkinBowel SoundsMental Status
Overdose
Document SI/ HI on all patients SI/HI must be re-assessed when clinically sober
Consider overdose in any patient with SIPoison Control 1-800-222-1222 must be called
for all ingestions/ overdosesOn-call toxicologist is available 24hrGet EKG
Consider overdose labs: Serum tox, LFTs, Utox
QUESTIONS
The ED patient with Psychiatric Complaint or Ingestion
Medical Clearance
Patients going to CIU require medical clearance if Over 50yo Has any medical PMHx
What needs to happen: Full physical exam
Some may need: EKG/ CXR/ Basic Labs Medical clearance means:
All medical problems resolved no IVs in medically stable
Overdose patients are not medically clear Check past charts
Psychiatric patients may not be forthcoming with their PMHx Once cleared:
Epic order “psych clearance” Alert patient’s nurse Call 688-1616 to give CIU signout
QUESTIONS
THE END
THANK YOU FOR YOUR ATTENTION