Welcome to ED O rientation

1. Welcome to ED Orientation Alina Tsyrulnik MDClinical Instructor Assistant Residency program director Off-service Resident Director Department of Emergency Medicine Yale University School of Medicine

2. Goal of this Orientation Prepare our off-service rotators for patient care in the ED from the moment they start their rotation

3. 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

4. LOGISTICS OF WORKING IN THE ED

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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 numbers • Logistics: 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 admitobs or obsadmit booking • Always make the attending aware of the change • The attending makes the final decision

12. 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)

13. Your ED Shift: Admission to an ICU • Step 1: notify Bed Manager • Step 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.

14. 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)

15. 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

16. 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)

17. Navigating EPIC in the ED Log in and pick correct environment Sign in Pick your work area

18. Navigating EPIC in the ED Typical day in ED

19. ED Notes in EPIC • Double click patient name • My note TAB is open • Pick My Note button • You are responsible for… • HPI: add chief complain • ROS • PE • If you did procedures (e.g. EKG) • EKG: change provider

20. ED Notes in EPIC • To view your full note click on Notes • Bellow PE and above Procedures free-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

21. ED Notes in EPIC • When finished documenting: Share • When 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

22. 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

23. 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

24. Discharging Patient in EPIC When ready to discharge, open Discharge Tab Pick Preview/ Print Section Click Print Hand Instructions to nurse with signed prescriptions

25. Questions

26. THE ED PATIENT WITH CHEST PAIN

27. 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 mortality IN THE ED, WE MUST THINK OF WHAT WILL KILL THE PATIENT • Acute Coronary Syndrome • Pulmonary Embolism • Aortic Dissection • Pneumonia • Pneumothorax • Pericarditis • Esophageal Rupture

28. 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

29. 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!

30. 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

31. Chest Pain Patient Disposition 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 • ACS • Heparin gtt • unstable vital signs • Cardiology team • Goodyer / General Cardiology • telemetry • CCU/CSDU

32. Cocaine Use Chest Pain • Rule in approx. 6% of time • Avoid Beta-Blockade • Treat chest pain and/or tachycardia with benzodiazepines

33. Questions

34. THE ED PATIENT WITH ANAPHYLAXIS

36. 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

37. Questions

38. THE ED TRAUMA PATIENT

39. 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 criteria THIS 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

40. 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

41. Clearing a C-collar • Done by senior resident/ attending ONLY • Clinical Rules for clearing C-collars • Canadian • Nexus • Midline tenderness • Focal neurological deficits • Altered level of consciousness • Intoxication • Distracting Injury

42. Trauma ABCDE’s Airway Breathing Circulation Disability (GCS) Exposure Document all injuries and formulate a plan for intervention/ imaging if necessary

43. 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

44. “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

45. 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

46. Questions

47. The Intoxicated ED Patient

48. 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/ HI • Re-evaluate after clinical sobriety

49. 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/ hour • Look 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

50. Overdose: Physical Exam Vital Signs Pupils Pulmonary Edema Skin Bowel Sounds Mental Status