HPI

Lectures

Procedures

Stab room Recording

The emergency department is always staffed with at least one emergency medicine (EM) staff physician, 1 or 2 G3 EM or G3 surgery residents ("the pit boss"), a G3 internal medicine (IM) resident from 3PM to 11PM and a variety of residents, physician assistants (PAs) and students. The EM staff physician and the EM or surgery G3 residents are collectively responsible for the overall function of the emergency department and for supervising the care of each and every patient in the department.

The G1 residents, PAs and students are the primary medical providers (PMPs) of the emergency department (ED) patients. It is your responsibility to evaluate and manage the patients in their assigned areas in consultation with the ED supervisors. This includes conducting the H and P, performing procedures, interpreting diagnostic tests and determining diagnoses, therapies, dispositions and follow-up plans on your patients. Not least among these duties is documenting the patient’s ED visit. *see Documentation

The ED staff is in the ED to teach. Do not hesitate to approach them with questions whenever you are managing patients in the department. In addition there are some important junctures at which you should consult the ED supervisor. The staff or pit boss should be involved whenever the patient has unstable vital signs, before ordering diagnostic tests, giving medications or performing  procedures , or if you need information to expand your differential diagnosis. You will also want supervisory input to discuss pathology, when deciding on discharge diagnoses, therapies and follow-up and before the patient leaves the department so that your chart can be reviewed and signed. Remember: you must bring an unstable patient to the attention of the ED supervisor immediately.

The IM G3 resident serves as a consultant on patients with internal medicine problems and a resource for the ED in deciding treatment modalities, disposition and follow-up on these patients. They should know about all admissions to internal medicine. The IM G3 should not be expected to staff trauma or OB/Gyn patients. Do not send a patient home based on the decision of a G3 medicine resident unless the patient definitely has a purely internal medicine problem.

Many of the nurses in the emergency department have been in emergency medicine for more than 10 years. It is well worth your time to listen to their impressions of the patients and to read their initial assessments. The nurses are a good resource and a crucial member of the team that you have just joined. Introduce yourself to the primary nurse for the area in which you are working when you first come on shift and make an effort to communicate through out the patient’s stay in the emergency department about that patient’s changing condition or plan. You should read the nurses notes on Emstat before going into the cube. You are responsible for knowing the content of the nurse’s notes.

Signing Up for a Patient

Patients in the department and adjacent areas are listed on the computer screens located in the control area and throughout the department. Each day you will be assigned a specific area of the ED in which to work. As much as possible stay in your assigned area. Choose the patient for whom you sign up by the following priorities:

• area
• acuity of complaint if there are any patients of acuity 5 (black on Red in Emstat)
• length of time in the department.

After signing up for the patient, read the nurse’s note and vital signs before entering the patient’s cubicle.

On the tour of the emergency department the mechanism of signing up for a patient using the computer will be demonstrated. Sign up for patients when you are ready to begin their care.  See patients one at a time.  When you have completed all possible the data collection, procedures, and documentation at that time for that patient then it is time to pick up another one.

Medications to be administered in the emergency department must be discussed with the ED staff or pit boss before they are ordered. The medication, it’s dose and route must be ordered on Emstat . In addition, you should verbally alert the nurse of the order and the reason for it. Only nurses give medications in the emergency department.

Do not consult other services without first consulting the EM staff, who have rather vast experience. We need consultants under 4 conditions:

• 1) A procedure needs to be done which we do not perform-- usually OR procedures, also D&C, and a few others .
• 2) for patients who need to be admitted to services other than medicine, the resident from that service will usually see the patient first.
• 3) when we are too busy to complete certain procedures without help–commonly call for help on facial and oral lacerations on Saturday nights.
• 4) Very uncommon: we’re not sure what to do.

Consults from surgery, OB, neurology and other services are requested at the instigation of the staff or pit boss in the ED. Consultation in the ED serves another purpose: the specialty resident benefits by the evaluation of the complex patient and often learns from the ED staff. Consultants are only that - consultants. No patient is to leave the ED on the advice of the consultant until staff has concurred with the recommended diagnosis, treatment and disposition.

After you have decided, in conjunction with the staff and/or pit boss, to admit a patient, make sure you ask the patient if he/she will agree to admission.

• Determine, with the EM staff or senior resident, the admitting diagnosis and service. The staff will tell you whether a service needs to be consulted before the patient is admitted.
• Tell the Health Unit Clerks (HUCS). They will ask you the patient’s name, admission diagnosis, service to which you want him/her admitted and condition.
• Tell the primary nurse that the patient is being admitted so that they can call the nursing report and prepare the patient for admission.
• The HUC will ask you whether you are ready to talk to the admitting team. When you are, the HUC will page the admitting team for you to give report.

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