Loma Linda University Medical Center

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See something cool that you won’t deal with everyday in your chosen specialty.
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Learn about how Emergency Medicine interacts with the other specialty services.
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Appreciate some of the unique challenges and opportunities inherent to the acute care setting.
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Practice forming and risk-stratifying differential diagnoses.
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Appropriately apply diagnostic strategies to the acute workup of patients.

Almost 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...

Teamwork
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Although we see our patients in parallel, rather than in the traditional inpatient team model, you are still part of the team.
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Get involved in resuscitations and traumas that “belong” to the senior residents.
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If you hear about a procedure that you’re interested in, ask to be involved.
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Your patient flow and your attitude affect everyone else.

Own your patients
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The patient is your responsibility from the time you pick up the chart until they physically leave the ED.
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Reexamine the patient as often as needed.
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Be proactive in following up on test results.
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If something is delayed, find out why and try to fix it.
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Get discharge materials ready as soon as everything else is finished.

Productivity
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You expected to see a minimum of 10-15 patients/shift depending on your level of training (i.e., PGY-1 vs PGY-3).
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At times, the RIC (Resident-in-Charge) may assign you charts out of the rack to help with department flow.
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Expect to carry up to 4-5 undifferentiated or undispositioned patients at a time.
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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.
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Check in with the RIC any time you need to step out of the department.

Professionalism
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Be on time and work hard until your shift is over. Then relax.
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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.
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If you have questions about the sick policy, please ask.

Patient Care
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Nurses may ask you too "clear this patient off a backboard"; Do not clear spines unless directly supervised by an attending.
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If you have a patient who is crashing or unstable, grab a senior or attending right away.

When you arrive for your first shift, find the senior resident on duty and ask them for a tour. They should show you:
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Different treatment areas/designations
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Supply locations, including carts and storage rooms
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Ultrasound machine
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The rack (new patients)
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The charge nurse and unit secretary
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Where to find paperwork
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FirstNet, including the tracking board, notes, and discharge instructions

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Resident in Charge
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An EM resident on the senior shift
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Charge Nurse (55070)
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Techs / Unit Secretary
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ED Pharmacist
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(Kyle is pictured, Kayvon is our other pharmacist)

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Take the chart highest on the rack (do not go out of order or cherry pick!)
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The location is written on the colored dot
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Colored dots = acuity
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Red: Dying/Critical
Orange: Emergent or high pain level
Yellow: Urgent
Green: Low acuity
Blue: Stable

You must select
‘Emergency’ in
The department
Field
Select Direct
Supervision
But leave supervisor field blank
In the next window enter one of the current attendings working

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Log in versus sign in
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In addition to logging in and out, you must also sign in at the beginning of your shift and sign out at the end
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Logging in gives you access to the system. Signing in lets others know you are available for patients
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When Signing out you will select the oncoming resident so that all of your patients will be switched to them

Sign-in
Right click on a
Name in the
Resident
Section
Pick ‘Sign in
Another Provider’
And pick yourself
Sign-out
Click the sign-out
Icon,
In the field for
The provider
Who is replacing
You, search for the
On-coming resident

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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.

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You may want to spend up to 5 minutes looking up the patient in the system.
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Doing the H&P interview should take no more than 15-20 minutes.
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Be intelligently detail-oriented. Form your list of differentials as you go, and ask the questions that pertain.

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Give them a patient sticker
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Tell the room number and the patient’s basic information
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Be concise and organized in your presentation
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Formulate a differential and plan together
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Try to be proactive with your decision making. Don’t just ask what they want you to do.
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Order labs and imaging as agreed upon with the attending

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Give orders to the tech in the patient’s area to be placed in the computer.
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Contact Radiology if necessary (usually nights and weekends)
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Discuss the plan with the patient and with their nurse.
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Keep the patient's nurse and the charge nurse informed about pending admissions and discharges.

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Once you have all your data back, and you have reassessed the patient, recheck with the attending regarding a consult or discharge.
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For Admissions:
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1: Order a “bed request” to alert the house supervisor that the patient is to be admitted
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2: order a consult from the service to admit (the consultant will still need to be paged)

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

For consults:
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Be concise and specific.
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Every call should involve a clear question or reason why the patient requires their care.
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Provide them with the pertinent details to frame your question.
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Decide with the attending before calling as to who the appropriate consulting service will be.

For discharges:
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You write discharge instructions by accessing Discharge tab in epic
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Fill in a diagnosis, prescriptions, instructions (some topics have prepared educational info, others must be improvised), a work or school note if needed return precautions, follow-up plans, and finally an order to the nurse to discharge the patient.
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Print the discharge instructions
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Some prescriptions will not print if the patient has previously set up ePrescription plan at a specific pharmacy. If the patient now wants a paper Rx, you must delete the pharmacy info from the prescription order information window

For discharges:
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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.

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Occasionally, patients will be appropriate for Obs
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Patients who need prolonged testing or observation determine their disposition (low risk chest pain, cellulitis needing IV Abx, drunks needing time to sleep)
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To place a patient in the Emergency Department
Observation Unit, additional steps are required
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The patient is still your patient once in Obs

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If the plan is to place the patient in EDOU (obs), then start the orders as soon as you can because billing is based on time in obs
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1) Obs orders (order set, general obs, select EDOU in the “Admit to Location”
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2) Obs H&P: new blank note, in the template section search for ED Obs
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3) Obs DC note (probably sign out to next resident)

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You may write orders for pain meds as appropriate before chiefing with an attending.
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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.
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Avoid seeing a new patient until the previous one is staffed and in progress (at least for the beginning of the month)
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A senior resident or the attending is always available to supervise any procedure which you aren’t comfortable doing on your own.

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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.
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If there is a scribe present you only need to write ~1paragraph addendum
✤ choose “ED Note” (rather the “ED Providor Note”) as your note type.
Location will be “ED, Adult”
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These do not need to be sent to the attending for a signature unless they specifically ask you to.
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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.

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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.

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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)
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To help minimize those risks, we have a formal signout checklist on the program website, which we are asking you to use.
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Here are some of the highlights…

During the last hour of your shift, you should:
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Finish all minor procedures
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As a rule LPs, lac repairs, reductions, disimpactions, I and Ds, rectal exams, pelvic exams, etc., should not be signed out.
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Check for recommendations or admission orders for all patients awaiting consultation. Call the consultants again if necessary.

During the last hour of your shift, you should:
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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.
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Take some time to work on your notes.
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For patients awaiting transfer to an outside facility (Kaiser,
BMC…) you must complete the note before you leave.
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All notes must be completed within 24 hours.

During the last hour of your shift, you should:
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Formulate a final plan with the attending
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If [blank] is positive, then …
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If [blank] is negative, then …
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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)
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Prepare discharge and prescriptions for patients who will likely be discharged

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Print out a list of your patients for the oncoming resident.
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At the end of your shift, sign out to the senior resident who started most recently.
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Your sign out must include every patient still physically in the department, even if they are admitted, discharged, or have a consult pending.
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Bedside rounds are at the oncoming resident’s discretion, and recommended for potentially unstable patients.

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Use the following template to review each patient:
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D isposition (Admit/discharge/pending and sick/not sick)
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A ssessment (Brief history with a working diagnosis and relevant findings)
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D iagnostics pending (Labs, Imaging)
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S pecial Concerns (any potential issues that may arise with a specific patient)
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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?

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

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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
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Sometimes nurses work off of protocols (chest pain, abdominal pain)
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Other times a PA, NP, Senior Resident, or Attending may start a basic workup from triage to help expedite their care
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You still are responsible for that patient the same as for any other chart you pick up

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MRI will need to be ordered and then discussed with the radiology resident (page the appropriate resident according to the posted call list)
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Ultrasound orders are more complicated (see following slides)

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For ultrasounds you may need to page the Radiology Resident to notify the radiology tech, or notify the tech directly. There are currently
3 different possibilities depending on time/date
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Weekday mornings, just order the study
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Nights (2300-0600)and weekends, order and page the resident
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Weekday evenings(1700-2300), order, page resident, page the tech
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The rads resident on call can be found on a posted call list
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The Rads tech can be paged at 8897 or swingshift@my2way.com

As convoluted as that sounds, I’m not making this up

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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.
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There are some unique aspects of Emergency Medicine that affect our cognitive approach, which we expect you to appreciate during this rotation.
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Here are some of the most essential points:

Emergency Medicine Treatment and Active Labor Act (EMTALA)
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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.
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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.
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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.
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The bottom line: the ED is the front line for all things EMTALA

Tests: the intelligent approach
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What are the pros/cons/sensitivity/specificity of each test I’m ordering?
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What are the risks of the tests?
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How will the results (either positive or negative) affect my subsequent management?
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Are there any tools that can potentially help me avoid performing the test?

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

When we first see a patient, here are the basic questions that we have to address:
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Is this patient sick or not sick?
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Is this someone who obviously warrants admission, obviously will go home, or isn’t clear?
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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.
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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?

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When you see a patient, use your gestalt assessment to help you form a broad differential
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Direct your questioning towards those possibilities
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Refine and reprioritize that list as information comes back...
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...until the patient is appropriately risk stratified and dispositioned accordingly.

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LLUMC Chief Resident: Matt Barden , MBarden-9126
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RCRMC Chief (LLUMC Backup): Michelle Iwaki , miwaki/9420
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Scheduling: Sha Brennan SBrennan@llu.edu
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EM Department Office: Kathy Haimson and Ruby Navarro
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558-4344, 558-4085