Welcome to ED Orientation
ALINA TSYRULNIK MD
CLINICAL INSTRUCTOR
ASSISTANT RESIDENCY PROGRAM DIRECTOR
OFF-SERVICE RESIDENT DIRECTOR
DEPARTMENT OF EMERGENCY MEDICINE
YALE UNIVERSITY SCHOOL OF MEDICINE
Goal of this Orientation
PREPARE OUR OFF-SERVICE ROTATORS FOR
PATIENT CARE IN THE ED FROM THE
MOMENT THEY START THEIR ROTATION
Objectives of this Orientation
 Logistics of working in the ED
 Your ED team
 Observations vs. Admission
 EPIC details
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
Admission/ Discharge
Note completion
 High- Yield Emergency Medicine Topics
 Cardiac Chest Pain
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Anaphylaxis
Trauma
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ACS: STEMI vs. NSTEMI
Low/ Moderate risk CP
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
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Staffing:
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Green: 9 beds +2 resuscitation bays
Purple: 10 beds + 2 resuscitation bays
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
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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
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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
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See all new patients
Introduce self to old patients
Your ED shift: Seeing patients
 All patients assigned to your bed assignment are YOUR
patients
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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
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Especially for high-risk CC: HA, CP, AP, BP
Document all communication in chart
 AMA discharge: ALWAYS alert the attending ASAP
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Document capacity to make decision
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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 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
Your ED Shift: Medical Admission
 Enter order in EPIC: “ED Admit”
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Observation vs. Admission
Medical vs. Non-medical

For medical, pick team:
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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 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 pushback you get from the admitting team.
Your ED shift: Admission to CPC
 CPC or in-hospital ROMI
 Both:
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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”
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Order all out-patient medications
In-Hospital ROMI: most will NOT get a stress test
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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 workedup)
 Orthopedic team evaluates patient (as all other ortho
consultations)
 Computer orders:
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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 in
 Pick 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 button
 You 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 Notes
 Bellow PE and above Procedures
free-text Assessment and Plan

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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: 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
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 Section
 Click Print
 Hand Instructions to nurse
with 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 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
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:
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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
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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
Chest Pain Patient Disposition
Low/ Moderate Risk CP
High Risk CP
 Need a ROMI
 EKG and enzymes q3-6hrs
x 3 times +/- stress
 ACS
 In-hospital ROMI vs.
CPC

Decision made by ED
attending in consultation
with cardiologist and PMD
 Heparin gtt
 unstable vital signs
 Cardiology team
Goodyer / General
Cardiology
 telemetry
 CCU/CSDU

Cocaine Use Chest Pain
 Rule in approx. 6% of time
 Avoid Beta-Blockade
 Treat chest pain and/or tachycardia with benzodiazepines
QUESTIONS
THE ED PATIENT WITH
ANAPHYLAXIS
Anaphylaxis/ Angioedema
 Immediate Medications
 Epinephrine:
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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 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
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 ONLY
 Clinical Rules for clearing C-collars
 Canadian
 Nexus
Midline tenderness
 Focal neurological deficits
 Altered level of consciousness
 Intoxication
 Distracting Injury

Trauma ABCDE’s
 Airway
 Breathing
 Circulation
 Disability (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
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Old people: subdural/ intraparenchymal
splenic lacerations

Immediately alert the attending for any vital sign abnormalities
or changes in mental status
 Vital Signs
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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

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Hypoglycemia
Head trauma
other toxic ingestions
 At minimum:
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
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
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
Overdose: Physical Exam
 Vital Signs
 Pupils
 Pulmonary Edema
 Skin
 Bowel Sounds
 Mental Status
Overdose
 Document SI/ HI on all patients
 SI/HI must be re-assessed when clinically sober
 Consider overdose in any patient with SI
 Poison Control 1-800-222-1222 must be called for all
ingestions/ overdoses
 On-call toxicologist is available 24hr
 Get 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
THANK YOU FOR YOUR
ATTENTION
THE END