1. ALINA TSYRULNIK MD CLINICAL INSTRUCTOR ASSISTANT RESIDENCY PROGRAM DIRECTOR OFF-SERVICE RESIDENT DIRECTOR DEPARTMENT OF EMERGENCY MEDICINE YALE UNIVERSITY SCHOOL OF MEDICINE Welcome to ED Orientation

2. PREPARE OUR OFF-SERVICE ROTATORS FOR PATIENT CARE IN THE ED FROM THE MOMENT THEY START THEIR ROTATION Goal of this Orientation

3. ED Rotation Orientation Process and Resources Mandatory  ED orientation (mandatory): you are here  ED online module (mandatory): must send attestation  yaleem.org Resources  Doc Launcher App  Full ED Orientation (yaleem.org)  Mobile Heartbeat phones

4. Objectives of this Orientation Logistics of working in the ED  Your ED team  Observations vs. Admission  EPIC details  Admission/ Discharge  Note completion  Introduction to Doc Launcher 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

5. LOGISTICS OF WORKING IN THE ED

6. 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  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  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

7. ED Layout- Other areas of Interest Patient entrances/ triage/ registration areas:  Ambulance  Waiting Room 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

8. 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)

9. Your ED shift: Arrival and Sign-out Arrival: at least 5 min. prior to scheduled time  A side  Green: beds 4-12, r1-2  Purple: beds 1-3, 13-19, r3-4  B side  EM intern takes beds 15,16,1,2,3  EM PA takes beds (8)9-14  Off-service resident takes beds 4-(8)9  C side  Divide beds among available providers (3-4 teams) Sign-out: Done by attending or senior resident After sign-out  See all new patients  Introduce self/ re-evaluate old patients

10. 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

11. 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- admitted patients’ PMDs notified by BA  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

12. 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

13. 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)

14. 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. 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.

15. 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)

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 Also, free-text  PMD/ consultants contacted 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. Doc Launcher: getting started Choose appropriate clinical department from “Apps Menu”

26. Finding specific items

27. Doc Launcher Cogwheel “Cogwheel” at bottom left  recently viewed content  Apps menu

28. QUESTIONS

29. THE ED PATIENT WITH CHEST PAIN

30. 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

31. 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/ Ticagrelor  Heparin 5000U  +/- morphine  +/- nitroglycerin  +/- Beta-blocker ACTIVATION IS BASED PURELY ON EKG and PATIENT’S PRESENTATION

32. 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  Other signs that may be present  Dysrhythmia  Reciprocal changes  Dynamic changes  New LBBB Why should you care?  As an MD (doesn’t matter what specialty), you must know what to do with acute chest pain!

33. 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

34. 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 Chest Pain Patient Disposition

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

36. QUESTIONS

37. THE ED PATIENT WITH ANAPHYLAXIS

39. 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

40. QUESTIONS

41. THE ED TRAUMA PATIENT

42. 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

43. 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

44. 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

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

46. 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

47. “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

48. 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

49. QUESTIONS

50. The Intoxicated ED Patient

51. 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

52. 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

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

54. 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

55. QUESTIONS

56. The ED patient with Psychiatric Complaint or Ingestion

57. 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

58. QUESTIONS

59. THE END THANK YOU FOR YOUR ATTENTION