NOTES FROM THE FAT MAN! Welcome to Yale Emergency Medicine.

This guide is meant to provide you with a reference to the daily workings of the Yale Emergency department. Use this guide to orient yourself to the Adult ED and also use it as a !how"to# guide for situations commonly encountered for the ED. We$ve tried to present the information in a concise and compartmented manner. We also attempted to incorporate many e%periences from senior residents to help you navigate the disarray of internship. This is a work in progress&. you are e%pected and invited to contri'ute revise and improve this guide as you gain e%perience in this residency and as the residency evolve. We wish you luck as you em'ark on this (ourney that will transform you into a competent Emergency )hysician. *o +hen ,-../ )0Y"1 and the 2urvival 0uide Team3 Thomas 4o'ey ,-.5/ )0Y"6 +hris 27le7ak ,-.5/ )0Y"6 *rooks Walsh ,-../ )0Y"1

As a junior resident in the ED, you are expected to... .. Always 'e ten minutes early. ;t-s possi'le the person you are relieving is likely the person that$s relieving you .6 hours later. 6. 2ee all of the patients assigned to your team color in a timely fashion. 5. Alert your senior or attending if you suspect a patient is unsta'le. 8alse alarms are 'etter than a dead patient. ,a high sensitivity is preferred/ 1. Make succinct presentations to the senior resident or attending. Always always know what the current vital signs are. <. +ome up with 'road differential diagnosis = remem'er you are in Emergency Medicine think of what can the most dangerous diagnosis with this presentation. >. ?arrow your differential diagnosis 'y using o'(ective data and evidence 'ased medicine. This you$ll improve at as you 'ecome more e%perienced @. Do the leg work in ordering studiesAmedications calling consults dictating admissions and calling )MDs. Do the orders as soon as you see the patient ,this will get the 'all rolling/. B. ?ECE4 ECE4 lieDDD i.e. ;f you didn$t do the rectal e%am say so and go do it. E. +ommunicate. You are part of a team of doctors nurses and techs make sure everyone is aware of the plan or any changes to the plan. .:. +omplete your portion of the chart 'y the time the patient is ready to leave the ED.

8irst Edition )rint Date3 9une 6:.:

Shi ts and Si!nouts in the ED @am = 2ignout for3 @am @35:am Eam ..a 6pm 5pm 15:pm @pm = 2ignout ?orth 2ide 0reen *lue 2enior Attending. 2outh 2ide 0reen Morning report after sign out for the new shift. Fvernight crew gets e%tra credit for attending. 2outh 2ide *lue ,@5:a"15:pm/ no signout ?orth 2ide )urple ,Ea"@p/ no signout 2outh 2ide )urple ,Ea"@p/ no signout ?orth 2ide AGua ,..a"..p/ no signout 2outh 2ide AGua ,..a"..p/ no signout ?orth 2ide Frange ,6p"6a/ no signout ?orth 2ide 2eniorAAttending signout 2outh 2ide *lue residentAattending signout ?orth 2ide 0reen )urple *lue ,@p"@a/ ?orth 2ide Trauma start ,@p"@a/ takes )urple signout. 2outh 2ide 0reen )urple ,@p"@a/ ?orth 2ide AGua signout to 0reenAtrauma 2outh 2ide AGua signout to 0reenA)urple 2outh 2ide *lue signout to covering )A or ?orth 2ide 2enior

"enera# Notes a$out %hartin! and &or' F#o( .. When patients are 'rought 'ack to the rooms they usually have a triage sheet with their ++ and current vitals. 2ometimes sick patients can 'e mis"triaged or their conditions worsened while waiting always look at the vitals prior to seeing a patient. 6. 0ive your patient one of your provider 'usiness cards and ask who their regular doctors are early in your encounter. 5. Ha's and radiology are ordered on 2+M as stat la's. A short cut is type3 !+ommon 2tat# to pull up the most often used la's. Type !Ed D# for ED diagnostics %ray or +T. 1. All radiology studies e%cept plain films and ?on"contrast head +Ts must 'e approved 'y the radiology resident at )**+),*-. During the day ultrasounds can 'e approved 'y .--+,/.0. <. There are A))HE2 ,predetermined/ la'sA%rays for specific complaints ,ie3 chest pain sepsis/ these can 'e found when you scroll through 2+M on the left hand side under Emergency departments or simply type !apples#. >. Medications ;Cs and other non"la' orders are done through the ordering sheet in the chart. Write the orders and put the chart in the !orders to 'e done# rack. *ut please tell the appropriate nurse of your orders charts in the rack can 'e easily overlooked when it gets 'usy. AHWAY2 T;ME A?D DATE YFU4 F4DE42. @. When documenting in your section of the chart in addition to free"writing the I); you must circle the appropriate symtoms listed for that complaint. And at the end of the 4F2 you MU2T +;4+HE !All systems otherwise neg#. ,This is a 'illing issue/ B. Always sign your charts even if you have not finished documenting. E. Disposition3 2ee specific parts for rules of admission discharge AMA. .:. A post"op transplant patient must have a transplant surgery consult even for non"transplant related complaints such as an ingrown toe"nail. ,liver transplants are consulted to the liver transplant fellow/

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Rando1 Tips or the 2ntern .. 2peak with confidence. This will indicate your a'ility and that you are in control. 6. Always make time to gra' a 'ite. Work will always 'e there and will pile up when you are gone that is a fact of ED life. *ut you also need to have fuel for your 'rain and 'odyJ this is a fact of life. Make sure you let your attending or senior know prior to leaving. 5. Drink plenty of fluids 1. UrinateD <. Think ahead if you have free time standing around ,very rare/ think a'out the ne%t step for your patients. ;f anticipating discharge start working on the discharge papers. This will save time later if you get too 'usy. >. ;f you disagree with the care of a patient with your attending 'ring up your concerns respectfully and in a timely manner. Unless your attending$s decision will lead to catastrophic conseGuences or lifeAdeath situations you are e%pected to carry"out the decision even in disagreement. @. When working Ma(or Med always check the intu'ation eGuipment. 2upplies are in the supply closet outside of the chest pain center and ne%t to the ultrasound parking on +" side. ;f anything cannot 'e found please ask your tech they usually know more places to look. B. You can 'e more efficient if you can develop the skill to either chart as you see the patient or chart later on. You may find yourself in a situation where you have to see multiple patients 'efore charting.

The Dischar!e 3rocess .. Discharge instructions are found under the EMA) ,aka Hyn%/ system 6. 8ind the patient$s name and click on the rightmost !D;2)# column. 5. ;nstructions can 'e found in pre"written for under various specialties. ?ote that some instructions are not necessarily put under the right specialty ,i.e. !Angioedema# is under dermatology/ 1. You have the option of printing pre"written instructions in 2panish. <. )rint 6 copies so the patient receives one and you keep one after the patient signs it. >. ;f you do not preview or print the instructions the system will not save them. @. *e sure to include ,or repeat/ important information or follow"up instructions in the free te%t. B. Enter discharge order in 2+M. Type !ED disc# in the order field. Discharge Against Medical Advice: This is generally for patients who wish to leave the ED prior to their work ups 'eing completed. To leave AMA a patient must 'e3 legally so'er clinically competent and a'le to ver'ali7e understanding of the risks of leaving AMA. An attending must 'e aware of AMA discharges. .. Do not antagoni7e the patient. Always encourage them to come 'ack or seek help if they feel their condition is worsening. 6. AMA form can 'e found under Hyn%. +lick on the patient$s name and scroll under !physician forms# 5. They should always get a discharge instruction for their complaint 'ecause it has warning signs to return. AMA instructions are also in the discharge instructions under !miscellaneous#. 1. Enter the discharge order as AMA.

Ru#es o Ad1ission There are multiple steps in an admission process. This is a general overview of the most common admissions. A## 1edica# ad1issions re4uire dictations. ,2ee the !Iow to Dictate# 2ection./ Chest Pain Center (ED admissions): At Yale we have a four 'ed chest pain o'servation unit ne%t to our department. This unit can accommodate patients with solitary chest pains for 4FM;s. Eligi'ility includes3 2ta'le ?on"complicated co"mor'idities ,ie. )t won$t need +")A) at night/ ?ot likely to need significant medical attention in the ne%t 61 = 1B hrs and +hest pain free at admission. The steps to admitting to the Chest Pain Center are: .. *ook the patient in 2+M 'y typing !ED o's# this will 'ring up the F'servation 'ooking. 6. Medical Team is !AED attending# 5. 2ervice is !Emergency Medicine 1. Attending physician is !Unknown University Attending# <. After 'ooking there are specific chest pain order sets in !apples cpc#. *e sure to click all the 'o%es in that order set including !?otice to cardiology#. >. 0o to EMA) and print out all forms related to +)+ admissions and fill out the sheet that essentially asks for pt$s risk factors alternative d% and first la' results. @. Fn the order sheet printed out order the patients$ regular home medications. B. Then let your team know the patient is cleared for +)+ admission. E. ?o dictation needed.

Chest pain/ROMI, !ncope (o"servation admissions): ;f the patient is coming in for chest painAromi or syncope many times medicare will not reim'urse a full hospital admission. 2o they are admitted under !o'servation# status.

Under the orders menu in 2+M type in !ed o$s# this will pull up a choice for admission for o'servation. Then 'ook and dictate as with other admissions.

#eneral Medicine Admission: This is for sta'le patients going to the floor or monitored 'ed. 4emem'er monitored 'eds are only for E+0 monitoringJ patients who need pulse"o% monitoring need the 2tep Down Unit or M;+U. .. 8ind out who the patient$s primary physician is. +all the physician and find out whether they would admit ,2ee section on talking to consults for guidance/. ;f the private )MD does not admit they will usually refer to hospitalist. )atients from )++ won$t need a call. 6. Under 2+M type in !ED admit# choose !ED admission Medical#. 5. Under !Team#3 if private admission choose !all other medical admit# )++ choose 0eneralist if +ardiologist ,AKA 0oodyear/ choose +ardiology Team Decompensated liver patients go to Kat7kin Fncology pts go to oncology team hospitalists go to hospitalist team. 8or admissions to specific teams refer to the specific sections. 1. 2ervice is always !Medicine#. +ontinue to fill in the reGuired areas. <. ;f 'ooking to hospitalist or )++ click physician !not found# to 'ook to unknown university attending. >. Fnce 'ooking is done on 2+M dictate the admission ,2ee the !Iow to Dictate# section for guidance/ @. Hast thing is complete your charts 'ecause you$ll never know when the patient will 'e ready to go and you may not 'e availa'le to finish the chart at that time.

Cardiolog! Admissions: 2ometimes patients will 'e admitted to their cardiologist. ;n that case patients should 'e 'ooked to the !cardiology team.# All other processes are the same. CC$ Admissions: The ++U fellow must 'e notified and agree with the admission unless it$s a private cardiologist wanting ++U admission. .. 8ind out who the admitting attending is from the ++U fellow. 6. *ook under 2+M under ++U team fill in all other fields 5. )age the ++U resident on"call and give a 5ER6A7 sign out. You can find out who is the on"call resident in amion.com = password !yale.# 1. ?o dictation needed. Decompensated %iver Admissions: )atients with liver failure or liver related issues usually go to the Klat7kin team. The liver fellow must 'e notified and agree to the admission. *e sure to find out who the attending is. ;f the team is capped the admission goes to hospita#ist tea1. Onocolog! Admissions: )atients with active esta'lished cancer diagnosis and active issues should 'e admitted to the oncology team. The oncology fellow must 'e notified. *e sure to ask who the attending is. Then admit as you would a general admission. ;f the team is capped or if your patient needs telemetry ,no tele 'eds in onc/ the admission goes to hospita#ist tea1. $&%E &O'ED, A%% O( ')E PRE*IO$ ADMI RE+$IRE DIC'A'IO& , IO&

'EPDO-& $&I': )atients who are slightly unsta'le or have the potential to 'e unsta'le can go to the 2tepdown Unit. ;t is a step 'etween M;+U and the floors. This is also the most limited type of 'ed. ;f there are no stepdown 'eds availa'le the patient should 'e upgraded to M;+U. .. 8ind out via your nursing team leader or nurse supervisor whether a stepdown 'ed is availa'le. ;f not the patient gets 'ooked to M;+U. 6. ;f a 'ed is availa'le page the on"call M;+U fellow and present the case for step"down. 5. Fnce agreed 'y the fellow 'ook the patient in 2+M under stepdown unit. 2ometimes the primary physician will admit most of the time it will 'e !unknown university attending# ie. Iospitalist or Donaldson team. 1. Fnce a team is identified 'y 'ed assignment you must give a CE4*AH sign"out to the team. Fur ;As will help you with the team and num'er to page. The key thing to remem'er is that these patients are a 'it of a moving target in terms of sta'ility. They need constant reassessment to determine if they need to 'e upgraded to M;+U status. MIC$ Admission: )atients who are actively unsta'le intu'ated or have other meta'olic derangements that reGuire .3. nursing care gets admitted to the M;+U. .. *ook the patient to the M;+U under unknown university attending. )rivates do not admit in the M;+U e%cept a specific )UHMF?A4Y group with Drs. 0erstenha'er or 4ogol. ;f you patient has a private pulmonologist and are going to the M;+U 'e sure to call them. 6. )age <:.@ ,M;+U admit pager/ and give a ver'al sign out.

pecialt! and .rgical Admissions: These admissions need to 'e accepted 'y the specialty service 'efore 'ooking. Usually they would have 'een consulted on in the ED and you$d 'e told on who and where to admit to. ;n many cases you may need to remind the consultant to tell you who the admitting attending is. .. ;n 2+M type !Ed Admit# +hoose ?F?"Medical admission. 6. 8ill out the 'lanks. You will A7&A8S need an admitting physician$s name. 5. *e sure to 'ook to the right teamAservice. 1. You do not dictate the patient. ;f the patient is consulted on in the ED you do not need to give ver'al sign out. &on/Medical IC$ ( .rgical/&e.ro): 2ame as regular non"medical admissions. You do not need to call any fellows. Pediatric Admissions: The 'ooking process is essentially the same for all pediatric admissions. .. 2+M type !ED Admit# +hoose pediatric admission for all medical and surgical admissions. 6. Always put an admitting physician$s name. ;t$s usually the patient$s primary pediatrician. ;f 'ooking to hospitalist or )++ the admitting physician$s name for that month is usually on the wall in the )edi ED. 5. After 'ed is assigned you MU2T give ver'al sign out to the team. Admission pagers for various units are on the wall in the )edi ED as well. 1. 2ign"out to the pediatric pager for non"surgical admissions. Fnly )eds surgery admissions does not need a sign out. <. );+U admissions are usually signed out 'y the )eds EM fellow to );+U fellow. 4esident to resident sign"out is superfluous.

Ho( to Dictate All medical floor admissions must 'e dictated. This is a convenient sign"out to the team. You can o'tain your dictation ;D through medical records. Keep it handy. .. Dial >BB"E>5: 6. Wait for prompt to enter dictation ;D enter your num'er and end with L 5. Enter the patients M4? and end with L. 1. )ress 6 to 'egin dictatingJ press 6 again to pause. 4emem'er how many times you$ve pressed the 'uttonJ there-s no reminder if it is paused or is recording. <. When finished press < to get the specific dictation num'er and document it for your record in the patient$s chart. 4emem'er this is a dictation not a full presentation. Fnly include pertinents and take no longer than two minutes to record. Iere is an e%ample3 Hello, this is Dr. Smith in the ED dictating an admission for patient Johnson MR !"#$%&'. Patient(s admission diagnosis is chest pain. His c)rrent *ital signs are +ithin normal parameters and sta,le. This patient is a %% male smo-er +ith a histor. of HT , DM, and high cholesterol, presenting +ith s)dden onset left sided chest pain radiating to his left arm +hile +al-ing. He +as diaphoretic at the time, ,)t denies n/*, f/c, or other s.mptoms. He has no PE risfactors. His last stress test +as reportedl. normal % .ears ago. 0pon arri*al, his *ital signs +ere sta,le, his pain +as completel. gone, and his e1am .ielded no significant findings. His 2nitial E34 sho+ed a normal sin)s rh.thm +ith chronic t5+a*e in*ersions that are )nchanged since last E34. His C6R +as normal, and his la, res)lts are at his ,aseline +ith a negati*e first troponin. He recei*ed a f)ll dose aspirin, ! 7iter of 289, and a P: ,eta ,loc-er in the ED. ;t this point, +e are admitting him for a R:M2. 2f .o) ha*e f)rther <)estions please contact me at &==5>>>>.? End $y 3RESS2N" 9. 6e sure to record the dictation nu1$er.

%a##in! a %onsu#t As Emergency )hysicians we rely on the availa'ility of specialty consults to deliver timely and effective care. Iere are some tips for calling consults3 Paging Cons.ltants: As interns you should learn how to do this yourself. Fur *A$s can page for you 'ut they are often too overwhelmed. There are several ways to find the num'ers. .. The AM;F? on call sheet = the daily on"call schedule is posted the home page in most Y?II computers. To get there type !cws# in the 'rowser address 'ar. +lick A and find !Amion#. 6. ;f you are una'le to find the consultant$s num'er or the list is incorrect ,a regular occurrence/ you can call the page operator at >BB"5... for more up to date assistance. They can also overhead page for you for rare emergencies. 5. Allow .< minutes 'etween pages and always document in the chart the num'er of times paged and who you paged. ;n case a consult says !;$ve never 'een paged.# 1. 2ome specialty radiology pager num'ers are not listedJ your radiology colleagues at >BB">.B: have 'een a'le to offer assistance to this in the past. ,Use sparingly and 'e polite as this is not their (o'./

pea0ing to Cons.ltants: )resenting a case to a consulting specialty can 'e a nervewracking e%perience. This will test your a'ility to present the case in a succinct manner and pose the appropriate Guestion to the consults. Iere are a few tips to talking to consults3

.. 8irst thing is to identify what the consult is for. ;f you have

a diagnosis or suspicions of a diagnosis tell them 'efore the presentation. i.e.3 Hi, 2(m calling .o) to cons)lt on a patient +ith ne+ onset sei@)reA.? Het the consults know if that patient was seen 'y that specialty ,'y whom/ in the past as they may have prior records that can 'e helpful. May also get less push 'ack. )resent the salient I); and positive findings to illustrate how you come to the diagnosis or suspect a diagnosis. ;t$s FK to say 2 don(t -no+ +hat the e1act diagnosis is, ,)t 2(m +orried a,o)t this patient and 2(d li-e .o)r opinion.? ;f there are Guestions you cannot answer or decisions you cannot make you will always have a senior or attending to 'ack you up. There are rare occasions when the consulting resident can make comments that may'e intimidating or inappropriately insulting. DF ?FT get into arguments over this as it is not productive to patient care. 4eport any such incidents to your attending. 4emem'er3 patient care comes firstD

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'al0ing to ED Radiolog!: As mentioned earlier all studies e%cept for full traumas %rays and non"contrast head +T must 'e approved 'y radiology at >BB>.B:. Enter the order and then call. When you call&. .. ;dentify the study you are reGuesting or if you are not sure let them know right off the 'at. 6. )resent the case in a concise manner with pertinent positives and why you need to study. 9or e1ample: Hello, 2(m calling to re<)est a a,d/pel*is CT +ith contrast for a s)spected appendicitis on a Mrs. So5and5 so in the ED. Her MR is 6666666. She is a #% B: presenting +ith R7C pain and fe,rile to !D! toda.. E1am has R7C tenderness +ith a positi*e Ro*sing(s sign, positi*e o,t)rator sign, and a negati*e psoas sign. Her pel*ic e1am +as normal. Her EFC is slightl. ele*ated at !# +ith a left shift. 0; and 0C4 are negati*e. Ee are loo-ing for appendicitis +ith this st)d..? 5. Always know the patient$s pregnancy status and creatinine when calling for ;C contrast +Ts. 2ometimes you may 'e asked for more clinical information. )lease do your 'est to provide this information. 4adiologists do not work in a 'o%J their readings are informed 'y the clinical scenario.

3rocedures in the ED As Emergency Medicine physicians we are capa'le of performing procedures across many domains of patient care. Arterial 1lood #as: 2upplies are generally in the glass closet supply closet on the A* side in Ma(or Med or Iallway. The A*0 forms are usually 'ehind the *A$s desk ask. .. ;dentify the lim' site with the strongest pulse. 6. There are two needles in the A*0 kit the short 'lue one is for the wrist the longer grey one is for femoral sticks. 5. Use the needle cover DF ?FT recap needles and always keep in mind on where the open needles are. 1. )rep the skin and sGuirt out the heparin through the needle <. Use the tips of your fingers ,not the pad/ to palpate the position and course of the pulse. >. Keeping your finger on the pulse aim the needle along the course of the artery and insert at a 1< degree angle to the skin. @. Watch for flash as you advance the needle. A true arterial sample in a relatively normotensive patient will fill the syringe without drawing 'ack on the plunger. B. 2 you 1issed palpate with your free hand and identify which side the pulse is in relation to the needle. E. Then withdraw your needle almost to the tip 'ut not leave the skin then make a small ad(ustment to the direction of the needle toward the pulse. Do this in small increments as you will hit the artery eventually. Aiming toward and chasing the pulse often is an unsuccessful strategy. .:. *e sure to hold pressure for at least . minute at the wrist and < minutes in the groin after your 'lood draw. ... At Yale the sample does not have to 'e sent on ice. .6. Ha'el the specimen and fill out the A*0 slip. Tear off the top sheet and give it to your *A who will write the results for you when they call.