UNC Department of Emergency Medicine
Campus Box 7594
Office phone: 966-5933
Emergency Department phone:
966-4721
The Emergency Department (ED) attendings work 10
and 8 hour shifts, 7a-4:30p, 1p-10:30p, 4:30p-1a, 10:30p7a. Two attendings are on duty, with the
exception of the time period from 2a to 6a when one attending is on duty.
The ED has 3 main areas. The Acute Care area has 24 beds including 2 cardiac rooms and 3
trauma rooms. Minor Trauma is an
adjacent area with 8 beds. Minor Trauma
is open noon to midnight daily.
Pediatric Acute Care is a separate unit staffed by Pediatric attendings
and residents. Pediatric Acute Care is
open 9a-11p daily. After those hours,
pediatric patients (ages 15 and below) are treated in the main ED. During your rotation, you will be assigned
shifts in both the Acute Care area of the ED and the Minor Trauma area.
Guidelines for Houseofficers
Department of Emergency Medicine
The University of North Carolina at Chapel Hill
Introduction
and General Principles
Welcome
to the Department of Emergency Medicine!
During this rotation, you will learn skills that are essential to your
medical education. You will be
supervised by faculty members who are Board Certified or Board Eligible in
Emergency Medicine. Our faculty have
practiced in a variety of institutions and settings, and thus, your experience
here will be enhanced by exposure to different styles of practice.
Emergency
Medicine differs in many respects from the inpatient and clinic settings. During this rotation, you will see a broad
spectrum of illness ranging from the most trivial complaints to
life-threatening disease. It is
important to remember that all patients come to the ED for a reason. Many present to the ED early in the course
of their illness, therefore a serious disease may initially present to you as
an apparently benign complaint. Many
may present with complaints that could best be handled elsewhere. It is our role to ensure our patients
receive our best efforts to guide them through the increasingly complex
healthcare system as well as to diagnose and treat acute care conditions. Remember the Emergency Department is an
important portal of entry into the hospital and provides a strong impression of
the institution to patients, their families, and referring physicians from
other medical centers.
Houseofficer
Requirements for Successful Completion of
Emergency
Medicine Rotation
2001-2002
Academic Year
1. Completion of the
Online Orientation Module
Each houseofficer must complete the online orientation course
and exam before starting their Emergency Medicine rotation. The orientation module is available online
at www.med.unc.edu/wrkunits/2depts/emergmed.
2. Assigned Shifts in
the Emergency Department
Be prompt for your assigned shifts. If you are ill or must miss an assigned shift, you need to
contact:
·
Your chief resident. Chief residents from each
rotating department will be responsible for providing replacement coverage for
their individual department residents who are unable to fill an assigned shift.
·
The ED attending physician working at the time your shift begins
(966-4721).
In order to
successfully complete the ED rotation as required by your residency, you must
complete all assigned shifts. Illnesses
are only excused if verified by your personal physician (not a resident
physician) or your residency director.
3.
Resident Conferences
In
order for the Departments of Emergency Medicine, Medicine, Surgery, Family
Medicine and OB/Gyn to meet the requirements of the Residency Review Committee,
weekly attendance at our Emergency Medicine Conferences is MANDATORY. These conferences are held on Wednesday
mornings from 7a to noon. The schedule
of topics is available monthly.
Emergency Medicine interns/residents are required to attend conferences 5
hours per week. Off-service
interns/residents are required attend 3 hours per week. During your rotation, you will likely be
scheduled in the ED on one or more Wednesday mornings. On these mornings you should attend sign
out rounds and check in with the ED attending prior to departing for conference. When you are not scheduled to work in the
ED, you should attend at least part of the Wednesday morning conference. Attendance will be taken at these
conferences and reported to individual residency directors at the end of each
rotation along with your final evaluation.
If you have questions or
concerns, please feel free to contact:
Cherri Hobgood, MD
Assistant Professor
Education Director
966-6440
Guidelines
for Housestaff:
Department
of Emergency Medicine
The
University of North Carolina at Chapel Hill
Important Items to Keep in
Mind:
1.
Although you will be quite busy at times, make sure you speak to any family or
visitors who may be in the waiting room after you have finished your
evaluation. It is important to let them
know how well the patient is doing and give them an estimate of the anticipated
length of stay. Always overestimate the
length of stay. Things take longer than
you think.
2.
Laboratory studies and X-rays are ordered only if they impact on acute
treatment, immediate decision making, or are essential for the provision of
follow-up care. The Emergency
Department is not the place to begin an extensive workup of non-critical
problems.
3.
Every patient should be given instructions for follow-up care and referred to a
follow-up physician, no matter how trivial the problem may seem. (see documentation and charting guidelines)
4.
You should be able to arrive at a reasonable clinical diagnosis on most
patients. If you lack a definitive
diagnosis, you must have formulated a clear differential diagnosis and have
ruled-out all possible life-threatening conditions before the patient can be
discharged safely.
5. Information concerning
patients seen or discussed in the ED is confidential. It should not be discussed anywhere else,
other than in a medical conference setting.
This means you must not discuss patient information in the hallways, nor
the elevators, nor in downtown restaurants, etc. You are a professional and must conduct yourself as such.
6. All patients who are seen
in the Emergency Department are the ultimate responsibility of the attending
emergency physician. Consequently, THE
EMERGENCY DEPARTMENT ATTENDING MUST SEE EVERY PATIENT AND SIGN EVERY CHART
PRIOR TO THE PATIENT’S DISCHARGE, ADMISSION OR TRANSFER.
7. Some patients have such
serious illness at the time of presentation that they may decompensate in a
very short period of time. Because of
this, there are certain circumstances when it is vital for you to notify the
attending physician of the patient’s condition IMMEDIATELY AND POSSIBLY BEFORE YOU HAVE FINISHED YOUR INITIAL
EVALUATION. (You will find a
list of these circumstances attached in this handout.) If
you think a particular patient is unstable, alert the attending on duty.
8. SMS Informatics System (SMS):
All ED patients are tracked on a computer system called SMS. When you arrive in the ED, you will be
instructed how to use this system to sign up as the provider for the patients
you are evaluating. In order to access
this system, you must have a valid UNC Hospital code and password.
9. As patients enter the Emergency Department,
they are triaged by the nursing staff. The
triage designations are:
|
|
ESI-1 |
ESI-2 |
ESI-3 |
ESI-4 |
ESI-5 |
|
Stability of vital
functions |
Unstable |
Stable |
Stable |
Stable |
Stable |
|
Life-threat or organ-threat |
Obvious |
Reasonably
likely |
Unlikely
(possible) |
No |
No |
|
Severe pain or severe
distress |
Immediately |
Sometimes |
Seldom |
No |
No |
|
Expected resource intensity |
Maximum: staff at bedside continuously;
mobilization of outside resources |
High: multiple, often complex diagnostic
studies; frequent consultation; continuous (remote) monitoring |
Medium: multiple diagnostic studies; or brief
observation; or complex procedure |
Low: one simple diagnostic study; or simple
procedure |
Low: exam only |
|
Med/staff response |
Immediate
team effort |
Minutes |
Up
to 1 hr |
Could
be delayed |
Could
be delayed |
|
Expected time to
disposition |
1.5
hr |
4
hr |
6
hr |
2 hr |
1
hr |
|
Examples |
Cardiac
arrest, intubated/hypotensive trauma patient, acute (<3 hr) MI or stroke |
Most
chest pain, stable trauma (MOI concerning), elderly pneumonia patient,
altered mental status, behavioral disturbance |
Most
abdominal pain, dehydration, esophageal food impaction, hip fracture |
Closed
extremity trauma, simple lac, simple cystitis, typical migraine |
Sore
throat, minor burn, recheck |
In general, patients should be seen in the order in which they arrive in the ED, however patients triaged as “1” or “2” should be evaluated before those designated “3-4-5”. If you are unsure which patient you should evaluate next, ask the attending or a senior resident to direct you.
SCHEDULE
Housestaff
will be assigned to one section of the department and will report ONLY to the
attending staffing that section.
RESPONSIBILITIES
Role
of the Emergency Department Attending
The ED attending is
primarily responsible for patient flow and consultation. The ED attending will be responsible for the
supervision of all medical students and houseofficers. Housestaff cannot sign student orders.
Role of the PGY-III
Resident
The PGY-III Emergency
Medicine Resident has three main responsibilities in the ED:
1. Directly evaluate patients as the primary physician,
with particular attention to critically ill or injured patients.
2. Ensure that patient flow in the ED is maintained.
3. Supervise one or more PGY-I residents who are working
in the ED.
4. Perform or supervise procedures required for patient
care.
5. At times, these residents may take a turn at being
“in charge” of the ED under the supervision of the attending.
Role of the PGY-III
Medicine Admitting Officer
The role of the PGY-III
Medicine Admitting Officer is to admit patients to the medicine services. This requires “calling the patient in” to
bed control and calling the intern or team who will be admitting the patient as
well as evaluating the patient for proper placement within the hospital.
Role
of the PGY-I and PGY-II Residents and Medical Students
The
PGY-I resident and medical student are primarily responsible for patient
evaluation and management. Remember
that you are here to learn and that specific questions are expected. It is
better to ask and ask early!
PATIENT CARE
AND CASE PRESENTATION
It will be the responsibility
of the EM PGY-III resident, all PGY-I residents, and medical students to pick
up new patients as they are added to the board by the triage nurse. Patients are to be seen according to their time of entry into the ED unless
another patient with a potentially life-threatening complaint has not yet been
evaluated. Patients with life-threatening complaints are designated by a
triage classification of “1” (in red) and should be seen promptly. If you are not certain whether a particular
patient is to be seen, ask the attending physician or triage nurse.
The
residents will see and evaluate the majority of patients. This initial evaluation is to consist of a
history and physical examination, which may be “directed” if the patient has an
obviously isolated problem (such as a minor extremity injury). All other patients should have a complete
history and physical examination including social and family history,
medications and allergies. This
evaluation should take no longer than 5 to 10 minutes to complete.
ANY PATIENT WITH A CONDITION
WHICH MAY DETERIORATE PRECIPITOUSLY MUST BE CALLED TO THE ATTENTION OF THE ED
ATTENDING IMMEDIATELY, EVEN IF THE INITIAL EVALUATION IS NOT COMPLETED. A list of such conditions is listed in this handout.
After
formulating a differential diagnosis and treatment plan, but before writing
orders, the intern is to present the patient to the ED attending. At that time, an evaluation and treatment
plan can be formulated and orders written.
All orders written by housestaff must be countersigned by the ED
attending. No verbal orders are
acceptable.
After
all ancillary studies have been completed, the houseofficer is to present the
case to the ED attending again, this time noting the results of laboratory
values, X-rays, etc. At this time a
disposition will be made and the patient will be either discharged, admitted or
transferred to a different institution.
The attending must countersign the chart at this time.
All
admissions to the general medical service are to be referred to the Medicine
Admitting Officer for notification of the floor team.
TYPES OF
PATIENTS SEEN
Adult
patients with a wide variety of complaints are seen in the Acute Care area of
the ED. In addition to evaluating and
treating patients with general medical and surgical problems, you will gain
experience with patients whose complaints include the following:
Psychiatric - Our
responsibility is medical clearance; be especially careful with elderly
patients or those with confounding medical problems; some psychiatric patients
will be seen directly by the Psychiatric consultants.
OB-Gyn - Women at 20 weeks or
greater gestation are transferred directly to Labor and Delivery. The exceptions to this are if they have any
type of trauma or a complaint totally unrelated to pregnancy. All women between 10-60 should be assumed to
be pregnant until proven otherwise by a negative urine pregnancy test.
Trauma - Major trauma
patients, as determined by criteria, are seen by the Trauma team, EM Attending
and Senior Emergency Medicine Residents.
Patients with lesser trauma are evaluated and treated by the general ED
staff.
Pediatrics (ages 15 and below)
- These patients are seen directly by a Pediatric resident, either in Pediatric
Acute Care (9a-11p) or in the Acute Care ED at other times.
ANCILLARY SERVICES
Laboratory Studies
1. Laboratory studies are ordered in writing on the
order sheet. Be specific, the ordering
of panels is discouraged.
2. Laboratory reports results can be obtained on the
computer and hard copies are provided in the ED, although they may take
longer. Be sure to check the computer
frequently for results so the patient can receive disposition in a timely
manner.
3. All laboratory studies must be documented on
the chart, including those that are
pending at the time of disposition.
Radiologic Studies
1. If a patient needs an X-ray, write the order on the
order sheet and place in the
new
order rack. You need to write a reason
for the X-ray study, i.e. R/O CHF,
R/O
free air. After 5pm and weekends,
special studies such as IVP’s, CT scans and V/Q scans require the ordering
physician to call the radiology resident to arrange the test. The X-ray orders are entered into the
computer by the nursing staff.
2. Look at the patient’s X-rays even though the
radiologist’s interpretation is written on the X-ray jacket. Remember that you have the advantage of
knowing the patient’s clinical presentation and thus may notice something the
radiologist might have misses.
4. If you cannot find the radiologist’s interpretation
in the radiology reading room, you can dial the dictated report on RTAS.
(x66831).
5. If you have any questions regarding the
interpretation of a particular radiograph, you may consult the ED attending,
the PGY-III resident or the radiology resident, whose name and beeper number
are posted in the X-ray reading room.
6. All radiologic studies must be documented on
the chart!
7. On the discharge sheet, there is a box to check to
let the patient know that the X-ray interpretation is preliminary until the
attending radiologist has reviewed the films.
All films after 5pm on weekdays and on weekends are preliminary
readings. If there is a change in the
reading, the patient will be contacted.
INSURANCE
DESIGNATIONS
Patients with Medicare,
Medicaid, or Carolina Access should be called to the attention of the
attending. The attending MUST
specifically see these patients in order to bill for our services.
MEALS
Housestaff
may briefly leave the ED for nutrition breaks as patient flow permits, but
only after notifying the attending that they are leaving.
DOCUMENTATION
STANDARDS
It is your responsibility to see that these
standards are met on every chart. Charts will be returned to you for
completion if documentation standards are not met.
DISCHARGE
INSTRUCTIONS AND FOLLOW-UP
All
patients are to receive a discharge instruction sheet prior to leaving the
Emergency Department. There are
specific items that must be included on the discharge form.
CONSULTATIONS
Consultation
for admission to the General Medicine Services should be directed to the
PGY-III medicine resident. Any patient
who requires surgical evaluation or possible admission to the surgery services
must be referred to the senior surgery resident on call (Beeper #1111). The beeper numbers of the other on-call consultation
residents can be found on the SMS computer call list, by calling the hospital
operator or by asking the ED clerk. It
is usually best to discuss the calling of consultants with the attending or a
senior resident before seeking consultation from other services.
PATIENTS
LEAVING THE EMERGENCY DEPARTMENT AGAINST MEDICAL ADVICE (AMA)
All
patients who threaten to leave the Emergency Department against medical advice
(AMA) must be seen by the ED attending immediately. The patient is required to sign an AMA form on the back of the
chart and must be properly informed of the risks of departing AMA.
SECURITY AND
PARKING
Escorts
to the parking decks are available 24 hours a day. USE THEM!! Use the Point to Point Service
(962-7867) or have hospital security accompany you! You cannot park in the ED patient parking lot.
DRESS CODE AND
IDENTIFICATION
Name
badges must be worn at all times.
Housestaff are expected to look and act like professionals at all
times. Scrubsuits are acceptable for
wear in the Emergency Department provided they are clean and in good
condition. Jeans, shorts, sweats and
T-shirts are not permitted.
ROUNDS AT THE
MONITORS
At
7a, 3p, 7p and 11p “Rounds” are held at the monitors on A side in the Acute
Care Area. All interns, residents,
students and attendings working in the ER briefly present their patient’s
medical condition and the status of their evaluation.
WHEN
YOUR SHIFT ENDS
You
must turn your patients over to an intern or resident on duty in the ED. If your patient is nearing completion of
their evaluation – please fill out the paperwork completely including the
discharge form if appropriate. If the
evaluation is in progress, please have a clear plan to pass on to the next
doctor.
Medical Conditions Requiring
Immediate Attending Physician Notification
The
following is a list of conditions that require immediate notification of the
Emergency Department attending physician, regardless of your level of
training. This list does not cover all
possible situations, and you should feel free to notify the attending
immediately if you have a patient you feel may deteriorate precipitously or if
you are uncomfortable given your present level of training.
1. Any
patient who presents with or develops acute cardiopulmonary arrest.
2. Any
patient with a complete or partially obstructed airway.
3. Any patient who presents with or develops a
significant cardiac arrhythmia, whether stable or not.
4. Any patient with acute onset Alteration of
Mental Status (AOMS). This includes any
patient presenting with this as the chief complaint or any patient whose mental
status deteriorates while in the ED.
5. Any patient with significant hypotension or
hypertension. For these purposes,
significant hypotension will be defined as blood pressure of less than 100 mmHg
systolic and significant hypertension will be defined as a blood pressure of
greater than or equal to 180 mmHg or hypertension associated with acute
alteration of mental status.
6. Any patient with severe respiratory
distress. For these purposes,
significant respiratory distress will be defined as a respiratory rate greater
than 30 breaths/minute, any patient with a pulse oximeter reading of less than
or equal to 90 mmHg, any patient with an acute elevation of pCO2 greater than
or equal to 60 mm Hg, any patient with a complaint of shortness of breath
accompanied by diaphoresis, use of accessory muscles of respiration, cyanosis,
alteration of mental status, bradycardia, or any other signs consistent with
imminent respiratory failure.
7. Any patient with significant tachycardia or
bradycardia. For these purposes,
significant tachycardia is defined as a heart rate greater than or equal to 150
beats/minute and significant bradycardia is defined as a heart rate less than
or equal to 60 beats/minute.
8. Any
patient with a significant cardiac arrhythmia.
9. Any patient with either clinical or EKG
evidence of acute myocardial infarction.
11. Any patient with significant
hypothermia. For these purposes, significant
hypothermia is defined as a rectal temperature less than or equal to 95
degrees Fahrenheit.
12. Any patient with severe abdominal pain or
abdominal pain associated with peritoneal signs.
13. Any
female with abdominal pain and a positive pregnancy test.
14. Any patient with significant upper or lower
GI bleeding (whether hypotensive or not).
15. Any patient who develops seizure activity
while in the Emergency Department.
16. Any patient with significant abnormality of
any laboratory value (e.g. hypo/hypernatremia, hypo/hyperkalemia, symptomatic
hypercalcemia, hematocrit less than 28, etc.).
17. Any
patient with a history of significant trauma.
18. Any
patient with a pregnancy and sign/symptoms of a precipitous delivery.
19. Any patient with an overdose of prescription
or over-the-counter medications.
20. Any patient or visitor who gives evidence of
becoming significantly agitated, violent, or suicidal.
21. Any
patient with a blood sugar of less than 70 mg/dL.
22. Any
patient with a snakebite.
23. Any patient with significant bleeding, or
bleeding associated with hemophilia (blood dyscrasias).
24. Any
patient with a significant allergic reaction.
Documentation Standards
The
following information is required on all charts for all Emergency Department
patients for legal and billing purposes.
Please review this in conjunction with the copy of the chart included in
this packet.
1. Fill in the vital signs at the top of the
doctors note. Alternately, you can
write them at the beginning of your physical exam.
2. At the top of the chart or at the bottom the
chart, under where it says “Attending Signature” write the name of the
attending with whom you are seeing the patient. YOU MUST DO THIS!
3. Fill in the time at the top, left-hand
corner of the chart, the time you began seeing the patient, which is not
necessarily the time you are writing in the chart.
4.
Use history/present illness to include
information on the Past Medical History (PMH), Social History (SH) and Family
History (FH), even if all you write is noncontributory. Important and pertinent social history in
the ED settings includes uses of tobacco or alcohol and with whom the patient
lives.
5. You need to list the medications the patient
is taking and any drug allergies the patient has. If the patient has no allergies, write none; if no medications,
write none. If you don’t write
anything, others will not know if there are none or you don’t know or you
didn’t ask.
6. The history of the present illness and
physical exam should be limited to what is pertinent to the patient’s main
complaint.
7. All laboratory studies, EKG, and X-rays are
recorded along the right side of the chart.
8. Fill in the review of systems as pertinent
to the patient. If you have described
this in the HPI, note that. Keep in
mind, for complex patients (basically any patient ill enough to be
admitted) you must include 10 (ten) different ROS - even if the comment
is “no change” or “0” null sign.
9. Fill in the Physical Examination. For complex or critically ill patients you
have to be complete. These patients are
required to have 8 (eight) body systems examined.
10.
After you record the history and physical, write a short assessment including
differential. Alternately, you can make
a problem list (acute problems). In the
differential, include what you believe is the patient’s problem, as well as the
worst case scenerio. For example:
Pt. # 1: Young man with
diffuse abdominal pain, nausea and vomiting –
Probable viral gastroenteritis. Rule out appendicitis. Rule out nephrolithiasis. Rule out Pancreatitis.
Pt. #2:
Young female with reproducible sternal pain --
probable musculoskeletal chest wall pain / costochondritis, doubt
cardiac chest pain
Based on the differential problem list that you have established, it should be obvious by reviewing the chart how you distinguished among the possibilities and came to your final diagnosis. Some examples: GI cocktail given, patient with complete relief; Phenergan 25mg IV given, nausea relieved and patient tolerating PO well.
If you make a clinical diagnosis without any
work-up, you need to explain that. For
example: 20 year old white female with reproducible chest wall pain, no risk
factors for CAD and no associated symptoms, likelihood of cardiopulmonary
disease as the underlying etiology is very low. We will treat her with NSAID’s.
Patient knows to return if symptoms change or worsen.
11. If the patient is in the Emergency Room for a
significant length of time waiting for disposition or a bed, you need to make
note that you reevaluated the patient during this time. For example: 2:45 pm Patient now afebrile and tolerating oral
fluids well. Many conditions such
as respiratory distress, chest pain and abdominal pain require frequent
reevaluation, and you need to document it.
12. If you counseled the patient about a health
problem (i.e. diet, importance of taking HTN meds, need to drink less ETOH),
write on the chart that you did this.
All patients evaluated for STD’s must be counseled about HIV, and you
must write this down.
13. If you call a consultant to see the patient,
write down the time and who you talked with at the bottom of the Attending note
box. For example: 6 pm Discussed case with Dr. Smith(General
Surgery) who will evaluate patient.
“Curbside” consultations are not official. If there is really a question, the patient must be seen by the
consultant.
14. Write a procedure note for all procedures
done on the patient: Lumbar puncture, thoracentesis central
lines, etc. You need to write this
in the procedure box bottom left corner of chart.
15.
For lacerations, you need to include the following information by filling out
the box in the lower left corner of the chart.
·
location on body (make drawing if you are so
inclined).
·
size (must be in cm) and is it dirty? Describe wound.
·
you need to describe the repair (irrigation
solution and amount, type of suture material, type of sutures (interrupted,
subcutaneous, etc.), how many layers, anesthesia (solution, how much, local vs.
digital vs regional).
·
Remember
to ask about tetanus status for all wounds and document this.
16. Diagnosis:
The first written down pertains to why they are here today, but if they have
underlying disease that is pertinent to what is going on, you need to write
that down as well. For example:
Pt #1: Chest pain, rule out MI
HTN
Type II
DM
Pt. #2: R/O cryptococcal meningitis
AIDS
Severe
Hemophilia A without inhibitor
17. Attending Note – The
attending evaluating the patient with you will need to write a detailed note in
the area designated “Attending Note” – so please leave that space open. At the bottom right of the chart under
“Evaluation and Management” is the patient charge as determined by the
Attending physician – leave that blank.
18. Injury Assessment (bottom right of chart) –
please fill this area in if your patient has been injured. Check the appropriate boxes to answer the
questions if you have the information available.
19. Signatures at the
bottom of the chart: You need to sign
as the examining physician with your physician code. The attending will sign at the bottom right of the chart.
20. Condition on Discharge
- Be honest but statements such as
“Good” or “Improved” are best. “Stable”
is also acceptable. If the condition is
“poor”, “serious” or “critical” – the patient should usually be admitted.
DISCHARGE
INSTRUCTIONS
These are very
important and reviewed in detail. This is a common source of legal problems in
Emergency Medicine – so take the time to do it thoroughly.
You
must include on this sheet: