Emergency Medicine

Dr. Alice Beckman

Email: ab5186@cumc.columbia.edu 

EM Rotation Liaisons

EM Chief Residents: nypemchiefs@gmail.com (specify "Columbia" in subject line)     

Chief resident on Call: 17242

Chief residents do all scheduling

EM Faculty: Dr. Sayan Osman

1. Become comfortable in triage and care of acutely ill adults. 

2. Familiarize yourself with NYP ED and Milstein systems.

3. Exposure to additional populations within our community.

4. Opportunity to perform procedures including ABG, suturing, displaced shoulder reduction, lumbar puncture, paracentesis. 

Rotation Objectives: (You will be evaluated on these. In parentheses are the relevant ACGME milestones for reference)

1.  Obtain relevant history and physical exam for patients presenting to Adult ED. (PC1)

2.  Diagnose and manage common medical, surgical, gyn, and psychiatric emergencies with attention to appropriate differential diagnoses and use of protocols. (PC1)

3.  Appropriately recognize, triage, monitor and reassess situations requiring urgent or emergent care. (PC1) 

4.  Arrange appropriate transitions of care for admission or discharge. (PC1)

5.  Coordinate team-based care with cultural competency: Clearly communicate with ED colleagues, consultants, and patients/families regardless of race, age, sexual orientation.. (PC1, SBP4, PROF3, C1, C2, C3)

6.  Clear and concise documentation in notes. (C3)

7.  Demonstrate initiative and proactive learning. (PBL2)

8.  Act professionally (includes arriving on time) (PROF2)

9.  Obtain informed consent for and perform urgent procedures under supervision (PC5)

10.  Explain the indications, contraindications, and complications of urgent procedures (PC5)

ED Schedule 

**You must watch this orientation video prior to starting the rotation: ED orientation video

•  Review your schedule and rotation guide at least one week prior to starting so that you are familiar with your schedule and expectations.

•  Notify chiefs and rotation liaison if you will not be present for any expected activities.

**All shifts in the emergency department belong to family medicine and must always be covered. 

• Any sick calls out require another family medicine resident to be pulled to cover the emergency room shift. 

• Always notify the family medicine chief residents immediately if you anticipate coverage problems. 

• Requests for scheduling changes are due 10 weeks prior to start of block and can be made using the request form  on the EM website 

• Send names to Diana of attendings that you work with (she will send medhub eval to them). You may send these names throughout the rotation.

• Attendance at Thursday AM All Staff Meeting IS required.

• Attendance at Tuesday Morning Report and Thursday Lecture are NOT required. 

• No nursing home shifts.

• Complete “ED Rotation Evaluation by Resident” on the final week of your rotation

1. General

   • ED shifts: 2 ED shifts per week: Tuesday day shift (8a-8p) and Friday night shift (8p-8a).  

   • Wear scrubs and sneakers (try to be comfortable; you will be on your feet a lot!). 

   • If you prefer, professional attire with white coat is also acceptable.

   • You can store your things in a locker in the ED Resident Room (0-3-4-2 for resident conference room (from Vanderbilt entrance: pass the PH elevators, when you have almost reached the end of the hallway, it is on the right, directly across the security office on your left). There are lockers that you can use, bring your own lock for any valuables.

   • You will rotate through Areas B, C, and D over the course of the month. 

     • Areas B and C: you will work with senior ED residents (3rd/4th years) and will generally present patients to them.  Areas B/C are more medically acute, and it is common to carry anywhere from 5-8 patients over the course of the shift. 

     • In area D you work directly with an attending. Area D is where most of the psychiatric patients go, as well as medically less acute, and it is common to carry up to 10-12 patients here.

2. DAY SHIFT:  

• Attend Morning Conference at 9:15 AM (mandatory). 

• Make sure to take time for a lunch break- please check in with your supervisor prior to taking break. 

• Rounds:

1. In Area B, the attendings switch at 8am and 8pm. 

2. In Area A/C, the attendings and PGY4s work q8h. They round at 8am, 4pm, and 12am. If you are not coming on/off your shift, you do not need to round with the attending.

3. When you leave, sign out all your patients to the incoming resident using the eD-PASS method below. eD-PASS (emergencyDisposition, Patient Summary,Action List, Situational Awareness, Synthesis)

• Disposition

  • "The patient is... Under Evaluation (dispo not decided yet) vs. Pending discharge vs. Bed requested vs. Admitted but not Endorsed vs. Admitted and Endorsed to (Accepting Team)?"

• Patient summary

  • Chief Complaint, a brief history and summary of interventions

• Action list

  • What needs to be followed up? Labs, radiology readings, repeat labs to be done, repeat EKG, consults, etc.

• Situational awareness/contingency plan

  • • What will keep the pt from meeting planned disposition

    • If X happens, then Y should be done? Social issues?

• Synthesis by receiver: Oncoming resident, attending, PA/NP closes the loop of communication by repeating back a short synthesis

•   Admitting a patient:

• Once you've decided patient needs to be admitted, order "ED bed request" and fill in specifics. Usually you need labs resulted before they will assign a team.

• Wait for the patient to be assigned to a team (which you see will under team assignments)

• Once a team has been assigned, order "ed consult" and page the team you need to endorse to

• Endorse patient, and get the last name and pager of the person you endorsed to because it is required to document this in your "ED Dispo" note.

• Once you endorse, the patient's management belongs to the admitting team, so page them if any issues arise. BUT if they become unstable you are the closer doctor, make sure you have a peripheral awareness of them.

• This process can be confusing as it is very different from the Allen where most admissions go to Hospitalist PA who then distributes appropriately. At Milstein, the ED attending (and you as the resident) determine the appropriate team and put in a bed request for that specific team. The bed coordinator then agrees or disagrees with your choice (305-9150). The accepting team also has the ability to block the admission if they feel it is not appropriate for their service. If you are not sure what to do, ask for help.

FHC Sessions: WED and THURS AM FHC sessions

• Wednesday you have a shortened tally so that you can get to the Allen to cover FMIS by 12pm

• Didactics are optional

FMIS Coverage: 

• On Wednesday afternoons you cover the FMIS service so that the day senior can go to clinic.  

• You have a short Farrell tally so that you can be to the Allen by 12pm to receive sign out. 

• You are expected to assist the interns with normal tasks and addend the day admission for Wednesday afternoon.  

• You will sign out the list to the night senior at 8:30pm. 

• You also cover overnight admissions for the inpatient service on Saturday overnight. You are to arrive to the Allen by 9pm and are responsible for 2 admissions and any bounce-backs on Saturday night.  

• You do not cover the entire service (this is the Behavioral resident role).

• Can assist behavioral person with light tasks for floor patients - please make behavioral person aware of any critical values or RN pages of any changes with patients (these are behavioral responsibilities). Can hold the pager if things are quiet to allow Behavioral resident to sleep. Typically, goal is to allow behavioral senior to get some sleep since they are on the 24 hour shift.

Printing an ED List:

1. Go to File -> Print Reports.

2. In the "Report Selection" window, select "Current Time Snapshot - Milstein" -> On the bottom, select "Options"

3. In "Selection Criteria", look at the "View List" and use the dropdown menu to choose only the Area you are working in. Leave the status as it is.

4. At the top, hit the "Distribution" tab and choose the number of copies you want to print.

5. Hit Print, and then close out.

Helpful Links:

• 2019 Adult ED online orientation can be accessed at http://www.nypem.org/home/rotating-resident-resources

• Phone Directories

• Guidelines for rotating residents athttps://docs.google.com/document/d/1_7f5Wm_gYCfBeaxvblxXyQ37is_Vn2NOxkWDdRTBkac/edit

Lock combos:

• 1-5-3 for most code protected rooms including supply room between areas B and D and the water/ice dispenser sauna room between A and B. (there is also a water/ice dispenser tucked into the corner near D).

• 1-2-3-4-ENTER for most of the code protected carts

• 0-3-4-2 for resident conference room (pass the PH elevators, it is on the right, directly across the security office on your left)

• 911# to enter via ambulance bay

General Tips:

• Check "Paper Documents" for EKGs and EMS reports.

• RNs do initial labs and iv. Afterwards, all labs and EKGs should be done by techs.

• For patients up to age 65, you must offer HIV tests and document the response or else you get a hard stop prior to discharge

• No patient is ever in the room listed on the status board. Patient verification is super important. Update the status board with the right location.

• When a pt is listed in Room #-v (ie: 3V) it means they are in the vicinity of the room # listed, mostly in the hall across or around the corner from the room.

• "Notifications" are when critical, time sensitive patients are coming in. A nurse will usually make an overhead announcement preparing the area. (ie: "Notification to Area A"). These include: STEMI, STROKE, ONC, or coding patients. If there is a PGY3 EM resident working with you, they will often take the lead on these patients.

• ONC STAT is when a patient on chemo spikes a fever. risk for neutropenic fever. basically there's a protocol. routine labs, blood and urine cultures, antibiotics as soon as possible (depending on what kind of cancer, solid vs liquid) and page the onc fellow.

• Stroke notification involves immediate eval, stroke labs (ed order set stroke), vitals including fingerstick, likely non-con Head CT, and paging the neuro stroke team to eval for tPa ASAP.

• STEMI notification involves reviewing EKG and immediately paging MI team to prepare cath lab among other typical ACS management.

• Prior to calling a consult discuss w/ attending or PGY4 first. Then use order: 'ED consult' for specific service, not the usual paging system so that it is in orders and time stamped.

• Please email attending names to Diana so that a Medhub evaluation can be sent to them.

• Ask for feedback

• Ask for feedback on a specific skill

• Ask for direct observations: Would you be able to observe me do bedside ultrasound? 

Your feedback is important and invited. 

Please complete the end of rotation evaluation on medhub.

Informal feedback can be provided to Dr. Beckman