ED

Alice Beckman, MD 

Emergency Medicine Rotation Liaisons:

EM Chief Residents: Contact at nypemchiefs@gmail.com - Please specify “Columbia” in the subject line

- Chief Resident on Call: 17242

- Chief residents do all scheduling

- Dr. Sayan Osman (faculty)

Residents must have emergency department experience. Residents must have at least 200 hours (or two months) or 250 patient encounters dedicated to the care of acutely ill or injured adults in an emergency department setting.  

Transit Welcome Packet 

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

• Familiarize yourself with NYP ED and Milstein systems.

• Exposure to additional populations within our community.

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

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

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

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

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

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

• 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)

• Clear and concise documentation in notes. (C3)

• Demonstrate initiative and proactive learning. (PBL2)

• Act professionally (includes arriving on time) (PROF2)

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

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

Before you begin...

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

All shifts in the emergency department belong to family medicine and must always be covered. Any sick calls 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 the start of the block and can be made using the request form on the EM website. 

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

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

You will be scheduled for 3 EM shifts per week

Third week of the rotation is nights

No one should be doing more than 3 D shifts total in a month, please contact Dr Beckman if this occurrs

Everyone should get at least 2, but ideally 3, fast track shifts

On Wednesdays, you will have AM and PM FHC sessions.   PLEASE DOUBLE-CHECK THE ORANGE SCHEDULE EACH WEEK AS THIS MAY CHANGE.

You will have 12 shifts per rotation (approximately 3 shifts per week). All of your shifts in the ED belong to family medicine and must always be covered. You are expected to be at the assigned shifts. Any sick calls 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 the start of the block and can be made using the request form on the EM website.

See below for further details and logistics about ED shifts. ****

The following are the most important items to understand prior to starting your first shift. Please see the website for a more comprehensive overview of the ED. 

On Tuesday afternoons are protected POCUS time

Ideally 2 of the Tuesdays will be time with Dr. Beckman at the Allen scanning patients 

1 of the Tuesday afternoons will be with a US tech

1 of the Tuesday afternoons will be with radiology reading US

Please use the following dot phrases in your documentation: 

.resmdm for medical decision making in the "assessment and plan" portion of your ED provider note

.resdispo to write a progress note each time that you discharge or admit a patient.

Admitting a patient:

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

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

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

• Endorse the patient, and get the last name and pager of the person you endorsed 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.

You are required to have ONE EVALUATION PER SHIFT. At the start of your shift, determine which EM attending is the one who will complete your evaluation form (the one with whom you spend over half your shift). This is a great time to discuss:

1. objectives of the EM rotation

2. your learning goals for the shift

3. the timing for the completion of the evaluation form (especially when the shifts end at different times for the resident and the supervising attending)

At the agreed upon time, approach the attending with the QR code for the evaluation form (it will be sent in your welcome email), which would ideally be completed immediately, and be accompanied by a brief face-to-face learner centered feedback session reviewing:

1. your learning goals

2. your self-assessment (what you feel you did well and what you would like to improve on)

3. faculty response to your learning goals and self assessment

4. key learning points from the shift

During the first few shifts, please let the EM senior resident and the attending know that you will need extra guidance, please don't hesitate to ask for help! 

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. In 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.

You should attend the Morning Conference at 9:15 AM. This has replaced the noon conference. Make sure to take time for a lunch break- please check in with your supervisor prior to taking a break.  

Rounds:

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

2. 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.

Helpful ED Tips:

A. 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.

B. 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

C. 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

 D. 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 patient is listed in Room #-v (i.e.: 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. (i.e.: "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 oncology fellow.

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

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.

Complete “ED Rotation Evaluation by Resident” on MedHub during the final week of your rotation.