ER intro

Please note ER is my passion so these are about to be hella in depth, maybe not this deck but still.

R/o the worst case scenarios then get’em out of here (treat ‘em and yeet ‘em), cast a wide net

ER Mindset

r/o the big and scary stuff then I don’t care (based on the threat to patient safety)

How are DDX prioritized in the ER?

Discharge → check for results → admit/discharge → see new homies

Order of Work in the ED - the goal is always to get people away from me

Hx, exam, assessment, labs, imaging, necessary orders/results/consults, tentative disposition

What information do you need to find out in report from the out going shift?

shift change

When is the most dangerous time in the ER?

Review age, sex, CC, vitals (2x), look at nursing notes (especially the triage report), Talk to your nurses about how the patient got into the room if needed (walked, wheel chair, etc)

Tips for going and seeing a new patient in the ER

Allergies, meds, pertinent PMHx, last meal/bowel movement/void, preceding events

What do I mean by getting an AMPLE hx?

Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time

What do I mean by “OPQRST” when describing pain?

If you need to see the skin, look at the skin; Use Chaperones as needed, Do thorough focuses exam (think above, below and superficial/deep)

Tips for Physical exams in the ED

2 EKGs (one in pain, one out of pain)

Chest pain peeps need…

Tell the story using the SOAP format, have a tentative plan (you got this)

Tips for presenting patients - IF THEY ARE CRASHING DON’T WAIT TF

Aggressively treat the sick, try to stick to oral meds if you can, we don’t mess with chronic meds that a PCP thing, don’t keep your patients in pain

Treating people in the ER

IV access, O2, Vitals, CXR, CBC, CMP, Maybe preg, UA, tox screen, EKG, fingerstick

General shot gun orders

EMTALA (Patient Anti-dumping statute)

A federal law that requires anyone coming to an ER to be stabilized and treated regardless of insurance or ability to pay (transfers can only be done to a higher level of care)

Medical Screening Exam

A brief emergency medical exam that is to rule out or identify life-threatening problems (satisfies EMTALA but if your wrong there’s a liability risk)

not resuscitating

A 109 patient goes into V.fib while under your care in the ER. His nurse informs you he has a DNR. What are you doing?

ask before you need it, if patient becomes unresponsive before that conversation or with unclear wishes the next of kin makes that decision

DNR tips

they compensate great and then crash, weaker immune systems so there’s different things to think about, Hx from caretakers, can be difficult to perform a physical, watch your orders (some like radiation cause long term harm), meds are weight based, considered the parents in the management plan, maintain a suspicion for neglect/abuse

Tips to handling Ped patients

Often present in a less acute manner (stoic, reduced pain sensation), cast a wide net (like lots of things cause AMS), hypothermia may present instead of hyperthermia, avoid anti-histamines (may cause delirium/excitation), be careful with pain meds, maintain suspicion for elder abue

Tips for geriatric patients

Determine whether there are life threatening injuries (ex if they were choked get a head CT) and if the patient wants a SANE exam → then transfer to the SANE nurse

Step 1 in dealing with SA patients in the ED

remove clothing, perform GU or rectal exams

If your patient wants a SANE exam → what are we not doing (unless we literally have to)

STI PEP (rocephin (ceftriaxone), azithromycin, HIV pep maybe); hep panels, anti-HBs, HCV screen, HIV screen, RPR

Orders for SANE work-ups

SI, HI, deteriorating mental health that leads to the being a danger to self

What do we need to determine in psychiatric emergencies?

Is the patient chill when the drugs wear off?

What do I mean by “attempt metabolization to freedom”

Emergency Detention (ED)

Removes the patient’s ability to leave the facility for 48 hrs (2 business days) that can only be determined by law enforcement

Mental illness, substantial risk of serious risk to self or others, risk of harm is imminent, ED is the least restrictive (you can’t ED a voluntary patient)

What is law enforcement looking for before writing an ED?

oral meds

How are we chemically stabilizing cooperative patients?

IM medications (increase compliance and safety for patient and healthcare team)

How are we chemically stabilizing non-cooperative patients?

Labs (usually CBC, CMP, Preg, UA, urine tox, maybe alcohol), EKG, imaging PRN

How can we medically clear patients for psychiatric care?