Emergency Medicine

• Katrina Wade, MD and Emily Fite, MD (EM clerkship EM-410 directors)

• Samantha Bergesch, EM Department Coordinator (samantha.bergesch@health.slu.edu)

• Kate Forrester, MD, (PEM site director) (kate.forrester@health.slu.edu)

• Faculty: PEM, EM, and general pediatrics

  • Attending 1. Works primarily with the PEM fellows and EM residents.

  • Attending 2. Works with residents and students.

  • Attending 3. If present, their primary duty is to perform sedations and see patients on their own. If flow dictates, they can staff residents as well.

• PEM fellows

• Residents: pediatric, EM, family medicine

• Emergency Medicine Clerkship (EM-410) Fourth Year Students. Up to 2 students are scheduled at CG each 2w block. Students have the option of spending 2 or 4w of their EM month at CG. Those applying in pediatrics or combined programs have priority for CG spot.

• PA students: 2 per 2w period

• Third year pediatric clerkship or CE students: 1 per 1 or 2w block. On occasion if no M4s are present (Eg. capstone) 2 M3s might be scheduled

• Multidisciplinary healthcare team providers: nurse practitioners, EMTs, social workers, consulting services, scribes

• Review the Learners on Pediatrics Spreadsheet/EM for your schedule

  • PEM Shifts

    • “Regular” 8hr shifts. Preferred

      • 7AM-3PM

      • 3PM-11PM

      • 11PM-7AM

    • “Less preferred” 4hr shifts: 1-5PM. Less preferred as overlaps with other learners; utilized if regular shifts not available

  • Fourth Year EM Clerkship Students. You will have the opportunity to submit EM clerkship site and schedule requests prior to the rotation. requests which include spending either 2w or 4w of your EM rotation at CG. Each student is scheduled for a total of fifteen 8 hr shifts including at least 3 night shifts. Once the schedule is made, any shift changes will need to be approved by the EM clerkship directors

  • Third Year Students (Clerkship or CE-PED 302)

    • • Have the option of requesting PEM as their clinical site. Please be aware that EM shifts for Clerkship and CE students are skewed towards evenings and nights due to both the nature of ED and the M4/PA schedule. Looking through the M3 schedule of prior students on Learners on Pediatrics Spreadsheet/EM will give you a good idea about the typical schedule.

      • Your scheduling is more complex as the availability of the preferred “regular” shifts is dependent on the the M4 and PA schedule which is done by the EM group ~1-2w prior to the start of the M4 block.

      • Once the M4/PA student schedule is shared with us, we invite you to use the “insert comment feature” to request any open shifts.

        • Total number of shifts. You can request as many open shifts as you like. Aim at minimum of 24 clinical hours per EM week (~12-16 hours dependent upon availability during the abbreviated week 7 and ACS/Holiday weeks)

        • Weekends, evenings, and nights. You can request as many weekend, evening (3-11) and night (11-7) shifts as you like. These can count for up to 1 of your required weekends and up to 1 of your required late stays. (The others need to be on general inpatient)

        • Academic half days. The required clerkship academic half day is 1:00-4:00. You are able to work the 7AM-3PM or the 3PM-11PM shift that day and plan to leave early or arrive late. Please take that into account in your hours calculations

        • Shifts outside of your designated EM week. While typically most of your shifts will occur during your designated EM block, you can requests shifts outside of that block IF you happen to have availability (Eg. Day off, individual study day). Keep in mind

          • • Your assigned clinical site takes priority

            • You can request as many of these shifts as you like. When finalizing the schedule, the student scheduled for the ED during a given week gets priority regardless of how many others also requested the shift. No worries about “stealing” shifts from your colleagues! Similarly if it's your ED week and a colleague had already requested a shift you want, please add your name.

            • A special note to students scheduled in the ED during weeks 6 and 7. If possible, we recommend completing some ED shifts earlier. ED shifts tend to be skewed towards late evenings and nights which are hard to do right before your NBME.

      • Shift request deadlines

        • To allow for better schedule planning for all students we ask that you request shifts

          • Monday week 1 of the clerkship (along with all other schedule personalization tasks), for weeks where the M4/PA schedule is available at the start of the clerkship

          • Within 48hrs of our office notifying you the M4/PA schedule is posted for weeks the the schedule is not available at the start of the clerkship.

      • We will notify you when the schedule is finalized!

• Download the free Cardinal Glennon ER Reference App

• Individual Study

  • Textbook: Fleisher and Ludwig’s "Pediatric Emergency Medicine." The first half of the book consists of brief chapters on common complaints. Each is 3-5 pages long, easy to read and a great review.

Dress code: white coats and scrubs optional

Essentially ALL the conditions on our pediatric syndrome list

Location:

• Map: Cardinal Glennon Pediatric Emergency Department

• Plan to arrive 20-30min before your first shift to allow for site orientation which will be typically performed by a student coming off shift, resident, or fellow.

• Introduce yourself to the senior and junior residents and attendings. Be sure to let them know your level of training

• Get an ASCOM phone from the pink bin on the shelf in the physician work room

• Write your name, level of training, and ASCOM on the white board across from the Charge Nurse’s desk. This board lists the nurses, their assigned areas and ASCOM phone numbers. It has other useful numbers and information, such as the service on call for that month for facial or hand surgical issues.

• All your patients will be shared with a resident

  • Senior resident: if there are no M4 students during the shift

  • Junior resident: if there is an M4 student working with the senior resident

• The resident with be the assigned provider on the track board

• Due to need for time efficiency (time to doctor, time to disposition, etc are closely tracked ED quality metric), third year students are asked to go in the room with a resident. Students are encouraged to use this as an opportunity for direct observation and coaching being the primary person obtaining history and physical exam.

• You can present directly to the attending if it has been cleared by the senior resident and the attending.

• • Observed patient encounters: EM is a great potential setting for problem based encounters. Be conscious of time as efficiency is crucial in the ED.

  • Medical documentation assessment: Up to one ED note per student can be used. Submit note to evaluated by Dr. Forrester (PEM site director) NOT the ED attending you are seeing the patient with.

  • Document required clerkship encounters (OASIS)

    • Problem based complaints

    • +/- Vaccine (influenza, catch-up) administration

  • Qualtrics self-assessment and formative feedback. Possible though typically not ideal as you work with a number of different attendings. You could share with Dr. Forrester to submit based on her own experience and feedback (coaching evaluations) submitted by others.

• There is currently one EM didactic day scheduled per week (usually lasts from 8:30am - 2 or 3pm)

• If you are assigned to work a shift on a didactic day, you must attend didactics and then report to their respective shifts after didactics have finished

• Graded assignments include weekly quizzes, required procedure checklist, and a case presentation during the last two weeks of the rotation

• A list of required procedures is provided that students must perform while being supervised by an attending, resident, or nurse

• You are the assigned provider on the track board

• You will typically staff the patient directly with the ED attending. A handful of attendings (Dr. Floor, Dr. Laffey, Dr. Peter, and Dr. Charney) prefer that all students staff patients with residents first. When in doubt, please check with your attending.

• Department CG Emergency Dept

• Medical documentation expectations. Documentation optional for third year students and expected of fourth years.

• Orders

  • Clinical Students (both third and fourth years) are encouraged to place orders! Orders are NOT “active” until co-signed by a physician

  • ­We have several standing orders for labs and X-rays which may be initiated by the nursing staff in triage. The order is placed in the name of the attending on duty, even if they have not seen the patient. The nurses can give fever reducers, pain meds, order nebulizer treatments, obtain X-rays, strep swabs, urine testing, etc.

  • The nursing staff requests that we also notify them of new orders on their ASCOM phone, and this should be done when possible, especially if the order is urgent. Click on “Phone List” on top of the track board or check the main white board. If you are unsure who to call, you can always call the Charge Nurse at ext. 3910.

• Signing In and assigning patients: After logging into Epic and logging into the ED context, be sure to click the “Sign In” button at the top of the Dashboard, enter your ASCOM number

  • For every patient that you decide to see, right click on the patient’s name and click “Assign Me,” this will assign you and your associated ASCOM to the patient so that the nurses know who to call for questions

  • Remember to “Sign Out” at the end of each shift and “Reassign” your patients to the student taking over for you.

Above is a screenshot of the ED trackboard.

• When you first log in, adjust the column sizes so that the nurses name, attending names and resident names are visible. The board view can be customized by clicking on the column headings. Some residents find it helpful to group the patients by Resident (double click on the “Resident” heading). That will keep your patients together and the unassigned patients grouped at the top of the board

• Pay particular attention to the “AC” (Access Center) column and the “Comments” column. An “ED” notation in the AC column or a “CALL IN” notation in the Comments column means this patient has been called in through our Access Center. In these cases, be sure to read the call-in note at the top of the chart when you first click on the patient. There may be orders that the referring private or specialty physician has requested, so expedite these. Also note the referring physician call-back preference!

• Patient acuity (ESI) is assigned in triage. ESI of 1 are the highest acuity, 5 are the lowest. The highest acuity patients should be seen first, especially 1’s and 2's , then by Door–to –Doc time. The bell is green 0-20 min from arrival, it turns yellow at 20 minutes, then red at 30 minutes. We try very hard to see patients before 30 minutes

• We ask that a senior resident, fellow, or attending be the primary ED physician for patients with concerns for abuse (Complaint is abuse, sometimes noted as SAM, CAM, or “concerns”) independently. Students are welcomed to accompany the more senior physicians in taking the history and performing the physical exam. There are several reasons for this. Repeat histories and exams are to be avoided. There are also more documentation constraints given higher likelihood of the case proceeding to court. If photographic documentation is required, it needs to be performed by a fellow or attending.

• IF YOU FEEL YOUR PATIENT NEEDS ATTENTION RIGHT AWAY, PLEASE INFORM THE SUPERVISING PHYSICIANS ATTENDING IMMEDIATELY.

• Time management is extremely important in the ED. Use common sense to decide if you are not being efficient, which can be either too many or too few patients. Make sure you track the progress of orders, labs, admissions, discharges, and keep families informed of plan of care, its progress, and any delays.

• Keep track of TIME – if there are delays, especially consults, etc, keep the attending and families informed!

• It is an understatement to say that patients are brought to the ED for less than emergent complaints. While we can be frustrated with this, we must also be aware that we are not privy to the forces at work in the lives of some of our families. They have weak or nonexistent support systems, with few safety nets. They often just need reassurance that they are not missing something - and a prescription for a fever reducer. We can debate solutions, but in the ED, be respectful, acknowledge their concerns even if they seem trivial to you, reassure, and educate kindly. Too often it was Grandma who told them they had to come. Also, our patient population includes those at high risk for more serious illness than the parent describes.

• While appropriately focusing on the primary reason for the ED visit, don’t forget the rest of the patient. ­Every patient, even with a finger injury, should have an adequate history and physical, within a reasonable time frame, of course. Many patients do not see their physicians regularly and have ongoing or unrecognized health problems.

The unit secretary handles all paging. They will request the name of the patient to ensure the right person gets the return call. Check the “PCP” column on the track board to see that the call has been placed and whether there has been a response. Be sure to document in the chart that you spoke to the PCP. If you are unable to make contact, be sure to document that as well, and your efforts to do so.

• For pediatric medicine patients, floor or TCU, ask the unit secretary to page the appropriate admitting resident, present the patient, and obtain the name of the inpatient attending. For PICU, there is attending to attending communication first, then resident-to-resident.

• For pediatric medicine patients admitted to the general floor only, interim orders to cover the first 2 hours are placed in Epic. Start with the lower left “Admit” button, click on the bolded blue “Click here to place orders” at the top, and follow the 4 screens, including the ED admission order set. Again, this is only for the first 2 hours of inpatient stay. Order only what is needed, - most initial meds and treatments should already be done in the ED anyway. Do not order home meds because the floor team needs to review and re-order these. Finish the interim orders by clicking the “sign and hold” tab at the lower right of the final screen.

• For all other patients – PICU, TCU, surgical, DO NOT click the “Admit” button, even though that would make sense. Rather, since you are not entering interim admission orders for these patients, it is much easier to click the “Order” button and type admit as an ED order. This will bring up only the Place patient in box, that allows you to order the bed. You need to know the attendings name as well (admitting and attending are the same) For all floor patients, whether surgical or medicine, place in “general medicine”. For the TCU, place in “Intermediate Step Down” (I didn’t do this…..). PICU is the same, and if a patient goes directly to the OR, the charge nurse places the order. For any patient being admitted to the Hematology/Oncology service, place in “oncology”. You only need to enter the 4 screens highlighted in red.

• A yellow banner should pop up if the patient’s primary attending wishes to admit patients to their own service. This is becoming less common but it is VERY IMPORTANT to clarify when contacting the attending for admission.You must contact the pediatric admitting resident for all medicine admissions, all levels.

• ALWAYS make sure the family is informed of the plan to admit, and keep posted of any delays.

• ALWAYS ask the Unit Secretaries to call the PCP, even if the patient is being admitted to a surgical service. The Unit Secretaries have been instructed to call the PCP as soon as the disposition (admission) decision is made. Document your call in the Medical Decision Making section.

• Subspecialty follow up appointments are scheduled using the SSMDIRECT Service

  • In the discharge flow, in the area where you write prescriptions, enter: “ssmdirect.”

  • Choose the appropriate sub specialty from the list. If the sub specialty is not listed, they do not participate in SSMDirect.

  • Click on the highlighted text following the yellow exclamation point.

  • You do not need to specify a specific provider, but you do need to specify a specific sub-specialty. To enter a subspecialty, type “CG ACC”. A list of clinics will follow choose the appropriate clinic.

  • Sign the order

  • When you proceed to the “Follow Up” section of the discharge flow, the appropriate clinic will be listed.

  • Schedulers will contact the family within the next 2 working days to set up an appointment. The family should not need to call for an appointment.

• Print the discharge papers and any prescriptions, place in the green folder, and put that in the patient’s room slot in one of 3 areas of front and back nursing stations. The nurse will discharge the patient. Do not discharge patients yourself, and do not expect the nurse to print the discharge papers - prescriptions have been missed!

• You must refresh the chart before signing in order to populate the diagnoses from your discharge or admission screens – very important!

• Make sure you include ALL pertinent diagnoses, including underlying conditions if they impacted the patient’s care. For example, the child may have a viral illness, but if they also have a VP shunt, asthma, etc. that required assessment, include those diagnoses as well.

• If you still have patients you are working up, sign them out to the medical student starting their shift and let the senior resident know that you are doing that. You should record that in your note (i.e. "Name, MS4 agreed to assume care of this patient"

• Check with the resident

• Students invited to attend if their clinical schedule allows.

• PEM Fellows Conference: Tuesday 2PM, ED Conference Room and zoom

• Mock Code, 1st Tuesday of the month 11AM, CG ED