Sharp Grossmont ED

Please contact the Rotation Director (Erik Strukel) and Rotation Coordinator (Magdalena Bonilla) at least 4-5 weeks prior to the start of the rotation. Point of contact: Magdalena.Bonilla@sharp.com, estrukel@yahoo.com.

***You cannot start your rotation (work any shifts) until after you complete the mandatory day-long training listed below.***

The Sharp Grossmont ED schedule can be found through the Block Calendar & Schedules pages.

Please also complete the rotation paperwork below NLT 8 weeks in advance and submit to Castor.

Grossmont Resident Paperwork.pdf

ORIENTATION on Day 1:

If you haven’t been there before, they have a ½ day in-briefing in the AM. You can test out of EPIC training, but still a bunch of stuff and paperwork that Monday morning. So don’t plan on having access Monday morning for a shift. Earliest would be an afternoon shift and schedule your orientation with Magdalena for that morning ahead of time (she sometimes works from home). They should also get you set up with basic Dragon phrases for notes/procedures. If not, you can steal from someone who's been there in Epic's SmartPhrases.

Paperwork: you will re-sign everything in person. But my understanding is you still have to send all the packet in.

Schedule: you get to make it…just have to do it ahead of time and Dr. Tanaka/Sadowski check it. No last minute changes, or reach out to ACRs/Sadowski to let them know.

Shift times 8a, 4p, 12p. If you’re there by yourself, don’t need to do overnights. But also don’t screw over your other residents. We’re the only ones there!

Attendings do up front/triage for 1st 2 hours of shift then come back to B pod. Try to not see patients in the waiting room or unless an attending grabs your for something cool up there. We’re there for acuity, not runny noses and UTIs.

Most of the attendings are great, I tried to work with Navy people because they get it, but they’re mostly strong. If you’re on with Dr. Weinstein, he’ll do subclavian lines with you.

Stop picking up 2ish hrs before end of shift. There’s no turnovers other than psych. So you’ll stay late to dispo if you pick up late.

Cafeteria/Food:

$25/shift in food credit at the cafeteria!!! There's some weird times, especially on the weekends. But more than enough for a few energy drinks, bubbly water and warm meal on shift.

ER Set-Up

The ER is divided into different “pods”. Residents work in the B pod mostly (sick/critical pod, where ECMO/CPRs go), but A 15-A16 and C 15-16 are resus rooms too.

A pod has a lot of psych, but E pod is all the psych holding area/locked facility. D pod is fast track. You might get taken over for a nerve block, eye stuff or weird procedure. But really try to pick up all of B, sick ones in A & C and then can grab others in A & C if bored and nothing going on. Don’t pick up psych, long stays with long turnovers. You’re not expected to either.

It is Tri-City without the psych patients and Mercy without the drunks

Stroke Codes – follow stroke code protocol

- Immediate exam in ambulance bay if BIB EMS or if walk-in will be taken back by the back hallway between A/B near the elevators

- Put in stroke code orderset if not already done

- Have ER Clerk call neurologist for you

- Call Neuro IR ASAP if patient has even mild possibility of large vessel stroke (neurologist can help determine)

Procedural Sedations

Order ED sedation order set

Pre-sedation form

Consent for sedation and procedure

Discharge instructions for sedation

Document procedure in-service time

Sepsis protocol

Severe sepsis protocol: lactic acid > 2.0 or other organ dysfunction

Broad spectrum antibiotics within 3 hours

Document time of diagnosis of severe sepsis

Septic shock protocol: lactic acid > 4.0 or hypotension

Broad spectrum antibiotics within 3 hours

30ml/kg fluid bolus (or document why not giving…aka fluid overload & CHF)

Document time of diagnosis of septic shock and

Document time of re-assessment exam

ECMO:

For ECMO’s, you run the code,m intubate and can do a CVL. We are legally not allowed to do femoral lines for cannulation, but great to watch (they'll be busy so run the code)

IM admission is an incredibly confusing process, but BLUF:

1) Look up PCM & compare to list, if no PCM or they’re not on list, go to step 2

2) Look up insurance under Chart Review > Far left 4 color tile/icon > face sheet > under insurance section

3) Go to notes and look up recent admission and see if is one of the Sharp Grossmont hospitalists recently admitted

4) THEN, you can look at the CSN (under the MRN): Odd vs Even last digit goes to corresponding hospitalist on call in QGenda

***also can just ask the attending or the Clerk

PLEASE use the following templates while at grossmont

"INSERT SEPSIS"

SEPSIS DOCUMENTATION:

SEVERE SEPSIS:

Time of diagnosis of severe sepsis: "INSERT TIME" DIAGNOSTIC:

1)Suspected source of infection is: "INSERT SOURCE"

2)SIRS Criteria noted: Fever; tachypnea; tachycardia; leukocytosis.

3) Organ dysfunction noted: hypotension; elev creatinine; plts <100,000; INR >1.5; PTT > 60 secs; lactate > 2.0

TREATMENT:

1) Lactate was ordered within 3 hrs

2) Antibiotics were administered within 3 hrs. Antibiotics included: "INSERT ABX" 3) Blood cultures were ordered prior to administration of antibiotic.

4) Because the lactate was >2.0, repeat lactate was ordered within 6 hrs. 5) Patient received a fluid bolus of 30ml/kg over "insert number" hours SEPTIC SHOCK:

Time of diagnosis of septic shock: "INSERT TIME"

Diagnosis of "septic shock" was made because patient demonstrated:

Systolic BP < 90; MAP < 65; Systolic BP dropped > 40 from baseline; Lactate > 4.0 Since hypotension persisted, vasopressors were initiated.

"Insert Central Line"

Procedure done under the guidance of *****.

The patient emergently required central line access and presumed consent was provided. The patient was prepped and draped in the usual fashion including maximal sterile barrier precautions. Sterile ultrasound probe cover and technique was used. I was able to identify the right internal jugular and using ultrasound guidance large-bore needle was able to access the right IJ with good blood flow. The wire was advanced without difficulty. Using Seldinger technique I advanced the catheter over the wire. I have good blood flow from all ports. The line was secured. There is a post chest x-ray that reveals good placement.

"Insert Critical Care"

The high probability of clinical deterioration in this patient resulted in the patient requiring my full and direct attention, intervention and personal management for 30 minutes while the patient was critical. This critical care time was independent of any procedures performed.

"Insert Homeless"

This patient is determined to lack a permanent residence and therefore further assistance at the time of discharge has been provided, including but not limited to, found to be stable for discharge, offered a meal, offered weather appropriate clothing if needed, referred to outpatient behavioral health or medical clinics and an attempt at contacting those clinics was made if during business hours, the patient was provided a prescription, if medically necessary, and the medication can be filled at the on campus pharmacy if during operating hours or at a local pharmacy of the patients' choosing and the location of those pharmacies provided, patient has been referred for screening of infectious diseases, appropriate vaccinations provided during a county determined outbreak, transportation offered to their location of choice, and screening or enrollment into a health plan was attempted.

"Insert Intubation"

Done under the supervision of ****.

The patient required emergent intubation and emergency consent was implied.

The patient was sedated with _____and paralyzed with _____. once adequately sedated and paralyzed a (device) was placed in the vocal cords were visualized. A (size) endotracheal tube was then passed with direct visualization through the vocal cords. The cuff was inflated, CO2 detector placed with a change in color. Breath sounds were auscultated and fogging in the tube was noted. Currently pending chest x-ray for confirmation of placement. Patient tolerated procedure well without any immediate complications.

"Insert Procedural Sedation"

Done under the supervision of ****.

Consent: Documented

All questions answered for the patient. Patient was placed on cardiac monitors including end-tidal CO2 and supplementary oxygen. After a brief timeout ****was pushed IV nurse. The patient then slowly became sedated in the intended procedure was performed. The patient experienced no complications and remained spontaneously breathing without any hemodynamic compromise during the duration of the procedure and sedation.

The patient tolerated the procedure well without any immediate complications.

"Insert Stroke"

STROKE CODE SUPPLEMENTARY DOCUMENTATION

Last known well time: "INSERT TIME"

NIHSS (Stroke score): "INSERT SCORE"

Neurologist was consulted by phone at: "INSERT TIME"

Patient was not a candidate for TPA because: "INSERT REASON"

CTA was not done because "INSERT REASON"

Patient was not a candidate for endovascular therapy because: "INSERT REASON"

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