Emergency

Case Author: Anthony Huffman, Class of 2021

Content Reviewer: Dr. Manpreet Sidhu, R2 Family Practice

Case Objectives

To describe an approach to staying organized during an emergency department shift
To identify the location of patient charts in the ED as well as outline where useful information can be found on the charts.
To outline a suggested approach to the evaluation of a patient in the emergency department.
To provide students with an opportunity to attempt delivering a structured emergency presentation.
To demonstrate how to write orders in the ED.
To describe the difference between workflow on major versus minor side of the emergency department.

Case Narrative: Starting your Shift

You're on for a 3:30-11:30 PM shift in Emergency and it’s your first day on the job. You show up 15 min early and drop off your backpack and dinner in the ER doctors lounge. You head into the ED and check the whiteboard near Trauma bay 2 and see that Dr. R is also starting at 3:30 PM, she’ll be your preceptor for the shift.

ER Whiteboard

Found beside Trauma Bay 2. Simply find which ER doc starts at the same time as your shift. This will be your preceptor!

You meet Dr. R and she hands you a chart.

She says: “I’ve only briefly seen this patient and ordered an ECG, they look well enough and I think you should see them. I’ll give you about 20-30min, do a history, a physical and let me know what you want to do about it”

You say “Thanks, I’ll come find you after!”.

You suspect that it’s going to be an interesting but busy night...

Objective 1 & 2: How to stay organized during an emergency shift & Where to find patient charts

Your rotation in the ED is often your first opportunity to see undifferentiated patients. This means it is a good opportunity to practice working through a broad differential. The ED is busy, you’ll see multiple patients, and it’s easy to get caught up worrying about being efficient. Don't do this, at least for the first few shifts. Staying organized is a good approach to learning in the ED, and there are many ways to do this.

Example Patient Organizer

We suggest using a separate piece of paper to keep track of all the patients you’ll see over the course of a shift. Each patient chart comes with ID stickers, take one of these and place it on your paper. Beside the sticker you may find it useful to record the chief complaint, your differential, and any pending investigations you need to follow-up on. This will help you take ownership of your patients. Be sure to shred this document at the end of your shift.

ED map: Chart Locations

Sometimes a preceptor will simply hand you the chart, other times you may grab them yourself.

Charts can be found in several locations:

1. In the wall-mounted slots behind triage: these are typically patients in the Acute Emergency Room Waiting Area who will later be seen in the Triage Bays.

2. In the rack above the Nursing Unit Clerk (NUC) station: these are more acute patients that you’ll want to see first.

3. In the rack between the two NUC desks: these are charts with pending lab work and imaging orders.

4. In the slots at each of the nursing stations surrounding the ER core: the slot numbers correspond to bed numbers in the ED.

Objective 3: An approach to evaluation of a patient in the ED.

The chart/triage assessment form is filled out by a triage nurse situated at the entrance to the ED. When patients are triaged by the nurse, a fair amount of standard information is gathered from the patient. This should help to acquaint you with what you’ll be evaluating. You’ll at least get the initial chief complaint, a brief nursing assessment, allergies, past medical history, medication and an initial set of vitals. There are some other sections of the form, but these aforementioned sections will be most useful to you. While this form is very useful, it is far from complete and beware that sometimes what the patient tells the triage nurse will differ from what they tell you. Beneath these notes is a lined section for you to write your notes and orders.

Example Emergency Department Care Form

This is the form you'll be writing on while on your emergency rotation. No need to become overly familiar with this, simply understand that there are several areas on the chart that you will be reviewing, another for you to write you notes, and another to write patient orders. Beware that while some of this form will be completed by the triage nurse, you need to re-confirm this information in your own evaluation as a patients story may change since they were seen at triage.

Case narrative: you examine the chart

Note: what follows is a simplified version of the chart above with some sections missing. This is in order to emphasize where the bulk of the information can be found.

Your preceptor said the patient appeared stable despite those vitals, but under the guise of introducing yourself, you take a quick look: He appears well enough, a little short of breath, and the monitors roughly approximate the set of vitals on your chart. You also confirm the chief complaint: He confirms he came in because he was "short of breath".

You step outside, now would be a good time to think about the differential for dyspnea.

Practice: coming up with a differential diagnosis for dyspnea

Feel free to use any resource you like to come up with a differential. When thinking about it, try to recall a few points on history and physical exam for each item, especially for the critical diagnoses. Go through this now before taking a look at the following chart.

[Click here for an example DDx for dyspnea]

Critical

- Tamponade
- ACS
- Anaphylaxis
- Airway Obstruction
- PE
- TPTx
- Sepsis

Non-Critical

COPD/Asthma
Pneumonia
Malignancy
ILDz
Effusion
Pericardial eff.
CHF
CAD
Arrhythmia
Valvular d/o
Endocarditis
Anemia
Metabolic
Hyperthyroid
Drugs

Patient evaluation and note-taking

The only real way to get comfortable evaluating a patient is by doing it in real life so we will skip this for now. What follows is an example of what a chart might have looked like for this patient after you have seen them:

Pro-tips on note taking in emergency

Ask your preceptor how much space they want you to leave at bottom of chart.
Write all over the chart to save space - if another item appears on PMHx/PSHx, or allergies etc., put it in the already existing box (as above).
Make your headings clear and try to leave space in the chart if you can.
Comment on vitals in physical exam, no need to re-write them
Leave a spot on the chart for your remaining differential diagnosis.

Let's go through this chart

The following will discuss the purpose of the various components included in the patient chart:

Patient chart as a whole: Review and confirm the notes taken by the nurse.
- Under Past Medical History, note that on further questioning the patient revealed a recent NSTEMI as well as surgery!
- A Pharmanet may be printed and attached to patient chart - list of prescriptions that have been filled by this patient.
CC: re-stated in patients own words
HPI: focused on the chief complaint, timeline and associated features.
PMHx, PSHx, Meds, Allergies: confirmed and elaborated on in the spaces provided above the notes Go back and look at the above chart to see how these sections have been "elaborated on" (cholecystectomy, NSTEMI, allergy to bee stings).
FHx and SHx: looking for risk factors
Review of systems: Used to rule in/out other diagnoses. This is only a suggested approach but it’s laid out in such a way that pertinent positives are noted first and pertinent negatives follow. In this example words in "quotation marks" describe the message we are trying to convey to the preceptor when we say/write the underlined words:
- Endorses orthopnea, nocturia, pre-syncope w exertion, bilateral ankle swelling, cough, palpitations. ”Could this be CHF, other cardiac etiology?”
- No chest-pain, N/V, diaphoresis. “Likely not typical acute coronary syndrome”
- No allergic/other exposures, aspiration. “Likely not anaphylaxis, airway obstruction”
- No recent travel, surgery, prior DVT or unilateral leg pain. “Likely not a DVT/PE”
- No sputum fevers. No sick contacts. “Likely not a pneumonia, COPD or asthma exacerbation”
- No abdo pain, melena stools/BRBPR. “SOB likely not due to an underlying anemia”
On Exam (O/E) is laid out with vitals, general appearance, followed by pertinent positives and negatives similar to history. You’ll get familiar with some short-hand note-taking over the year.
Small space for your Impression/DDx and a few lines for the preceptor to write any additional notes after yours. Including a DDx is sometimes useful when the answer is not definitive.

Remember: The chart is a communication tool as well as a legal document showing that we have been thorough and considered life-threatening conditions. This approach to writing notes is useful because it keeps the writer organized and it’s easy for the reader to interpret, but you will inevitably find an approach to writing ED notes that resonates with you.

Objective 4: To provide students with an opportunity to attempt delivering a structured emergency presentation.

In this section we'll cover and practice an approach to giving a patient presentation based on the above case.

Once you've evaluated the patient, be sure to STOP and think about your likely diagnosis, your differential diagnoses, and COMMIT to a management plan: disposition, investigations, and treatment.

A suggested approach to giving a concise patient presentation

Summary statement: Demographics, Risk Factors for your suspected diagnosis (look them up), and Chief Complaint;
HPI (OPQRST);
Pertinent Positives/Negatives (Assoc. symptoms that support your Dx’s and refute other items on your DDx, preceptors appreciate when you show them you asked about the critical ones);
Vitals;
Pertinent findings on physical exam (signs that support your Dx’s and refute others, similar to pertinent positives + negatives on hx);
State your DDx (Numbered list including why/why not);
Work-up (labs, imaging based on DDx);
Treatment (disposition, medications, consults).

Come up with a summary statement for this patient.

Try this out yourself, take a few minutes and summarize the information gathered on the chart and suggest a plan. Feel free to use the above template to help keep you organized.

[Once you've attempted a summary statement, click here to see an example summary statement]

Example: This is a 60 y/o male w/ a recent NSTEMI and vascular risk factors who presents with shortness of breath and fatigue at rest. The symptoms came on gradually over the last 4 days, began as exertional, now present at rest and nothing seems to improve it. Present with these symptoms, he endorses orthopnea, dry cough, palpitations, nocturia, mild presyncope w exertion, and bilateral ankle swelling. He denies CP, N/V, diaphoresis. No recent travel, surgery, hx of DVT nor leg pain. No allergic exposures or aspiration. No sputum with cough, fevers nor recent illness. No abdo pain, melena stools or BRBPR. On exam he is tachypneic and tachycardic. He appears relatively stable, and of elevated BMI. He appears slightly short of breath with some accessory muscle use, elevated JVP, exhibits bilateral crackles at lung bases, there is pitting edema to the knee bilaterally and slow cap refil. His airway is clear, no cyanosis, trachea is midline and chest wall movements are symmetrical. Heart sounds are unremarkable. No calf tenderness. Abdomen soft, not-tender, benign. Differential diagnosis for this patient includes:

Acute exacerbation of congestive heart failure because of his previous MI and gradual onset of heart failure symptoms.
Arrhythmia, also because of his previous MI and presence of palpitations.
Atypical presentation of acute coronary syndrome as he is diabetic with other vascular risk factors.
Any other diagnoses you may suspect and reasons why
- Eg. Sepsis: based on vitals, this patient meets SIRS criteria...
Potentially comment on critical diagnoses that you have tried to rule out.
- Eg. Don’t think it is a PE: Well’s score 1.5, but PERC (+) for age

Think about what is left on your differential, especially the critical diagnoses, and ask yourself what work needs to be done to rule them out and then if there is any treatment we can start right now for this patient:

To investigate a cardiac cause, I’d like to order Troponins, BNP and I think we should also order a CBC with electrolyte and renal studies. Patient is technically PERC (+), consider D-dimer. I’d like to follow up on his ECG and order a chest XR. In terms of management, I think he should stay for now with potential internal medicine (IM) consult. Keep him on monitors with supplemental O2 and order him some Furosemide 40mg PO. If internal doesn’t take him, potentially an outpatient echo with close GP follow-up.

Objective 5: Writing orders in the emergency department

Orders are written under the Physician Orders column. This can include any investigations - blood tests ECGs and imaging; as well as treatment - drug, dose and route. Writing orders in emergency differs from writing orders on the wards in that you are not required to write them on a separate Physician Orders sheet and have them countersigned. As long as the ED care form has the attending physician signature on it, and you have discussed it with the attending, the orders can be carried out. To submit orders for lab tests and imaging, write the orders and place the chart in the wire rack at the Nursing Unit Clerk desk (Location #3 in the above map). To order medications, you need to write the orders and either notify the nurse specifically looking after the patient, or by 'flagging' the chart with the provided chart flags, and placing it in the slot corresponding to the patients bed. Note it is always a good idea to chat with the patients nurse.

Remember to follow-up on your orders, make a note of which orders are pending for which patient and check Powerchart for the results regularly between seeing other patients. It’s useful to keep in mind: where is this patient headed, ie. what is their eventual disposition?

Tip: Ask yourself if you would be comfortable sending them home tonight and if you’ve ruled-out the critical items on the differential.

Condensed review of a consult on the Major side of the Emergency Dept.

Obtain a patient chart and write your preceptors name and time you took the chart in the space provided.
Note the chief complaint, nursing notes and vitals
Look at the patient: sick (and we need to do something right now) vs. stable (and we have some time to think), confirm the chief complaint.
- Think through the ABC’s and consider the necessity of early pain management.
Formulate a differential diagnosis for the chief complaint: critical vs. non-critical.
See the patient: history and physical and then rule-in/out items on your differential.
- Don’t forget to confirm the items on the chart that were gathered at Triage
Think about the items on your differential (symptoms, exam findings and risk factors), especially the critical diagnoses.
Commit to a management plan: Investigations (Lab work and Imaging) to rule-in/out items on your DDx; Treatment (Symptomatic, Definitive, Empiric); Other (admission, consults)
Formulate your patient presentation and deliver it to your attending.
Write orders for Investigations and Treatment.
Follow-up on results, check on your patient.

Objective 6: Difference between Major and Minor sides of the Emergency Dept.

For your reference, you’ll end most shifts in the Minor Treatment side. This is an area where you’ll typically encounter less severe presentations such as MSK injuries, lacerations and flu-like symptoms. These diagnoses are typically more straightforward and efficiency in patient evaluation is often emphasized. You’ll certainly want to think about the critical diagnoses but for the most part, the history and physical exams will not be as thorough.

An example of an assessment for a laceration:

How and when did this happen?
What is your medical history, ie. are you immunocompromised and need prophylactic antibiotics?
Is you tetanus up to date?
Examine extent of the wound, establish neurovascular status.
Present to the preceptor.
Suture the wound.

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