1
What is the purpose of the emergency department (ED)?
The purpose of the ED is primarily to stabilize the patient, provide a diagnosis if possible, initiate treatment, and determine patient disposition. Possible dispositions include discharge to home, admission to an inpatient floor, or temporary observation.
2
Describe the law regarding the ED’s responsibility for patient treatment and transfer
The Emergency Medical Treatment and Active Labor Act (EMTALA) was a statute passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). This law requires that any patient who comes to the ED requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination, and, if determined to have an emergency condition, must be treated until stable regardless of ability to pay. Under this law, the hospital must also be sure to properly stabilize the patient before considering transfer to another facility.
3
List the staff in the ED and describe their roles
There are various physicians, physician extenders, nurses, and staff within the emergency department. Their roles are described in Table 2-1 .
| Staff | Role |
|---|---|
| ED physicians | Provide medical care including patient assessment, treatment, and disposition. Can include attending physicians, emergency medicine residents, and off-service residents. |
| Off-service residents | Residents training in other specialties may rotate in the ED to gain experience with emergency care. In addition to providing care, they may also have specific roles varying by institution, such as determining to which inpatient service a patient should be admitted. |
| Physician extenders (e.g., physician assistants) | Healthcare professionals with specific postgraduate training. Depending on state laws, they may be able to practice independently, although most operate under the direction of a physician. |
| Nurses | Conduct regular checks on the patient, check vital signs, administer medications, and execute physician orders. In some situations, they may be able to initiate orders on specific patients (e.g., ordering x-rays on a patient with a wrist injury). |
| Technicians (e.g., emergency medical technicians or paramedics) | May start intravenous lines and draw blood samples. Depending on their level of training, they may also be able to apply splints or perform electrocardiograms. However, they cannot write prescriptions. |
| Clerks | Manage phone calls and paging, submitting orders, general paperwork, and patient registration. May also serve roles as patient liaisons. |
| Social workers | Arrange outpatient needs for patients who are uninsured, have limited access, or have other extenuating circumstances. |
| Trauma team | A team of surgeons, residents, physician extenders, and nurses that is responsible for patient care during a trauma situation along with the ED staff. Although this team is not actually a part of the ED staff, they are on call in larger institutions and are usually in the ED before patient arrival. |
| Consultants | Provide a specialist opinion when ED physicians feel it is necessary for patient care. |
4
Describe the layout of the ED
In general, most EDs consist of a waiting room, triage area, patient rooms, trauma/resuscitation bays, an urgent/minor emergency area, and an observation area.
Patient rooms are usually standardized across an individual ED. When one starts an emergency medicine rotation, it is a good idea to look through a patient room to learn what is available and where things are located. Many hospitals will have set locations in the hallway for patients when other patient rooms become full. These locations are surrounded by curtains and are commonly referred by a numbering system for the hallways within the ED. Some hospitals will have additional rooms for specific injuries such as an ophthalmic room with a portable slit lamp for patients with acute eye injuries.
The trauma/resuscitation bays are reserved for patients with the most severe injuries. These bays are larger in area, allowing more room for the multiple healthcare providers involved in patient care. They are equipped with additional materials, such as surgical lighting, telemetry, a portable ultrasound machine, and quick access to other portable radiology machines.
The urgent/minor emergency area is for patients who do not require extensive work-up, such as patients with simple lacerations that need suturing. This area usually has limited space and less equipment.
The observation area is generally reserved for patients who are awaiting admission to the floors or who are being followed as part of a protocol but no longer require active management. For example, patients with chest pain, who are deemed to have low-risk for myocardial infarction (MI) after an initial work-up, might be followed with serial cardiac enzyme measurements in an observation area as part of a “chest pain protocol.”
5
List the possible patient pathways into the ED
Patients can enter the ED through a variety of mechanisms. Upon arrival they enter triage and are subsequently sent to the appropriate location within the ED. The various pathways through which patients may arrive are displayed in Fig. 2-1 .
6
What is triage?
When patients arrive at the ED, they are first sent to triage. The process of triaging includes obtaining a patient’s vital signs including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation, along with a brief history of the reason for presentation. Most patients are assigned a priority level on the basis of their vital signs and the severity of their condition. The patients with the most acute conditions, such as those with chest pain or difficulty breathing, are taken to a treatment room immediately and are seen by a physician as soon as possible. Patients who appear stable with less acute complaints may be initially sent to the waiting room, depending on the availability of patient rooms. If patients require immediate resuscitation, such as for respiratory distress, active seizure, or severe trauma, they may bypass triage and be taken directly to the trauma/resuscitation bay for initiation of care.
7
What is a medical student’s role during the emergency medicine rotation?
The medical student’s role primarily includes the following: gathering a thorough history, performing a full physical examination, presenting pertinent positive and negative symptoms to either a resident or attending physician, proposing a differential diagnosis, and suggesting follow-up laboratory results and studies. Before beginning to gather a history, be sure to quickly check the patient’s vital signs and to ensure that the patient is stable. If the patient appears unstable, find a resident or attending physician immediately to determine whether immediate action is necessary before obtaining a history. Please note that time in the ED is limited. A general guideline is for students to try to conduct their assessment in 30 minutes, with 15 minutes to obtain the history, 10 minutes to conduct the physical examination, and 5 minutes to organize thoughts and devise a plan.
Medical students are also involved in performing a variety of procedures, such as starting intravenous lines (IVs), placing Foley catheters, placing nasogastric (NG) tubes, and drawing blood for measurement of arterial blood gases (ABGs). Under supervision, students may also participate in lumber punctures, central line placement, chest tube insertion, and endotracheal intubation.
8
How should a patient presentation in the ED be structured compared with a similar presentation on the inpatient wards?
Compared with the inpatient environment, time is limited and interruptions are frequent in the ED. A presentation of the history should include a one- to two-sentence synopsis at the beginning of the presentation followed by further details. Focus on pertinent positive and negative symptoms. When presenting the physical examination, be sure to include vital signs such as temperature, heart rate, blood pressure, respiratory rate, and pulse oximetry. These tend to play a crucial role in the ED and should not merely be summarized as “vital signs stable.”
Presentation of the physical examination should include only relevant information. After the physical examination, continue with pertinent laboratory results and studies performed recently. When presenting a differential diagnosis, be sure to include a broad range of possibilities. Include anything that could severely harm the patient, and consider these possibilities first! Remember to think about multiple organ systems and to not just focus on the obvious one. Some students find it helpful to think of two parallel (and sometimes overlapping) differential diagnoses, one of which considers the life-threatening conditions of a symptom and another that consists of the most common. Next, present supporting and refuting information for each diagnosis in the differential. Finally, propose a plan for further laboratory results and studies to determine what steps are necessary to stabilize the patient or narrow the differential diagnosis.
9
Explain shift work
In the ED, faculty and staff work in shifts. Common shift lengths are 8, 10, or 12 hours. An example of a shift schedule would be a day shift from 7 am to 3 pm , an evening shift from 3 pm to 11 pm , and a night shift from 11 pm to 7 am . Shift changes are generally staggered among attending physicians, residents, and nurses to provide some continuity of care and to ensure that all staff taking care of one patient do not switch at the same time. Because new attending physicians and residents come on every shift, there is no overnight call. Instead, there are shifts during the night.
10
How is shift work different than an inpatient schedule?
When “on service” in an inpatient service, medical students and residents are expected to stay until all work for that day for all patients on the service is complete. At that time, residents sign out their patients to the residents on call. Unlike the traditional inpatient schedule, when working in the ED, medical students and residents finish at the end of their shift. Different medical students and residents start with the next shift. At each shift change, the physician finishing up will sign out all of the patients he or she has been following to the physician coming on. Sign out involves a careful transfer of patient care to the oncoming team, including a review of the medical history, description of pertinent physical examination findings, a synopsis of laboratory results and studies performed thus far, a list of further necessary laboratory results, studies, and consults, and a presumed disposition. Conscientious transfer of care is essential for patient safety and high-quality care.
11
How many shifts do emergency medicine physicians work?
Emergency medicine physicians typically work 12–16 shifts per month. These shifts are usually divided among day, afternoon, and night shifts. Some physicians may work fewer shifts because of administrative or research commitments. ED physicians often have the ability to make scheduling requests to accommodate personal obligations. In addition, some hospitals will “weigh” shifts differently. For example, a day shift might be worth 0.8 shifts, an evening shift worth 1.0 shift, and a night shift worth 1.2 shifts. Medical students are usually required to work 12–15 shifts during an emergency medicine rotation, but this varies by institution.
12
How are emergency medicine physicians paid?
Physician reimbursement for medical services within the emergency department varies by institution and sometimes even within a single hospital. Physicians are most commonly paid either with an annual salary or by the hour. Some hospitals will pay physicians more during the night to encourage physicians to work these shifts.
13
Describe how ambulance vehicles are positioned for anticipated emergencies
Because emergencies are not scheduled occurrences, it is often difficult to anticipate the location of a future incident. However, certain locations such as urban areas typically have more emergencies than rural towns and are therefore covered by more ambulance vehicles. One common technique is as follows. Within a specific area, several ambulances are positioned so that they are equidistant to all locations in the area. When an ambulance is called in for an emergency, the remaining vehicles must be repositioned so that they are again equidistant. Because of this technique, an ambulance vehicle may move many times throughout the night despite not being called in to provide medical care.
14
What is the role of the medical student while in an ambulance?
Some institutions allow medical students to take shifts in an ambulance usually in an observer capacity. When arriving to an emergency, students must be sure to first survey the scene to assure it is safe to enter. This involves taking cues from the more-experienced medics and avoiding placing oneself in jeopardy such as in the flow of traffic or becoming exposed if there is ongoing gunfire or interpersonal violence. Once on the scene, a medical student may be allowed to do a number of tasks under supervision of the medics such as obtaining a history, performing chest compressions, intubating, or placing an intravenous line. The other members of the ambulance team will facilitate what the student can and cannot perform. Students should take advantage of the medics’ experiences and learn about prehospital care issues. In addition, a student may be able to provide additional education about more detailed medical concepts.
15
What are the ABCs?
In the emergency department, people will often refer to the ABCs . The ABCs stand for A irway, B reathing, and C irculation. It is important to first assess these three factors in the initial examination of a patient. In the ED, while assessing the airway, also be sure to protect the cervical spine if there is any concern regarding trauma.
Another common mnemonic used in the ED is ABC-IV-O2-Monitor . This refers to assessing the ABCs, then inserting necessary intravenous lines, providing the patient with oxygenated air for breathing, and attaching a cardiac monitor.
16
Describe the approach to a trauma patient
The approach to a trauma patient is defined by advanced trauma life support (ATLS), which is a product of the American College of Surgeons. This approach is taught in a 2-day course, which is summarized briefly in Table 2-2 . Most medical centers will also have a trauma system that activates both the ED and a surgical team to jointly and expeditiously evaluate patients with potentially serious injuries.
