Guidelines for ER learners

Welcome to the North Bay General Emergency Room! We are a busy community ER,
seeing some forty thousand visits per year. We are staffed entirely by family medicine
trained graduates, some of whom have an extra year of EM training.

Quick Tips to a successful shift

- Introduce yourself by name to everyone you meet, and especially the staff MD, the
charge nurse and the desk clerk.

- Wear your name tag at all times.

- Grab a clipboard and a blank sheet of paper. Your education hinges on remembering
and studying around the cases you see. Therefore, track the name, sex, triage
presentation and discharge diagnosis of each chart you touch. This will allow you to
remember the learning points from each case. Or, use the handy dandy template on
the back of this booklet.

- With very few exceptions, finish cases before starting new ones.

- When in doubt, ASK. Similarly, if you don’t know, SAY SO. “I don’t know” is a perfectly
good answer to questions. Nothing in medicine is so dangerous as “knowing
everything”.

- Follow the patients you have seen in the ER if they end up on the floors, in the OR,
when they bounce back to ER or if they consulted off to specialists. Even if that
specialist is the coroner.
Logistics

- The location of the patient is recorded by room number at the top left of the chart.
- The nurses responsible for each area are recorded by name on the whiteboard.
- Don’t hoard the charts. Once you’ve put down orders and recorded your notes, make
sure the chart finds its way into the hands of the nurse, clerk or into the appropriate
“pending” slot.
- Likewise, make SURE the chart ends up with the staff doc once the case is done. We
depend on the “blue sheets” to get paid and we have to sign off on the charts or they
come back to haunt us at medical records.
- If there are orders that need to be done, locate the nurse responsible for that area and
tell them about it face-to-face. This is more accurate and more efficient than just
leaving them in the box.
- Pay attention to the CTAS code of each patient you take (top left of the chart).
- Occasionally, the department will become a complete zoo. This is the nature of
emergency medicine, and is unavoidable. Early year students will be asked to read
around the cases they have already done, switch preceptors, do some online learning
on UpToDate, use the MicroSim critical care simulator or simply leave and try again
another day. The option for later level students is to glue themselves to their preceptor
and learn by osmosis, with little expectation for didactic teaching, until things calm
down.

Charting

The pink chart contains all the demographic info you need to start. The triage nurse will
already have done a preliminary history in the left-hand box, as well as vitals. In our ER,
the nurses also order preliminary bloodwork they deem potentially useful. They are not,
however, responsible, for ordering every test you may need.

CTAS status upon arrival is recorded on the top left of the pink sheet.

If you find that the history is different than what the nurse has written, don’t cross their
charting out. Simply amend the information in your subsequent charting.

Most staff docs dictate any case of importance.

In cases that may be legally or medically controversial, the staff should complete the
charting rather than the learner.
Heuristics and Tricks

- train yourself to CIRCLE every abnormal vital or test (as well as pertinent normals),
partly to document that you saw them, and partly...well...to SEE them.
- Feel free to use the entire charting space to record your notes. If you are planning on
dictating as well, the paper chart can be used for shorthand notes. The staff MDs
generally dictate most notes of any importance.
- three letters. P. D. A. Get one. Learn to use it.
- Do not hoard charts. If there’s a Next Case you really want to see but haven’t gotten to
it just yet, just write your name in the charting box beside the Time In.
- To ensure charts don’t get “thieved” from you halfway through your workup, write your
name and scribble something in the charting area immediately.

- Big Hint: if you want to really shine, keep in mind what expectations will be placed
upon you at the NEXT level of training and strive to achieve them NOW.

CTAS

The Canadian Triage Acuity Scale is a means of roughly sorting out how "serious" ER
cases are when they present. It is also your friend. The triage nurse uses CTAS to alert
you as to how “worried” you might need to be about a given case, and to put the cases
in the order they might need to be seen in.

1 = worst of the worst. Can die or have serious morbidity if not seen immediately:
(MI in progress, multitrauma, anaphylaxis)
2 = serious medical problems that can become life threatening:
(chest pain in progress, abdo pain with peritonism and fever, CHF and dropping sats)
3 = the "bread and butter" of ER, medical illness but no emergent problem:
(abdominal pain in young woman who is stable, fever NYD in a toddler, asthma)
4 = single system medical problems with little possibility of decompensation:
(strep throat, bee stings with normal vitals, acute sprained wrist)
5 = entirely non-urgent problems:
(prescription refills, blackfly bites, sore ankle for a year)

Incidentally, the CTAS number is also loose code for the number of patients of that level
that an R3 resident is expected to be able to juggle at the same time.

Be aware, though, that CTAS is not foolproof, and a patient can change their status over
time. Patients have died of aortic aneurysms in ER washrooms while waiting under a
CTAS 3. Not here, mind you. But I heard about it.
Expectations by year

High School and non-medical trainees (career exposure):

- Act professionally
- Maintain patient confidentiality
- Display interest

Early Med School with no clinical exposure (observerships):

- Read around previous cases that have generated a learning point
- Follow up on previous patient encounters of interest
- Stick to your preceptor like GLUE (unless they tell you to do something else)

Year 3 medical school “clerks”:

- See and complete one case at a time before moving on to the next case unless there
will be a test or observation lag and you’ve been told to move on.
- Perform a compete history and physical. (SOCRATES)
- Think out in advance tests that may need ordering and write them down.
- Think out a FULL differential and write it down. (VINDICATE)
- Interpret the results of the tests with help from staff.
- Choose a most likely diagnosis and suggest a disposition and plan with help from staff

Year 4 medical school clerks, pre-residency, or with prior ER exposure:

- Present Hx, Px and findings in an organized fashion including a focussed differential.
- Suggest a disposition and plan without prompting if the case is familiar, otherwise...
- Do diagnosis and treatment searches online when required, without prompting.
- Ensure that either the handwritten medical record is complete, including discharge/
follow-up instructions, or dictate important cases.

R1 medical residents (all streams):

- Choose necessary tests and have organized treatment plans for common problems.
- Learn to dictate appropriately.

R2 residents (family medicine pre-grad):

- Complete familiar cases from start to finish and present the full Dx and plan to staff
before final disposition.
- Handle multiple cases within the limits of your ability to stay organized.
- Communicate with consultants appropriately.

R3 residents (EM program or FRCP stream):

- Manage departmental “flow”.
- Appropriately transfer care to attendings and other facilities.
- Be more up-to-date than your attending with respect to emerging ER evidence. ;-)
Do’s and Don’ts

- DO wear your ID badge, introduce yourself to the patient by name and declare
yourself as a learner

- DON’T discharge patients from the ER without reviewing the case with staff. Yes, even
for CTAS 5’s. Yes, even if you’re an R2.

- DO get the chart countersigned before putting it in the discharge box.

- DO record your Time In as soon as you pick up the chart and Time Out when patient
leaves your care. This is used to calculate efficiency stats for the hospital.

- DO document directly on the pink sheet what discharge instructions, Rx’s and criteria
for followup were given to the patient.

- Before R3, almost NEVER manage more than one CTAS 1’s or 2’s at a time.

- DON’T order a test that you don’t know how to interpret.

- DON’T order a test that you aren’t going to act on.

- DON’T criticize work that has been done previously...unless it was done by you.

- DON’T pick up “heavy” cases within 1 hour of the end of your shift.
Maxims and Gnomes

- pC02 should be lower than P02

- Do what you can to keep the patient’s heart rate higher than yours.

- All bleeding stops.

- All tachycardia slows.

- Repeat tests until they are normal, then stop.

- The louder they are, the sicker they aren’t.

- The correct rate for effective CPR happens to be the same tempo as Stayin’ Alive by
the Bee Gees. Or, Another One Bites the Dust by Queen. You choose.

- when their age exceeds their weight in pounds, there will be trouble.

- Rational clinical decision-making is directly related to the physician’s serum glucose

and inversely proportional to bladder volume (the exceptions being when the physician is in DKA or on dialysis.)

- Look wise, say nothing, and grunt. Speech was given to conceal thought. (Osler)
Cases

Patient Triage HPI Final Dx Learning Points

Ms Example 66yo chest pain pulmonary embolus usage of Ddimer

J26384 sudden onset vs CT scan

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