Health Sciences Centre
ADULT EMERGENCY DEPARTMENT
University of Manitoba
Orientation Manual
Revised October 31, 2003
Also available at
Welcome to the Health Sciences Centre Emergency Department. Your rotation here is designed to give you exposure to acutely ill and injured patients requiring rapid diagnostic and therapeutic interventions and decision-making. All of this in a setting of 24 hour/day, 7 days a week attending faculty coverage, and under the care of skilled, specialized emergency nurses. The patients you will see run the gamut from minor to critical illness/injury. Many have primary physicians in the community or at the HSC, and many do not. Many are already involved with specialty services here at the HSC, and many have never been here before. All are worried, or nervous, or frightened to some extent, and all will be looking to you as part of the Emergency Medicine (EM) Team to care for them with efficiency, professionalism, and confidentiality. Speed, personal care, and privacy are often the first 3 casualties in a busy Emergency Department, and it will be a major part of your learning process while here, to develop your skills in these areas, along with your diagnostic and procedural acumen. The attending physicians in the Department of Emergency Medicine are committed to helping you learn these process skills as well as expanding your medical, surgical, critical care, orthopedic, neurologic, toxicologic and psychiatric fund of knowledge utilizing evidence based medicine whenever possible, supplemented by experience, and the pearls of wisdom in their combined EM experience.
During your rotation you will interact not only with patients, but also with house staff and faculty from nearly all the consulting services at the HSC, Respiratory Therapy, Physiotherapy, Geriatric Program Assessment Team (GPAT), Home Care and Social Work. You will also be involved in the care of patients referred by physicians from all over Manitoba, Northwestern Ontario and Nunavit. In addition, you will work closely with the Winnipeg paramedics and police. In all these conversations and interactions, it is important to remember that you represent the Emergency Department at the HSC, and that to the person you are speaking to, you ARE the HSC Emergency Department.
This orientation packet will be separated into several sections, designed to acquaint you with the patient types, patient flow, documentation, consultation pathways, and various procedures in the Emergency Department.
1. EMERGENCY DEPARTMENT PATIENTS
At the HSC Adult Emergency Department, we see approximately 40 000 patients per year. This translates to 90 -120 patients per day. Our patients have a much higher acuity rate and complexity level than those seen in many other ED's. The HSC is the Trauma and Neuro Surgery centre as well as the major tertiary care referral centre for Manitoba, Northwestern Ontario and Nunavit. Therefore, patients often refuse more in depth evaluation due to their underlying illness or the distance they live from Winnipeg.
EVERY patient that presents to the Emergency Department is the ultimate responsibility of the Emergency Medicine faculty on duty at that time. This includes patients that may have been in contact with another service in the hospital prior to arrival, as well as all patients transferred in from surrounding facilities. Unless another attending physician or service is IN the ED to meet and take charge of the care of a patient, they are the responsibility of the Emergency Physician on duty. All decisions as to testing, therapy and disposition MUST be cleared with the ED faculty on duty. NO ONE leaves the HSC ED without being seen and examined by the ED faculty, unless another service has assumed their care IN PERSON. This policy is important to assure appropriate evaluation and management of EVERY patient that presents to the HSC ED, and there are NO exceptions.
2. NAMES AND CONTACT NUMBERS
HSC Adult Emergency DepartmentTel 787-3168
HSC PagingTel 787-2071
HSC and Section of Emergency Medicine website:
Anita Bourgeois (Administrative Assistant)Tel 787-2934Office
Dr. Wes Palatnick (Director)Tel 787-2950Office
Dr. Lindy Lee (Assistant Director)Tel 787-2934
Dr. Cam Peterson (Schedule coordinator)Email
Dr. John Sokal (Orientation)Email
Other Faculty (may be contacted through Anita Bourgeois)
Dr. Lisa BryskiDr. Michael HaDr. Richard Peters
Dr. David EastonDr. Anthony HerdDr. Sheila Peters
Dr. Darren GravesDr. Ron MaierDr. Don Schellenberg
Dr. Rob GriersonDr. Travis MinishDr. Bob Sweetland
Dr. Jo-Ann Talbot
3. BEFORE YOU START…
The Adult Emergency Department is located on the first floor in the Health Sciences Centre Main Hospital complex. The Attending Emergency Physicians’ office is located within the ED. You may store your coat and bag in this office during your shift. Be aware that this office is often unlocked. Also, as this is a working office space for the ED Physicians, you may not be able to access this space at all times. Work-related phone calls may be placed using the telephones in the main department or in the office. Personal phone calls may be conducted using the resident library telephone across the hall.
The Administrative Assistant to the Emergency Department is Anita Bourgeois (telephone 787-2934). Anita will contact you with your schedule approximately 2 weeks before the start of the rotation. She will also have an Orientation handout for you (this one). Please ensure that you have given Anita your ITER before the rotation begins. You will need to review your completed ITER with Dr. Wes Palatnick or his designate at the end of the rotation in order to pass.
Dr. John Sokal or his designate will give you an initial orientation session to the Emergency Department followed by an academic seminar within the first week of your rotation. Anita will inform you when this is to take place. It is mandatory that you attend this. There is a handout that goes with this academic seminar (Anita will give it to you). In this session, Dr. Sokal and one of the Senior ED RNs (CRN) will brief you on the rotation and the department. This is followed by a 2-hour academic seminar on “Assessment of Critically Ill Patients”. Following this is a tour of the Adult Emergency Department. Dr. Sokal will also cover the following topics: schedule, mid and end rotation evaluations, dress code, promptness, charting requirements, role of CRN, and a schematic of the department. If you have any questions or concerns about this session, please contact Dr. Sokal at .
Dr. Wes Palatnick is the Adult Emergency Department Director. He is also Head of the Section of Emergency Medicine in the Department of Family Medicine. He may be contacted through telephone (787-2950) or email (). Dr. Lindy Lee is the Assistant Director, and may be contacted through Anita Bourgeois. Either Dr. Palatnick or Dr. Lee will give you the mid-rotation evaluation and the end-rotation evaluation. It is imperative that you hand your ITER form in to Anita at the beginning of the rotation so we are able to document your performance in a timely manner. Anita will contact you during your shifts to arrange mutually agreeable meeting times for the evaluations.
4. WORK ETHIC
You are expected to approach this rotation with the work ethic appropriate to a mature physician. Make sure that you are prompt in starting your shift. Dress appropriately in clean, conservative attire (no jeans, no ripped clothes, no bare midriffs). Introduce yourself to the ED Physicians and other staff if you have not met them previously. If it is one of your first shifts, notify your supervising doctor and be sure to ask questions if you are uncertain as to procedure/protocol. We all went through this. If you have a specific topic you’d like to discuss or goals you would like to meet, discuss this with the faculty doctors as well. We want to ensure that your experience is a fantastic one.
5. RESIDENT SCHEDULE
Dr. Cam Peterson (email ) is in charge of scheduling. Please notify him at least 1 month ahead of time if you have specific scheduling requests. While he will do his best to accommodate your request, he may or may not be able to accommodate them all. The maximum number of shifts you will be scheduled for are 18 shifts of 8 hours each. These shifts include 7 days, 7 evenings and 4 nights. You need to complete all 18 shifts in order to be considered for a passing grade in this rotation. The only exception is if you are scheduled to work 8 hours during a STAT day in the rotation. You may discuss with Dr. Peterson which shift you are allowed to take off as a STAT-day-back. The HSC ED rotation will only acknowledge STAT days earned during the rotation as earning a shift off.
Your schedule for the rotation is most likely very different from that which you have or will experience on other services in the hospital. While the total hour commitment each week is similar, there is no call and on busy days you may go an entire 8-hour shift with only 1 or 2 breaks. Fully 75% of all the hours in the ED are at times other than weekday day shifts. Evenings, nights and weekends predominate on the ED calendar, and holidays, birthdays, anniversaries, etc all need to be covered. The rotating resident schedule in the ED is designed to try and provide maximum contact between residents and ED faculty, while attempting to provide the best service to the ED patients. Just as the ED faculty MUST be here for each and every shift they are scheduled for, so too must you. There will always arise emergency situations that demand changes in the schedule. However, please understand the importance of adherence to the schedule. Therefore, IF you are in need of a change, for whatever reason, you MUST speak to Dr Cam Peterson in the Emergency Department. Dr. Peterson MUST approve any and all changes to the resident schedule BEFORE they can occur. There will occasionally be conferences, grand rounds, etc that occur during your scheduled shift in the ED. It is always reasonable to discuss these with Dr. Peterson and the ED faculty you are working with that day to see if arrangements can be made to free you up to attend. It is NEVER reasonable to simply leave the department without working out a plan with the ED faculty to cover the patients you are caring for at the time.
Your Academic Halfday is sacred. We expect you to leave your shift in a timely manner to attend your ENTIRE Halfday. Please wrap up your work in a timely manner and review all patients still present in the Department with the Attending Emergency Physician before you go. This ensures continuity of patient care, and that nothing will be missed. Please notify Anita or Dr. Peterson ahead of time as to when your Halfday is. You will not be expected to make up the half-shift. However, you will be expected to complete the other half of the shift not affected by Halfday.
6. EVALUATION
Your evaluation depends on your performance within the Emergency Department environment. All the physicians you work with in the Emergency Department will evaluate you on attendance, promptness, patient presentation, management of patients, multitasking ability, clinical and procedural skills, teamwork performance, professional attitude and ethics, and evidence-based knowledge.
You will have a mid-rotation evaluation with Dr. Palatnick or his designate. If there are concerns with your performance, Dr. Palatnick will discuss them with you as soon as possible. If there are concerns, a written evaluation will be reviewed with you, along with a written plan of action to help you succeed in this rotation. Remember, areas of weakness can be turned into areas of strength. Learning is why you are here in this rotation. You will also have an end-rotation evaluation in which Dr. Palatnick will review your written ITER with you. On occasion, a resident has needed to do additional learning time in order to master a skill of Emergency Medicine. You will be notified at the mid-evaluation if this potentially applies to your case.
We also request that you complete evaluation forms for the attending physicians you work with. These evaluations are collated and are used to evaluate the attending ED physicians. Forms will be distributed in your rotation package. Additional forms are available from Anita Bourgeois. It is not mandatory that you sign the evaluation form.
7. PATIENT FLOW
All patients are seen at triage by an EM nurse, vitals taken, a brief interview conducted, and an acuity level is assigned. The HSC ED uses the 5 Level Canadian Triage Acuity (CTAS) Scale. A triage form is completed with meds/allergies/vitals/complaint and any important findings. Extremity x-rays or simple lab such as U/A, pregnancy test may be sent from triage. An Admitting Clerk then registers them and a chart is generated. They may be asked to wait in the waiting room until a space is ready in the ED. If they are more acutely ill, they will be brought directly back to a bed.
Ambulance patients are generally more acutely ill/injured than ambulatory patients but not always! Critically-ill or injured patients are taken immediately into the Resuscitation Room.
Once in the ED, non-critical/stable patients are first seen by an ED nurse. First, they are asked to put on an appropriate gown and wounds are uncovered, cleansed, etc. After basic history/exam, certain steps may be taken including application of cardiac monitors, IV access, EKG, O2, basic lab sent, etc. If the patient is acutely ill/injured, the nurse will summon you and/or the ED attending physician. The chart remains where it is placed on the chart/workspace tabletops. If the patient has yet to be seen and assessed, the Attending/Resident signature will be blank and the “time seen” box will be empty on the chart.
As soon as a chart appears, you should take either the more seriously ill patient or the patient with the longest time from triage, read the triage and nursing notes present, note the entrance complaint and vital signs, note the patient's age and primary physician if one is listed. You should now sign and indicate the time on the chart that you are now seeing this patient. You should then introduce yourself to the patient, confirm any information in the nurses notes, obtain additional history as needed to address the patient's chief complaint, examine the patient as fully as needed to address the patient's complaint and determine their condition, and then return to the nursing station to present the case to the ED faculty. While it is important to be thorough and complete, it is counterproductive to be compulsive. Looking up information in the patient's old chart can be very helpful. However, your evaluation of this patient is a work in progress, and your presentation of the case to the ED faculty is an integral part of this work.
Remember to involve the ED attending physician IMMEDIATELY if the patient is seriously/critically ill or injured. Do not allow your history-taking or charting to delay any critical treatment that the patient may need.
8. ORDERING TESTS AND TREATMENT
Learning the efficient use of lab, x-ray, and consultative services is another goal of your rotation. To accomplish this, we ask that you involve the ED faculty early in such decisions to avoid redrawing lab, sending the patient for repeat films, or waiting for results that may not affect the outcome/disposition of the patient. This is especially true of consultations. Often, we can make decisions here without involving other services. This may differ greatly from your experience on the wards, and is another of those process skills we hope you take away from your rotation. Therefore, with the exception of obvious lab/x-ray, we ask that you discuss the patient with the ED faculty prior to major orders. As you become more familiar with the faculty, this requirement will obviously modify itself somewhat.
Once you decide to order laboratory studies, it should be noted on a proper order sheet attached to the chart. You should then locate and notify the patient's primary RN as well.
When ordering x-ray studies, you must ask the ward clerk for an X-ray order form using the patient’s hospital number, fill out the necessary history and physical exam info at the top of the form, indicate the studies you want done, include the ED faculty doctor’s name behind your signature, then print in the doctor’s name you wish a copy of the report sent to. Next, leave the X-ray form on the patient’s chart and notify the RN that the patient and form are ready for X-ray. Non-routine CT scans (eg. abdomen, chest, neck) must be cleared with the Radiology on-call Doctor. Ultrasounds and V/Q scans must be arranged through the Ultrasound Department and Nuclear Medicine Department.
If, after discussion with the ED faculty, your patient requires nursing intervention (fluids, meds, lab draw, foley, NG, etc.) you should write the orders on the order sheet of the chart, and find and notify the patient's primary nurse in person. Nothing is better than face-to-face communication, especially in a busy ED.