Emergency Medicine Residency Handbook 2009 Edition table of contents chapter page

KCH ADULT ED

I. Introduction
Welcome to the Kings County Hospital Center Emergency Department. At over 125,000 patient visits per year, it is one of the largest Emergency Departments in the country. This patient volume and the high acuity will serve as the classroom for one of the most hands-on, educational experiences you will have during your training. When you start your first clinical shift, you should ask the senior resident for a tour of the ED and a description of the available resources and supplies.

Our E.D. is subdivided into several areas based upon triage and patient age:

1. CCT - Critical care and trauma

2. Suite A/B – General medical/surgical illness/Obstetrics/Gynecology

3. Pediatric ED

4. Fast track

I. CCT-Critical Care Trauma

This area is what makes your residency experience at Kings County so special. It is essentially an ICU based in the ED where the most acute patients are stabilized and treated. This includes both medical and trauma patients. One attending with a senior and a junior resident staffs the CCT. You will be expected to perform procedures including but not limited to lumbar punctures, central lines, CVP lines, and arterial lines. There is good nursing staffing and a PCT in the CCT but be expected to put in IV lines if the patient is in extremis. Juniors, it is expected of you to arrive to your shift at least 15 to 20 minutes early to check the resuscitation bay and stock your airway equipment and IV equipment, prepare the level one infuser and make sure you are ready to handle anything that comes in. Use your time in the CCT to learn from your attendings, seniors, and patients.

2. Suite A/B

The majority of cases will challenge your knowledge of basic medicine and recognition of potential emergencies, such as acute myocardial infarction, pulmonary embolism, diabetic ketoacidosis, sickle cell crisis, and impending respiratory failure in asthmatics. Here too, you will experience a good degree of independence. Reading for this area should be focused on interesting cases that you see. Our advice is to pick one topic each day to review or learn, based on what you saw during your shift.

There are usually several nurses in this area, physician assistants, who see patients, a respiratory therapist, who will cover the asthma room during the day, and patient care techs. You will frequently be responsible for IVs and blood work. ECGs and patient transport to X-Ray and CT are the PCTs’ responsibility, but it may be necessary to assist with these tasks as well.

Teaching opportunities by the attending staff is abundant in this area. Please ask questions! This is an excellent time to learn from the attending staff, many of who have sub-specialized in various areas of medicine. You will be asked questions about your choice of management during close out rounds, so make sure you know why you are managing a patient a certain way. Also, challenge yourself to practice your differential diagnosis skills.

III.FAST track-As part of the ortho/FT rotation

A day in the Fast track, as with other areas of the department, starts off with sign out rounds.  Although done a bit informally, as compared to its counterparts, it is not unusual to do bed side rounds.  The fast track area offers an excellent opportunity to manage minor trauma, laceration repair, I&D, orthopedics, ophthalmology and countless gynecological cases. You will be given a great deal of independence in this area and the majority of your cases will be managed to completion. The fast track may be one of our less acute areas; however, don't be fooled, many times very sick patients present to the treatment room.

Expect to do all blood draws.  In addition, you may need to get or deliver your patient to X-Ray and CT scan to expedite matters. There is usually a patient care technician assigned to the treatment room and the tech will be the one to accompany the patients that need evaluation at other areas of the hospital (i.e. for official sonography,). There is only one nurse assigned to this area and he/she will administer all medications. If consultations are needed, phone the page operator at x3141, give her the requesting service and your call back number.  Once you and the attending have reached a disposition, you can ask the clerk to schedule an appointment if the patient is being discharged or put the patient in for admission.

2. Roles and Responsibilities of Resident Physicians

Morning Report: Morning report is the opportunity for our department to discuss cases in a more formalized manner. This conference is held after morning rounds on Mondays, Tuesdays, Thursdays, and Fridays. Residents will present a case for discussion. Attendance is mandatory for all residents working the day shift and residents who worked the previous overnight shift.
Wednesday Conference: Conference for EM residents will be held each Wednesday in the department conference room, unless posted otherwise. Attendance is mandatory. The conference is composed of various didactic lectures covering the core curriculum of Emergency Medicine, specialized case discussions pertaining to Pediatrics, the MICU, Trauma, Journal club, morbidity and mortality conference, a CPC, and monthly grand rounds.
Sign Outs: If you are leaving the ED for lunch, lecture or at the end of your shift, all patients assigned to you must be signed out. The attending that has reviewed the patient with you should be aware that you are leaving. Always inform the most senior person if you are leaving the clinical area.
III. Consults
Specialty consultations are available in all services. All consults must be ordered in the computer. If, as the Resident Physician, you are having difficulty contacting a given service, you are to discuss this immediately with the attending of record for the case. OB-GYN consultation for all stable patients and pregnant patients less than 20 weeks will take place in the ED in Suite A/B. All pregnant patients greater than 20 weeks who arrive via EMS must first be triaged in the ED, if they are ambulatory they can be guided directly to S5 (L&D).

IV. Admitting process

At the time it is determined that a patient requires general admission to the hospital, you must discuss the case with an attending physician. The clerk and nurse should be notified of the admission. All medical admissions are discussed with the medical senior who will call in the admission. All admissions to the ICU or specialty services must first be discussed with the appropriate contact person.

V. Radiology Services

The Department of Radiology provides efficient, full-service radiological services. Please be aware that CTs do not need to be approved by the radiologist before the technician will perform them. Preliminary readings of films may be obtained by the radiology resident by calling or walking over to the radiology department (x1406). All plain films are to be reviewed by yourself and the Attending Physician of record on the PACS system, located on each computer. The radiology senior should be contacted via the UHB page operator (270-2121) to discuss all off-hour specialty studies.

VI. Physician Documentation

Currently, we utilize the T-system charting tool. Please become familiar with it. It is expected that you will complete the patient chart, providing all pertinent historical, physical, and laboratory/radiological/EKG interpretive information—both positive and negative—prior to patient disposition. Since T-sheets often get separated from the main chart, it is advisable to also document any important findings, test results, lab results or other significant patient information in the “ED quick note” under MYSIS. You must sign and stamp all charts for patients you care for. ALL charts must be signed and stamped by an attending physician prior to patient disposition. It is your responsibility to note on the chart, in the designated area, which attending was involved in your supervision of the care of this patient (i.e. “d/w Dr. Smith). In addition, all patients must also have the following information noted on the chart: time/date seen by MD, disposition (including time/date), and final diagnosis. If a patient is to be discharged, all patients must have specific discharge instructions, including time and place of follow up appointments, return instructions, and any medication/care instructions. Micromedex Aftercare Instructions should be used for discharge instructions.

VII. Follow-up Appointments

Follow up appointments can be obtained by asking the clerk in your area. The general clinic appointment number is 245-3325. The discharge template in MYSIS also has an area for documenting follow-up appointments. A clinic appointment must also be ordered in MYSIS.

VIII. Clinical Schedule

The Scheduling Chief Resident is responsible for the making and distribution of the monthly KCH ED schedule. The Chief Resident on-call is the most important person with respect to the intricacies of the daily schedule and is the first person to approach with scheduling questions and requests. All schedule changes must be approved by Chief Resident on-call. The following is a brief outline of policies related to the monthly schedule.

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  Any late requests will not be accepted.
  
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  Please check the schedule, even if you requested certain days off. Requests are not guaranteed, but every effort will be made to honor them.
  

Please refer to the “Resident Schedule” section for details.

IX. Educational Objectives
Emphasis will be placed on orientation to the different emergency department environments. Residents should learn to document a chart appropriately (C,PC,MK,P), prioritize and organize activities, perform basic procedural skills, work with EMS(C,P,PC), deal with friends and families of patients (particularly those who are critically ill or dying (P,PC,C,SBP) and deliver quality patient care(P,PC,MK). The resident should demonstrate accurate and appropriate history and physical exam skills, practice generating differential diagnoses and care plans and exhibit the appropriate usage of x-rays and labs (PC,SBP,MK). A PGY 1 should evaluate no more than one to two new patients at a time. They should not accept responsibility for more patients until a senior staff member has evaluated his present patient. Their total caseload will be determined by their need for supervision, as well as patient acuity. PGY 2 and PGY 3 residents will be expected to further develop their clinical acumen, sharpen their physical exam techniques and hone their procedural skills. Their organizational abilities are expected to be more refined and they should be able to manage more patients simultaneously. PGY 4 residents are expected to “run the room” and act as junior attendings. They should know all the patients in the ED, facilitate their management and disposition, and supervise and teach junior residents and medical students.

At the completion of this rotation, residents should be able to demonstrate competency in and be able to:

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  Decide which patients require admission, transfer, or discharge (MK,PC,SBP)
  
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  Perform histories and physicals on Emergency Department patients (MK,PC)
  
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  Understand the necessity for prioritizing patients (PC,SBP)
  
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  Prioritize their activities (SBP,PC)
  
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  Formulate differential diagnoses on their patients (PC,MK)
  
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  Plan appropriate work-ups based on their differential diagnoses (PC,MK)
  
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  Plan admission, transfer and discharges (PC,MK,SBP)
  
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  Appropriately order and utilize laboratory data and ancillary studies (PC,SBP)
  
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  Carefully understand and utilize universal precautions (MK,SBP)
  
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  Appropriately utilize specialty consultation (P,C,PC)
  

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  Function as a team member during resuscitations (P,C)
  
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  Maintain patient follow up and rotation evaluation (PBL)
  

KCH Important Phone Numbers

S-ED Areas			Paging
Suite A	4616, 4617, 4618		KCH	3141, 3142
Suite B	4619, 4620, 4621		Downstate	718-270-2121
CCT	4601-04
Fast Track	4610		Overhead Paging
Peds	3638, 3643, 3860		*9 for waiting rooms (front and radiology)
Reception	3183, 3185, 3187
Triage - EMS	1426		Zone paging	dial *0, then…
Triage - Walk-In	4638		Suite A	24
			Suite B	25
Labs			CCT	26
Chemistry	5342		FT	27
Hematology	5373		Peds	15
Micro	5354		Reception	28
Blood Gas	4632		Rads Read	13
Blood Bank	4897
			Offices
Radiology			Dept. EM	4790
CT ED	3378 / 1408		fax	4799
S-2	3733 / 4985		Head RNs
XR Control	4645		Medical Records	4200
MRI	5585		Messenger	4268
Reading Rm	1406, 1407		Patient Rep	3917
Ultrasound	1405, 4699		Pharmacy	7129
			Respiratory	4526
Inpatient Svcs			Social work	4628 (ED), 4011
Med RED Team	347-231-5922
Med BLUE Team	347-231-5851		Environment of Care
Med Senior	347-386-5976		Biomed (ECG, etc.)	2932
Peds GREEN	917-760-0068		Facilities - daytime	2943
Peds RED < 4yo	917-760-1301		off-hour	2952
			electrical	5138
Behavioral Health			plumbing	2941
BH ER	2310-12		IT Help Desk	4357 (HELP)
BH - Internist	347-992-7938		Linens	4673
Psy Consult - bpr	917-760-0786		Telecom	3333
office	5209
			Units
Outside #s			CCU	7580-2
FDNY Dispatch	718-422-7395		Labor & Delivery	4571
FDNY Help Team	347-865-8658		MICU	7583
Medical Examiner	212-447-2030		Morgue	5313, 5423
NYC Poison CC	212-764-7667		OR	4040
			PICU	7028
			SICU	7003