How the System is Set Up

How the system is set up:

FRONT ROOM: Intake for new traumas.

●         When they come in, grab an H&P (students should help with this), carbon copy 501 general consent form (for all pts to sign), and put on gloves to do your primary and secondary surveys.

●        All new patients need: Discharge Summary (save and close), updated problem list, updated current medications, updated allergies in the computer.  Also grab two stickers - one for the front room list and one for the back room book in the morning.

●        Print out and read all of the trauma protocols on the Stroger intranet (go to the bottom of the home page to "trauma," then click on protocols near the top of the page).  This will guide your work-ups in the front room.

●        Use the Trauma Resus caresets (just type in “trauma” to see options) to help you order the correct items.

●        EVERY admission from the front room to Obs/ICU/Floor should be signed out to the back room resident.

●        Everyone should get FirstNet access for the Front Room.  PowerChart is for the back room.

●        There is no transport service here, so it's up to us to get pts to and from tests expeditiously.

●        Get all imaging prelim read by the radiology resident, and all CT arch reads done by an attending.

●        All GSW + retained missiles on imaging should add up to an EVEN number.  If they don’t, look elsewhere for the missing bullet.  Think carefully about possible trajectory and potentially injured structures.

●        Very unstable patients go straight to the shock room next to the entrance.  If you have a patient coming in there, put on a yellow gown, gloves, and make sure there is a knife for cric, thoracotomy tray, chest tube kit, and Cordis ready..

●        Follow base deficit to guide your resuscitation of an unstable patient in the front room.

●        Anyone with LOC gets admitted for neurochecks for 23hrs to obs unless they have someone to go home with that will do them.

●        Post neg DPL pts also get admitted for 23hrs for abdominal exams to eval for evidence of perforated viscous.  Post angio pts get groin checks and lie flat for 6hrs.

●        Morning report presentations are very formulaic: Ex: 20yoM transferred from ___ after rollover MVC with +LOC (describe scene). He was brought in by CFD boarded and collared, primary survey was intact (or list anything abnl - HR, BP, BE), GCS was 15, CAGE (EtOH) and Abuse (violent)screens were negative, secondary survey revealed _____ (head to toe - describe locations, DON'T POINT).  His workup included: list all imaging and pertinent labs.  Say each result after each test bc we have to record them one by one.  Dispo: He was admitted to obs for neurochecks, which will be done at 11pm, 23h after the injury.

BACK ROOM: Includes observation unit, ICU and all floor patients.

●        Surgical Junior holds the back room book, which has every patients to-do list for the day as well as notes (we do sometimes look back at this book, so be thorough, update constantly, and write legibly)

●        All meds in PowerChart are generic, so you will have to use Epocrates often.

●        The ICU and floor lists are populated on PowerChart automatically, but we have to add each individual patient to the floor list (it has to be proxy-ed to you by someone else so you can see it)

●        An ER resident fills out the clip board daily sheet for each ICU patient (this is a hospital requirement).

●        You are primarily responsible for your patients, so complete all tasks discussed on rounds (this includes CTs, daily labs, calling consults, discharging patients, etc), then sign out what you're done to the back room by early afternoon.  If you do not sign out to them, they will not know what they do and do not still have to do.

●        All patients should be on Lovenox 30mg SQ BID and SCD if no contraindications (head bleed, solid organ injury, ongoing bleeding).

●        All patients who are NPO should be on Pepcid, UNTIL they are started on a diet or on goal tube feeds, then D/C.

●        Things to renew EVERY DAY: all continuous IVF (pressors, sedation, insulin), vent settings, RESTRAINTS, narcotics (PO and IV), daily labs (3am)

●        Update the discharge summary with one line of the days events EVERY DAY. This should not be left until the last day.  SAVE and CLOSE so you can update it until the pt’s last day.

●        Check cultures daily if sent to see if antibiotics need to be tailored.  Keep a record of posistive cultures on more complicated patients.  Keep note of when the last negative blood culture was, so we

●        Daily sedation holidays and SBTs (spontaneous breathing trials) on all intubated patients.  Pts do not have to be completely off sedation to do an SBT, in fact, it is better to have a little sedation to keep them comfortable with an ETT shoved in their throat).  RTs/Seniors can help with this.  Report RSBI in am.

●        All patients on narcotics should be on a bowel regimen (Colace)

●        Use your supurb clinical pharmacist and dietician to your full advantage (Natasha and Vicki), and respect their expertise.

●        All TPN needs to be written and sent to pharmacy before 11am.  Get nutrition labs (prealbumin, transferrin) every Mon and Thurs.

●        Skin exam every Mon/Thurs - document all decubitus ulcers in a separate progress note (this is a billing issue)

●        THINK ABOUT PLACEMENT EARLY - consult SW, PT/OT and rehab early if you anticipate rehab bc placement is a lengthy process. Interdisciplinary rounds at 1pm qTues in intake room.

●        Senior residents will help you with any procedures or if you have ANY questions about ICU management.  Never be afraid to ask!

Again, thanks to Marie Ziesat, MD :-)