"Nuts & Bolts 2" - A Guide to the Clinical Years Section 3: Insider's Guide to Inpatient Settings Table of Contents Hypothetical Admission Case Scenario: Mr. Jones is working in the garden when he begins having chest pain. His wife calls the paramedics and he is brought into the Emergency Room. Emergency Room Triage Desk Initially, the patient is seen by the triage nurse who determines the severity of Mr. Jones' chest pain. Is the pain due to myocardial ischemia or did he lean back on a nail? Vital signs are taken. The paramedics relay a short history before they leave. Hint: If you are in the ER when the patient comes in, it is helpful to be able to discuss the case with the paramedics before they leave and get their firsthand assessment of the situation. Emergency Room Doctors The patient, if relatively stable, is normally seen first by the fourth-year student or the intern who is in the emergency room rotation. This student does the initial complete history and PE, sends off lab tests and starts an IV (if necessary), and then presents the case to the resident and/or attending working in the Emergency Room who reviews the findings. They usually make the decision regarding admission. If the patient needs to be admitted into the hospital, the resident in charge of the ward team for the next admission is called. This may be the medicine resident, neurologist, OB-GYN, surgeon, etc. The ward resident then evaluates the patient. If the resident agrees the patient needs to be admitted, s/he calls the ward intern and/or the ward medical student. The ward intern/medical student performs a complete admission history and PE, checks on labs and orders additional tests if necessary. IVs are usually put in by ER personnel. Sometimes, the ER staff will draw blood cultures if necessary (although this is the ward team's responsibility). LPs and other special procedures are also the responsibility of the ward team. These procedures are often done in the ER before going up to the floor. Prior to being admitted, the patient needs to have admission orders (ADC VAAN DIMSL) written by the ward intern/medical student. Hint: It is a good idea to perform procedures in "procedural areas" (e.g., ER) rather than performing invasive actions on patients in their own rooms. You will find this is especially true in pediatrics. Hint: Always ask the ER resident if extra blood was drawn. Once the decision to admit has been made, you may need more tests; if samples are already available, the patient (and you!) will be saved a needlestick. Hint: Check the chart about fluids and blood given in the ER, as you will often be asked how much fluid and/or blood are given. Since the med student is expected to have the most detailed history and PE, s/he must spend extra time with the patient collecting data. This may be continued when the patient reaches his/her room on the ward. After completing the data collection, the admission note is written. Interns need to get the note in the chart immediately, whereas third-year medical students may be allowed a certain "grace period" to read about the disease (if known) and differential diagnosis. The medical student should know about the suspected disease and differential diagnosis and be ready to present the next morning. Note: Some people wonder about the need to memorize presentations. As a third-year student, you will probably follow only one new admission per call night; although it is possible to memorize your hx, PE, assessment and plan, it is usually not required or expected. However, do NOT read your presentation from your note, there is little else more boring than to hear someone reading their presentation at 6:30 AM. It is a little more difficult to memorize all of the lab data, although some attendings require it to show that you really know your patient. Notes on Unstable Patients When a patient is unstable, the preceding scenario does not hold true. The patient is taken to a special room (e.g., Trauma Room) where s/he is usually seen simultaneously by the senior ER resident and the attending. Some hospitals have a separate intensive care (ICU) or coronary care unit (CCU) intern and resident who will admit the patient to "the unit." Otherwise, it is the ward resident and the intern who will be called in to admit the patient into the unit. Medical students are usually not allowed to act as the primary caregiver for unit patients unless they are doing a senior ICU or CCU elective, but this can be site, team-, or unit-attending-dependent, and it is worth finding out how involved you are allowed to be. The ward or unit intern usually has the responsibility for writing notes and orders on the unit patients. If there is no separate unit intern, there are usually separate ICU/CCU residents and attendings who follow the patients in the units. Notes and presentations in the unit are not in the SOAP format, but instead are done by organ system. You may not need to know this method for third-year clerkships, but you will in the fourth. Doing ICU presentations well can make you shine. It is not that much more difficult than the floor where there is just more information. Once you have the format down, it is good to follow the patient in the ICU.