LBJ ER pointers for Interns and Residents

1) The hand off of patients from the ER to the Medicine teams on call is a critical exchange of information, whereby the patient could suffer delay of appropriate care and/or unnecessary studies, if handled lightly or ineffectively.

2) Interns should, before calling the medicine team, locate the patient’s chart, review it in detail, and prepare a short verbal synopsis of the case.

3) The Intern should anticipate the types of questions that may be asked about the case, such as what was the chief complaint, the brief PMHx, the current vital signs, pertinent studies which justify the admission, results of any imaging studies done to date, and how the patient is being treated for the presumed problem. Many times it is difficult to make a perfectly accurate diagnosis is the rushed/chaotic ER setting. This is OK, but the intern should be honest if not sure what’s going on…do not fabricate a diagnosis that sounds good enough to admit.

4) If the Intern feels they cannot “get in the ball park” on the reason for admission, the intern should ask the ER attending for help with the check out.

5) Plan ahead for the patients that are hanging around near the shift change. Make every effort to decide on disposition within the hour preceding shift change and talk to the attending. When possible, the intern should call checkout on those patients to be admitted before their shift ends. This insures the least disruption in the continuity of care for the patient. DO NOT RELY on the ER attending for continuity of care. No one knows your patient better than you.

6) Shift change is a dangerous time in the ER. There have been multiple recent publications to this affect. When the intern receives the list of patients at shift change, the intern MUST personally examine each patient, review the chart and all of the studies. This should be done quickly and BEFORE a new chart is taken off of the rack. This is solely for the safety of the patient.

7) The medicine residents on call are not allowed to refuse admissions on the basis of merit, but are allowed to respectfully express concerns about level of care to the ER attending. If they are unable to reach an agreement, the on-call resident should respectfully ask to counsel with his or her own attending about the case. From that point forward, the attendings will reach an agreement on what is the appropriate level of care for the patient. The resident should refrain from becoming emotionally involved in the discussion and maintain a professional demeanor at all times. Remember, we represent the University of Texas at Houston Department of Internal Medicine with every word we speak and every action we take. We have good reason to be proud and should take pride in our work.

8) The ER is a very difficult, busy, but very rewarding rotation. It gives you the opportunity to make a diagnosis from scratch and on your own. Have fun and enjoy the experience that LBJ has to offer!