PRESBYTERIAN HOSPITAL

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PRESBYTERIAN HOSPITAL EMERGENCY SERVICES
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A Brief History of Emergency Services

• It was recognized early on that rapid treatment
  of the injured resulted in higher survival rates.
  This led to increasingly better modes of
  transportation to medical care.

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1916 Model T Ambulance used in World War 1
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1970s Ambulance Cadillac model. First design of
the raised roof allowed more space for patients
and staff.
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Ambulances today are equipped with advanced
technology and supplies
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We need a room

• The Emergency Room was originally staffed by
  the physician on call regardless of their trained
  specialty
• 1968 ACEP was formed
• 1970s First Emergency Medicine residency
  programs for physicians
• 1976 ABEM was incorporated
• 1979 Formally recognized as a medical specialty

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Life in the fast lane

• Emergency Medicine Today
• Highly trained Emergency Physicians
• Depth of resources available to the ED patient
• Collaborative specialty care

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ED is a unique area of the facility

• Different equipment, different approach
• Pre Hospital collaboration
• Rapid Key Interventions
• Independent resources
• Specialized care, consult services
• Protocols to streamline the process

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The ED Physician

• Specialized training
• Fast paced decision making
• Challenging environment
• Collaboration with other specialties
• Broad knowledge base
• ED is open 24/7

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The ED Nurse

• Learn critical care skills
• Organization and prioritization
• Physically, mentally and emotionally challenging
• Skills that will benefit you in all that follows
• Pros and Cons to the schedule of work

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PH Emergency Department Statistics

• 2008 ED Patients 80,817
• Compared to 65,310 in 2004
• Average 221 patients per day
• Variable by season
• February 2008 we saw 7,366 patients (263/day)
• November 2008 we saw 6,359 patients (212/day)
• Trauma Patients
• About 2000 trauma patients per year
• 922 Reportable trauma patients to NC Trauma
  database
• Admissions
• 16,433 patients in 2008 (about 45 per day)

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Triage a critical factor

• Main Entry
• triage
• Pronunciation
• \tre-äzh,
• Function
• noun
• Etymology
• French, sorting, sifting, from trier to sort,
  from Old French
• Date
• 1918
• 1 a the sorting of and allocation of treatment
  to patients and especially battle and disaster
  victims according to a system of priorities
  designed to maximize the number of survivors b
  the sorting of patients (as in an emergency room)
  according to the urgency of their need for care2
  the assigning of priority order to projects on
  the basis of where funds and other resources can
  be best used, are most needed, or are most likely
  to achieve success
• triage transitive verb

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• 5 level triage system
• Emergency Severity Index
• Assesses patients by acuity and resource needs
• 4 decision points

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TRAUMA CODE ACTIVATION CRITERIA

• CODE 2
• Penetrating or blunt trauma head, neck torso
  
• without compromise
• Head injury Glascow 9 - 14
• Airway compromise not requiring intubation
• Suspected abdominal injury, significant MOI
• Pregnancy over 20 weeks with significant MOI w
  bleeding or pain
• Severe penetrating injury distal to elbow or
  knee, stable
• Burns meeting transfer criteria
• Vascular injury moderate arterial bleed
  distal extremity
• Amputation distal to elbow or knee
• Spinal injury without deficit
• Suspected or obvious proximal longbone
  fractures
• Significant MOI, stable
• Falls over 10 feet
• Pedestrian struck by vehicle
• Motorcycle crash
• MVC with
• Ejection

• CODE 1
• Trauma arrest
• GCS lt 8 and/or RTS lt11
• Shock BP lt 90
• Pulse gt130 lt 50
• RR gt30 lt10
• Airway compromise requiring intubation
• Major burns
• Major vascular injury arterial bleed proximal
  extremity
• Suspected unstable pelvic fracture
• Falls gt 20ft w/ long bone or pelvic fx
• Penetrating wound to head, neck or torso
  w/compromise
• Traumatic amputations proximal to elbow or knee
• Spinal injury with neurological deficits
• Administration of blood products necessary to
  maintain VS
• Partial or full thickness burns
• gt25 body area
• Involves face, eyes, ears, hands, feet or
  perineum.
• Crosses major joints

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Case Study ED patient

• June 2008 22yo male gunshot wound to the thigh.
• ED course
• 1710 arrived - Level 1 triage
• 1715 VS on arrival 122/70 88 18 GCS 15 sats
  100 96.1 axillary temp.
• Extremely diaphoretic, difficult to arouse
• No meds, no allergies
• Shooting happened just prior to arrival
• Arrived via private car
• No active bleeding visible in triage, dried blood
  on clothing
• 1715 to trauma room 3 via wheelchair. GSW to
  inner thigh 1.5 inch diameter circular wound,
  thigh swollen, wound bleeding, controlled. Pedal
  pulses palpable in injured leg
• 1715 IV1 placed in. Dr Wood at bedside. BP
  118/89
• 1715 CMPD notified. Forensic program manager at
  bedside collecting evidence
• 1720 radiology performs ordered films
• 1720 Trauma surgeon arrives at the bedside
• 1722 IV 2 placed in VS remain stable
• 1738 IV Ancef given in prep for OR
• 1741 VS stable BP 122/84
• From ED to OR as soon as surgeon ready for case.
  The patient was in the ED about 2 hours. Pt
  considered to be stable, but is an urgent
  surgical patient.

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Case Study continued

• Admission diagnoses
• Gunshot wound left thigh
• Left foot ischemia
• Left thigh compartment syndrome
• Left femur fracture
• Summary
• This patient suffered a gunshot wound to the left
  thigh with increasing blood loss over the first
  day of his treatment. He had loss of perfusion to
  the left lower extremity as a result of the
  bleeding in the leg. He had a comminuted distal
  femur fracture. He was taken to the OR urgently
  and a hematoma was evacuated and a fasciotomy
  performed to relieve the swelling in the leg. The
  following day he was taken back to the OR to
  stabilize the femur with internal fixation.
• Complication related to the injury The patient
  suffered from extensive bleeding from the wound.
  He required over 20 blood products while in
  intensive care. He faced a life threatening
  injury to his lower leg with extensive tissue
  damage, compartment syndrome, large blood volume
  loss which placed him at risk for multisystem
  organ failure. He was at high risk for DVT, PE,
  kidney damage and other problems. He was on a
  ventilator in ICU for several days.
• 9 days after admission, this patient was
  ambulatory and ready for discharge from the
  hospital. He has done well in recovery from his
  injury since.

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What to expect from your ED visit

• The ED changes by the hour
• A lot of distractions
• Things happen quickly
• Challenging environment
• Staff will welcome and educate you

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What can you do to get the most out of your ED
visit?

• Ask questions!
• Focus on the patient
• Observe every person in their role
• Think safety
• Put the pieces together
• Thinking ahead
• The collaboration of services and specialties

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