Harborview Medical Center Emergency Department

This is unpublished

HMC ED

Emergency Department is split up into two main parts: medicine and trauma.  The trauma side consists of the trauma resuscitation bays, which will appear on the trackboard as rooms starting with MED, R1, R2, or R3, as well as the trauma hallway beds which will appear as THW. The medicine side is split into the blue side (B) and the green side (G), corresponding to the color of the numbers designating the beds. Medicine also includes resuscitation bay 5 (R5), the blue isolation room near the ambulance bay (Blui), the east isolation rooms (E-ISO), and the blue and green hallway beds (HWB and HWG). You will only be picking up patients on either trauma or medicine depending on your rotation structure. Do not sign up for any patients in RME or PES beds. 

HMC Medicine 

Who Do I Staff With? 

You can staff with either attending. The “purple” attending generally sits in the blue zone and the “gold” attending generally sits in the green zone. You do not have to staff patients by zone. Whichever attending is available is who you should discuss your patients with.  Sometimes, you may be asked to staff with the R4 EM resident instead.  

Roles on the HMC Medicine Team 

The Dyad 

  • Dyad shifts are from 6a-2p, 2p-10p, and 10p-6a 
  • Senior Dyad (SD): generally an emergency medicine senior resident except for Thursday mornings when the EM residents have didactics 
  • The SD resident typically will see the high-acuity medic patients and a large volume of the patients in the department. Depending on whether or not the SD resident is an EM R3 or R4, they may also be responsible for staffing patients who are seen by medical students and interns. SD residents staff directly with the attendings.  
  • Junior Dyad (JD): generally an emergency medicine R1 or R2 except for Thursday mornings when the EM residents have didactics 
  •  The JD resident may see the high-acuity medic patients depending on their comfort level.  If the JD resident is an intern, they may staff with the SD resident if the SD is an R4; otherwise, they will staff with the attending.  

Non-dyad (ND) 

  • Non-dyad shifts include the following: 10a-6p, 5p-1a, 9p-5a 
  • Non-dyad residents function similarly to the junior dyad residents. They can pick up any patient that is available to be seen. They will staff with any available medicine attending (at HMC) or the EM R4 supervising resident. 
  • ND residents will sign out to either an on-coming non-dyad resident or the senior or junior dyad resident if there is no on-coming ND. Sign-out for ND residents occurs at the end of the scheduled shift. You should ensure that prior to leaving your shift after sign-out, you have finished all of your documentation, performed any necessary procedures including sensitive exams, and discharged any patients who are ready to discharge.  

HMC Trauma 

Roles on the Trauma Team 

Trauma Senior 

  • Trauma senior shifts are from 6a-2p, 2p-10p, and 10p-6a 
  • Trauma seniors are emergency medicine R3 or R4 residents 
  • The trauma senior resident will staff all the patients on the trauma side of the HMC emergency department and supervise the department alongside the trauma attending. During resuscitations, they can assist the trauma doc, act as team leader for the resuscitation, and perform or supervise necessary procedures. 

Trauma Doc 

  • Trauma doc shifts are from 6a-2p, 2p-10p, and 10p-6a 
    • Trauma Doc Responsibilities 
      • Trauma docs will answer the trauma medic radio and provide medical direction to the paramedics and alert the department about incoming trauma patients  
      • Trauma docs will carry the trauma pager and respond to pages by communicating with medics on the Medic One radio to provide medical direction and alert the department about incoming trauma patients 
      • Trauma docs will run all modified and full trauma activations, collaborate with the trauma surgery team and necessary consultants, and be responsible for documentation, procedures, consults and dispositions for these patients 
      • Trauma docs will staff their patients with the trauma senior or the attending if there is no trauma senior 

Trauma Team 

  • Trauma team shifts are from 6a-2p, 2p-10p, and 10p-6a 
    • Trauma Team Member Responsibilities 
      • Trauma team (TT) members will see patients who do not meet criteria for “trauma activations” on the trauma side of the HMC emergency department. TT members will be expected to evaluate patients independently, commit to a management plan, discuss with the senior resident (R4) or attending, place orders, and call consultations for their patients. 
      • Trauma team members may staff their patients with the trauma doc if the TD is a senior EM resident, with the trauma senior, or with the attending if there is no trauma senior or the trauma doc is not a senior EM resident. 
      • Trauma team members should be present at all modified and full trauma activations unless they are involved in active patient care 
    • Roles during trauma activations for trauma team members 
      • Placing orders: Before putting in any orders, assign the ED attending to the patient. You can then place orders more efficiently. The trauma doc or the trauma surgery team will verbalize orders during the resuscitation. Making sure these orders are placed in Epic so they can be swiftly executed is critical for patient care. 
      • Bedside tasks: Help exposing the patient, obtaining an ABG, and performing a FAST ultrasound exam 
      • Procedures: depending on necessity and patient acuity, trauma team members can help at the bedside with procedures such as chest tubes, joint reductions, splint applications, and obtaining central venous access. These procedures are usually performed by senior members of the resuscitation team, such as the trauma doc or the general surgery R3 or the trauma senior

Procedures in the Trauma Bay 

  • We want to support your education, and if performing procedures is part of your educational goal, please let the trauma senior and/or the attending know!  
  • Some procedures will necessarily be performed only by EM residents or anesthesia or general surgery residents (ie., intubations, chest tubes, etc.). However, you will likely get the opportunity to perform or at least be involved in procedures if that is something of interest for your specific learning goals. 

 

HMC ED Operations 

Calling Consults 

  • Please discuss with your attending or senior resident before calling a consult 
  • To page a consultant, call the ED operator using the work phone (passcode 4074) and ask them to page the team you would like to reach. They will ask you for your name, the number you are calling from, and the patient’s MRN. Document within the ED course when you page.  
  • Consultants are expected to call back within 20 minutes and to have seen the patients within 45 minutes unless there are extenuating circumstances. If you still have not heard back from the consult team within 30 minutes of the initial page, you should re-page them. Notify your attending if you have not heard back from the consultant within 1 hour of the page so the attending can escalate appropriately. 

Transfers 

  • As a level 1 trauma center, HMC receives many transfers from outside hospitals in both the trauma and medicine sides of the ED.  
  • If patients have undergone imaging at the outside hospital before coming to HMC, please order overreads so that our radiologists can review those images and submit their independent findings. Make sure to follow up on these overreads via the imaging tab in the patient’s charts! 
  • Most patients who have transferred to HMC have an accepting service. You can find this via the “Encounters” tab in the “Chart Review” section of the patient's chart – there will be an “Intake” encounter that details the transfer process. Typically, we will involve those services in the patient’s care by consulting them – please check with your attending or senior EM resident before paging the consult.  

Discharging Patients 

  • When your patient’s work-up is complete and they are safe for discharge (please check in with your attending to discuss this), mark them as “Discharge” on the Dispo tab, insert their clinical impressions, order any prescription medications and place appropriate referrals, and attach discharge instructions. Once this is complete, scroll to the bottom of the Dispo tab and click “Ready to Go,” which will mark the patient as Ready to Discharge for the nurse. 
  • Please make sure you check in with your patients, explain the results of their workup, care instructions, follow-up instructions, and return precautions with them before discharge 
  • Enter all applicable Clinical Impressions in the disposition tab before you sign your notes 

Admissions 

  • Once your patient’s work-up or presentation makes it clear that they need to be admitted to the hospital, discuss with your attending what team they would need to be admitted to.  
  • Page the team for admission. They will call back, and you will provide them with sign-out. Once you have discussed the admission with this team, navigate to the Dispo tab, mark the patient as “Admit,” and then place a bed request by selecting the “Bed Request” button and designating the appropriate accepting team.