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Archive for July, 2010

Electric Ring Cutter

Written by reuben

July 24th, 2010 at 5:10 pm

EHC Cardiac Room Eval

In our continued quest to get more evaluations from the cardiac room, Weingart has created an online form at http://eval.ehced.org.  It is basically identical to the new innovations eval (and the paper forms in the cardiac room).


Attendings: sometime during your cardiac shift, please go to http://eval.ehced.org and complete an eval of the resident you’re working with. No username/password required.  Should be super fast.  Your input is invaluable and the residents deserve it.  Alternatively, you can log on to New Innov or complete a paper form.

Residents: sometime during your cardiac shift (don’t wait until the attending is wrapping up to go home), pull up the evaluation on http://eval.ehced.org, complete the general info (your name, attending name and date) and then ask the attending to complete the evaluation.  This is probably the best way to ensure you get an evaluation and feedback.

The web address is also posted on the wall next to the attending computer in the Elmhurst cardiac room.

As always, feel free to email/call with questions/concerns. Thanks,
Kaush

Written by phil

July 24th, 2010 at 4:16 pm

Posted in Residents

Jewish Home patients admitted by geriatrics service

Written by reuben

July 21st, 2010 at 10:44 pm

Posted in Admitting

4th Year Student Objectives and General Info

EMERGENCY MEDICINE CLERKSHIP

CLINICAL POLICY OVERVIEW
Clerkships require students to actively participate in the care of patients. Students are required to attend all clerkship activities and educational sessions.

Students are duty-bound to develop skills in providing care that is humanistic, grounded in the fundamentals of medical ethics, and performed to the highest standards of professionalism.

ELECTRONIC DIAGNOSIS & PROCEDURE TRACKER
To ensure adequate exposure to a variety of presenting complaints, we require that students log clerkship-specific diagnoses into our web tracking system, accessed through E-Value (www.e-value.net). The list of must-see diagnoses for this clerkship are listed on the back of this card Students are responsible for maintaining a procedure record and entering them into E-Value. All information requested must be completed. A list of school-wide core procedures and clerkship-specific procedures are listed on the back of this card.

CLERKSHIP OBJECTIVES: By the end of the clerkship, must:

Obtain an accurate history and physical focused on key problems
Recognize life or limb threatening problems
Monitor response to treatment
Make proper dispositions and follow up plans for the patient
Perform basic procedures; know the indications, contraindications
Be able to discuss preventable illness and injuries
Educate patients regarding their treatment and follow up plan
Develop skills to evaluate an undifferentiated patient in a culturally sensitive manner
Develop a differential diagnosis based on likely diagnoses and diagnoses not to miss
Develop a management plan for the evaluation (ED, inpatient or OPD as appropriate) using on line resources and discussion with the preceptor
Interpret common lab results and imaging studies; review with preceptor or radiology
Learn key topics in the educational core
Demonstrate effective use of information technology to solve patient problems, improve your knowledge base, develop case presentations
Effectively communicate with patients and family members utilizing translation services when needed
Be aware of your bias and promote a compassionate and non judgmental approach to all patients
Work collegially with the health care team
Present cases in an accurate, complete and concise manner which delineates the primary problem(s) and plan
Document your work in an accurate, organized manner that is appropriate to the level of care provided
Exhibit a strong work ethic: be punctual, conscientious and responsible for your patients
Exhibit honesty and integrity in patient care; complete all work discussed and report and document accurately
Practice ethical decision making
Be accountable; sign out all patients when you are taking a lunch break and at the end of the shift
Project a professional appearance
Be sensitive to cultural issues re: age, gender, culture, disability, etc.
Make an appropriate referral from the ED; in some cases this may involve calling a consultant for permission to overbook to a subspecialty clinic for an urgent follow up
Be sensitive to medication costs and resources available to your patient
Appreciate the role of emergency medicine in the community, as a safety net, and its impact on patient care

WORK SCHEDULE/HOURS
14 Shifts (8-12hours); 13 shifts for QHC/JCMC
Minimum 2 weekend, 2 night, 2 Fast Track
6 Required Didactic Sessions
1 Resident Conference Day (5hours)

IMPORTANT CONTACT INFORMATION:

Ombudspeople: Dr. Nathan Goldstein: nathan.goldstein@mssm.edu

Dr. Helen Fernandez: helen.fernandez@mssm.edu

Absences: Notify Clerkship Director(s), Clerkship Coordinator, Site Director and medstudentabsence@mssm.edu
Sites, transportation, housing & reimbursement: Judith Quintana
212-241-8752 judith.quintana@mssm.edu


MUST-SEE DIAGNOSES: These must be logged into E-Value
Abdominal Pain
Airway Management 
Altered Mental Status
Bleeding
Chest Pain
Dyspnea/SOB
Extremity Trauma
Fever
Fluid and Electrolyte Management
Hypotension
Urologic Disorders
Weakness

CORE PROCEDURES:
By graduation, students must successfully complete 3 of each of the following core procedures:
Dressing changes
EKG
Intradermal skin testing
Intravenous line placement
Nasogastric tube insertion
Obtaining peak flow measurements
Suture removal
Throat cultures
Urethral catheter placement & removal
(M and F)
Venipuncture

SUGGESTED PROCEDURES:
Arterial Blood Gas
Laceration Repair
Abscess I&D
Splinting
Bedside Ultrasound

KEY ROTATION CONTACTS

Clerkship Director/MSSM Site Director
Dr. Barbara Richardson
barbara.richardson@mssm.edu?212-241-2274?
Assistant Clerkship Director
Dr. Braden Hexom
bjhexom@yahoo.com
414-807-8228

Course Coordinator
Minerva Camacho
minerva.camacho@msnyuhealth.org

Site Directors
Dr. Sebastian Abdelnur, MSH-Queens
sabdelnur9@gmail.com                    
718-267-4390

Dr. Ravi Kapoor, Queens Hosp Center
ravikapoormd@gmail.com              
718-883-3070

Dr. Michael Silverman, Morristown Hosp
msilverman@pol.net                         
973-971-7926

Dr. Tim Walther, Elmhurst Hospital and Visiting Students
Timwalther@yahoo.com                  
718-334-3050

Dr. Victoria Cespedes
victoria_cespedes@hotmail.com


Written by reuben

July 21st, 2010 at 4:09 am

Posted in Students

Expiration Chart / Post-Mortem Navigator

Valued Mount Sinai Emergency Clinicians:

Valued Mount Sinai Emergency Clinicians:

All patients who are pronounced in the ED must have an expiration chart filled out using the “ED MD Post-Mortem Navigator.” Expiration chart is the responsibility of the case attending, but may be delegated to other members of the clinical team. Note that the checklist may be filled out in pieces, so that, for example, when the next of kin is notified, that part can be entered, then later when the primary care physician is notified, that part can be entered.

If you forget to fill this out, don’t worry, you will be reminded by your friendly peer review team.

reuben

We’re not allowed to post screenshots of epic. To get to the post-mortem navigator from within a patient chart, use the “more activities” button on the bottom-left; this brings up a menu where you can select the post-mortem navigator. Under “expiration documentation” click “new reading.”

The “ME Guidelines” is from the old IBEX expiration chart, and hasn’t been brought over to Epic yet.

Mount Sinai Citrix Presentation Server

Written by reuben

July 16th, 2010 at 6:38 pm

Posted in Death

Letters of Reference for Med Students

For Sinai students, I write the Departmental letter which is co-signed
by Andy Jagoda. Additionally the Sinai students have been told to
select
one other Attending with whom they have worked closely and ask for a
letter.
For visiting students, Tim writes the evaluations. He has written
letters for some students, but if he does not know them well, then
they
may ask for a letter from a faculty member with whom they have worked
a few shifts.  Certainly a system in which a student works many shifts
with a faculty member would be best but not possible to achieve in our
complex system.  Any student requesting a letter should meet with you
and forward to you:
ERAS sheet with AAMC applicant number
CV
personal statement
We can also provide performance data on the student at the end of the
Block when the data is in.  Use the SLOR on the saem.website.
For Sinai students, I write the Departmental letter which is co-signed by Andy Jagoda. Additionally the Sinai students have been told to select one other Attending with whom they have worked closely and ask for a letter.
For visiting students, Tim writes the evaluations. He has written letters for some students, but if he does not know them well, then they may ask for a letter from a faculty member with whom they have worked a few shifts.  Certainly a system in which a student works many shifts with a faculty member would be best but not possible to achieve in our complex system.  Any student requesting a letter should meet with you and forward to you:
ERAS sheet with AAMC applicant number
CV
personal statement
We can also provide performance data on the student at the end of the  Block when the data is in.  Use the SLOR on the saem.website.
Barbara

Written by reuben

July 14th, 2010 at 9:48 pm

Posted in Students

EM Clerkship Expectations and Laminated Cards

Message from Dr. Barbara Richardson
 
 
Dear Faculty and Residents:
 
You are receiving this e mail because it explains laminated green cards coming your way via Suzi (for Tim to distribute to all attendings who teach students in ED along with this e mail), site directors for distribution to your attendings with the following e mail and to house staff who will find the green card in your Sinai mailbox.
 
MSSM will be audited by LCME within a year, and will query staff on what the objectives of the EM clerkship are and what the students are expected to know/do/learn. Similar to the development of the badge cards for JCAHO, the Clerkship Directors at Sinai got together to produce cards for each clerkship, using a similar format modeled after a successful program at Case-Western who was recently surveyed. The goal is for students, residents and Attending to be on the same page regarding expectations. Orientation was today; they start tomorrow. Please distribute these to your Attendings.  They were costly and time consuming to produce so please ask people NOT to randomly discard them (I cannot easily replace them). I have chosen the lovely lime color to provide contrast, better visibility for the small font size we needed, and to stand out from other disposable pocket items.
 
Please note:
1. These are the expectations of the fourth year students rotating through EM. 
2. If there are those who are not keeping up, the site director needs to know to provide some guidance before end of clerkship.
3. The “Must See: diagnoses are at least one of each per student per rotation. The core procedures are what a student is required to do for graduation, the
suggested are additional we are requiring for the clerkship. NGT, foleys, were deleted from our required because they are covered in Surgery, OB. Intradermal skin tests and throat cultures get done in clinic and Peds but if a student needs to do more and the opportunity arises, they can do them in the ED.
 
For your information, the following students have expressed interest in EM: 
Block I   MSSM: Raphael Falk, Daniel Chien, Joseph Freedman
          Visiting: Jessica Murphy, Kevin Tierney, Sammy Yu
 
Finally just an easy concept for teaching at the bedside from CCF, 2001:
 
ASK  What do you think is going on (if they have not already given their differential) or what led you to that conclusion?
TELL Teach a general rule (what they did well, what they could improve, be specific)
ASK  What do they take away from this conversation? What do they want to investigate further, read up on, etc.
 
Thanks for your attention to great teaching and have a terrific summer.
Best
Barbara R
 
Thanks to Minerva for emailing to MSSM faculty; mailing cards to JCMC, QHC, Morristown
Thanks to Suzi for e mail forward to residents and carried acrds to Tim W
Thanks to Alex (student) who carried cards to Dr Lee for Dr Abdelnur 7/6

Written by phil

July 14th, 2010 at 7:54 pm

Posted in Students

Deep Sedation

The Sedation/Analgesia (“Conscious Sedation”) Policy
 
The Sedation/Analgesia Policy was amended to delete the section on Deep Sedation.  Deep Sedation has been reclassified by CMS as “Anesthesia.”  Physicians and Dentists performing Deep Sedation must be credentialed specifically to perform deep sedation by their Chief of Service and maintain standards of care and documentation that are equivalent to the Department of Anesthesiology standards.  (Policy # A2-307)

Written by phil

July 14th, 2010 at 5:34 pm

Pregnancy Status Documentation

The Hospital Staff Rules and Regulations, Section on History and Physical was amended to include:
 
·         Pregnancy status must be documented on all patients of child bearing potential within 24 hours of admission and prior to any diagnostic or therapeutic procedures. 
·         Refusal of pregnancy testing must be documented, as applicable.  
·         Adult patients refusing pregnancy testing may sign a “Refusal of Pregnancy Testing and Release” form, which is available on the Intranet, section on the Consent Policy. 
·         If a Pediatric patient requires care, please call the Adolescent Health attending physician on-call.
 
To find the revised Rules and Regulations on the Intranet copy this address: http://intranet1.mountsinai.org/admin_policies/rules_regs/frame_RR97.htm

Written by phil

July 14th, 2010 at 5:31 pm

Posted in OB/GYN

Fourth Year Medical Students interested in EM

Raphael Falk                  Mount Sinai
Joseph Freedman        Mount Sinai
Daniel Chien                   Mount Sinai
Jessica Murphy            New York Med
Sammy Yu                      Chicago Medical School
Kevin Tierney               UMDNJ – New Jersey Med

Written by phil

July 14th, 2010 at 5:30 pm

Posted in Residents

Detox Referrals – Mr. Allen

Mr Allen will pick up your patient requesting detox from 8a-10p, 7 days per week. All abuse substances are eligible (alcohol, opiates, benzodiazepines) though they prefer not to detox cocaine alone or marijuana alone, but who needs detox from cocaine or marijuana alone? No one. They are always also using alcohol or opiates, so call Mr. Allen.

917-532-8918 or 917-806-8049

Hello everyone,

I wanted to share some information with you about making detox referrals. We in the psych ER have been working with St. John’s Riverside for a while now, and I spoke with their transportation person Mr. Allen (cell 917-532-8918) earlier this week about our likelihood of making more referrals now that North General has closed and we are likely to get more patients needing detox (and he did say he had been getting more calls from us over the last couple of weeks).  He told me that St. John’s has 54 detox beds as well as 30 rehab beds.  They are rarely full, and thus usually able to take our referrals.  If for some reason, they are unable to take a referral, he will work with us to find another suitable location (often ACI, but other facilities like Beth Israel also).  St. John’s takes most insurances, but not self-pay (these people would need to be referred to a city hospital like Bellevue, Metropolitan, Harlem).  Mr. Allen can be called from 8am-10pm seven days/week and provides transportation from our ER to the detox facility.  I’m sure he’d be happy to answer any additional questions anyone has and I’d also like to say I’ve personally found him to be very responsive and helpful and I think he and St. John’s can be good resources for us going forward.  Also, for those of you doing shifts in the psych ER, please indicate when you’ve referred someone to detox by writing a note in the comments section on the patient log.  Thanks.

Amy Johnson

Hello everyone,
I wanted to share some information with you about making detox referrals. We in the psych ER have been working with St. John’s Riverside for a while now, and I spoke with their transportation person Mr. Allen (cell 917-532-8918) earlier this week about our likelihood of making more referrals now that North General has closed and we are likely to get more patients needing detox (and he did say he had been getting more calls from us over the last couple of weeks).  He told me that St. John’s has 54 detox beds as well as 30 rehab beds.  They are rarely full, and thus usually able to take our referrals.  If for some reason, they are unable to take a referral, he will work with us to find another suitable location (often ACI, but other facilities like Beth Israel also).  St. John’s takes most insurances, but not self-pay (these people would need to be referred to a city hospital like Bellevue, Metropolitan, Harlem).  Mr. Allen can be called from 8am-10pm seven days/week and provides transportation from our ER to the detox facility.  I’m sure he’d be happy to answer any additional questions anyone has and I’d also like to say I’ve personally found him to be very responsive and helpful and I think he and St. John’s can be good resources for us going forward.  Also, for those of you doing shifts in the psych ER, please indicate when you’ve referred someone to detox by writing a note in the comments section on the patient log.  Thanks.
Amy

Written by reuben

July 14th, 2010 at 4:39 pm

Posted in Contacts,Toxicology

Epic eLearning Modules

Please check out the new Epic web page
http://intranet1.mountsinai.org/epic/
<http://intranet1.mountsinai.org/epic/> . Our team has spent a great
deal of effort making it both useful and easy to use. Among the things
you can find are: downtime procedures, training information
e-learning(online learning of how to do things in Epic), quick reference
quides, epic request forms(enhancements, reports, etc) and updates on
the inpatient, pharmacy, and ed implementations.
Joseph Kannry MD
Lead Technical Informaticist
Epic EMR Clinical Transformation Group
Mount Sinai Medical Center

Use your novell log in to enter the e learning modules on the intranet (i.e. at Sinai or via onsitehealth).

http://intranet1.mountsinai.org/epic/

Our team has spent a great deal of effort making it both useful and easy to use. Among the things you can find are: downtime procedures, training information, e-learning(online learning of how to do things in Epic), quick reference guides, epic request forms(enhancements, reports, etc) and updates on the inpatient, pharmacy, and ed implementations.

Joseph Kannry MD

Lead Technical Informaticist

Epic EMR Clinical Transformation Group

Mount Sinai Medical Center

Written by reuben

July 13th, 2010 at 12:51 am

Posted in Epic

Death Management Protocol

EMERGENCY DEPARTMENT POLICIES
SUBJECT:
Death Management Protocol
NO. 28
PAGE NO. 1 of 4

Original Date of Issue:  4/25/85

Current Revision:  4/03
Emergency Department staff are responsible for expeditiously coordinating the procedures following the death of a patient in the Emergency Department in accordance with hospital policy A3-115

PURPOSE:
Upon the death of a patient, all efforts must be made to assure for the proper care and disposition of the body and every reasonable effort must be made to inform the next of kin. In circumstances when there is no next of kin identified, attempts should be made to notify a significant other or emergency contact if no one has been identified. All such efforts must be appropriately documented in order to assure that all procedures have been properly adhered to. The individual accountabilities for the disposition of a deceased patient are outlined in this policy and include the roles and responsibilities of the physician who pronounced the patient, attending physician, Care Center Director, Clinical Nurse Manager/Nurse Administrator or designee, the Clinical Nurse, and the Business Associate (BA).

RESPONSIBILITIES:
PHYSICIAN
Notification Notification can occur via:
Direct contact with the next of kin and/or significant other/emergency contact if present at the time of death.
Telephone contact with the next of kin and/or significant other/emergency contact
Direct contact with the patient’s attending physician. Document in the medical record that the attending has agreed to notify the next of kin and/or significant other/emergency contact.

For patients admitted from an Extended Care Facility (i.e., Nursing Home, Subacute or Rehab facility), the Extended Care Facility must also be notified of the patient’s death.
If, after two (2) hours, attempts to notify the next of kin and/or significant other/emergency contact are not successful, or if the contact is still unknown, the physician must contact the Clinical Nurse Manager/Nursing Administrator or designee who will follow the procedures in policy A3-115
B.    Notifies NY Regional Transplant Program (1-800-GIFT-4-NY) NOTE: May be designated to the clinical nurse if appropriate.
C.     Obtains Post Mortem Consent
D.     When applicable, notifies  HYPERLINK “http://intranet1.mountsinai.org/risk_mgmt/admin/MEDICALEXAMINERREFERRALS.pdf” Medical Examiners Office at (212)-447-2030.  See ME guidelines attached.
E.     Completes Death Certificate and/or Medical Examiner Form

CLINICAL NURSE
Provides emotional support for next of kin and/or significant other/emergency contact. Assists  regarding procedures to be followed:  the body will be taken to the morgue and that they should notify a funeral director.
Notifies the Clinical Nurse Manager/Nurse Administrator or designee/Nurse Administrator and BA of the patient death.
Provide post mortem care (see procedure Post Mortem Care Nursing Procedure # 806)
Ensure that NY Regional Transplant Program has been contacted .(1-800-GIFT-4-NY).
Document in the medical record that all of the above has been accomplished.

BUSINESS ASSOCIATE (BA)
If trained, the BA may assist in the completion of death certificates and enters time of death into Cerner.
The BA notifies transportation (x44443) to transport body to the Morgue, except for direct removal (see Section V., Care of the Orthodox Jewish Patient).

Prepares the chart and forwards the chart, death certificate and related materials to Medical Records, B2 Level. On nights, the Assistant Administrator ensures that death certificates and charts are forwarded to Medical Records.
Signs the death certificate activity log. (Note: except with autopsy where the record accompanies the deceased to the morgue)
CLINICAL NURSE MANAGER/ASSISTANT ADMINISTRATOR
Coordinates the NY regional transplant process once they have been informed
Assists the clinical nurse and BA as needed
Assures that all records and forms are completed and received by medical records
Contacts the private attending or assigned attending pursuant to Section II, 1A and documents in decedent follow-up log the name of next of kin and/or significant other/emergency contact informed of the death, the time and the individual who notified the patient.
Initiates the protocol for unsuccessful notification of patient’s death as needed (see below).

UNSUCCESSFUL NOTIFICATION OF PATIENT’S DEATH PROTOCOL: Refer to Mount Sinai Policy A3-115

Medical Examiner Cases: Reportable Deaths
The Chief Medical Examiner (OCME) has jurisdiction over deaths occurring
under the following circumstances:
All forms of criminal violence or from an unlawful act or criminal neglect
**Applies whether the death occurs immediately and directly, or indirectly after a lapse of weeks, months, or even years**
All accidents (motor vehicle, industrial, home, public place, etc.)
All suicides
All deaths caused or contributed by drug and/or chemical overdose or poisoning
**Any infectious complication of intravenous drug use should also be referred to the OCME (i.e. AIDS, Hepatitis, endocarditis, etc)**
Sudden death of person in apparent good health
Deaths of all persons in legal detention, jail, or police custody
**This includes a prisoner who is a patient in the hospital, irrespective of the cause of death**
Deaths during diagnostic or therapeutic procedures or from complications of such procedures
Deaths of particular health significance (i.e. anthrax, smallpox, etc)
Deaths due to disease, injury, or toxic agent resulting from employment
When a fetus is born dead in the absence of a physician or midwife
Deaths unattended by a physician and where no physician can be found to certify the death
“Unattended” meaning not treated within 31 days prior to death
When there is intent to cremate the body or dispose of a body in any fashion other than internment in a cemetery
Dead bodies brought into the city without proper medical certification.
Deaths in any suspicious or unusual manner
There is no “24 hour rule” in NYC regarding deaths that need to be reported to the OCME. Rather, it is the circumstances surrounding the death that dictate whether the OCME needs to be notified.

NYC OCME Telephone #:   212-447-2030

Written by phil

July 12th, 2010 at 12:50 am

Posted in Death

Discharging Admitted Patients in the ED

1. Disposition in ibex changed to- discharge from inpt.
2. Inpt team discharges pt. They give pt inpt discharge paperwork.
3. ED BA notifies supervisor to convert case back to ED and discharge case.

1. Disposition in ibex changed to- discharge from inpt.

2. Inpt team discharges pt. They give pt inpt discharge paperwork.

3. ED BA notifies supervisor to convert case back to ED and discharge case.

Kevin Baumlin

Written by reuben

July 8th, 2010 at 5:16 pm

Pediatric Critical Care Diversion – Alternate PICU Contact Numbers

NYU-Tisch/Bellevue PICU Transport Pager – 917 616 1111 (gets you NYU Peds Chief)
Cornell PICU – 212 746 0308 (direct to PICU Charge Nurse for bed availability)
Cornell Transfer Center (PICU/Floor/Burn Unit) 212 746 4703
Columbia PICU 212-305-6591 (direct to PICU Nursing Station for bed availability)
ColumbiaTransport Number 1 800 697 7828  (NYP STAT)
Children’s Hospital at Montefiore PICU – 718-741-2000 (Direct to PICU)

NYU-Tisch/Bellevue PICU Transport Pager – 917 616 1111 (gets you NYU Peds Chief)

Cornell PICU – 212 746 0308 (direct to PICU Charge Nurse for bed availability)

Cornell Transfer Center (PICU/Floor/Burn Unit) 212 746 4703

Columbia PICU 212-305-6591 (direct to PICU Nursing Station for bed availability)

ColumbiaTransport Number 1 800 697 7828  (NYP STAT)

Children’s Hospital at Montefiore PICU – 718-741-2000 (Direct to PICU)

Written by reuben

July 4th, 2010 at 3:15 pm

Posted in Contacts,Peds