Owning the Emergency Room does NOT denote that doctors 'rule the ER' or are in any way the 'boss'.
Rather the idea behind 'OTER' arose after a conversation with one of our previous residents, Dr. Rob Brunelle. We were discussing why for many of the family practice residents, one of their biggest anxieties was working in the ER. An ER orientation can help residents know 'where things are', but for many it was a question of 'how does this thing work'.
So in an effort to teach residents 'how things work' they now have a 2 - 3 hour 'orientation' in the ER at the beginning of their rotation here on Salt Spring Island. Anxiety levels seem to drop once you know 'how things work'.
Every doctor working in an ER should know how every piece of equipment works, regardless if it's the usual duty of the nurse to know. The 'big city' doctors have the luxury of having nurses and RT techs who do this for them, but having worked in very remote settings it is apparent that we as doctors don't always have that luxury of having nurses to start the IV, hook up wall oxygen, suction etc etc.
So doctors working in an ER should not just know 'the medicine', but they should 'know their environment'. In fact not just know it, they should "own it".
The list below (in no particular order of importance) covers the ER in our hospital and the things covered in the 'OTER' session. It obviously may not apply elsewhere.
Below that is an MS Word copy of this list.
1. Locate Storage Rooms. One is on the Acute Care level. Know the key code and what is in the room. The other is the ‘Stores’ room in the basement. Know where the key is and where the room is. Most of the ER equipment is located on the left wall as you go through the door.
2. Stretcher - Lock/unlock, raise, lower, Trendelenburg, reverse Trendelenburg, raise IV pole, raise/lower railings
3. Restraints – locate, know how to 4 point restrain a violent patient.
4. Suction - Put together a new suction bottle and hook up to wall suction - Hook up suction tubing
5. Wall Oxygen - Attach regulator to wall suction. - Apply nasal prongs to Pt at 3 lpm.
6. Bag Valve mask – locate, know how to run 15 lpm
7. EtCO2 – 2 kinds – colormetric and in line. Know how to hook up to Lifepac, mobile EtCO2 and Philips Monitor.
8. Airway cart. Go through all the drawers, familiarize yourself with contents (scopes, blades, cric kit etc)
9. RSI drugs – know were Induction drugs and paralytics are located in the ER.
10. Detox kit. Location and contents.
11. IV bags - Spike a bag, flush IV line and connect Y connector to new IV.
12. IV pump - Set up pump for regular IV rates (125 ml/hr), change rate on pump. If you are really good, set up pump for infusion (ie mcg/min)
13. IV – know how to use and start a regular IV.
14. IV pressor drugs. Know how to mix IV push pressors (Epi and Phenylephrine)
15. Pleuro-vac- know how to set up/prime with sterile water, connect to wall suction
16. Philips Vitals monitor – start, how to stop alarm, connect SpO2 and EtCO2, NIBP manual and auto, set NIBP frequency to q 2, 3, 4 etc minutes.
17. Ventilator – set up BiPAP (NIV) and Mechanical Vent. Know where circuits, nebulizer attachments, suction tubing attachments and NIV masks are located.
18. Ultrasound – how to turn on, change probes. Clean with proper cleaner.
19. Tonometer – location and how to use
20. Lifepac – Start, attach leads to patient, set leads on monitor (paddles, lead II etc), attach EtCO2, SpO2, Charge button, Pace button
21. Magnifier and Sx glasses. Where they are, how to use.
22. IV Drug list. (by resusc bed 1)
23. IV Infusion charts. Location (crash cart)
24. Intraosseous – Sternal and EZ-IO. Location and how to use.
25. Cast cart – Location, contents. How to cut and repackage fiberglass. “Casted.ca course’ handout.
26. Oxygen tanks. Where they are located. How to attach regulator. Where they attach on the stretchers. How long will the tank last when using 4 lpm, 15 lpm.
27. ER Guidelines book. Location.
28. Slit Lamp. Location and how to use it.
29. Procedural sedation checklist and RSI checklists. Where to locate. Familiarize yourself with checklists.
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