ER (Emergency Room) Trauma Checklist for Interns and Staff

 ER [Emergency Room] Trauma Checklist for Interns and Staff

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YOUR BEST FRIEND IN THE ER - THE TEN CRUCIAL STEPS!

Patients come into the ER by EMTs, usually already prepped with IV and oxygen [ambu bag if not breathing on own, nasal cannula/mask otherwise] and bandaged if bleeding. The EMTs [Emergency Medical Technicians] will usually inform you of whats going on icly. AS an intern or Doc,  it is your job to:

0. DON'T BE SCARED! Get the facts from your patient and then role play [rp] it out. Deep breaths! Don't feel stressed just have fun! Or you'll be the one in the ER!

1. Survey and assess the A B Cs first! Airway, Breathing, Circulation.

Treat most severe cases first! And with individual patient their most life threatening injuries first. Now is a good time to hook up heart monitors and get baseline vital signs! If not breathing and/or no pulse, go immediately to steps 5. and 6. If respiration and pulse present, continue to Step 2.

2. Insert an IV into their arm for fluids if not done already by the EMTs. You will improve their situation greatly doing so, and provide a fast means to inject drugs. Move to Step 3.

3. Then a quick head to toe gross [gross meaning 'total' not, 'yuck!'] examination [make this quick don't make the player sit there for hours, now is a good time to IM your patients player and ask them what the hell is going on!]

4. If there is major trauma to the torso, the nurse or doctor should remove the clothing to unrestrict the lungs and to open the space for you to work your magic. Limbs are important too, but can be tourniqueted [short-term only!] or wrapped until the serious trauma has been resolved. Move to step 7!

5. If the patient isn't breathing and/or has no pulse, a CODE BLUE will be required right away. [You will need an IV access if not already done] CPR and Defibrillation to return the heart beat, intubation to assist with respiration. Remember: Do NOT shock a flatline! Give epinephrine and then shock. If it's a suspected myocardial infarction [MI or heart attack], order STAT cardiac enzymes and a 12-lead EKG, and remember MONA! [Morphine, Oxygen, Nitroglycerin, Aspirin.] If the MI is due to a clot, a clot buster injection will break it free or, the patient may need to go to the cath lab for angioplasty / stenting. Move to step 6!

Cardiopulmonary Resuscitation [CPR]:

http://www.emedicinehealth.com/cardiopulmonary_resuscitation_cpr/article_em.htm

6. REMEMBER: Air/oxygen needed in all major trauma and cardiac cases, especially smoke inhalation, fire, chemical, allergic reactions, MI, etc. If the body can't breath the heart and brain dies. Nasal Cannula in the nose, or a oxygen mask. An ABG [Arterial Blood Gas] to check oxygen levels in the blood can be done. Also check their airway to make sure they didn't choke on something or are having an allergic reaction and their throat closed up! 

Severe allergic reactions:

http://www.emedicinehealth.com/severe_allergic_reaction_anaphylactic_shock/page7_em.htm#medical_treatment

7. Pale and bleeding out patients need BLOOD, GAUZE and PRESSURE! Start with gauze and pressure to clot the bleed. If patient has lost a lot of blood returning their fluids and electrolyte balances are crucial to their healing and survival. So do a blood transfusion using O neg [the universal blood]. This is critical for all major trauma where the patient is unconscious after stab wounds, gun shot wounds, blunt force trauma causing internal bleeding, etc. [As the player you can find that out using blood pressure cuff and checking their vitals. 120/80 is typical. 45/70? That's bad.] 

Blood Pressure chart here:

http://www.vaughns-1-pagers.com/medicine/blood-pressure.htm

8. It is also important for pain management to decide on what sort of medications the patient will need. Pain can keep the heart racing - and a racing heart sucks away all the precious oxygen. Usual medications are morphine in IV form or if they have an allergy to that, Dilaudid, both given IV push as needed. Other typical pain medications are Local Lidocaine injections for suturing cuts, or cream versions for burns. Orally, Oxycodone for moderate pain or just regular old Ibuprofen for broken limbs and/or headaches, contusions etc. Tylenol is also given for pain and fevers. Ask the patient to rate their pain on 1-10 scale to give you an idea of what med to start with.

Other medications in the link:

http://arthritis.about.com/od/analgesic/a/factsanalgesics.htm 

9. And most stabbings will require a tetanus shot, antibiotics to avoid infections and anti-inflammatory meds. 

10. Surgery - when to cut and when not to cut! For RP purposes, broken arms DO NOT need surgery unless the bone is jutting out through the skin. Surgery is used mainly in serious trauma, examples are: Stab wound to the abdomen penetrating through the intestines. YES! Cut them open and clean them up! Heart Bypass requires surgery, Cancer that can be cut out like breast cancers, prostrates, etc, you can conduct surgery, anything that you would think, hey is this wound possibly penetrating a vital organ? Means surgery.  So start them on General anesthesia and move them into surgery. Use the links below to help guide you or check on Google!

Encyclopedia of Surgery:

http://www.surgeryencyclopedia.com/

11. Possible but not common in CD, Patient having a Stroke?!

Cerebrovascular Accident [CVA or stroke] is a neurological emergency that can be life threatening. Order a STAT head CT, preferably with contrast if the patient's kidney function is OK. If the CT is negative but you suspect there is a CVA going on anyway, [patient is symptomatic, e.g. paralysis on one-side, slurred speech, etc.], order an MRI. If the CT or MRI shows intercranial bleeding, they may need to go to a neuro center for possible craniotomy, aneurysm clipping, etc.  If there is no sign of intercranial bleeding, the CVA is considered ischemic [vs. hemorrhagic] and a clot buster -- tPA -- can be given for this, too, if they are a good candidate [no recent surgery or major bleeding, door to drug time <3 hours]. If tPA is contraindicated, the patient may need a surgical procedure to remove the clot. 

Stroke Treatments: http://www.strokeassociation.org/STROKEORG/AboutStroke/BLS/Treatment_UCM_310892_Article.jsp

NOTE: DO NOT ASSUME MISS KITTY BAND-AIDS CAN RESOLVE ALL INCOMING TRAUMA SITUATIONS! More band-aids does NOT mean better care. Please rp out the best you can with your note cards and Google searches, to make it a fun realistic eventful experience for the player. And NEVER make fatal decisions for players - leave their fate up to them! If they do not wish to die, then downgrade the injuries. Being a RP Doctor is awesome, and you'll learn a ton of medical facts as you play!

[ALWAYS CONCLUDE YOUR RP WITH A CHART ON YOUR PATIENT. A GOOD RULE OF THUMB IS TO OPEN THEIR FILE WHEN THEY ARRIVE AND ADD TO IT AS YOU RP, THAT WAY YOU'RE NOT STUCK WITH IT AT THE END, YOU JUST CONCLUDE AND CLOSE IT UP ALL FINISHED.]

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ONLINE LINKS 

Now its time to treat what's causing the trauma to the body:

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Gunshot wound - CT scan, Surgical removal of bullets

http://www.trauma.org/index.php/main/article/601/

Stab/puncture wound - closure of vessels and tissues, sutures, Abdominal Stab wounds could require more serious operation, and CT scans, and Ultrasounds

http://emedicine.medscape.com/article/82869-overview

Severe lacerations - cleaning and debridement, sterilization and sutures.

http://www.emedicinehealth.com/cuts_or_lacerations/page6_em.htm#medical_treatment

Severe Burns - cleaning and debridement, antibiotics and medicated creams, grafting etc.

http://www.oculusis.com/mexico/is/burns/burn2.php

Punctured Lung/Collapsed Lung - intubation, chest catheter or Tracheostomy to open airway. 

https://www.nlm.nih.gov/medlineplus/ency/article/002955.htm

Disease - ask what the disease is and use google to see the right protocol. Recommend WebMD. Medications etc.

http://www.webmd.com/

Broken bones/fractures - Xrays, depending on severity of the break, set the bone, cast/splint, medication if needed.

http://www.webmd.com/a-to-z-guides/understanding-fractures-treatment

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Other common things that could occur are:

Drug addiction/overdose treatment

http://www.emedicinehealth.com/drug_overdose/page6_em.htm

https://en.wikipedia.org/wiki/Naloxone

Abortion

http://www.fpa.org.uk/helpandadvice/unplannedpregnancy/abortion#Gave

Rape Kit

http://www.pandys.org/articles/rapekit.html

DNA test

http://www.orchidcellmark.com/paternity/paternity-testing-procedures.html

Pregnancy test

https://www.nlm.nih.gov/medlineplus/ency/article/003432.htm

Taser burns/punctures

http://www.ehow.com/how_8170597_treat-tasered-man.html

Head trauma

http://www.emedicinehealth.com/head_injury/article_em.htm

Giving birth/Pregnancy

https://www.mayoclinic.com/health/labor-and-delivery/PR00105

Psychosis, most common schizophrenia and depression. http://psychology.about.com/od/psychotherapy/tp/list-of-psychological-disorders.htm

http://www.schizophrenia.com/diag.php

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For a more detailed ER Trauma article read the following PDF: http://www.nmdhb.govt.nz/filesGallery/New%20Website/03Health%20Concerns/MajorTraumaGuidelines2010.pdf

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What if my patient Dies?

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Someone who's died under your care should have their injuries note carded and have them IM a medical examiner if they want an autopsy role play. 

That's it! Happy RPing!