Emergency and Surgical Medicine I 2025 PDF

Heme/Onc/ ID Week 1 Emergency and Surgical Medicine I 2025 Josh Formaneck Objectives ESM1 Describe the organizational structure and key personnel within a typical emergency and surgical department. ESM2 Identify the various types of settings in which emergent and surgical care takes...

Heme/Onc/ ID Week 1 Emergency and Surgical Medicine I 2025 Josh Formaneck Objectives ESM1 Describe the organizational structure and key personnel within a typical emergency and surgical department. ESM2 Identify the various types of settings in which emergent and surgical care takes place. ESM3 Discuss resources commonly available in an emergency department or surgical suite. ESM4 Discuss the mechanisms of communication between providers in emergency and surgical services and those consulting or referring providers. ESM5 Identify and describe appropriate use of each of the following types of surgical instruments. ESM6 Describe the rationale and processes associated with undergoing a surgical procedure.  General Organizational Structure and Key Personnel CEO/President Support Staff: CMO Administrative Staff: Chief Medical Officer Manage scheduling, patient records, and administrative tasks. Coordinate communication between different departments. Department Head/Director: Technicians and Technologists: Responsible for overall leadership and management of the emergency and surgical department. Conduct diagnostic tests such as X-rays, CT scans, and lab work. Sets departmental goals, policies, and ensures compliance with Maintain and operate medical equipment. regulatory standards. Collaborates with other hospital departments and administrators. Quality Improvement and Compliance Officers: Monitor and evaluate the quality of care provided. Medical Director: Ensure compliance with regulatory standards and implement Oversees medical staff within the department. improvement initiatives. Ensures quality of care, adherence to protocols, and continuous Social Workers and Case Managers: medical education. May be involved in the development of clinical guidelines and Assist with discharge planning and coordinate post-hospital care. procedures. Provide support and resources for patients and their families. Infection Control Specialists: Implement and oversee infection control measures. Ensure a safe and sterile environment in the surgical department. ESM 1 Emergency Department (ED) Personnel Emergency Physicians/Providers: Provide initial assessment and treatment of patients in the emergency room. Coordinate with other specialists as needed for more complex cases. Nurses: Triage patients based on the severity of their condition. Administer medications, perform diagnostic tests, and assist physicians in procedures. Paramedics and Emergency Medical Technicians (EMTs): Bring in patients from the field and assist in initial assessment and stabilization. ER Techs Vital Signs Monitoring Assisting with Procedures Transporting Patients Basic Patient Care Equipment Setup and Maintenance Surgical Department Personnel Surgeons/Surgical PAs Perform/Assist with surgical procedures May consult with other specialists and coordinate pre-operative and post-operative care. Surgical Nurses Assist surgeons during procedures Provide pre-operative and post-operative care, including monitoring patients in the recovery room Anesthesiologists/ Nurse Anesthetists Administer anesthesia during surgical procedures Monitor patients' vital signs and manage their pain during and after surgery Surgical Technician Preparation for Surgery Sterile Technique Handing Instruments to Surgeons Counting Instruments and Supplies Assisting with Patient Positioning Operating Room Cleanup Types of Settings Hospital Emergency Departments (EDs): Urgent Care Centers: EDs are equipped to handle a wide range of medical Facilities that provide immediate care for non-life- emergencies and injuries. threatening conditions. They provide initial assessment, stabilization, and treatment Handle minor injuries and illnesses, offering more for patients with acute conditions. accessibility than emergency departments. Trauma Centers: Mobile Surgical Units: Specialized facilities equipped to handle severe injuries and Deployable units that bring surgical capabilities to specific trauma cases. locations, such as disaster areas or remote regions. Often categorized into different levels (Level I, Level II, etc.) Provide essential surgical care in situations where traditional based on resources and capabilities. facilities may be unavailable. Ambulatory Surgical Centers (ASCs): Specialized Surgical Hospitals: Facilities designed for outpatient surgical procedures that do Hospitals focused exclusively on surgical procedures, often not require an overnight hospital stay. equipped with specialized equipment and personnel. Focus on efficiency and cost-effectiveness for minor and May include centers for cardiovascular surgery, orthopedic elective surgeries. surgery, etc. Hospital Operating Rooms (ORs): Military Field Hospitals: Dedicated surgical suites within hospitals where a wide Deployed in military operations to provide emergent and range of surgeries are performed. surgical care in combat zones. Equipped with advanced surgical tools and technology. Include surgical units capable of handling trauma and injuries sustained in the field. ESM 2  Emergency Department (ED) Resources Triage Area: Emergency Medications: Used for the initial assessment of patients to determine the Stocked with a wide range of medications for various severity of their condition. emergent conditions. Includes vital signs monitoring equipment, such as blood Includes pain management drugs, anti-seizure medications, pressure cuffs, pulse oximeters, and thermometers. and medications for allergic reactions. Resuscitation Rooms: Isolation Rooms: Equipped for critical cases requiring immediate attention Designed to prevent the spread of infectious diseases. and resuscitation. Equipped with appropriate isolation measures and Contains advanced life support equipment, including protective gear. defibrillators, cardiac monitors, and airway management tools. Trauma Bays: Diagnostic Equipment: Specialized areas for the assessment and treatment of trauma patients. X-ray machines, CT scanners, and ultrasound devices for rapid diagnostic imaging. Equipped with trauma carts containing supplies for rapid interventions. Laboratory facilities for blood tests, urinalysis, and other diagnostic procedures. Communication Systems: Procedure Rooms: Intercoms, phones, and electronic medical records systems for efficient communication among healthcare staff. Dedicated spaces for minor procedures and interventions. Equipped with necessary instruments and supplies for suturing, wound care, and other minor treatments. ESM 3 Surgical Suite Resources Operating Rooms (ORs): Post-Anesthesia Care Unit (PACU): Equipped with surgical tables, lighting systems, and anesthesia Area for immediate post-operative recovery and monitoring. machines. Equipped with monitoring devices, oxygen support, and pain Maintained at controlled temperatures and humidity levels. management resources. Surgical Instruments: Central Sterile Supply: Sterile instruments specific to various surgical procedures. Facility responsible for cleaning, sterilizing, and maintaining surgical instruments. Includes scalpels, forceps, scissors, retractors, and other tools. Provides a steady supply of sterile instruments to the OR. Anesthesia Equipment: Emergency Backup Systems: Anesthesia machines for administering and monitoring anesthesia during surgery. Uninterruptible power supply (UPS) systems and backup generators to ensure continuous power during emergencies. Ventilators for respiratory support. Integrated Communication Systems: Surgical Imaging Equipment: Communication systems for coordination among surgical team C-arm fluoroscopy machines for real-time imaging during certain members, including surgeons, nurses, and anesthesiologists. procedures. Operating microscopes for precise visualization in microsurgeries. Specialized Equipment: Equipment specific to certain surgical specialties, such as orthopedic Sterilization and Infection Control: drills, neurosurgical navigation systems, or robotic surgery systems Autoclaves and other sterilization equipment for ensuring the sterility of instruments. Strict infection control protocols to minimize the risk of surgical site infections.  Communication Verbal Communication: Telemedicine and Video Conferencing: Handoffs and Shift Changes: During shift changes or handoffs between Remote Consultations: Telemedicine enables consulting providers to remotely healthcare providers, verbal communication is essential. This includes assess patients, review diagnostic images, and discuss treatment plans with conveying critical patient information, updates on ongoing treatments, and any on-site teams. This can be especially valuable in rural or remote areas. changes in the patient's condition. Teleconferencing: Video conferencing platforms facilitate multidisciplinary Code Announcements: In emergency situations, codes are often used to discussions and consultations, allowing specialists from different locations to communicate specific emergencies within the hospital. For example, "Code collaborate on patient care. Blue" may signal a cardiac arrest, prompting a rapid response from relevant healthcare providers. Secure Messaging Systems: Written Communication: HIPAA-compliant secure messaging platforms enable healthcare providers to exchange patient information, updates, and queries securely. This can be Medical Records and Electronic Health Records (EHRs): Detailed particularly useful for quick communication without compromising patient documentation in medical records or electronic health records allows privacy. providers to review patient history, previous treatments, and diagnostic results. EHRs facilitate communication between different departments within Care Coordination Teams: a hospital and with external providers. Dedicated care coordination teams facilitate communication between Pager and Phone Systems: different healthcare providers, ensuring that all members of the care team are informed about the patient's status, treatment plan, and follow-up care. Emergency Pager Systems: Pager systems are commonly used in hospitals, especially in emergency situations, to notify on-call providers or specialists. Standardized Communication Protocols: These pagers may include specific codes or messages indicating the urgency and type of consultation needed. Use of standardized communication tools and protocols, such as the Situation-Background-Assessment-Recommendation (SBAR) framework, Phone Consultations: Direct phone communication is often used for helps streamline information exchange and reduce the risk of consulting or referring providers to discuss patient cases, share information, miscommunication. and coordinate care plans. This can be particularly important when rapid decisions are required. Health Information Exchange (HIE): Interdepartmental Meetings and Conferences: HIE platforms allow for the electronic sharing of patient health information across different healthcare entities, supporting seamless communication and Regular meetings and conferences bring together healthcare providers from care coordination between emergency and surgical services and other various departments to discuss complex cases, share knowledge, and providers. establish protocols for communication and collaboration. ESM 4  Surgical Instruments ESM 5  Scalpels For incising the skin. Rarely used inside the body. Knife Handle Used to hold a blade to make a scalpel Can be sterilizable or disposable CAUTION! Never use your fingers to place or change blades. Use a needle holder. Do not hand off scalpels. Place in neutral zone. Scalpel blade #10 Generally used to make incisions in the skin, esp. in abdominal surgeries Scalpel blade #11 Used for small, controlled incisions and punctures Blade size commonly used for port placement, abscesses Palmar grip Pencil grip Palmar grip used for large opening incisions Pencil grip used for small incisions and when (#10) more control is needed (#11 or #15) Scissors Used to cut Straight Mayo scissors Use(s): used to cut suture Description: heavy scissors w/straight blades Curved Mayo scissors Use(s): dissect or undermine heavy fibrous tissues Description: heavy scissors w/curved blades and blunt or sharp tips. Metzenbaum scissors Use(s): dissect and undermine delicate tissue Description: a longer, thinner scissors w/curved or straight blades that can have blunt or sharp tips Iris scissors Use: cutting fine tissue Description: small, curved with sharp points Bandage scissors Use: cut bandages Description: Heavy scissors with a blunt, widened lower jaw Littauer scissors Use: cut suture Description: scissors with hook on lower jaw to get underneath suture Forceps For grasping tissues Allis Forceps Use(s): lifting, holding, and retracting slippery dense tissue that is being removed. Commonly used for tonsils; for vaginal, breast, and thyroid tissue; or for grasping bowel during resection. Description: curved or straight w/multiple, interlocking fine teeth at the tip that reduce injury to the tissue. Babcock forceps Use(s): is used for grasping and encircling delicate structures such as ureters, fallopian tubes, bowel, ovaries, and appendix. Description: an atraumatic forceps w/a flared, rounded, hollow end w/smooth, flattened tips. Ring forceps Use(s): is used to create a sponge stick, for grasping tissues such as the lungs, or for removing uterine contents. Description: can be curved or straight and has two round tips w/horizontal serrations. DeBakey forceps Use(s): grasps numerous types of tissue; commonly used in cardiac and vascular surgery Description: an atraumatic tissue forceps w/an elongated, narrowed blunt tip. A set of parallel fine serrations runs the length of one jaw w/a center row of serrations on the opposite side that interlocks to grip when closed. Adson forceps (AKA pick-ups) No teeth Use(s): grasps delicate tissue Description: fine tips w/horizontal no teeth serrations With teeth Use(s): aligns wound edges during suturing or stapling of the skin Description: two small teeth on one side and one small tooth on the other side that fit together when closed. with teeth  Clamps Used for clamping vessels for hemostasis Kelly clamp (AKA hemostat, snap) Use: occlude bleeders before cauterization or ligation. Description: a curved or straight clamp w/horizontal serrations that run the complete length of the jaws. Halstead clamp (AKA mosquito) Use(s): occlude bleeders in small or superficial wounds before cauterization or ligation. Used often for delicate or small confined procedures. Description: a curved or straight clamp w/fine tips and horizontal serrations that run the length of the jaws. Towel Clamp Use(s): holding towels in place when draping, when grasping tough tissue, and during reduction of small bone fractures. Description: a ratcheted instrument with curved, sharp, tine-like jaws (penetrating) or flat, serrated jaws (non-penetrating.). CAUTION! Exercise care when handling penetrating forceps. The sharp tips can easily compromise the integrity of your gloves, the patient’s skin or pierce the drape and compromise sterility.  Retractors Retractors are used to deflect or retract tissue or other structures away from the surgical field. You Weitlaner retractor Use: locking retractor used for superficial soft tissue or small, deep wounds. Prongs may be blunt or sharp. Description: self-retaining, finger ring retractor with a cam ratchet lock used for holding back tissue and exposing a surgical site. The prongs interdigitate when the instrument is closed. Balfour retractor Use: Holding laparotomy open for examination or evaluation, such as cesarean sections and bowel resection. Description: self-retaining retractor Richardson retractor Use: Holding back multiple layers of deep tissue during laparotomies Description: handheld, single end, right-angle retractor Richardson-Eastman retractor Use: Holding back multiple layers of deep tissue during laparotomies Description: Handheld, double-ended, right-angle retractor Army-Navy retractor Use: holding back layers of tissue, generally small incisions Description: small, handheld, right-angle retractor with one short and one long end Deaver retractor Use: Holding back abdominal wall and deep tissue during laparotomy Description: curved handheld retractor Malleable retractor (AKA ribbon) Use: Holding back deep tissues and organs during laparotomy Description: Malleable flat blade, comes in multiple sizes Harrington retractor (aka sweetheart retractor) Use: Holding back deep tissues and organs Description: handheld curved retractor with a heart-shaped flat blade Senn retractor Use: used primarily for retraction of surface tissues Description: double-ended, handheld retractor with one angled, blunt end and three prong, rake tip facing the opposite direction. The prongs may be sharp or blunt. Other Tools Needle holder/driver Use(s): holding needles when suturing. Description: has a broader jaw that is rounded at the tip w/crisscross pattern on the inner jaw. Bovie electrosurgery pencil Use(s): Can be used to cut, coagulate, desiccate or fulgurate tissue. Description: Pencil-like instrument with disposable electrode. Must be connected to a power generator as well as the system must be grounded to the patient. Yankauer suction tip Use(s): suctioning in all types of wounds. Allows effective suction w/out aspiration damage to the surrounding tissue. Description: a hollow plastic tube w/a grip handle and a slightly bent shaft that terminates w/a bulbous tip and large opening. Poole suction tip Use(s): suctioning large amounts of blood and/or fluids from a body cavity. Description: can be disposable or reusable. Has two components: an outer sheath and an inner cannula. Pre-op Management ESM6 Pre-op Management Reassurance Assessment- History, Exam, Diagnostics High Risk Patients Prescriptions Preparation Patient Understanding/ Informed Consent Follow-up Reassurance Clear communication between the surgical team and the patient/family is essential for: Promoting patient-centered care Ensuring safety Enhancing patient satisfaction Achieving optimal surgical outcomes Reduce anxiety Establishing trust Managing expectations Addressing concerns Cultural Sensitivity and Language Barriers Effective communication also involves being sensitive to cultural differences and overcoming language barriers Providing information in a language and manner that patients and families can understand is essential for ensuring comprehension and participation in decision-making Assessment Opportunity to ID co-morbidities to determine the risk to the patient of performing the surgery Pt History Pre-op Examination Pre-op Diagnostics Timing of History High risk procedure Initial evaluation should occur at least 24 hours prior to the surgery (longer is better), but should be within last 30 days Repeat evaluation on day of surgery Moderate risk procedure Day before surgery Low risk procedure Day of surgery General Pre-op Assessment- History Brief hx of why pt is having sx What procedure pt is having. Confirm side if applicable. PMH- full hx. CV- may need further investigation Respiratory- COPD? Renal- kidney issues? Endocrine- DM, thyroid GERD- may alter anesthesia techniques Pregnancy- test mandatory on females of reproductive age Sickle Cell Disease- History Past Sx Hx- any prior issues Past Anesthesia Hx- any post-op N/V Drug Hx- meds on, allergies, etc. Family Hx Social Hx- smoking, drugs, alcohol, language spoken, living situation QUESTIONNAIRE 1. Age. Height. Weight. Sex. 2. Are you: Female and 55 or older? If yes, are you 70 or older? Male and 45 or older? If yes, are you 70 or older? 3. Do you take anticoagulant medications (“blood thinners”)? 4. Do you have or have you had any of the following heart-related conditions? Heart disease Heart failure Angina (chest pain) Irregular heartbeat Heart attack within the last 6 months Valvular heart disease 5. Do you have or have you ever had any of the following? Diabetes Stroke or TIA Bleeding disorder Rheumatoid arthritis Kidney disease Liver disease 6. Do you get short of breath when you lie flat? 7. Are you currently on oxygen treatment? 8. Do you have a chronic cough that produces any discharge or fluid? 9. Do you have lung problems or diseases? 10. Have you or any blood member of your family ever had a problem other than nausea with any anesthesia? If yes, describe: 11. If female, is it possible that you are pregnant? Pregnancy test: Please list date of last menstrual period: General Pre-op Assessment- Physical Exam Full Physical Exam Initial assessment Vital signs Any signs of comorbid conditions such as decompensated CHF, unstable coronary disease (MI