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The start of the shiftThe login system in Fruitland is different from all of the other sites. You will need to log in using your St Lukes username and password. This is the username/password combination that you use to log in to the radiology program, etc. You will also likely want to sign out at the end of your shift. Since you are logged in individually, Dragon knows who you are and you won't need to login separately there. Resources: MRI and Ultrasound are available on a variable basis. Please check the paper sorter hung by a couple of desks for the most current times when those services are available. MRI and US are available during the day everyday. PVL is 8:30AM to 4:30 PM Monday through Friday. Outpatient testing: You can order outpatient tests for patients that need a study that isn’t available at the time when a patient is in?the ED. Unfortunately?when you order a?test this way, it?will no longer be considered an emergent test and will require preapproval just as it would for the clinic. Scheduling will do that, but you will not be able to give the patient?a fixed time.??The same rule and approach applies for PVL. But the tech should generally be able to get the procedure done the next day. Consider anticoagulating the patient overnight with NOAC. When you have a patient that needs a PVL, but can wait overnight. If you choose to order an outpatient test, there are a few ways to have the results addressed depending on how critical you expect the case to be.? You can have it addressed by your replacement in the ED, but should discuss it with the doc at shift change.? Or,?you can route the results to Sean Hackett from the walk-in clinic and have the patient follow up with them to address the results.? You don’t need to contact them before doing this. Lastly, you could route to the patient's PCP, but may need to contact their on-call to solidify the follow-up plan.Patient distribution:Admitting:When choosing where to admit, we honor patient preference so long as their preferred location is capable of meeting their needs. First ask the patient where they would like to be admitted. One thing that you may want to inform patients of is that being transferred to any facility will incur a transfer charge. It is St Luke’s policy that they go by ambulance. The patient has the right to refuse ambulance transport, but should sign paperwork to refuse ambulance transport.Notes about the different locations and services:Ontario: Does not have many specialty services. They do have an ICU, which is intended for patients that will only need short term critical care. Please check the flip page sorter for a list of specialty services that they have if you think that the patient may need specialist help. Because of the somewhat limited services in Ontario, the hospitalists there will ask more questions and will expect somewhat more thorough workups than hospitalists at other sites. If the patient prefers Ontario and the patient has a local primary care provider, let the Ontario transfer center know that as they may call the provider for that group rather than their hospitalist. Since some of the primary care providers admit their own patients in Ontario. Unassigned patients will obviously all go to the hospitalist/appropriate specialist. West Valley in Caldwell has a few more specialist services than Ontario. The hospitalist admits almost all patients there.Nampa-Generally the default admission site for our medical patients. You should be able to admit to Nampa anything that you would be able to admit there from their own ER. When putting the order in Epic, you need to choose transfer within St Lukes and fill out the EMTALA form.Boise/Meridian-Generally we choose Meridian if they have resources to address the problem, but Boise is fine. To admit to one of these sites, you have to request a bed and fill out the EMTALA form.General Surgery: Meridian surgicalists still don’t have enough capacity to admit our patients. They would prefer our patients to be admitted to the Boise surgicalist.Discharging:Assigned patients who are discharged can obviously be instructed to followup with their primary doctor. Unassigned patients can be referred to follow up with the walk-in clinic in Fruitland by designating Sean Hackett as the followup provider. The walk in clinic is a very full-service clinic. They are happy to see all of our patients that either don't have a primary care provider or can't get into their primary care provider in the time that we designate. So, for example we could say that the patient should followup with their doctor within 2 days or followup with the walk-in clinic if they can't be seen in that timeframe. The walk-in clinic is also happy to schedule MRIs and schedule specialist appointments for the patients. For example, if you do not know what days the cardiologist is in town, you could have the patient followup with the walk-in clinic and they could arrange for stress testing and cardiology followup. The walk-in clinic is also happy to perform followup abdominal exams etc. In fact, the walk-in clinic is attached to us. The surgeons report that we don't need to call them for next-day followup. Specialist followup: We have a call/referral list including specialty groups in town. Those that have a specific call rotation will have a specific doctor identified. Generally speaking, for specialty services that are not provided in the Fruitland area, we will send them to followup according to the Meridian call list. A special note about cardiology follow-up since we use them frequently. The follow up plan for cardiology patients will be identical for Fruitland pts as it is in TV. You place the referral in EPIC the same way that you do in TV. When SLICA has timely openings in Fruitland or Caldwell, then the pts can follow up closer to home. Other specialist services to be aware of:Dermatology: you can refer to either Andersen of Snake river dermatology or Thornfeldt. Both are receptive to our patientsOral Surgery: Ryan Hillam is the local oral surgeon. He is receptive to our calls and patients.Podiatry: Troy Fowler is a local podiatrist very interested in seeing our patients. He can see just about anything below the mid tib-fib, including fractures.Helicopter Transfer Call St. Luke's Transfer Center to coordinate transfer. They will get the closest chopper (ASL or Lifeflight). STEMI/Cardiac arrest-They will immediately activate the Cath Lab so cardiology is waiting. Staffing We typically have 3-4 nurses on. We also have respiratory on 24h/d. CAPs will be there part of the day. Getting away to get into the doctor's sleep room and EMS room in Fruitland, you will use the same codes as you use in Nampa. Specifically, sleep room-3337* and EMS room (where there are snacks and food) 7079* Lab Lab/blood bank is going to have 2u O+, 2u O-, and 2u FFP as well as full dose Rhogam. For now, Dig and Li will be sendouts. They did this, since the machine is very expensive and upkeep is also costly. So, when we have a patient that needs that test, it’s a long wait (about 4h). Social work / PsychSocial work by Life counseling is on call 24h/d. There is also a good outpatient resource for us in Lifeways. They do have a walk-in clinic, which is available Monday through Friday 9 AM to 3 PM. People can go there with no appointment. If we have someone that is not completely critical, but needs close follow-up, this is a useful resource for us. Frequently, Life counseling can provide similar service. Lifeways also has a 24 hour a day access provider for their facility. If we have a person that they have sent to us, this person should be aware of the situation, and should be able to give us background about why the patient was sent our way. This person can be reached at 541-889-9167. Region 3 is another less useful resource for us, typically they are consulted for patients brought in by police. Social work has also prepared a large book full of resources to help us manage these patients. It is near the EMS phone.Tonometry We have both the iCARE tonometer and Tonopen in Fruitland. If you would like to try the iCare, instructions for its use can be found at the following website: . There is also a card attached to it with step by step instructions. It is reportedly more accurate than the tonopen. Pharmacy There is no 24h pharmacy in Fruitland/Ontario. Therefore, we have a starter pack system. You can find orders for the medications we stock under pre-pack in EPIC. Or, if acceptable, you can give a first dose of most medications in the ER and instructions to fill Rx's in the morning. Here are the home packs that we have. Amoxicillin 250mg / 500mg suspension Keflex 500mg suspension Septra DS 800 / 160mg Azithromycin 250mg Cipro 250mg Nitrofuantoin 100mg Pyridium 100mgSulfa / Trim oral suspension Ondansetron ODT 4mg Promethazine 25mg Pain Home Packs are not available for legal reasonsYou can also find some supplemental prescriptions in the discharge medications orders that also have the term “Pre-Pack” These prescriptions will allow you to prescribe the additional amount of medication needed to finish a 7 or 10 day course.Checklists Lastly, procedural support checklists. We have a couple of procedural support tools that are available to you in Fruitland. These are found over the next few pages. First is the Intubation checklist. It may be available in the other ER’s as well. This can be found attached to the glidescope.Intubation meds:Drug:Normotensive dose70kg pt doseHypotensive doseKetamine2mg/kg140mg0.5mg/kgEtomidate0.3mg/kg20mg10mgPropofol1.5-3 mg/kg150mg15mgSucc1.5-2 mg/kg140mg2 mg/kgRocuronium1.2 mg/kg80mg1.6 mg/kgVecuronium0.3mg/kg20mgPretreatment drugsLidocaine1.5 mg/kg100mg1.5mg/kgFentanyl3 mcg/kg200mcgPost tube sedation/analgesFentanyl2mcg/kg bolus then 1mcg/kg140mcg then 70mcg/kg/hHydromorphone0.5mg bolus rpt q10”prn0.5mg bolus rpt q10”prnMidazolam0.05 mg/kg then 0.025mg/kg/hInitial vent settings:AC/Volume modeVt 6-8 ml/kg ideal body weightRR 16 (10 in asthma or COPD) faster if acidoticIFR 60 l/min (80-100 in asthma/COPD)PEEP 5 (0 in asthma/COPD)FiO2 40%Tidal volume table based on 7mL/kg ideal body weight5'5'2”5'4”5'6”5'8”5'10”6'6'2”6'4”Male350380415445480510545575610Female315350380415445480510545575PEEP table-PEEP should rise with FiO2 titrate up q 5-10”FiO20.40.40.50.50.60.70.70.70.80.91PEEP58810101012141414-1818-24Sux contraindicationsHx malignant hyperthermiaStoke with hemiparesis >72hNMJ disease/myasthenia gravisMuscular dystrophiesPreexisting hyperkalemiaGuillain-BarreThen there are also a couple of delivery checklists. These are hanging on a clipboard on the infant warmer.Uncomplicated deliveryHave the unit clerk call Payette County for immediate transport to Ontario for any impending delivery and the clerk should then call Ontario transfer center to notify them that an impending delivery is coming. Lastly, call OB.Perform a sterile digital examination for cervical effacement and dilatation.Drape the Perineum with towels and don PPEControl the baby's head with the nondominant hand. Use the other hand to support the perineum.Usually, the amniotic sac has broken; if not, open it now. Note the color and consistency of the amniotic fluid. If thick meconium, the infant will need intubationOnce the head emerges, have the mother momentarily withhold pushing. Routine suctioning of the nose and mouth is no longer recommended.Check the neonate's neck for the umbilical cord; If it is wrapped around the neck, pull it gently over the head. If this is not possible, double clamp the cord and divide the cord between the clamps. Recheck the neck, as the cord may be wrapped more than once.With both hands on the head, gentle traction toward the mother's posterior usually delivers the anterior shoulder; if this attempt is unsuccessful, try pressing down over the mother's bladder to move the anterior shoulder posteriorly. If this is unsuccessful, a number of options to address this exist: deliver the posterior shoulder, rotating the anterior shoulder posteriorly, and then delivering that shoulder; or, fracture the anterior clavicle (a difficult maneuver at best).Once the shoulders are out, keep the nondominant hand in place, controlling the baby's head, and slide the dominant hand under and along the baby as it emerges. Once the feet are out, rotate the baby 180° into a football hold. Double clamp the cord 7-10 cm from the baby, and cut the cord between the clamps.If the child starts breathing and moving, turn the baby over to nursing personnel for vigorous drying, suctioning, and warming. If the child is not breathing or moving, take the infant straight to the warmer for resuscitationIf the birth is complicated by thick meconium (amniotic fluid that is thick and pea green), do not stimulate the baby to cry. Instead, use a 3.0 endotracheal tube, intubate the trachea, and suction it; then, stimulate the baby's breathing.Feel the uterus; if it is almost in the pelvis, probably only one fetus exists. Unclamp the cord to collect a clot (red top) tube for laboratory studies. Deliver the placenta slowly (it may take 30”). Do not pull on the cord; guide the placenta out as it is expelled. Inspect the placenta to ensure that it is entirely expelled and send the placenta for pathologic plicated delivery:Post Partum hemorrhage:Establish second IV1L IVNSMethergine 0.2mg IM Oxytocin drip at 10u/hEstimate blood lossEmpty bladder with straight cath or foleyType and Cross 2U PRBCKeep patient warmCord prolapsePush cord back into vaginaHave mother assume knee-chest or Trendelenburg positionleave the hand in place, applying pressure against the presenting fetal part to keep it as far out of the pelvis as possible to prevent cord promised neonateSlow pulse (<100)assure adequate ventilation then supplement O2.after 30s of resuscitation start positive pressure ventilation (rate 20)pulse <60 after 30s of adequate assisted ventilation start chest compressions (rate 120)pulse <60 after 30s of chest compressions, start epinephrine at 0.01 to 0.03 mg/kg (1:10,000 solution) should be given IV. If epinephrine must be administered via endotracheal tube, a dose of 0.05 to 0.1 mg/kgLow satassure adequate ventilation then supplement O2.If apneic or gasping start positive pressure ventilationStop resuscitation if no signs of life after 10min. ................
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