INTRO TO THE PEDI ED: �AN INTERN'S GUIDE

originally by Alison Casserly, MD PhD

updated by Residency Leadership and PEM team thereafter!

Last updated: July 2025

WELCOME TO THE PEDI ED!

• Objectives:
• Orient you to the Pedi ED and staff
• Define Intern roles and expectations
• Review patient encounter logistics
• Picking up a patient
• Staffing a patient
• Placing orders
• Calling consults
• Documentation
• Discharging a patient
• Admitting a patient
• EMH doc to doc
• Traumas

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WHERE DO I GO?

• You can enter the PED from either side
• Badge through the door to the right of Elevator D to take you to the entrance pictured here!

WHERE DO I GO?

• You can enter the PED from either side
• From Elevator C, walk through the wooden double doors like you are going to the back of the cafeteria. Look to your left and follow the hallway for MRI Suite B (1) all the way down. When you reach the end, badge through one of the doors on the other side of the hallway (2). Hang to the left and walk past the Radiology desk (3). Hang a right and the PED doors will be on your right (4).

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WHERE DO I SIT?

• You can find the "Doc Box" next to the nurse's station and Secretary
• Find a computer to use in here. 
• Generally, workstations on the right-hand side are up for grabs. 
• If you aren't sure where to sit, just ask!
• Pro-tip: WIPE DOWN YOUR WORK STATION
• Just say no to viral gastro

WHO WILL I WORK WITH?

• Attending: You will be staffing patients with the attending and they will be overseeing your care and helping you with management plans and procedures.
• Fellows: You may also be on shift with a PEM fellow (max 1 at a time).  They generally function in an attending role.
• Other residents: Pedi, M/P, EM, FM, and ophtho residents all rotate through the PED.
• Pod Attending: Works in addition to the main unit attending from 1p-11p.  They see more "Fast track" patients in the Pods independently. However, Pedi residents can also staff with them, so you may be asked to pick up a Pod patient here and there. 
• Nurses: Usually are on their WOWs just outside of the Doc Box when not providing patient care.
• Resource nurse: In charge of flow for the unit. Prioritizes which patients come back for triage and where they are roomed. 

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WHO WILL I WORK WITH?

• PED Tech: Usually sits behind the Secretary's desk. They help with obtaining VS, assisting procedures, other aspects of patient care. They are also great resource for finding any equipment. 
• RT: They sit in the hallway connecting the ED to the adult pod.  They set up all respiratory supports and administer nebs.
• Child Life: They sit in the same hallway as RT.  They are there most daytime and evening hours. They are instrumental for performing procedures and helping our psych boarders. Notify them early if you will be performing a procedure. 
• Secretary: Sits at the desk next to the Doc Box.  They will page consultants for you (so you can continue moving about the unit for patient care).
• If there is no PED Secretary on, you should use a secretary in another pod by calling them for requests
• Social Work:  The ED has their own 24/7 social worker to provide any support or help with consultations. 
• "Sitters": PCAs that sit in the hallway to serve as 1:1 for psych boarders. Some are specially trained mental health PCAs. 

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PATIENT ROOMS

• 14 Patient rooms run along the walls in one big circle and are labeled 1-14
• 6 Pods are located at the opposite end from the Doc Box and are labeled A-F
• The "Consult Rooms" are labeled XPBHA1-3 and XPBHB1-3. These can hold up to 3 behavioral health patients each and are located just outside the unit entrance furthest from the Doc Box. 

Pods

Standard room

EQUIPMENT

• A lot of standard equipment will be in the patient rooms
• Swabs, tongue depressors, tape, gauze, urine cups, towels, emesis basins, etc. 
• Other materials can be found in the carts located around the unit or in the stock room. Ask an RN or tech if you need help finding something. 
• Any time you do a procedure make sure you have ALL your materials gathered before starting. 
• Code carts and airway carts are also located around the unit.
• Familiarize yourself with where they live. 
• Never open them unless it’s a code.

IV cart              Ortho cart      Suture cart

INTERN EXPECTATIONS

• Improve your clinical and diagnostic skills through performing careful histories and physical exams on a large volume and variety of patients with unknown diagnoses. 
• Develop broad differentials.
• Propose thoughtful work-ups.
• Practice hands on procedures (LP, suturing, splinting, reduction of simple dislocations, feeding tube replacement, intubation, etc.).
• You are expected to carry 2-3 active patients at a time.
• This increases when you become a senior

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EXPECTATIONS - SCHEDULE

• Let your attending know when your clinic days are in advance if they overlap with a scheduled shift. 
• Email the attending who is working that day in advance
• Write it on the printed schedule posted on the wall in the Doc Box
• This applies only to interns (seniors will never be in clinic during a scheduled ED shift)
• Be on time.
• Wear scrubs and close toed shoes.

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Top 5 Tips for Residents - by a Senior Nurse

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1. Say communications in person to the nurse, not in an Epic Chat if the nurse is around [learn names! ]

2. Place orders that are useful and executable, e.g. liquid Tylenol for 3 y/o, not tablet

3. Communicate the plan of care with nurses (parents are always asking)

4. Give printed discharge instructions and have form signed when providing final counseling to families

5. Avoid practices that duplicate work for nurses, e.g. some nurses may like to interview the patient together

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STARTING YOUR SHIFT

Log on to the UNV EMERGENCY DEPT context

SIGNING IN 

• Click Sign In in upper left-hand corner

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• Sign into your shift

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• If you forget to sign in, you will not be able to sign up for patients on the ED board. 
• If you cannot assign yourself to a patient, check to make sure you are actually signed in!

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PEDI BOARD

• At the top you will see buttons for all the ED units (with the # of patients in parentheses)

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• Use the wrench to keep only the tabs you will use across the top. (other tabs will remain available in the drop down carrot)

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PEDI BOARD

• To see the entire ED board, with all the patients in the rooms, pods and consult rooms, you will want to click "Pediatrics"

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• To see only patients that you are covering (assigned to), you can use "My+Unassigned"
• This is also an easy way to watch for new patients that arrive and need a resident (aka unassigned)

PEDI BOARD RAINBOW

• The square colors before the patient name in the left-most column indicate patient status.

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Dark blue: In triage

Dark teal: Waiting for a room

Red: Waiting for a provider (needs a resident!)

Purple: Behavioral health evaluation (signed out to EMH, medially cleared)

Pink: In Process (already has a resident)

Orange: Bed Requested (admitted boarder)

**Note – PICU patients remain under care of ED until transported

Bright teal: Waiting for a triage

**Note if you see in this in the unit, patient has probably arrived by EMS

Brown: Inpatient bed assigned

Black: Dirty

Bright Green: Ready for Discharge

Additional colors exist, but these are the most common you might see.

• Hover over the color to see what it means if you aren't sure

PEDI BOARD

• On the board you will see a lot of columns including:
• Patient name, Age/Gender
• Complaint (as reported and assigned by triage nurse)
• Acuity Score 
• 1-5, with 1 being the most acute, 5 being the least acute
• 1: Patients coming into the trauma bay or occasional a resuscitation room
• Keep in mind these are assigned in triage and the patient may look different than when they first presented (better or worse!)
• These help resource RN decide who gets pulled back and when
• RN, ED/IP (attending), Res/APP: Initials of assigned providers
• Comments 
• This is a great place to put major To Dos (ex: radiology studies, consults, time to re-eval, PO challenge, etc.)
• Double click over the comment on a patient to update this 
• This keeps everyone in the loop on where the patient stands 

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PICKING UP A PATIENT

• When you are ready to pick up a patient, watch for a new patient to be brought back to a room/Pod 
• Red: Awaiting provider
• Bright Teal: Awaiting Triage (probably brought in by EMS)
• Patients should be picked up based on acuity and how long they have been waiting
• Never try to preferentially snag "fun" cases, and do not avoid difficult complaints 
• If the complaint makes you uncomfortable, that represents a great learning opportunity!
• NEVER pick up/assign yourself to a patient from the waiting room 
• That's considered cherry-picking and you acquire legal liability if they leave without being seen

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PICKING UP A PATIENT – VIEWING TRIAGE NOTES

• To view their Triage Note before signing up:
• Double Click on the patient name to be brought to their chart
• Click the Triage tab to see the triage HPI and vital signs

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PICKING UP A PATIENT 

PATIENT CARE

• Always introduce yourself.
• After completing your H&P, give the family a brief heads up on what to expect next.
• Even if that is "I am going to discuss this with my supervising doctor, and we will come back to discuss the plan"
• Never promise anything you are not sure you will deliver
• Do not answer patient questions that you do not know the answer to.
• It is ok to say "I'm not 100% sure, let me discuss this with my supervising doctor so I can give you a definite answer"
• You do not want to confuse patients with conflicting information.
• Use your pediatric dosing and code card for guidance.
• Use order sets when possible (ask your attending, fellow, seniors).

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PATIENT CARE

• If you arrive at a patient room and the patient is very ill or actively decompensating (respiratory failure, altered mental status, screaming in pain, etc.) 
• Ask only essential questions
• Do only essential targeted exam
• Get an attending/senior resident IMMEDIATELY so they can help (or ask someone to get them for you)
• In code situation there is a blue staff assist button on the wall at the head of the bed that will sound an alarm and bring hands to the room.
• You will want to prioritize getting stabilizing treatments in action ASAP over a complete H&P
• You can always go back and get more info once the patient is in a safer position. 

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PATIENT CARE

• DO NOT touch IV pumps
• If you are trying to talk to a family and it keeps alarming, you can silence it, but tell the nurse ASAP that their pump was alarming
• You MAY titrate O2 flow
• BUT you MUST immediately inform the rest of the care team (Nurse and RT) to make sure they are aware
• Failing to inform the RN and RT is a BIG MISTAKE

STAFFING A PATIENT

• After a complete H&P, get back to the doc box to staff your patient.
• You will present to the attending a full H&P followed by your assessment and plan
• Present your top DDx with reasoning
• Make sure to include dangerous diagnoses you might need to rule out, even if they are less likely
• If very unlikely, make sure to state why you DON'T think it is something 
• Ex: For abdominal pain that is clearly constipation, make sure to say you have no concern for an acute abdomen, appendicitis, ovarian torsion, intussusception, etc. based on specific aspects of your history and exam. 
• Suggest well thought out treatments and work-up (labs, imaging, consults).

PLACING ORDERS

• Use the Order Tab
• You will see suggested ED Pedi Quick Orders that you can use
• ED Imaging is also useful (make sure you order the correct side! R vs. L)
• For orders not on the quick tab, you can search in the panel to the right
• Use your dosing card
• Use order sets when available 
• Search "ED Pedi" under Order Sets to view what's available 
• If you are ordering nebs, it's good practice to find RT and give them an FYI
• If they are busy in another unit and you need them urgently for breathing support or nebs, you can ask nursing to call them 

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STAFFING A PATIENT

• Make sure to staff your patient promptly
• It's ok to take a few moment to develop a well thought out plan and look things up while you wait for an attending
• The sicker the patient is the sooner you will want to staff
• Special cases:
• Oncology and sickle cell patients with fever may not look very sick when they first come in
• These patients can decompensate quickly
• You need to get antibiotics into them within 1 hour of arrival, so grab an attending ASAP after seeing them so you can get the plan rolling. 

CALLING CONSULTS

• If the patient needs a consult, ask the secretary to page for you
• This allows you to continue working rather when waiting for a call back yourself.
• It may seem like you are bothering them, but it actually makes their life harder if you page yourself since they won't know where to send the call if it comes in. 
• If you are waiting for a call and are headed into a patient room, let the secretary know so she can either grab you or use the overhead PA system
• Remember to place the consult order in Epic
• To page Ortho, simply place the consult order and it pages them
• If you don’t hear anything from them in a while or it is very urgent, ask the secretary to re-page them
• For hand/wrist/distal forearm injuries – Consult "Hand" 
• Ortho and Plastics rotate coverage for Hand, so the secretary will look up and page the appropriate team.

MONITORING YOUR WORK-UP

• Use the Work-up tab to see new results for labs or imaging you ordered, updated VS, and medication administrations. 

MONITORING YOUR WORK-UP

• Another useful feature of the Work-up tab is the Flowsheet Doc
• You can see VS, med administrations, nursing notes in order of occurrence

MONITORING YOUR PATIENT

• Make sure to frequently reassess your patient
• Did your interventions help?
• Did that neb improve their aeration and work of breathing?
• Did they keep those 2 oz of Pedialyte down?
• Did that migraine cocktail improve their symptoms?
• Are they getting worse?
• If a patient is ill, you will need to make more frequent reassessments to ensure their condition is not worsening.
• Try to update families of results as the come in, even if you have not determined disposition yet
• Many families have MyChart and get results on their phones in real time. They will be anxiously waiting to have them explained. 

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DOCUMENTATION

• Use the My Note Tab
• When seeing a new patient, you will write a full H&P by creating a new ED Provider Note
• Complete your note using the buttons for each section (HPI, ROS, PE, MDM)
• It is acceptable to free-text pertinent +/- ROS in the HPI
• MDM = Medical decision making (aka A&P)

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DOCUMENTATION - MDM

• History Obtained
• When documenting MDM, be sure to at least click off who you obtained the history from 
• Patients are all minors so usually “from family” but there may be special circumstances that warrant checking off the other boxes. 
• NEVER check off anything in Critical Care time
• This is for billing purposes

DOCUMENTATION

• You can keep the ED Course updated at the bottom of the Work-up Tab.
• You can add free text for significant events, patient re-assessments, consult recommendations, interpretations of results, updates to the plan, etc.
• You can double click pertinent results and VS on the Work-up Tab to be added to the ED course.
• The ED course is pulled into the bottom of your note.

DOCUMENTATION ETIQUETTE

      Whenever you are not actively writing, SHARE and CLOSE your note to the         attending can get some documentation done if they chose

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       You are expected to complete your notes within 24 hours if they are admitted, 48 hours

        if they are discharged

• Remember patient care always comes first, so you should not expect to always complete a note for a completed encounter before seeing your next patient

        For patients admitted to the PICU, complete your note before the end of the shift

        For patients you are admitting to 5E or signing out to the next shift, have at least         pertinent history, physical and MDM documented 

• Ideally the note is completed. 

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CONTINUING CARE DOCUMENTATION

• On intern shifts, it is unusual to receive sign out from an outgoing resident when you arrive.
• If it does happen, you can document the sign out in an ED Continuation of Care note

CONSENTS 

• For transfusions, sedations, and some procedures, you will need to obtain written consents 
• This can be completed under the Procedure tab in Epic

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CONSENTS

• For ED Procedures, search the procedure to be performed (most often LP or Moderate Sedation)
• Fill out the rest of the required fields as indicated 
• You are able to use iPads for parents to sign consent forms
• If you aren't familiar with how to do this, as your senior/fellow/attending

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PROCEDURE NOTES

• For procedures you should file a Procedure note, under the Procedure tab
• These might include, but are not limited to, laceration repair, suture removal, intubation, LP, feeding tube replacement, I&D, Nursemaid's and other joint reduction, foreign body removal, splint application)
• If you aren't sure if the procedure needs a note, ask!

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PROCEDURE NOTE

• Select the type of procedure if available
• It should pre-populate the relevant information for you to document. 
• Quick and Easy!

PROCEDURE NOTE – EXAMPLE (LAC REPAIR)

DISCHARGING A PATIENT

• To Discharge a patient, head to the Disposition Tab
• Select Discharge Home/Self Care 
• Unless they are being transferred or discharged back to a psych hospital

DISCHARGING A PATIENT

• Make sure to select a Clinical Impression
• From suggested or search new
• You may add more than 1 clinical impression if appropriate
• This may be a specific diagnosis, or may remain ambiguous if you have not made one
• Example: Acute otitis media vs Fever
• NEVER choose viral syndrome, viral URI, viral gastro
• Instead consider choosing their chief complaint (ex: cough or vomiting and diarrhea)
• It is ok to discuss viral syndromes in your MDM

DISCHARGING A PATIENT

• Discharge medications may be ordered to outpatient pharmacies under Prescriptions & Orders
• Click New Order
• Make sure the correct pharmacy is selected 
• Follow-up
• Indicate which providers they should follow-up with and when
• This adds the clinic phone numbers to the AVS 

DISCHARGING A PATIENT

• Paitent Instructions
• You can add suggested attachments if appropriate
• Free text patient instructions
• Brief summary of their visit in patient-friendly language.
• Instructions for aftercare including supportive care, any new medications, follow-up (PCP, subspecialists).
• Specify reasons to return to medical care.

DISCHARGING A PATIENT

• Excuse Notes
• You can create school, work, sports, etc. excuses from this tab

DISCHARGING A PATIENT

• Print AVS
• Preview the After Visit Summary (AVS) 
• Print the AVS, attachments and any excuse notes you have prepared. 
• The patient's guardian will take the AVS with them as a reference (follow-up phone #s and DC instructions).

DISCHARGE ETIQUETTE 

• Make sure your attending agrees the patient is ready to go home and let the patient's nurse know you are getting them ready for DC

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• Make sure the patient has NORMAL VITAL SIGNS documented before they are discharge -OR- have a darn good explanation why they are abnormal.
• Ex: Patient is still tachycardic, but received a bunch of albuterol for asthma exacerbation. The respiratory rate and O2 sat are otherwise improved. 

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• Print your own AVS and bring it with you to the patient room
• Discuss clear discharge instructions with the family yourself
• The last page requires a signature from the parent.  Have them sign and place this page in the scan bin. 

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DISCHARGE ETIQUETTE 

• If the patient has an IV, DO NOT pull it yourself unless you explicitly ask the nurse taking care of the patient and they want you to do so.

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• If the patient is ready to leave after you discuss the discharge instructions, you may take them off any monitors and let them leave.
• BUT you MUST inform the patient's RN and ideally resource nurse
• This will allow them to get the room cleaned and ready for the next patient promptly. 

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ADMITTING A PATIENT

• If your patient will need admission, use the Disposition tab
• Click the admit button

ADMITTING A PATIENT

• If your patient will need admission, use the Disposition tab 
• Click the admit button
• A bed request panel should appear
• IP Bed Request (5E Wards)
• ICU Bed Request (PICU)
• Fill in the appropriate information, you will need the admitting attending's name

ADMITTING A PATIENT – SIGN OUT

• It is not enough to place the bed request
• You must sign out the patient to the accepting team
• For 5E Gen Peds: ask the secretary to page Pedi Admitting
• The admitting Pedi residents will call and you will give them a verbal sign out over the phone.
• They may tell you they are tied up and it will be a bit before they can come see the patient – keep a close eye on your patient until they assume care!
• Once they are seen and have orders, they become "Floor boarders" - they are off the ED service and all orders should be placed by the Pedi Wards team residents. 
• For PICU: The PED attending will sign out the PICU attending, who will confirm they accept the patient
• When the PICU resident comes down, they should find you for sign out.
• In some scenarios, the PICU resident may be unable to come down before the patient is transferred upstairs. They should be calling down for a sign out.
• There are NO PICU Boarders!  The PICU patients remain your responsibility until they are transferred out of the ED

ENDING YOUR SHIFT

• Typically, you won't want to pick up a new patient in the last 30 min of your shift
• If you aren't sure, you can always check in with your attending for the most reasonable plan of action. 
• Use that last 30 min to package up the patients you are currently carrying. 
• Try to have all of your discharges completed or at least prepared (Patient instructions).
• Complete all procedures.
• Make sure all planned consults are called.
• Make sure all your admitted patients are all signed out.
• If will need to stay in the ED beyond the end of your shift, make sure to sign them out to an incoming resident.
• Typically sign them out to the resident who will remain in the ED the longest. (Example: the 5P-2A vs the 5P – 12A)
• Let the family know you are going off shift, and that another doctor will be assuming their care

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BEHAVIORAL HEALTH CONCERNS/SECTION 12

• You will see many patients with behavioral health/psychiatric concerns
• Most often suicidal ideation or agitation/aggression
• Many of these patients will come in on a Section 12
• Allows for an individual to be brought against his or her will to such a hospital for evaluation
• A physician, qualified psychiatric nurse, qualified psychologist, licensed independent clinical social worker, or police officer may apply to admit anyone to a facility if he or she believes that the person would "create a likelihood of serious harm by reason of mental illness."

BEHAVIORAL HEALTH CONCERNS/SECTION 12

• Section 12 Criteria:
• The person poses a substantial risk of physical harm to him/herself as manifested by evidence, threats of, or attempts at suicide or serious bodily injury; or 
•  The person poses a substantial risk of physical harm to others as evidenced by homicidal or violent behavior or evidence that others are in reasonable fear of violent behavior and serious physical harm from that person; or 
• The person’s judgment is so affected that there is a very substantial risk that the person cannot protect himself or herself from physical impairment or injury, and no reasonable provision to protect against this risk is available in the community.

BEHAVIORAL HEALTH CONCERNS/SECTION 12

• If a patient is NOT already on a section and meets criteria
• You may fill out a section 12
• Notify patient's nurse and family
• If you are not sure if they meet criteria, ask your attending!
• Most commonly will encounter SI with a plan, SI with attempt
• Fill out Section 12 in Epic!
• Carrot on top right screen --> Forms
• To the Right of Section 12(a) click "create abstraction"

BEHAVIORAL HEALTH EVALUATION

• Your Role: 
• Get the story 
• What happened?
• SI/HI and risk assessment (plan, prior attempts, access to lethal means)
• Any injuries
• Any ingestions
• Any assaults/abuse
• Any sexual activity
• Prior psych history
• Get collateral from guardians (can interview patient and guardians separately) but try not to get too in the weeds
• Medical clearance!!!
• Physical exam
• Complete any work up necessary (labs/imaging) --> NOT always necessary
• Do not get tox screens/drugs of abuse screens unless altered mental status

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BEHAVIORAL HEALTH EVALUATION

• Once you have medically cleared the patient, they will need evaluation by Emergency Mental Health Providers.
• Document that the patient is "medically cleared"
• Call EMH and request a "Doc to Doc"
• Sign out the patient to an EMH provider
• They will come evaluate the patient or move them to EMH but this can take time (never promise a patient or family a timeframe)
• Order ED Place in Behavioral Health Hold"
• Order COVID-19 Surveillance of Asymptomatic Patient – EMH ONLY
• Order HOME MEDS
• If the patient is boarding in the ED, you continue to be responsible for their care as an EMH boarder. 
• EMH will discharge the patient or keep them on an Inpatient Bed Search per their determination. 

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TRAUMAS

• Traumas will be called in over the EMS line and paged out.
• You are not expected to go to traumas if you are not interested.
• In some cases, you may be asked to stay in the ED to help take care of the patients there while the Attending and Fellow go. 
• To find the Trauma Bays, exit the PED on the end closest to the Doc Box and walk straight back through the double doors. 
• If you ARE interested, ask to join!
• Ask the attending to define your role (even if that is observer) and where to stand
• If you are in the way, get out
• After the patient is stabilized, the patient will be transported to a room in the PED.
• At that point, a resident in the PED will need to assume their care with the trauma team and other subspecialties consulting. 

GENERAL TIPS

• Keep your ears out on the EMS call ins, this will keep you aware of what is coming. 
• If you have down time between patient evaluations, you can pre-chart the patients in the waiting room.
• BUT remember, never assign yourself to a patient in the waiting room
• If someone else is doing a procedure, ask to join/observe if you have time!
• Child Life can be your best asset for getting procedures or exams done on difficult/anxious kids.  Find them and let you know you need help with distraction!
• From 1p-11p there is an additional "Pod Attending" doing lower acuity encounters in the Pods.
• If you have room for another patient, ask the PED unit Attending if it is ok to pick up a Pod Patient
• You will staff the Pod patient with the Pod attending as you would any other patient

GENERAL TIPS

• At the top of your screen the ED Weblinks Menu has a lot of useful links
• UpToDate and other references
• Call Schedules
• PowerShare (for looking up imaging done outside of the UMass system)
• Get comfortable dictating!
• Make sure PowerMic Mobile is working on your phone
• No one is listening to you anyway, so be brave! (unless you are being obnoxious and shouting your dictation)
• Make sure to follow precautions and gown/glove if needed
• Avoid the intern ED viral gastro!
• Wipe down your surfaces, keyboards, phones, stethoscopes