Rotation: Emergency Medicine                                Site(s): St. Mary’s Health Center.

 

Course Director: Robert Wiele, M.D.                     Duration: 1 month

                               

Associate Course Directors:  Jonathan Rill, M.D., Scott Soerries, M.D.

 

General description and goals:

St. Mary’s Health Center’s Emergency Department provides comprehensive, full-service adult emergency medical care except for major trauma. The Emergency Department has approximately 42,000 patient visits annually and is the major source of in-patient medical admissions. There is round-the-clock coverage and supervision by board-certified attending staff. Residents are exposed to a wide spectrum of medical, surgical, psychiatric and gynecological conditions with a full range of acuity, from cardiopulmonary arrests and resuscitations to minor surgical procedures and ambulatory care. The objective of this rotation is to equip residents with diagnostic skills in the acute care and emergent setting with a specific focus on directed, efficient and prompt evaluation, work-up, management and disposition. Residents are also exposed to ED initiatives for risk management issues and quality assurance and improvement measures as per CMS criteria.

 

Resident responsibilities:

Medical residents work in shifts under the supervision of specific ED attending physicians who are affiliated with the residency program. They are assigned patients for initial evaluation, laboratory and radiological work-up, chart documentation including H&P’s, formulation of a diagnosis, assessment/ plan, appropriate management and disposition after discussion with the supervising attending. They additionally communicate with primary care physicians, hospitalists and appropriate consultants regarding plans for admission, discharge and further work-up and therapy. The PGY-3 internal medicine residents are expected to achieve competency in the diagnosis and management of all medical emergencies equivalent to that of a certified general internist. The PGY-1 residents are expected to achieve competency in the triage of all medical emergencies such that correct initial evaluation and management is initiated and appropriate consultation made. 

 

Educational objectives:  

1. Evaluate patients with medical emergencies and formulate an appropriate, cost-effective diagnostic and therapeutic plan. Recognize medical conditions requiring acute intervention and hospitalization.

Demonstrate appropriate history taking skills for all patients presenting to the emergency department. Demonstrate the ability, based on the history acquired, to do an immediate assessment and initial stabilization, followed by a complete directed examination.  Combine the knowledge defined in the objectives below with the history and physical examination, to develop an appropriate differential diagnosis for all presentations.  

           

2. Understand and develop skills in appropriate triage, classification and prioritization of patients based on their degree of severity, acuity and symptomology in order to reduce unnecessary ED wait time and delayed therapeutic interventions for more acutely ill patients.

 

3. Achieve competence in the performance of the following procedures: participating and directing ACLS protocols, endotracheal intubation, lumbar puncture, ABG collection, central line placement, I and D of an abscess, basic suturing techniques, abdominal paracenteses, thoracocenteses, arthrocenteses, lumbar punctures. 

 

4. Access and utilize all available resources for appropriate patient disposition. This includes the decisions to hospitalize with requisite level of care (floor, stepdown, and ICU) and discharge to home or other facility. Initiate management of patients not requiring hospitalization including gatekeeper functions to other clinics and primary care physicians with a focus on psychosocial issues, preventive care and patient education.

  

 5. Decide on need for specialty and subspecialty consultation along with appropriate choice of subspecialty type. 

 

6. Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues respecting confidentiality and patient privacy and obtaining informed consent. 

 

7. Interact with patients, families, ED personnel, and consultants in a respectful, appropriate manner.  Learn basic ethical and legal principles relevant to emergency medicine. Apply ethical principles to specific patient encounters to assist in decision making. Learn the similarities and differences between legal and ethical principles relating to emergency medicine.

 

8. Use information technology, attending feedback, recognition of errors and deficiencies in knowledge base to improve patient care individually and as a system. Develop an understanding of quality improvement and risk management programs and their application to the operation of an emergency department. Develop an understanding of the function of emergency medicine within the institution and its relationship with other departments. Understand JCAHO requirements relating to the Emergency Department with emphasis on medical error reduction, quality assurance and patient transfer regulations.

 

9. Demonstrate competence in the interpretation of diagnostic modalities - EKGs, plain x -rays, CT scans, ABGs, common laboratory assays for blood, serum, CSF, urine and other body fluids.

 

10. Demonstrate an appropriate knowledge base, diagnostic work-up and management skills for the following problems:

 

• chest pain
• dyspnea
• abdominal pain
• arterial or aneurismal dissection or rupture
• acute thromboembolism
• headache
• anemia, pancytopenia, clotting/ bleeding disorders
• pneumonia, UTI, sepsis/ SIRS, fever, hypo-and hyperthermia.
• asthma/COPD exacerbation, respiratory failure
• common infections - STDs, community acquired-, nosocomial-, nursing home- acquired infections and opportunistic infections in patients with HIV/ AIDS or other immunocompromised states,
• hepatic and renal dysfunction or failure
• cardiac arrhythmias, heart failure, myocardial infarction, ACS, hypertensive urgencies/emergencies
• altered mental status including CVAs, coma, delirium, agitation, dizziness, syncope, hypotension
• gastrointestinal bleeding, epistaxis, hemoptysis

·     toxic or inhalant exposure, poisoning including accidental or suicidal ingestion or overdose. Learn the presenting signs, symptoms, laboratory findings, patho -physiology and treatment of common therapeutic drug poisonings, drugs of abuse, natural toxins, and general household poisons.  Learn the common hazardous materials (HAZMAT) of the workplace and prehospital operations with regard to HAZMAT incidents. 

•  allergic or anaphylactic reactions
•  fluid and electrolyte disorders, hypo-and hyperglycemia.
• acute weakness or paralysis,  musculoskeletal trauma, sprains, fractures and falls
• abnormal uterine bleeding and common gynecologic diseases including pregnancy related medical disorders
• common dermatologic and psychiatric disorders
• common acute rheumatological, ophthalmological and ENT disorders
• wound management including burn wounds, frost-bite and gangrene
• pain management and substance abuse
• hemodynamic instability, shock, cardiopulmonary arrest and resuscitation
• disaster plan awareness and participation in mock trials. Understand common environmental, toxicological, and biological hazards encountered in the prehospital care setting as well as injury prevention techniques.  
• proper ED record documentation for proper billing and Medicare fraud avoidance
• ED radiology

 

 

Learning Venues: 

1. The primary site for ED training is the Emergency Department at St. Mary’s Health Center. Cases are seen initially by house staff and then reviewed with attending physicians. 

2. Residents are encouraged to attend medical grand rounds and noon conferences. 

3. There are online resources available in the department including Up-to-date and website syllabi. 

 4. Numerous books are available in the ED for use by residents. Residents are encouraged to read current journal articles and reviews pertaining to emergency medicine.

5. Residents are required to keep a log of all procedures performed during this rotation.

 

Required Reading:

Emergency Medicine: A Comprehensive Study Guide: American College of Emergency Physicians, Judith E. Tintinalli, M.D.

 

Mosby’s Manual of Emergency Care: Practices and Procedures

 

Review and journal articles for reading assignments will be as per Course Director’s instructions.

 

Competency Evaluation: 

An end-of-rotation web-based global evaluation form will be completed by the attending and reviewed face-to-face with the resident to assess all six competencies.   This is a good opportunity for feedback.  The resident will also be required to evaluate the rotation and provide feedback on the attending’s teaching skills and other attributes. All residents are required to maintain active BLS and ACLS certification throughout their residency training.

 

Outcomes Assessment: 

The national in-service examination will be used to provide outcome assessment for the individual resident. A score of 50^th percentile or better for each resident is a reasonable goal.