HO I - Emergency Med

Specific Educational Goals and Education

Level: PGY-1

Service: Emergency Medicine

Supervision: PGY-1 → Emergency Medicine Chief Resident → Attending

All management decisions will be discussed with the chief resident and faculty.

Duty Hours:

Hours are to be logged into GMEOne on a weekly basis and will be reviewed weekly by the Program Director for ACGME violations and reviewed weekly for delinquencies by the Program Coordinator. Over a four week period; you will not average more than 80 hours a work week, you will have one day in seven free of clinical duty, in-house call will be no more frequent than one in three nights, you should receive 10 hours free between all duty periods and after in-house call and you will not be on duty for more than 30 consecutive hours. If you are assigned more hours than mentioned heretofore or have patient care duties that are extending you beyond these limits, it is your responsibility to notify your supervising resident or faculty so arrangements can be made to relieve you.

Educational Activities:

1. Recommended Reading
   1. Schwartz's Principles of Surgery
   2. SCORE curriculum modules 
2. Conferences
   1. Wednesday Resident Educational Curriculum

Competency Based Performance Objectives:

Patient Care:

Goal: The resident will be able to use the acquired principles in the management of surgical patients

Objective: The resident will be able to:

1. Perform triage of emergency trauma patients
2. Establish emergency stabilization of the traumatized patient via the following precautions:
   1. Fracture management/stabilization
   2. Cervical spine protection
   3. Prevention of hypothermia
3. Assess patients presenting emergency conditions using the appropriate diagnostic protocol
4. Prioritize requests for diagnostic studies based on need to know and the time required to obtain results
5. Establish the following airways:
   1. Perform bag-mask ventilation
   2. Insert nasopharyngeal or oropharyngeal airways
   3. Perform endotracheal intubation (oro- and naso- pharyngeal)
6. Assist with acute resuscitation procedures as indicated
7. Function as a surgical consultant, assessing and developing differential diagnoses and discussing recommendations with senior resident or attending
8. Ascertain the severity of injury and identify patients require operative intervention
9. Perform emergency diagnostic and therapeutic procedures such as
   1. Peritoneal lavage
   2. Insertion of chest tubes
   3. Pericardiocentesis
   4. Suprapubic catheter insertion
   5. Central line insertion
   6. External/transvenous pacemaker
   7. Insertion of intracranial pressure monitoring device
10. Perform minor surgical procedures as
    1. Drainage of abscesses
    2. Wound closure
    3. Removal of foreign bodies
    4. Wound debridement
    5. Bladder catheterization
11. Provide appropriate treatment for non-emergency problems presenting to the emergency department
12. Explain patients condition and proposed therapy to his/her family and obtain appropriate informed consent
13. Discuss management options with the patient and his/her family
14. Recommend further diagnostic and/or radiographic studies to clarify diagnosis and focus patient management
15. Communicate the importance of injury prevention to patients, patient families and staff in the quest for control of trauma as a disease of modern society

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Manage a variety of surgical conditions in an emergency setting, demonstrate knowledge of patient stabilization, transport, and physician-to-physician communication in an emergency situation, demonstrate the ability to evaluate and effectively manage all acute or life-threatening conditions, including major trauma in an emergency setting, demonstrate knowledge of disaster management, including the role of triage; and display the ability to apply this knowledge to the emergency setting

Objectives: The resident will be able to:

1. Complete the coursework and testing to obtain Basic and Advanced Cardiac Life Support (BLS and ACLS), Advanced and Trauma Life Support (ATLS), and Fundamental Critical Care Support (FCCS) certification
2. Describe the initial management of the injured patients in the following stages of care:
   1. Care in pre-hospital setting including BLS
   2. Triage in emergency department
   3. Serve as team leader and member during ATLS
   4. Coordinate patient transport to tertiary facility
3. Outline the basic principles of triage in the emergency department, including:
   1. Immediate treatment
   2. Ambulatory treatment
   3. Delayed treatment
   4. Expectant treatment
   5. Psychiatric considerations
4. Explain priorities for the diagnosis and/or assessment of illness/injury for patients presenting to the emergency department, keeping the following issues in mind:
   1. Discuss requests for diagnostic studies comparing the urgency of the need to know with:
      1. The time required to obtain results
      2. Potential danger to unstable patient
      3. Quality of information obtained if a stat procedure compromises preparation of the patient
   2. Compare the need for provision of expedient, cost effective work-ups against the appropriateness of using the emergency setting for extensive work-ups at the risk of over utilizing limited resources
5. Explain the ATLS protocol for the emergency resuscitation and stabilization of a seriously ill or injured patient
   1. Cite working knowledge of the ABC's of resuscitation
   2. Define the essentials of AMPLE history (Allergy, medications, Past illnesses, Last meal, Events of illness/injury)
   3. Define the essentials of the Primary and Secondary Surveys
6. Describe the considerations for establishing an airway appropriate to the patient's condition, including:
   1. Nasal trumpets/nasopharyngeal airway
   2. Bag-mask assistance
   3. Endotracheal tube
   4. Surgically Created Airways (cricothyrotomy-needle or tube)
7. Describe the typical case scenarios for the following life-threatening problems requiring appropriate urgent/emergent action:
   1. Multiple system trauma
   2. Shock (cardiogenic, neurogenic, septic, and hypovolemic)
   3. Traumatic neurological injuries
      1. Head injury without altered consciousness
      2. Head injury with altered consciousness, including deteriorating mental status
      3. Subarachnoid/subdural hemorrhage
      4. Penetrating head trauma
   4. Chest injuries (penetrating and blunt)
   5. Abdominal and pelvic injuries (penetrating and blunt)
   6. Vascular injuries (penetrating and blunt)
   7. Myocardial infarction
      1. Complicated (with congestive heart failure [CHF], hypotension, dysrhythmia)
      2. Uncomplicated
   8. Pulmonary embolus
   9. Diabetic ketoacidosis and other metabolic derangements
      1. Hyper- and hypo- kalemia
      2. Hyper- and hypo- natremia
      3. Hyper- and hypo- calcemia
   10. Gastrointestinal bleeding
   11. Pancreatitis
   12. Ectopic pregnancy
   13. Phlebitis
   14. Burns, including inhalation injury
   15. Poisoning
   16. Hypothermia
8. Describe the principles of evaluation and management for the following less 'serious problems:
   1. Drug abuse and suicide attempts
   2. Seizures/coma
   3. Facial injuries
      1. Lacerations of face and scalp
      2. Fractures of facial bones and jaw
      3. Epistaxis
   4. Pneumonia
   5. Cardiac verus other chest pain
   6. Acute abdominal pain
   7. Hand injuries
   8. Long bone fractures
9. Discuss the principles of evaluation and management for the following common minor problems:
   1. Laceration evaluation
   2. Tetanus prophylaxis
   3. Wound treatment
   4. Surgical repair of wounds
   5. Appropriate dressings
   6. Soft tissue infections
   7. Headache
   8. Eye, ear, nose, and throat infections
   9. Bronchitis
   10. Gastroenteritis
   11. Hemorrhoids
   12. Wildlife injuries (animal bites, insect and marine envenomations)
   13. m. Follow-up instructions
10. Explain the indications and appropriate methods for
    1. Peritoneal lavage
    2. Insertion of chest tubes
    3. Pericardiocentesis
    4. Suprapubic catheter insertion
    5. Central line insertion
    6. External/transvenous pacemaker placement
    7. Cricothyrotomy
    8. Rapid rewarming BAIR Hugger, CAVR (Continuous Arterial Venous Rewarming)
11. Recommend ways in which the ED physical environment can be adapted to better meet the special needs of elderly patients, discuss these problems
    1. Little privacy or confidentiality
    2. Poor lighting
    3. High ambient noise level
    4. Lack of adequate communication and/or reassuring dialogue
12. Analyze the medicolegal responsibilities of the physician in the field as an accepting physician coordinating transport
13. Define the requirements for informed consent in the emergency setting:
    1. Life-threatening conditions
    2. Minor surgery
    3. Patients who are minors
    4. Patients unable to provide informed consent (non compos mentis)
       1. Amnesia for event
       2. Drug or alcohol use
       3. Dementia
14. Summarize significant steps in the examination for and treatment of dental/oral emergencies with which a general surgeon should be familiar:
    1. Toothache
    2. Gingival bleeding (gingivitis, periodontitis, HIV-related hemorrhagic conditions)
    3. Buccolingually displaced tooth or teeth
    4. Dental or periodontal abscess or fistulous tract
    5. Cellulitis, including Ludwig's Angina
    6. Peritonsillar abscess (Quinsy)

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for Emergency Medicine procedures

Objectives: The resident will demonstrate the ability to obtain informed consent, outlining the risks and benefits of planned procedures

Goal: Communicate effectively to discharge patients after evaluation.

Objectives: The resident will demonstrate the ability to instruct patients regarding:

1. Discharge instructions after emergency care

Goal: Communicate effectively as a member of the healthcare team.

Objectives: The resident will demonstrate the ability to communicate effectively by:

1. Providing appropriate check out when handing patients to another team member
2. Requesting consults from other services with appropriate information
3. Dictating operative reports in a timely fashion
4. Dictating discharge summaries in a timely fashion

Professionalism:

Goal: Maintain patient confidentiality

Objectives: The resident will demonstrate

1. The ability to protect health-related patient information per HIPAA compliance
2. List and be aware of sites in the hospital and clinic where loss of privacy for the patient may occur

Goal: Maintain appropriate professional relationships

Objectives: The resident will demonstrate professional interactions with:

1. Medical students
2. Nursing and support staff
3. Supervising faculty
4. Consulting residents
5. Physician peers
6. Patients and their families

Practice-Based Learning and Improvement

Goal: Identify personal and practice improvement strategies

Objective: The resident will demonstrate:

1. Receptiveness to faculty instruction and feedback
2. Ability to use medical information with the ability to access information through tradition and online sources to support their educational experience

Goal: Use medical evidence to evaluate Emergency Medicine practices

Objective: The resident will demonstrate the ability to:

1. Discuss studies regarding management of emergency conditions

Systems-Based Practice

Goal: Provide safe patient care

Objective: The resident will:

1. Attend Crew Resource Management courses as required by the hospital
2. Demonstrate compliance with Medical Center policy for surgical site identification
3. Demonstrate compliance with Medical Center policy for patient identification

Goal: Discharge patients with appropriate follow-up

Objective: The resident will demonstrate the ability to:

1. Refer patients appropriately to home health services
2. Refer patients appropriately to psychiatric services
3. Refer patients appropriately for social services

Duties/Responsibilities:

1. Serve as PGY-1 on the Emergency Medicine service
2. Appropriate, professional supervision of student teaching in light of educational goals
3. Attend Emergency Medicine shifts as assigned
4. Attend educational conferences
5. Attend other conferences as listed

Evaluation:

1. Performance feedback will be given to the resident as appropriate for educational events and mid-term progress will be discussed.
2. Global evaluation will be performed by the Emergency Medicine attending physicians at the completion of each rotation and yearly by the nursing and support staff
3. Surgical case logs will be evaluated for the appropriate number and breadth of procedures and will be present in the resident's portfolio to be reviewed at the Program Evaluation meeting held twice yearly.
4. At the completion of this rotation, the resident is required to complete a rotation evaluation form assessing the quality of the rotation. The resident should also address the teaching undertaken by the attending physicians on the rotation at the conclusion of this rotation.