Emergency Medicine

Overview

Residents complete a one-month requirement in Emergency Medicine. Attendings during this rotation are Altoona Hospital emergency medicine specialists. There is significant opportunity for residents to adapt this rotation to their learning needs and/or desires. Residents have the option to help design their own schedule for this rotation. Emergency physicians are responsive to resident requests and some residents have chosen to participate in ground ambulance and helicopter transport teams. Altoona Hospital is a level two trauma center, which provides ample trauma experience. All second year family practice residents become ATLS certified by taking the American College of Surgeons Advanced Trauma Life Support course.

Family practice call is kept to a minimum during this rotation.

Emergency room physicians give the residents autonomy to evaluate patients, but are readily available and always in the emergency room to teach, supervise procedures, etc.

Work hours during this rotation include 40 hours per week in the emergency department plus two half days in the family medicine office. The 40 hours can often be scheduled as the resident chooses. but are to include at least one weekend shift per week and to reflect a variety of shifts (i.e. some days, some evenings and some nights).

Emergency Medicine

Rotation Year PGY-1, PGY-2, & PGY-3

Competency-based Goals and Objectives

Rotation description and general goals:

The Altoona Campus of the Altoona Regional Health System has a very busy emergency department which handles nearly 50,000 patient visits per year. The hospital is also a level II trauma center so there is ample opportunity for residents to experience the initial care of trauma patients in addition to seeing patients with medical urgencies and emergencies.

Residents will all do block rotations in the Emergency Department.

The residents will be actively responsible for the care of patients under the direct supervision of the full-time Emergency Department physician. Each patient that the resident sees should be presented to the Emergency Department attending physician. The Emergency Department attending will review the case with the resident in detail, will examine the patient, and complete an additional note. This type of close supervision has obvious merit from an educational point of view. The resident should also bear in mind that the Emergency Department attending has the full medical-legal responsibility for each and every patient that the resident sees in the Emergency Department.

The resident is reminded they are in the Emergency Department as an educational experience. The overall goal of the rotation is to have the resident gain experience in assessing patients with urgent or emergent problems, and to initiate work-up and treatment for those patients. It is important that the intern/resident become involved in the most interesting and challenging cases that present to the Emergency Department. In some cases this will mean that the intern/resident is involved more in the capacity of assisting and observing the Emergency Department physician than in taking primary care initially for the patient. This would be particularly true in cases such as multiple trauma, cardiac arrest, etc. As the resident’s level of experience increases, he/she may become more involved with initiating care of the patient, including ordering appropriate laboratory and imaging studies as well as initial treatment. Emergency Department attending physicians are strongly encouraged to allow the resident an appropriate level of increasing autonomy as the resident’s level of knowledge and skill improves.

The resident's hours while in the Emergency Department will be variable and will allow the resident to experience patient care in the Emergency Room during various shifts. The variety of shifts allows the resident to gain exposure to different types of Emergency Department patients, which, in general, tend to present according to times of day. This also gives the resident experience in seeing patients where access to specialists and consultants is not as convenient. The resident may also spend a brief time working with the paramedics and ride in the trauma helicopter. .

Each resident does a one-month block of emergency medicine during the PGY-1 year as well as two blocks of two weeks each during the PGY-3 year. While on the emergency medicine rotations, the resident is required to work in the emergency department for a minimum average of forty hours per week in addition to their continuity office hours. Residents are permitted to design their own schedules to include working some evenings and overnight shifts, but the schedule must be submitted to the Program Director for approval prior to the rotation. The Program Director checks the proposed schedule for total hours worked and to make certain that there is sufficient variability in the shifts. The schedule must also be designed to ensure compliance with ACGME & AOA work hour requirements. Residents may also do electives in the emergency department.

Teaching Methods:

Didactic teaching: Tintinalli’s “Emergency Medicine” text is used as a basic reading source while on the emergency medicine rotation. The Director of the emergency department has selected a series of readings for residents on the rotation. Residents are also required to attend several pertinent courses including BLS, ACLS, ATLS, PALS, and NRP. In addition, the noon conference schedule includes numerous emergency medicine topics.

Clinical teaching: The majority of the teaching, including demonstration of and supervision of procedures, is done by ER attending physicians at the bedside. Additionally, there is ample opportunity for interaction with specialty attending physicians through their consultative role in assisting with patient care.

Supervision:

A board certified emergency physician is on site 24 hours a day, 7 days a week and is responsible for the supervision of the resident physician on the emergency medicine rotation, as well as that resident’s evaluation. The resident generally sees the patient first and then presents the case to the attending physician, who then sees the patient and confirms the residents’ findings. During true emergencies the resident and attending physician may see the patient simultaneously. Altoona Regional has a very busy emergency room which is staffed by multiple physicians at any one time. The resident may work with one or more attending physicians during a given shift.

Consulting physicians may be called to assist with patient cases and may assist in supervising the resident on the emergency medicine rotation.

Altoona Family Physicians faculty may occasionally be called to assess patients in the emergency department and may include the resident on the emergency medicine rotation in the teaching about those patients.

Resident & Program Evaluation:

Each resident on the emergency medicine rotation is required to obtain a competency-based written evaluation from any attending physicians with whom they worked for a significant amount of time while on the rotation.

Residents evaluate the rotation on an annual basis, but are also encouraged to do a written evaluation each month, and they can give input about the rotation either via the chief resident in faculty meeting or via the Curriculum Committee.

Procedures: It is expected that residents on the emergency medicine rotation will learn endotracheal intubation, insertion of a chest tube, lumbar puncture, EKG interpretation, insertion of a Foley catheter, and insertion of a nasogastric tube, but none of these procedures is required. Most of these procedures are also taught in other courses or rotations.

SAMPLE SCHEDULE:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
AM Noon PM LatePM	AFP Conf	ED Conf ED	AFP ED ED	ED Conf ED	ED Conf ED	ED ED ED ED
AM Noon PM	AFP Conf	ED Conf ED	AFP ED ED	ED Conf ED	ED Conf ED	ED ED ED
AM Noon PM LatePM	AFP Conf ED ED		AFP Conf ED	ED Conf ED	ED Conf ED ED		ED ED ED
AM Noon PM LatePM	AFP Conf ED ED	Conf ED	AFP ED ED	Conf ED ED	Conf ED ED

Competency 1: Patient Care: Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

PGY-1:

Develop the ability to obtain a rapid and focused history and pertinent physical examination of emergency department patients.

Recognize signs of impending deterioration of a patient’s clinical condition including unstable vital signs, mental status changes, arrhythmias, decreased oxygenation, and overall worsening of symptoms.

Develop the ability to triage the more emergent from the less urgent patients and address them in a timely fashion.

Order pertinent laboratory studies and diagnostic imaging on emergency department patients based on differential diagnoses developed from the residents’ history and physical examination findings.

Observe and assist in procedures commonly performed in the emergency department, and subsequently perform those same procedures under supervision of the attending physician. (For list of procedures see previous listing).

PGY-2 and PGY-3:

Improve on the above objectives in terms of judgment and accuracy as confirmed by the attending physicians, as well as time-efficiency.

Take initiative in primarily handling more complex and difficult cases.

Become adept at judging the proper disposition of patients to ICU, general medical floor admission, or discharge from the emergency department as confirmed by the ED attending physician.

Develop enough experience and expertise to perform some or all of the listed procedures independently or with minimal supervision of the attending physician.

Assess patients’ past history for relevance to current disposition.

Competency 2: Medical Knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:

PGY-1:

Learn the work-up of general complaints such as abdominal pain, chest pain, fever, shortness of breath, dizziness.

Understand the diagnosis and initial treatment of life-threatening conditions such as arrhythmias, congestive heart failure, respiratory failure, seizures, strokes, sepsis, metabolic abnormalities, diabetic ketoacidosis, acute coronary syndromes, and multiple traumas.

Learn how to assess, diagnose, and treat acute injuries and acute localized pain syndromes.

Understand laboratory and diagnostic imaging results on emergency department patients. Residents should review the results on the patients they have seen in the ED with the attending physicians for accuracy of interpretation

Become familiar with the work-up and standard treatments for acute poisonings and drug overdoses.

Apply knowledge of assessment and management of the following conditions: Blunt, penetrating and localized trauma; Environmental disorders such as burns, electrocutions, bites, stings, and drownings; Victims of violence; acute neurological disorders; Thyroid emergencies; GI hemorrhage; acute urinary system disorders including nephrolithiasis, pyelonephritis, urinary retention, and priapism; Compartment syndromes; Mass casualties.

PGY-2 and PGY-3:

Improve their differential diagnosis of difficult emergency department patients. These differentials should be reviewed with the attending physician on each case.

Consider less common diseases in their differential diagnoses.

Become increasingly aware of how psychological and behavioral factors affect patient presentations and outcomes. Residents should also seek out and assess patients with psychiatric emergencies.

Competency 3: Practice Based Learning and Improvement: Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to:

develop skills and habits to be able to meet the following goals:

o identify strengths, deficiencies, and limits in one’s knowledge and expertise;

o set learning and improvement goals;

o identify and perform appropriate learning activities;

o systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;

o incorporate formative evaluation feedback into daily practice;

All Residents:

Read on a regular basis about the cases and diseases that they encounter on the emergency medicine rotation.

Use information technology to retrieve information, help manage their patients, and support their own education.

Use evidence-based findings to support their decision-making.

Present interesting or difficult cases at weekly family medicine round conferences.

Attempt to obtain follow up on patients they have seen in order to “critique” their previous care and improve upon future decision-making.

Competency 4: Interpersonal and Communication Skills: Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:

PGY-1

Obtain adequate historical information from patients and, when necessary, from their families, friends, and caretakers.

Present cases to the emergency medicine attending physicians in a logical and accurate fashion.

Discuss difficult cases with consultants who may assist in the care of the patients.

Communicate with patients and families such that they understand what is being said by the resident. The residents are also able to comprehend and address the concerns of the patients and families.

Sign out all patients with pending tests to the next shift of physicians at the completion of their shifts.

PGY-2 and PGY-3

Develop the ability to detect non-verbal communication from patients, as well as the ability to detect denial, misinformation, malingering patients, and other more difficult assessments.

Improve case presentations to be more concise and focused.

Improve their ability to communicate the disposition of patients to their primary care physicians.

Competency 5: Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

All Residents:

Report on time and offer their assistance to the emergency department “team”.

Demonstrate compassion, tact, integrity, and honesty.

Complete thorough yet concise medical records.

Dress in an appropriate manner.

Maintain patient confidentiality in an environment where that is sometimes more difficult.

Competency 6: Systems-Based Practice: Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

All Residents:

Understand that the emergency department is often extremely busy, and for reasons of optimal patient care they may need to occasionally take more of an observational role on more difficult cases.

Coordinate admissions and discharges from the emergency department with nurses (both ED and floor/ICU), case management, and other appropriate personnel.

Determine admission versus observational status on those patients being hospitalized.

Be mindful of possibility of system errors and make all attempts to minimize those opportunities.

Be mindful of cost-effectiveness when ordering tests and treatments on emergency department patients.

Required Readings:

UpToDate Articles:

Approach to the patient with headache syndromes other than migraine

Diagnostic Approach to Adults with Abdominal Pain

Causes of Acute Abdominal Pain in Children

Emergency Medicine Reports

Infection Control and the Emergency Department

Evaluating and Treating Atrial Fibrillation in the Emergency Department

Right Lower Quadrant Pain in Females

Orthopedic Pearls and Pitfalls

Abdominal Pain in Young Children: Intussusceptions and Midgut Volvulus – Pediatric

Critical Rashes to Identify in the Emergency Department - Pediatric

Hip Fractures: Evaluation and Management – Trauma Reports

Tintinalli, J. E. Emergency Medicine, 5^th ed. McGraw-Hill, 2000 , textbook in AFP library