Emergency Medicine PGYII

Description of Rotation or Educational Experience

Emergency Medicine education is provided by a two week rotation under the supervision of emergency physicians at NMC of Bentonville. Additional experience in managing emergency medical problems is obtained while on the Family Medicine Service rotations and the five week rotation experience for PGY I residents in Emergency Medicine at NMC of Springdale.

The family physician, as a broad specialist in the health care profession, must develop the knowledge, skills and attitudes appropriate for managing the social, psychologic and physical problems of all patients, regardless of age or gender. Because there is considerable similarity in the patient population served by the family physician and the emergency physician, there is a natural and significant overlap in their training. The residents work 4-5 12 hour shifts per week combined day and evening hours.

Goal I: To achieve competence in diagnosing and managing emergency conditions as appropriate for the primary care physician.

Goal II: To achieve competence in recognizing, stabilizing, and referring complex emergencies.

Other educational activities related to this field are provided by:

• Opportunities for learning while on family medicine call and night float.
• Discussion of case presentations in family medicine and other conferences.
• Lecture topics pertinent to emergency medicine.
• ACLS/ATLS

Patient Care

Goal

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

Competencies

·         Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families.

·         Gather essential and accurate information about their patients.

·         Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.

·         Develop and carry out patient management plans.

·         Counsel and educate patients and their families.

·         Use information technology to support patient care decisions and patient education.

·         Provide health care services aimed at preventing health problems or maintaining health.

·         Work with health care providers, including those from other disciplines, to provide patient-focused care.

·         Become familiar with procedures considered essential for the area of practice.

1.       Airway management

2.       Anesthetic techniques

a.       Local anesthesia

b.       Regional and digital nerve blocks

c.       Intravenous sedation and analgesia

3.     Initiation of vascular access

a.       Central lines (femoral, subclavian) with central venous pressure monitoring

b.       Intraosseous infusion

4.       Diagnostic / therapeutic procedures

a.       Control of epistaxis (anterior and posterior packing)

b.       Lumbar puncture

c.       Arthrocentesis

d.       Nasogastric intubation

e.       Thoracentesis

5.       Skeletal procedures

a.       Fracture / dislocation immobilization techniques

b.       Fracture / dislocation reduction techniques

6.       Artificial circulation

a.       advanced cardiac life support skills (for any age)

Other

a.       Repair of skin lacerations

b.       Multiple patient management

c.       Grief and loss counseling

d.       Critical incident stress debriefing

e.       Foreign body removal

f.         Wound debridement and I & D

Objectives

The resident will:

• Quickly and accurately gather information pertinent to the emergent patient from all sources available.

• Discuss the roles played by the various disciplines involved in the care of the emergent patient and how to best use those individuals to provide excellent patient care.
• Access information resources available to aid in the care of the emergent patient.
• Demonstrate the ability to effectively manage the patient’s airway be able to explain the various methods by which this can be accomplished.
• Demonstrate the ability to achieve vascular access and discuss the various methods by which this can be accomplished.
• Demonstrate the ability to perform the procedures commonly encountered in the care of the emergent patient.

Medical Knowledge

Goal

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 become familiar with the following:

Competencies

• Principles of Care

      1.  Pre-hospital emergency care

      2.  Prioritization and triage

      3.  Resuscitation and stabilization

      4.  Reassessment and monitoring

      5.  Consultation

      6.  Disposition

• Assessment and management of:

      1.  Trauma

            a.  Primary and secondary assessment

     2.  Neurological Emergencies

           a.  Altered consciousness/coma

           b.  Cerebrovascular disorders

                 1.  Stroke

                 2.  Aneurysm

           c.  Infectious disorders

           d.  Seizure disorders

           e.  Acute headache

     3.  Psychiatric emergencies

          a.  Thought disorders (acute presentation)

          b.  Mood disorders (suicidal ideation, homicidal ideation)

          c.  Acute anxiety/panic attack

          d.  Somatoform disorders / hysterical conversion / hypochondriasis

          e.  Addictive disorders / overdose / drug seeking behaviors

          f.  Risk assessment and involuntary commitment

     4.  Environmental disorders

          a.  Burns

          c.  Heat and cold injuries

          d.  Bites and stings

               1.  Management of insect bites and stings

               2.  Management of human and animal bites

          e.  Poisonous plants

          f.  Hypersensitivity reactions / anaphylaxis

     5.  Toxicological emergencies

          a.  Acute overdose

          b.  Accidental poisonings

          c.  Access to poison control databases

     6.  Obstetric and gynecological emergencies

          b.  Ectopic pregnancy

          c.  Threatened or spontaneous abortion

          d.  Vaginal hemorrhage

          e.  Emergency contraception

     7.  Victims of violence

     8.  Respiratory emergencies

          a.  Acute respiratory distress

          b.  Pulmonary embolism

          c.  Pulmonary infections

          d.  Pleural effusions / empyema / pneumothorax / hemothorax

          e.  Obstructive / restrictive lung diseases

     9.  Cardiovascular emergencies

           a.  Dysrhythmias

           b.  Cardiac arrest

           c.  Acute coronary syndrome

           d.  Thoracic and abdominal aneurysms

           e.  Acute thrombolytic therapy

10.   Metabolic disorders

           a.  Diabetic ketoacidosis

           b.  Thyroid disease emergencies

11.   Indications and interpretation of diagnostic tests

a.       Electrocardiograms

b.       Radiologic exams

c.       Plain films

d.       CT scan

e.       Laboratory testing

12.   Medical-Legal Issues

           a.  Informed consent and competency

           b.  Withholding / termination of treatment

           c.  Laws (Commitment, reportable conditions, Good Samaritan, EMTALA,

                 HIPPA)

           d.  Liability (duty to treat, negligence and standard of care, risk management)

13.   Disease prevention

a.  Active and passive immunizations

b.  Antibiotic prophylaxis

Objectives

• The resident will be able to quickly assess and triage emergency patients.
• The resident will demonstrate the ability to recognize and stabilize emergency medical conditions.
• The resident will be able to effectively utilize diagnostic tests in the evaluation of the emergent patient.
• The resident will be knowledgeable about the laws and liability issues pertinent to emergency medicine.

Practice- Based Learning and Improvement

Goal

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 :

Competencies

• Locate, appraise and assimilate evidence from scientific studies related to their patients’ health problems

Objectives

• The resident will be able to utilize printed, digital and online information databases to provide excellent evidence-based care for the emergent patient.

Systems Based Practice

Goal

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:

Competencies

• Coordinate patient care within the health care system relevant to their clinical specialty
• Incorporate considerations of cost awareness and risk-benefit analysis in patient care

Objectives

• The resident will be able to coordinate care of the emergent patient from the initial encounter outside the hospital, during transport, while in the emergency department, and to the final disposition of the patient.
• The resident will be able to evaluate and explain the risks and benefits of treating an individual patient.

Professionalism

Goal

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

Competencies

• Compassion, integrity, and respect for others
• Demonstrate adherence to ethical principles
• Show sensitivity and respect to diverse patient populations
• Know when to seek consultation from other appropriate specialists to either manage or co-manage a patient for optimal care.
• Work quickly and efficiently to assess the patient according to the urgency of the patient’s problem.

Objectives

• The resident will exhibit compassion and respect for patients, families and other members of the health care team.

Interpersonal and Communication Skills

Goal

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.  Residents are expected to:

Competencies

• Communicate effectively with physicians, other health professionals, and health related agencies
• Maintain comprehensive, timely, and legible medical records

Objectives

• The resident will be able to present the patient’s medical problems in a complete and concise manner to consulting physician and health care personnel involved in the treatment of the patient.
• The resident will maintain adequate medical records for all patient encounters and be able to discuss the importance of thorough, timely record keeping by all participants in providing the patient with excellent care.

Assessment Method

At the conclusion of each resident rotation, the residency coordinator sends a formative-type, rotation-specific performance evaluation form to the rotations’ supervising physician.  When the completed evaluation is returned, the resident physician and the resident’s faculty advisor review the evaluation and attest to reviewing it by signing/initialing the form.  Next, the program director reviews and attests to the document.  Once all three have reviewed and attested the evaluation, it is included in the resident’s permanent file. 

Each resident is asked to evaluate the rotation and supervising physician(s) at the end of the rotation.  The resident’s faculty advisor and program director review the evaluation and attest to reviewing it by signing/initialing the form. These evaluations are filed together by resident year.

Educational Resources

References available at the AHEC Library:

Rosen, Peter. Emergency medicine: concepts and clinical practice. 4^th ed. St. Louis: Mosby Year Book, 1998.

Tintinalli, Judith E. Emergency medicine: a comprehensive study guide. 5^th Ed. New York: McGraw-Hill, 2000.

Mattox, Kenneth. Trauma. 4^th ed. New York: McGraw-Hill, 2000.

Civetta, Joseph M. Critical care. 1997.

Taylor, Robert W. Techniques and procedures in critical care. 1990.

On Line Resources:

UpToDate and DynaMed