Emergency Medicine Residency Handbook 2009 Edition table of contents chapter page

1.The Emergency Department

The Emergency Department underwent renovations. The new 36-bed treatment center contains a critical care area, a trauma room, a Pediatric Emergency Department, and a fast track area. The Emergency Department also has a its own radiology suite. Our emergency radiology area is a state of the art digital installation with a dedicated staff of radiology technicians and a CT technician. The Department of Diagnostic Radiology provides 24-hour Attending Coverage, either in-house or through Teleradiology (Night- Hawk).
The Fast Track facility and the Pediatric Emergency Department are staffed by a physician as well as a physician extender (typically a physician assistant). The Pediatric Emergency Department is staffed by either an Emergency Medicine Attending Physician, or a Pediatric Emergency Medicine Attending Physician. The Fast Track area sees over 33,000 visits per year of which nearly 15,000 are minor trauma related. Minor trauma entities seen in the Fast Track area include: Abrasions, bites, burns, contusions, fractures, dislocations, Lacerations, sprains, and foreign bodies. The main Emergency Department functions as Three separate teams, each with a Physician Assistant or Resident and an Attending Physician, and two to three nurses.
Team A is responsible for all critically ill patients as well as victims of trauma.

Team B covers all Medical/ Surgical patients within a defined geographical area of the Emergency Department as well as patients with obstetric/gynecological complaints.

Team C is responsible for patients within a defined geographical area of the main Emergency Department, as well as for patients whose main complaint is asthma.

Each resident will have the opportunity to rotate through all areas of the Emergency Department. There is no required rotation to the Pediatric Emergency Department.

Teaching Curriculum

Attendance is mandatory for all the following conferences at Brookdale Hospital.

• 
  Morbidity and Mortality Conference: Monthly
  

• 
  Trauma Conference: Monthly
  
• 
  Tuesday / Thursday morning lecture: Weekly
  

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  There will also be short morning report conferences to be held three to four times per week in the Emergency Department
  

2.Resident Responsibilities

• Scheduled shifts are 12 hours long starting at either 7:00 am or 7:00 pm . All residents are expected to be punctual and professionally dressed ( minimum matching scrubs)

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  Prior to the start of the rotation, each resident will be contacted for schedule requests, orientation and conference schedules.
  

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  If you cannot report for an Emergency Department shift, the Site Director Dr. Valladares, as well as Ms. Stephanie Lane, and the EM Chief Resident on call must be notified.
  

• 
  All conferences are mandatory with the exception of a reported illness or unless otherwise granted by the Site Director Dr. Valladares. Morning report attendance is mandatory only for those residents who are presenting for or departing from an Emergency Department shift.
  

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  If there are any questions or problems involving any rotation at the Brookdale Hospital Medical Center, it is imperative that the Site Director Dr. Valladares at Brookdale Hospital be contacted.
  

BROOKDALE ED FACULTY

Glenn Valladares, MD, MBA, FACEP (Site Residency Director)

Pierre Dodard, MD

Collie Oudkerk, MD

Omiel Powell, MD

Philip Puthumana, MD

Walter Raza, MD

Emmeline Kwon, MD

Arlene McTeer, MD

Allen Cherson, DO (Assistant director)

Lewis Marshall, MD, JD (Chairman)

Betty Chang, MD, RDMS

Nick Alexandrou, MD

Lee Leak, MD, FACEP

Phil McPherson, MD

Leoncio Dilone, MD

Walter Raza, MD, FACEP

Danielle Gilman, MD, FACEP

Staten Island University Hospital
Orientation Packet
2008-2009

I. Introduction

Welcome to the Staten Island University Hospital Emergency Department. At over 70,000 patient visits per year, and the only Level I Trauma Center on Staten Island, it is the busiest ED in the borough. It is also a cardiac catheterization, regional stroke and burn center. The patient volume and high acuity will serve as a great clinical experience for your training. At the same time, because it is a community hospital, it will serve as a valuable opportunity to learn Emergency Medicine in a small community setting.

Our Emergency Department (ED) is subdivided into:

1. 
   ED 1
   
2. 
   ED 2- which is comprised of:
   

1. 
   Urgent Care
   
2. 
   Pediatrics- All patients under 20
   

ED 1

The ED 1 area (previously referred to as the “Main ED”) is where we see our most critical (and often most interesting) patients. Patients seen in this area may be having (for example) an active MI, acute cholecystitis or diabetic cellulitis. It is also the area where we receive all major traumas. In this area you will receive a good degree of independence, approaching the undifferentiated patient first, then formulating your own patient care plan and disposition. Reading should be focused on interesting cases that you see. Pick one topic each day to review based upon something you saw during your shift. We promise you will see something worth reading about!

The Nursing Care Coordinator (NCC or “charge nurse”) supervises all patient flow within the ED. He or she manages the tracking board, determines patient location and also assigns the nurse to care for the patient. One standout quality of our ED is our nursing staff. They are extremely dedicated and hard working and have often seen the patient prior to any physician or mid-level provider (MLP). When a patient is ready to be assessed by a physician or MLP the NCC will place the chart in the rack by her podium. Charts should be picked up in a time wise fashion unless advised by an Attending Physician or the NCC. Often, after their initial assessment, the nurse caring for the patient will feel that the patient is more acute than previously thought and will approach a physician or PA to see that patient. In this case, you should physically go and see that patient if possible. Our nurses are a valuable resource with years of experience, and their opinions are often extremely accurate and astute.

Teaching opportunities by the attending staff is abundant in this area. Please ask questions! This is an excellent time to learn from the attending staff.

All MLP’s work 12-hour shifts. Shifts begin at 7am, 10am, 11am, and 7pm.

ED 2

The ED2 area is subdivided in to UCC and Pediatrics. For patient flow purposes the areas are to be combined, seeing the most acute patient first, but then seeing all patients in time order regardless of complaint. The combination of both areas affords our patients and our doctors the opportunity to utilize all available resources for each area, as it is required. Under this model residents get to see a wide variety of cases during each shift.

Staffing for ED 2 is created to serve the entire area, not just UCC or pediatrics. All MLP’s work 12-hour shifts. Shifts begin at 7am, 10am, 1pm and 7pm.

From 3am to 9am all ED 2 cases should be presented to an ED 1 attending. From 9am to 3am there is at least one dedicated ED 2 attending available in the area.

UCC

The Urgent Care area is open 24 hours a day. The urgent care area offers an excellent opportunity to manage minor trauma, small surgical procedures (laceration repair, I and D), orthopedics, ophthalmology, ENT and OB-GYN. You will be given a great deal of independence in this area and the majority of your cases will be managed to completion. In this area you will work along side other residents and physician assistants. You will also be able to assess your ability to see a higher volume of lower acuity patients.
Pediatric ED

The pediatric E.D. has an annual census of approximately 15,000. It is open 24 hours a day, 7 days a week and serves all patients less than 20 years of age, regardless of complaint.

II. Roles and Responsibilities of the Resident Physician

PGY-2

At this point in their training, the second year resident should feel comfortable evaluating any patient who presents to the E.D. To this end, we would like to focus on the resident’s organizational ability. (PBL, MK, C) He or she should be able to manage at least 3-4 patients simultaneously. The resident will work closely with the attending to assess, manage, admit or discharge the patient. An appropriately credentialed senior resident or faculty member should directly supervise all procedures performed by the resident. All charts will be co-signed by a faculty member.

Although primarily assigned to ED1, if there is a need, the resident may be shifted to ED2 for a short period of time. This will be utilized to facilitate speedy and appropriate patient care in times of unusual demand.

PGY-3

At this point in training the resident should feel comfortable seeing patients independently. Furthermore, the resident should start to demonstrate increased competence in managing critically ill patients. To this end, the PGY-3 resident will spend the majority of his/ her rotation, managing patients that require a monitored setting. (MK) The resident will be asked to run codes and resuscitations while under the supervision of the faculty attending physician.

The third year resident will have the ability to make admission, transfer and discharge decisions after discussing the case with a faculty attending physician. (MK, C, P, SBP) All charts must be co-signed by a faculty member.

If primarily assigned to ED1, the resident may be shifted to ED2 for a short period of time. This will be utilized to facilitate speedy and appropriate patient care in times of unusual demand. The converse is true if primarily assigned to ED2.

In ED2 the PGY-3 resident will function as a senior resident: directing resuscitations, performing all procedures, and taking presentations from medical / PA students all under the direct supervision of the attending.

PGY-4

In the last year of training the resident must be able to demonstrate progressive responsibility for the overall clinical and operational management of the E.D. In essence, the PGY-4 should be ready to assume an attending-like position. With the guidance of the faculty attending physician, the senior resident will help manage patient flow (SBP, PBL, C, P, MK, PC), train and assist junior residents (MK, C, P, PC), run codes and resuscitations, and see patients independently (MK, PBL, P, PC). Senior residents will be able to independently admit, transfer or discharge patients after informing the attending physician. All charts must still be co-signed by a faculty member.

Although primarily assigned to ED1, if there is a need, the resident may be shifted to ED2 for a short period of time. This will be utilized to facilitate speedy and appropriate patient care in times of unusual demand.

Sign Outs

If you are leaving the E.D. for any reason, including the end of your shift, all patients assigned to you must be signed out. The attending that has reviewed the patient with you should be aware that you are leaving.
III. Consults

Specialty consultations are available in all services, 24 hours a day. The clerks maintain a log of all on call physicians. If you need to reach a consultant, simply write it on an orders sheet and the clerk will page the physician for you. If you are having difficulty contacting a given service, you are to discuss this immediately with the faculty attending of record for the case. (P, C)