Emergency Medicine Residency Handbook 2009 Edition table of contents chapter page

IV. Admitting process

At the time it is determined that a patient requires general admission to the hospital you must discuss the case with the faculty attending. You should then contact the patient’s private physician. If the patient does not have a private physician, or if their physician does not admit to the hospital, the patient should be admitted to the hospitalist service. Then, you should sign the patient out to the Medical Admitting Resident (MAR), who accepts all floor and telemetry admissions. He/ she can be reached directly by calling 9182. All admissions to the ICU, CCU, telemetry, or specialty services must first be discussed with the appropriate contact person. (P, C). Record the name of each person you spoke to, and the time at which you spoke to them, and then hand the chart to the clerk to admit the patient.
V. Radiology Services

The Department of Radiology provides efficient, full-service radiology services. There is an emergency x-ray department is located within the ED1. CT Scans are performed in an area adjacent to the E.D. An ultrasound technician is available 24 hours a day. Readings of all films by an attending radiologist or radiology resident are done 24 hours a day. We also have our own ultrasound machine within the department, and resident are encouraged to utilize it whenever possible.

VI. Physician Documentation

It is expected that you will complete the patient chart, documenting all pertinent historical, physical, and laboratory information prior to patient disposition. Both the resident and attending physician must sign and stamp all charts. In addition, all patients must also have the following information noted on the chart: time/date seen by M.D., disposition (including time/date), and final diagnosis. If a patient is to be discharged, all patients must have specific discharge instructions, including time and place of follow up appointments, return instructions, and any medication/care instructions. (P, SBP)

VII. Follow-up Appointments

We provide the patient with the contact information of the physician they will be following up with. This may include their private physician, an on call specialist, or a preferred provider. Any information not in Exit Care is available from our clerical staff.

VIII. Clinical Schedule

Dr. Kass is responsible for making and distributing the SIUH ED schedule. The schedule for all MLP’s is made at one time, and often in 12-week segments. Therefore, you may be asked to submit requests between 1 and 3 months prior to the beginning of your rotation. Please let Dr. Kass know as soon as possible if you have any specific needs or requests. Requests are not guaranteed, but every effort will be made to honor them.

The PGY 2 resident rotates for 4 weeks in ED 1, working 17 shifts including 2 full weekend.

The PGY3 resident rotates for 4 weeks in ED 2, working 15 shifts including 1.5 weekends.

The PGY 4 resident rotates for 4 weeks in ED 1, working 14 shifts including 1.5 weekends.

Residents will be scheduled a combination of 7am, 10am, 11pm and 7pm shifts, as deemed necessary by Dr. Kass.

During the week business dress code is mandatory but scrubs may be worn at night or on weekends. White coats are preferred but not mandatory.
IX. Sick Call Procedure

If you are going to be unable to make a shift, for whatever reason, please follow the guidelines that have been set up by the directors of your program. In addition, please contact Dr. Kass and the lead physician in the clinical area.

X. Directions & Parking

Traveling by car take the BQE (278) westbound toward the Verrazano-Narrows Bridge. Go over the bridge taking the lower level. Get off the second exit, Lily Pond Avenue. Circle around the exit and go straight for 6 lights. Along the way, Lily Pond turns into Father Capodano Boulevard. At the 6^th light, make a left turn onto Seaview Avenue. The hospital is approximately ¼ mile down on the right hand side. Turn right into visitor parking. On your first day park in visitor parking you will be given an ID card that will allow you to park for free.

If you are taking the ferry, take either the 1/9 to South Ferry or the 4/5 to Bowling Green and get on the ferry. Be advised that in the morning, the ferry runs on the half hour. After getting off the ferry, there is a sign to take the train (don’t worry it only goes in one direction). Take the train to the Dongan Hills stop. Exit the train go down stairs onto Seaview Avenue. You will go underneath an overpass. Cross over Hyland Boulevard and walk another 2 blocks. The hospital will be on your right.

The express bus also runs between Staten Island, Brooklyn and Manhattan. Review http://www.mta.info/nyct/bus/index.html for any pertinent bus information.

Additionally, we can make attempts to share rides with other residents, PA’s and attending physicians if Dr. Kass is notified in a timely fashion.

The Residency reimburses bridge tolls. Contact Stephanie Lane for further information.

XI. Contact Numbers/Email

Dr. Ardolic 917-354-4612 (pager)

718-226-8083 (office)

[e-mail]

Dr. Kass 917-817- 0078 (mobile)

718-226-9158 (office)

[e-mail]
Useful Hospital Numbers (all numbers start with the prefix 226)


Main E.D. 9140

Urgent Care 9108

Pediatric E.D. 9120
Admitting 8414

Blood Bank 9409

Cath Lab 8392

Echo 9486

Lab 9400

9257 (stat)

9457 (chem)

9405 (heme)

Medical Records 9017

Microbiology 4023

Morgue 9373

Operator 8044

PACS 1806

Patient Rep 6319

Pharmacy 9232

Radiology 9183 (file room)

8634 / 8598 (reading room)

8815 / 8300 (CT)

9037 (X-Ray)

Security 9396

Social Services 9170

Ultrasound 8816

SIUH ED FACULTY

Brahim Ardolic

Ruven Averick

Amanda Beard

Vincent Broillet

Nicole Berwald

John Calabro

Yusra Farooqui

David Finkelstein

Yvonne Giunta

Chris Graziano

Barry Hahn

Dara Kass

Boris Khodorkovsky

Juan Maguina

Eric Maniago

Nima Majesi

Jaimee O’Connor

Erica Olsen

Elzbieta Pilat

Rosemary Pitkin

Matthew Pius

Dara Raspberry

Charlotte Reich

Krista Savarese

Nishant Shah

Amanda Smith

Arthur Treyster

Anthony Vassallo

Moshe Weizberg

VAMC – NYHHCS (Brooklyn Campus)

Emergency Department
VHA is the largest integrated healthcare delivery system in the nation. On an annual basis, VHA provides medical care services on a national basis to over six million unique veterans at over 150 hospitals, 800 outpatient clinics, and 120 nursing homes. VHA mission is to ensure that the health care needs of these veterans are met by providing them with primary care, specialized care including emergency care, and related medical and social support services.

The VA Hospital at Fort Hamilton, Brooklyn, New York serves as a University Hospital for SUNY Downstate University. The veterans are one of the most special communities in the US, deserving the best emergency care .

VA Brooklyn, is located in Fort Hamilton Park at the base of the Verrazano Bridge., with one of the most spectaculars views over the bridge and the New York Bay. Conveniently located to the belt parkway, subway lines and constant shuttle buses from 23^rd street and second avenue in Manhattan.

Statistics

65-85 patients’ daily visits; 22,000 annual visits
12-16 acute care patient admissions daily

Low-intermediate acuity patients. 2-3 daily admissions to critical care.

Resident’s admissions Teams from Medicine, Surgery, Podiatry
 

 VA Medical Center is a tertiary care medical facility caring for eligible veterans.  The Emergency Department sees over 23,000 patient visits. For the past 50 years, the Brooklyn Campus, a part of the New York Harbor Healthcare System, has provided state of the art cardiac, intensive care, medical and surgical services as well as a broad range of both medical and surgical subspecialties.  The new expanded ED is fully operational since January 2006.

 

Contact Information:

 

Antonio J. Saliba MD, MPH

Chief Emergency Department

Brooklyn VA Campus

O [phone]

F [phone]

C [phone] 
Getting to VAMC

We are located at 800 Poly Place. If you are driving, take the BQE (278 East), and get off at the last exit before the Verrazano Bridge (92^nd Street).  At the light, make a left onto 92^nd street.  Go straight (2 lights), until you hit the end of the street (7^th avenue).  Victory Memorial Hospital will be on your left and Poly Prep Academy will be on your right.  Make a right onto 7^th avenue, and take it straight to Poly place.  Make a left onto Poly place.  The Hospital entry/parking lot will be on your right.  You must show a photo ID to enter the hospital property.  The Emergency Department is located on the ground floor.

From Long Island & Queens:

Take the Belt Parkway to Bay 8th Street/14th Avenue exit. Make a left at the first light onto Cropsey Avenue. Make a left at the second light onto 14th Avenue. Follow 14th Avenue as it curves and turns into Poly Place. Make left at the next light into the parking lot.

From Staten Island:

On the Verrazano Bridge, stay in the right lane and exit at 92nd Street. Make a right at the first traffic light onto 92nd Street and drive to 7th Avenue. Make a right onto 7th Avenue and continue around the golf course to the Medical Center on your right. Make a right into the parking lot entrance at the next light.

Public Transportation;

By Subway: From Manhattan or Coney Island, take the "N" train to 8th Avenue, then take the #70 bus to the Medical Center.

 
Computer Access, ID, Human Resources processing, and Pharmacy Privileges

The above must be completed one to two weeks prior to your start date. Please contact our office directly, Ms. Mary Lucas (ED assistant manager) at [phone] for scheduling a date for processing. Processing Packets are available at SUNY, through Stephanie Lane, however, a package can be sent directly to your home address if necessary by requesting one from Ms. Lucas.

 

Scheduling

Working in the ED scheduling is unique, flexible and under the supervision of a board Certified Emergency Physician. Shifts are either 10 or 12 hours long, most of them during the week, Wednesdays are non-clinical because residents are expected to attend the weekly seminars at Kings County Hospital.

All shifts will be 10 to 12 hours long on Mondays, Tuesdays, Thursdays and Fridays. All shifts start at 8 am.  Please contact Ms. Mary Lucas (ED Assistant manager) at [phone] with any special requests. These must be made two months prior to your start date.

 

Clinical Orientation

It will be the day of your first shift in the ER (the first Monday of the new block). It will include a tour of the facility, introduction to staff, an overview of the computer system, and a brief discussion on what’s expected.

 
Evaluation and Feedback

You will be evaluated based on 6 core competencies: medical knowledge, patient care, professionalism, communication and interpersonal skills, system-based practice (knowing the big picture), and practice-based learning (eagerness to learn new information and gain new clinical experiences).

 

We encourage you to voice your opinion regarding the quality of your rotation at the VAMC. Please feel free to contact any of the faculty listed above for any problems or suggestions. In addition, you will be required to evaluate each of the teaching faculty members that you work with at the end of the rotation.

Educational Objectives:

PGY-1 Emergency Medicine Residents will rotate for a four-week block on the in-patient Medical Services at the Brooklyn VA. The Emergency Medicine Residents will be integrated into the schedule of the Department of Medicine by the respective Chief Medical Residents. The Emergency Medicine Residents will function in the role of a PGY-1 Internal Medicine Resident, and will have direct patient care responsibility. They will be under the direct supervision of a PGY-3 Medical Resident and Internal Medicine Attending Physician. Residents will also attend daily attending rounds, daily educational conference, weekly Medicine Department Grand Rounds and the monthly Morbidity and Mortality Review.

At the completion of this rotation the resident will be familiar with and demonstrate competence in:

• 
  Performance of a comprehensive history and physical examination on acutely and chronically ill patients(PC,MK)
  
• 
  Development of an integrated problem list for patients, including detailed differential diagnoses.(MK,PC)
  
• 
  Management of complex medical problems on an acute and chronic basis.(MK,PC,SBP)
  
• 
  Transfer and discharge planning.(SBP,PC,P)
  
• 
  Utilization of laboratory data and ancillary studies in the care of internal medicine patients(MK,PC)
  
• 
  Blood and body fluid precautions(MK,SBP)
  
• 
  Necessary precautions for Tuberculosis and other airborne pathogens(PC,MK,SBP)
  
• 
  Appropriate utilization of specialty consultation(C,P,PC,MK)
  

Medical Knowledge and Patient Care:

• 
  Understanding the model of a Universal Health Care System in the US
  
• 
  To have experience with the oldest and most comprehensive Computerized Patient record system (CPRS) in the country.
  
• 
  Understanding how to improve Patient Safety as a pillar for Joint Commission of hospital accreditation (JCAHO) system
  
• 
  How to intuitively recognize and surpass benchmarks for Performance Measures as a requirement for JCAHO.
  
• 
  Recognizing and managing the emergency needs for geriatric patients in the ED.
  
• 
  Recognizing and promptly managing walk-in emergencies
  
• 
  Understanding the process for accepting and transferring emergencies for definite management.
  
• 
  Understanding the operation of the Fast track Clinic.
  
• 
  Evaluation and admission of low risk patient into the ED Chest pain Unit
  
• 
  Using the 23 hours observation beds as an option for patient disposition
  
• 
  Management of congestive heart failure
  
• 
  Management of asthma/COPD
  
• 
  Management of gastrointestinal bleeding
  
• 
  The evaluation and management of fluid and electrolyte disorders
  
• 
  The evaluation and management of hypothermia and hyperthermia
  
• 
  The evaluation and treatment of suspected spinal cord compression
  
• 
  Management of diabetes: its acute (DKA, Hyperosmolar Coma), and chronic (leg ulcers, renal failure, neuropathy, retinopathy) manifestations
  
• 
  The evaluation and treatment of acute and chronic renal failure
  
• 
  Initial management of myocardial ischemia
  
• 
  Recognition and treatment of the initial stages of septic shock
  
• 
  The differential diagnosis of wide-anion gap and non-anion gap metabolic acidosis
  
• 
  Management of pneumonia
  
• 
  Diagnosis and management of patients with CNS and systemic infections
  
• 
  Development of the Doctor-Patient relationship as the resident interacts with patients and their family’s during the stress of illness and death
  

Description of clinical experiences:

Residents should have experience and demonstrate competence in the following procedures on this rotation:

• 
  Advanced Cardiac Life Support
  
• 
  Emergent airway management
  
• 
  Diagnostic lumbar puncture.
  
• 
  Abdominal paracentesis
  
• 
  Peripheral blood smear analysis
  
• 
  Thoracentesis
  
• 
  Arterial blood gas sampling and its analysis
  
• 
  Lymph node aspiration for cytology diagnosis
  
• 
  Peripheral IV catheter placement
  
• 
  Central IV placement and care
  
• 
  Urinalysis
  
• 
  Blood and tissue culture techniques
  
• 
  Viral culture techniques
  
• 
  Nasogastric intubation
  
• 
  Debridement of decubitus ulcers
  

Description of didactic experiences:

The resident will attend all lectures offered by the Internal Medicine department.

The following topics should be covered in the resident’s reading during this rotation:
Hypertension Pulmonary embolism

Diabetes insipidus Deep vein thrombosis

Diabetes mellitus Malignancy

Diabetic ketoacidosis Paraneoplastic syndromes

Diabetic hyperosmolar state Lymphoma/leukemia

Electrolyte disturbances Metabolic acidosis

Acute and chronic renal failure Asthma/COPD

Anemia Pneumonia

Hemolysis Sepsis

AIDS TB

Brain abscess Infectious diarrhea

Connective tissue disorders Vasculitis

TTP ITP

Acid-peptic disorders Spinal cord compression

Pancreatitis Hepatitis

Upper GI bleeding Lower GI bleeding

Congestive heart failure Myocardial ischemia

Atrial fibrillation Atrial tachycardias

Sarcoidosis
 

FACULTY

 

Antonio Saliba, MD, MPH

Aleksandr Gleyzer, MD

Eunace Park, MD

Gerard Casey, MD

Abel Cherian, MD

Joseph Chirayil, MD

Boris Khodorkovsky, MD

Jay Itzkowitz, MD

Ethan Cowan, MD

Jonathan Fogel, MD

Paul Leo, MD

Zhiang Lu, DO


EDUCATIONAL OBJECTIVES

EDUCATIONAL OBJECTIVES – PGY 1
Emphasis during this year will be placed on orientation to the different emergency department environments. By the end of the year, the resident will demonstrate the ability to prioritize and organize activities; chart documentation; perform basic procedural skills; work with hospital staff; deal with friends and families of patients (particularly those who are critically ill or dying); and most importantly, perform quality patient evaluations. The resident should demonstrate accurate and appropriate history and physical exam skills; how to generate differential diagnoses and care plans; and the appropriate usage of x-rays and lab exams. A PGY-1 should evaluate no more than one or two new patients at a time. They should not accept responsibility for more patients until he or she presents the patient to a senior resident or attending. Their total caseload will be determined by their need for supervision, as well as patient acuity. The PGY-1 should expect their evaluation to be repeated by their supervisor. A PGY-1 cannot make independent admission, transfer or discharge decisions, but they should formulate and offer their plan for the aforementioned. A faculty member must co-sign all charts.
At the completion of this training year, the resident will demonstrate competence in and be able to:

• 
  perform histories and physicals on Emergency Department Patients: adults and children
  
• 
  understand the necessity for prioritizing patients
  
• 
  prioritize their activities
  
• 
  formulate differential diagnoses on their patients
  
• 
  plan appropriate work-ups based on their differential diagnoses
  
• 
  plan admission, transfer and discharges
  
• 
  appropriately order and utilize laboratory data and ancillary studies
  
• 
  carefully understand and utilize universal precautions
  
• 
  appropriately utilize specialty consultation
  

• 
  function as a team member during resuscitations
  

Description of clinical experiences:

First Year Residents should have experience and demonstrate competence in the following procedures:

• 
  physical examination
  
• 
  oxygen administration
  
• 
  bag-valve mask device usage
  
• 
  closed chest compression
  
• 
  oropharyngeal and nasopharyngeal airways
  
• 
  pelvic examination
  
• 
  phlebotomy
  
• 
  peripheral intravenous lines
  
• 
  Foley catheter placement
  
• 
  arterial blood gas sampling
  
• 
  nasogastric tube placement
  
• 
  thoracentesis
  
• 
  vaginal deliveries
  
• 
  central line placement
  
• 
  lumbar puncture
  
• 
  arthrocentesis
  
• 
  paracentesis
  
• 
  basic wound management
  
• 
  incision and drainage of simple abscesses
  
• 
  basic suturing of uncomplicated (non-facial, non-hand) lacerations
  
• 
  splinting of strains and sprains
  
• 
  anterior and posterior nasal packing
  

Core Competencies
Patient care

• 
  Procedural practice
  
• 
  Physical exam
  
• 
  Formulate treatment and disposition plans
  
• 
  Triage of patients and prioritization
  
• 
  Practice experience
  
• 
  Skills labs
  
• 
  Simulator time
  
• 
  SDOT
  

Medical Knowledge

• 
  Conference attendance and participation
  
• 
  Topic review groups
  
• 
  Webtests
  
• 
  Inservice exam
  
• 
  Bedside teaching rounds
  
• 
  Responsibility for preparing case conferences
  
• 
  Participation is skills labs
  
• 
  Simulator time
  
• 
  SDOT
  

Professionalism & Interpersonal

• 
  Modeling of behavior by faculty
  
• 
  Observation during clinical shifts
  
• 
  Web-eval system
  
• 
  SDOT
  
• 
  Simulator time
  
• 
  Responsibility for presenting case conferences
  

Communication

• 
  Modeling of behavior by faculty
  
• 
  Observation during clinical shifts
  
• 
  Web-eval system
  
• 
  SDOT
  
• 
  Simulator time
  

System based practice

• 
  Observation during clinical shifts
  
• 
  Web-eval system
  
• 
  SDOT
  
• 
  Simulator time
  
• 
  Participation in CQI committee
  
• 
  Participation in M&M committee
  

Practice based learning

• 
  Simulator time
  
• 
  Participation in CQI committee
  
• 
  Participation in M&M committee
  
• 
  Participation in weekly conference
  
• 
  Resident portfolio and reflective statement