Emergency Medicine Residency Handbook 2009 Edition table of contents chapter page

EMS Rotation Information

The EMS rotation starts on the Monday morning of the first week of the 2-week block. Residents from Emergency Medicine programs throughout New York City meet at 9am with one of the EMS Medical Directors at the Fire Department’s Headquarters at 9 MetroTech Center in Downtown Brooklyn (Office of Medical Affairs, 4^th floor conference room).

Enter the building from the courtyard side (not the entrance on Flatbush Avenue). You will need a picture I.D. in order to get past the police checkpoint outside the building, and also to obtain a visitors’ pass once inside the building (it is useful to have your hospital I.D. with you in addition to your driver’s license). Once inside, you will need to pass through a metal detector and will not be allowed upstairs with any knives, weapons, explosives, etc. (so please leave any such items at home as there aren’t any lockers or places for storage).
The morning of the first day includes a series of lectures and discussions about EMS in New York City as well as various academic EMS-related topics. The schedule and requirements for the rest of the rotation will be reviewed at that time. Usually there is a lunch break followed by some more discussions and a visit to the 911-communications center. The day is over by 4pm (and usually an hour or two earlier).
Each Resident will be given an individualized schedule for the 2-week block. Most days will require ride-alongs with either ALS or BLS ambulances. One of the days will be an observation at the On-Line Medical Control Facility (“Telemetry”) and there may also be a day assigned to teaching or testing EMT’s or Paramedics at our training academy. Most observations or ride-alongs are 8-hours long (e.g., 8am-4pm, 10am-6pm, 3pm-11pm). Weekends are usually left unscheduled. You will be required to be signed in and out each day.
There will be a few assignments for you to complete during the rotation. The assignments often include a write-up of an interesting patient you encountered during the ride-alongs or a simple research project on an assigned EMS topic.
The ride-alongs offer an opportunity for you to observe the capabilities of EMS providers and to give you insight into the care provided to patients prior to their arrival at the Emergency Department. The pre-hospital environment is less controlled than the E.D., and therefore you must always be cognizant of scene safety and the potential for unsuspected situations to arise. The EMT’s and Paramedics are acutely aware of such things, and I always advise the Residents to stay close by your assigned providers at all times.
You will find the EMT’s and Paramedics are eager to involve you in the assessment and care of patients in order that they may gleam some of your medical knowledge and skills. However, your role on the ride-alongs is officially as an observer only.
The rotation concludes on the Friday of the second week. On this day everybody again meets at the Fire Department Headquarters (or another predetermined location) to discuss the rotation, present the assigned topics, as well as review some other EMS issues. Your attendance as well as performance on the assigned topics helps determine your grade for the rotation.
One more point worth mentioning. The first and last days of the rotation will be at the FDNY Headquarters building. As this is an office environment, you will be expected to dress accordingly (pants/skirt, shirt/blouse, tie). Some of the Medical Directors are very strict on the appropriateness of dress, and will not allow you to stay if you are wearing scrubs, jeans, etc. (and if you are dismissed from the first day then you will not be able to do the rotation for that 2-week block). When riding-along on an ambulance, you will be expected to wear dark pants and a work shirt (e.g., long-sleeve button-down). It is especially important to wear shoes that are comfortable to do a lot of walking in. Please do not wear jeans, t-shirts, or sneakers on the ride-alongs. Of course, always have your hospital I.D. with you.
If you would like to gain extra knowledge or experience, or if you are interested in doing a Fellowship in EMS or Disaster Management, we also offer a 2 or 4-week EMS elective rotation that you might consider. Additionally, we welcome Residents who are interested in working on EMS research (either joining an ongoing project or developing one of your own).
If you have any questions or require additional information, feel free to contact Dr. Kaufman, the Resident Rotation Program Director (718-999-1872, [e-mail]), or Olethea Wernersbach, the Resident Rotation Coordinator (718-281-8463, [e-mail]).

Bradley Kaufman MD, FACEP

Emergency Medicine Resident Emergency Medical Service rotation:

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  Didactic sessions:
  
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    Two sessions conducted with Dr. Kaufman
    
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    Session one is an introductory session to Emergency Medical Services. This session reviews the following topics:
    
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      The goals and objectives of the rotation
      
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        The role of the emergency medicine physician in the prehospital sector
        
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      Review safety (including infection control) issues related to field EMS observation
      
      • 
        Use of PPE
        
      • 
        Resuscitation practices and procedures
        
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        Needle stick issues
        
    • 
      Discuss the history of EMS in New York City
      
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      Discuss the operational characteristics (including limitations) of the New York City FDNY/EMS 911 system
      
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        Call receiving, CRO, and dispatching
        
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        Operational statistics: daily and annual
        
      • 
        Integration of FDNY/EMS, and Voluntary 911 units
        
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        Destination hospital receiving facilities and Specialty Referral Centers
        
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        The role of the Volunteer sector and commercial transport system relative to 911 service
        
    • 
      Discuss the role of Telemetry
      
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        Role and responsibility of the telemetry physician
        
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        Issues related to audio documentation
        
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        Real time contact requirements
        
    • 
      Discuss the system participants: levels of certification, training requirements, on scene responsibilities
      
      • 
        CFR-D
        
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        EMT-B
        
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        EMT-A/Paramedic
        
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        EMS-MD
        
    • 
      Review the role and general structure of Incident Command
      
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        Role of the physician in transport decisions
        
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        The relationship between the on-scene physician and incident command function
        
    • 
      To discuss the issues of social customs and the field responder
      
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        Its effect on EMS training and the EMS medical director
        
    • 
      To discuss the basics of disaster management and response
      
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        Including EMS/USAR national responses
        
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        14 ^th Street subway incident
        
      • 
        Basics of domestic (B-NICE) terrorism
        
      • 
        Review the Tokyo Subway Sarin incident
        
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          Its effect on the prehospital system in the US
          
        • 
          The hospital associated issues of the event
          
    • 
      Complete review of the S.T.A.R.T. (Triage) system
      
      • 
        EMS triage process: color coding designation
        
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          Clinical expectancy issues
          
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        Role of the emergency medicine (field) physician in the different medical sectors
        
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        Limitations of EMT and Paramedic triage
        
      • 
        Exercise in the START process: multiple case based exercise
        
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      Assign final day presentations
      
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        Five to ten minute PowerPoint presentation
        
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        Selected topic on a prehospital/emergency medicine topic (see attached)
        
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        All topics in the same related area
        
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        Internet based
        
    • 
      General administrative activities
      
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        Review and distribute the resident schedule for the rotation
        
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        Complete the necessary administrative Ambulance Observation form
        
      • 
        Complete a resident demographic form
        
  • 
    Ambulance Field Rotations
    
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      Residents are scheduled for ALS and BLS field observation
      
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        Residents are scheduled (unless specifically requested) for FDNY units in close proximity to their residencies
        
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          To afford them to observe their patients in their home environment
          
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          Work with units that typically respond to their facility
          
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        Scheduled rides are usually limited to units that have had resident observers in the past and are accustomed to physician observers
        
  • 
    Telemetry Rotation
    
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      One day rotation
      
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      Observe the telemetry physician as he/she manages incoming calls for:
      
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        Cardiac arrest
        
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        Transport decisions
        
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        RMA field contacts
        
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        Medication orders
        
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    Session two is conducted on the final day of the rotation, this includes the following:
    
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      Rotation resident issues:
      
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        Issues that need to be addressed
        
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          Ambulance observation
          
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          Telemetry
          
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          Missed rotation sessions
          
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          Recommendations for rotation change or modification
          
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      Review of Telemetry rotation:
      
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        Telemetry session and the role of RMA’s, cardiac arrest, and provision of medical care
        
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        The documentation process and the need for physician contact
        
      • 
        The issue and rational of transportation decisions
        
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      Review of field operations:
      
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        The interaction with patients in their homes
        
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        The interaction with other emergency responders at the scene
        
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        Transportation decisions
        
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        Interaction and management of patients on the street (including subways and offices)
        
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        Use of equipment by EMS: EKG, pulse oximetry, etc.
        
      • 
        Reception and interactions at destination hospitals
        
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      Topic presentation and discussion
      
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      Dr. Kaufman review and summation of rotation
      
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        Relevance to emergency medicine
        
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        Final review and discussion of the assigned topic
        
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          Its relationship to prehospital and Emergency Department operations
          
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          The relationship and potential public health issues
          
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          “System” preparedness
          

Directions to FDNY Headquarters

9 MetroTech Center is located on the SW corner of Flatbush Avenue and Tech Place in downtown Brooklyn. The front entrance to FDNY Headquarters faces Bridge Street in the MetroTech complex. Please note that there is no public parking available at FDNY Headquarters, metered and commercial parking is available nearby on Flatbush Avenue.
Directions by Car:

From the Brooklyn Bridge:

After crossing the Bridge make the first left turn onto Tillary Street. Proceed to the second traffic light at Flatbush Avenue. Turn right onto Flatbush Avenue. Proceed one block to Tech Place. FDNY will be on your right; parking is ahead one block.
From the Manhattan Bridge:

Continue straight off the Bridge onto Flatbush Avenue. Proceed through the light at the intersection of Tillary Street and Flatbush Avenue for one block to Tech Place. FDNY will be on your right.

From the Brooklyn Queens Expressway West:

Exit at Tillary Street; turn left at the second traffic light onto Flatbush Avenue. Proceed one block to Tech Place. FDNY will be on your right.

From the Brooklyn Queens Expressway East:

Exit at Cadman Plaza West. Make a left onto Cadman Plaza West. Make a left at Tillary Street (second light) to Flatbush Avenue (third light). Turn right and proceed one block to Tech Place. FDNY will be on your right.

Directions by Subway: Call 718-330-1234 for updated information.
A, C, or F subway to the Jay Street/Borough Hall station.
R or M subway to the Lawrence Street / MetroTech station.
Q or B subway to the DeKalb Avenue station; change to the R or M subway (Manhattan bound) to the Lawrence Street / MetroTech station.
2, 3, 4 or 5 subway to the Court Street / Borough Hall station. Change for the R subway (Manhattan bound) to the Lawrence Street / MetroTech station.
Directions by LIRR: Call 718-217-5477 for updated information.

From the Flatbush Avenue Station in Brooklyn, take the Q or B train one stop to DeKalb Avenue (Manhattan bound). At DeKalb Avenue, go across the platform for the R or M subway to the Lawrence Street / MetroTech station.

From Lawrence Street:

Walk toward the Commons on Lawrence Street, then diagonally across the Commons to 9 Metro Tech on the Flatbush Avenue side.

From Jay Street:

Walk diagonally across the Commons to 9 Metro Tech on the Flatbush Avenue side.

TOXICOLOGY

EM Faculty Liaison: Dr. Sage Wiener
Description and Goals of Rotation: The rotation at the New York Poison Control Center (NYCPCC) is your opportunity to exclusively focus on medical toxicology. During the rotation you should make an effort to become familiar with general approaches to the poisoned patient and clinical presentations of common toxidromes. You should also develop a basic understanding of poison prevention techniques, pharmacokinetics, toxicokinetics, resuscitation of the poisoned patient and commonly used antidotes.
Meeting Place: 8:15 AM in the Bellevue Hospital Emergency Department conference room for morning report. After morning report, residents should go to the New York City Department of Health/NYCPCC ground floor conference room. The address is 455 1^st Avenue (corner of 26^th Street). Check in with one of the toxicology fellows upon arrival.
NYU/Bellevue Hospital Center

New York City Poison Control Center

Schedule: Weekdays: 8:15 AM - 4:00 PM

Contact: Dr. Lewis Nelson, Director, Fellowship in Medical Toxicology

Tel: [phone]

Special Considerations:

1. 
   Attendance at the Bellevue Department of Emergency Medicine Morning Report is mandatory.
   
2. 
   The morning will be spent doing follow-up calls and the afternoon generally is dedicated to didactic teaching rounds.
   
3. 
   All residents rotating at the poison center are required to present a topic (project) that interests them by the end of their rotation. When deciding on a presentation topic, , discussion with one of the toxicology fellows is imperative so that you may be properly focused. The talk should be designed to educate the group (toxicology attendings, fellows, residents and medical students) and attempt to answer a question that has been raised regarding a specific clinical case. The talk should be at most 10 minutes in length. A handout may be helpful but a formal Powerpoint slide presentation is excessive.
   
4. 
   Once a month, there will be a Consultants’ Conference meeting scheduled on the first Thursday at 2:00 PM. It is usually held in the ground floor auditorium of the Department of Health building where the poison control center is located. You are welcome to continue going to these conferences during other blocks if you are free. This is an especially good idea if you are considering applying for a toxicology fellowship.
   
5. 
   Take advantage of your time at the NYCPCC as other physicians from all over the United States and other countries come to New York City to participate in the elective. This is not the month to “blow off” days. Be on time and actively participate in toxicology rounds.
   
6. 
   Residents are required to attend weekly KCH Wednesday Emergency Medicine Departmental Conference
   

RESEARCH

Active participation in a research project is a requirement for all residents in the Department of Emergency Medicine. Residents will receive a two-week period during the second year of residency and a two-week period during the third year of residency dedicated to their research projects. These research periods will be assigned during an Emergency Department rotation at Kings County. In order for this time to be productive, it is extremely helpful to have a project planned before you begin the initial two-week period. The resources necessary to successfully complete your project, including statistical and administrative support will be provided by the department.

Attendance at Wednesday conference is mandatory.
If the resident does not contact the research director at least 4 weeks prior to beginning the research rotation, the resident will be scheduled for shifts in the ED.
One Thursday at 11am during month, the resident will participate in a combined Emergency Medicine/Trauma Service simulation session in the simulation lab. Contact Dr. Gillet for further information the month prior to the start of the rotation.


How to Start?
On the first Wednesday of every month, ongoing projects are reviewed and new research projects are presented during conference. This information is available on the ED website in the Research Update newsletter. The Research Update is also posted monthly on the research bulletin board outside of the conference room. All PGY II and III residents should contact Dr. Zehtabchi at least one month prior to the start of their research rotation to setup a project. Residents are strongly encouraged to start a new project, starting from literature search, study design, planning the logistic aspects of the project, etc. However, residents may join projects already in development, and completing or helping to complete a research project of suitable quality for publication may fulfill the requirement. For authorship in a manuscript, residents need to meet the criteria outlined in the AEM authorship policy that is published in the monthly research update.

IRB Certification:
All attendings and residents are required to obtain the certification for “Human Participants Protection Education.” To complete your certification, please sign on to CITI (Collaborative IRB Training Initiative) computer based training program at http://www.miami.edu/bb/sunyreg.
Didactic Research Lectures:

The first Wednesday of each month, the research division will have a one hour lecture dedicated to research methodology, biostatistics, and evidenced-based medicine. All residents and faculty are welcome to attend these lectures. The topics of these lectures are published at the beginning of each year in the annual research update handbook.

Research Office Hours:

Every Wednesday Dr. Sinert and Dr. Zehtabchi will be available in their offices (9 am to 4 pm) to meet with faculty and residents on research issues. Please contact them one week in advance to set up a time.

How to Choose a Project:

The department of emergency medicine offers the residents research projects in a variety of emergency medicine fields. Residents are welcomed to start their own projects or to join the investigators of one of the active projects. The faculty and residents of the department of emergency medicine have conducted several research projects in the field of Trauma and Hemorrhagic Shock, Sickle cell Anemia, Toxicology, Evidenced-Based Medicine, and Medical Student/Resident Education.

Academic Associates Program:
The Academic Associate Emergency Medicine Clinical Research Program teaches the fundamentals of research to undergraduate pre-med students and medical students. This course is modeled after the novel clinical research elective Dr. Hollander first developed at SUNY Stony Brook. The Academic Associates work in conjunction with the ED staff to help identify and enroll patients who meet the specific inclusion/exclusion criteria for our clinical trials. The Academic Associates are responsible for the appropriate paperwork and data processing within the required time frame for each of the studies. Duties include data collection, collation, forms processing, and assisting in database configuration, statistical analysis, and abstract and manuscript preparation. Coupled with the “hands-on” data collection, a didactic program focusing on research design, and basic statistics will be organized for the academic associates by the research division. This program stresses professional responsibility, independent thinking, research design and data collection methods. Non-medical student Academic Associates (college students) are not permitted to draw blood, or handle laboratory specimens. Please remember that they are college students with no formal medical training.
Please make them feel at home and do not hesitate to help them perform their tasks in any way you can.
Policy: Authorship and Contributorship

Byline Authors

An "author" is generally considered to be someone who has made substantive intellectual contributions to a published study, and biomedical authorship continues to have important academic, social, and financial implications. (1) In the past, readers were rarely provided with information about contributions to studies from those listed as authors and in acknowledgments. (2) Some journals now request and publish information about the contributions of each person named as having participated in a submitted study, at least for original research. Editors are strongly encouraged to develop and implement a contributorship policy, as well as a policy on identifying who is responsible for the integrity of the work as a whole.

While contributorship and guarantorship policies obviously remove much of the ambiguity surrounding contributions, it leaves unresolved the question of the quantity and quality of contribution that qualify for authorship. The International Committee of Medical Journal Editors has recommended the following criteria for authorship; these criteria are still appropriate for those journals that distinguish authors from other contributors.

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  Authorship credit should be based on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3.
  
• 
  When a large, multi-center group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript (3). These individuals should fully meet the criteria for authorship defined above and editors will ask these individuals to complete journal-specific author and conflict of interest disclosure forms. When submitting a group author manuscript, the corresponding author should clearly indicate the preferred citation and should clearly identify all individual authors as well as the group name. Journals will generally list other members of the group in the acknowledgments. The National Library of Medicine indexes the group name and the names of individuals the group has identified as being directly responsible for the manuscript.
  
• 
  Acquisition of funding, collection of data, or general supervision of the research group, alone, does not justify authorship.
  
• 
  All persons designated as authors should qualify for authorship, and all those who qualify should be listed.
  
• 
  Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.
  

Some journals now also request that one or more authors, referred to as "guarantors," be identified as the persons who take responsibility for the integrity of the work as a whole, from inception to published article, and publish that information.

Increasingly, authorship of multi-center trials is attributed to a group. All members of the group who are named as authors should fully meet the above criteria for authorship.

The order of authorship on the byline should be a joint decision of the co-authors. Authors should be prepared to explain the order in which authors are listed. .

For further information on this and other policies visit http://www.icmje.org.

Research Contact Numbers:

Dr. Richard Sinert:

Director of Research

Telephone extension 2976

E-mail: [e-mail]

Dr. Shahriar Zehtabchi

Associate Director of Research

Beeper: [phone]

E-mail: [e-mail]

Dr. Lorenzo Paladino

Assistant Director of Research

Beeper: [phone]

[e-mail]