Emergency Medicine Residency Handbook 2009 Edition table of contents chapter page



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ED-BASED TRAUMA



Meeting Place: KCH ED

Contact Number: EM Chiefs
Daily Rounds: ED morning report
Schedule: The EM Trauma intern will be expected to function the same as our regular EM interns but will have a different shift distribution. You will also be scheduled for an intensive 2 day session of Trauma skills-stations and lectures.
EM Faculty Liaison: Dr. Bonny J. Baron pager: 917-760-1344
Description of rotation:

During the Trauma rotation, the PGY-1 Emergency Medicine Residents will rotate through the KCH ED for a 2 week time period. During that time, they will be responsible for 5 CCT shifts and 4 Pod A shifts. They should try to focus on traumatized/injured patients but can and should see any patient that presents to their area that needs to be cared for.


In addition to this 2 week block, each PGY 1 will be assigned a 2 day slot when they attend a “Focused Trauma Workshop.” Please make sure you look at your yearly schedule and you know when you are supposed to attend this workshop. It will run the better part of a Thursday and subsequent Friday so make sure you are free on those days. If you are in an EM month, you may need to request these 2 days off to ensure that you are free to attend this workshop. Please do not forget this. During this time period, the resident will have multiple activities to complete. The days will begin with a number of trauma-oriented lectures. They will then participate in multiple hands-on small group learning sessions involving critical trauma skill sets and will be exposed to multiple simulation cases involving traumatized patients. Lastly, there will be a reading list made available on the KCH EM web site where a number of trauma-oriented PDF papers can be downloaded. The resident is responsible for reading these papers prior to the completion of their PGY 1 residency year.
The Emergency Medicine Resident will have direct patient care responsibility: In the Emergency Room, they will be doing what all of the other PGY 1’s are doing that month with the exception being that they are supposed to be concentrating on traumatized patients. Just like the other PGY 1’s in the ED that month, the resident rotating on trauma will have to attend regular Wednesday EM Conference and morning reports according to the usual rules for absence. During the shifts in the Main ED, the resident will focus on injured patients. If no injured patients are waiting to be seen, then the resident will see normal ED patients
At the completion of this rotation the resident will demonstrate competence in the following:
MEDICAL KNOWLEDGE, PATIENT CARE

  • Recognition of the various stages of traumatic shock, including its earliest manifestations

  • The principles and endpoints of resuscitation, including the roles of:

-Crystalloid volume replacement

-Colloidal volume replacement

-Blood volume replacement

-Inotropic support



  • The initial assessment of the multiply injured patient (ABC’s)

  • Identification and treatment of immediately life-threatening injuries after the initial assessment

  • The role of radiographic studies in the initial and subsequent management of the injured patient

  • Common injury patterns associated with penetrating head trauma

  • Common injury patterns associated with blunt head trauma

  • How the presence of a closed head injury impacts management of a multiply injured patient

  • Management of elevated intracranial pressure

  • The anatomic zone system of the neck, and appropriate work-up and management of a penetrating injury to each of the zones

  • Indications for operation in penetrating chest trauma

  • Identification and management of patients at risk for pericardial tamponade

  • Recognition of a widened mediastinum on X-ray, its significance and work-up

  • Physiologic scoring

  • Evaluation of blunt abdominal trauma including:

-Physical exam

-Diagnostic peritoneal lavage

-Abdominal CT scanning

-Abdominal sonography

-Laparoscopy

-Non-operative management



  • Classification of pelvic fractures and radiographic studies used for their diagnosis

  • Diagnosis and management of the bleeding associated with pelvic trauma, including:

-external fixation

-angiography



  • Diagnosis and management of urologic complications associated with pelvic trauma

  • Evaluation and management of gross hematuria following trauma

  • Signs of peripheral vascular injury and the indications for angiography and operative management

  • Special concerns in the care of patients with spinal injuries

  • Special concerns in diagnosis and management of elderly injured patients

  • Importance of long bone fractures in the short and long term outcome of the multiply injured patient

  • Appropriate utilization of specialty consultants in the management of multiply injured patients

  • The concept of triage within the confines of available resources, including recognition of non-salvageable patients (PC,SBP,MK)

  • Pulmonary artery catheterization for hemodynamic monitoring

  • Identification of potential organ donors and their management to maximize yield of organ procurement(PC,SBP,P,C)

  • Patient discharge and transfer decisions, including formulation of long-term care plans for patients with spinal cord injuries and major disability(PC,P,C,SBP)

  • Compassionately interact with patients and their families during the stress of illness and death, including the ability to obtain DNR orders(PC,P,C)

  • The patterns and demographics of the urban trauma patient(PC,SBP,PBL)


Educational Expectations:

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


ATLS Hemodynamic monitoring

Volume resuscitation (crystalloid and colloid)

Neuro-intubation Resuscitation with blood products

Rapid sequence intubation Inotropic support

Intubation with cervical spine trauma SVO2 as a guide to resuscitation

Intubation with facial trauma Lactate and base deficit to monitor perfusion deficit

Mechanical ventilation Shock(hemorrhagic,neurogenic,cardiogenic)

Spinal trauma Physiologic scoring

Spinal shock Tissue ballistics

Penetrating and blunt thoracic trauma Trauma in pregnancy

Penetrating and blunt abdominal trauma Trauma in the elderly

Penetrating and blunt neck trauma Pediatric trauma

Head trauma

Glasgow Coma Scale

Pelvic trauma

Facial trauma

Long bone fractures (open and closed)

Vascular injury




OBSTETRICS

Meeting Place: S building 5th floor
Daily Rounds: 9am
Schedule: Contact Ms. Stephanie Goeloe (OB residency coordinator) (718) 270-3320.

If unable to reach Ms. Goeloe, the Chief resident of OB at KCH should be able to help. You can reach the OB Chief Resident through the KCHC operator at (718) 245- 3141



Educational Objectives:

PGY-1 Emergency Medicine residents will spend a two-week block on the Obstetrics in-patient service at Kings County Hospital. Residents will also rotate through the outpatient clinics. The Emergency Medicine Residents will be under the direct supervision of an Obstetrics/Gynecology Senior or Chief Resident and Attending Physician. They will act in the role of a PGY-1 OB/GYN Resident, providing direct patient care, and assisting with in-patient and Emergency Department consultation. They will also assist in the operating rooms. The Emergency Residents will attend the Department of Gynecology’s daily conferences and monthly Grand Rounds, as well as Emergency Department Educational events, if patient care requirements allow. The purpose of this rotation to perform at minimum the 10 deliveries required by the RRC for graduation. All deliveries are to be documented in New Innovations for credit.


At the completion of this rotation, the resident will demonstrate competence in and be able to:

· Evaluate and treat the patient with pre-eclampsia/eclampsia (PC,MK)

· Make admission, transfer and discharge decisions on OB patients (PC,MK,C,SBP,P)

· Utilize laboratory data and ancillary studies appropriately in the care of OB patients (PC,MK)

· Utilize in-patient consultation appropriately (PC,MK,C,P,SBP)

· Compassionately interact with patients and their families during the stress of illness and death (PC,C,P)


Description of clinical experiences:

Residents will have experience in and demonstrate competence in the following procedures:



  • Vaginal deliveries

  • Assisting in C-sections

  • Monitoring of patients in labor

  • Management of the ecclamptic patient

  • Management of episiotomies

  • Culdocentesis

  • Assisting in the operating room

  • Pelvic sonography

  • Pelvic examination

  • Assisting with the treatment of incomplete and complete abortions

  • Appropriate bacterial and viral culture techniques

  • Repair of vaginal lacerations

  • Removal of vaginal foreign bodies


Description of didactic experiences:

The residents will participate in the daily, weekly, and monthly OB/GYN conferences as well as the Emergency Medicine conferences if it is does not interfere with patient care requirements.


The following topics should be covered in the Resident’s reading during this rotation:
Pelvic and abdominal pain Abnormal vaginal bleeding

Ovarian cysts and rupture thereof Tubo-ovarian abscess

Spontaneous abortion Threatened abortion

Endometriosis Pelvic inflammatory disease

Ectopic pregnancy Uterine incarceration

Ovarian torsion Mittelschmerz

Vaginitis/vaginosis/vulvitis Urinary tract infection

Sexually transmitted disease Atrophic vaginitis

Infertility Vaginal foreign bodies

Sexual assault Contraception

Drug and radiation exposure in pregnancy Diagnosis of pregnancy

Nausea and hyperemesis gravidarum Premature rupture of membranes

Vaginal bleeding in early pregnancy Molar pregnancy

Contraception Hysterectomy

Pelvic relaxation Amenorrhea

MICU



Meeting Place: KCH MICU D building
Contact Number: (718) 245-3774 (KCH) or (718) 270-1566 (SUNY)
Daily Rounds: Contact KCH Medical Chief Resident for the block
Schedule: Contact the KCH Medical Chief Resident at least 2-3 weeks before the

start of the rotation.


EM Faculty Liaison: Dr. Ian DeSouza Cell: 917.903.1765

Special Considerations:

The Medical Intensive Care Unit at Kings County Hospital is a four week rotation for PGY-1 Emergency Medicine Residents. The Emergency Medicine Resident will function as a PGY-1 Internal Medicine Resident, providing direct patient care. The Emergency Medicine Resident will be supervised by a Senior Medical Resident, Critical Care Fellow and the Intensive Care Unit Attending Physician. The Emergency Medicine Resident will attend daily Attending Rounds, daily lectures with the Department of Internal Medicine, weekly Critical Care Conferences, monthly Internal Medicine Grand Rounds, and participate actively in the monthly Emergency Medicine / MICU interdisciplinary conference. The resident must attend the weekly Emergency Medicine Departmental conference.


At the completion of this rotation, the resident will demonstrate competence in and be able to:

· Perform a comprehensive history and physical examination on critically ill patients(MK,PC)

· Develop differential diagnoses for life-threatening problems, and create cohesive care plans based on these diagnoses(MK,PC,PBL)

· Manage critically ill patients in an intensive care unit setting(MK,PC,PBL)

· Make admission, transfer and discharge decisions for patients with life-threatening and potentially life-threatening illness(MK,PC,C)

· Appropriately utilize and interpret invasive monitoring(MK,PC)

· Appropriately utilize and interpret culturing techniques, results and use of antibiotics(MK,PC)

· Utilize laboratory data and ancillary studies appropriately in the care of critically ill patients(MK,PC,SBP)

· Utilize in-patient consultation appropriately(MK,PC,C,P,SBP)

· Compassionately interact with patients and their families during the stress of illness and death(PC,P,C)




Description of clinical experiences:

Residents should have experience with and demonstrate competence in the following procedures on this rotation: (MK,PC)

· Airway management and endotracheal intubation

· Placement and care of central venous catheters

· Placement and care of arterial catheters

· Placement and care of pulmonary artery catheters

· Interpretation of Swan-Ganz-catheter readings

· Utilization of oxygen delivery devices and mechanical ventilators

· Lumbar puncture

· Arterial blood gas sampling and analysis

· Abdominal paracentesis

· Thoracentesis

· Chest tube placement

· Placement of esophageal/gastric balloons


Description of didactic experiences: (MK,PC)

The Emergency Medical resident will actively participate in the interdepartmental conferences.

The following topics should be covered in the resident’s reading during this rotation:
Airway management and endotracheal intubation

Mechanical ventilation ACLS

Interpretation of invasive monitoring Drug induced paralysis

ARDS Asthma/COPD

Pneumonia Meningitis

Opportunistic infection Super-infection

Broad spectrum antibiotics Acute renal failure

Hemodialysis/peritoneal dialysis Gastrointestinal hemorrhage

Intracerebral bleeding/CVA Hepatic encephalopathy

Shock Sepsis

Uremic encephalopathy Anticoagulant therapy

Pulmonary embolism Coma/brain death examination

Cardiogenic pulmonary edema Dysrhythmias

Fever Acid base derangements

Electrolyte abnormality Nutrition: parenteral and enteral

Disseminated intravascular coagulation Hemolysis



INTERNAL MEDICINE at the VA




Meeting Place: VA Hospital 9th floor chief resident office on the 1st day of the rotation
Daily Rounds: Contact the Medical Chief Resident, 718-836-6600 ext. 6514, before first day of rotation

Schedule: Contact medicine chief resident at least 2-3 weeks before the start of the rotation.

EM Faculty Liaison: Dr. Antonio Saliba
Antonio J. Saliba MD, MPH

Chief Emergency Department

Brooklyn VA Campus

O (718) 630-3607

F (718) 630-2821

C (347) 831-5346 



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:

  • Management of the immune-compromised patient

  • Management of the patient with accelerated hypertension, and hypertensive urgencies

  • 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

  • The metastatic work-up

  • Nutrition: parenteral and enteral

  • 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

  • Evaluation and treatment of patients with vasculitis and connective tissue disorders; lupus, scleroderma, mixed connective tissue disorder

  • 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

PGY-2 OFF SERVICE ROTATIONS

Airway Management/ENT


Research
CCU at SIUH
NICU at UHB
SICU at KCHC
Neurology at SIUH
Orthopedics/FT at KCH
AIRWAY MANAGEMENT

Location: KCHC OR
Faculty Liaison: Dr. Christopher Doty
Contact: Ms. Wharton, LRNA

245-4398 or 245 4408
Structure:

The rotation takes place during a two-week block during the second year. During this time the residents will report to the clinical instructor at 7 a.m. every weekday. The resident will have the opportunity to develop his/her airway management skills under close supervision in the controlled setting of the OR. The rotation is embedded with the ENT rotation. When not in the OR the resident will participate in scheduled ENT clinic. 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.


Goals and Objectives:

    1. The resident will develop and demonstrate competence in the following clinical skills:

      1. Airway opening techniques.

      2. Use of oral and nasal airways.

      3. Bag valve mask ventilation.

      4. Safe administration of sedatives and muscle relaxants.

      5. Laryngoscopy anatomy and technique.

      6. Orotracheal intubation.

      7. Techniques for confirming endotracheal tube placement.

      8. Basic ventilation parameters.

      9. The use of the laryngeal mask airway for primary ventilation and airway salvage.




    1. The resident will demonstrate competence in and detailed knowledge of the following topics:

      1. Airway anatomy and physiology in adults and children.

      2. The pharmacology of commonly used sedative and paralytic agents.

      3. Airway management in trauma.

      4. Airway management in the patient with suspected intra-ocular of intra-cranial injury.

      5. Airway management in children.

      6. Indications for primary and salvage intubation with the laryngeal mask airway (including the intubating laryngeal mask airway).

      7. Familiarity with the combitube SA.


Reading Suggestions:


  1. The text for this course is The Airway Cam Guide to Intubation and Practical Emergency Airway Management, by Rich Levitan MD. This is a short paperback text written by a national leader in the field of airway management. It covers all of the areas germane to the rotation objectives.

  2. The residents will be expected to view the Airway Cam videos. These were also developed by Rich Levitan, M.D. and take the resident through airway anatomy, use of different laryngoscopic equipment, different intubation techniques, and the management of the difficult airway. The total video time is approximately one and a half hours.


Evaluation:

At the end of each rotation, the supervising faculty will complete the evaluation form provided by the Department of EM and will discuss it with the resident. An evaluation of the rotation from the resident will also be solicited. Both of these will be placed in the resident’s folder and reviewed by the residency directors.



CCU
Meeting Place: Emergency Department at SIUH 7:30AM. On the first day of the rotation go directly to the CCU, which is located in the Heart Tower on the second floor.
Schedule: Contact the Luane Shaleesh (ext. 6205) (lshaleesh@siuh.edu with requests as soon as possible. Then contact the Internal Medicine Chief Resident at least 2-3 weeks before the start of the rotation to confirm your call schedule. Overnight call will occur approximately every 3rd night.
Chief resident office: 718-226-9523

In-house page 1295


Lastly, please see Jennifer Cohen (ext. 1548) (jennifer_cohen@siuh.edu) in the Emergency Department prior to the start of you rotation. She will help you with acquisition of an SIUH ID that will allow you to park as well as get around the hospital. For directions to SIUH (driving or ferry) consult the SIUH ED section of the resident handbook.
EM Faculty Liaison: Christopher Doty pager: 917-760-2005
Educational Objectives:

The Coronary Care Unit at SIUH will be the PGY-2 Emergency Medicine Resident’s introduction to the cardiac patient. In this four week rotation the Emergency Medicine Residents will act in the role of a PGY-1 Internal Medicine Resident. They will be providing direct patient care in the CCU. Emergency medicine residents will be supervised by either a senior resident (PGY-3), chief resident, cardiac fellow, pulmonary fellow, pulmonary critical care fellow, hospitalist, intensivist, or a cardiology attending. The Emergency Medicine Resident will attend daily Attending Rounds and all daily lectures with the Department of Internal Medicine.


Day-to-Day Assignments:

  1. Under the supervision of senior residents and the attending teaching staff, the resident is responsible for the care of assigned patients in the CCU.

  2. At 7:30 am the senior and junior residents assigned to the CCU meet in the emergency room to review and accept sign-outs for all the patients admitted to their service the night before by the on-call team. CCU bedside rounds begin at 8:00 am with the cardiologist and are followed by pulmonary rounds with Dr Costellano, which start at 9:15am (1:00 pm on Mondays). You are expected to prepare for rounds by updating yourself on your patients’ overnight courses before the 8:00 am rounds with the pulmonologist.

  3. The resident is responsible for creating daily progress notes (6 days/week), reviewing all recommendations of the clinical staff, writing all orders and developing an ongoing diagnostic/therapeutic plan.

  4. Bedside teaching is accomplished during the interaction with senior residents and with the attending faculty.

  5. During the day and on-call, the residents admit new patients, discharge patients, evaluate change in status, review clinical data, coordinate the treatment plan and perform procedures on their respective patients.


On-Call:

Residents are on call for a 24-hour period, at which point the rest of the team will take over their patients’ care. The on-call residents should finish their work by 7:30 am and must complete their sign-out within three hours and leave the hospital by 10:30 am.


Conferences:

The department of critical care medicine provides the residents with its own assortment of lectures that are prepared by the attending faculty members. This occurs at 12 pm Monday through Friday in the ICU conference room. The lectures span a multitude of important topics related to critically ill patients.


Important Telephone Numbers:

1. ICU 718-226-9250

2. CCU 718-226-9240

3. ER 718-226-9140 / 41 / 42

4. Dr. Maniatis (ICU Director) 718 980 5700
At the completion of this rotation, the Resident should demonstrate competence in and be able to:


  • Perform a comprehensive history and physical examination on cardiac patients (PC, PROF)

  • Develop differential diagnoses for chest pain and cardiac problems, and create cohesive care plans based on these diagnoses (PC, MK, SBP)

  • Manage cardiac patients in an intensive care unit setting (SBP, PC, MK)

  • Make admission, transfer and discharge decisions for patients with cardiac disease and potentially life-threatening illness (SBP, PC)

  • Diagnose and treat supraventricular and ventricular dysrhythmias (PC, MK)

  • Evaluate and treat hypertensive crisis (PC,MK)

  • Evaluate and manage myocardial ischemia (PC.MK)

  • Evaluate and manage acute myocardial infarction and its complications, including wall rupture, valve failure, congestive failure, dysrhythmias and pericarditis (MK, PC, SBP)

  • Evaluate and manage dissecting thoracic aortic aneurysm (MK,SBP,PC)

  • Evaluate and manage hypertrophic cardiomyopathy (MK,PC)

  • Evaluate and manage cardiogenic pulmonary edema (MK,PC)

  • Evaluate and manage class III and IV congestive cardiomyopathy (MK,PC)

  • Evaluate and manage infective endocarditis (MK,PC)

  • Evaluate and manage failed or infective prosthetic heart valves (MK,PC)

  • Evaluate and manage pericardial tamponade (MK,PC, SBP)

  • Evaluate and manage pericarditis (MK,PC)

  • Run a cardiac arrest situation (MK,PC, PROF, COM, SBP)

  • Appropriately utilize thrombolytic therapy and manage its complications (PBL, SBP)

  • Interpret EKG’s quickly and accurately (MK,PC)

  • Appropriately utilize and interpret invasive monitoring (MK, SBP, PC)

  • Utilize laboratory data and ancillary studies appropriately in the care of critically ill patients (MK, PC, SBP, PBL,)

  • Utilize in-patient consultation appropriately (COM, SBP, PROF)

  • Compassionately interact with patients and their families during the stress of illness and death (PROF, COM)


Description of clinical experiences: (MK,PC)

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



  • Advanced Cardiac Life Support

  • Airway management and endotracheal intubation

  • Placement and care of central venous catheters

  • Placement and care of arterial catheters

  • Placement and care of pulmonary artery catheters

  • Utilization of oxygen delivery devices and mechanical ventilators

  • Arterial blood gas sampling and interpretation

  • Exercise stress testing

  • 24 hour ambulatory monitoring

  • Bedside echocardiography

  • Alternative EKG lead placement for the diagnosis of dysrhythmias and infarction

  • Internal and external temporary pacemaker placement


End of Rotation Requirement:

Over the course of your CCU rotation, you will encounter many interesting or novel EKG’s. It is your responsibility to find one interesting EKG and either make a copy of it or scan it electronically and submit it to your residency directors. This EKG will go up on the department’s web site as an “EKG of the Month.” In addition to submitting this EKG, you must also submit a short paragraph discussing the reading of the EKG and why it is interesting or novel. This should not be more than 3 or 4 sentences just stating what the rate, rhythm and axis are plus any other interesting findings noted on the EKG.


Description of didactic experiences: (MK,PC, PBL, SBP)

The following topics should be covered in the Resident’s reading during this rotation:


Chest pain (differential diagnosis of) Coronary artery disease

Hypertensive crisis Dissecting aortic aneurysm

Coronary artery spasm Cardiogenic pulmonary edema

Acute myocardial infarction-diagnosis Treatment of AMI

Myocarditis Pericarditis

Pericardial tamponade Congestive heart failure

Restrictive cardiomyopathy Hypertrophic cardiomyopathy

Congenital heart disease Nitrates/Beta-blockers /Digoxin

Calcium channel blockers Heparin/coumadin

Thrombolytic therapy Pacemakers

Dysrhythmias-supraventricular Dysrhythmias & Anti-dysrhythmics

ACLS protocol Cardiac catheterization

Echocardiography Electrophysiologic studies

Stress testing Nuclear cardiology

Invasive pressure monitoring Intra-aortic assist devices

Heart blocks Wolff-Parkinson-White syndrome

All residents completing an Off-service rotation are required to meet with that rotation’s EM faculty liaison/coordinator for an exit interview in oral exam type format.

This shall serve as an evaluation of the rotation and the fulfillment of the educational expectations.


NICU

Meeting Place: 7 am NS35, NICU, 3rd Floor UHB
EM Faculty Liaison: Dr. Antonia Quinn
Contact : Dr. Gloria Valencia, Director NICU, Vice Chair UHB Clinical Services
Schedule: Email requests to Pediatrics Chief Residents (pedschiefs@hotmail.com)

and Dr. Valencia who makes the NICU schedule (2 months ahead of time)


Educational Objectives:

As a PGY-2, the resident will rotate for four weeks in the NICU in the role of a junior resident. The resident will work under the supervision of an Attending Neonatologist. The resident will also be present at “difficult” or complicated deliveries and gain experience in neonatal resuscitation and stabilization.



  • To become competent in the initial resuscitation of the premature and term neonate during both complicated and routine deliveries.

  • To understand and manage the unique respiratory and nutritional needs of the premature infant.

  • To properly order and interpret laboratory and radiographic tests for the purpose of diagnosis and treatment of the neonate in the intensive care unit.


Clinical Experience:

The resident will demonstrate competence in the evaluation and management of the following neonatal disorders:



  • Esophageal reflux

  • Viral hepatitis exposure

  • Aganglionic megacolon

  • Congenital GI lesions

  • Hernias

  • Malrotation of bowel

  • Pyloric stenosis

  • Dysrhythmias

  • Congenital heart disease

  • Hypoglycemia

  • Neonatal Jaundice

  • Anemias

  • Meningitis

  • Neonatal seizures

  • Hydrocephalus

  • Congenital cysts

  • Bronchopulmonary dysplasia

  • Bacterial pneumonia

  • Perinatal and congenital infections

  • Congenital kidney abnormalities

  • Undescended testes

  • Vaccination

  • Pharyngeal – Tracheal lumen airway

The resident will understand and demonstrate competence in the mechanics of assisted ventilation and the proper methods for monitoring adequate oxygenation:




  • Mechanical ventilation

  • End-tidal CO2 monitoring

  • Pulse oximetry

The resident will demonstrate competence in the following procedures:



  • Umbilical vein catheterization

  • Umbilical artery catheterization

  • Familiarity with chest tube placement in neonates

  • Use of paralytic and sedation agents

  • Orotracheal intubation


Description of didactic experiences:

The resident will attend all educational conferences and meetings while on the NICU Service. The resident will be responsible for the list of suggested readings for the NICU Rotation in addition to any provided by the NICU Service. The resident will be fully incorporated into the NICU Care Team and participate in all rounds, conferences and didactics including Perinatology Conference and Neonatal Morning Report weekly. Attendance at the Wednesday Emergency Department Conferences will be at the discretion of and with the permission of the NICU attending on service if patient care needs allow.


Please see attached rotation description.


ENT

Meeting place: ENT Clinic – U Building 2nd floor
Contact Number: (718) 245-3470
Schedule: 1:00pm until clinic ends (usually 4pm),

weekdays except Thursdays


EM Faculty Liaison: Mark Silverberg

Educational Objectives for ENT rotation:

PGY-2 Emergency Medicine Residents will rotate for two weeks on the Otolaryngology service at Kings County Hospital. (These are the same two weeks you will rotate on the Airway service.) The Emergency Medicine Residents will be integrated into the clinic schedule of the Department of Otolaryngology by the Chairman of the Department of Otolaryngology. The EM Resident will function in the capacity of an Otolaryngology Resident. The resident will see patients in the clinic, in the operating room, as a consultant to the Emergency Department, on the general floors and in the critical care units of the hospital. The Resident will be under the direct supervision of an Otolaryngology Attending Physician, and senior Otolaryngology residents. Residents will attend daily attending rounds, daily educational conferences, and weekly Otolaryngology Grand Rounds. They will also attend all Emergency Medicine Department Conferences and educational events as their patient care schedule allows.


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

· Examination of the head, ears, nose, throat and neck (PC)(MK)

· Normal and abnormal anatomy (MK)

· Management of nasal bleeding (PC)

· Management of trauma to the face (PC)(MK)

· Management of trauma to the ears (PC)(MK)

· Management of trauma to the nose (PC)(MK)

· Management of trauma to the mouth (PC)(MK)

· Management of trauma to the neck (PC)(MK)

· Recognition, identification and management of tumors of the head and neck (PC)

· The evaluation and treatment of hoarseness (PC)

· Management of airway emergencies (PBL, PC, MK)

· Evaluation of acute and chronic hearing loss (MK)

· Evaluation and treatment of the patient with extra-cranial infection of the head including: sinusitis, otitis externa, otitis media, facial cellulitis, Ludwig’s angina, pharyngitis, retropharyngeal abscess, and acute epiglotitis (PBL, MK, PC)

· Evaluation and treatment of infections of the neck (PC, MK)

· Care of the tracheostomy patient (PC, MK, SBP)

· The role of an Otolaryngology Consultant on both emergent and non-emergent patients (SBP, COM, PROF)

· Appropriate admission of patients to the hospital on the Otolaryngology service (SBP, PC, COM)

· Develop the Doctor-Patient relationship as the resident interacts with patients and their families (PROF, COM, PBL)


Description of clinical experiences: (PC, MK, PBL)

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


· Control of epistaxis, including anterior cauterization

· Anterior and posterior nasal packing

· Topical anesthesia

· Laryngoscopy: indirect (mirror)

· Laryngoscopy: direct (fiberoptic nasopharyngolaryngoscopy)

· Management of nasal lacerations

· Management of nasal fractures and other nasal trauma

· Management of injuries to the external ear

· Management of injuries to the middle and inner ear

· Management of common neck wounds

· Incision and drainage of oral, pharyngeal and cervical abscesses
Description of didactic experiences:

The following topics should be covered in the resident’s reading during this

rotation:
Acute hearing loss Sinusitis

Otitis Media Facial Cellulitis

Otitis Externa Ludwig’s Angina

Ear Foreign bodies Salivary Gland Problems

Epistaxis Maxillofacial fractures

Nasal Fractures Odontogenic Infections

Rhinitis Epiglottis

Acute Upper Airway Obstruction Cricothyrotomy

Emergency Tracheostomy Endotracheal Intubation

Post adenotonsillectomy Bleeding Peritonsillar Abscess

Retropharyngeal Abscess Parapharyngeal Abscess

Pharyngitis Upper Airway Foreign Bodies

Ruptured Tympanum Vertigo

Tracheostomy Tracheostomy Tube Placement

Cholesteotoma Mastoiditis

Tumors of the head and neck



SICU

Meeting Place: SICU D3
Contact Number: (718) 245-4522/3982
Daily Rounds: 6:30 am daily
Schedule: The on-call schedule is made by the Department of Surgery. EM residents will have similar call responsibilities as surgical residents

Residents will NOT be required to attend the weekly ED educational conferences
EM Faculty Liaison: Dr. Bonny Baron

Educational Objectives:

PGY-2 Emergency Medicine Residents will spend four weeks in the SICU at Kings County Hospital. The Emergency Medicine PGY-2 resident will function as PGY-2 Surgical Residents. They will have critical care patient responsibilities under the direct supervision of a PGY-4 general surgery resident and general surgery/trauma/critical care attending physicians. While on rotation they will attend daily patient care work rounds and attend daily educational rounds. They will attend the weekly trauma conference.

At the completion of this rotation, the Resident will demonstrate competence in and will be able to:


  • perform initial ICU assessment of critically ill and injured patients using history and physical examinations

  • understand the indication for invasive monitoring and its goals and complications

  • master the principles of shock resuscitation especially as defined by oxygen transport parameters

  • understand the indications and complications of inotropes, vasopressors, preload reducing agents, and afterload reducing agents

  • understand the proposed mechanisms of multiple organ failure including mediators of the inflammatory response and therapies designed to modulate this response

  • understand the modifications necessary in resuscitation of patients with closed head injuries

  • master the indications for, and use of mechanical ventilators including the ability to wean a patient from a ventilator

  • understand the indications for and use of enteral and parenteral nutritional support

  • identify the signs and symptoms of early sepsis and the work-up necessary for full investigation

  • understand the rationale for antibiotic use in the Intensive Care unit: prophylactic and therapeutic

  • assess renal function in critical illness, including the use of creatinine clearance, free water clearance and fractional excretion of sodium as diagnostic tools

  • understand the evaluation of hepatic function in critical illness

  • manage life threatening gastrointestinal bleeding

  • mange drainage tubes

  • understand the mechanism and treatment of common coagulopathies associated with organ failure in critical illness

  • compassionately interact with patients and their families during the stress of illness and death, including the ability to obtain DNR orders


Description of clinical experiences:

Residents demonstrate competence in the following procedures on this rotation:



  • Cardiopulmonary resuscitation

  • Airway management and endotracheal intubation (nasal and oral)

  • Management of ICP monitors and ventricular drains

  • Placement and care of central venous catheters

  • Placement and care of arterial catheters in all sites

  • Placement and care of pulmonary artery catheters

  • Utilization of oxygen delivery devices and mechanical ventilators

  • Lumbar puncture

  • Obtaining cultures from all sites and tissues

  • Placement of enteral feeding tubes

  • Arterial blood gas sampling and analysis

  • Abdominal paracentesis

  • Thoracentesis

  • Tube thoracostomy

  • Placement of esophageal/gastric balloons

  • Assisting in performance of peritoneal dialysis and continuous A-V hemofiltration

  • Assisting in endoscopic examination of the upper and lower GI tracts


Description of didactic experiences:

The residents will attend daily, weekly and monthly surgical/critical care/ trauma conferences.

The following topics should be covered in the resident’s reading during this rotation:
Airway management ACLS

Mechanical ventilation High frequency ventilation

Interpretation of invasive monitoring ARDS

Post-operative management Wound management

Pneumonia A-V hemofiltration

Blood product usage Super-infection

Broad spectrum antibiotics Acute renal failure

Hemodialysis/peritoneal dialysis Gastrointestinal hemorrhage

Intracerebral bleeding/CVA Hepatic encephalopathy

Shock Sepsis

Uremic encephalopathy Anticoagulant therapy

Pulmonary embolism Coma/brain death examination

Cardiogenic pulmonary edema Dysrhythmias

Fever Acid base derangements

Electrolyte abnormalities Nutrition: parenteral and enteral

Disseminated intravascular coagulation Hemolysis

Sedation Drug induced paralysis

Core Competencies addressed in this rotation

Patient Care


  • Mastering surgical resuscitation.

  • Experience with longitudinal care of the trauma patient

  • Experience with the complications of severe fractures

  • Experience with the complications of severe thorax injuries

  • Experience with the complications of severe vascular injuries

  • Experience with the complications of severe head injuries

  • Experience with the complications of multi-organ dysfunction

  • Post-operative care of the critical patient

  • Ventilator Management


Medical Knowledge

  • Learning and avoiding common errors in surgical critical care

  • Gaining an understanding of the unique issues pertinent to surgical patients

  • Gaining an understanding of the unique issues pertinent to post-op patients

  • Pain control strategies

  • Cognitive mastery of emergent trauma care

  • Ventilator weaning protocols and procedures


Interpersonal and Communication Skills

  • Working with surgical, trauma, orthopedic, nutrition, rehab, neurosurgical and medical professionals

  • Working with respiratory, Social Services, PT ancillary services

  • Integration into an ICU team with critical injuries

  • Patient/family communication and comfort


Professionalism

  • Integration into an surgical critical care team

  • Pain Management


Systems-Based practice

  • Integration into the ancillary services of Social Services, discharge planning, utilization review, OT and PT.

  • Admission and transfer criteria for critical surgical patients


Practice Based Learning and Improvement

  • Participate in CQI system of surgical department

  • Participate in trauma/surgical M&M case conferences

  • Maintain resident portfolio

NEUROLOGY
Meeting place: SIUH hospital, Third floor, East side (3E). The “Neuro floor”
Contact Number: (718) 683-3766
Daily Rounds: 8 am
Responsibilities: Morning report with Dr. Najjar or one of the neurology faculty. Go to see the daily neurology consults for all in house and emergency department patients.
EM Faculty Liaison: Dr. Mark Silverberg Cell: 917-822-4510

Educational Objectives:

PGY-2 Emergency Medicine Residents will rotate for two weeks on the Neurology service at SIUH. They should be there at 8am on Monday, Tuesday, Thursday and Friday. Wednesdays they are to show up for the regular EM conference at Kings County Hospital at 7am. While rotating at SIUH, residents will work under the direction of the Neurology Attending staff as part of the Neurology consultant team.


Each day that the residents are at SIUH on the neurology service, they should attend the interactive morning report conducted by the Neurology Attending Staff. In addition, the EM resident will attend all Department of Neurology conferences and educational events.
At the completion of this rotation the resident will demonstrate competence in the following concepts:

  • Performance of a comprehensive neurologic history and physical exam. (MK,PC)

  • Development of an integrated problem list for patients, including detailed differential diagnoses. (MK,PC)

  • Learn to localize neurological lesions in the CNS after performing a comprehensive neurological history and physical examination. (MK,PC)

  • Management of the neurologic manifestations of AIDS. (MK,PC)

  • Management of different types of headache. (MK,PC)

  • Management of stroke; ischemic and hemorrhagic. (MK,PC)

  • Evaluation and treatment of the Transient Ischemic Attack. (MK,PC)

  • Management of the seizure patient. (MK,PC)

  • Management of multiple sclerosis exacerbations. (MK,PC)

  • The evaluation and treatment of pseudotumor cerebri. (MK,PC)

  • The evaluation and treatment of neuro-muscular diseases. (MK,PC)

  • Management of the neurologic manifestations of diabetes. (MK,PC)

  • Diagnosis and management of patients with CNS infections. (MK,PC)

  • Basic Head CT and MRI interpretation. (MK,PC)

  • Development of the Doctor-Patient relationship as the resident interacts with patients and their families during the stress of illness and death. (PC,C,P)



Description of clinical experiences:

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

· Lumbar puncture

· Electroencephalography

· Electromyography

Description of didactic experiences:

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


Cerebral aneurysm Arteriovenous malformation

Hemorrhagic stroke Ischemic stroke

Vertebro-basilar insufficiency Transient ischemic attack

Subarachnoid hemorrhage Bell’s palsy

Trigeminal neuralgia Amyotrophic lateral sclerosis

Neuro-intubation Multiple sclerosis

CNS abscess Meningitis/encephalitis

Myelitis Neuritis

Guillain-Barré Syndrome Myasthenia gravis

Peripheral neuropathy Spinal cord compression

V-P shunts Headache

Pseudotumor cerebri Normal pressure hydrocephalus

Seizure disorders Anti-seizure medication

EMG EEG


Head CT and MRI evaluation Brain death and its examination

Emergency Orthopedic/Fast Track Rotation - Handbook
Orthopedics is a major component of the daily cases seen by Emergency Medicine physicians. The goal of this rotation is to increase orthopedic exposure to the emergency medicine residents so that they feel comfortable managing various orthopedic emergencies.
The rotation is 4 weeks spent in the fast track emergency department at Kings County Hospital. The resident is to evaluate every orthopedic emergency case that comes through the emergency department in addition to seeing fast track cases. Residents are allowed to cherry pick orthopedic cases from the call to treatment list. When orthopedic cases are identified in Suite A and B, Fast track by other ED attendings or residents, the ED orthopedic resident will be paged (there is an orthopedic pager – pick it up from Stephanie or the previous resident on Ortho). If there are no orthopedic cases (fractures/sprains), the resident should see musculoskeletal cases. If there are no orthopedic or musculoskeletal cases the resident should see regular fast track cases.
Every orthopedic case and procedure must be placed in the residents’ personal logbook, which will be collected at the end of the rotation and must be turned in prior to the exam.
If the orthopedic case requires surgical intervention, admission, requires additional assistance or is beyond the scope or comfort of the Emergency Medicine attending, the orthopedic resident should be called. When able to, the ED orthopedic resident should be the one calling the orthopedic resident for the consult.
Emergency Medicine residents should also see pediatric orthopedic cases; however, the orthopedic resident should be called to see these cases as well.
On days when the emergency medicine resident is working during the day, the resident is to also go to morning orthopedic surgery resident rounds to go over the patients that were formally consulted the previous day. Be prepared.
The resident work schedule is the following:

Monday and Tuesday 6a-6p (Morning report is at 6am in C – 3 and you are required to be there)

Thursday and Friday 11a-11p (no morning report on these 2 days)
Contact Dr. Gore prior to the start of your rotation –

Robert.gore@downstate.edu or 312-399-3451
Orthopedic Examination Required Reading


  1. General Principles of Orthopedic Injuries (from Rosen’s) – a copy will be provided for you

  2. Ankle and Foot – (from Rosen’s). A copy will be provided for you

  3. Injury to the Hand and Digits – Tintinalli p1665-1674

  4. Wrist Injuries – Tintinalli p 1674-1684

  5. Injuries to the Shoulder Complex and Humerus – Tintinalli p1695-1702

  6. Knee Injuries – Tintinalli p1726-1734

  7. Leg Injuries – Tintinalli p1734-1736

On the last Wed conference of the block (before you switch) at 7am, the residents will have a closed book examination. A passing grade will be 80% or above. The exam will consist of multiple-choice questions and five essays. The essays will consist of interpretation of orthopedic x-rays, including injury complications, correct orthopedic fracture nomenclature and management of these various injuries. It should take ~1 hour to 1 ½ hours to complete the entire exam.


PGY-3 OFF SERVICE ROTATIONS


EMS


Toxicology
Ultrasound
Research

EMS
Contact:


EMS – FDNY

Dr. Bradley Kaufman

(718) 999-1872


Faculty Liaison:

Olethea Wernersbach

(scheduling)


Contact:
Christopher Doty, MD

(718) 281-8463

((917)760-2005





















Educational Objectives:

The EMS rotation will provide a general exposure to the medical, regulatory, legislative, administrative, political, and organizational aspects of pre-hospital care. By completion of this rotation, the resident will have developed the basic groundwork for understanding the structure and function of Emergency Medical Services. The resident will spend two weeks on this rotation. The base for the rotation will be the Fire Department of the City of New York. The Emergency Medicine Resident will accompany EMTs and Paramedics on ambulance runs. This will be supplemented with experience at the FDNY on-line medical control center and at the EMS academy where residents will participate in Paramedic and EMT training. Residents will be under the direct supervision of the Medical Directors at the Fire Department’s Office of Medical Affairs.


At the completion of this rotation the Resident will demonstrate competence in the following concepts:

  • The history and development of EMS(MK)

  • The political forces which impact on EMS(SBP)

  • Hospital and departmental categorization(SBP)

  • The principles of disaster management and preparedness(MK)

  • The training of prehospital personnel(C,P)

  • The role of the Emergency Physician and Department in the training of pre-hospital personnel(P,C,PBL)

  • The contributions of the various participants in an EMS system(MK,P,C)

  • The various organizational structures of EMS systems(MK,SBP)

  • The concepts of medical control(MK,SBP)

  • The various EMS protocols and their applications(MK,SBP)

  • The principles of EMS communication and 911(MK,SBP,C)

  • Fiscal and regulatory issues related to EMS(MK,SBP)


Description of clinical experiences(MK,PC)

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



  • Assessing scene safety

  • Functioning as off-line medical control

  • Functioning as on-line medical control

  • Providing medical care in the pre-hospital environment; including procedures as:

  • Extrication

  • Immobilizations and spine injury precautions

  • Airway management in the field

  • Vascular access in the field


Description of didactic experiences: (MK,PC,SBP)

The following topics should be covered in lectures or readings during this rotation:

A. Overview

1. History of EMS

2. National, state, and local

3. Various types of service

4. Level of care

5. Volunteer vs. hospital based vs. city/county based vs. commercial

B. Fiscal Aspects of EMS

1. Costs and resources, billing

C. Organizational Aspects of EMS

1. Levels of EMT training and skills; fire, police, MD, administrators

2. Equipment and vehicles

3. Local, state, and federal regulations

4. EMS Medical Director

5. Development of 911

6. Receiving and dispatch

7. Communications and telemetry systems

8. Field triage

9. Interface with other services (police and fire)

D. Categorization and designation of hospitals and hospital services

E. Medical Control

1. Centralized vs. decentralized

2. The role of the Medical Director

3. The role of the Emergency Physician

4. Development and implementation of protocols

5. On-line and off-line medical control

6. Call review and CME for the prehospital provider

F. Air Transport Systems

G. Disaster Planning and Management

1. Planning for prehospital disasters

a. The EMS role

b. The hospital role

2. Special disasters

a. Biological

b. Chemical

c. Radiation

H. Education

1. CPR

2. EMT


3. AEMT

4. EMT-P


5. First aid and first responder training

6. Public education

I. The Role of EMS in Public Education

1. Issues of organization

2. Issues of medical treatment and level of care


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