Clinical Curriculum

Overview

FIRST YEAR CLINICAL CURRICULUM

The first-year fellow spends approximately four months in the Pediatric Emergency Service; three of these months are dedicated exclusively to the Pediatric Emergency Service. Additional time in the PEM occurs during other rotations. One month each is spent in the Pediatric Critical Care Unit at LPCH, the Department of Anesthesiology at LPCH, the Adult Emergency Service at Stanford University Hospital Center. One month elective time is completed at San Francisco Division of the California Poison Control Service. The first-year fellows participate in a didactic orientation series that is combined with fellows from the Pediatric Critical Care Fellowship at LPCH covering core topics such as rapid sequence induction, procedural sedation and essential procedural skills and are exposed to a variety of clinically oriented conferences throughout the year.

SECOND YEAR CLINICAL CURRICULUM

The second-year fellow spends approximately five months in the Pediatric Emergency Service (PEM). It is expected that the second-year fellow will take on an increased responsibility for leadership in the PEM under the supervision of the faculty. One month each is spent in the Emergency Service at Santa Clara Valley Medical Center. Two weeks are spent with the San Mateo Bureau of Emergency Medical Services. One month of elective time is completed. The second-year fellow is involved in a variety of clinically oriented conferences throughout the year. 

THIRD YEAR CLINICAL CURRICULUM

The third-year fellow spends approximately five months in the Pediatric Emergency Service (PEM). It is expected that the third-year fellow will demonstrate the skills necessary to independently manage the PEM. One month is completed in the Adult Emergency Service either at Stanford University Hospital or at the Kaiser Permanente Medical Center – Santa Clara. One month of elective time is completed. The third-year fellow is involved in a variety of clinically oriented conferences throughout the year.

Goals and Objectives

CLINICAL CURRICULUM – FELLOW 1,2,3

COMPETENCY* 

Goal

To develop an evidence based approach to the care of patients presenting to the emergency department with both common and life-threatening disease processes and chief complaints

 

Objectives

Utilize an understanding of the pathophysiology of disease in clinical decision making

MK1

 

Utilize an understanding of the epidemiology of disease in clinical decision making

MK1

 

Perform a directed history and examination

PC1

 

Select and interpret appropriate laboratory tests

PC4

 

Select and interpret appropriate radiologic tests

PC4

 

Arrive at a presumptive and alternative diagnoses

PC6

 

Describe initial management priorities

PC2

 

Describe appropriate use of consultants

ISC3

 

Describe appropriate disposition and referral

PC3,8

 

Use appropriate monitoring techniques

PC7

 

Utilize information resources to evaluate and improve care.

PBLI1

 

Conduct oneself in a respectful, professional, ethical manner

PC3

 

Demonstrate self-confidence, flexibility and maturity

PROF3,5

 

Demonstrates awareness of limits, continuous improvement and ability to deal with uncertainty

PROF1,2

 

Participate in the detection and critical evaluation of medical errors

SBP2

 

Advocate for patients experiencing difficulties with the health care system

SBP1,

PC4

Goal

Develop competency in cardiopulmonary resuscitation

 

Objectives

Recognize and manage airway compromise

PC5

 

Recognize and manage respiratory distress and failure

PC5

 

Recognize and manage shock

PC5

Goal

Develop competence in commonly performed emergency procedures

 

Objectives

Describe indications and contraindications

 
 

Describe equipment and monitoring needs

PC9,10

 

Describe anatomic approach and technique

PC9,10

 

Recognize and manage complications

PC9,10

 

Obtain informed consent

PC9,10

Goal

Learn the skills necessary to prioritize and manage the emergency care of multiple patients

 

Objectives

Demonstrate the ability to prioritize the simultaneous care of multiple patients

PROF4
 

Interact with patients and families in an ethical, professional manner which takes into the accounts the stresses associated with acute illness, injury and death

PROF3,4

ICS1,2

 

Communicate and collaborate effectively as part of a health care team

ISC3

 

Describe key aspects of the health care system that impact patient care

SBP1

Goal

To facilitate the learning of medical students, residents, nurses and consultants in the clinical environment.

 

Objectives

To provide one on one education and consultation in the care of an individual patient

PROF4, ICS3
 

Provide feedback to learners

PC11 

MK – Medical Knowledge,

PC - Patient Care 

P - Professionalism

PBL - Practice Based Learning and Improvement 

ISC - Interpersonal Skills and Communication

SBP - Systems Based Practice 

Core Content

An extensive listing of the pediatric emergency medicine core content as well as a percentage breakdown for content areas for the certification examination may be found on the American Board of Pediatrics web site at http://www.abp.org.

(Click on Certification Then Subspecialty Policies then Content Outlines for Subspecialty Certifying Exams.) In addition to the topics outlined in the core contents, the fellow should be able to evaluate an undifferentiated chief complaint.

Procedural Skills

The development of appropriate procedural skills and the ability to teach these skills are essential components of both the clinical and teaching curriculums. Procedural skills workshops, simulation scenarios, participation in advanced resuscitation courses and a variety of clinical experiences provide the fellow with the opportunity to develop and teach these skills.

PROCEDURE DOCUMENTATION

Documentation of experience with these skills is essential for board eligibility and credentialing in many circumstances. The American Academy of Pediatrics requires registrants to the Pediatric Emergency Medicine Board Exam to complete a procedures performed questionnaire. In addition, many institutions now require documentation of procedural skills in order to apply for faculty positions. Each fellow on entering the program will use the web based New Innovations or smart phone application to assist in documenting these requirements.

The ACGME has specifically requested tracking of resuscitations independent of specific procedures. I have separated these into TRAUMA and MEDICAL resuscitations and have further categorized them by age as: < 2 years, 2-18 years and > 18 years

The ACGME provides the following definition of resuscitation:

  • 1. Cardiac and respiratory arrest
  • 2. Respiratory distress requiring intubation
  • 3. Shock requiring large amounts of intravenous fluids or vasopressors,
  • 4. Status epilepticus requiring airway management,
  • 5. Multi-system trauma requiring a coordinated evaluation, intravenous access and airway control, etc.

MONITORING THE ACQUISITION OF PROCEDURAL SKILLS

Each trainee is observed directly by the Pediatric Emergency Medicine faculty or rotation coordinator during each rotation. Performance of procedures is emphasized as a goal of each rotation. All procedures are recorded in the fellow’s procedure log (via MedHub) and are reviewed by the program director semi-annually.

Procedure skill performance is also assessed during teaching of Advanced Pediatric Life Support courses and during division procedure skill workshops. The fellows also participate in outside workshops such the LPCH PICU bootcamp course, advanced airway course and ultrasound course. Procedures performed during skills workshops, simulation scenarios, resuscitations and simulations should be documented as well. This is particularly true for uncommon procedures (see table below). The ultrasound curriculum is discussed separately after the procedures list.

Required Procedures

AIRWAY

NEUROLOGY 

Artificial Ventilation*

Lumbar Puncture* 

Cricothyroidotomy/Transtracheal Ventilation

OBSTETRICS 

Endotracheal Intubation*

Vaginal Delivery 

Tracheostomy Tube Replacement

ORTHOPEDIC 

ANESTHESIOLOGY

Arthrocentesis 

Regional Anesthesia*

Closed Reduction – Simple fracture/dislocation* 

Procedural Sedation*

Splint Placement* 

Rapid Sequence Intubation*

RESUSCITATION 

CARDIOLOGY

Medical < 2 years* 

Cardiac Pacing - External

Medical 2-8 years* 

Cardioversion/Defibrillation

Medical > 18 years 

Supraventricular Tachycardia Conversion*

Trauma < 2 years* 

Pericardiocentesis

Trauma 2-8 years* 

ENT

Trauma > 18 years 

Foreign Body Removal*

SURGERY 

INTRAVENOUS ACCESS

Abscess Incision and Drainage* 

Arterial Catheterization

Gastrostomy Tube Replacement* 

Central Venous Catheterization

Laceration Repair* 

Intraosseous Access*

Tube Thoracostomy and Needle Decompression 

Umbilical Vessel Catheterization

Pediatric emergency physicians need to perform procedures necessary for the practice of this subspecialty. PEM physicians must also recognize the need for and consult subspecialty services when patients require procedures that fall outside their scope of practice.

*Indicates procedures commonly performed in the practice of pediatric emergency medicine. This list is not meant to be all-inclusive and given the changing nature of PEM practice this list 38 should be revised periodically. Point of care ultrasound is an example of a procedure that is established practice in emergency medicine but not yet in PEM.

Other procedures are uncommon in the daily practice of PEM but physicians should have a working knowledge of how to perform them. Simulation training may be the primary method for PEM physicians to learn and practice these procedures.

Ultrasound Curriculum

Point-of Care Ultrasound has become a standard of care in the emergency department. The availability of ultrasound equipment in the ED and appropriately trained and certified physicians has been shown to: expedite patient care, provide rapid bedside diagnosis, guide to management and aid physicians in performing procedures increasing safety and reducing adverse events. Point of care ultrasound is integral part of emergency medicine residency training and is quickly becoming an essential component of PEM fellowship education.

GOALS

To develop skills in obtaining high quality images while performing point-of-care ultrasound that will serve as a foundation for diagnostic interpretation and therapeutic interventions
 

OBJECTIVES

To understand the basic principles of emergency ultrasound

To become familiar with ultrasound equipment and technology

To understand the clinical indications for emergency ultrasound

To develop competence in ED ultrasound applications. (see below)

To understand the limitations of emergency ultrasound
 

DIAGNOSTIC APPLICATIONS

ABDOMINAL
E-Fast – Intra-abdominal hemorrhage in the trauma patient

Renal - Hydronephrosis in renal colic

RUQ – Cholelithiasis, cholecystitis in abdominal pain

Inferior vena cave/Aorta ratio – Volume status, guide fluid resuscitation

RLQ – Appendicitis

General – Intussusception

CHEST

E-Fast – Pneumothorax, hemothorax, hemopericardium

Limited echocardiography – LV function, pericardial effusion

Pulmonary – Pneumonia, bronchiolitis, pleural effusion

MUSCULOSKELETAL/SOFT TISSUE

Long bones - Fractures

Hips - Joint effusion

Cutaneous – Cellulitis, abscess, foreign body identification

OB/GYN
Evaluation of intrauterine pregnancy in first trimester
 

PROCEDURAL APPLICATIONS

Peripheral and central venous line placement

Bladder ultrasounds prior to catheterization

Identification and removal of soft tissue foreign bodies

Abscess incision and drainage

Pleural effusion drainage

DIDACTIC CURRICULUM

Ultrasound education is provided on a continuous basis via lectures, workshops, hands-on sessions and one-on-one sessions with ultrasound faculty, independent scanning sessions and formal monthly image review.

In the beginning of their 1st year, fellows participate in an intensive US seminar with formal lectures on: the physics of ultrasound, knobology, scanning techniques for all major applications and hands-on session on commonly used applications such as E-FAST, TVUS, PVL/CVL placement, foreign body identification and limited cardiac echo.

PEM fellows are required to do a 2-week ultrasound elective. All fellows are also given the opportunity to get credentialed for all applications listed above based on the published ACEP guidelines. The department of Emergency Medicine has an ultrasound fellowship program and the conferences and teaching experiences are available to our fellows.

TRAINING EXPECTATIONS

1ST YEAR FELLOWS

Extended FAST

Early pregnancy - Transvaginal ultrasound for detection of IUP 

Soft tissue US – Identification of abscess, cellulitis

Procedural guidance – PVL, bladder catheterization, abscess incision/drainage

Volume status assessment

2ND YEAR FELLOWS 

Musculoskeletal US – Detection of fractures and joint effusion

Procedural guidance – CVL placement, Foreign body identification and removal

Renal US – Hydronephrosis

RUQ US – Cholelithiasis, cholecystitis 

3RD YEAR FELLOWS

Limited cardiac echo

Evaluation for intussusception, appendicitis, pyloric stenosis

Lung US

CREDENTIALING

Currently credentialing is based on the ACEP guidelines: 25 high quality studies with all required views for each application, which will be reviewed and credited on a monthly basis by the ultrasound faculty. The emergency medicine applications based on ACEP are: E-FAST, renal, gallbladder, 1st trimester pregnancy, cardiac echo, deep vein thrombosis, and abdominal aortic aneurysm. You are credentialed independently for each application.

RESOURCES

There are a number of web sites that provide excellent instruction

NYU/Bellevue Department EM ALEX Site https://alex.med.nyu.edu/portal/

Ultrasound Guide for Emergency Physicians http://sonoguide.com/introduction.html

Department of EM Vanderbilt University http://learn-us.vanderbiltem.com/

ACEP main ultrasound website http://www.sonoguide.com/introduction.html

ACEP Ultrasound Testing Site http://www.emsono.com/acep/ACEP_EUS_Exam.html