Emergency Medicine

The Emergency Medicine Rotation

Description

Unlike other block rotations, the Emergency Medicine rotation combines facets of all subspecialties while focusing on acute care management and critical care, improving differential diagnosis insight and skills, and coordinating inpatient and outpatient healthcare with primary care providers and other services. In addition, the Emergency Medicine rotation provides a great deal of primary care services for members of the Stanford medical community.

The Emergency Department of Stanford Medical Center is prepared and equipped to provide comprehensive emergency care to patients of all ages in consultation with the center’s medical and surgical specialties. The American College of Surgeons has re-verified the Stanford Emergency Department as a Level I Adult & Pediatric Trauma Center - the highest level possible. Stanford University Medical Center is the only trauma center in our county with this designation and verification; and serves as a regional trauma center for northern and central California, as well as adjacent states.

Orientation to the Emergency Department

Residents rotate through the Emergency Department on 12 hour shifts; working directly with an Emergency Medicine senior resident and attending physician.  An orientation video for new interns/residents to the department is located on the Emergency Medicine website http://emed.stanford.edu

The Emergency Department is divided into three sectors: the front, middle, and back halls.  Shifts in the front hall consist primarily of critical care, trauma, and acute medical/surgical and psychiatry beds; and in the middle hall consist of urgent care, obstetrics/gynecology, ENT, and orthopedics.  The back hall consists primarily of pediatric emergency medicine and although internal medicine residents do not rotate in this sector they can, and are encouraged to, cover these patients with the emergency medicine faculty.  An online orientation handbook specific to pediatrics is available through the Pediatric Emergency Medicine website http://pem.stanford.edu.

Contacts:

Phillip M. Harter, MD
Program Director
Emergency Medicine Residency
Alway Building - M121
Office: (650) 723-9215
Fax: (650) 723-0121

Resident Role & Expectations During Rotation

Residents are expected to be present on time for their scheduled shifts to take over care of those patients whose work-up and management is in progress; as well as start the evaluation and treatment of new individuals who present to the department during their shifts. 

Residents are expected to write-up complete and accurate history & physical exams, review old patient records when available, to confirm medication profiles with patients and families, and to assist primary care providers in the care of their patients. 

Residents are expected to share the burden of patient load in a fair manner with their cohorts and inform the attending physician on duty of any difficulties that might be arising.

Residents are expected to interact with physicians of different services in a collegial manner and make them selves available to assist in providing the best care for patients and their families.

Residents will be expected to develop more detailed differential diagnoses and streamlined work-up and treatment plans as they advance from PGY1 to PGY3 in their respective residency programs.

PGY1 residents will be expected to report to and discuss their treatment plans with the senior resident on duty; while PGY2 and PGY3 residents will be expected to function independently and report directly to the Emergency Medicine attending on duty.

Level of Supervision

One or more Emergency Medicine attending physicians is in the Emergency Department at all times and is immediately available to the residents.  Senior Emergency Medicine residents and Fellows are also available most hours of the day to assist the residents in their patient care plans and dispositions.  It is not unusual to have Community Attending Physicians and Staff Attending Physicians from other services in the Emergency Department to assist in the urgent care of shared patients; and for them to educate students and residents on acute care within their subspecialty.

Educational Goals & Learning Objectives

Goal 1: To develop improved and more streamlined diagnostic approaches, clinical evaluations, and differential diagnoses of disease and correlate history and physical exam findings with disease patterns.

Goal 2: To develop the attitudes, knowledge, and skills for competent care of injured and/or infirmed individuals of all ages, socioeconomic statuses, and ethnic backgrounds; including disease prevention, recognition of disease presentation, and promotion of optimal health habits. 
 
Goal 3: To learn basic procedural skills such as wound care, suturing, and splinting; as well as advanced skills such as fracture management, central venous lines, acute airway management, and resuscitation.

PATIENT CARE & MEDICAL KNOWLEDGE

A. Patient Care:
Objective 1: Demonstrate clinical skills of medical, surgical, and psychiatric history and physical examination; including competency in developing a comprehensive differential diagnosis of illness.

Objective 2: Demonstrate clinical skill in the diagnosis and management of both acute and chronic illnesses in patients including competency skills in needs assessment for severity of disease, its management, and needs assessment upon discharge to home, inpatient hospitalization, or to a skilled nursing facility.

Objective 3: Demonstrate clinical skill and competency in medical management of patients for safe and appropriate discharge planning, including arranging follow-up care, contacting appropriate follow-up services to coordinate outpatient care, and social services involvement of those patients without defined PCPs or social/family support.

B. Medical Knowledge:
Objective 1: Embrace opportunities to see the entire spectrum of the aging process from pregnancy and its complications, to newborn care and pediatrics (not required but recommended) to adolescent and adult care, geriatrics, and cross specialty health conditions. 

Objective 2: Evaluation and treatment of multiple medical and surgical conditions; including appropriate testing and imaging; laboratory and radiographic interpretation, pharmaceutical management, and sub-specialty consultations where indicated.

Objective 3: Describe common presentation of illnesses, and responses to therapy; including the pharmacokinetics and pharmacodynamics of common medical treatments.

Objective 4: Preventive care, including primary and secondary interventions with special emphasis about iatrogenic complications and prevention.

Objective 5: Recognize the legal requirements for psychiatric holds, inter-facility transfers, surgical and procedural consents, and advanced directives and describe the process to patients, families, and/or their legal representatives.

PROFESSIONALISM: INTERPERSONAL & COMMUNICATION SKILLS

A. Professionalism
Objective 1: Demonstrate respectful and compassionate use of medical skills for all individuals. This includes the utility of high-quality care and technology and, in the event of terminal illness, an awareness of the limits of medical intervention and the obligation to provide humane care.

Objective 2: Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, sexual orientation, and/or disabilities.

B. Interpersonal & Communication Skills
Objective 1: Communicate clearly when writing medical orders and when giving verbal orders with attention to language. Avoid abbreviations as per hospital policy.

Objective 2: Communicate clearly, audibly, and with respect when speaking to patients and families with attention to language, and tone. Avoid medical jargon. Utilize hospital interpreter services in all cases where language or cultural factors may influence patient care.

Objective 3: Create a positive relationship with the patient and family to assure optimal medical care, assuring the emotional and cultural needs and expectations of all patients.

Objective 4: Participate and work effectively with others on interdisciplinary and/or multidisciplinary services to promote optimal patient care.

Objective 5: Work professionally with nursing and ancillary staff to promote optimal patient care.  Document and verbalize all orders and obtain an understanding of one’s request from the nursing/ancillary staff.  Communicate effectively with primary care providers concerning their patients’ clinical presentations, assessments, conditions, and disposition planning.

TEACHING METHODS/SETTINGS

Emergency Department Faculty Teaching: Residents rotate through the Emergency Department on 12 hours shifts; working directly with an Emergency Medicine senior resident and attending physician.

Didactic Lectures:  Morning didactic lectures are prepared by the Emergency Medicine faculty.  Due to the nature of Emergency Medicine and the flow dynamics in the emergency department, it can often be difficult to complete planned formal didactic sessions.  However, short case presentations and discussions are the norm throughout the rotation. 

Core Curriculum Conferences: Lectures are held every Wednesday morning from 8:00am to 12:00pm that follow a 12 month core curriculum. Lectures and workshops are conducted by residency faculty, visiting faculty, and emergency medicine residents. Joint lectures with other training programs, such as radiology, pediatrics, surgery, and internal medicine, are also a part of the core curriculum. Grand Rounds are held monthly.

Journal Club:  Journal club is held one evening a month in an informal setting: either the home of a faculty member or a local restaurant. Emphasis is placed on learning how to critically read medical literature and foster discussion between residents and faculty, as well as to find current research that may change one’s practice. Journal clubs may be theme-based, joint meetings with other programs such as pediatrics, or reviews of a variety of recent articles.

Recommended Readings:
Mahadevan SV, and Garmel GM:  “An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department”  Cambridge University Press, 2005.

Tintinelli JE, Kelen GD, and Stapczynski, JS: “Emergency Medicine: A Comprehensive Study Guide, 6th Edition”  McGraw-Hill, 2003.

Educational Resources:
Educational resources and guidelines are available throughout the Emergency Department to assist residents in their patient evaluations and managements.  A fully stocked reference library is present in the attendings’ office and online references are available via the internet with services provided by the Stanford School of Medicine and the Lane Medical Library.  In addition, the main Emergency Medicine website: http://emed.stanford.edu/ has links to a multitude of medical resources and educational programs for the residents to explore.

ASSESSMENT METHODS

ACGME Competencies

According to Accreditation Council of Graduate Medical Education (ACGME), training and evaluation must include the following competencies: Patient Care, Medical Knowledge, Practice – Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and System-Based Practice.

Patient Care will be evaluated by global assessment of the attending physicians and additional information from nursing staff. Procedures performed will be documented.

Medical Knowledge will be evaluated by global assessment of the attending physicians, and chart audits.

Practice-Based Learning & Improvement will be evaluated by chart audit.

Interpersonal & Communication Skills will be evaluated by global assessment of attending physicians and additional information from nursing and ancillary staffs, patients and families.

Professionalism will be evaluated by global assessment of attending physicians and additional information from nursing and ancillary staffs, co-residents, patients and families.

System-Based Practice will be evaluated by global assessment of attending physicians, and chart audit.

The evaluation method is primarily accomplished electronically. Residents' performance in Emergency Medicine is evaluated by the attending physician and Emergency Medicine Chief Residents. Daily patient log sheets are completed by students and rotating pediatric residents. They are available to the internal medicine residents as well to assist in tracking patients and completion of procedure logs.  Evaluations may be reviewed with the residents for formal feedback. Face to face interaction between the attending physician and the resident is an option. At any point of the rotation, the resident is encouraged to approach the attending physician that they have worked with primarily to assess and discuss performance. In addition, ongoing feedback is provided related to residents’ patient care responsibilities and activities.

Residents will provide documentation of the Emergency Medicine rotation in MedHub, e.g. procedures performed, attending staff evaluations, rotation evaluation.

 

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