4th year Medical Student Emergency Medicine Rotation

WELCOME TO LOUISVILLE

Table of Contents

Left Click on any of the headings below to link to that slide or series of slides , you may easily return to the Table of Contents by simply left clicking on and slides title Study Guide Welcome Hospital Policies Introduction to EM The Department Orientation Triage Scheduling and Attendance Room 9 Student Roles and Responsibility Main Department Typical Student Shift X-ray Didactics EPS Resources and Reading First Care Important Names and Numbers Evaluation Louisville Info

Welcome
Welcome to the University of Louisville Department of Emergency Medicine! Founded in 1971, we are one of the oldest programs in the country. Here you will find an atmosphere that promotes clinical excellence and education through collegiality among the residents, attending physicians and staff. Our stability is rooted in dedicated faculty, institutional support and the recruitment of fun, energetic, and hardworking residents that thrive in the setting of autonomous yet supervised practice. It is this approach that hones our residents clinical and decision making skills well prior to their graduation.
Again, welcome. Prepare to work hard, study, and to learn skills that you can use throughout your career.

Introduction to EM
Emergency Medicine is a fun, fast paced, fluid and exciting specialty. We treat whatever may show up at the door. You will have the opportunity to provide critical, surgical, medical, gynecological, obstetrical, psychiatric, and even palliative care to a wide range of patients. Procedures abound in the emergency department and you are invited to participate. Frequently, we perform trauma and medical resuscitations, FAST scan ultrasounds, central venous line placements, tube thoracostomy, fracture and dislocation reduction and splinting, intubation, incision and drainage, and laceration repair.

We have a lot for you to do and learn. Come to the shift excited and be prepared to get your hands dirty.

Introduction to EM
Student Goals and Objectives
Develop good clinical judgment and learn to apply it patient care Deliver appropriate and compassionate emergency care Broaden and apply your medical knowledge to patient care Work to communicate effectively with both patients and colleagues Always remain ethical, responsible, and reliable Learn what resources are available to the ED and how to utilize them Learn to recognize and treat a patient in distress

Introduction to EM
Student Core Competencies
Patient care Medical knowledge Problem based learning Interpersonal communication skills Professionalism Systems based Practice

Introduction to EM
What we expect from you
Strong work ethic with a desire to learn and then teach what you learn Punctuality Follow through with what you are asked or volunteer to do If a patient appears to be in distress, you need to IMMEDIATELY get help from an upper level resident or attending, DO NOT try and handle it by yourself! Professionalism is a must! All staff --from environmental services to patients and consultants-- are to be addressed in a professional and respectful manner. Remember, this is a team sport.

Orientation
1-2 weeks prior to the scheduled start of your rotation please call to confirm at 502-852-1273
On your first day, arrive in the ED academic office at 10am. It is located in the emergency department. Just ask anyone and they will show you back Dress is business casual You will be making your own schedule this day, so bring your IPhone, planner, lunch napkin, or whatever you use for organization You will tour the department, be given your ID and pass cards, and all the other formalities this day.

This will also be your opportunity to meet with course director, review the syllabus, ask question, and get know the other students on the rotation

Scheduling and Attendance

Scheduling coverage is part of the EM career. Therefore, we leave it to you to create your own schedules. Here are the rules Students are required to work 15 shifts in the ED, of which 4 must be on a weekend, the rest evenly between D/E/N All shifts (arrive 15min early) 8a-4p 4p-12a 11p-8a

Scheduling and Attendance

You must do one extra shift during the month at one of the following
Procedure shift in ED Poison Control Air Methods Lifeflight

There is an attendance sheet that needs to be signed and returned to Robin at the end of the rotation

Scheduling and Attendance

No more than 2 students may work any one shift.
Work hour rules apply to students No student may exceed 60 work hours in one week Students may not work double shifts Must not work more than 5 days in a row Must have as many hours off between shifts as they worked the previous shift (i.e. work 8 off 8 hours) Switching is allowed, but you are responsible for finding a student to switch. All need to be addressed with the course director or Robin Thixton 24 hours before the scheduled shift Students are required to attend residents lecture days during the rotation. Lectures are on Tuesday and Wednesday from 9a-11a. Exceptions are working the night before or the day of

Scheduling and Attendance

Students are required to attend the student didactics lectures and hands-on teaching sessions presented by the residents or attendings. Schedules for these lectures will be distributed at orientation. All students are required to come prepared and actively participate. These should be fun.
Students scheduled to work on Tuesday and Wednesday day shifts will work directly with the attendings while residents are at conference. Each student should try to schedule at least one to two of these shifts a rotation. You are excused from conference during this time. In the event that a student is unable to attend a shift due to an emergency or illness, the student is responsible for calling (502) 5623015 and speaking to the third year resident on that shift.

Interview season
Interviews are important!!! Your schedule should accommodate most of your interviews as your schedule is self made and flexible You are required to complete 15 shifts regardless if you have 0 interviews or 12 If you have an interview scheduled on a day you are suppose to work, it is your responsibility to switch shifts and make it up

Student Roles and Responsibility

All students are responsible for the following:
Completing history and physicals Formulating clinical decisions Ordering treatment and additional tests with supervision Learning and performing procedures Determining patient disposition Learning how to obtain and completing consultation as directed by your resident Assisting in treatment of critically ill patients in room 9

Typical Student Shift

Arrive for your shift 15 minutes early At the beginning of each shift, we round with an attending on all patients in the department. At this time, the residents turn over patients under their care to the oncoming residents. For new patients, when you go in the room make sure that the patient appears stable. If the patient appears to be unstable or have a true emergency, get a resident immediately.

Typical Student Shift

AGAINIf you are at all concerned about the well being of the patient do not hesitate to get the upper level resident IMMEDIATELY. Caution will never be viewed as weakness. If a resident is not readily visible, go to the secretarys desk and ask them to page them to that room STAT. Take the patients history, PMHx, etc. Perform a physical exam. We ask that you only document past medical, surgical and social history with a review of systems. The resident is responsible for documentation of the HPI and physical exam. You will be documenting on an electronic T-System. An on-line orientation must be completed prior to your first shift. You should receive more information from Robin Thixton and Rita Bole Formulate a differential diagnosis Formulate a plan of action Present a concise history, physical, diagnosis, and plan to an upper level resident. Include labs and x-rays you would like, along with the likely disposition

Typical Student Shift

You and the resident will then see the patient, and they will assist you in ordering relevant studies. Once the orders are placed, be sure you follow up and get the results of the labs and x-rays. However, you must be quick if you want to beat the resident to them. Once disposition is determined, the resident will guide you in obtaining consultation, admission, or discharge

Any procedures that need to be performed, you will be expected to participate

Learn something from every patient you see

Keep enough patients to stay active but not overwhelmed

Typical Student Shift

At the end of the shift, we will round again.
You will be responsible for presenting those patients you have to an oncoming resident in front of the attending. Be prepared to be asked questions related your medical knowledge of the diagnosis or injury. Usually, the residents have already taught this to you. You are not expected to know everything. But you are expected to at least know the basics regarding your patients condition.

Remember, this is an ED, so your presentations will vary in length. They should be concise with pertinent positives and negatives throughout and conclude with a disposition. See the example on the next slide

Typical Student Shift

Sample presentation GM is a 67 y/o AA male. Presented to the ED today with worsening angina with exertion. Pain free on presentation. Came because his wife made him. Hx of CAD, CABG. Pt is a smoker. Physical exam unremarkable. Labs all negative including enzymes. EKG unchanged from previous with evidence of an old inferior infarct. Last Cath 3 years ago. Pt has had ASA, O2, IV, Lovenox. Dx is unstable angina. Cardiology consulted. Last check 30 min ago patient was pain free. Patient to be admitted to cardiology for likely repeat cath. If you use a term, know the definition. A likely question here is What are the different types of angina and how do you treat them? Know why you did things. Why did you give this patient Lovenox? Question are meant to teach you things and to also make sure that the residents are teaching you as well.

Didactics
Didactic lectures, geared directly towards students will be given throughout your rotation. You are expected to attend all (unless on previous night shift). Several will be hands on experiences. The lecture topics and time/location will be emailed to you at least one day prior so be sure to check your email nightly.
You are encouraged to attend any or all resident lectures held on Tuesdays and Wednesdays from 9:00a-11:00a (if not scheduled to work in the department).

Resources and Reading

Books Rosens and Tintinalli are the staples for emergency medicine Read about the topics outlined in the study guide

Organizations www.acep.org www.emra.org www.saem.org www.aaem.org www.abem.org

Evaluation
Student Grades will be compiled from three components with the following weights 70% evaluation by residents and faculty Each student should have a minimum of 15 evals One of your evaluations can be discarded 5% On line SAEM quizzes 25% final exam There is an optional section at the end of the test which must be completed in order to honor the course

Evaluation
Written Evaluations Based on Core Competencies Patient care Medical knowledge Problem based learning Interpersonal communication skills Professionalism Systems based Practice

Evaluation
Written Exam
This is a 100 question exam, meant for a knowledge level of at least PGY-1 Use the study guide for list of topics covered The optional section consists of multiple choice questions that MUST BE COMPLETED in order to honor the course

Evaluation
Quizzes
You are required to complete three quizzes during the rotation

The quizzes can be found at http://www.saemtests.com You need to complete 3 by the end of the rotation You can do as many as you want Only the first 3 submitted will be counted toward your grade

Evaluation
You will be asked to evaluate the residents just as they are asked to evaluate you. Please fill these out honestly as they value your feedback greatly, especially on the effectiveness of their teaching skills

Resident evaluations are located in Blackboard.

Blackboard
Blackboard is the exam system used by UofL Contains the final written exam, honors portion, resident evaluation, and course evaluation Access to the final exam and evaluations is one week prior to and one week after your last rotation day.

T-Systems
Electronic patient medical record Students are to document past medical, surgical and social history with a review of systems, and procedure notes. Remember to lock your charts after documenting. Contact Rita Bole, RN in the ED office for questions regarding charting or locking charts.

IMPORTANT TO KNOW
Your final grade will not be released until you have:
a) Completed the resident and course evaluation in Blackboard b) Locked ALL of your patient charts in T-System c) Return copy of Current DX and Treatment in Emergency Medicine Textbook

Study Guide
The following information is meant as a broad based guide for the questions one may encounter on the test at the end of the rotation. Any and everything about each topic is considered fair game.

Study Guide
HEENT
Otitis media Bells Palsy The red eye Pharyngitis Vertigo Ocular foreign body Glaucoma Epistaxis Globe rupture

Environmental
Lightning Hypothermia Hyperthermia Diving High altitude sickness Drowning

Study Guide
Toxicology
Beta-blockers Snake bite Cyanide Tylenol ASA TCA ETOH CO Spider Bite

Trauma
Resuscitation Management of multiple trauma Burns Cervical x-rays EMS management Shock

Study Guide
Respiratory
Dyspnea Airway Management ABGs P.E. Pneumonia Asthma/COPD

Abdomen
Gallbladder Pyelonephritis Abdominal pain Acute abdomen SBO Mesenteric ischemia

Wounds
Suture Wound Care

Pediatrics
Trauma Infections

Study Guide
OB/GYN
Pregnancy Eclampsia Abortions Vaginal Bleeding Ectopic Pregnancy PID

Neurology
Meningitis CVA/ Stroke Mimicry of CVA Seizures Headaches

Psychiatric
Safety Measures Suicidal/Homicidal Pt Psychosis

Dermatology
Stevens Johnson Syndrome RMSF Lyme Disease

Study Guide
Ortho
Sprains Splints Fractures Hand Injuries Arthritis

Endocrine
Adrenal Thyroid Anaphylaxis Graves Disease DKA

Cardiology
MI Arrhythmias CXR ACLS

Hospital Policies
Fire Safety- we follow the RACE method R- rescue persons from fire, know exit locations and fire compartments, feel doors for heat, search while yelling blue flash or fire A-Activate alarm pull station while yelling Blue Flash or fire. Dial 20 (Code Phone) to report fire location

C-Control/Contain the fire, Close all windows and doors

E-Extinguish or evacuate using portable fire extinguish

Hospital Policies
Blood Exposure - If you experience a needle stick or other occupational blood exposure, please do the following:
Obtain consent from the patient involved for HIV testing and contact the nursing supervisor Complete an incident report If you have a needle stick from a high risk patient call 852-6446 immediately and ask to speak to the MD on call. Start PEP within one hour Follow all exposure protocol and if you have any questions, call 852-6446 which is answered 24 hours a day

The Department
The following is a quick tour of our department, with relevant information about each area. This will give you an idea of the layout of the ED, where people can be found, and an idea of how the ED flows.

Triage
Patients sign in here and are sent to the proper location based on illness Occasionally, residents are called to triage for evaluation of a pediatric patient, to assess for stability to transfer to Kosair Childrens Hospital

Room 9
Room nine is our medical and trauma resuscitation room. This is one of the four bays pictured on your right.

When you are in the main department and hear a buzzer sound followed by Room 9, please drop what you are doing and proceed to this room to participate.

Room 9
Generally, only critically ill patients are seen in room 9. Everything we need is right at hand and things move very quickly. As your rotation progresses, you will be allowed to participate with increasing frequency in room 9. So get yourself prepared by paying close attention at first.

Room 9
As the residents become more comfortable with you, your knowledge base, and your skills, you may be asked to do procedures in room 9. So read up on nasal and oral intubation, chest tubes, and central lines. If you do not know how to perform that procedure or are uncomfortable doing it, say so immediately. Do not pretend to know how to do something you dont know how to do! If you dont know how, we will teach you and you can do the next one.

Room 9
Sometimes room 9s are not that serious and you may be dismissed to see patients in the department. When dismissed, please return to the main department and help the resident not in room 9. Sometimes the patient is too ill to be a teaching case. In this instance, you may be asked to stand aside and just watch. Please do so promptly, this is only done when a patients life is on the line. Dont take it personally.

Main Department
This is a partial view of the main department. The design is an arena style with patients room peripherally and staff located centrally.

This is a view of where the residents and attending sit and work. The third year resident sits at the far computer, and the second year at the one closest to you. There are x-ray reading computers located behind each resident. This is where you will come to present your patients to the residents.

Main Department
This is a picture of the glass room in the center of the department. We call it the fish bowl. This is where our consulting services will do their work once we call them. That is Dr. Dan Danzl on the telephone, he is the chairman of our program. Of note, his name also appears on the cover of Rosens. The phones and radios in this picture are located right behind the residents seat. These are used to take transfer calls from other facilities and to provide medical control for EMS. Please do not use these phones at anytime.

Main Department
Remember, emergency medicine is a team sport and a hallmark of our program is collegiality among all persons in the department. Can you imagine what it would be like if no one took pride in keeping the ED clean?

An important thing to learn from this point on in your training is that being nice to nurses will save you a lot of time and work. Plus, they deserve it, they work as hard or harder than we do.

Main Department
We also see a good number of homeless patients. Often they will ask for a sandwich. This is the refrigerator where you can get food for them if it is approved by your resident. Sometimes, this is a good way to break the ice and make them feel more welcome and forthcoming about their complaints.

X-ray
We have our own dedicated radiology suites and CT scanner. They are located in the hall just behind the department. There is also 24 hr radiologist coverage. They can be found for direct consultation at anytime.

EPS
EPS stands for Emergency Psychiatric Services. Patients that present to the ED with only a psych complaint will be seen here by a psychiatrist 24 hours a day. Patients with both psych and medical complaints will be seen in the main department. If their medical condition permits, the patient will be transferred to EPS after appropriate care.

First Care
First care is a fast track area. It is staffed by midlevel providers, usually in the afternoons and evening. Patients presenting to the ED with minor complaints are sent here during their normal hours of operation. All other times, they are seen in the main department.

Important names and Numbers

Course Director Melissa Platt, MD Course Coordinator Robin Thixton Residency Director Mary Nan Mallory, MD Chairman Dan Danzl, MD All can be reached by calling the office at 502-852-5689 or by email