Emergency Medicine

Emergency Medicine - Handbook (PDF)

Objectives

I. Knowledge and Life-Long Learning

A core knowledge base relevant to emergency medicine topics will be taught by direct patient care and supervision, human patient simulation cases, and small group didactics. By the end of the emergency medicine clerkship, the student will demonstrate the ability to:

-Develop the skills to evaluate an undifferentiated patient in real time

- Develop a differential diagnosis based upon the initial patient presentation with awareness of worst case diagnoses recognizing immediate life threatening illnesses

-Obtain an accurate history and physical exam on either actual patients or simulated patients, focused on key symptom oriented problems including the following:

Abdominal and pelvic pain:

Aortic aneurysm
Appendicitis
Bowel obstruction
Cholelithiasis/cholecystitis
Diverticulitis
Ectopic pregnancy
Ovarian torsion
Nephrolithiasis
Testicular torsion

Alteration/loss of consciousness:

Hypoglycemia
Seizure
Syncope

Chest Pain:

Acute coronary syndromes
Aortic dissection
pneumothorax

Environmental exposures:

Burns including chemical and thermal
Envenomations including hymenoptera, latrodectus, and crotalus
Hypothermia and hyperthermia

Eye pain and vision change:

Acute angle closure glaucoma
Trauma
Retinal detachment

Gastrointestinal bleeding:

Upper including peptic, variceal
Lower including diverticulosis, hemorrhoids, malignancy

Headache

Mass lesions
Meningitis
Migraine

Poisoning/overdose

Anion gap metabolic acidosis
Decontamination
Specific poisionings incuding:

Acetaminophen
Carbon monoxide
Opioids
Salicylates
Tricyclic antidepressants
Toxic alcohols

Psychiatric

Acute psychosis
Substance abuse
Suicidal ideation and attempt risk assessment

Resuscitation

Basic airway management
Basic airway maneuvers
Airway adjuncts
Bag-valve-mask ventilation
First minute of a medical or traumatic code
Cardiopulmonary resuscitation
Dysrhythmia identification/treatment

Shock

Anaphylactic
Obstructive
Cardiogenic
Hypovolemic
Septic

Shortness of breath

Airway obstruction
Asthma/COPD
Heart failure
Pneumonia
Pulmonary embolism

Traumatic injuries

Abdominal
Thoracic
Extremities including dislocation and fracture management
Head injuries
Neck and spine
Pediatric non-accidental trauma
Domestic violence

Vaginal bleeding

Abortion including threatened, complete, incomplete
Ectopic pregnancy
Placenta previa
Placental abruption

Weakness/dizziness

CVA including embolic, hemorrhagic, thrombotic
Vertigo

Wound care

Irrigation
Local anesthesia
Primary closure
Tetanus prophylaxis

-Develop the following procedural skill sets taught with appropriate supervision, through either actual or simulated patients:

ECG interpretation
Interpretation of cardiac monitoring
Peripheral intravenous access
Pulse oximeter
Nasogastric tube placement
Wound closure
Splint application
Venipuncture
Chest tube insertion
Endotracheal tube placement

-Develop a management plan for the evaluation and treatment of the patient:

Understanding of the mechanism of action and use of common ED medications including:

Antibiotics
Vasopressors
Pain medications
Cardiac medications
Sedatives
Induction agents
Paralytics

Appropriate disposition including:

Discharge from the ED
Hospitalization
23 hour observation
Nursing home
Hospice

Health promotion

Discussion of preventable illness and injuries Education of patients insuring comprehension of:

Outpatient treatment plans
Medication use
Follow-up

-Interpret the results of common diagnostic procedures and tests (laboratory and radiology).

-Effectively use available information technology to solve patient care problems, improve knowledge base, and develop case presentations

II. Interpersonal and Communication

It will be expected that the student will demonstrate interpersonal and communication skills essential to emergency medicine, including:

Effective communication with patients and family members, including those from diverse cultural, ethnic, and socioeconomic backgrounds Present cases in a complete, concise and orderly pattern Clearly delineate primary problems and management plan Complete documentation when indicated in an accurate, well organized form that is appropriate for the level of care provided

III. Professionalism

It will be expected that the student will demonstrate the following humanistic qualities essential to emergency medicine, including:

Compassionate and nonjudgmental behavior to all patients Work in a collegial manner within a health care team

The student will demonstrate professional medical behavior and personal behavior through the ability to:

Maintain professional boundaries with patients including physical, sexual
financial and emotional
Be conscientious, on time and responsible
Exhibit honesty and integrity in patient care
Practice ethical decision making abilities
Maintain courtesy and professionalism with staff, colleagues, consultants,
patients and families
Maintain patient confidentiality
Demonstrate scholarship in the form of contributing to a positive learning
environment, collaborating with colleagues and performing selfassessment
and self-directed learning
Continually assessing one’s strength and weaknesses and be willing to
accept supervision and constructive feedback

Readings/Assignments

Emergency Medicine: An Approach to Clinical Problem Solving, 2nd Ed, Hamilton, Sanders, Strange, Trott. The textbook is loaned to students for their use during their clerkship.

Material from the chapters listed below correlates with the Small Group Discussion/Sim Lab sessions

Chapter 01 - Orientation to Emergency Medicine
Chapter 02 - Airway Management
Chapter 03 - Cardiopulmonary Cerebral Resuscitation
Chapter 04 - Shock
Chapter 05 - Acute Abdominal Pain
Chapter 08 - Chest Pain
Chapter 09 - Syncope
Chapter 10 - Hypertension
Chapter 31 - Altered Mental Status
Chapter 37 - Acute Dyspnea
Chapter 38 - Wheezing
Chapter 41 - Multiple Blunt Trauma
Chapter 42 - Penetrating Trauma
Chapter 43 - Abdominal Trauma
Chapter 44 - Chest Trauma

Policies

• Grading

60% of grade derived from clinical work

Turn in evaluation form to resident/attending at the end of each shift

10% from attendance/professionalism at clinical shifts, small group discussions and sim labs, as well as Friday resident conferences

30% from test

• Absence

Clerkship Sites

Small Group Discussion/Sim Lab Sessions

WSU, Department of Emergency Medicine
Cox Heart Institute
3525 Southern Blvd.
Kettering, OH  45429
(937) 395-8839

Corey Heitz, M.D., Clerkship Director
corey.heitz@wright.edu

Raymond Ten Eyck, M.D., Simulation Lab Director
raymond.teneyck@wright.edu

Lynn DeWine, Medical Student/Sim Lab Coordinator
lynn.dewine@wright.edu

Clinical Sites

Children’s Medical Center
Good Samaritan Hospital
Greene Memorial Hospital
Kettering Medical Center
Miami Valley Hospital
Wright Patterson AFB Medical Center

Lecture Material

Abdominal Pain Session Objectives

Skill Sets

1. Nasogastric tube insertion

2. Foley catheter insertion

Learning Objectives

1. Develop differential diagnosis and diagnostic strategy for abdominal pain in women

2. Discuss rational lab use in the context of abdominal pain evaluation in the ED

3. Discuss the importance of pelvic exam

4. Discuss timeliness of surgical consultation in abdominal pain

5. List clinical signs/symptoms that raise suspicion for AAA

6. Understand appropriate resuscitation and stabilization methods for patients with life threatening causes of abdominal pain

7. Discuss resuscitation/stabilization/treatment in elderly patients

8. List a comprehensive differential diagnosis in elderly patients with abdominal pain

9. Discuss rational lab use, diagnostics (radiographs, ultrasound, CT)

10. Discuss understanding of pain management in abdominal pain

11. Differentiate classic presentations of pancreatitis, cholelithiasis and cholecystitis

12. Summarize classic findings in appendicitis

13. Discuss diagnostic modalities in AAA

14. Describe classic risk factors for obstruction

Altered Mental Status Session Objectives

Skill Sets

1. Head CT interpretation

   1. Subdural

   2. Epidural

   3. Intracerebral

   4. Subarachnoid

2. Lumbar puncture

3. Airway control

Learning Objectives

1. Perform initial stabilization of a patient with altered mental status

2. Discuss the evaluation of a simulated patient with AMS addressing a comprehensive differential as represented by the mnemonic AEIOU TIPS

3. Initiate appropriate therapy for the cause of AMS

4. Arrange for the correct disposition

5. Airway evaluation and management appropriately

6. Recognize hypoglycemia as a common cause of altered mental status

7. Know that the most common causes of confusion with depressed level of consciousness are metabolic or systemic in nature

8. Demonstrate an organized approach to discern the cause of a patient’s AMS

9. Correlate physical findings with specific pathologic conditions

10. Know five life-threatening and reversible processes to be considered in the patient with altered mental status

11. Demonstrate appropriate ordering of a head CT based on history, physical and/or initial lab findings

12. Demonstrate timely utilization of the three drugs empirically used for patients with AMS

13. Demonstrate appropriate and timely disposition of patients seen in the ED with AMS based on findings in history/physical and/or ancillary studies

Chest Pain Session Objectives

Skill Sets

1. EKG interpretation

   1. Acute MI

2. CXR interpretation

   1. Dissection – wide mediastinum

   2. Pneumothorax

3. Chest tube thoracostomy

Introduction

1. Summarize the importance of recognizing ACS in the emergency department

2. List the risk factors for coronary heart disease

3. Summarize the importance of vitals signs in patients with chest pain

4. Review aspects of cardiac monitoring

5. Review the role of the EKG in the patient with chest pain

Learning Objectives

1. Define angina, unstable angina and acute coronary syndrome

2. Review diagnosis of ACS – history, physical, EKG

3. Discuss use of laboratory in patients with chest pain

4. Identify key management principles in acute coronary syndrome

5. Discuss the risk factors for venous thromboembolism

6. Review the diagnosis of PE - D-dimer, V/Q and CT scans

7. Review the management of PE - Heparin, Lovenox, Coumadin, tPA

8. Review the role of CXR in the diagnosis of acute chest pain

9. Discuss the management of dissection – surgical versus medical management

10. Review and demonstration of chest tube thoracostomy

11. Discuss the 6 priority diagnoses of acute chest pain in the undifferentiated patient

Airway-Dyspnea Session Objectives

Skill Sets

1. Basic airway control techniques
   Jaw maneuvers
   Nasal/oral pharyngeal airways
   Bag-mask ventilation

2. Endotracheal intubation techniques
   RSI
   Standard

3. Rescue airways
   LMA
   Combitube
   Cricothyrotomy
   Newer Modalities

Learning Objectives

1. List the basic approach to airway support

2. Identify the specific indications for airway management

3. Describe the settings in which each of the following would be most appropriate: chin lift; jaw thrust; oral pharyngeal airway; nasal pharyngeal airway

4. Describe the elements of an initial assessment that allow differentiation of an airway problem from a breathing problem.

5. Describe the various forms of supplementary oxygen delivery

6. Thought process involved in deciding when to initiate bag-mask ventilation

7. Factors predictive of a difficult airway

8. Risk factors associated with intubation

9. The 6 P’s of RSI

10. Contraindications to RSI

11. Technique of oral tracheal intubation

12. Nasotracheal intubation technique and risks/benefits

13. Confirmation of tube placement

14. General assessment of a patient with dyspnea

15. Clinical conditions causing dyspnea

16. Emergency treatment of asthma

17. Treatment of pneumonia

18. Treatment of COPD

19. Treatment of CHF

20. Causes of stridor and their treatment

21. Pediatric considerations for stridor

22. Importance of following an emergency airway protocol when managing a patient with an airway emergency

23. Rescue airway modalities

Trauma Session Objectives

Skill Sets

1. Needle thoracostomy

2. Chest tube thoracostomy

Leaning Objectives

1. Understand importance of mechanism of injury in trauma

2. Primary and Secondary survey

3. Appropriate fluid resuscitation in trauma

4. Five immediate life threatening injuries

5. Timing of procedures in trauma resuscitation

6. Appropriate management of C-spine injuries

7. Appropriateness of diagnostics/imaging modalities in trauma patients

8. Acute reduction of fractures

9. Fluid management in burn patients

10. List appropriate fluid resuscitation modalities

11. List 5 immediate reversible life threatening processes to be anticipated in trauma patients

12. Identify clinical signs and symptoms of tension pneumothorax

13. Identify clinical signs and symptoms of cardiac tamponade

14. Discuss order and timing of needle decompression, chest tube placement and airway management

15. Review the importance of thorough history surrounding falls in elderly

16. Discuss how co-morbid conditions affect elderly trauma patients (Coumadin)

17. Review airway management in burn patients

18. Discuss pain management in trauma patients