Orthopaedic Surgery Residency Program

Michael Herbenick, M.D., Director

Emergency & Trauma Center Rotation
Rich Lemos, M.D.

General: This is a required rotation for a duration of one month for R-1 and R-2 levels. It is an optional rotation for R-3 residents for a duration of one month.

Where to report the first day: Emergency Department (South) nursing station, ask for Physician Assistant on duty. The orientation will be held in the ETC Conference room, located next to the South station. Note that schedules are prepared one month in advance; all requests should be submitted to the Chief Resident. Schedule requests need to be made by the 10th of the prior month.

Conferences to be attended:

  • Resident Forum (if possible). Notify Dr. Lemos or attending in advance of your plans to attend.
  • Noon Conference (if assigned day shift).
  • Emergency Medicine Conference, Friday, 1-5 p.m., Kettering Medical Center.

Patients per shift: Expected number = 15 per shift.

Didactic sessions: No formal session, discuss each patient with attending.

Learning modules: None.

Procedures:

May have opportunity for phlebotomy, arterial puncture for ABG, endotracheal tube insertion, central venous catheter insertion, laceration repair, control of nasal bleeding. Let the attending physician each shift know which procedures are of interest to you. Attempts will be made to facilitate your participation.

Rotation Goals and Objectives

  1. To assist the student in developing a thorough, systematic approach to the rapid recognition, evaluation, treatment, and disposition of the critically ill or injured patient.
  2. To set forth and teach a defined body of knowledge and skills which constitute emergency medicine.
  3. To define acceptable standards of treatment for frequently encountered emergency department problems.
  4. To introduce the student to the field of pre-hospital emergency care.
  5. To maintain sufficient flexibility to meet the needs of the trainee.
  6. Ultimately, to improve the quality of emergency care.

Hospital and Emergency Department Profile

Miami Valley Hospital is an 800-bed hospital, which offers a full range of health care services. The Emergency & Trauma Center sees approximately 97,000 patients per year. In addition to emergency medicine residents, there are residents from internal medicine, surgery, IM/Peds, obstetrics/gynecology, orthopedics, dental, and family practice who rotate through the emergency department. There are generally 7-12 residents and two students assigned per month to the emergency department. Furthermore, six physician assistant students, along with numerous dental residents, will be assigned to the emergency department annually.

Attending Physicians

Andrew Campbell, D.O.
Steven Chapman, D.O.
Mary Chellis, M.D.
Rich Lemos, M.D.
Phyllis Doerger, M.D.
Mark Eilers, M.D.
Bryan Fitzgerald, D.O.
Harold Guadalupe, M.D.
Ramesh Gupta, M.D.
Andrew Hawk, M.D.
Namchi Le, M.D.

Richmond Lemos, D.O.
Tim MacLean, D.O.
Kathy Malone, M.D.
Randy Marriott, M.D.
Roger Pacholka, M.D.
Darin Pangalangan, M.D.
Stephen Rymer, M.D.
Norm Schneiderman, M.D.
Tom Susec, M.D.
William Wright, M.D.
Brian Zimmerman, M.D.


Resident Responsibilities

Shifts and Schedules:

The monthly resident and student schedule is prepared one month in advance by the Wright State University Department of Emergency Medicine Chief Resident. Requests for vacation, educational leave or necessary time off must be submitted to the Chief Resident of Emergency Medicine by the 10th of the month prior to actual rotation. No deletions or changes in the schedule can be made after this date. If no requests are submitted, the schedule will be made and will not be subject to change. Residents wishing to change their hours may trade with residents of lateral R training. Permission for these changes must be approved by the Scheduling Coordinator (Chief Resident). Unauthorized changes will be counted as unexcused absences.

Shifts are 10 hours in length for both residents and students. The standard shifts are 7 a.m. to 5 p.m., noon to 10 p.m., 5 p.m. to 3 a.m., and 10 p.m. to 8 a.m. There are generally six to seven night shifts scheduled per month. Chief Residents have two less shifts per month than other R-3's.

  • R-1 residents are required to work 50 hours/week.
  • R-2 residents are required to work 45 hours/week.
  • R-3 residents are required to work 40 hours/week.
  • Chief residents are required to work 35 hours/week.

Vacations/Meetings:

Make sure requests are in writing and dated.

The Emergency Medicine Rotation is a full one-month service. No more than (1) one vacation/meeting request will be approved in any one week period per month (to avoid overlap).

Vacation/meeting requests are on a first come, first served basis; seniority will overrule if requests are for the same time frame.

NO vacation/meeting requests will be considered unless submitted at least one month prior to beginning of the rotation.

Requests will not be approved without Dr. Lemos' signature; no other signature will be considered valid. Verbal requests will not be approved and no unapproved vacations will be honored.

If residents are scheduled to work during their clinic hours, they are to notify the attending ETC physician of the need for the absence. Hours before and after the clinic are to be worked as usual.

Sign-in sheets will be available for the Emergency Medicine Conference at Dean Amphitheatre at Kettering Medical Center (Fridays from 1 to 5 p.m.). Parking passes for the garage may be obtained from the Emergency Medicine Chief Resident (Scheduling Coordinator) during the conference. Attendance is mandatory unless you are scheduled to work a shift in the Emergency Department. You are not automatically excused from a shift to attend Friday conference. If you wish to attend, approval to miss your shift must be obtained from Dr. Lemos or the Chief Resident.

Passing the Rotation:

Residents will be evaluated every shift.

Having more than three unexcused absences (15 percent) will result in an automatic failure.

ALL residents are required to attend (unless working) the Emergency Medicine Lectures held on Fridays at the Kettering Medical Center. Residents will be informed of the location and topic.

The resident will be responsible for having the attending with the same shift assignment fill out his or her evaluation at the end of each shift. You may need to remind the attending.

A copy of the resident's evaluation will be forwarded to his or her department at the completion of the rotation.

Medical students will be evaluated in the same manner.

Orientation:

Orientation to the emergency department will be given by Greg Kooyman, Chief P.A. You will be notified by letter of the date and time of the orientation. Attendance is mandatory, even if you have completed a prior orientation in the ETC here at MVH. If you are unable to make the scheduled orientation, you must notify us ahead of time and reschedule with Greg Kooyman prior to your first shift. You will not be permitted to work your shifts until orientation is complete. Every shift you miss will be added on to the end of your month or in lieu of vacation or"free" days.

All residents who are not MVH residents must report to the Medical Education Department on the 7th floor, between the hours of 8:30 a.m. and 5 p.m., Monday through Friday, on or before your first rotation. Until you receive a parking assignment and parking card, you may park in the Apple Street garage for a limit of one day, or in the Fairgrounds lot (across the street from the hospital on Main Street.)

YOU ARE NOT TO PARK IN THE EMERGENCY & TRAUMA CENTER PARKING LOT! If you park in the Apple Street garage, the ETC Admin. Office will supply you with a parking pass before you leave. Please pick up 8 a.m. to 4 p.m., Monday through Friday only.

Illness:

No one expects the doctor to be sicker than the patients he or she sees. If you find yourself unable to work due to illness, notify Dr. Lemos or the Chief Resident. The resident may be expected to make up such days. Dr. Lemos will determine how and when shifts will be made up depending on the number of missed shifts.

Dress Code:

Appropriate and professional attire is required; lab coat (and tie when appropriate) is preferred. Please present for duty with a good attitude and neat appearance.

Resources:

Reference books are presently stored at the nursing station, on the desks adjacent to rooms 3 and 4 and in the cabinet by the x-ray view boxes. Included is an emergency department reference guide which contains helpful information needed in day-to-day operations (policies, article reprints, medical facts, etc.) A wet lab with a microscope for analysis of wet mounts, gram stains, etc., is available for resident and student use.

Patient Care Outline:

A. Triage and Registration: Patients are triaged by a nurse on arrival in the ETC.
B. General guidelines for room assignments are as follows:

North Station
Rooms

Trauma

35 & 36

Resuscitation

40 & 41

Monitored Medical Beds

25,32,33,34,42

Medical/Hazmat

26,37,38,39

ENT

27

South Station
Rooms

Medical Monitors

43-46,49-51,16,17,24

Medical

14

Psychiatric

47 & 48

OB-GYN

18 & 23

Conference

15

East Station
Rooms

Medical

1-10

Cast Rooms

11 & 31

OB-GYN

19 & 22

Select Care
Rooms

Fast Track Medical

62-73

Observation
Rooms

Medical Monitors

51-61

Charts:

Charts are divided into five components with a full sheet that contains demographics such as patient name, age, address, family doctor, insurance status and time of arrival. The third page of the chart (page 2 is transcribed history and physical) is for recording the diagnosis and writing orders. You must sign your name on the bottom of this page in the designated place. Also, you must print the name of the attending emergency physician with whom you consulted on the case. The fourth page of the chart is for recording lab, EKG and x-ray results, as well as progress notes. The attending physician is required to sign this page. It is the responsibility of the resident/medical student to have his/her charts co-signed by an attending emergency physician. The last page is for discharge instructions.

Initial Patient Contact:

Charts of patients to be seen are placed in a"to be seen" rack in order of priority. When you are ready to see another patient, take the top chart in the rack. Occasionally, a nurse may ask you to see a patient before a chart is available.

Physician Referral System:

Each physician on the Active, Courtesy, Academic Attending and Consulting Medical Staff of MVH is sent a biannual letter requesting his/her preferences in being notified and specialist referral when his/her patients present to the ETC. This referral is available on the attending physician's computer in all stations. This information is available for the physicians who complete and return the letter).

When a patient who has a primary physician presents to the emergency department, be sure to check the"Physician Referral" program on the computer. Ensure the physician's instructions are followed.

Orders:

All orders should be written on the chart when possible. After the orders have been written, place the chart in the order rack. Utilize the appropriate color clip to delineate responsible party. White clip - nurse order; purple clip - HUC order; green clip - dismissal, etc. Verbal orders should be limited.

PACS

There is a new radiology system in place in each of the nursing stations of the ETC. You will be trained on how to use it during orientation.

Transcription System:

A medical transcriber is scheduled outside the department 24 hours a day when full coverage is available, to transcribe the dictated history and physical exam onto the emergency department record. Disposition, final diagnosis, prescriptions and discharge instructions should be hand written because they constitute such a small percentage of the chart. Medical students are asked to write, rather than dictate, the history and physical. The location of the dictating equipment and the dictation procedure will be explained by the attending during your orientation session. A document outlining instructions will be given to you during your orientation. Please use the"resident" button on the dictaphones for your dictations. If you use your own I.D. number, please use #77 as the work type.

Disposition:

After the orders have been completed and x-ray, lab work, etc., are back, the chart will be placed in the disposition rack. The resident should make it a habit to look through the disposition rack.

Patient Follow-Up:

The resident is encouraged and expected to follow-up with his/her admitted patients. Take the time to go to the floor and review each admitted patient's chart. There are times when a patient is asked to return to the emergency department for wound checks, etc., and the resident may ask the patient to return at a time he/she is working in order to follow-up the results of his/her work. Check with your attending for specifics regarding the follow-up of a patient in the emergency department. Any instructions to patients to return to the emergency department must be documented on the patient's Discharge Instruction Sheet.

Patient Care Responsibilities:

A) Medical Students

Medical Students are scheduled to rotate with a resident during each assigned shift. Students are not to see patients unattended. After performing a history, physical and plan of action, the student will discuss the case with an attending physician. If the patient is felt to be"unstable", the student may see the patient in concert with a resident or attending physician. Responsibilities delegated to a medical student depend on his/her level of expertise. Students who are recognized to have a strong background in both medical and surgical evaluations and procedures will be (on a case-by-case basis) given more responsibility. Students who, by the same token, demonstrate less depth of knowledge and ability will obviously have to be supervised more closely. The emergency-attending physician will be primarily responsible for making this determination. Students will be supervised performing suturing of lacerations, incision and drainage of abscesses, drawing venous or arterial blood samples, starting central lines, placement of chest tubes or performing intubation. All orders and procedures done by the student must be discussed with an attending before being executed. Medical students are asked to write, rather than dictate, the history and physical exam.

B) R-1 Residents

The R-1 resident is accountable to the attending physician at all times. Initially, all patients should be discussed with the attending before lab or x-ray is ordered. Procedures should also be done under the direct supervision of an attending. With experience, more independence will be given.

C) R-2 & R-3 Residents

All patients need to be discussed with and seen by the attending physician, but with experience comes more independence. R-3 emergency medicine residents are encouraged to use the telemetry system for communication with paramedics. Also, residents (particularly R-3 residents) are expected to take an active role in teaching R-1 residents and medical students.

Residents consulting with patients in the ETC are to recognize that patients not yet admitted to an in-patient service are the responsibility of the ETC. Residents assume responsibility for the definitive care only when admission has been concluded. Orders and disposition of care depend on this differential between the ED physician (ED attending or emergency-medicine resident) and the consulting resident.

Emergency Department physicians (attending or residents) are responsible for patient care while the patient is admitted to the ETC; a consulting resident on the in-patient service is responsible for patient care when the in-patient admission is concluded.

Neither resident nor attending must hesitate to obtain additional attending consultation where differences in opinion exist.

The resident must respect the seniority and experience of the attending (teaching physician) at all times. Decisions which alter management significantly must be carefully considered and scrutinized by all caregivers, and differences resolved regardless of the admission status of the patient, if necessary, by ATTENDING TO ATTENDING consultation.

Patient Disposition:

A) Admission

  1. Private patients - a doctor will be listed on the demographic page of the chart. This physician should be contacted regarding possible admission.
  2. Before contacting a private physician, let the attending emergency physician on duty know you are calling them. Certain physicians are very particular about talking directly to the ETC attending. Don't take this as an insult.
  3. Private unattached patients will be assisted in selection of a physician. Evaluation for possible admission to general medicine is rotated between the family practice resident on call and the medicine resident on call.
  4. Staff patients will be referred to the house officer on call on the appropriate service.

Notes:

  1. Private patients are referred to their private physicians. Depending upon the specialty, the referral pattern changes for private unattached patients. You should talk to the attending regarding the specifics of referral.
  2. Staff patients are referred to the appropriate clinic. Check with the attending ETC physician before referring these patients.
  3. All patients with industrial injuries or illnesses are considered private patients. The attending physician will refer these patients appropriately. There is a separate follow-up instruction sheet for industrial patients - this is to be completed by the emergency-attending physician only.

B) Discharge

All patients must have discharge instructions and access to follow-up care (i.e. primary physician, Med-Surg, Carefinders, etc.). Document the diagnosis on the pre-printed discharge instruction sheet (you should read these sheets before you hand them out). Make sure your instructions are legible and easily understood by non-medical people. Discharge instructions should be both time and physician specific. Residents/Students do not discharge patients without prior approval and signature from the attending physician.

C) Restraints

Complete and sign the appropriate behavioral restraint order form. This form is required by law. THERE ARE NO PRN RESTRAINT ORDERS.

General Ed Behavior/Interpersonal Skills:

Make it a point to introduce yourself to the ETC personnel. Politeness to nurses, unit coordinators, clerical personnel, and fellow physicians goes a long way. Take time to talk to the EMS personnel. Discuss x-ray problems with x-ray technicians. Talk to the lab personnel when necessary.

You will find the emergency department to be quite noisy at times. Often it is very difficult to hear on the phone, etc. Please try to do your part to help curtail some of the unnecessary chaos.

It is important to make the time to talk to family members both for valuable medical information and good public relations. Try to inform both the patient and family, when possible, what they can expect (i.e. lab tests, x-rays, IV, observation, etc.) When needed, a family conference room is available adjacent to the waiting room and ambulance entrance.

Staffing:

When presenting patients, give the patient's name and room number first. It helps to orient everyone. You may want to keep a list of your patients.

Don't be afraid to say "I don't know" or "I forgot to ask that question."

Let the ETC attending physician know what is going on with your patients at appropriate times. Keep in mind when you should expect all your test results to be back. Look for them!

Use your time wisely. Write discharge instructions and prescriptions expectantly when possible. Do not leave prescription pads out, however.

Miscellaneous:

Ancillary services available as listed below:
  • Physician Assistants
  • Patient Relations Representatives
  • Volunteers
  • Orthopedic Technicians
  • Social Service
  • Pastoral Care
  • Behavioral Assessment Team Evaluation
  • Victim/Witness Representatives

The orientation check-off list includes:

Stat Lab

ENT Room

Gyn Room

Peak Flow Meter

Pneumatic Cuff

Irrigation Set-Up

Fiberoptic Scope

Nitrous Tank

Repeat Visit File

Telemetry

Dictation System

Intercom System

Care of Equipment

Telephones

Micromedix

Trauma Alert

Nurse/Patient
** Assignment Board

CareFlight
** Orientations to pad/helicopter
** Safety

Patients who present with trauma to the mouth must be seen by the emergency physician before dental referral unless it is a referral from another facility to see the dental resident only.

CareFlight is a 24-hour, seven-day-a-week regional air emergency medical service based at Miami Valley Hospital. We have two helicopters available for patient transport. They are staffed by two critical care RNs The full-time attending ETC physician on duty functions as the Medical Control Physician for CareFlight. Dr. Andrew Hawk is the Medical Director of CareFlight.

The Mobile Intensive Care Unit (MICU) is available 24 hours a day to transport high acuity patients requiring admission or transfer to or from Miami Valley Hospital or Good Samaritan Hospital. It is staffed with a registered nurse, a certified paramedic and an EMT driver. All MICU nurses have the same advanced training as the nurses who staff the CareFlight air ambulance program. Dr. Andrew Hawk is the Medical Director of the MICU.

Lists are available for both stock drugs and starter dose packs. Please try to select your medicines from these lists. Starter doses are only available during nighttime hours when pharmacies are closed.

Nursing service of the ETC consists of a dedicated group of RN's , LPN's, ED Tech's, Service Associates, Health Unit Coordinators and

Registration Staff: A total of 98 percent of the RN staff are ACLS and TNCC certified, and many are PALS certified. Please feel free to approach the nursing staff with questions or concerns regarding department operation or care of your patient.

There is a patient relations representative available Monday through Friday from 8 a.m. to 11:30 p.m. and noon to 12:30 a.m. on weekends to provide families and friends in the waiting area a status report on patients, handle patient/family issues and problems, and resolve complaints. These representatives serve as a liaison between the patient, family and medical/nursing staff.

General Guidelines to remember while treating patients in the ETC:

  • Make sure vital signs are recorded on the chart.
  • Be sure to examine the backs of all trauma patients.
  • Order an EKG on all diabetics over age 40 with chest or abdominal pain.
  • Assume the worst and disprove it.
  • Never trust an intoxicated patient.
  • Examine the patient undressed. (Them, not you)

Sign the emergency record (on the page containing the physicians' orders and provisional diagnosis) and document the initials of the emergency-attending physician with whom you staffed the patient. Be sure to dictate an H&P on each patient you see. Charts should be completed in a timely manner. Otherwise, you may be contacted to complete these charts after your rotation ends.

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