PGY1 Emergency Medicine

Educational Goals & Objectives

PGY1 Psychiatry residents have the opportunity to complete one four-week long rotation in Emergency Medicine as their elective choice. The emergency medicine rotation will provide the resident with an opportunity to evaluate and manage patients with common acute physical and mental illnesses within a finite time span. Training will emphasize the rapid gathering of a pertinent history, a focused physical exam, and the triage of serious versus minor illnesses as well as the appropriate social and medical disposition of patients.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

1. All residents must be able to provide compassionate, culturally-sensitive, and appropriate care for patients presenting to the emergency department.
2. Residents will demonstrate the ability to take a succinct, pertinent history and perform a focused physical exam. PGY1s should be able to differentiate stable from unstable patients and appreciate and characterize the following physical findings:

• Abnormal respiratory patterns
• Abnormal heart and lung sounds
• Assessment of volume status
• Peritoneal signs
• SIRS physiology and symptoms and signs of shock
• Focal neurologic abnormalities

Medical Knowledge

1. Residents will become knowledgeable in the following issues pertaining to emergency care:

   PGY1s

   • Addiction and withdrawal syndromes
   • Domestic violence, and elder and child abuse
   • Homelessness

2. Residents will become comfortable with a basic approach to some common medical and surgical conditions affecting patients from pediatrics to geriatrics. These conditions range from acute life-threatening illnesses to sub-acute and chronic illnesses presenting to the ED. The goal is to understand basic pathophysiology, differential diagnosis, focused diagnostic evaluation, and therapy for these disorders. As experience depends on the case mix at any given time, residents are strongly encouraged to develop their knowledge further with supplemental reading to ensure they become familiar with the following conditions:
   • Abdominal pain
   • Acute psychiatric emergencies, such as panic attack, psychosis, or suicidality
   • Acute renal failure
   • Airway compromise
   • Anemia
   • Asthma and COPD exacerbations
   • Ataxia and gait disturbances
   • Back pain
   • Bites and stings
   • Bleeding, including GI, nasal, anticoagulation-related, traumatic, and vaginal
   • Burns
   • Chest pain and cardiac arrhythmias
   • Congestive heart failure
   • Common eye, ear, and mouth disorders
   • Common poisonings and overdoses
   • Common systemic infections
   • Deep venous thrombosis and pulmonary embolus
   • Delirium and obtundation
   • Diabetic ketoacidosis and hyperosmolar hyperglycemic state
   • Diarrhea
   • Electrolyte abnormalities
   • Fever
   • Fluid and blood resuscitation
   • Headache
   • Heat emergencies and hypothermia
   • Hypertensive urgency and emergency
   • Nausea and vomiting
   • Pelvic pain
   • Peripheral neurologic lesions
   • Pregnancy and obstetric emergencies
   • Rash
   • Seizure
   • Sexually transmitted diseases
   • Shock
   • Sprains, fractures, and overuse injuries
   • Stroke and TIA
   • Syncope
   • Trauma
   • Urinary retention
   • Urinary tract infections
   • Vertigo and dizziness
   • Wheezing and stridor
   • Wounds

3. Residents will be able to understand the indications for ordering and interpretation of results from diagnostic studies, including:

PGY1s

• Arterial blood gas – interpretation of oxygenation and basic acid-base status
• Computed tomography imaging of head, chest and abdomen
• EKG
• General laboratory studies ordered in the Emergency Department
• MRI head
• Radiographs of chest, abdomen, and extremities
• Ultrasound of abdomen, pelvis

Practice-Based Learning and Improvement

1. PGY1s should be able to access current clinical practice guidelines from journals and online sources to apply evidence-based strategies to patient care.
2. Residents should learn to coordinate care by involving the patient’s primary care doctor and hospital consultants to optimize patient care.
3. Residents should effectively transition patients within the system to the inpatient team, oncoming ED staff, or home.
4. Residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

1. PGY1s must demonstrate interpersonal verbal and written (electronic) communication skills that facilitate the timely and effective exchange of information and collaboration with patients, their families, and other health professionals.
2. All residents need to ensure patients and their families understand discharge and follow up instructions.

Professionalism

1. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.
2. PGY1s should be able to educate patients and their families in a manner respectful of gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation on choices regarding their care.
3. Residents should be able to use time efficiently in the ED to see patients and chart information

Systems-Based Practice

1. PGY1s must have a basic understanding that their diagnostic and treatment decisions involve cost and risk and affect quality of care.

Teaching

1. Supervised patient care in the Emergency Department:

Residents will initially be directly observed with patients, to facilitate the acquisition of excellent history taking, physical exam, and procedural skills.

• As residents become more proficient, they will interact independently with patients and present cases to faculty.
• Initial emphasis will be on diagnosis and basic management.
• When residents have mastered these skills, focus will be on medical decision- making, and residents will work with supervising physicians to finalize a care plan.

2. Conferences
   • Specialty-specific didactics

3. Independent study will be the primary source of didactic material: 20 hours per week

• A reading list will be provided at the start of the first Emergency Department rotation with the expectation that it will completed by the conclusion of the resident’s final Emergency Department rotation during residency
• Journal and Textbook reading: primary sources should be the following:
  • Tintinalli’s Emergency Medicine, A Comprehensive Study Guide
  • Roberts and Hedges’s Clinical Procedures in Emergency Medicine
• Online educational resources
  • Pain management and addiction: HHS How to Respond to an Opioid Overdose
  • Up to Date
  • Clinical Key

Evaluation

1. Mini-CEX
2. Verbal feedback at the end of shift
3. Written attending shift evaluations of resident performance based on observations and chart review

Rotation Structure

1. Residents should contact ED Education Director or the Emergency Department Manager 1-3 days prior to the rotation start date to determine start time and location. Residents must notify the attending physician promptly if they cannot be available for their designated shifts.
2. Residents will spend their time in the Emergency Department, doing a variety of different shifts, with the purpose of providing a broad range of experience to achieve the above educational goals. Residents should communicate any specific areas of interest to the ED Education Director.
   • Residents are the primary care providers and have first-contact responsibility for a sufficient number of unselected patients presenting to the ED. Residents will be involved in discussion of patient presentation, generation of a differential diagnosis, development of a treatment plan, and patient follow up.
3. Case-based learning is most effective. Nightly reading/study should be based on patients seen during the day.
4. Residents may be asked to do focused literature searches or presentations during the course of the rotation.
5. Call and weekend responsibilities to be determined by Course Director.

• Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.

4. Residents have specialty-specific didactics and should be excused in a timely fashion to attend.