Rotation Details
Orientation Preparation
Goals and Objectives
Requirements
Policies and Procedures
Attendance
EM Management Pearls
Orientation Preparation
You are expected to review the following (on our website) before arrival:
1) Rotation Overview
2) Reading Materials
3) Downloadable Forms:
a) Approach to ED management
b) EM approach to stable and unstable patients
Goals and Objectives
Following the rotation the student will be able to:
1. Understand the EM-based approach, differential diagnosis, and management of patients presenting with:
a. Acute chest pain
b. Cardiac arrhythmias
c. Shock
d. Altered mental status
e. Syncope
f. Abdominal pain
g. Major trauma to the head, spine, thorax, abdomen, and extremities
h. Overdose
i. Seizure
j. Family violence
k. Environmental exposures
l. Hypertension emergencies vs. urgencies
m. Gastrointestinal bleeding
n. Eye complaints
o. Alcohol related emergencies
p. Diabetic emergencies
q. Asthma exacerbations
r. Acute headaches
s. Vaginal bleeding
t. Acute febrile illness
u. Acute musculoskeletal complaints
v. Psychotic behavior
2. Describe
a. Appropriate wound management, including suturing and tetanus prophylaxis.
c. Indications, complications and techniques of splint application.
Requirements
In order to receive PASS for this elective, the medical student must:
1. Be on time and work hard during all scheduled shift hours
2. See at minimum 75% of the index cases (your goal should be 100%). This must be documented on your handout and turned in to Gay at the end of the rotation.
3. Maintain a log of all patients you have managed primarily, and follow-up on four patients during the month. Turn this log into Gay at the end of the rotation.
4. Obtain “Satisfactory” or higher on all of your clinical evaluations.
5. Score 70% or more on the written final exam.
6. Attend the orientation meeting.
7. Attend the suturing/splinting workshop.
8. Attend at least 75% of medical student lectures
9. Attend at least 75% of DEM Grand Rounds (Thursdays 9:00a – 1p).
Failure to complete these requirements will result in an “Incomplete or Fail” grade. Any questions, scheduling problems, or exceptions must be discussed with Dr. Fernandez in advance.
Policies and Procedures
1. Students, interns and residents on this elective rotation are to be supervised by Emergency Medicine residents, mid-level providers (NP/PA), and/or attending physicians only. Elective students, interns and residents are not to be supervised by, or follow orders from, others. (e.g. interns, non-DEM residents, or consultants).
2. When in doubt ASK! There is almost never such a thing as a “stupid question”. The sign of a mature medical student/intern is to know what you know, know what you don’t, be willing to admit that you don’t, and be willing to improve your knowledge by seeking out assistance.
3. Use the DEM residents,and attending staff as your main source of guidance. Other sources of information include: recommended reading and other major texts, online resources selected journal articles, teaching sessions, mentoring sessions and Journal Club. Other members of the department, including nurses, and physician assistants have a great deal of experience and can be another very good source of knowledge and assistance.
4. Medical students should never perform any invasive procedures or exams, e.g., arterial blood gases, LP, pelvic exams, incisions and drainage of abscesses, suturing, etc. unless they have discussed it with a DEM resident, midlevel provider, or attending and are actively supervised during the procedure.
5. Routinely, medical students perform venipuncture and start IV lines on their own patients. You should attempt these procedures frequently during the rotation, even if you already know how to perform them. If unsuccessful or you have never done this before, ask for help. Ultimately, the responsibility for starting lines is the RNs’ and residents’; however, they will undoubtedly appreciate your help during busy times.
6. If you sustain a needlestick while working in the DEM, you must inform your resident or th attending immediately. This is to ensure you receive the proper documentation and management of your needle stick injury.
7. Please be professional and courteous at all times to patients, consultants, and staff, including nurses clerks, paramedics, and x-ray technicians.
8. Notify the nearest DEM resident or attending physician immediately if you notice that a patient appears acutely ill, in distress, or is worsening. Get help!
9. Occasionally you may be asked by a resident to help with tasks or duties on a patient other than your own, particularly in emergent situations with a relative manpower shortage. Please volunteer to help. You should not need to routinely transport patients though. If this occurs, please notify Dr. Fernandez
10. Medical students in the DEM must wear their ID badge fully visible at all times.
11. Standard attire is clean, matching, surgical scrubs with a white lab coat.
12. DEM Grand Rounds are held each Thursday morning from 9:00am to 1:00pm in GH Room 1645. These are mandatory. There are also weekly medical student lectures: please check with Gay for time and location. These lectures are also mandatory even if it is your day off. In order to pass the rotation, you must attend 75% of both conferences and lectures. Any scheduling exceptions must be discussed with Dr. Fernandez in advance.
13. Your learning experience centers around you seeing your own patients and actively/independently developing a differential diagnosis and plan. Merely observing someone else (passive learning) offers much less return than active learning.
14. There is no quota of patients to be seen during a shift; your rotation is learning oriented, not service oriented. Quality of care is emphasized over quantity of patient’s seen. Make sure you have finished with one patient (all orders entered) before starting to see another, unless you are just waiting for lab or XR results, etc.
15. Students do not take pass-ons at shift change without the direct involvement of a resident and attending. No exceptions.
16. Trading shifts with other students is not permitted without approval in advance by Dr. Fernandez.
17. When you leave the clinical area during a shift for any length of time (e.g. for food, lecture, workshop, or conference, or when finishing a shift), update the DEM resident you are assigned to as to the progress of your patient’s workup. At the end of a shift, it is your responsibility to pass-on the responsibility of care of each of your patients to a resident. Both you and your resident should always sign your charts. Even patients who have been dispositioned and are awaiting transportation home or for a bed should be passed on, if they remain in the area after you leave.
18. In general, take your meal breaks at the same time as your supervising resident.
19. If you need to be unexpectedly absent from an assigned shift (acceptable reasons include residency interviews, personal illness, or illness or death in your family) email Dr. Fernandez and call Gay at ext. 96812 during daytime hours. Always call the area to which you are assigned and speak with either your assigned resident, the “two star” resident or faculty. If they are not available contact any DEM resident in the area. Please ask them to notify Gay that you called.
20. Please attempt to arrange residency interviews on your days off. If you are schedule to have an interview during one of your assigned shifts, then permission to be absent must be obtained from Dr. Fernandez in advance. You also must provide Gay with proof of your interview in writing.
21. If you have prior commitments that you must keep during the elective (i.e. - tutoring, ongoing medical care), speak with Dr. Fernandez about this on the first day of your rotation in order to obtain approval and to make arrangements.
22. You must be present on your assigned shifts during your assigned hours. A very high degree of responsibility for attendance is required of our residents. The same level of responsibility for attendance is required of medical students and interns rotating through the DEM. Furthermore, you must be punctual at all lectures, workshops, and conferences in order to pass the rotation.
23, Students on elective are not allowed to work in the clinical areas aside from their assigned times, unless given permission by Dr. Fernandez or another DEM attending physician in advance.
24. If you have questions, comments, complaints, suggestions, etc., which cannot be addressed by your supervising resident, please notify Dr. Fernandez and Gay IMMEDIATELY for help! Don’t wait until the rotation is nearly ended,
25. All charts of patients worked up by interns and medical students must be co-signed by the assigned DEM Resident AND attending staff physician prior to patient disposition (discharge, admission, or transer).
26. All medication orders and prescriptions must be co-signed by your assigned resident or tattending.
27. When working in the clinical areas, introduce yourself to all staff, residents, attending physicians. That way, you will be recognized by everyone and taught when interesting cases or procedures arise.
28. It is your responsibility to request for evaluations from your supervising residents and attendings. You are required to give a blank evaluation form with your name on it to your supervising resident on the last day you are assigned to work with them. If you forget, you must contact Gay immediately, so that you can email that resident with two attachments containing: a) a blank evaluation form and b) a photograph of yourself. Additional evaluations (from other residents or attendings besides your assigned resident) are optional though highly encouraged. If you would like to find out if your evaluation has been submitted, you may call Gay Lewis-Taylor x96812.
Attendance
USC Keck School of Medicine Office of Student Affairs policy states that medical students who need time off, for academic reasons or for illness, may be granted ONLY 1 day off during each 4-week elective. If students need more days off, they will have to perform make-up work in the form of extra shifts, an ACLS course, or a paramedic ride-along during their own free time. All requested days off or trades must be approved in advance (Dr. Fernandez, Gay, and your resident should each be notified), and permission will frequently be granted but is not guaranteed until approved by Dr. Fernandez.
In order to pass this elective clerkship, students must demonstrate 100% professionalism and punctuality. This includes showing up on time for all scheduled shifts, lectures, workshops, and grand rounds conferences.
EM Management Pearls
1. Undifferentiated patients present with symptoms, not diagnoses. Therefore, you must be able to generate an EM-focused differential diagnosis for each chief complaint. THINK THE WORST FIRST. Our job is focused on the recognition and treatment of life-threatening conditions. For example, every patient with chest pain should have six life-threatening diagnoses reasonably ruled out by a detailed H+P: acute coronary syndrome (including MI and UA), aortic dissection, pulmonary embolism, esophageal rupture or perforation, tension pneumothorax, and cardiac tamponade.
2. The patients in the ED are often scared and in pain. Be aggressive about pain management and be sensitive to patients’ fears. Pain relief is a JCAHO mandate, and documentation of pain scores is now required.
3. Privacy issues are very important in the ED. This applies to your patient interview and any interactions you have with other staff when discussing the case. The HIPPA federal mandate attempts to deal with this issue and requires all of us to be particularly conscious of confidentiality. Make sure to log off of all computer programs when finished.
4. Timely patient disposition is our job. We don’t want to send patients home with a life threatening condition, yet we need to discharge patients who should go home efficiently. Patient flow is a major concern because it impacts the care of all of the patients in the department, including the waiting room.
6. Presenting your patients. This is a key part of your success during the rotation. Presentations to attendings and residents should be thorough and complete. Always include the following information. Why is the patient here? Abnormal vital signs? Pertinent red flags on history? Relevant positive or negative physical exam findings? EM-based differential diagnosis? Proposed work-up, treatment and disposition? When in doubt, be more thorough and conservative.
A great resource for you on this topic is http://www.saem.org/inform/patient.pdf.
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