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EMERGENCY MEDICINE RESIDENCY

Core CurriculumGoals and Objectives

2014-2015

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Table of Contents

Rotation Page(s)Legend 3Adult/Pediatric Emergency Medicine 4-27Anesthesiology 26-30Medical Intensive Care Unit 31-36CCU 37-42Ultrasound 43-48Surgical Intensive Care Unit (SICU) 48-55Radiology 56-59Obstetrics/Labor and Delivery 60-65Toxicology 66-70Emergency Medical Services (EMS) 71-75PICU 76-81Administration 82-86Orthopedics 87-91

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Legend:Milestone Level

Description

1 The resident demonstrates milestones expected of an incoming resident.2 The resident is advancing and demonstrating additional milestones, but is not

yet performing at a mid-residency level.3 The resident continues to advance and demonstrate additional milestones; the

resident demonstrates the majority of milestones targeted for residency in this sub-competency

4 The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target.

5 The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals, which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.

Core Competency (CC)ICS Interpersonal Communication Skills

MK Medical Knowledge

PC Patient Care

PBL Practice-based Learning and Improvement

Prof Professionalism

SBP System-based Practice

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Adult/Pediatric Emergency Medicine

EM-1 YearGoals: 1. Develop the fundamental skills of the practice of emergency medicine that include but are

not limited to:

a. Perform an appropriately focused history and physical examinationb. Develop an appropriate differential diagnosisc. Develop and carry out basic treatment plans through admission or discharge

Objectives:

At the end of the EM-1 year, the resident should achieve a level 2 (defined as advancing and demonstrating additional milestones, but is not yet performing at a mid-residency level) or higher for all milestones.

Milestone Objective CC AssessmentMethod

Level 1: Recognizes abnormal vitals signs.Level 2: Recognizes when a patient is unstable requiring immediate intervention.Performs a primary assessment on a critically ill or injured patient.Discerns relevant data to formulate a diagnostic impression and plan.

PC Observed resuscitation, simulated patient encounters, checklists,

Level 1: Perform and communicates a reliable, comprehensive history and physical exam.

Level 2: Perform and communicates a reliable, comprehensive history and physical exam which effectively addresses the chief complaint and urgent patient issues.

PC Global ratings of live performance, mock oral boards, simulation

Level 1: Determines the necessity of diagnostic studies.

Level 2: Orders appropriate diagnostic studies.Performs appropriate bedside diagnostic studies and procedures.

PC Oral Boards, standardized exams (ITE), chart review, simulation

Level 1: Constructs a list of potential diagnoses based on chief complaint and initial assessment.

Level 2: Constructs a list of potential diagnoses, based on the greatest likelihood of occurrence. Constructs a list of potential diagnoses with the greatest potential for morbidity and mortality.

PC as baseline, global and shift evaluations, simulation, mock oral boards, chart review

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Level 1: Knows the different classifications of pharmacologic agents and their mechanism of action. Consistently asks patients for drug allergies.

Level 2: Applies medical knowledge for selection of appropriate agent for therapeutic intervention. Considers potential adverse effects of pharmacotherapy.

PC MK

ITE, mock oral boards, global evaluations, shift evals

Level 1: Recognizes the need for patient re-evaluation.

Level 2: Monitors that necessary therapeutic interventions are performed during a patient’s ED stay.

PC Mock oral boards, shift evaluation, simulation

Level 1: Describes the basic resources available for care of the ED patient.

Level 2: Formulates a specific follow-up plan for common ED complaints with appropriate resource utilization.

PC SBP

Shift evaluations, simulation, chart review, multi-source feedback

Level 1: Manages a single patient amidst distractions.

Level 2: Task switches between different patients.

PC Simulation, multi-source feedback, shift evaluation

Level 1: Identifies pertinent anatomy and physiology for a specific procedure. Uses appropriate Universal Precautions.

Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.

PC MK

Procedure logs, simulation, cadaver lab, mock oral boards

Level 1: Describes upper airway anatomy. Performs basic airway maneuvers or adjuncts (jaw thrust/chin lift/oral airway/NPA) and ventilates/oxygenates using BVM.

Level 2: Describes elements of airway assessment and indications impacting the airway management. Describes the pharmacology of agents used for rapid sequence intubation including specific indications and contraindications. Performs RSI in patients with adjuncts. Confirms proper ETT placement using multiple modalities.

PC MK

Shift cards, cadaver labs, simulation, SDOT, procedure log

Level 1: Discusses with the patient indications, contraindications and possible complications of local anesthesia. Performs local anesthesia using appropriate doses of local anesthetic and appropriate technique to provide skin to sub-dermal anesthesia for procedures.

Level 2: Knows the indications, contraindications, potential complications and appropriate doses of analgesic/sedative

PC, MKICS

Simulation, shift evaluations, mock oral boards, global assessment, procedure log

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medications. Knows the anatomic landmarks, indications, contraindications, potential complications and appropriate doses of local anesthetics used for regional anesthesia.Level 1: Describes the indications for emergency ultrasound.

Level 2: Explains how to optimize ultrasound images and identifies the proper probe for each of the focused ultrasound applications. Performs an eFAST

PC, MK

Simulation, videotape review, procedure log

Level 1: Prepares a simple wound for suturing (identifying appropriate suture material, anesthetize wound and irrigate.Demonstrate sterile technique. Places a simple interrupted suture.

Level 2: Uses medical terminology to clearly describe/classify a wound (e.g., stellate, abrasion, avulsion, laceration, deep vs superficial). Classifies burns with respect to depth and body surface area. Compares and contrasts modes of wound management (adhesives, steri-strips, hair apposition, staples) identifies wounds that require antibiotics or tetanus prophylaxis.Educates patients on appropriate outpatient management of their wound.

PC MK ICS Prf

Simulation, mock oral boards, global and shift evaluations, procedure log

Level 1: Performs venipuncture. Arterial puncture and places a peripheral line.

Level 2: Describes the indications, contraindications, anticipated undesirable outcomes and complications for various vascular access modalities. Performs insertion of: an arterial catheter, CVP using ultrasound and universal precautions, intraosseous access. Assesses the indications in conjunction with the patient anatomy/pathophysiology and select the optimal site for a CVP catheter. Confirms appropriate placement of CVP catheter.

PCMKICS

Simulation, global and shift evaluations, procedure logs

Level 1: Passes initial national licensing exams (USMLE step 1 and step 2 or COMLEX 1 and 2).

Level 2: Resident develops and completes a self-assessment plan based on the ITE results. Completes objective residency training program examinations and/or assessments at an acceptable score for specific rotations.

MK USMLE, COMLEX, ITE, on line question banks, monthly modular exams

Level 1: Adheres to standards for maintenance of a safe working environment. Describes medical errors and adverse events.

Level 2: Routinely uses basic patient safety practices, such as time-outs and “calls for help.”

PCSBPProf

Global and shift evaluations, multi-source feedback

Level 1: Describes members of the ED team (ex nurses, technicians and security)

Level 2: Mobilizes institutional resources to assist in patient care.Participates in patient satisfaction initiatives.

PCICSSBPProf

Global and shift evaluations, multi-source feedback, simulation

Level 1: Uses the electronic health record (EHR) t order tests, medications and document notes and respond to alerts. Reviews

PCICS

Simulations, global and shift

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medications for patients.

Level 2: Ensures that medical records are complete, with attention to preventing confusion and error. Effectively and ethically use technology for patient care, medical communication and learning.

SBPProf

evaluations, multi-source feedback.

Level 1: Describes basic principles of evidence-based medicine.

Level 2: Performs patient follow-up.

PBLMK

Journal club, simulation, patient follow-up logs, global evaluations

Level 1: Demonstrates behavior that conveys caring, honesty, genuine interest and tolerance when interacting with a diverse population of patients and families.

Level 2: Demonstrates an understanding of the importance of compassion, integrity, respect, sensitivity and responsiveness and exhibits these attitudes consistently in common/uncomplicated situations and with diverse populations.

ProfICS

Mock oral boards, simulation, multi-source feedback, global and shift evaluations

Level 1: Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress/grooming, rested and ready to work, delivery of patient care as a functional physician.Maintain patient confidentiality. Uses social media ethically and responsibly. Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, procedure reporting.

Level 2: Identifies basic principles of physician wellness, including sleep hygiene. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance.Demonstrates knowledge of alertness management and fatigue mitigation principles.

ProfICS

Mock oral boards, simulation, multi-source feedback, global and shift evaluations, direct observation

Level 1: Establishes rapport with and demonstrate empathy toward patients and their families. Listens effectively to patients and their families.

Level 2: Elicits patients’ reasons for seeking care and expectations from the ED visit. Negotiates and manages simple patient/family-related conflicts.

ProfICSPC


Level 1: Participates as a member of a patient care team.

Level 2: Communicates pertinent information to emergency physicians and other health colleagues.

ProfICSPC

Direct observation, mock oral boards, simulation, multi-source feedback, global and shift evaluations

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EM-2 YearGoals:1. Develop skills in efficiency that include but are not limited to the above plus:

a. Develop proficiency in multi-taskingb. Develop and institute more advanced treatment plansc. Develop and hone resuscitation skillsd. Begin to develop bedside teaching skills

Objectives:At the end of the EM-2 year, the resident should achieve at least a level 2 (defined as advancing and demonstrating additional milestones, but is not yet performing at a mid-residency level) for all milestones and may be approaching a level 3 (defined as a resident who continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency) for some milestones.


Level 2: Recognizes when a patient is unstable requiring immediate intervention. Performs a primary assessment on a critically ill or injured patient. Discerns relevant data to formulate a diagnostic impression and plan.

Level 3: Manages and prioritizes critically ill or injured patients. Prioritizes critical initial stabilization actions in the resuscitation of a critically ill or injured patient. Reassesses after implementing a stabilizing intervention.Evaluates the validity of a DNR order.


Level 2: Performs and communicates a reliable, comprehensive history and physical exam which effectively addresses the chief complaint and urgent patient issues.

Level 3: Prioritizes essential components of a history given a limited or dynamic circumstance. Prioritizes essential components of a physical examination given a limited or dynamic circumstance.


Level 2: Orders appropriate diagnostic studies. Performs appropriate bedside diagnostic studies and procedures.

Level 3: Prioritizes essential testing. Interprets results of a diagnostic study, recognizing limitations and risks, seeking interpretive assistance when appropriate. Reviews risks, benefits, contraindications, and alternatives to a diagnostic study or procedure.



Level 3: Uses all available medical information to develop a list of differential diagnoses including those with the greatest potential for morbidity or mortality. Correctly identifies “sick versus not sick” patients.Revises a differential diagnosis in response to changes in a patient’s course over time.


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Level 3: Considers array of drug therapy for treatment. Selects appropriate agent based on mechanism of action, intended effect, and anticipates potential adverse effects. Considers and recognizes potential drug to drug interactions.

PC MK



Level 3: Identifies which patients will require observation in the ED.Evaluates effectiveness of therapies and treatments provided during observation. Monitors a patient’s clinical status at timely intervals during their stay in the ED.


Level 2: Formulates a specific follow-up plan for common ED complaints with appropriate resource utilization.

Level 3: Formulates and provides patient education regarding diagnosis, treatment plan, medication review and PCP/consultant appointments for complicated patients Involves appropriate resources (e.g., PCP, consultants, social work, PT/OT, financial aid, care coordinators)in a timely manner. Makes correct decision regarding admission or discharge of patients. Correctly assigns admitted patients to an appropriate level of care (ICU/Telemetry/Floor or observation unit).

PC SBP



Level 3: Employs task switching in an efficient and timely manner in order to manage multiple patients.


Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.

Level 3: Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.

PC MK



Level 3: Uses airway algorithms in decision making for complicated patients employing airway adjuncts as indicated. Performs rapid sequence intubation in patients using airway adjuncts Implements post-intubation

PC MK


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management. Employs appropriate methods of mechanical ventilation based on specific patient physiology.Level 2: Knows the indications, contraindications, potential complications and appropriate doses of analgesic/sedative medications. Knows the anatomic landmarks, indications, contraindications, potential complications and appropriate doses of local anesthetics used for regional anesthesia.Level 3: Knows the indications, contraindications, potential complications and appropriate doses of medications used for procedural sedation. Performs patient assessment and discusses with the patient the most appropriate analgesic/sedative medication and administers in the most appropriate dose and route. Performs pre-sedation assessment, obtains informed consent and orders appropriate choice and dose of medications for procedural sedation. Obtains informed consent and correctly performs regional anesthesia. Ensures appropriate monitoring of patients during procedural sedation.

PC, MKICS


Level 2: Explains how to optimize ultrasound images and identifies the proper probe for each of the focused ultrasound applications. Performs an eFAST.

Level 3: Performs goal-directed focused ultrasound exams. Correctly interprets acquired images.

PC, MK


Level 2: Uses medical terminology to clearly describe/classify a wound (e.g., stellate, abrasion, avulsion, laceration, deep vs superficial). Classifies burns with respect to depth and body surface area. Compares and contrasts modes of wound management (adhesives, steri-strips, hair apposition, staples) identifies wounds that require antibiotics or tetanus prophylaxis. Educates patients on appropriate outpatient management of their wound.

Level 3: Performs complex wound repairs (deep sutures, layered repair, corner stitch). Manages a severe burn. Determines which wounds should be closed primarily. Demonstrates appropriate use of consultants. Identifies wounds that may be high risk and require more extensive evaluation (ex: x-ray, ultrasound, and/or exploration).

PC MK ICS Prof



Level 3: Inserts a CVP catheter without ultrasound when appropriate. Places an ultrasound guided deep vein catheter (ex: basilica, brachial and cephalic veins).

PCMKICS


Level 2: Resident develops and completes a self-assessment plan based on the ITE results. Completes objective residency training program examinations and/or assessments at an acceptable score for specific rotations.


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Level 3: Demonstrates improvement of the percentage correct on the ITE or maintain an acceptable percentile ranking.Level 2: Routinely uses basic patient safety practices, such as time-outs and “calls for help.” Level 3: Describes patient safety concepts.Employs processes (ex: checklists, SBAR), personnel, and technologies that optimize patient safety (SBAR). Appropriately uses system resources to improve both patient care and medical knowledge.

PCSBPProf



Level 3: Practices cost-effective care. Demonstrates the ability to call effectively on other resources in the system to provide optimal health care.

PCICSSBPProf



Level 3: Recognizes the risk of computer shortcuts and reliance upon computer information on accurate patient care and documentation.

PCICSSBPProf

Simulations, global and shift evaluations, multi-source feedback.


Level 3: Performs self-assessment to identify areas for continued self-improvement and implements learning plans. Continually assesses performance by evaluating feedback and assessment. Demonstrates the ability to critically appraise scientific literature and apply evidence-based medicine to improve one’s individual performance.

PBLMK



Level 3: Recognizes how own personal health beliefs and values impact medical care; consistently manages own values and beliefs to optimize relationships and medical care. Develops alternate care plans when patients’ personal decisions/beliefs preclude the use of commonly accepted practices.

ProfICS


Level 2: Identifies basic principles of physician wellness, including sleep hygiene. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance. Demonstrates knowledge of alertness management and fatigue mitigation principles.

Level 3: Consistently recognizes limits of knowledge in uncommon and complicated clinical situations; develops and implements plans for the best possible patient care. Recognizes and avoids inappropriate influences of marketing and advertising.

ProfICS



Level 3: Manages expectations of those who receive care in the ED and uses communication methods that minimize the potential for stress, conflict and misunderstanding. Effectively communicates with vulnerable

ProfICSPC


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populations, including both patients at risk and their families.Level 2: Communicates pertinent information to emergency physicians and other health colleagues.

Level 3: Develops working relationships across specialties and with ancillary staff. Ensures transitions of care are accurately and effectively communicated. Ensures clear communication and respect among the team members.

ProfICSPC


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EM-3 YearGoals:1. Develop skills in ED management and clinical competence that include but are not limited to the above plus:

a. Develop proficiency in multi-taskingb. Develop and institute more advanced treatment plansc. Develop and hone resuscitation skillsd. Begin to develop bedside teaching skills

Objectives:

At the end of the EM-3 year, the resident should achieve at least a level 3 (defined as a resident who continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency) for all milestones and may be approaching a level 4 (defined as a resident who is advanced so that he or she now substantially demonstrates the milestones targeted for residency) for some milestones.


Level 3: Manages and prioritizes critically ill or injured patients.Prioritizes critical initial stabilization actions in the resuscitation of a critically ill or injured patient. Reassesses after implementing a stabilizing intervention. Evaluates the validity of a DNR order.

Level 4: Recognizes in a timely fashion when further clinical intervention is futile. Integrates hospital support services into a management strategy for a problematic stabilization situation.



Level 4: Synthesizes essential data necessary for the correct management of patients using all potential sources of data.



Level 4: Uses diagnostic testing based on the pre-test probability of disease and the likelihood of test results altering management. Practices cost effective ordering of diagnostic studies. Understands the implications of false positives and negatives for post-test probability.


Level 3: Uses all available medical information to develop a list of differential diagnoses including those with the greatest potential for morbidity or mortality. Correctly identifies “sick versus not sick” patients. Revises a differential diagnosis in response to changes in a patient’s course over time.


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Level 4: Synthesizes all of the available data and narrows and prioritizes the list of weighted differential diagnoses to determine appropriate management.Level 3: Considers array of drug therapy for treatment. Selects appropriate agent based on mechanism of action, intended effect, and anticipates potential adverse effects. Considers and recognizes potential drug to drug interactions.

Level 4: Selects the appropriate agent based on mechanism of action, intended effect, possible adverse effects, patient preferences, allergies, potential drug-food and drug-drug interactions, financial considerations, institutional policies, and clinical guidelines, including patient’s age, weight, and other modifying factors.

PCMK


Level 3: Identifies which patients will require observation in the ED.Evaluates effectiveness of therapies and treatments provided during observation. Monitors a patient’s clinical status at timely intervals during their stay in the ED.

Level 4: Considers additional diagnoses and therapies for a patient who is under observation and changes treatment plan accordingly.Identifies and complies with federal and other regulatory requirements, including billing, which must be met for a patient who is under observation.


Level 3: Formulates and provides patient education regarding diagnosis, treatment plan, medication review and PCP/consultant appointments for complicated patients Involves appropriate resources (e.g., PCP, consultants, social work, PT/OT, financial aid, care coordinators) in a timely manner. Makes correct decision regarding admission or discharge of patients. Correctly assigns admitted patients to an appropriate level of care (ICU/Telemetry/Floor or observation unit).

Level 4: Formulates sufficient admission plans or discharge instructions including future diagnostic/therapeutic interventions for ED patients. Engages patient or surrogate to effectively implement a discharge plan.

PC SBP



Level 4: Employs task switching in an efficient and timely manner in order to manage the ED.


Level 3: Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.Level 4: Performs indicated procedures on any patients with challenging features (e.g. poorly identifiable landmarks, at extremes of age or with co-morbid conditions). Performs the indicated procedure, takes steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure.

PC MK


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Level 3: Uses airway algorithms in decision making for complicated patients employing airway adjuncts as indicated. Performs rapid sequence intubation in patients using airway adjuncts Implements post-intubation management. Employs appropriate methods of mechanical ventilation based on specific patient physiology.

Level 4: Performs airway management in any circumstance taking steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure. Performs a minimum of 35 intubations. Demonstrates the ability to perform a cricothyrotomy. Uses advanced airway modalities in complicated patients.

PC MK


Level 3: Knows the indications, contraindications, potential complications and appropriate doses of medications used for procedural sedation. Performs patient assessment and discusses with the patient the most appropriate analgesic/sedative medication and administers in the most appropriate dose and route. Performs pre-sedation assessment, obtains informed consent and orders appropriate choice and dose of medications for procedural sedation.Obtains informed consent and correctly performs regional anesthesia.Ensures appropriate monitoring of patients during procedural sedation.

Level 4: Performs procedural sedation providing effective sedation with the least risk of complications and minimal recovery time through selective dosing, route and choice of medications.

PC, MKICS


Level 3: Performs goal-directed focused ultrasound exams. Correctly interprets acquired images.

Level 4: Performs a minimum of 150 focused ultrasound examinations.

PC, MK


Level 3: Performs complex wound repairs (deep sutures, layered repair, corner stitch) Manages a severe burn. Determines which wounds should be closed primarily. Demonstrates appropriate use of consultants. Identifies wounds that may be high risk and require more extensive evaluation (ex: x-ray, ultrasound, and/or exploration).

Level 4: Achieves hemostasis in a bleeding wound using advanced techniques such as: cautery, ligation, deep suture, injection, topical hemostatic agents, and tourniquet. Repairs wounds that are high risk for cosmetic complications (such as eyelid margin, nose, ear).Describes the indications for and steps to perform an escharotomy.

PC MK ICS Prof


Level 3: Inserts a CVP catheter without ultrasound when appropriate.Places an ultrasound guided deep vein catheter (ex: basilica, brachial and cephalic veins).

Level 4: Successfully performs 20 central venous lines. Routinely gains venous access in patients with difficult vascular access.

PCMKICS


Level 3: Demonstrates improvement of the percentage correct on the ITE or maintain an acceptable percentile ranking.

MK USMLE, COMLEX, ITE, on line question banks, monthly

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Level 4: Obtains a score on the annual in- training examination that indicates a high likelihood of passing the national qualifying examinations. Successfully completes all objective residency training program examinations and/or assessments. Passes final national licensing examination (e.g. USMLE Step3 or COMLEX Level 3).

modular exams

Level 3: Describes patient safety concepts. Employs processes (ex: checklists, SBAR), personnel, and technologies that optimize patient safety (SBAR). Appropriately uses system resources to improve both patient care and medical knowledge.

Level 4: Develops and applies a consistent and appropriate approach to evaluating appropriate care, possible barriers and strategies to intervene that consistently prioritizes the patient’s best interest in all relationships and situations. Effectively analyzes and manages ethical issues in complicated and challenging clinical situations.

PCSBPProf



Level 4: Can form a plan to address impairment in one’s self or a colleague, in a professional and confidential manner. Manages medical errors according to principles of responsibility and accountability in accordance with institutional policy.

PCICSSBPProf



Level 4: Uses flexible communication strategies and adjusts them based on the clinical situation to resolve specific ED challenges, such as drug seeking behavior, delivering bad news, unexpected outcomes, medical errors, and high risk refusal- of-care patients

PCICSSBPProf



Level 4: Recommends changes in team performance as necessary for optimal efficiency. Uses flexible communication strategies to resolve specific ED challenges such as difficulties with consultants and other health care providers. Communicates with out-of-hospital and nonmedical personnel, such as police, media, hospital administrators.

PBLMK



Level 4: Applies performance improvement methodologies. Demonstrates evidenced-based clinical practice and information retrieval mastery. Participates in a process improvement plan to

ProfICS


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optimize ED practice.Level 3: Consistently recognizes limits of knowledge in uncommon and complicated clinical situations; develops and implements plans for the best possible patient care. Recognizes and avoids inappropriate influences of marketing and advertising.

Level 4: Participates in an institutional process improvement plan to optimize ED practice and patient safety. Leads team reflection such as code debriefings, root cause analysis, or M&M to improve ED performance. Identifies situations when the breakdown in teamwork or communication may contribute to medical error.

ProfICS


Level 3: Manages expectations of those who receive care in the ED and uses communication methods that minimize the potential for stress, conflict and misunderstanding. Effectively communicates with vulnerable populations, including both patients at risk and their families.

Level 4: Participates in processes and logistics to improve patient flow and decrease turnaround times (e.g., rapid triage, bedside registration, Fast Tracks, bedside testing, rapid treatment units, standard protocols, and observation units). Recommends strategies by which patients’ access to care can be improved. Coordinates system resources to optimize a patient’s care for complicated medical situations.

ProfICSPC



Level 4: Uses decision support systems in EHR (as applicable in institution).

ProfICSPC


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EM-4 YearGoals:1. Develop skills in ED management and clinical competence that include but are not limited to the above plus:

a. Supervise junior residents as they manage critically ill patientsb. Demonstrate administrative skills with attention to patient flowc. Demonstrate teaching skills at the bedside and during rounds

Objectives:

At the end of the EM-4 year, the resident is expected to achieve at least a level 4--defined as a resident who is advanced so that he or she now substantially demonstrates the milestones targeted for residency. Some residents may also achieve a level 5—defined as a resident who has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach Level 5.


Level 4: Recognizes in a timely fashion when further clinical intervention is futile. Integrates hospital support services into a management strategy for a problematic stabilization situation.

Level 5: Develops policies and protocols for the management and/or transfer of critically ill or injured patients.


Level 4: Synthesizes essential data necessary for the correct management of patients using all potential sources of data.

Level 5: Identifies obscure, occult or rare patient conditions based solely on historical and physical exam findings.


Level 4: Uses diagnostic testing based on the pre-test probability of disease and the likelihood of test results altering management. Practices cost effective ordering of diagnostic studies. Understands the implications of false positives and negatives for post-test probability.

Level 5: Discriminates between subtle and/or conflicting diagnostic results in the context of the patient presentation.


Level 4: Synthesizes all of the available data and narrows and prioritizes the list of weighted differential diagnoses to determine appropriate management.

Level 5: Uses pattern recognition to identify discriminating features between similar patients and avoids premature closure.

PC Baseline, global and shift evaluations, simulation, mock oral boards, chart review

18


Level 5: Participates in developing institutional policies on pharmacy and therapeutics.

PC MK


Level 4: Considers additional diagnoses and therapies for a patient who is under observation and changes treatment plan accordingly. Identifies and complies with federal and other regulatory requirements, including billing, which must be met for a patient who is under observation.

Level 5: Develops protocols to avoid potential complications of interventions and therapies.


Level 4: Formulates sufficient admission plans or discharge instructions including future diagnostic/therapeutic interventions for ED patients. Engages patient or surrogate to effectively implement a discharge plan.

Level 5: Works within the institution to develop hospital systems that enhance safe patient disposition and maximizes resource utilization.

PC SBP

SDOT, shift evaluations, simulation, chart review, multi-source feedback

Level 4: Employs task switching in an efficient and timely manner in order to manage the ED.

Level 5: Employs task switching in an efficient and timely manner in order to manage the ED under high volume or surge situations.


Level 4: Performs indicated procedures on any patients with challenging features (e.g. poorly identifiable landmarks, at extremes of age or with co-morbid conditions). Performs the indicated procedure, takes steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure.

Level 5: Teaches procedural competency and corrects mistakes.

PC MK


Level 4: Performs airway management in any circumstance taking steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure. Performs a minimum of 35 intubations. Demonstrates the ability to perform a cricothyrotomy. Uses advanced airway modalities in complicated patients.

Level 5: Teaches airway management skills to health care providers.

PC MK

Shift cards, cadaver labs, simulation, procedure log

Level 4: Performs procedural sedation providing effective sedation with the least risk of complications and minimal recovery time through

PC, MK

Simulation, shift evaluations, mock

19

selective dosing, route and choice of medications.

Level 5: Develops pain management protocols/care plans.

ICS oral boards, global assessment, procedure log


Level 5: Expands ultrasonography skills to include: advanced echo, TEE, bowel, adnexal and testicular pathology, and transcranial Doppler.

PC, MK

Simulation, videotape review, Procedure log, simulation, shift evaluations

Level 4: Achieves hemostasis in a bleeding wound using advanced techniques such as: cautery, ligation, deep suture, injection, topical hemostatic agents, and tourniquet. Repairs wounds that are high risk for cosmetic complications (such as eyelid margin, nose, ear). Describes the indications for and steps to perform an escharotomy.

Level 5: Performs advanced wound repairs, such as tendon repairs and skin flaps.

PC MK ICS Prf


Level 4: Successfully performs 20 central venous lines. Routinely gains venous access in patients with difficult vascular access.

Level 5: Teaches advanced vascular access techniques.

PCMKICS



Level 5: Passes ABEM certifying examinations. Meets all the requirements for the ABEM Maintenance of Certification program set forth by national certifying agency.



Level 5: Develops institutional and organizational strategies to protect and maintain professional and bioethical principles.

PCSBPProf



Level 5: Develops institutional and organizational strategies to improve physician insight into and management of professional responsibilities.

PCICSSBPProf


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Trains physicians and educators regarding responsibility, wellness, fatigue, and physician impairment.

Level 4: Uses flexible communication strategies and adjusts them based on the clinical situation to resolve specific ED challenges, such as drug seeking behavior, delivering bad news, unexpected outcomes, medical errors, and high risk refusal- of-care patients.

Level 5: Teaches communication and conflict management skills.Participates in review and counsel of colleagues with communication deficiencies.

PCICSSBPProf



Level 5: Participates in and leads interdepartmental groups in the patient setting and in collaborative meetings outside of the patient care setting. Designs patient care teams and evaluates their performance.Seeks leadership opportunities within professional organizations.

PBLMK


Level 4: Applies performance improvement methodologies.Demonstrates evidenced-based clinical practice and information retrieval mastery. Participates in a process improvement plan to optimize ED practice.

Level 5: Independently teaches evidenced-based medicine and information mastery techniques.

ProfICS



Level 5: Uses analytical tools to assess healthcare quality and safety and reassess quality improvement programs for effectiveness for patients and for populations. Develops and evaluates measures of professional performance and process improvement and implements them to improve departmental practice.

ProfICS



ProfICSPC


21

Level 5: Creates departmental flow metric from benchmarks, best practices, and dash boards. Develops internal and external departmental solutions to process and operational problems. Addresses the differing customer needs of patients, hospital medical staff, EMS, and the community.


Level 5: Recommends systems re-design for improved computerized processes.

ProfICSPC


22

By the conclusion of the EM-4 year, the resident is expected to demonstrate competency and log at least the minimum required numbers of the following procedures:

Procedure Minimum number

Procedure Minimum number

Adult medical resuscitation 45 Intubations 35Adult trauma resuscitation 35 Lumbar puncture 15Anesthesia and pain management

* Pediatric medical resuscitation 15

Cardiac pacing 6 Pediatric trauma resuscitation 10Central Venous access 20 Pericardiocentesis 3Chest tubes 10 Procedural sedation 15Cricothyrotomy 3 Vaginal delivery 10Dislocation reduction 10 Vascular access *ED bedside ultrasound ** Wound management *

*The program director will assess each resident’s competency in these procedures as minimum numbers have not been set.

**The resident is to demonstrate competency in a minimum number of 25 scans in each of the following areas: eFAST, aorta, biliary tract, urinary tract, early pregnancy, cardiac, DVT

Rotation Experience:The objectives listed above will be achieved through the adult and pediatric Emergency Department rotations at Jacobi and Montefiore Medical Cemters.Preceptor: ED Attendings

A. Clinical Activities EM-1 and EM-2 Year

1. All entering EM-1 residents will receive a one-day orientation to the Emergency Department (ED).

2. All residents will be certified in BLS, ACLS and PALS unless certification has already been achieved.

3. The resident will perform the initial evaluation of patients triaged to the ED 4. The resident will formulate a working diagnosis, treatment plan and disposition

on every patient evaluated for discussion and consultation with the EM-3 or EM-4 resident and/or attending physician.

5. The resident will perform procedures under the guidance of EM-3 or EM-4 residents and/or attending physician.

6. The resident will receive bedside teaching and supervision from the EM-3 or EM-4 resident and the attending physician supervising that designated area of the ED. All cases must be presented to the attending for management and disposition decisions.

7. The resident will maintain adequate electronic health records (EHR) of the patients in his or her care.

23

8. The EM-1 and EM-2 resident’s charts will be reviewed by the EM-3 and EM-4 residents and will be co-signed by the attending physician prior to the discharge of the patient.

9. The resident will serve as a junior member of the trauma team under the organizational leadership of the EM-3 resident, EM-4 resident, senior-level trauma residents and attending physicians.

10. The resident must maintain a record of any manipulative procedures which will be reviewed monthly be the program director or designated faculty member.

EM-3 Year1. The resident will monitor and prioritize management for all patients in the

designated area in the ED.2. The resident will decide upon a working differential diagnosis, treatment plan,

and disposition for each patient under the supervision of the EM-4 resident and the attending physician.

3. The resident will oversee the proper out-patient disposition planning of patients being discharged from the ED.

4. The resident will serve as the organizational team leader of the trauma team under the direct supervision of the EM-4 resident and attending physician.

5. The EM-3 resident will be the supervising member of cardiorespiratory arrests, whose authority is be superseded by the EM-4 resident or attending physician.

6. The resident will serve as the interface between the ED and the surgical trauma team when the two services are managing the patient.

7. The resident will serve as the organizational leader of the ED staff leading rounds.

8. All cases must be presented to the attending for management and disposition decisions.

9. The resident will maintain a record of all manipulative procedures which will be reviewed monthly be the program director or designated faculty member.

EM-4 YearUniversity Hospital:

1. The resident will provide on-line teaching and supervision for the senior medical students, rotating interns and EM-1, EM-2 and EM-3 residents.

2. The resident will receive on-line supervision and teaching from the attending physician.

3. The resident will assist in training the EM-1, EM-2 and EM-3 residents in performance of manipulative procedures.

4. The EM-4 will serve as the primary diplomatic interface between the designated area in the ED and the various in-patient and consultative services when disagreements arise.


6. The resident will maintain a record of all manipulative procedures.

24

East Orange Veteran’s Administration Hospital: 1. The EM-4 resident will primarily evaluate, perform diagnostic procedures and

formulate treatment plans for patients under the direct supervision of EM faculty.2. The EM-4 will serve as the primary diplomatic interface between the designated area

in the ED and the various in-patient and consultative services when disagreements arise.


4. The resident will maintain a record of all manipulative procedures.5. All EHR will be reviewed and co-signed by the supervising EM faculty member.

A. Evaluation The resident will be evaluated using milestone-based shift cards (either electronic or paper) at least 10 shifts per EM block. Each shift-card will be discussed with the resident after completion of the evaluation for immediate feedback. Both resident and faculty members must sign the shift cards. Residents will be given the opportunity to input comments on the shift cards following review with the faculty member. All shift cards will be reviewed by the Clinical Competency Committee (CCC) and a summary of all shift cards will be presented to the resident during the biannual global evaluation.

B. Feedback 1. Immediate feedback will be given to the resident by the attending on a case-by-

case basis and after each shift.2. Each resident will maintain a log of manipulative skills performed that will be

reviewed periodically by the program director or designated faculty member.C. Remediation

At a minimum of twice yearly, the program director, in conjunction with the CCC, will determine whether the EM resident is competently meeting program requirements and achieving appropriate milestone levels. Residents found to be deficient in their performance will be remediated in a manner based in the competency that was judged as insufficient. Remediation plans may include but are not limited to:

2. Medical Knowledge and Practice-Based Learning: a. Residents will be assigned additional required reading and assigned an

examination that they must pass. b. Develop and conduct a lecture pertinent to emergency medicine under

the supervision of the preceptor.c. Development of an individualized learning plan which may include:

online review questions, assigned podcasts, one-on-one faculty mentoring.

25

d. Intense review of patient case follow-up logs.3. Professionalism:

a. Residents will be counseled regarding their deficiency and assigned a self-reflective writing project addressing the issue.

b. Residents may be asked to complete online courses pertaining to specific professionalism issues.

c. One-on-one faculty mentoring.4. Systems based practice:

a. Residents will be assigned a faculty mentor for close evaluation of QA/PI projects.

b. Residents may be asked to serve on specific hospital committees.5. Communication and interpersonal skills:

a. Residents will be counseled and monitored closely for improvement.b. Development of an independent learning plan including but not limited

to: one-on-one faculty mentoring, simulation exercises, online courses regarding communication.

6. Patient Care:a. An individualized learning plan will be created that includes but is not

limited to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs, ultrasound shifts.

D. Required Reading Texts 1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 th Ed , Tintinalli

JE et al. McGraw-Hill, New York 2011.2. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8 th Ed , Marx JA,

Hockberger RS, Walls RM. Saunders, Philadelphia, 2014.3. Clinical Procedures in Emergency Medicine. 6 th Ed , Roberts JR, Hedges JR.

W.B. Saunders Co, Philadelphia, 2014.4. Advanced Trauma Life Support Manual for Physicians, 9th Ed. American College

of Surgeons, 2012.5. Advanced Cardiac Life Support. American Heart Association, 2011.6. Goldfrank’s Toxicologic Emergencies. 9 th Ed, Nelson LS, et al. New York,

McGraw Hill, 2011.7. Pediatric Advanced Life Support (PALS). Disque KA. Satori Continuum

Publishing, 2013.

E. Additional Resources 1. Online podcasts: EM Rap, EM Crit, Sono Sound2. Emergency Medicine Periodicals: Annals of Emergency Medicine, Academic

Emergency Medicine, Journal of Emergency Medicine3. Online question banks: Rosh review, Q bank, CORD question bank, Peer VIII

26

Anesthesia Rotation

EM-1 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Anesthesia that include but are not limited to:1. Perform an appropriately focused history and physical examination2. Perform appropriate airway needs assessment for preoperative patients 3. Develop competence in providing definitive airways by a variety of techniques for

adults and children

Objectives: At the end of the this rotation the resident should achieve competency in all nonmilestone based objectives and approach a level 2 (defined as advancing and demonstratingadditional milestones, but is not yet performing at a mid-residency level) or higher for allmilestones.

Non-Milestone Objective CC Assessment Method

Perform endotracheal intubations under the supervision of the Anesthesiology attending physician.

PC Direct observation, rotation evaluation

Demonstrate competency in airway management skills including: Demonstrate knowledge of the normal anatomy of the upper

airway in all age groups Oropharyngeal and nasopharyngeal airways CPAP and BiPAP masks Bag-valve mask device Endotracheal and nasotracheal intubation Use of LMA and other advanced airway techniques Mechanical ventilators

PCMK

Direct observation, rotation evaluation, ITE

Demonstrate the way to use and interpret standard hemodynamic and respiratory monitoring modalities including:

Pulse oximetry End-tidal CO2 monitoring/capnometry

PCMK


Milestone Objective CC Assessment Method

Level 1: Knows the different classifications of pharmacologic agents and their mechanism of action. Consistently asks patients for drug allergies.


PC MK

SDOT, ITE, mock oral boards, global evaluations, shift evals


Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and

PC MK


27

potential complications for common ED procedures.Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications Performs post-procedural assessment and identifies any potential complications.Level 1: Describes upper airway anatomy. Performs basic airway maneuvers or adjuncts (jaw thrust/chin lift/oral airway/NPA) and ventilates/oxygenates using BVM.


PC MK

Direct observation, procedure logs

Level 1: Discusses with the patient indications, contraindications and possible complications of local anesthesia. Performs local anesthesia using appropriate doses of local anesthetic and appropriate technique to provide skin to sub-dermal anesthesia for procedures.

Level 2: Knows the indications, contraindications, potential complications and appropriate doses of analgesic/sedative medications.Knows the anatomic landmarks, indications, contraindications, potential complications and appropriate doses of local anesthetics used for regional anesthesia.

PC, MKICS

Direct observation



PCSBPProf

Direct observation, rotation evaluation

Level 1: Uses the electronic health record (EHR) to order tests, medications and document notes and respond to alerts. Reviews medications for patients.


PCICSSBPProf

Direct observation, rotation evaluation, chart review



PBLMK




ProfICS


Level 1: Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress/grooming, rested and ready to work,

ProfICS


28

delivery of patient care as a functional physician. Maintain patient confidentiality. Uses social media ethically and responsibly.Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, procedure reporting.

Level 2: Identifies basic principles of physician wellness, including sleep hygiene. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance. Demonstrates knowledge of alertness management and fatigue mitigation principles.Level 1: Establishes rapport with and demonstrate empathy toward patients and their families. Listens effectively to patients and their families.


ProfICSPC




ProfICSPC


Rotation ExperienceEM-1 Year, 1 block (2-week) rotation at Jacobi Medical Center

Preceptor: Anesthesia

A. Clinical Activities1. The resident will work in the operating room five days per week under the direct

supervision of an attending anesthesiologist.2. The resident’s responsibilities will include:

a. Perform pre-operative patient assessmentb. Select and administer medication to induce anesthesia and neuromuscular

blockadec. Provide definitive airway management for the patient on a case-dependent

basisd. Participate in monitoring of ventilatory and hemodynamic status during

relatively brief procedures.e. The resident will log the procedures accomplished during the rotation.

B. Evaluations 1. At the time of completion of the rotation, the preceptor will submit a formal

evaluation of the rotation.2. Residents will additionally provide the program with anesthesia faculty names with

whom they have worked extensively for evaluation since rotation experiences can vary, who will be assigned rotation evaluations.

29

C. Feedback 1. Residents will be provided with real time feedback by their preceptor/supervisor

during their OR time.2. Residents will receive feedback on their rotation performance at their bi-annual

evaluation.D. Remediation



examination that they must pass. b. Develop and conduct a lecture pertinent to anesthesiology under the

supervision of the preceptor.c. Development of an individualized learning plan which may include:


d. Intense review of procedure logs.2. Professionalism:









limited to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs.

30

E. Reading Assignments1. Residents are encouraged to complete any reading assignments from the

Anesthesiology department.2. The following Chapters in the textbooks indicated below:

a. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 th Ed, Tintinalli JE et al. McGraw-Hill, New York 2011.

Chapter 28: Nonivasive Airway Management Chapter 29: Pediatric Airway Management Chapter 30: Tracheal Intubation and Mechanical Ventilation Chapter 38: Acute Pain Management in Adults Chapter 39: Pain management in Infants and Children Chapter 40: Local and Regional Anesthesia Chapter 42: Adults and Chronic Pain

b. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8 th Ed , Marx JA, Hockberger RS, Walls RM. Saunders, Philadelphia, 2014.

Chapter 1: Airway Chapter 2: Mechanical Ventilation and Noninvasive Ventilatory

Support Chapter 3: Pain Management Chapter 4: Procedural Sedation and Analgesia

c. Clinical Procedures in Emergency Medicine. 6 th Ed , Roberts JR, Hedges JR. W.B. Saunders Co, Philadelphia, 2014.

d. Advanced Trauma Life Support Manual for Physicians, 9th Ed. American College of Surgeons, 2012.

F. Additional Resources1. Online podcasts: EM Rap, EM Crit, Sono Sound2. Emergency Medicine Periodicals: Annals of Emergency Medicine, Academic


31

Medical Intensive Care Unit (MICU)-University Hospital

EM-1 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Critical Care that include but are not limited to:1. Perform an appropriately focused history and physical examination2. Provide daily monitoring and management of MICU patients 3. Develop procedural skills and carry out treatment plans through discharge

Objectives:At the end of the rotation, the resident should achieve competency in all non-milestone objectives a level 2 (defined as advancing and demonstrating additional milestones, but is not yet performing at a mid-residency level) or higher for all milestones.

Non-Milestone ObjectivesDescribes the different types and indications for invasive and non-invasive ventilation.Describes the major complications of mechanical ventilation.Demonstrates competent ventilator management strategies.Describes the hemodynamic profile for various types of shock.Interprets arterial blood gases and acid-base disorders.Demonstrates and understanding of the pathophysiology and management of multiple organ failure.Identifies the indications for and complications of transfusion of blood products.

MKPC

Direct observation, Rotation evaluation


Level 1: Recognizes abnormal vitals signs.


PC Direct observation, Rotation evaluation







32




Level 1: Knows the different classifications of pharmacologic agents used in the treatment of critically ill patients and their mechanism of action. Consistently asks patients’ for drug allergies.


PC MK



Level 2: Monitors that necessary therapeutic interventions are performed during a patient’s ICU stay.






Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED and ICU procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.

PC MK


Level 1: Performs venipuncture, arterial puncture and places a peripheral line.


PCMKICS




PCSBPProf


Level 1: Describes members of the ICU team (ex nurses, technicians and security).

PCICS


33


SBPProf



PCICSSBPProf




PBLMK




ProfICS


Level 1: Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress/grooming, rested and ready to work, delivery of patient care as a functional physician. Maintain patient confidentiality. Uses social media ethically and responsibly. Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, procedure reporting.


ProfICS




ProfICSPC




ProfICSPC


34

Rotation ExperienceEM-1 Year, 2 Block (4-week) rotation in the MICU at Jacobi Medical CenterPreceptor: Dept. of medicine Dr. Gutwein

A. Clinical activities 1. The resident will admit, manage, and discharge critically ill patients under the

supervision of the critical care attending physicians and fellows.2. The EM-1 resident will perform all necessary invasive procedures on MICU

patients assigned to them.3. The resident will document all notes and summaries according to standards in

the MICU.4. The resident will attend all MICU conferences and rounds unless excused by

their supervisors.5. The resident will participate in all codes according to the standards in the MICU.6. The resident will be required to attend the emergency medicine core lecture

conferences when possible.7. The resident must record all manipulative procedures in the procedure log.8. The resident will comply with all duty hours documented in the EM program

requirements and keep a daily log of duty hours (to be reviewed by the program director or his/her designee).

B. Evaluation 1. Upon completion of the rotation, a formal written evaluation will be submitted by

the critical care attendings to the program director. Evaluations will be reviewed by the CCC, PD and residency administration and discussed with the resident.

C. Feedback 1. The resident will receive informal real-time feedback from the critical care fellows,

senior residents, chief residents, and faculty during the one-month block.2. The evaluation will be incorporated into the formal bi-annual review with the PD,

APD, or designee.3. Programmatic features of the rotation will be discussed informally at monthly

resident/attending meetings.D. Remediation



examination that they must pass.

35

b. Develop and conduct a lecture pertinent to critical care under the supervision of the preceptor.

c. Development of an individualized learning plan which may include: online review questions, assigned podcasts, one-on-one faculty mentoring, literature review.











E. Reading Assignment Residents are encouraged to complete any reading assignments from the Medicine Department and the Division of Critical Care.The following Chapters in the textbooks indicated below:

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 th Ed , Tintinalli JE et al. McGraw-Hill, New York 2011.

Chapter 28: Nonivasive Airway Management Chapter 30: Tracheal Intubation and Mechanical Ventilation Chapter 33: Venous and Intraosseous Access in Adults Chapter 34: Hemodynamic Monitoring Chapter 35: Cardiac Pacing Chapter 36: Defibrillation and Cardioversion

2. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8 th Ed , Marx JA, Hockberger RS, Walls RM. Saunders, Philadelphia, 2014.

Chapter 1: Airway

36

Chapter 2: Mechanical Ventilation and Noninvasive Ventilatory Support

Chapter 5: Monitoring the Emergency Patient Chapter 6: Shock Chapter 7: Blood and Blood Componenets Chapter 8: Adult Resuscitation

3. Appropriate chapters in the flowing text pertaining to procedures performed in the MICU: Clinical Procedures in Emergency Medicine. 6 th Ed , Roberts JR, Hedges JR. W.B. Saunders Co, Philadelphia, 2014.

F. Additional Resources Online podcasts: EM Rap, EM Crit, Sono Sound Emergency Medicine Periodicals: Annals of Emergency Medicine,

Academic Emergency Medicine, Journal of Emergency Medicine Online question banks: Rosh review, Q bank, CORD question bank,

Peer VIII

37

Cardiac Intensive Care Unit (CCU)-Jacobi/Einstein Hospitals

EM-1 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Cardiac Intensive Care that include but are not limited to:4. Perform an appropriately focused history and physical examination5. Provide daily monitoring and management of CCU patients 6. Develop procedural skills and carry out treatment plans through discharge

Objectives:At the end of the rotation, the resident should achieve competency in all non-milestone objectives a level 2 (defined as advancing and demonstrating additional milestones, but is not yet performing at a mid-residency level) or higher for all milestones.

Non-Milestone ObjectivesDescribes the different types and indications for invasive and non-invasive ventilation.Describes the major complications of mechanical ventilation.Demonstrates competent ventilator management strategies.Describes the hemodynamic profile for various types of shock.Interprets arterial blood gases and acid-base disorders.Demonstrates and understanding of the pathophysiology and management of multiple organ failure.Identifies the indications for and complications of transfusion of blood products.

MKPC



Level 1: Recognizes abnormal vitals signs.









38




Level 1: Knows the different classifications of pharmacologic agents used in the treatment of critically ill patients and their mechanism of action. Consistently asks patients’ for drug allergies.


PC MK



Level 2: Monitors that necessary therapeutic interventions are performed during a patient’s CCU stay.






Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED and CCU procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.

PC MK


Level 1: Performs venipuncture, arterial puncture and places a peripheral line.


PCMKICS




PCSBPProf


Level 1: Describes members of the CCU team (ex nurses, technicians and security).

PCICS


39


SBPProf



PCICSSBPProf




PBLMK




ProfICS




ProfICS




ProfICSPC




ProfICSPC


40

Rotation ExperienceEM-1,and EM-2 Year, 2*2 Block (4-week) rotation in the CCU at Jacobi Medical CenterPreceptor: Dept. of medicine Dr. Gutwein

G. Clinical activities 9. The resident will admit, manage, and discharge critically ill patients under the

supervision of the critical care attending physicians and fellows.10. The EM-1 and Em-2 resident will perform all necessary invasive procedures on

CCU patients assigned to them.11. The resident will document all notes and summaries according to standards in

the CCU.12. The resident will attend all CCU conferences and rounds unless excused by their

supervisors.13. The resident will participate in all codes according to the standards in the CCU.14. The resident will be required to attend the emergency medicine core lecture

conferences when possible.15. The resident must record all manipulative procedures in the procedure log.16. The resident will comply with all duty hours documented in the EM program

requirements and keep a daily log of duty hours (to be reviewed by the program director or his/her designee).

H. Evaluation 2. Upon completion of the rotation, a formal written evaluation will be submitted by

the critical care attendings to the program director. Evaluations will be reviewed by the CCC, PD and residency administration and discussed with the resident.

I. Feedback 4. The resident will receive informal real-time feedback from the critical care fellows,

senior residents, chief residents, and faculty during the one-month block.5. The evaluation will be incorporated into the formal bi-annual review with the PD,

APD, or designee.6. Programmatic features of the rotation will be discussed informally at monthly

resident/attending meetings.J. Remediation


6. Medical Knowledge and Practice-Based Learning: e. Residents will be assigned additional required reading and assigned an


41

f. Develop and conduct a lecture pertinent to critical care under the supervision of the preceptor.

g. Development of an individualized learning plan which may include: online review questions, assigned podcasts, one-on-one faculty mentoring, literature review.

h. Intense review of procedure logs.7. Professionalism:

d. Residents will be counseled regarding their deficiency and assigned a self-reflective writing project addressing the issue.

e. Residents may be asked to complete online courses pertaining to specific professionalism issues.

f. One-on-one faculty mentoring.8. Systems based practice:

c. Residents will be assigned a faculty mentor for close evaluation of QA/PI projects.

d. Residents may be asked to serve on specific hospital committees.9. Communication and interpersonal skills:

c. Residents will be counseled and monitored closely for improvement.d. Development of an independent learning plan including but not limited


10. Patient Care:b. An individualized learning plan will be created that includes but is not


K. Reading Assignment Residents are encouraged to complete any reading assignments from the Medicine Department and the Division of Critical Care.The following Chapters in the textbooks indicated below:




Chapter 1: Airway

42




L. Additional Resources Online podcasts: EM Rap, EM Crit, Sono Sound Emergency Medicine Periodicals: Annals of Emergency Medicine,


Peer VIII

43

Emergency Ultrasound Elective

EM-1 and EM-4 Year:

Goals:1. Develop and demonstrate proficiency in the fundamental skills of ultrasonography in the

Emergency setting that include but are not limited to: Perform FAST (Focused Assessment with Sonography in Trauma) examination Perform pelvic and obstetric ultrasound examination on pregnant patients Perform basic ultrasound examination of RUQ (specifically gallbladder) and lower

extremities (specifically vessel patency) Perform ultrasound guided procedures such as peripheral and central venous

catheter insertion

Objectives: At the end of the rotation, the resident is expected to achieve competency in all of the non-milestone based objectives. By the end of the EM-4 year, the resident is expected to achieve a level 4 in all milestones.

Non-milestone objective CC Assessment MethodBecome competent in selecting and performing ultrasound studies pertinent to the practice of emergency medicine such as:

eFAST exams First trimester Patency of lower extremity vascular patency RUQ ultrasound Renal/GU tract Cardiac ultrasound Ultrasound-assisted vascular access

PCMK

Direct observation, rotation evaluation, image review

Develop a structured approach to the interpretation of ultrasound findings.

PCMK

Direct observation, Rotation evaluation, image review

Demonstrate competency in knowing the indications and limitations of ultrasonography.

PCMK

Direct observation, rotation evaluation, image review

Milestone objective CC AssessmentMethod

Level 3: Performs goal-directed focused ultrasound exams.Correctly interprets acquired images


Level 5: Expands ultrasonography skills to include: advanced echo, TEE, bowel, adnexal and testicular pathology, and transcranial Doppler.

SDOT, simulation, videotape review, procedure log

Level 3: Determines a backup strategy if initial attempts to PC Procedure logs,

44

perform a procedure are unsuccessful.Correctly interprets the results of a diagnostic procedure.

Level 4: Performs indicated procedures on any patients with challenging features (e.g. poorly identifiable landmarks, at extremes of age or with co-morbid conditions). Performs the indicated procedure, takes steps to avoid potential complications, and recognizes the outcome and/or complications resulting from the procedure.

Level 5: Teaches procedural competency and corrects mistakes.

MK simulation, cadaver lab, mock oral boards



Level 5: Develops institutional and organizational strategies to protect and maintain professional and bioethical principles.

PCSBPProf

SDOT, global and shift evaluations, multi-source feedback

Level 3: Practices cost-effective care.Demonstrates the ability to call effectively on other resources in the system to provide optimal health care.


Level 5: Develops institutional and organizational strategies to improve physician insight into and management of professional responsibilities. Trains physicians and educators regarding responsibility, wellness, fatigue, and physician impairment.

PCICSSBPProf

SDOT, global and shift evaluations, multi-source feedback, simulation


Level 4: Uses flexible communication strategies and adjusts them based on the clinical situation to resolve specific ED challenges, such as drug seeking behavior, delivering bad news, unexpected outcomes, medical errors, and high risk refusal- of-care patients.

PCICSSBPProf

SDOT, simulations, global and shift evaluations, multi-source feedback.

45

Level 5: Teaches communication and conflict management skills. Participates in review and counsel of colleagues with communication deficiencies.

Level 3: Performs self-assessment to identify areas for continued self-improvement and implements learning plans.Continually assesses performance by evaluating feedback and assessment. Demonstrates the ability to critically appraise scientific literature and apply evidence-based medicine to improve one’s individual performance.


Level 5: Participates in and leads interdepartmental groups in the patient setting and in collaborative meetings outside of the patient care setting. Designs patient care teams and evaluates their performance. Seeks leadership opportunities within professional organizations.

PBLMK

Journal club, SDOT, simulation, patient follow-up logs, global evaluations

Level 3: Recognizes how own personal health beliefs and values impact medical care; consistently manages own values and beliefs to optimize relationships and medical care. Develops alternate care plans when patients’ personal decisions/beliefs preclude the use of commonly accepted practices

Level 4: Applies performance improvement methodologies.Demonstrates evidenced-based clinical practice and information retrieval mastery. Participates in a process improvement plan to optimize ED practice.

Level 5: Independently teaches evidenced-based medicine and information mastery techniques.

ProfICS

SDOT, mock oral boards, simulation, multi-source feedback, global and shift evaluations


Level 4: Participates in an institutional process improvement plan to optimize ED practice and patient safety. Leads team reflection such as code debriefings, root cause analysis, or M&M to improve ED performance. Identifies situations when the breakdown in teamwork or communication may contribute

ProfICS

SDOT, mock oral boards, simulation, multi-source feedback, global and shift evaluations, direct observation

46

to medical error.

Level 5: Uses analytical tools to assess healthcare quality and safety and reassess quality improvement programs for effectiveness for patients and for populations. Develops and evaluates measures of professional performance and process improvement and implements them to improve departmental practice.



Level 5: Creates departmental flow metric from benchmarks, best practices, and dash boards. Develops internal and external departmental solutions to process and operational problems. Addresses the differing customer needs of patients, hospital medical staff, EMS, and the community.

ProfICSPC

SDOT, mock oral boards, simulation, multi-source feedback, global and shift evaluations, direct observation



Level 5: Recommends systems re-design for improved computerized processes.

ProfICSPC

SDOT, direct observation, mock oral boards, simulation, multi-source feedback, global and shift evaluations

Rotation ExperienceEM-3 or EM-4 Year: 2-week or 4-week rotation, In the ED at University HospitalPreceptors: Dr. Andrew Shannon

A. Clinical Activities 1. The resident will attend regularly scheduled meetings with the Ultrasound faculty

in the Emergency Department.2. Residents will perform ultrasound examinations on patients deemed appropriate

for the six core areas of emergency ultrasound.

47

3. The resident will save all images and submit them for review.4. The resident will ensure that appropriate care and maintenance of the ultrasound

machine is achieved throughout the rotation.5. The resident will attend Wednesday EM conference and Friday conferences6. All procedures must be recorded in the procedure log.

B. Evaluation

The rotation preceptor upon completion of the rotation will submit a formal written evaluation.

C. Feedback 1. The resident will receive informal real time feedback from the EM attending

during the 4-week block.2. The evaluation will be incorporated into the formal biannual review with the

residency director.3. Programmatic features of the rotation will be discussed informally at monthly



1. Medical Knowledge and Practice-Based Learning: a. Residents will be assigned additional required reading and

assigned an examination that they must pass. b. Develop and conduct a lecture pertinent to emergency ultrasound

under the supervision of the preceptor.c. Development of an individualized learning plan, which may include:

online review questions, assigned podcasts, one-on-one faculty mentoring, literature review.







48

a. Residents will be counseled and monitored closely for improvement.

b. Development of an independent learning plan including but not limited to: one-on-one faculty mentoring, simulation exercises, online courses regarding communication.

5. Patient Care:a. An individualized learning plan will be created that may include but

is not limited to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs.

E. Reading Assignments

The appropriate corresponding Sections and/or Chapters in the textbooks indicated below:


Chapter e299.4: Emergency Ultrasound2. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8 th Ed , Marx

JA, Hockberger RS, Walls RM. Saunders, Philadelphia, 2014.3. Clinical Procedures in Emergency Medicine. 6 th Ed , Roberts JR, Hedges JR.

W.B. Saunders Co, Philadelphia, 2014.4. Manual of Emergency and Critical Care Ultrasound, 2 nd Ed. Noble VE, Nelson

BP. Cambridge University Press, Cambridge, 2011.



49

Surgical Intensive Care Unit (SICU)EM-2 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of surgical critical care that include but are not limited to:1. Perform an appropriately focused history and physical examination2. Provide daily monitoring and management of SICU patients 3. Develop procedural skills and carry out treatment plans through discharge

Objectives: At the end of the rotation, the resident should achieve competency in all of the non-milestoneobjectives and achieve at least a level 2 (defined as advancing and demonstrating additionalmilestones, but is not yet performing at a mid-residency level) for all milestones and may beapproaching a level 3 (defined as a resident who continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency) for some milestones.

Non-Milestone Objectives CC AssessmentMethod

Describes the different types and indications for invasive and non-invasive ventilation.Describes the major complications of mechanical ventilation.Demonstrates competent ventilator management strategies.Describes the hemodynamic profile for various types of shock.Interprets arterial blood gases and acid-base disorders.Demonstrates and understanding of the pathophysiology and management of multiple organ failure.Identifies the indications for and complications of transfusion of blood products.

MKPC





PC Direct observation, rotation evaluations






50

Level 3: Prioritizes essential testing. Interprets results of a diagnostic study, recognizing limitations and risks, seeking interpretive assistance when appropriate. Reviews risks, benefits, contraindications, and alternatives to a diagnostic study or procedure.Level 2: Constructs a list of potential diagnoses, based on the greatest likelihood of occurrence. Constructs a list of potential diagnoses with the greatest potential for morbidity and mortality.





PC MK

Direct observation, rotation evaluations

Level 2: Monitors that necessary therapeutic interventions are performed during a patient’s ICU stay.

Level 3: Identifies which patients will require observation in the ED.Evaluates effectiveness of therapies and treatments provided during observation. Monitors a patient’s clinical status at timely intervals during their stay in the ICU.





Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED and ICU procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.

Level 3: Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.

PC MK


Level 2: Describes elements of airway assessment and indications impacting the airway management. Describes the pharmacology of agents used for rapid sequence intubation including specific

PC MK


51

indications and contraindications. Performs RSI in patients with adjuncts. Confirms proper ETT placement using multiple modalities.

Level 3: Uses airway algorithms in decision making for complicated patients employing airway adjuncts as indicated. Performs rapid sequence intubation in patients using airway adjuncts Implements post-intubation management. Employs appropriate methods of mechanical ventilation based on specific patient physiology.Level 2: Knows the indications, contraindications, potential complications and appropriate doses of analgesic/sedative medications. Knows the anatomic landmarks, indications, contraindications, potential complications and appropriate doses of local anesthetics used for regional anesthesia.

Level 3: Knows the indications, contraindications, potential complications and appropriate doses of medications used for procedural sedation. Performs patient assessment and discusses with the patient the most appropriate analgesic/sedative medication and administers in the most appropriate dose and route. Performs pre-sedation assessment, obtains informed consent and orders appropriate choice and dose of medications for procedural sedation. Obtains informed consent and correctly performs regional anesthesia. Ensures appropriate monitoring of patients during procedural sedation.

PC, MKICS


Level 2: Explains how to optimize ultrasound images and identifies the proper probe for each of the focused ultrasound applications. Performs an eFAST.

Level 3: Performs goal-directed focused ultrasound exams.Correctly interprets acquired images.

PC, MK



Level 3: Inserts a CVP catheter without ultrasound when appropriate.Places an ultrasound guided deep vein catheter (ex: basilica, brachial and cephalic veins).

PCMKICS


Level 2: Routinely uses basic patient safety practices, such as time-outs and “calls for help.” Level 3: Describes patient safety concepts.Employs processes (ex: checklists, SBAR), personnel, and technologies that optimize patient safety (SBAR). Appropriately uses system resources to improve both patient care and medical knowledge.

PCSBPProf



Level 3: Practices cost-effective care. Demonstrates the ability to call

PCICSSBPProf


52

effectively on other resources in the system to provide optimal health care.Level 2: Ensures that medical records are complete, with attention to preventing confusion and error. Effectively and ethically use technology for patient care, medical communication and learning.


PCICSSBPProf




PBLMK




ProfICS


Level 2: Identifies basic principles of physician wellness, including sleep hygiene. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance.Demonstrates knowledge of alertness management and fatigue mitigation principles.


ProfICS


Level 2: Elicits patients’ reasons for seeking care and expectations from the ICU visit. Negotiates and manages simple patient/family-related conflicts.

Level 3: Manages expectations of those who receive care in the ICU and uses communication methods that minimize the potential for stress, conflict and misunderstanding. Effectively communicates with vulnerable populations, including both patients at risk and their families.

ProfICSPC


Level 2: Communicates pertinent information to emergency physicians and other health colleagues.Level 3: Develops working relationships across specialties and with ancillary staff. Ensures transitions of care are accurately and effectively communicated. Ensures clear communication and respect among the team members.

ProfICSPC


53

Rotation ExperienceEM-2 Year, 1 Block (2-week) rotation in the SICU at Jacobi Medical CneterPreceptor: Dr. Mel Stone

A. Clinical activities 1. The EM-2 residents will be responsible for admission, management, and

discharge of their patients.2. The resident will admit, manage, and discharge critically ill patients under the

supervision of the surgery attending physicians and fellows.3. The EM-2 resident will perform all necessary invasive procedures on SICU

patients assigned to them.4. The resident will document all notes and summaries according to standards in

the SICU.5. The resident will attend all SICU conferences and rounds unless excused by

their supervisors.6. The resident will participate in all codes according to the standards in the SICU.7. The resident will be required to attend the emergency medicine core lecture

conferences on the fourth Wednesday of the month (Grand Rounds Wednesday) from 8am to 1pm.

8. The resident must record all manipulative procedures in the procedure log.

B. Evaluation 1. Upon completion of the rotation, a formal written evaluation will be submitted by

the surgical critical care attendings to the program director. C. Feedback

1. The resident will receive informal real-time feedback from the fellows, senior residents, chief residents, and faculty during the one-month block.

2. The evaluation will be incorporated into the formal biannual review with the residency director.

3. Programmatic features of the rotation will be discussed informally at monthly resident/attending meetings.

D. Remediation At a minimum of twice yearly, the program director, in conjunction with the CCC, will determine whether the EM resident is competently meeting program requirements and achieving appropriate milestone levels. Residents found to be deficient in their performance will be remediated in a manner based in the competency that was judged as insufficient. Remediation plans may include but are not limited to:



54

b. Develop and conduct a lecture pertinent to critical care under the supervision of the preceptor.


d. Intense review of procedure logs.2. Professionalism: a. Residents will be counseled regarding their deficiency and assigned a self-

reflective writing project addressing the issue.b. Residents may be asked to complete online courses pertaining to specific

professionalism issues.c. One-on-one faculty mentoring.3. Systems based practice:







E. Reading Assignment Residents are encouraged to complete any reading assignments from the Trauma/Critical Care Division of the Department of Surgery.The following Chapters in the textbooks indicated below:




Chapter 1: Airway

55






Peer VIII

56

Radiology

EM-2 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Radiology that include but are not limited to:

1. Perform basic plain radiograph interpretation2. Perform basic CT interpretation3. Perform basic ultrasound interpretation

Objectives: Upon completion of the rotation, the resident is expected to achieve competency in the non-milestone based objectives and should achieve a level 2 (defined as advancing and demonstrating additional milestones, but is not yet performing at a mid-residency level) or higher for all milestones.


Demonstrate competency in selecting and interpreting all common radiographs pertinent to the practice of emergency medicine.

MKPC


Develop a structured approach to the interpretation of plain radiographs.

PC Direct observation, rotation evaluation,

Demonstrate competency in knowing the indications and limitations of special imaging modalities.

MKPC


Demonstrate knowledge in the amount of radiation exposure and effective shielding techniques for common emergency department radiographs.

MKPC

Direct observation, rotation evaluation,




PBLMK

Direct observation, rotation evaluations,



ProfICS


Level 1: Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress/grooming, rested and ready to work, delivery of patient care as a functional physician. Maintain patient confidentiality. Uses social media ethically and responsibly.Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, procedure reporting.

ProfICS


57

Level 2: Identifies basic principles of physician wellness, including sleep hygiene. Consistently recognizes limits of knowledge in common and frequent clinical situations and asks for assistance.Demonstrates knowledge of alertness management and fatigue mitigation principles.Level 1: Participates as a member of a patient care team.


ProfICSPC


Rotation ExperienceEM-2 Year: 2-week rotation, Monday through Friday in the Radiology Department at University Hospital. Preceptors: Dept of radiology

A. Clinical Activities 1. The resident will attend regularly scheduled radiology reading with the Radiology

faculty in the reading room, reviewing radiographs. Two days will be allotted each to: chest, bone, abdomen, ultrasound, and neuroradiology.

2. Residents will perform as observers during these sessions3. The Resident will attend all regularly scheduled Radiology conferences and

teaching sessions.4. Residents will attend regular EM conferences.

B. Evaluation


C. Feedback 1. The resident will receive informal real time feedback from the Radiology

attending during the 2-week block.2. The evaluation will be incorporated into the formal biannual review with the




1. Medical Knowledge and Practice-Based Learning:

58

a. Residents will be assigned additional required reading and assigned an examination that they must pass.

b. Develop and conduct a lecture pertinent to radiology under the supervision of the preceptor.

c. Development of an individualized learning plan, which may include: online review questions, assigned podcasts, one-on-one faculty mentoring, literature review.







a. Residents will be counseled and monitored closely for improvement.

b. Development of an independent learning plan including but not limited to: one-on-one faculty mentoring, simulation exercises, online courses regarding communication.

5. Patient Care:a. An individualized learning plan will be created that may include but

is not limited to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs.

E. Reading Assignments Residents are encouraged to complete any reading assignments from the Radiology Department.The appropriate corresponding Sections and/or Chapters in the textbooks indicated below:

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 th Ed , Tintinalli JE et al. McGraw-Hill, New York 2011. Section 27: Principles of Imaging


59

3. Clinical Procedures in Emergency Medicine. 6 th Ed , Roberts JR, Hedges JR. W.B. Saunders Co, Philadelphia, 2014.



60

Obstetrics/Labor and Delivery

EM-2 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Obstetrics that include but are not limited to:

1. Perform an appropriately focused history and physical examination2. Provide daily monitoring and management of obstetric patients 3. Develop competence in assessing stage of labor, fetal positioning, potential

complications of labor, and delivery of the uncomplicated newborn

Objectives: At the end of this rotation, the resident should achieve all of the non-milestone based objectives and should achieve a level 2 for all of the milestones and may achieve a level 3 for some or all of the milestones by the end of the EM-2 year.

Non-Milestone Objectives CC Assessment Method

Develop an organized approach to the history and physical examination of obstetric patients including:

The early recognition of obstetrical emergencies, including the use of ultrasound techniques.

Demonstrate knowledge of medications that are safe for use in pregnancy.

MKPC

Direct observation, Rotation evaluation, ITE

Learn to recognize and manage medical complications of pregnancy including:

Iso-immunization Prolapsed cord Pregnancy-induced hypertension Pre-term labor

MKPC


Formulate a differential diagnosis and explain the management of third trimester bleeding including placenta previa and abruptio placenta.

MKPC


Discuss the diagnosis and treatment of the following complications that may occur during labor:

Premature rupture of membranes Fetal Distress Ruptured Uterus

MKPC


Discuss the diagnosis and treatment of complicated deliveries including: Dystocia Prolapsed cord Uterine inversion Multiple births

MKPC


61



Level 3: Manages and prioritizes critically ill or injured patients.Prioritizes critical initial stabilization actions in the resuscitation of an obstetric patient. Reassesses after implementing a stabilizing intervention. Evaluates the validity of a DNR order.












Level 3: Considers array of drug therapy for treatment. Selects appropriate agent based on mechanism of action, intended effect, and anticipates potential adverse effects. Considers and recognizes potential drug-to-drug interactions.

PC MK





Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards Knows indications, contraindications, anatomic landmarks, equipment, anesthetic

PC MK


62

and procedural technique, and potential complications for common ED procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complications. Performs post-procedural assessment and identifies any potential complications.

Level 3: Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.Level 2: Knows the indications, contraindications, potential complications and appropriate doses of analgesic/sedative medications.Knows the anatomic landmarks, indications, contraindications, potential complications and appropriate doses of local anesthetics used for regional anesthesia.


PC, MKICS


Level 2: Routinely uses basic patient safety practices, such as time-outs and “calls for help.” Level 3: Describes patient safety concepts.Employs processes (ex: checklists, SBAR), personnel, and technologies that optimize patient safety (SBAR). Appropriately uses system resources to improve both patient care and medical knowledge.

PCSBPProf




PCICSSBPProf




PCICSSBPProf




PBLMK


63



ProfICS


Rotation ExperienceEM-2 Year, a one-block (2-week) rotation at Jacobi Medical Center Labor and Delivery (L&D) SuitePreceptor: Dept of OB/GYN

A. Clinical activities 1. The Resident round daily with the obstetrics team and participate in all teaching

rounds and conferences as per the normal routine for the obstetrics team. 2. The Resident will be responsible for the history and physical examination of

patients admitted to L&D.3. The Resident will assist in deliveries with abnormal presentations and in

cesarean sections under the supervision of an Obstetrics Attending.4. Perform a minimum of ten vaginal deliveries under the supervision of an

Obstetrical Attending.5. Residents will record their procedures.

B. Evaluation

The rotation preceptor and obstetric faculty upon completion of the rotation will submit a formal written evaluation.

C. Feedback 1. The resident will receive informal real time feedback from the obstetrics attending during

the 2-week block.2. The evaluation will be incorporated into the formal biannual review with the residency

director.3. Programmatic features of the rotation will be discussed informally at monthly


At a minimum of twice yearly, the program director, in conjunction with the CCC, will determine whether the EM resident is competently meeting program requirements and achieving appropriate milestone levels. Residents found to be deficient in their performance will be remediated in a manner

64

based in the competency that was judged as insufficient. Remediation plans may include but are not limited to:


examination that they must pass. b. Develop and conduct a lecture pertinent to obstetrics under the

supervision of the preceptor.c. Development of an individualized learning plan which may include:












E. Required Reading Texts Residents are encouraged to complete any reading assignments from the Obstetrics and Gynecology Department.The following Chapters in the textbooks indicated below:


Section 11: Obstetrics and Gynecology

65



4. Advanced Trauma Life Support Manual for Physicians, 9th Ed. American College of Surgeons, 2012.

5. Pediatric Advanced Life Support (PALS). Disque KA. Satori Continuum Publishing, 2013.


Emergency Medicine, Journal of Emergency Medicine3. Online question banks: Rosh review, Q bank, CORD question bank, Peer

VIII

66

Toxicology

EM-3 Year:

Goals: Develop a solid foundation of medical knowledge in the field of Medical Toxicology that includes but is not limited to:1. Poison center organization and function2. Environmental and occupational toxicology 3. Acute care management of drug overdoses

Objectives: At the end of the rotation, the resident is expected to achieve competency in the non-milestone based objectives. The resident should achieve a level 3 in all milestones and may approach a level 4 in some milestones.

Non-Milestone based objective CC AssessmentMethod

Demonstrate a working knowledge of the major toxidromes.Demonstrate knowledge of the basic principles of drug absorption, distribution, metabolism, and elimination for selected drugs.Know drug interactions, side effects, and therapeutic levels of commonly used pharmaceutical agents.Demonstrate a working knowledge of decontamination.Demonstrate a working knowledge of adjunctive services, including NJPIES and the toxicology computer database POISONDEX.Demonstrate a working knowledge of commonly used antidotes

PCMK


Milestone objective CC Assessment Method


Level 4: Uses diagnostic testing based on the pre-test probability of disease and the likelihood of test results altering management.Practices cost effective ordering of diagnostic studies. Understands the implications of false positives and negatives for post-test probability.

PC Direct observation, rotation evaluations,


Level 4: Synthesizes all of the available data and narrows and prioritizes the list of weighted differential diagnoses to determine appropriate management.

PC Direct observation, rotation evaluations,

67

Level 3: Considers array of drug therapy for treatment. Selects appropriate agent based on mechanism of action, intended effect, and anticipates potential adverse effects. Considers and recognizes potential drug-to-drug interactions.


PC MK


Level 3: Demonstrates improvement of the percentage correct on the ITE or maintain an acceptable percentile ranking.


MK Direct observation, rotation evaluations,



PCSBPProf


Level 3: Performs self-assessment to identify areas for continued self-improvement and implements learning plans. Continually assesses performance by evaluating feedback and assessment.Demonstrates the ability to critically appraise scientific literature and apply evidence-based medicine to improve one’s individual performance.


PBLMK



Level 4: Applies performance improvement methodologies. Demonstrates evidenced-based clinical practice and information retrieval mastery. Participates in a process improvement plan to optimize ED practice.

ProfICS


68



ProfICS




ProfICSPC



Level 4:Uses decision support systems in EHR (as applicable in institution).

ProfICSPC


Rotation Experience

EM-3 Year: 4-week rotation, Monday through Friday in the New York Poison Center at NYU Preceptors: Dr. Lewis Nelson

A. Clinical Activities 1. The resident will attend NY poison control center daily from morning to afternoon

rounds2. The resident will respond to requests for consultation to the NY poison control

center under the supervision of the toxicology staff and full-time poison control center staff.

3. The resident will conduct follow up telephone calls for consults to outside institutions.

4. The resident will complete a brief report on a narrow topic in toxicology

69

5. The resident is required to attend regular Wednesday EM conferences.B. Evaluation


C. Feedback 1. The resident will receive informal real time feedback from the Toxicology





1. Medical Knowledge and Practice-Based Learning: a. Residents will be assigned additional required reading and assigned

an examination that they must pass. b. Develop and conduct a lecture pertinent to toxicology under the

supervision of the preceptor.c. Development of an individualized learning plan, which may include:










70

5. Patient Care:a. An individualized learning plan will be created that may include but is

not limited to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs.

E. Reading Assignments Residents are encouraged to complete any reading assignments from NJPIES.The appropriate corresponding Sections and/or Chapters in the textbooks indicated below:

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 th Ed , Tintinalli JE et al. McGraw-Hill, New York 2011. Section 15: Toxicology


3. Goldfrank’s Toxicologic Emergencies. 9 th Ed, Nelson LS, et al. New York, McGraw Hill, 2011.



71

Emergency Medical Services (EMS)

EM-1, EM-3 Years:

Goals: Develop a solid, working knowledge of the pre-hospital system that includes but is not limited to:

1. Common organizational structures of EMS2. Principles of pre-hospital triage and patient care3. Essential elements of disaster management

Rotation ExperienceEM-1: This 2-week EMS rotation will occur at the EMS headquarters.

Preceptor: Dr. Brad Kaufman through NYFD

Objectives:

Non-Milestone Objective CC AssessmentMethod

Become familiar with EMS operation and structure by: Learning the history of development of EMS. Observing and learning the daily activities, organizational

structure and administrative responsibilities of University Hospital EMS and North STAR.

Learning the education and skill levels of various EMS providers. Demonstrate knowledge of paramedic protocols. Differentiating pre-hospital care into BLS and ALS components

and describe the application to urban and rural locations.

MKSBP


ITE

Learn the function of the medical control physician of a pre-hospital ALS system by:

Becoming familiar with specialized radio and telemetry equipment.

Gain telemetry experience from the perspective of a telemetry medical control physician and of the paramedic team in the field.

MKPCSBP


ITE

Learn the principles of disaster management with respect to: Mass casualty field triage Command structure

PCSBP


ITE



Level 4: Recommends changes in team performance as necessary for optimal efficiency. Uses flexible communication strategies to resolve

PBLMK


72

specific ED challenges such as difficulties with consultants and other health care providers. Communicates with out-of-hospital and nonmedical personnel, such as police, media, hospital administrators.Level 1: Demonstrates behavior that conveys caring, honesty, genuine interest and tolerance when interacting with a diverse population of patients and families.



Level 4: Applies performance improvement methodologies. Demonstrates evidenced-based clinical practice and information retrieval mastery. Participates in a process improvement plan to optimize ED practice.

ProfICS






ProfICSPBL



Level 2: Elicits patients’ reasons for seeking care and expectations from the ED visit. Negotiates and manages simple patient/family-related

ProfICSPC


73

conflicts.


Level 4: Participates in processes and logistics to improve patient flow and decrease turnaround times (e.g., rapid triage, bedside registration, Fast Tracks, bedside testing, rapid treatment units, standard protocols, and observation units). Recommends strategies by which patients’ access to care can be improved. Coordinates system resources to optimize a patient’s care for complicated medical situations.Level 1: Participates as a member of a patient care team.




ProfICSPC


A. Clinical Activities1. Residents will be assigned to ride with a basic life support and an advanced life

support field unit as well as the EMS operated rescue truck. 2. The resident will observe the EMS medical director and begin to provide

medical control in the third year.3. The resident will attend statewide EMS meetings and other educational

meetings that occur during their block.4. The resident will review written and telemetry ambulance call reports with the

EMS Medical Director.5. The resident will spend time with the Special Operations Division and the NJS

EMS Task Force and accompany the teams to statewide disasters as they occur.

6. During the EM-3 rotation, the residents will ride along on four tours with the critical care transport ground unit and four tours with the air transport vehicle, North Star.

7. Additional tours with the ground units will be scheduled for those residents who do not wish to fly on the helicopter.

B. Evaluations 1. At the time of completion of the rotation, the preceptor will submit a formal

evaluation of the rotation.

74

2. Residents will additionally provide the program with EMS staff or other designated faculty names with whom they have worked extensively for evaluation since rotation experiences can vary, who will be assigned rotation evaluations.

C. Feedback 1. Residents will be provided with real time feedback by their preceptor/supervisor

during their time with EMS.2. Residents will receive feedback on their rotation performance at their bi-annual

evaluation.D. Remediation



examination that they must pass. b. Develop and conduct a lecture pertinent to EMS under the supervision of the

preceptor.c. Development of an individualized learning plan which may include: online

review questions, assigned podcasts, one-on-one faculty mentoring.3. Professionalism:






a. Residents will be counseled and monitored closely for improvement.b. Development of an independent learning plan including but not limited to:

one-on-one faculty mentoring, simulation exercises, online courses regarding communication.

6. Patient Care:a. An individualized learning plan will be created that includes but is not limited

to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs.

75

E. Reading Assignment The following Chapters in the textbooks indicated below:


Chapter 1: Emergency Medical Services Chapter 2: Prehospital Equipment and Adjuncts Chapter 3: Air Medical Transport Chapter 4: Neonatal and Pediatric Transport Chapter 5: Mass Gatherings Chapter 6 Disaster Preparedness and Response Chapter 7: Natural Disasters Chapter 8: Chemical Agents and Mass Casualties Chapter 10: Bioterrorism Recognition and Response: Implications for

the Emergency Clinician Chapter 11: Radiation Injuries


Chapter 1: Airway Chapter 2: Mechanical Ventilation and Noninvasive Ventilatory

Support Chapter 5: Monitoring the Emergency Patient Chapter 6: Shock Chapter 7: Blood and Blood Components Chapter 8: Adult Resuscitation




Peer VIII

76

Intermediate Nursery/Neonatal Intensive Care Unit

EM-2 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Neonatal Critical Care that include but are not limited to:

1. Perform an appropriately focused history and physical examination2. Provide daily monitoring and management of NICU patients 3. Develop procedural skills and carry out treatment plans through discharge

Objectives: At the end of the rotation, the resident should achieve competency in all of the non-milestoneobjectives and achieve at least a level 2 (defined as advancing and demonstrating additionalmilestones, but is not yet performing at a mid-residency level) for all milestones and may beapproaching a level 3 (defined as a resident who continues to advance and demonstrate additional milestones; the resident demonstrates the majority of milestones targeted for residency in this sub-competency) for some milestones.

Non-Milestone Objectives CC Assessment Method

Demonstrate competency in the knowledge of the common illnesses seen in neonatal patients by:

List the signs and symptoms of congenital and acquired cardiovascular disease and discuss appropriate management.

List the types, etiologies and management of congenital abnormalities of the endocrine system.

Recognize and appropriately assess jaundice, sepsis and seizures in the newborn patient.

List the signs and symptoms of the septic newborn. List the signs, symptoms and management of disorders of

glucose, metabolism and thyroid function.

MKPC


Demonstrate competency in the management of the neonatal patient with:

Obtaining an appropriate history and perform a physical examination of critically ill neonates

Appropriate fluid management, hemodynamic monitoring and airway management techniques for critically ill newborns.

Resuscitating the critically ill newborn. Recognizing and managing signs and symptoms of shock in the

newborn patient and formulate an appropriate management plan.

Obtaining vascular access.

MKPC


Milestone objective CC Assessment

77

MethodLevel 2: Recognizes when a patient is unstable requiring immediate intervention. Performs a primary assessment on a critically ill or injured patient. Discerns relevant data to formulate a diagnostic impression and plan.














PC MK





Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED procedures. Performs the

PC MK


78

indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complicationsPerforms post-procedural assessment and identifies any potential complications.

Level 3: Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.Level 2: Describes elements of airway assessment and indications impacting the airway management. Describes the pharmacology of agents used for rapid sequence intubation including specific indications and contraindications. Performs RSI in patients with adjuncts.Confirms proper ETT placement using multiple modalities.

Level 3: Uses airway algorithms in decision making for complicated patients employing airway adjuncts as indicated. Performs rapid sequence intubation in patients using airway adjuncts Implements post-intubation management. Employs appropriate methods of mechanical ventilation based on specific patient physiology.

PC MK




PC, MKICS


Level 2: Describes the indications, contraindications, anticipated undesirable outcomes and complications for various vascular access modalities. Performs insertion of: an arterial catheter, umbilical vessel catheter, CVP using ultrasound and universal precautions, intraosseous access.Assesses the indications in conjunction with the patient anatomy/pathophysiology and select the optimal site for a CVP catheter. Confirms appropriate placement of CVP catheter.

Level 3:Inserts a CVP catheter without ultrasound when appropriate.Places an ultrasound guided deep vein catheter (ex: basilica, brachial and cephalic veins).

PCMKICS


Level 2: Routinely uses basic patient safety practices, such as time-outs and “calls for help.” Level 3:

PCSBP


79

Describes patient safety concepts.Employs processes (ex: checklists, SBAR), personnel, and technologies that optimize patient safety (SBAR)Appropriately uses system resources to improve both patient care and medical knowledge.

Prof


Level 3: Practices cost-effective care.Demonstrates the ability to call effectively on other resources in the system to provide optimal health care.

PCICSSBPProf




PCICSSBPProf




PBLMK




ProfICS


Rotation ExperienceEM-2 Year, one month (4-week) rotation in the NICU/Intermediate Nursery at University HospitalPreceptor: Dr. Fofeh, Director NICU

A. Clinical activities 1. The resident will attend morning rounds and noon conferences with the NICU

team.2. The resident will accompany the NICU team into the delivery room and assist

in evaluation and resuscitation of neonates.3. The resident will perform all relevant diagnostic and therapeutic procedures

on their patients under the close supervision of the NICU attending physician.

80

4. The resident will participate in work round discussions and the formulation of patient treatment plans.

5. The resident will participate in all teaching rounds conducted in the normal course of business for the FIN/NICU teams.

6. The resident will attend noon conferences.7. The resident must record all manipulative procedures in the procedure log.8. The resident will be required to attend the emergency medicine core lecture

series on Wednesdays from 8am-1pm during the FIN/NICU month.B. Evaluation

1. Upon completion of the rotation, a formal written evaluation will be submitted by the NICU critical care attendings to the program director.

C. Feedback 1. The resident will receive informal real-time feedback from the critical care

fellows, senior residents, chief residents, and faculty during the one-month block.

2. The evaluation will be incorporated into the formal bi-annual review with the PD, APD, or designee.

3. Programmatic features of the rotation will be discussed informally at monthly resident/attending meetings.

D. Remediation At a minimum of twice yearly, the program director, in conjunction with the CCC, will determine whether the EM resident is competently meeting program requirements and achieving appropriate milestone levels. Residents found to be deficient in their performance will be remediated in a manner based in the competency that was judged as insufficient. Remediation plans may include but are not limited to:


examination that they must pass. b. Develop and conduct a lecture pertinent to critical care under the supervision of the preceptor.






81

a. Residents will be assigned a faculty mentor for close evaluation of QA/PI projects.b. Residents may be asked to serve on specific hospital committees.

4. Communication and interpersonal skills: a. Residents will be counseled and monitored closely for improvement.b. Development of an independent learning plan including but not limited to:

one-on-one faculty mentoring, simulation exercises, online courses regarding communication.



E. Reading Assignment Residents are encouraged to complete any reading assignments from the Pediatrics Department and the Division of Critical Care.The following Chapters in the textbooks indicated below:


Section 4: Resuscitative Procedures Section 12: Pediatrics


Volume 1, Part I: Fundamental Clinical Concepts


4. Pediatric Advanced Life Support (PALS). Disque KA. Satori Continuum Publishing, 2013.



Peer VIII

82

Administration/QI

EM-3 Yea r :

Goals: Develop a working knowledge of the administrative elements of the Emergency Department that includes but is not limited to:1. Quality assurance and performance improvement2. Stocking and equipment3. Patient billing

Objectives: By the end of the rotation, the resident is expected to achieve all of the non-milestone based objectives and should achieve a milestone level 4 by the end of the EM-4 year.


Demonstrate an understanding of contract principles. Analysis of clauses and components Employment versus independent contractor Negotiation

SBP Direct observation,Rotation evaluation

Become familiar with the essential features of operations in the Emergency Department:

Department administration Documentation Facility design Human resource management Information management Patient throughput Policies and procedures Safety and security

MKSBP


Develop a working knowledge of risk management, legal and regulatory issues as they relate to Emergency Medicine laws pertaining to:

Accreditation Compliance Consent and refusal of care Controlled substances Drug abuse Good Samaritan laws Patient transfer regulations/EMTALA Reportable conditions (assault, communicable diseases,

national practitioner data bank, etc) Risk management Liability and malpractice HIPPA Regulations and confidentiality

SBPMK

Rotation evaluation on, Direct observation

Discuss the development and implementation of performance improvement:

Customer satisfaction and service Error reduction Practice guidelines

MKSBP


83

Discuss various financial issues at the institution which affect the Emergency Department:

Budget and planning Cost containment Reimbursement issues Billing and coding

MKSBP


Discuss important principles applicable to patient care issues and emergency medicine research:

Death in the Emergency Department Ethics Impairment Leadership (leading, directing and mentoring) Personal well-being Professional development and learning

MK SBPPBL


Discuss communication and interpersonal issues pertinent to patient care and professional relationships:

Complaint management Conflict resolution Interdepartmental and medical staff relations Team building Teaching

SBPPBL


Identify typical stressors in emergency medicine.Discuss the programs at the hospital that deal with physician impairment.Participate in the planning of the biannual disaster medicine drill.Participate in the disaster medicine team at city mass gatherings events.

MKSBP


Milestone Objective CC Assessment Method



PCSBProf




PCICSSBProf

Direct observation, rotation evaluation, chart review



PBLMK



Level 2: Demonstrates an understanding of the importance of

ProfICS


84

compassion, integrity, respect, sensitivity and responsiveness and exhibits these attitudes consistently in common/uncomplicated situations and with diverse populations.Level 1: Demonstrates basic professional responsibilities such as timely reporting for duty, appropriate dress/grooming, rested and ready to work, delivery of patient care as a functional physician. Maintain patient confidentiality. Uses social media ethically and responsibly. Adheres to professional responsibilities, such as conference attendance, timely chart completion, duty hour reporting, procedure reporting.


ProfICS




ProfICSPC


Rotation ExperienceEM-3 Year, 2-week rotation at Jacobi or Monetiore Hospital

Preceptors: Thomas Perera MD

A. Clinical Activities3. The resident will attend to the director of operations for the two-week rotation

receiving one-on-one instruction in the administration of the ED and/or the EM residency.

4. During the rotation, the resident will be required to complete one afternoon session/week after the Wednesday core lecture series of quality assurance chart auditing during the rotation.

5. During the rotation, the resident will read and work on various projects (i.e. disaster drill planning, quality assurance chart auditing, systems-based practice projects) from 9am – 5pm Monday through Friday.

6. The responsible faculty member will discuss particular topics related to risk management and quality assurance in the context of actual case management.

7. The resident is encouraged to complete any reading material distributed by the preceptor and the reading assignment during the EM-4 year.

C. Evaluations 1. At the time of completion of the rotation, the preceptor will submit a formal

evaluation of the rotation.2. Residents will additionally provide the program with additional faculty names

with whom they have worked extensively for evaluation since rotation experiences can vary, who will be assigned rotation evaluations.

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C. Feedback 1. Residents will be provided with real time feedback by their

preceptor/supervisor during their time with administration.2. Residents will receive feedback on their rotation performance at their bi-

annual evaluation.C. Remediation


1. Medical Knowledge and Practice-Based Learning: b. Residents will be assigned additional required reading and assigned an

examination that they must pass. c. Develop and conduct a lecture pertinent to emergency department

administration under the supervision of the preceptor.d. Development of an individualized learning plan which may include:


e. Intense review of procedure logs.2. Professionalism:










E. Reading Assignments

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Residents are encouraged to complete any reading assignments from the Emergency Medicine Textbooks listed below:

4. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7 th Ed , Tintinalli

JE et al. McGraw-Hill, New York 2011.

a. Chapter 6: Disaster Preparedness and Responseb. Chapter 7: Natural Disastersc. Chapter 8: Chemical Agents and Mass Casualtiesd. Chapter 10: Bioterrorism Recognition and Response:

Implications for the Emergency Cliniciane. Chapter 11: Radiation Injuriesf. Chapter 297: Grief, Death and Dying, DNR/DNI Orders:

Delivering Effective Death Notifications in the Emergency Department

g. Chapter 298: Legal Issues in Emergency Medicineh. Chapter e298.1: Management of Prisoners Attending the

Emergency Department

5. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8 th Ed , Marx JA,

Hockberger RS, Walls RM. Saunders, Philadelphia, 2014.

a. Chapter 195: Observation Medicine and Clinical Decision Unitsb. Chapter 197: Process Improvement and Patient Safety

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Orthopedics

EM-4 Year:

Goals: Develop the fundamental skills of a junior resident in the practice of Orthopedics that include but are not limited to:

1. Perform an appropriately focused history and physical examination2. Provide daily management of Orthopedics patients 3. Develop procedural skills, such as fracture reduction and splinting, and carry out basic

treatment plans

Objectives: At the end of this rotation, the resident should achieve all of the non-milestone based objectives and should achieve a level 2 for all of the milestones and may achieve a level 3 for some or all of the milestones by the end of the EM-2 year.


Demonstrate appropriate emergency management and treatment of orthopedic injuries and infection in adult and pediatric patients.Demonstrate competent skill in treating orthopedic injuries reduction, splinting, casting, arthrocentesis

MKPC


Assess neurovascular status and evaluate tendon function in injured limbs and digits.

MKPC


Know the indications of special radiographic studies including special plain film, bone scans, CT scans, and arthroscopy.

MKPC


Identify and manage pediatric orthopedic injuries including: Epiphyseal plate injuries Greenstick fractures Common dislocations

MKPC


Perform the following manipulative skills: Fracture/dislocation reduction Application of supportive dressings Aspiration of joints Management of fingertip and nail bed injuries

PC Direct observation, rotation evaluation,






Level 3: Prioritizes essential testing. Interprets results of a diagnostic


88

study, recognizing limitations and risks, seeking interpretive assistance when appropriate. Reviews risks, benefits, contraindications, and alternatives to a diagnostic study or procedure.Level 2: Constructs a list of potential diagnoses, based on the greatest likelihood of occurrence. Constructs a list of potential diagnoses with the greatest potential for morbidity and mortality.





PC MK



Level 3: Identifies which patients will require observation in the ED. Evaluates effectiveness of therapies and treatments provided during observation. Monitors a patient’s clinical status at timely intervals during their stay in the ED.





Level 2: Performs patient assessment, obtains informed consent and ensures monitoring equipment is in place in accordance with patient safety standards. Knows indications, contraindications, anatomic landmarks, equipment, anesthetic and procedural technique, and potential complications for common ED procedures. Performs the indicated common procedure on a patient with moderate urgency who has identifiable landmarks and a low-moderate risk for complicationsPerforms post-procedural assessment and identifies any potential complications.Level 3: Determines a backup strategy if initial attempts to perform a procedure are unsuccessful. Correctly interprets the results of a diagnostic procedure.

PC MK



Level 3: Knows the indications, contraindications, potential

PC, MKICS


89

complications and appropriate doses of medications used for procedural sedation. Performs patient assessment and discusses with the patient the most appropriate analgesic/sedative medication and administers in the most appropriate dose and route. Performs pre-sedation assessment, obtains informed consent and orders appropriate choice and dose of medications for procedural sedation. Obtains informed consent and correctly performs regional anesthesia. Ensures appropriate monitoring of patients during procedural sedation.



PCSBPProf




PCICSSBPProf




PCICSSBPProf


Rotation Experience

EM-4 Year: 2-week rotation, Monday through Friday at Jacobi Medical Center. Preceptor: Dept. of orthopedics

A. Clinical Activities 1. The resident will attend orthopedics clinic and evaluate orthopedics patients under

the supervision of attendings and senior residents2. The resident will respond to the emergency department for all orthopedic

consultations.3. The resident will participate in admission and preoperative preparations of

orthopedic patients.4. Participate in all teaching rounds and conferences that occur during the normal

course of business5. The resident will attend regular Wednesday EM conferences6. Record all orthopedic procedures performed

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B. Evaluation


C. Feedback 1. The resident will receive informal real time feedback from the orthopedics






examination that they must pass. b. Develop and conduct a lecture pertinent to orthopedics under the

supervision of the preceptor.c. Development of an individualized learning plan, which may include:


a. Intense review of procedure logs.2. Professionalism:








5. Patient Care:

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a. An individualized learning plan will be created that may include but is not limited to: weekly simulation exercises, one-on-one faculty mentoring, monthly mock oral board exercises, direct faculty observation in the ED, enhanced simulation-based procedures, cadaver labs.

E. Reading Assignments Residents are encouraged to complete any reading assignments from the Orthopedics Department.The appropriate corresponding Sections and/or Chapters in the textbooks indicated below:


Section 22: Injuries to Bones and Joints Section 23: Musculoskeletal Disorders Section 27: Principles of Imaging




Emergency Medicine, Journal of Emergency Medicine3. Online question banks: Rosh review, Q bank, CORD question bank, Peer VIII4.

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