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Emergency Medicine Clerkship Syllabus

Contact Information (Office) 915-215-4624
Michael D. Parsa, M.D., Clerkship Director michael.d.parsa@ttuhsc.edu
Christy Graham, Unit Coordinator christy.graham@ttuhsc.edu

Welcome to the PLFSOM EM Clerkship

We have created a rotation that takes advantage of the unique learning opportunities that the ED provides. Here you will assess undifferentiated patients, coming up with your own diagnostic and therapeutic management plan, integrating and applying much of what you have learned in years 1-3. To compliment your clinical experience we have created additional educational opportunities through hands on exercises, simulations, lectures, readings and written and oral assignments. We have also incorporated pre-hospital and poison center exposure into the course. This clerkship is based upon the 2010 national curriculum guidelines for EM clerkships and is designed to contribute significantly to our overall institutional learning objectives. This syllabus contains all the information you will need to succeed during the rotation. Please note that assignment results may be anonymized and used for training or research purposes.

Table of contents


Objectives
Clinical Presentations
General Requirements
Recommended Reading
Grading Policy
Documentation
EMS Experience
Procedure Checklist
Case Presentations
Mid-Rotation Assessment
Test Questions
Op Log
Clinical Evaluation
Final Exam

TTUHSC Emergency Medicine Clerkship Objectives
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Patient Care

GOAL: Students who are able to provide patient-centered care that is appropriate and compassionate

OBJECTIVES: By the end of the clerkship students should be able to:

    • Demonstrate proper interviewing techniques (1.1)
    • Obtain an accurate problem-focused history and physical exam (1.1)
    • Develop a diagnostic and therapeutic patient management plan for the patient with both an undifferentiated complaint and a known disease process (1.3, 1.6)
    • Formulate a differential dx when evaluating an undifferentiated patient: (1.3)
      • List worst case scenarios
      • Prioritize likelihood of diagnoses based on clinical findings
    • Patient management skills (1.2, 1.9)
      • Monitor the response to therapeutic intervention
      • Develop appropriate disposition and follow up plans
    • Patient communication (1.8, 1.9)
      • Educate patients on safety and provide anticipatory guidance as necessary
      • Educate patients to ensure comprehension of discharge plan
      • Recognize immediate life-threatening conditions (1.4, 1.5)
      • Interpret basic diagnostic tests (1.3)
      • Execute accurate EMR documentation appropriate to the ED (1.7)
      • Initiate basic resuscitation and stabilization (1.5)
      • Demonstrate proficiency in the following basic skills (1.3)
        • Basic Airway Management
        • Peripheral Intravenous Access
        • ECG/cardiac rhythm analysis
        • Foley catheter placement
        • Cardiopulmonary resuscitation
KNOWLEDGE FOR PRACTICE

GOAL: Students who are able to apply their broad knowledge base to patient care in the ED clinical setting.

OBJECTIVES: During the clerkship the student will have opportunity to:

  • Apply diagnostic principles from years 1-2 to the ED clinical setting (2.2)
  • Apply evidence-based principles to patient care in the ED clinical setting (2.4)
PRACTICE BASED LEARNING AND IMPROVEMENTS

GOAL: Students who are able to apply scientific evidence to patient care and accept and apply feedback for improvement of patient care practices.

OBJECTIVES: Students will demonstrate the ability to:

  • Investigate a clinical question relevant to patient care through evaluation of primary research (3.1, 3.3, 3.6)
  • Act on corrective feedback (3.5)
  • Evaluate the medical literature (3.6)
  • Use information technology to improve patient care (3.6)
  • Accurately recognize the limits of their knowledge, experience and capabilities and take appropriate actions (3.1)
INTERPERSONAL AND COMMUNICATION SKILLS

GOAL: Students who are able to effectively communicate with patients, families, faculty, staff, residents and other students.

OBJECTIVES: Students will have opportunity to:

  • Develop and demonstrate professional interactions and effective communication with ED faculty, staff and consultants (4.2)
  • Demonstrate active listening skills (4.5)
  • Establish a therapeutic relationship with patients and families (4.1, 4.4)
PROFESSIONALISM

GOAL: Students who demonstrate a commitment to carrying out professional responsibilities, adhering to ethical principles, displaying sensitivity to a diverse patient population.

OBJECTIVES: Throughout the clerkship students will demonstrate:

  • Respect towards patients and families whose lifestyles, culture and values may be different from their own (5.1)
  • Ethical behavior, including patient confidentiality, privacy and consent (5.3)
  • Evaluate the medical literature
  • Reliability, by arriving on time and prepared for all required activities (5.4, 5.7)
  • Honesty and integrity in patient care (5.6)
  • Professional appearance (5.7)
SYSTEMS-BASED PRACTICE

GOAL: Students who demonstrate an awareness of the larger context of health care and understand how to effectively utilize system resources to provide optimal care.

OBJECTIVES: By the end of the clerkship students should be able to:

  • Describe the role of emergency medicine in the US health care system (6.1)
  • Demonstrate understanding of limitations patients face due to lack of resources (6.2, 6.3)
  • Know when accessing social services is indicated (6.5, 6.6)
  • Describe the role of the ED in the community, including access to care and its impact on patient care (6.1, 6.2)
  • Describe the role of poison centers in the US healthcare system (6.1)
INTERPROFESSIONAL COLLABORATION

GOAL: Students who demonstrate the ability to effectively engage as part of an interprofessional team.

OBJECTIVES: Throughout the clerkship student should have the opportunity to:

  • Develop teamwork and interdisciplinary communication skills during simulation activities and in the ED (7.3)
PERSONAL AND PROFESSIONAL DEVELOPMENT

GOAL: Students who demonstrate the principles required for lifelong professional growth

OBJECTIVES: During the clerkship students will have opportunity to:

  • Develop their own clinical question, identify appropriate research to answer the question and critically appraise this research, presenting their findings to fellow students (8.6)
  • Develop proper judgment regarding when to take responsibility and when to seek assistance with patient care, based on their current level of training (8.1)
Clinical Presentations
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The following clinical presentations (CPs) from year 1-2 will be revisited during this rotation:

              • Introduction to Health and Disease CPs:
                • Wound
              • Musculoskeletal/Dermatology CPs:
                • Fractures-Dislocations-Joint Injuries
              • Cardiovascular/Respiratory CPs:
                • Chest discomfort
                • Abnormal blood pressure: Hypertension and Shock
                • Abnormal Arterial Pulse
                • Dyspnea
                • Syncope
              • Gastrointestinal System CPs:
                • Abdominal pain and blood in GI
              • Endocrine System CPs:
                • Disorders of thyroid function
                • Diabetes and obesity/Metabolic syndrome
              • Neurological CPs:
                • Delirium, stupor, coma
                • Seizure and epilepsy
                • Headache
GENERAL REQUIREMENTS
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Show up for all shifts, on time, appropriately attired (scrubs or business attire, no dangling hair, no open toe shoes), ready to work, with a pen & a stethoscope. If an emergency arises preventing you from working your shift or you are ill, call Christy Graham (215-4624) and/or the attending in the ED (UMC 521-7700, Las Palmas 521-1266, Children’s 298-5443). The absentee policy during this rotation allows you up to 16 hours of missed shift work and complete the course if the missed shifts are for excused absences (illness, residency interview or family emergency). You will be required to make up any excused absence (if more than 16 hours) to complete the rotation. Contact Christy to reschedule any shift that needs to be rescheduled for any other reason. We have a strict no show policy. If you do not show up for a scheduled shift without notification this will result in a grade of FAIL on lack of professionalism grounds and you will be required to retake the course in its entirety to receive a PASS. It is your responsibility to know when you are scheduled to be in the ED.

You will usually be assigned to a single ED attending for each shift when you arrive in the ED. Typically, you are expected to act as the primary provider for the patients you see on these shifts. You will do a focused H&P, and then present the patient to the faculty with a differential diagnosis and diagnostic and therapeutic management plan. Students will be assigned 106 clinical hours in the emergency department in shifts varying in length, but never more than 12 hours. You will be required to work nights and weekends. You may request up to 3 dates to be off the schedule during the rotation. Requests can be given to Christy Graham. If you need to make additional shift changes you may work these out with your classmates and inform Christy of any shift swaps. Shift scheduling is required to abide by work duty hour restrictions as set forth by school policy. It is also required that you are available on the first and last day of the clerkship, per school policy.

All patients are to be presented to faculty before orders are written, before pelvic, rectal, and hernia exams, and before any procedures are done. You are not to do any of these things without direct physician observation. You must notify your faculty member of each patient you plan to pick up and obtain their approval first. If a patient appears unstable (i.e. looks really sick, has respiratory distress, or has abnormal vital signs) then notify your attending immediately.

Do not leave the department without advising your faculty. Expect to eat your meals in the ED, although you will be allowed to leave the department to get food from the cafeteria. There is a refrigerator and microwave oven in the ED for physician/student use.

You are required to attend 3 out of 4 Thursday morning conferences. If there is one week when conference is less relevant for students, we will notify you that you will be allowed to miss. In addition, you will be required to participate with EM Faculty and Residents in one Thursday Simulation exercise held after conference.

ED Documentation

For ED charting UMC and EPCH use Cerner. You will receive a personal login. You will receive training on how to use Cerner during orientation. Faculty vary as to their comfort level with students doing their own documenting. If you are documenting a patient note under your own name/login you must change the title of the note to "medical student note".

When you are working on your note and it is incomplete you may "save" the note, but when it is completed you must click "sign". You must forward all your notes to your attending for their signature. The residents and faculty will be able to assist you with any of this if you have questions. If you do not do these things you will be required to go to medical records at a later date to do so.

At Las Palmas you will not have your own computer login.

Recommended Reading
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Before the start of your rotation Christy will forward you the Emergency Medicine Clerkship Primer. We recommend you review chapters 2-19 prior to the end of the first week of the rotation. This introduction (written for students like you), is very easy reading, less than 70 pages, and will make the clerkship much easier for you.

We provide An Introduction to Clinical Emergency Medicine by Mahadevan and Garmel. This text is written for MS4s. You are encouraged to read any sections of the book you find interesting. Selected readings below reflect current national curriculum guidelines. We have also attached a list of websites/online videos with relevant educational content. These are optional.

              • Ch. 3 Cardiopulmonary and cerebral resuscitation (Read before Sim Cases Activity)
              • Ch. 6 Shock
              • Ch. 7 Traumatic injuries
              • Ch. 10 Abdominal pain
              • Ch. 11 Abnormal behavior
              • Ch. 14 Altered mental status
              • Ch. 17 Chest pain
              • Ch. 21 Diabetes-related emergencies
              • Ch. 30 Headache
              • Ch. 34 Pelvic pain
              • Ch. 37 Seizures
              • Ch. 38 Shortness of Breath in Adults
              • Ch. 47 Environmental emergencies
              • Appendix B Common emergency procedures (Read before Task Trainers Activity)
              • Appendix C Laceration repair
Grading Policy
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HONORS

We use the same NBME criteria as the 3rd year clerkships for honors eligibility with 75th percentile and 55th percentile limits for honors. To qualify for honors at the 55th percentile you will need above average shift evaluations by ED faculty. At the 75th percentile, only average faculty evaluations will be required for honors.

In addition to the above the following will be required for honors:

                • All course assignments submitted on time
                • All 4s and 5s on your clinical question presentation grading sheet
                • Complete a minimum of 60 Op-log entries
                • A model of professional behavior
                  • Never late, always ready to start on time
                  • Actively involved in educational activities (no Facebook, texting, etc., during educational activities)
PASS
                  • Final exam: 5th percentile or greater on first or second attempt.
                  • Complete all assignments to the satisfaction of the course director.
                  • Complete a minimum of 30 Op-Log entries
                  • Any assignments that are not completed or are completed poorly must be completed to the satisfaction of the course director before a PASS can be issued.
                  • The student must make up excused absences beyond 16 hours.
                  • All absences that are not excused must be made up.
                  • Attend all mandatory educational activities for which you don’t have an excused absence.
                  • Clinical evaluations must meet a minimum standard of the following:
                    • Professional behavior
                    • Patient evaluation skills
                    • Patient management skills
                  • Any remedial requirements given during the course must be completed to the satisfaction of the course director.
INCOMPLETE
  • This grade will be issued at the completion of the clerkship if the course requirements have not been met due to mitigating circumstances or failing the final exam on the initial attempt. Once the requirements have been met and/or the exam has been passed on the second attempt, the grade will be changed to PASS.
FAIL
  • Unprofessional behavior
  • Failing to show up for an ED shift without notifying faculty or staff
  • Failure to complete required remedial work in the allotted time
  • Failure to complete course requirements to a satisfactory level
Documentation
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Documentation is an important part of clinical practice. We require you to turn in one completed chart for Dr. Parsa to review during the first 2 weeks of the clerkship. This should be your own documentation (not part of the permanent medical record). It should be submitted in a standard typewritten format and should be sent by email as an attached file (Word document preferred) to Christy and Dr. Parsa. It should include the following mandatory items:

                  • History and physical (not exhaustive, but complaint-directed; appropriate for ED)
                  • ED course-Testing results with interpretation (K- 2.9-low). Differential diagnosis. Therapeutic interventions with indications and reassessment.
                    • 1730-Ondansetron given for nausea. 1800- no nausea, abdomen nontender, P90 BP 120/80
                  • Diagnosis
                  • Disposition (with treatment and follow up plan if discharged)

Your note should include what a proper ED physician’s note would include, such as one that would be dictated into a real medical record. We will provide feedback on this assignment noting your documentation strengths and weaknesses. If your documentation has significant weaknesses you will be required to repeat the assignment until adequate documentation is demonstrated.

Detailed Social History Assignment
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A typical county ED patient faces many life challenges; these may be related to poor decisions they have made or may be related to circumstances beyond their control. These challenges may include such difficulties as substance abuse, prior criminal activity and arrests, being a victim of crime, poverty, unemployment, lack of healthcare coverage, disability, legal problems, immigration status issues, transportation difficulties, complex close relationship issues (abuse, estrangement, etc.), family of origin/upbringing issues (i.e. parent was an addict).

Your assignment is to take a detailed social history on an ED patient recounting the specific challenges they face in regard to the above issues. Discuss the issues relevant to them and their situation. Please attempt to find out details and specific examples of how these challenges may have affected their health and how many of these challenges are linked together.

For example, a gentleman with EtOH dependence may have most of the above problems, all stemming from his EtOH use. He may have tried to quit many times (ask about what he has tried, how effective it was, why it did or didn’t work). Ask about some of the other issues above, and how EtOH has affected those issues. Ask where he gets money (if unemployed) and how he spends it, ask how he accesses healthcare (when was his last clinic visit, how beneficial was it, how did he get there, could he afford the prescriptions and ancillary testing); ask about living arrangements and family support.

Don’t ask questions as if going through a checklist, but try to do your best to truly understand the patient’s perspective on their struggles. Take what you have learned and write a one-page narrative including any personal reflections you may have and email it to Christy and Dr. Parsa by 5:00 p.m. on the last Thursday of the rotation.

Pre-hospital Experience
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Each student will spend 2 hours at the 911 command center where dispatchers receive calls. You do not need to bring anything. You will be able to see firsthand what happens behind the scenes.

West Texas Regional Poison Center Experience
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Each student will spend 4 hours observing operations at the poison center. This time will be spent listening in on calls and observing how calls are managed.

Procedure Checklist
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By the end of the rotation turn in your checklist documenting that you have performed 5 IVs/blood draws and 2 urinary catheterizations and (optional) one nasogastric tube placement.

Journal Club
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EM resident journal club happens monthly, we will notify you of the date and time. It is optional but encouraged for those interested in EM. If you wish to attend ask Christy to arrange the schedule accordingly.

Clinical question presentation
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Towards the end of your rotation each student will make a brief presentation to the other students and at least one faculty. This round table style presentation should be based on a clinical question of interest to you that has arisen during the clerkship. Once you have decided on something to investigate, find a primary research article that investigates this problem. You will probably need to review several studies before finding the one you wish to present. Do NOT choose a review article to present. You should discuss the methods and results pointing out strengths and weaknesses of the study and it’s applicability to patient care. Please let us know how you located the article, (PubMed, Google, etc.) why you chose it and why the question the article addresses is important to answer.

For example, if you are curious about the management of children with bronchiolitis, you could discuss an article relevant to the diagnosis of the illness (i.e. a study looking at the utility of CXR in diagnosis) or treatment (i.e. a study looking at outcomes comparing nebulized epinephrine to albuterol). These should be significant studies that are relevant to the clinical practice of emergency medicine. For the study that you will be discussing please email the article to Christy Graham at least 24 hours beforehand and she will email it to the other students. If you have questions or wish to discuss your ideas beforehand, contact Dr. Parsa. Please review the provided presentation evaluation form for further details on what will be expected. Scores of 4-5 in each category will be required to be eligible for honors in the course. Each student will be allotted 20 minutes and question/discussion time will be encouraged after each presentation.

Check-Out Procedures
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Books, binders, and safety glasses will be returned to Christy in her office immediately before or after the final exam. Grades will not be submitted if items are not returned.

Rotation Evaluation and at least one Faculty Evaluation sent to you by the Office of Curriculum, Evaluation, and Accreditation must be completed immediately following final exam. Grades will not be submitted until evaluations are completed. Below are the links which you will receive:

Rotation Evaluation: https://hscsurveys.ttuhsc.edu/inq/cgi-bin/qwebcorporate.dll?idx=86UK6F

Faculty Evaluation: https://hscsurveys.ttuhsc.edu/inq/cgi-bin/qwebcorporate.dll?idx=K7JCKR

Mid-Rotation Assessment
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Progress will be assessed for each student at the midpoint of the rotation. Dr. Parsa will review your clinical evaluations, Op-Log entries and early assignments during the second week. Any student who is not making satisfactory progress will meet with Dr. Parsa to discuss their perception of any problem, the student’s strengths and weaknesses and current life stressors. Steps will be taken to determine the precise problem and to work out an appropriate course of action. If you are proceeding well, you will receive an email notifying you of your satisfactory progress and you will not be required to meet with Dr. Parsa; but a meeting can be arranged if you request one.

Test Questions
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Practice test questions are available for educational purposes online at www.saemtests.org. You will receive login access at the beginning of the rotation. These are not required but many students find them to be helpful. Once answered, each question has a detailed answer which provides a great way to study.

Op-Log
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You will be required to complete Op-Log entries on all patients with whom you have direct, clinical contact—e.g., performing a patient’s history and physical examination, or performing or assisting in a diagnostic or therapeutic procedure. Involvement with a more advanced or critical patient in which significant faculty/resident teaching is involved should also be included.

You will be expected to record your encounters in Op-Log regularly and on at least a weekly basis using the observe-assist-manage format. Students must have their Op-Log recordings up-to-date by Thursday of the second week, for mid-rotation assessment and again by the final day of the rotation. Minimum of 30 entries is required to pass and 60 required for honors

Clinical Evaluation
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Clinical evaluations will be based on the attached form which you will provide to each faculty 30-60 minutes before the end of your shift. The faculty will fill it out and give it back to you to turn in. We require that you turn in all forms. This is our best way of documenting you were present in the ED for your shift. If you are missing a form we will consider that an absence that will require an explanation. If your presence at a shift cannot be confirmed this will be considered not showing for the shift, resulting in a failing grade. We have asked all faculty members to discuss their evaluation remarks with you personally at the end of each shift. Please bring completed forms each Thursday morning, when you come to morning didactics, and give to Christy.

Final exam
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A final exam will be taken on the last Friday of the rotation. It is an NBME shelf examination with 110 multiple choice items recently retired from USMLE Step 2 Clinical Knowledge and items developed by the emergency medicine NBME task force. Most item types are single-best-answer. The exam also contains several items in a new format, i.e. item sets that unfold and challenge you to use your clinical knowledge in problem-solving and managing patients over time. Total time for the exam is 3 hours; 15 minutes for the tutorial (optional) and 2 hours, 45 minutes for the exam.

If a student fails the final exam, he/she will receive an incomplete, but will have a chance to repeat the exam. If the student passes the exam on the second attempt, he/she will receive a passing grade. If the student fails on the second attempt, remediation will be offered.

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