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Emergency Medicine Clerkship Syllabus

Contact Information (Office) 915-545-7333
Michael D. Parsa, M.D., Clerkship Director michael.d.parsa@ttuhsc.edu
Christy Graham, Unit Coordinator christy.graham@ttuhsc.edu

Welcome to the TTUHSC 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. This course is based upon the 2010 national curriculum guidelines for EM clerkships. This syllabus contains all the basic information you will need to succeed during this rotation.

Table of contents


Objectives
Clinical Presentations
General Requirements
Required 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
  • Obtain an accurate problem-focused history and physical exam (PC-4)
  • Patient management skills
    • Monitor the response to therapeutic intervention
    • Develop appropriate disposition and follow up plans
  • Health Promotion
    • Educate patients on safety and provide anticipatory guidance as necessary
    • Educate patients to ensure comprehension of discharge plan
Medical Knowledge

GOAL: Students who are able to integrate basic and clinical science concepts to assess, differentiate, and manage common clinical conditions presenting to the ED.

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

  • Recognize immediate life-threatening conditions
  • Interpret basic diagnostic tests
  • Describe basic ED management of common acute clinical conditions
  • Formulate a differential diagnosis when evaluating an undifferentiated patient
    • List worst case scenarios
    • Prioritize likelihood of diagnosis based on patient presentation and acuity
  • Initiate basic resuscitation and stabilization
  • Demonstrate proficiency in the follow basic skills
    • Basic airway management
    • Peripheral intravenous access
    • ECG/cardiac rhythm analysis
    • Foley catheter placement
    • Cardiopulmonary resuscitation
  • Exposure to the following procedures/diagnosis
    • ED ultrasound
    • Orthopedic splinting techniques
    • Central venous access
    • Tube thoracostomy
    • Endotracheal intubation
    • Intraosseous access
    • Suturing and management of wounds
  • Develop a diagnostic and therapeutic patient management plan for the patient with both an undifferentiated complaint and a specific disease process
  • Propose proper patient disposition and follow-up
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 and values may be different from the students
  • Ethical behavior, including patient confidentiality
  • Cultural sensitivity
  • Reliability, by arriving on time and prepared for all required activities
  • Honesty and integrity in patient care
  • Professional appearance
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
  • Improve listening skills
  • Learn to establish a therapeutic relationship with patients and families
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: Throughout the clerkship students will demonstrate the ability to:

  • Evaluate own performance
  • Apply feedback
  • Evaluate the medical literature
  • Use information technology to improve patient care
  • Understand the limits of their knowledge, experience and capabilities
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
  • Demonstrate understanding of limitations patients face due to lack of resources
  • Understand when accessing social services is indicated
  • Describe the role of the ED in the community, including access to care and its impact on patient care
  • Describe when patients should be referred to the ED
  • Demonstrate understanding of the indications, cost, risks and evidence behind commonly performed diagnostic studies
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
    • 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 and a stethoscope. If an emergency arises preventing you from working your shift or you are ill, call Christy Graham (545-7333) and the attending in the ED (521-7700). The absentee policy during this rotation allows you up to two missed shifts to still pass the course if the missed shifts are for excused abscences. You will be required to make up any excused absence (if more than two) to pass the rotation. An unexcused absence will result in a grade of FAIL. You will be required to retake the course in its entirety to receive a PASS if you have an unexcused absences.

You will be assigned to a single ED attending for each shift when you arrive in the ED. You are expected to act as the primary provider for the patients you see on these shifts. You will do a focused History and Physical, and then present the patient to the faculty with a differential diagnosis and diagnostic and therapeutic management plan. Students will be assigned 92 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. Shift scheduling is required to abide by work duty hour restrictions as set forth by the Office of Student Affairs

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 faculty 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. You should aim to see 3-4 patients directly per shift.

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 for drinks and lunches.

You are required to attend 3 of 4 Thursday morning conferences. In some cases, we may notify you of which day of conference you may miss. For example, if there is one week when conference is less relevant for students, that is the day 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 our hospital uses 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". You must also sign all of your notes. 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". 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.

Required reading
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Before the end of the first week you are required to have completed chapter 2-19 of the Emergency Medicine Clerkship Primer. 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 will email you a pdf copy of the primer.

Please email Christy Graham and let her know when you have finished the reading. You will not be allowed to work any shifts after the first week if the reading has not been completed.

For required readings we provide An Introduction to Clinical Emergency Medicine by Mahadevan and Garmel. 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
  • 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
  • Appendix C Laceration repair
Grading Policy
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HONORS

The same criteria as PASS plus the following:

  • Final exam: above the 70th percentile nationally
  • All course assignments above average to outstanding
  • Clinical evaluations above average to outstanding
PASS
  • Perform above the 5th percentile nationally on the final exam.
  • Complete all assignments to the satisfaction of the course director.
  • Complete a minimum of 20 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 issue.
  • The student must make up excused absences that are beyond the maximum allowance set by TTUHSC
  • Unexcused absence will result in a grade of FAIL.
  • 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 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. Once the requirements have been met the grade will be changed to PASS.
FAIL

Unprofessional behavior

Unexcused absence

Failure to complete required remedial work in the allotted time

This grade will be issued if you have not completed the course requirements to a satisfactory level

Please Note: A FAIL can be changed to PASS-SUCCESSFULLY REMEDIATED if remediation is offered and is satisfactorily completed. If remedial work is not completed satisfactorily in the allotted time, the grade will remain a FAIL.
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). 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)

Do not include extra things here, such as detailed descriptions and extra summaries. 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.

EMS Experience
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Each student will spend 4 hours at the 911 command center where dispatchers receive calls. You do not need to bring anything. You will be able to see first hand what happens behind the scenes.

You will also spend one 8-hour shift with the fire department, and one 8-hour shift @ Life Ambulance with an ambulance crew.

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.

Case presentation
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Towards the end of your rotation each student will have to make a brief case presentation to the other students and at least one faculty. This round table style presentation should be based on a case of interest to you that 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 its 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 clinical practice; studies that current clinical practice is based upon. For the study that you will be discussing please bring a copy for all in attendance, or email it to Christy Graham at least 24 hours beforehand and she will email it to the other students. If you have questions and wish to discuss your ideas beforehand, contact Dr. Parsa. Please review the provided presentation evaluation form for further details on what will be expected. Each student will be allotted 20 minutes and question/discussion time will be encourage after each presentation.

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. We require that you take at least 3 tests on your own for educational purposes. Once answered, each question has a detailed answer which provides a great way to study. The tests will not be graded but we will receive confirmation from the website when you have completed a test. The final exam will be taken from the same database, different questions, but the same format.

Op Log
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You will be required to complete Op-Log entries on all patients with whom you have direct, "hands-on" 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 or 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. Students must have their Op-log records up to date by Thursday of the second week, for mid-rotation assessment and again by the final day of the rotation. Minimum of 20 entries is required.

Clinical Evaluation
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Clinical evaluation 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, that will be considered an unexcused absence which will result in a failing grade for the clerkship. We have asked all faculty members to discuss their evaluation remarks with you personally at the end of each shift. You will then turn in the evaluation forms up to that point to Christy Graham between Monday-Wednesday of the second week. These will be used for your mid-rotation assessment.

Final exam
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A final exam will be taken on the last Friday of the rotation. It will have 50 multiple choice questions for which you will have 90 minutes to complete. It is not open book. This is similar to a shelf exam and is used as a final exam across the country. Everything on the final exam will be covered in the required readings and other educational activities included in the rotation. The final exam is based on current national curriculum guidelines. Further information about the location of the exam will be provided.

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