Louisiana state university health science center new orleans emergency medicine residency program policies to supplement lsuhsc house officer manual


Guidelines To Rotations/Goals & Objectives



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Guidelines To Rotations/Goals & Objectives

Rotations and Scheduling





  1. All rotations at all hospitals begin on the first day of the month, regardless of the day of the week. The only exception to this is the month of January for which the Medical Director of MCLNO sets the first day in order to provide opportunity for all residents to have time off for either Christmas or New Years. This date will apply to all hospitals and rotations.




  1. Schedule requests must be submitted as delineated in the Rotation Guide. Be sure to request off the days you are assigned to take or teach advanced life support courses or to take In-Service Examination.



  1. Failure to report to work any assigned shift at any hospital or any service may result in suspension or dismissal. Residents are required to notify the emergency medicine staff person on duty at the hospital and the chief resident on duty (chief pager 423-2537) and the chief resident of the non-emergency department service to which they are assigned in advance if they are unable to report for duty. The resident must notify the residency office by phone on the day of the absence and the Residency Director in writing within one week of the reason of absence.

In case of illness, residents are required to report to the emergency department for diagnosis and management.





  1. Residents are expected to be punctual for their shifts. Repeated tardiness will result in disciplinary action. Residents may not leave early without permission from the supervising attending.


UH/ MCLANO Emergency Department

Dr.__________________________,


You are assigned to the UH ED, for the month of__________________.
Orientation: Mandatory for all interns, (day, night or off shift) at 7am on the first day of the month. (see section below for orientation review for residents)
Schedule: A choice of a prearranged schedule will be available on a first come first serve basis around the middle of the month preceding your schedule rotation in the emergency medicine office. Please see Kathy or the scheduling chief for schedule template.
Responsibilities: Interns and Residents are expected to manage their individual patients as well as assist in other areas as needs arise. It is the expectation that the intern and resident will work in harmony with the ER RN to accomplish all tasks.
Follow-ups: you are required to complete 2 follow-ups per month while in the ED and to request autopsy results on all deaths while you are in the ED. Follow-up can be achieved via the cliq system. To obtain an autopsy report, email Dr. Robin McGoey in the Dept of Pathology (rmcgoe@lsuhsc.edu) with the patient’s name and medical record number. The follow up documentation will be through Residency Partner. (See Follow-Up Log)

EMS Guidelines: NOHD & Acadian

In addition to the above educational activity, the resident will ride with New Orleans EMS and Acadian Helicopter EMS, on those days designated by the schedule during the time spent in the emergency department. Each shift is 10-12 hour shiftsgenerally from 11 am to 11 pm from Sunday to Thursday, 2 p.m. – 2 a.m. Friday and Saturday. During this period, it is his/her responsibility to provide medical control and aid with care and stabilization at the scenes of ambulance calls. For the purpose of gaining an insight into the ongoing activities of the paramedics, some individuals may be assigned to ride along on a shift with one paramedic crew.

Also the resident may be assigned to cover major events for the Superdome and the City of New Orleans, such as Mardi Gras, New Year’s Eve, etc. Each resident is responsible for picking up the uniform and the instructional manual at the beginning of the rotation. This manual has didactic information as well as information of how to get to NOHD, who to report to, rules and regulations of the rotation.
Acadian Guidelines

When you are assigned to Acadian Helicopter, you must show up for the shift.  We have no arrangement to switch shifts at the last minute due to the weather.  We have a contract with Acadian for 15 shifts per month. You may not change the schedule without getting approval from Kathy Whittington. If you miss a shift for any reason, you must make that shift up on the next day that you are not scheduled to work on a residency rotation.  In addition, you will be given a penalty shift within the next ER month.




Conference: All resident are expected to attend conferences on the appropriate day.
Extras: All procedures must be recorded and turned in at the end of the month.
Supervision: You will be supervised by board certified Emergency Medicine physicians.
Evaluations: Daily evaluations.

Meals: Provided by UH.
What follows are the goals and objectives for the MCLANO ED rotation, that will range from a 2 week to 1 month rotation, as assigned by the Program Director. The rotation will take place at the MCLANO University Hospital. The year of training may include PGY 1-5.
MCLANO EMERGENCY DEPARTMENT RESIDENT ORIENTATION

General

  • Be on time for start of your shift.

  • Dress and act professionally. (see Dress Code)

  • Place a note on every chart.

  • Work with other residents and nurses to enhance patient flow in the ED and Fast Track.

  • Notify attendings as soon as possible of disposition problems caused by lab, X ray, or consultant delays.

  • Make frequent rounds with attendings and discuss management of complex cases prospectively.


Educational

  • Give lectures as assigned by chief residents. (see M & M Presentations and

  • Supervise and teach junior residents, interns, and students through their patient care experiences.

  • Provide a written evaluation of each intern you work with using the form provided to you at the end of the month.

    • If an intern shows a consistent pattern of problems in any area including punctuality, attendance, attitude, knowledge, skills, or interpersonal relationships, notify Dr. DeBlieux, the EMS director immediately so that intern can be counseled.

    • No intern should receive a below average evaluation (4 or below) in any area without having feedback and an opportunity to improve.

    • Interns from other services such as OB GYN and Pediatrics are allowed to attend their required Continuity Clinic one half day per week when assigned to the ED. Surgery residents are allowed to attend conference on Saturday morning. They must "sign out" with the emergency medicine resident before leaving to ensure continuity of patient care.

  • Attend conference as required by Conference Attendance Policy (see Conference Attendance Policy)

  • Document all procedures on Residency Partner (see Residency Partner)

  • Maintain a patient list with major diagnosis.

  • Document at least 20 patient follow-ups per year.(Follow-Up Log)

  • Request autopsy results on all deaths: email Dr. Robin McGoey in the Dept of Pathology (rmcgoe@lsuhsc.edu) These reports count toward your 20 patient follow-ups per year for your portfolio.


Documentation

  • Document the initial time the patient was seen,

  • Document the times consults placed and answered.

  • Time all progress notes, procedure notes, and other significant events such as LOPA referrals, child abuse referrals, etc.

  • Time all orders for lab, X ray, medication, and other treatment.

  • If you use a separate order sheet, write "See separate order sheet" in orders section on route sheet.

  • Chart documentation must be legible and must conform to HCFA/AMA Guidelines.

  • The appropriate boxes indicating patient disposition and condition at discharge must be checked and time and date of discharge filled in.

  • Residents are to write the initial documentation of history, physical exam, medical decision making, and management for all Room 4/Trauma Bay patients and all Crisis Cube/Monitor Bay patients including procedure notes. The resident who runs the resuscitation is to complete the chart.

  • Consultants must document a written consult when they first evaluate the patient. If additional studies such as CT scans are requested, that should be included in the initial written consult. The consult can be updated and completed by the consultant when all studies are complete. The initial consult should address on going management issues, e.g., steroids for possible spinal injury.

  • Be sure all imaging studies have been reviewed by a radiologist before discharging any patient and that documentation of results indicates this review.

  • The Diagnosis box on the route sheet must always be filled in.

  • When a patient leaves AMA or deserts during treatment or is a "No Answer x 3", this status must be recorded in the Diagnosis box on the route sheet, e.g., Diagnosis #1 Scalp laceration, Diagnosis #2 Desertion.

  • An AMA form must be completed in layman's language and signed by the patient, the resident, and a witness for all AMA patients. Written discharge instructions should always be given to AMA patients and should indicate that patient has been encouraged to return at any time to complete treatment.


Orders

  • All X ray and lab slips must have the intern or resident's name and the attending's name in the "ordering physician" blank.

  • ICD-9 codes are mandatory on the lab and x-ray requests. The ECD-9 code list is located on the back of each billing sheet attached to the medical chart.

  • All X ray and lab slips must have an appropriate indicator in the "reason for study" box.

    • The indicator must be a sign or symptom such as ankle pain, chest pain, or shortness of breath. "R/O" diagnoses and such things as "MVA" or "S/P fall" are not acceptable.

    • ICD- 9 codes are required on all x-ray and lab requests.

  • Residents must use their name stamp below their signature on every medical record.



Consultation

  • Be familiar with the various consult policies, e.g., faces, hands, MICU, spinal injuries, cellulitis, etc.

  • Don't delay consults for lab results or other reasons when the need for consultation is clear from the initial history and physical exam.

  • Document time of consult and time answered on ED medical record in space provided.

  • All consults must be written on the hospital's consultation form.


Rapid Sequence Intubation

  • The decision to use RSI, the selection of protocol, drug dosages, and the actual orders must be by the attending physician.

  • Nurses cannot accept orders for RSI from a resident.

  • The entire RSI procedure is supervised by the ED attending who makes all decisions regarding RSI.

  • Interns may not participate in RSI.

  • RSI must be documented on the chart in a procedure note and the RSI CQI form must be completed by the resident and signed by the resident and attending physician.


Medical Control

  • Medical Control calls should be answered immediately.

  • Medical Control must be provided by an HO 2 or greater level resident.

  • Interns may observe but may not provide medical control.

  • Remember, all medical control calls are recorded.


Sexual Assault

  • Residents must give this exam priority as forensic evidence disappears rapidly in these patients.

  • Ovral is used for pregnancy prophylaxis when UPT negative.

    • Physician must document counseling of patient regarding risks and benefits.

    • Two pills are given in the ED and 2 are dispensed BY the physician to the patient to be taken in 12 hours.

    • The physician must write "Ovral 2 pills dispensed to patient by M.D. to be taken in 12 hours." in the Orders section of the chart. This language is needed by the Pharmacy Department when it undergoes JCAHO review.



Trauma Center

  • Trauma Center patients are identified by anatomic, physiologic, and mechanism of injury criteria.

  • All children up to and including 12 years of age must be "Room 4" activation level.

  • Those patients greater than 12 years of age meeting only the mechanism criteria can be designated as "Trauma Bay" activation level by the emergency medicine attending physician only.

  • All adult patients in Region One meeting anatomic or physiologic criteria are "Room 4" activations. Be familiar with the anatomic, physiologic, and mechanism criteria.

  • All trauma center patients must receive ETOH and urine tox screens.

  • Responsibility for patient assessment, communication with recording nurse, intubation, and performance of invasive procedures in Room 4 patients is that of the HO 2 or above resident and cannot be "passed down" to interns.

  • Be sure all trauma center patients receive a written surgery consult.

  • Interns may not sign the emergency blood release forms. Only a senior surgery or EM resident or EM or surgery faculty may sign.



Universal Precautions

  • Residents are expected to use universal precautions (gloves, gown, mask, and eye shield) in the ED whenever performing exams or invasive procedures and to make sure that interns, students, and others under their supervision do so also.

  • Any intern or resident who sustains a blood or body fluid exposure while on duty should report the exposure to the attending physician, complete a hospital incident report, and get a route sheet to obtain treatment and document the  exposure. Anti viral treatment is immediately available through Employee Health during the day and in the ED after hours.


MCLANO/UH ED ROTATION

GOALS and OBJECTIVES
At the completion of rotations in the MCLANO, the intern/resident will be able to:


  1. Perform basic assessment of patients with a variety of moderate and major traumatic conditions.




  1. Formulate a differential diagnosis for patients with various kinds of traumatic conditions and mechanisms of injury.




  1. Order and interpret appropriate diagnostic laboratory and imaging studies for trauma patients.




  1. Understand the interrelationships of the pre-hospital, emergency department, and in-house trauma team and perform as a team member of the emergency department trauma team.




  1. Competently perform minor procedures such as suturing of lacerations, incision and drainage of the abscesses, insertion of nasogastric tubes and urinary catheters, venipuncture, insertion of peripheral intravenous catheters, lumbar puncture, splinting of fractures and sprains, spinal immobilization.




  1. Demonstrate basic understanding of the principles of ACLS resuscitation as applied to persons in cardio-respiratory arrest.




  1. Achieve ability to perform an adequate history and physical exam, prioritize conditions, and form a differential diagnosis in adults with acute and chronic medical problems of varying severity presenting to the ED for care.




  1. Learn proper methods for stabilization of patients with life threatening conditions such as sepsis, respiratory failure, acute MI, CHF, status epilepticus, status asthmaticus, cardiac arrhythmias, severe GI bleeds, and overdose.




  1. Learn to evaluate, diagnose and initiate any needed therapy for a variety of specific medical problems such as asthma, seizures, anemia, stroke, GI disorders, urinary tract infections, pneumonias, and other respiratory illness.




  1. Learn to evaluate and appropriately manage a variety of patient complaints such as chest pain, abdominal pain, dizziness, headache, syncope, etc.




  1. Learn to perform an adequate history and physical exam in female patients with gynecologic problems or problems related to early pregnancy including abdominal bleeding, infection, threatened abortion, and ectopic pregnancy.




  1. Learn appropriate use of diagnostic lab and imaging studies for emergency patients and to have basic competence in their interpretations.




  1. Learn to use the following diagnostic aids: central venous pressures, pulse oximetry, arterial blood gases, EKG’s.




  1. Perform the following procedures with basic competency and to know indications and contraindications: venipuncture, starting an IV or heparin lock, arterial puncture, insertion of a Foley catheter, placement of a central venous line, thoracentesis, paracentesis, lumbar puncture, urinalysis with microscopic, wet prep of vaginal secretions.




  1. Become familiar with common medico-legal problems which present in emergency medical practice such as: consent, desertion, AMA, restraints, impaired patients, child or adult abuse or neglect.




  1. Be able to arrange appropriate follow-up for discharged patients and give adequate discharge instructions.




  1. Learn and use the available contributions of the Social Services Dept. to patient care in the ED and for discharge planning.




  1. Learn appropriate medical evaluation of mentally disturbed patients including techniques for restraint and control of violent patients.

Residents and interns will participate in the management of all emergency department patients under the supervision of emergency medicine faculty.


The clinical and didactic experiences used to meet those objectives included daily patient care of the MCLANO Emergency Department patients, along with bedside teaching. The rotating resident is to attend lectures as part of the greater emergency medicine curriculum, as scheduled by the LSU EM residency program.
The feedback mechanisms and methods used to evaluate the performance of the resident include daily self and faculty evaluations. Immediate feedback may also be given to the resident, and any significant problems will be discussed during the rotation with the LSU EM administration.
The resources and facilities in the institution that will be available to each resident include computer access to Up To Date and the LSU Library services, including current texts in surgery and emergency medicine. The residents will have access to the resources of the hospital including call rooms, the LSU Medical Library, Emergency medicine texts, medical records and meals.
The clinical experiences, duties and responsibilities the resident will have on the rotation: Residents will act as a part of the Emergency Medicine team under the supervision of a staff physician. The residents will participate in the management of patients in the emergency department.
The relationship that will exist between emergency medicine residents and faculty on the service: The overall goals of resident education and patient care will govern the relationship between faculty and residents. Residents will receive 24 hour supervision while on the rotation. All patient care and medical charts will be reviewed and signed by the EM faculty prior to patient discharge.
Duty hours for this rotation will not exceed an average of 60hrs/week, call not longer and will include 1 in 7 days off.
This rotation summary has been reviewed and agreed to by the service director and LSU Program Director.


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