Medical Student

OBJECTIVES OF THE EMERGENCY MEDICINE ROTATION:
The student will become familiar with the initial evaluation, assessment, and stabilization of patients who present with urgent and emergent medical problems and trauma.

The student will play an active role in managing acutely ill patients in a timely manner following their emergency department course, and deciding on an appropriate disposition.

Students will become exposed to a variety of invasive and non-invasive procedures that are performed in the emergency department, i.e. arterial lines, arterial punctures, central lines, suturing, chest tubes, resuscitation skills, lumbar punctures, IV lines, nasogastric tubes, Foley catheters and airway management.

The senior student will further enhance his/her basic clinical skills, history and physical exam skills, and learn how to identify any life-threatening process that could be present in all types of patients.

Student will learn the overall organization of the Emergency Department and its ancillary services and personnel.

The student will enhance his/her medical knowledge base on specific topics that will be discussed during the rotation and apply this knowledge to actual patient care.

The student will learn to communicate effectively with all types of patients regarding their medical condition and treatment plan.

Methods of Achieving the Objective Goals:

The senior student will function as a sub-intern in the Emergency Department with responsibility for the initial evaluation of assigned patients, history and physical exam, formulating a differential diagnosis, treatment plan, and determine a disposition for each of their assigned patients. The student will perform these duties under the direct supervision of either attending staff or senior emergency medicine residents.

Students must attend the orientation session at the beginning of each rotation period and gain the basic information needed to begin the rotation and function properly in their assigned areas.

Evaluation Process:

Clinical:

Students are evaluated by the emergency medicine residents and staff attending physicians with whom they have worked during the month. Criteria utilized to evaluate a student’s clinical performance include the following:

Case Presentation
Procedural Skills
History and physical exam skills
Dependability
Patient interpersonal skills
Professional qualities
Initiative and clinical judgment
Attendance/participation at conferences
Ability to formulate a differential diagnosis
Proper utilization of diagnostic studies
Medical knowledge base
Organizational skills
Ability to develop an adequate therapeutic pain
Procedure Log:

Students are required to keep a log of all procedures performed. The attending physician you work with each day must sign all procedures.

Shift Attendance:

You will be required to work 16 shifts. Attendance at all assigned shifts is mandatory!

Specific Guidelines for Senior Medical Students:

The Medical Record:

This is a very important document that must be treated accordingly and the basic format will vary depending on where you are rotating. Students must write legibly, be complete, yet concise and have their charts co-signed by an Emergency Medicine staff attending physician. You are to sign your names in the appropriate space provided on the chart with your school initials next to your name. It is critical to document all pertinent information when evaluating your patients. Remember, “If it isn’t charted, it didn’t happen”! Don’t write down anything you are not sure of or didn’t do. All charts are completed by second or third year Emergency Medicine residents or the Emergency Medicine attending staff once a final disposition is decided upon.

Medical Record Format:

Identify the chief complaint(s):

History of present illness (HPI): include pertinent positive and negatives

Review of Symptoms (ROS): pertinent to the HPI

Past Medical History (PMH): Diabetes, hypertension, TB, sickle cell, asthma, cardiac, kidney, etc.

Medications: includes prescribed and non-prescribed, over-the-counter medications

Allergies: (i.e. medications, contrast dyes, Iodine)

Social History: intravenous drug abuse (IVDA), smoker (ppd), alcohol abuse, crack or other illicit drugs

Family History: cardiac, MI’s, hypertension, diabetes, etc.

Tetanus update: especially in cases of abrasions or lacerations

Physical Exam:

General appearance, distress and pain assessment of the patient

Vital signs (temp, pulse, blood pressure, respiratory rate, pulse ox)

Head, eyes, ENT exam, neck, lungs, heart, abdomen, include rectal exam, pelvic, genitourinary exam, back, extremities, neurological and skin exams

Procedural Notes:

Should be written on the chart for any procedure performed i.e. suturing, lumbar puncture, chest tube, central lines

Differential Diagnosis:

All students will develop an initial diagnosis/impression list on each assigned patient and discuss this with the supervising physician.

Evaluation and management plan:

What treatment needs to be started and why; what diagnostic testing needs to be done and why?

Diagnostic/Laboratory Results:

Each student is expected to review all the radiological studies done on their patients, interpret any lab results, record them on the chart and discuss them with the supervising physician

Treatment plan/Disposition:

You are to discuss these plans with the attending staff on each assigned patient.

Length of Evaluations:

Your initial encounter with the patient should focus on the degree of possible life threat based on the patient’s complaint and general appearance, vital signs, and initial history and physical exam. Plan on presenting your patient to your supervising physician within 20 minutes after the patient arrives. You will be learning to evaluate patients quickly, and accurately, and should be able to see a minimum of 5-6 patients per shift worked. Of course, this will vary depending on the site you are assigned to, time of day, and overall patient volume.

Diagnostic Studies:

After developing a treatment plan for your patients, you will be expected to be able to determine what diagnostic studies are necessary, if any, and justify the clinical necessity of the studies. All orders should be written on the appropriate physician order sheet and co-signed by your supervising physician before they are initiated. Make certain that the lab data you have retrieved from the computer and documentation on the chart is the data from the present visit.

Therapeutic procedures/Medication orders:

Any therapeutic procedure (i.e. central line insertion, lumbar puncture) anticipated must be performed under the direct supervision of your attending staff. All medication orders must be written on the physician order sheet, and co-signed by your supervising physician. No verbal orders will be accepted! Do not administer any medication yourself!

Patient Disposition/Discharges:

All patients seen in the Emergency Department will have a final disposition plan once their emergency care has been completed. Patients may expire, be admitted to a general floor, intensive care unit, or operating room. They may be transferred to other facilities, or be discharged home. It is important to be able to insure that adequate follow-up instructions are given to any patient discharged home from the Emergency department. All patients are given some type of instructions regarding their medical condition, diagnosis, medications, and a follow-up doctor’s appointment upon discharge. It is necessary to contact any identified primary care physician regarding a patient’s follow-up. No patient is to be discharged without the attending physician’s signature on the sheet.

Attire:

Professional dress is expected at all times. Clean laboratory coats, with identification badges, and a complete set of scrubs are required.

Attendance:

Promptness is critical. Any unexcused tardiness or absence will prevent your successful completion of this rotation. If you have an unpreventable situation that may necessitate you being late or absent, contact the Emergency Medicine Medical Student Coordinator during business hours (leave a voicemail if necessary). Students are allowed a maximum of (2) schedule switches and these can only be done with the approval of the site coordinator.

Conduct:

You will be expected to be professional and personable in sometimes hectic, stressful situations in the Emergency Department. Your patience may be tested many times during the month, and your interpersonal skills will be further developed as you communicate with patients, colleagues, family and ancillary personnel. Address all patients as Mr., Mrs., Ms., and NOT BY THEIR FIRST NAMES. Please be sensitive to a patient’s privacy in the department and close doors, or pull curtains when examining them. A good way to overcome interpersonal conflicts is to “treat others as you would like to be treated”, and provide them with the best care you can.

Supervision:

HCFA has mandated that all procedures are directly supervised by an attending physician. All lacerations must be explored with the attending physician. Suturing must be done under the direct supervision of the attending physician. All procedures must be done with direct attending physician supervision e.g. lumbar punctures, central line placement, joint dislocation reduction, joint aspiration, etc.

Parking/Lockers:

You will be given information about parking and availability of lockers from Medical Education. All of your belongings must be placed in your locker before you come to work.