Rotations: July Orientation Month
Faculty liaison: Tommy Wong, MD
Location: Roosevelt
Description
This is the initial month for the first year EM residents. It is comprised primarily of lectures and demonstrations/labs by faculty and guests, which highlights the essential topics of Emergency Medicine. As part of the curriculum, a two-day introductory course on Emergency Medicine Ultrasound, splinting, suture and airway labs, and a one-day SAFE course also will be given. In addition, certification courses in PALS, BLS, ACLS, and ATLS will be provided. There are approximately 24 clinical hours during the four weeks in the emergency departments. This will enable first year residents to apply and integrate classroom teachings to actual bedside patient care.
Schedule
You will spend three eight-hour shifts in the ED (with a third year or with a faculty member) for clinical orientation so that you are prepared for your first official rotation in the ED. The workweek is approximately 40 hours. Lectures are usually in the morning and labs/clinical shifts will be in the afternoon. You are provided with the four-week lecture schedule on day one of the residency.
Tips
Remember to relax, enjoy the lectures, and enjoy getting to know your peers.
Useful texts
Rosen or Tintinalli is ideal.
Rotation: Adult Emergency Department
Location: Roosevelt and St. Luke's
Faculty liaison: Individual preceptors
Contact Person: EM chief residents: slremchiefs@yahoo.com, Universal beeper (#1000)
Goals
As an EM-1, your goal is to acquire the EM mindset and knowledge base. That is, how to evaluate patients with acute illness or injury, across the spectrum of severity, learning to do an efficient and appropriate complaint- focused work-up. You will present each case to faculty or senior residents, who will guide you in your decisions concerning work-up, evaluation, and disposition. Also take advantage of consultants who may be called to see your patients; they often do bedside teaching, or interpretation of x-rays, ultrasounds and EKGs.
Procedures/skills
See the procedure list required of EM Residents. Be sure to document each procedure in EMSTAT.
Schedule
A typical EM-1 schedule is 18-12 hour shifts/28 day rotation. Day shifts begin at 7am, swing shifts begin at 11am; night shifts begin at 7 p.m. At 7 a.m. and 7 p.m. there are departmental rounds, wherein the arriving team receives sign-out from the departing team. The arriving team will meet all the patients on the assigned team and review their ED course and status. These rounds are primarily intended as an organizational tool, as most teaching occurs at the time of presentation of patients to attendings. At both sites teaching rounds consisting of prepared mini-topics occur at 7am everyday. All attendings and residents will be expected to prepare numerous of these lectures throughout the year. A mini-conference schedule will be provided in conjunction with your ED schedule.
Each resident should take a total of 45 minutes for break/lunch during his or her shift. If it is busy, you may not take more than 30 minutes for lunch. Each break must be approved (sometimes assigned) by the EM3 to avoid more than one person breaking at one time.
You must work exactly the shifts you are assigned. If it becomes necessary to modify your schedule, you must notify the chief residents by e-mail (slremchiefs@yahoo.com) of the proposed change and it must be approved in advance. This being said, it is relatively easy to find residents to cover or switch shifts with you, should last minute surprises arise. All requests for days off must be received by the chief residents in writing, before they make the schedule for that block.
Tips
As an EM-1, don't be concerned about keeping the same pace as the EM-2's or 3's. Your job is to master the basics at a pace that is reasonable and educational for you. It is reasonable for an EM-1 to average one patient encounter per hour. Keeping the ED organized and moving patients through the system is a skill to be learned, but it is not a goal of your initial months. Use all the sources of information at your disposal, including textbooks, medical Internet sites, old charts, and conversations with private attendings.
Take the time and effort to develop concise, complete sign-outs to the person relieving you, so that they know all they need to care well for your patients. Expect and accept no less from the people you relieve.
Use the last half-hour to hour of your shift to tie together loose ends, push through lab results and make dispositions. Sign-outs should be succinct and specific. It is counterproductive to begin a complicated work-up during the last hour of a shift. Focus rather on the immediate patient care issues and let the incoming resident begin the official work-up (i.e. do a 1 minute history and physical and send of appropriate labs, and diagnostic tests.)
One of the many advantages of the life of an EM resident is time. While it is advisable to spend some of this time enjoying all NYC has to offer, an EM-1 goal should be to read 5 pages of Tintanalli per day. This pace will ensure completion of the text in one year.
Pitfalls to avoid
Arrive on time for your shifts.
Learn the names of all the ED staff including MD's, nurses, ED techs and clerks. Foster a good working relationship with them; teamwork is part of the fun.
Adhere to the dress code. Use the lounges at both sites for your belongings.
Rotation: Pediatric Emergency Medicine
Location: St. Luke's
Faculty Liaison: Angela Tangredi, M.D..
Description
This rotation in the Pediatric ED involves seeing cases of varying acuity. There is typically a high volume of patients with a wide array of pathology. You will see patients and present them to the attending, who will guide you in management.
Goals
Become comfortable in the evaluation and management of acutely injured or sick infants, children and adolescents.
Procedures/skills
Pediatric venous access, phlebotomy
Urinary bladder catheterization
Lumbar puncture
Pediatric sedation and analgesia
Laceration repair
Reduction of simple dislocations
Pediatric conscious sedation
Child Abuse evaluations
Endotracheal intubation
Schedule
18 12-hour shifts in the Peds ED. Shifts are either 9am-9pm, 11am-11pm or 7pm-7am. Check with the chief residents the month before you rotate to get the schedule.
Useful texts
Harriet Lane Manual, Barkin (EM Peds), Ludwig/Fleischer (EM Peds)
Crain/Gershel, Clinical Manual of Emergency Pediatrics
Tips
Wash hands often
Rotation: Anesthesia
Contact person: Dr. Sanborn and Willie Cortes (induction room anesthesia coordinator, Roosevelt)
Location: Roosevelt, 5th floor main building (O.R.)
Description
The primary goal of the rotation is to become skilled in airway management, including intubation, bag-valve-mask ventilation, and alternative airway techniques, such as LMA's. Gain familiarity with medications used for sedation, analgesia, and anesthesia.
Schedule
The day begins between 6:30 and 7am in the OR holding area, where you find your assigned room and/or patients for the day, and cases begin at 7.30am. Dr. Sanborn will typically assign you each day to an Anesthesia attending, but this may be flexible. You can consult with Willie as to the day's schedule, which cases may need intubation, and if you are not assigned to a room which cases you can join. You are responsible for filling out the pre-op checklist to assess pre-op risks and airway strategies, as well as putting in a heplock (use a bleb of Lidocaine). Cases continue throughout the day, but often by mid to late afternoon there are no intubations pending. Your day usually ends between 2pm. Each resident will do at least one case from beginning to end.
Try to accompany the anesthesiology team on-call to all in-patient arrests or intubations. To the extent possible, learn regional techniques, such as nerve blocks used for the orthopedic procedures. You will attend the Emergency Medicine Wednesday morning conference during this block.
Tips
We are generally not to intubate in rooms with first-year anesthesia residents, or in rooms where a difficult intubation is anticipated. Try to find attendings working by themselves.
Anesthesia residents tend to want intubations for themselves, especially at the beginning of the year.
Having chosen a case, introduce yourself to the attending and resident and participate in the Pre-op evaluation and pre- induction preparation (iv's, monitoring, etc.) of the patient. On some days you may be able to circulate from room to room, to maximize the number of intubations.
It is essential that you use this opportunity to become comfortable with the different types of drugs used to facilitate intubation as well as to gain confidence in your intubation skills.
Pitfalls to avoid
You will play a major role in determining the quality and quantity of your learning experience.
You must take the initiative to make your availability known to staff. If you simply loiter in the O.R. corridors and surgeons' lounge, the cases will proceed without you. It is also not appreciated if you zip into the room moments before the intubation, put the tube in the hole, and bolt.
Useful texts, etc.
Roberts & Hedges; Ron Walls' Manual of Emergency Airway Management
Rotations: ICU
Location: St. Luke's 7th floor
Contacts: Internal Medicine chief residents and ICU fellow
Description
This rotation is a special opportunity to follow critically ill patients with multisystem disease far beyond their time in the ED. In addition to critical care diagnosis and management issues, you will learn how what we do in the ED influences a patient's progress and prognosis over subsequent days in the unit.
Goals
Familiarity with the management of critically ill medical patients. Learn principles of hemodynamic monitoring. Basic skills in the use of ventilator; fluid and electrolyte management, pressor use.
Procedures/skills
Arterial lines
Central lines
Swan-Ganz
Paracentesis
thoracentesis
Airway management
Schedule
The ICU now has a night float system. You will be on call every 3rd day, but only until 10pm. You will be on night float for 1 week. Remember that while on call in the MICU, you are responsible to bring the Lifepak and actively participate in any medical codes that occur anywhere in the hospital. You will have your own assigned patients, as well as those you admit while on call. Patients are admitted to MICU from both the ED and the inpatient floors. Your daily responsibilities include rounding on your patients, writing progress notes, attending rounds, and scheduling and follow-up of all studies.
Each morning, interns must review their patients' course from the night before, and develop assessment and plans prior to Attending rounds which usually begin at approximately 9 A.M. (each attending sets the time). Rounds often last until noon or beyond. Afternoons are spent writing progress notes, doing procedures, scheduling and following up studies. There are relatively brief work/sign-out rounds in late afternoon to bring the on-call team up to date on all the patients. Depending upon the workload, a typical day ends between 4 and 6 P.M.
The on-call intern covers the unit, together with the resident, until the following morning at 8 a.m., and during this time carries the code beeper and takes new admissions. The resident rotating through the MICU is excused from Wednesday morning EM conference.
Tips
Write transfer notes/orders as a first priority, followed by progress notes. Get the paperwork done as early in the day as possible. Volunteer to do as many procedures as possible. Pay close attention to and ask questions about ventilator management. Extra hospital meals are available to on-call MDs since you are not allowed to leave the hospital.
Pitfalls to avoid
The unit can be a psychologically and physically demanding rotation. Keep in mind the general on-call rules to sleep when you can and not skip meals.
Useful Texts, etc.
Facts And Formulas'' booklet, Harrison's (text and pocket version), Marino: The ICU Book, Civetta's critical care text.
Rotation: Ob/Gyn
Location: St. Luke's, 4th floor, new building, L&D Suite
Contact person: St. Luke's Obstetrical chief residents (they rotate: see roster in L&D oncall room)
Description
You will take care of patients at least 20 weeks pregnant and presenting with a variety of OB and medical problems, as well as patients in active labor (whom you follow through delivery). You will participate in emergency room consults.
Goals
Experience doing normal vaginal deliveries (mimimum is 10 deliveries). Develop the ability to accurately evaluate pregnant patients' medical and obstetrical problems, perform confident and accurate pelvic exams, and informed evaluation of common gynecological problems. The ``day'' begins at 6 pm and lasts until 6 am the following morning.
Procedures/skills
Pelvic exam in both pregnant and non-pregnant women, determination of onset and stage of labor, determination of rupture of membranes, basic fetal monitoring, and normal vaginal delivery. Become proficient with Ultrasound examination of the pregnant and non-pregnant patient.
Schedule
4 weeks on L&D nights, Sunday night through Thursday night. The night begins at 5pm through 7am the next day. Consults on patients in the ED, performing OB/GYN history and physicals, pelvic exams, as well as Ultrasound examination.
Tips
When on L&D, you are most likely to deliver clinic patients, especially if they are multiparous. Pick them up when they initially present in the screening area and follow them through labor. Neither the patients nor staff appreciates your arriving on the scene at the last moment to do the delivery without having previously met the patient.
Useful Texts, etc.
Williams' Obstetrics (located in the main library and in the residency space library); Pearlman and Tintinalli, Emergency Care of the Woman, McGraw-Hill (1998).
Rotation: Cardiac Care Unit
Location: St. Luke's (6th floor, new building)
Contact person: St. Luke's Internal Medicine Chief Residents and Cardiology fellows
Procedures/skills
EKG interpretation, central lines, Swan-Ganz, critical care monitoring, thrombolysis.
Schedule
The CCU, similar to the ICU, now has a night float system. You will typically be on call every third day, but this just lasts until 10pm. You will be on the night float team for 1 week. The CCU team on call consists of an intern, a second year medicine resident, and the cardiology fellow. Work rounds with the fellow usually begin at 8 A.M. You should see your patients and review their course during the night before rounds. Attending rounds (usually beginning 9 or 9:30 a.m.) follow work rounds. The remainder of the day is occupied with chores generated during rounds (line changes, phone calls, progress notes, and scheduling and following up on studies round). You may sign out to the on-call team any time after 4 P.M. if your work is completed.
Tips
When you are on call, be sure to let the fellow know you are interested in being called with him or her to the ED for acute patients. The ED contacts the fellow when there is a patient who is critically unstable and/or is a candidate for thrombolytic therapy. When your in-unit workload permits, it is useful to follow the patient from the ED to the CCU. Otherwise you will not meet the patient until he/she arrives in the unit, and by that time the most acute and intense phase of his/her care and management will have past.
Useful Texts, etc.
Rosen, Marriott's EKG text, Harrison's (pocket version also), House Officer's Seriespocket book by J.W. Heger et. al.: Cardiology, ACLS text. Handbook of Coronary Care by Alpert Francis
