DScEM Curriculum_Updated.pdf

Complete Curriculum for DScEM Program

2022-2023

Didactic Portion

MEM6210 Introduction to Emergency Medicine Resuscitation, Shock, and Anesthesia (ED)

MEM6211 Emergency Treatment of Orthopedic Injuries, Emergency Ultrasounds, and Emergency

Radiology (Rad/US)

MEM6212 Toxicology and Oral Maxillofacial (Tox/OMF)

MEM6213 Cardiovascular, Pulmonary, Hematology, Oncology, and Psychosocial Diseases and Disorders

(CCU)

MEM6214 Gastrointestinal, Genitourinary, Obstetrics, and Gynecology (ED)

MEM6215 Pediatrics Non-Traumatic Musculoskeletal Disorders, Abuse, and Assault (Peds)

MEM6216 Emergency Wound Management, Environmental Injuries, and Trauma (SICU)

MEM6217 Infectious Disease, Endocrinology, and Neurology (MICU)

MEM6220 Advanced Emergency Medicine Resuscitation, Shock, and Anesthesia (ED)

MEM6221 Advanced Treatment of Orthopedic Injuries, Emergency Ultrasounds, and

Emergency Radiology (ED)

MEM6222 Advanced Toxicology and Oral Maxillofacial (ED)

MEM6223 Advanced Cardiovascular, Pulmonary, Hematology, Oncology, and Psychosocial Disorders (ED)

MEM6224 Advanced Gastrointestinal, Genitourinary, Obstetrics, and Gynecology (ED)

MEM6225 Advanced Pediatrics Non-Traumatic Musculoskeletal Disorders, Abuse, and Assault (Peds 2)

MEM6226 Advanced Emergency Wound Management, Environmental Injuries, and Trauma (ED)

MEM6227 Advanced Infectious Disease, Endocrinology, Neurology (ED)

Practical Clinical Rotations

MEM6142 Radiology (2 weeks)

MEM6143 Airway (2 weeks)

MEM6144 Toxicology (2 weeks)

MEM6231 Emergency Department 1 (4 weeks)

MEM6232 Emergency Department 2 (4 weeks)

MEM6233 Emergency Department 3 (4 weeks)

MEM6234 Emergency Department 4 (4 weeks)

MEM6235 Emergency Department 5 (4 weeks)

MEM6330 Orientation to Emergency Medicine (4 weeks)

MEM6336 Emergency Department 6 (4 weeks)

MEM6337 Emergency Department 7 (4 weeks)

MEM6338 Emergency Department 8 (4 weeks)

MEM6341 Elective (2 weeks)

MEM6346 Clinical Research

MEM6439 Pediatrics ED (4 weeks)

MEM6440 Pediatrics PICU/ED (4 weeks)

MEM6445 Emergency Ultrasound (3 day introductory course, 4 weeks dedicated course and hands on training throughout the residency)

MEM6447 Surgical Intensive Care Unit (SICU) (4 weeks)

MEM6448 Medicine Intensive Care Unit (MICU) (4 weeks)

MEM6449 Cardiac Care Unit (4 weeks)

MEM6450 Trauma Surgery (4 weeks)

Curriculum Syllabus

MEM6210 INTRO TO EMERGENCY MEDICINE – RESUSCITATION, SHOCK, AND

ANESTHESIA

1. DESCRIPTION: This section forms the basis of all of the knowledge and skills the EMPA Resident will develop throughout the course. This didactic section emphasizes the clinical side of resuscitation techniques and shock recognition and treatment used in the emergency department.

2. GOALS

a. Describe the American Heart Association recommendations and develop skills in the performance of standard resuscitative procedures (ACLS and BLS)

b. Describe the American College of Emergency Medicine and American Academy of Pediatrics recommendations and develop skills in the performance of standard resuscitative procedures (APLS)

c. Describe the principles of neonatal resuscitation

d. Describe the resuscitation issues related to pregnancy

e. Demonstrate airway management skills

f. Demonstrate vascular access skills

g. Describe the emergency department evaluation for Implantable Cardioverter Defibrillators (ICD’s)

h. Describe the fundamentals and interpretation of acid-base and fluid-electrolyte disorders

i. Describe the pathophysiology and general approach for a patient presenting in shock

j. Describe the principles in fluid and blood resuscitation

k. Demonstrate the ability to diagnose and treat septic, cardiogenic, anaphylactic, and neurogenic shock

l. Demonstrate local/regional anesthesia skills

m. Demonstrate Procedural Sedation and Analgesia (PSA) skills

n. Demonstrate familiarity with pharmacologic agents used for local/systemic anesthesia in the emergency department

o. Describe the indications and develop the technical skills needed to perform diagnostic and therapeutic interventions in critically ill patients

3. OBJECTIVES

a. Demonstrate ability to recognize dysrhythmias associated with cardiac arrest and knowledge of BLS protocols for their treatment. What are causes of sudden cardiac death? How do you recognize Brugada

Syndrome, WPW, Long QT Syndrome?

b. Discuss the dosages, indications and contraindications for pharmacologic therapy during cardiac arrest and following resuscitation. What medications can be administered by the endotracheal tube?

c. What are "Do not resuscitate" orders, advance directives, and living wills. What is the general consensus on ethical issues related to resuscitation?

d. Understand the APGAR scoring system and its application to the neonate.

e. Describe the resuscitation steps in the neonate. What medications and dosages are commonly used in the

PALS algorithms? What is the appropriate fluid bolus dose for hypotension due to volume depletion?

f. Demonstrate knowledge of the anatomy and physiology of the upper airway. What special considerations need to be taken when assessing the pediatric patient’s airway?

g. Describe airway management in the pregnant patient. Describe the algorithm for Cardiopulmonary

Resuscitation in pregnant patients. What special considerations must be taken regarding ACLS for the pregnant patient? What are indications and contraindications for perimortem cesarean section?

h. Demonstrate appropriate judgment regarding the need for airway intervention and the adjuncts available to maintain a patent airway (oral/nasal airways, BVM, esophageal airways, LMA). Be familiar with alternative airway management techniques.

i. Discuss the indications, technique, and complications for noninvasive positive-pressure ventilation.

j. Discuss the sequence of events in performing rapid-sequence intubation

k. Demonstrate skill in the use of pharmacologic agents used in rapid sequence intubation. What pharmacologic agents are commonly used? What are the indications, contraindications, time to onset and duration of action?

l. Describe the five most predictive factors in assessing a difficult airway.

m. Describe the principles of mechanical ventilator support and ideal positioning.

n. Describe indications for a surgical airway.

o. Describe the pathophysiology, clinical features, diagnosis, treatment, and disposition for patients presenting in distributive, cardiogenic, obstructive, or hypovolemic shock.

p. Demonstrate understanding of the pathophysiology, clinical features, management, and complications of fluid resuscitation and transfusion of blood. What are indications for transfusion?

q. Describe the physiology of acid production and excretion.

r. Describe the calculation of the anion gap.

s. Describe the differential diagnosis of wide and unchanged (normal) anion gap.

t. Describe the causes and be able to identify based on lab values: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. How does a metabolic acidosis affect serum potassium?

u. Describe the clinical approach to acid-base problems and mixed acid-base disturbances.

v. Describe the alveolar-arterial (A-a gradient) oxygen calculation.

w. Describe the general principles to follow in the initial evaluation of patients with fluid and electrolyte disorders.

x. Describe the definition for osmolarity and osmolality. Understand when to use osmolar gap calculation.

y. Describe the causes and manifestations of hyponatremia, hypernatremia, hypokalemia, and hyperkalemia. What are hypertonic hyponatremia, isotonic hyponatremia and hypotonic hyponatremia?

What are common causes? What determines the development of symptoms in regard to hyponatremia?

z. Describe the definition and emergency treatment for hyponatremia, hypernatremia, hypokalemia, and hyperkalemia. What is the risk if hyponatremia is corrected too rapidly? What is the mechanism of action for various drugs used to treat hyperkalemia?

aa. Describe the signs & symptoms of hypocalcemia, hypercalcemia and hypomagnesemia. What patient populations do you tend to see these electrolyte imbalances in? What electrocardiogram changes might be seen with different electrolyte abnormalities?

bb. Describe the treatment for hypocalcemia, hypercalcemia and hypomagnesemia

cc. Discuss the approach to the patient with a cardiac rhythm disturbance. What causes AV Reentrant

Tachycardia? How does pre-excitation occur? How do you recognize WPW? How do you treat supraventricular tachycardia associated with WPW?

dd. Discuss the pathophysiology, clinical features, diagnosis, and treatment of a patient presenting in septic shock.

What is SIRS?

ee. What is early goal-directed therapy? What are the specific goals of early goal directed therapy? Discuss follow on studies to include the ProCESS trial.

ff. Describe the indications, contraindications, methodology, complications, and demonstrate competency in performing the following procedures; oral endotracheal intubation, nasotracheal intubation, cricothyroidotomy, central venous catheterization, intraosseous access, and arterial line placement.

gg. Describe the Seldinger technique for central venous line insertion.

4. IMPLEMENTATION

a. Procedure laboratory – Monthly procedure labs will be conducted emphasizing skills required in your duties as an EMPA.

b. Reading assignments – Emergency Medicine A Comprehensive Study Guide 9th ed., Chapters: 11-13, 15-18, 22, 25, 27-31, 108-109.

c. Supplemental reading: Rosen’s Emergency Medicine Concepts and Clinical Practice Fifth ed., Chapters

186-188 pages 2616-2640, Chapter 191 pages 2658-2672, Chapter 198-199 pages 2725-2747, Chapter

200 pages 2747-2761.

d. ACLS AND PALS manuals. Selected journal articles may be given to each EMPA Resident to compliment the objectives listed.

e. Grand Rounds lectures – Weekly lectures will be attended. These lectures include over eleven hours on the topic of resuscitation and shock.

5. RESOURCES AND FACILITIES: Each EMPA Resident will be provided all texts required to complete the goals and objectives as outlined in the curriculum. Grand Round lectures will be held in the ED

Conference room or other locations as necessary. The Procedures lab will be held at designated areas at each

MTF. The Medical library at each MTF is available twenty-four hours daily for research or study requirements.

6. DUTIES AND RESPONSIBILITIES OF THE EMPA RESIDENT: The preceptor in the Emergency

Department will coordinate the duty hours during MEM6210 didactic section. Duty uniform will be either Class

B or ACU’s, and hospital/black scrubs during clinical shifts or appropriate civilian attire in local civilian hospitals. Attendance at Grand Round lectures and the monthly procedure laboratory is mandatory. Direct supervision will be present and the goal is to increase ability to evaluate/manage/treat pediatric patients presenting to the Emergency Department.

7. EMPA SUPERVISION, EVALUATION, AND FEEDBACK: The EMPA Resident will be under direct supervision by the staff physician or staff EMPA for the clinical rotation you are on. All patients evaluated by the EMPA Resident will be discussed and evaluated by the staff physician or staff EMPA prior to the patient being discharged. There will be a written examination at the end of the section covering the objectives listed.

8. CLINICAL ROTATION EVALUATION: See Grading Outline for EMPA Program at the end of this document. Failure to receive passing grade will result in placement on program level remediation, academic probation, extension of training, or termination from the program. At the end of each rotation, it is the residents’ responsibility to ensure their rotation evaluations are completed and submitted to the PD/APD.

9. WRITTEN EXAMINATION: There will be a written examination at the end of the section covering the objectives listed. The EMPA Residents are required to receive at least an 80% on the exam to receive the passing grade. If the residents receive less than an 80% on the end of rotation written exam, the residents will be required to retest. The highest grade the residents will receive on a retest is 80%. If they fail the retest, the residents are placed on academic probation and given a remediation plan. Failure after remediation may result in termination from the course.

10. GRADING SCALE: The course is graded as follows:

a. A = 94%-100% of points awarded.

b. A- = 90%-93% of points awarded.

c. B+ = 87%-89% of points awarded.

d. B = 84%-86% of points awarded.

e. B- = 80%-83% of points awarded.

11. SCHEDULING: This is an independent didactic study section.

Week 1 introduction, goals and objectives, reading assignment, grand rounds

Week 2 reading assignment, grand rounds

Week 3 reading assignment, grand rounds, procedure lab

Week 4 complete reading assignment, grand rounds written exam

MEM6211 EMERGENCY TREATMENT OF ORTHOPEDIC INJURIES,

EMERGENCY ULTRASOUNDS, AND EMERGENCY RADIOLOGY

1. DESCRIPTION: The MEM6211 section orients the Emergency Medicine Physician Assistant to the concepts of orthopedic conditions encountered in an emergency department environment, Radiology, and

Ultrasound in Emergency Medicine. This section is the basis for the comprehensive clinical rotations in the

Radiology Department, and in the Ultrasound Department. There is no formal orthopedic clinical rotation.

Familiarization with orthopedic conditions encountered in the ED environment will be accomplished through extensive ED rotations at the MTF or local civilian hospitals.

a. Demonstrate relevant history and physical exam skills

b. Describe the use of diagnostic imaging modalities available for the evaluation of orthopedic disorders

c. Demonstrate proficiency in the evaluation and management of musculoskeletal trauma

d. Describe principles of acute and chronic pain management in patients with musculoskeletal disorders

e. Demonstrate skill in the diagnosis and treatment of inflammatory and infectious disorders of the musculoskeletal system

f. Demonstrate competency in various procedures related to the care of Emergency Medicine patients

g. Describe the principles of ultrasonography (US)

h. Describe the application of the Focused Assessment with Sonography in Trauma (FAST)in trauma patients

i. Describe the application of ultrasonography in assessing first-trimester pregnancies

j. Describe the principles of contrast radiographic studies and their use in the Emergency Department

k. Describe the principles and application of Computed Tomography (CT) in the Emergency Department.

l. Describe the principles and application of Magnetic Resonance Imaging (MRI) in the Emergency

Department

m. Describe the application and interpretation of plain film radiographs

a. Discuss the pathophysiology of pain. Understand tools used to evaluate pain in the emergency department and what keys are to effective pain management.

b. Discuss common analgesics used in the Emergency Department to include dosing, onset peak effect, duration, and adverse effects, advantages and disadvantages. Discuss the classification of opioid analgesics.

c. Describe the levels of procedural sedation. Describe the American Society of Anesthesiologists Physical

Status Classification System. How do we monitor patients during sedation?

d. Describe the sedation agents typically used for procedural sedation to include dosing, titration, duration of action and potential adverse effects.

e. Describe the pain management options for patients prior to procedural sedation typically used to include dosing, titration, duration of action and potential adverse effects.

f. Describe the presentation, diagnosis, management and complications of rhabdomyolysis.

g. Describe the evaluation (resuscitation, airway management, physical examination) for injuries to the spine

h. Describe the loss of motor function for the level of a spinal cord lesion

i. Describe the methods of radiographic evaluation for the cervical spine

j. Describe the criteria to “clear” a cervical spine injury with and without radiographic views. Understand the limitations of cervical spine x-rays in terms of diagnosing c-spine injuries.

k. Describe the different types, mechanism, and radiographic findings of cervical spine injuries.

l. Describe the classifications of thoracolumbar spine injuries.

m. Describe incomplete spinal cord syndromes to include: Anterior cord, Central cord, Brown-Sequard and

Cauda Equina Syndromes.

n. Describe the orthopedic emergencies that require prompt recognition and management (open fracture, dislocation/subluxation, and neurovascular deficit).

o. Describe the situations that require orthopedic consultation prior to dispositioning the patient.

p. Demonstrate ability to describe a radiograph: open vs closed, location, orientation, displacement, separation and angulation.

q. Describe the Salter-Harris classification of fractures.

r. Describe the principles of splinting and the types of immobilization dressings for orthopedic injuries.

s. Describe the principles of evaluation for the hand and digits.

t. Describe the presentation and management of tendon, ligament, dislocation, and fracture injuries to the hand/digits.

u. Describe the presentation, management, and complications of the different types of elbow fractures and dislocations. Understand how to recognize a radial head fracture, both radiographically, and by physical exam.

v. Describe the presentation and management of the different types of forearm fractures. Describe the difference between a Monteggia and Galeazzi Fracture-Dislocation.

w. Describe the clinical assessment and radiographic findings seen in wrist injuries.

x. Describe the presentation and management of ligamental wrist injuries and carpal bone fractures. Know the most commonly fractured carpal bone the significance of this injury and the gold standard for definitive diagnosis.

y. Describe how to assess tendon or nerve injuries in the hand and digits. Understand how to assess and treat for an ulnar collateral ligament rupture, flexor digitorum profundus rupture, and high-pressure injection injuries in the hand.

z. Describe the cutaneous and motor function of the nerve supply to the hand.

aa. Discuss compartment syndrome of the hand and why it is more difficult to diagnose than at other anatomic sights.

bb. Describe the Colles’ and Smith’s fractures and the appropriate post reduction splint.

cc. Describe the imaging procedure of choice and the complications associated with posterior sternoclavicular dislocations.

dd. Identify the associated injuries seen with a scapular fracture.

ee. Demonstrate ability and know the different methods to reduce a glenohumeral joint dislocation.

Understand the most common complication of an anterior shoulder dislocation.

ff. Describe the classification and treatment of acromioclavicular joint injuries.

gg. Describe the complications associated with proximal humerus and humeral shaft fractures.

hh. Describe the presentation and management of femoral fractures.

ii. Describe the presentation and management of hip dislocations.

jj. Describe the presentation and management of knee dislocations.

kk. Describe the relevance of arthrocentesis in traumatic knee injury. Describe the mechanism for a tibial plateau fracture and the ligamentous injuries that are associated with a medial plateau fracture vs lateral plateau fracture.

ll. Describe the Ottawa and Pittsburgh knee rules for determining the need for radiographic evaluation of knee injuries.

mm. Describe the Ottawa Ankle Rules for determining the need for radiographic evaluation of ankle/midfoot injuries. Describe the ankle exam. Describe the presentation and management of ankle dislocations. Understand a Maisonneuve fracture.

nn. Describe the type of ankle injuries that require immediate consultation by an orthopedist in the emergency department.

oo. Describe the type of foot injuries that require immediate consultation by an orthopedist or podiatrist in the emergency department.

pp. Describe difficult to identify fractures on radiological images and how to manage.

qq. Describe the pathophysiology, common causes, anatomical compartments, diagnosis, and management of patients presenting with compartment syndrome. Understand timelines that are important in terms of nerve injury and limb salvage.

a. Procedure laboratory – Monthly procedure labs will be conducted emphasizing skills required as an

EMPA.

b. Lectures – There will be a minimum twenty hours of formal lectures on ultrasonography methodology for Focused Assessment with Sonography in Trauma (FAST) by Staff Emergency Medicine Physicians.

During your academic year, there will be formal Ultrasound Conferences hosted by the Ultrasound

Department.

c. Reading assignments - Emergency Medicine A Comprehensive Study Guide 9th ed Chapters: 35-38, 89, 267-271.

d. Supplemental reading - Rosen’s Emergency Medicine Concepts and Clinical Practice Fifth ed., Chapter

29 pages 233-240, Chapters 42-51 pages 467-737, Chapters 110-112 pages 1583-1618, Chapter 121 pages 1762-1770, Chapter 130 pages 1925-1943. Selected journal articles will be given to each EMPA

Resident to compliment the objectives listed.

e. Supplemental training resources – Intro to Radiology online interactive tool, modules, tests

(https://www.med-ed.virginia.edu/courses/rad/). The resident is required to complete the tests and turn in the certificate of completion to the program director for filing in the resident’s training record. The modules are:

1. Chest radiology

2. Plain chest radiograph

3. Gastrointestinal radiology

4. GU radiology

5. Plain abdominal radiograph

6. Male/female pelvis

7. Imaging of the cervical spine

8. Skeletal trauma

9. Head CT

10. CT pulmonary angiogram

11. Emergency body CT

f. The Ultrasound of Emergency Medicine Fourth ed. Selected journal articles may be given to each

EMPA Resident to compliment the objectives listed. ACEP Policy Statement on emergency ultrasound guidelines.

5. RESOURCES AND FACILITIES: Each EMPA Resident will be provided all texts required to complete the goals and objectives as outlined in the curriculum MEM6211. Grand Round lectures will be held in either the

ED residency area, or other locations as necessary. The Procedures lab will be held at designated areas at each

MTF. The Medical library at each MTF is available 24 hours a day for research or study requirements.

6. DUTIES AND RESPONSIBILITIES OF THE EMPA RESIDENT: The preceptor will coordinate the duty hours during the MEM6211 didactic section. EMPA Residents are required to report fifteen minutes prior to scheduled clinical shifts to check all airway carts in the department. Duty uniform will be either Class B or ACU’s, and hospital/black scrubs during clinical shifts or appropriate civilian attire in local civilian hospitals. Attendance of Grand Round lectures and the monthly procedure laboratory is mandatory. Direct supervision will be present and the goal is to increase ability to evaluate/manage/treat pediatric patients presenting to the Emergency Department.

https://www.med-ed.virginia.edu/courses/rad/

7. EMPA SUPERVISION, EVALUATION, AND FEEDBACK: The EMPA Resident will be under direct supervision of an Emergency Medicine Staff Physician, radiology Resident or an Ultrasound Staff member. It is the Resident’s responsibility to ensure a Procedural Skills Assessment is completed by the Emergency

Medicine Staff Physician for all procedures/studies attempt. There will be a written examination at the end of the section covering the objectives listed. The evaluation will be accomplished using Institution specific residency management software.

8. CLINCAL ROTATION EVALUATION: See Grading Outline for EMPA Program at the end of this document. Failure to receive passing grade will result in placement on program level remediation, academic probation, extension of training, or termination from the program. At the end of each rotation, it is the residents’

9. WRITTEN EXAMINATION: There will be a written examination at the end of the section covering the objectives listed. The EMPA Residents are required to receive at least an 80% on the exam to receive the passing grade. If the residents receive less than an 80% on the end of rotation written exam, the residents will be required to retest. The highest grade the residents will receive on a retest is 80%. If they fail the retest, the residents are placed on academic probation and given a remediation plan. Failure after remediation may result

10. GRADING SCALE:

b. A- = 90%-93% of points awarded.

c. B+ = 87%-89% of points awarded.

Week 1 introduction, procedure lab, goals and objectives, reading assignment, grand rounds

Week 2 reading assignment, grand rounds

Week 3 reading assignment, grand rounds

Week 4 completion of reading assignment, grand rounds, written exam

MEM6212 TOXICOLOGY AND ORAL MAXILLOFACIAL

1. DESCRIPTION: The MEM6212 section develops the EMPA

Residents knowledge of toxicological and oral maxillary facial presentations encountered in the emergency department.

2. GOALS: TOXICOLOGY

a. Describe the pertinent aspects of the history and physical exam relative to acute poisoning with particular emphasis on clinical recognition of major toxic syndromes (toxidromes) b.Describe the generic aspects of clinical management of poisoning, including stabilization and decontamination

c. Describe the principles, methods, and controversies of decontamination and enhancement of elimination of toxins d.Describe the fundamentals of poisoning epidemiology, pharmacokinetics, and biotransformation

e. Describe the presenting signs, symptoms, laboratory findings, pathophysiology and treatment of common therapeutic drug poisonings, drugs of abuse, natural toxins, and general household poisons

f. Describe to recognize, diagnose, assess and emergently manage acute and chronic complications of substance abuse

g. Describe the emergency departments’ role in planning for hazardous materials (HAZMAT) incidents and be familiar with chemical and biological agents use in weapons of mass destruction (WMD)

h. Describe the use of adjunctive services, including the toxicology laboratory and poison center, in the management of acute poisonings

i. Describe the specific indications and implementation of specific therapeutic modalities, such as the use of antidotes, hemodialysis, and hyperbaric oxygen

j. Demonstrate competency in various procedures related to the care of Emergency Medicine patients

k. Demonstrate the knowledge and skills necessary to interpret laboratory, radiographic, and EKG data used to assess patient pathology

3. GOALS: ORAL MAXILLOFACIAL

a. Demonstrate relevant history and physical examination skills

b. Describe the principles of ocular trauma management

c. Describe to recognize and treat emergent causes of visual loss

d. Describe the evaluation and management of common ophthalmologic complaints

e. Describe the evaluation and management of common and emergent problems of the head, neck, and oral cavity

f. Demonstrate competency in various procedures related to the care of Emergency Medicine patients

4. OBJECTIVES: TOXICOLOGY

a. Describe the pertinent aspects of the history and physical exam relative to acute poisoning with particular emphasis on clinical recognition of major toxic syndromes (toxidromes).

b. Discuss common toxidromes to include representative agents, common findings, signs and symptoms and potential interventions. (opioid, sympathomimetic, cholinergic, anticholinergic, salicylates, sedative-hypnotic, hypoglycemic, hallucinogenic, serotonin, extrapyramidal).

c. Describe the principles, methods, and controversies of decontamination and enhancement of elimination of toxins.

d. Describe the presenting signs, symptoms, laboratory findings, pathophysiology and treatment of common therapeutic drug poisonings, drugs of abuse, natural toxins, and general household poisons.

e. Describe the use of adjunctive services, including the toxicology laboratory and poison center, in the management of acute poisonings.

f. Describe the specific indications and implementation of specific therapeutic modalities, such as the use of antidotes, hemodialysis, and hyperbaric oxygen.

g. Demonstrate knowledge of basic principles of drug absorption, redistribution, metabolism, and elimination.

h. Demonstrate knowledge of the principles of hemodialysis and hemoperfusion and the toxic agents which can be removed by these methods.

i. Describe the pathophysiology, clinical features, diagnosis and treatment of patients with the following ingestions: cyclic antidepressants, atypical antidepressants, MOAIs, antipsychotics, alcohols, opioids, cocaine/methamphetamines, aspirin/salicylates, acetaminophen, NSAIDS, digoxin, beta-blockers, calcium channel blockers, Iron, pesticides, and anticholinergics.

j. Described Neuroleptic Malignant Syndrome and understand the differentiating features from Serotonin

Syndrome

k. Discuss the five stages of toxicity of Iron ingestion.

l. Discuss significant drug interactions for NSAIDS.

m. Discuss the pathophysiology, clinical features, common causes, diagnosis and treatment of methemoglbinemia.

5. OBJECTIVES: ORAL MAXILLOFACIAL

a. Describe the principles of ocular trauma management.

b. Describe the presentation and treatment for lid and conjunctiva infections

c. Describe the presentation, diagnosis, and treatment for patients presenting with herpes simplex keratoconjunctivitis and herpes zoster ophthalmicus.

d. Describe the presenting signs, symptoms and management/disposition of periorbital and orbital cellulitis, and corneal ulcers.

e. Describe the presentation, diagnosis, and treatment/disposition for patients presenting with lid lacerations, superficial, blunt, penetrating, and chemical ocular trauma.

f. Describe the clinical features, diagnosis, and treatment/disposition of patients presenting with painful/painless acute loss of vision.

g. Describe the presentation and treatment for Bell’s Palsy, Diabetic/ Hypertensive Cranial Nerve Palsies, Posterior Communicating Artery Aneurysm, Horner’s Syndrome, and Pseudotumor Cerebri (Idiopathic

Intracranial hypertension), and optic neuritis.

h. Demonstrate knowledge of the dosages, indications and contraindications of topical and systemic ophthalmologic medications.

i. Describe the presentation, diagnosis, treatment, and complications common ear complaints (otalgia, tinnitus, vertigo, hearing loss, otitis externa, and otitis media infections)

j. Describe the diagnosis and treatment of traumatic disorders of the ear (thermal, hematoma, foreign bodies, and tympanic membrane perforation).

k. Describe the clinical features, diagnosis, treatment/ disposition for patients presenting with facial cellulitis.

l. Describe the evaluation and management of disorders of the mandible including dislocations and infections.

m. Discuss disorders of the salivary glands.

n. Describe the clinical features, diagnosis, treatment/ disposition for patients presenting with anterior or posterior epistaxis.

o. Describe the clinical features and treatment for nasal fractures, nasal foreign bodies, sinusitis, and nasal septal hematoma.

6. IMPLEMENTATION

a. Clinical rotations – The EMPA Resident will be required to work in the area of his or her clinical rotation. Evaluation will include all acuity levels of patients presenting to the emergency department and the Resident will evaluate, manage, and disposition several patients each shift. During the orientation month there will be an intensive lecture series on toxicology. Each Resident is to aggressively seek procedures during clinical shifts.

b.Procedure laboratory – Monthly procedure labs will be conducted emphasizing required skills.

c. Reading assignments Toxicology - Emergency Medicine A Comprehensive Study Guide 9th ed., Chapters: 176-180, 185-187, 189-191, 193-195, 198, 201-202, 207, 241-244.

d.Supplemental reading - Rosen’s Emergency Medicine Concepts and Clinical Practice Fifth ed., Chapters 141-159 pages 2063-2216. Chapter 65-67 pages 892-938. The Wills Eye Manual Third ed.

Roberts/Hedges Clinical Procedures in Emergency Medicine Third ed. Selected journal articles may be given to each EMPA Resident to compliment the objectives listed.

e. Selected journal articles will be given to each EMPA Resident to compliment the objectives listed.

f. Lecture – Eight hours of toxicology and six hours of OMF will be given during the initial orientation month.

g.Grand Rounds lectures – Weekly lectures are mandatory. These lectures include over ten hours on the topic of toxicology and six hours on OMF.

7. RESOURCES AND FACILITIES: Each EMPA Resident will be provided all texts required to complete the goals and objectives as outlined in the curriculum. Rotation shifts will be conducted at the MTF ED or local civilian ED. Grand Round lectures will be held in the ED Conference room, or other location as necessary. The Procedures lab will be held at designated areas at each MTF. The Medical library at each MTF is available 24 hours a day for research or study requirements.

8. DUTIES AND RESPONSIBILITIES OF THE EMPA RESIDENT: The preceptor in the Emergency

Department will coordinate the duty hours during the MEM6212 didactic section. Residents are required to report fifteen minutes prior to clinical shift to check all airway carts in the department. Duty uniform will be either Class B or ACU’s, and hospital/black during clinical shifts or appropriate civilian attire in local civilian hospitals. Attendance at Grand Round lectures and the monthly procedure laboratory is mandatory. During clinical shifts, the resident will be required to evaluate six to ten patients per shift. Direct supervision will be present and the goal is to increase ability to manage multiple patients.

9. EMPA SUPERVISION, EVALUATION, AND FEEDBACK: The EMPA Resident will be under direct supervision of the Emergency Department staff (physician, physician assistant). All patients evaluated by the EMPA Resident will be discussed and evaluated by the ED staff prior to the patient being discharged. It is also the responsibility of the EMPA Resident to ensure an evaluation (weekly counseling form) of clinical shifts is completed and that a Procedural Skills Assessment is completed by the ED staff for all procedures attempted. There will be a written examination at the end of the rotation covering the objectives listed. The evaluation will be accomplished using Institution specific residency management software.

10. CLINCAL ROTATION EVALUATION: See Grading Outline for EMPA Program at the end of this document. Failure to receive passing grade will result in placement on program level remediation, academic probation, extension of training, or termination from the program. At the end of each rotation, it is the residents’ responsibility to ensure their rotation evaluations are completed and submitted to the

PD/APD.

11. WRITTEN EXAMINATION: There will be a written examination at the end of the section covering the objectives listed. The EMPA Residents are required to receive at least an 80% on the exam to receive the passing grade. If the residents receive less than an 80% on the end of rotation written exam, the residents will be required to retest. The highest grade the residents will receive on a retest is 80%. If they fail the retest, the residents are placed on academic probation and given a remediation plan. Failure after remediation may result in termination from the course.

12. GRADING SCALE:

f. A = 94%-100% of points awarded.

g. A- = 90%-93% of points awarded.

h. B+ = 87%-89% of points awarded.

i. B = 84%-86% of points awarded.

j. B- = 80%-83% of points awarded.

13. SCHEDULING: This is an independent didactic study section.

Week 2 reading assignment, grand rounds

MEM6213 CARDIOVASCULAR, PULMONARY, HEMOTOLOGY, ONCOLOGY,

PSYCHOSOCIAL DISEASES AND DISORDERS

1. DESCRIPTION: The MEM6213 section is a foundation for the Emergency Medicine Physician Assistant (EMPA) in the specialty of Emergency Medicine. This rotation emphasizes the didactics of neurology, psychiatry, gerontology, and anesthesia used in the emergency department. This will form the basis of knowledge for clinical rotations that consists of endocrinologic, hematologic, and oncologic diseases encountered in an emergency department environment, as well as in the

CCU/ SICU/ MICU clinical environment.

a. Assimilate concepts of general medicine, history taking and physical examination skills to develop a systemic evaluation and differential diagnosis for patients presenting to the emergency department

b. Describe the indications for admission and the criteria for discharge for a wide variety of medical conditions

c. Demonstrate knowledge of the pathophysiology, presentation, and management of common hematologic diseases and oncologic emergencies

d. Demonstrate competency in various procedures related to the care of Emergency Medicine patients

e. Demonstrate the knowledge and skills necessary to interpret and effectively utilize laboratory and radiographic data used to assess patient pathology

f. Demonstrate an understanding of quality improvement and risk management programs and their application to the operation of an emergency department

g. Demonstrate an understanding of the function of emergency medicine within the institution and its relationship with other departments

h. Demonstrate an understanding of the function of accrediting agencies and their relationship with emergency medicine

i. Demonstrate the ability to rapidly evaluate, diagnose, stabilize, and disposition critically ill patients

j. Master understanding of the diseases of the cardiovascular system, including pathophysiology, evaluation, and stabilization/treatment

k. Master comprehension of the diseases of the respiratory system, including pathophysiology, evaluation, and stabilization/treatment

l. Demonstrate competency in various procedures related to the care of Emergency Medicine and critically ill patients

m. Demonstrate the knowledge and skills necessary to interpret laboratory, radiographic, ECG data, and other diagnostic tests used in the management of critically ill patients

n. Demonstrate the ability to rapidly evaluate, diagnose, stabilize, and disposition critically ill patients

o. Master understanding of the diseases of the cardiovascular system, including pathophysiology, evaluation, and stabilization/treatment

p. Master comprehension of the diseases of the respiratory system, including pathophysiology, evaluation, and stabilization/treatment

q. Describe the indications for admission and the criteria for discharge for a wide variety of medical conditions

r. Demonstrate competency in various procedures related to the care of Emergency Medicine and critically ill patients

s. Command the knowledge and skills necessary to interpret laboratory, radiographic, ECG data, and other diagnostic tests used in the management of critically ill patients

3. OBJECTIVES:

a. Describe the pathophysiology, initial approach, clinical features, ancillary testing, and differential diagnosis for patients presenting with chest pain.

b. Describe the approach to the patient with low probability of acute coronary syndrome. Describe risk stratification for patients presenting with chest pain.

c. Describe the clinical features, physical exam findings, and electrocardiographic findings of patients presenting with ACS. Describe serum cardiac markers of myocardial injury, including peak time and duration of elevation after myocardial injury. Describe the disposition of patients presenting with acute coronary syndromes.

d. Describe intervention strategies and disposition of patient with acute coronary syndromes.

e. Describe the pathophysiology, etiology, differential diagnosis, and emergency department evaluation for patients presenting with syncope.

f. Describe the pathophysiology, clinical features, and treatment for patients presenting with heart failure and pulmonary edema.

g. Describe the pathophysiology, clinical features, diagnosis, and emergency department care for patients presenting with cardiac valvular emergencies.

h. Describe the pathophysiology, risk factors, symptoms, diagnosis, treatment, and disposition for patients presenting with pulmonary embolism and DVT.

i. Describe the classifications, pathophysiology, clinical evaluation, management, and types of emergencies associated with patients presenting with hypertension. Discuss pharmacologic agents used in the treatment of hypertensive emergencies.

j. Describe the clinical features, risk factors, diagnosis, radiographic findings, and treatment for patients presenting with aortic dissection/aneurysms.

k. Describe the pathophysiology, clinical features, diagnosis, and treatment of common respiratory symptoms (dyspnea, hypoxemia, hypercapnia, wheezing, cough, hiccups, cyanosis) presenting to the emergency department. What are the most common causes of chronic cough?

l. Describe the pathophysiology, clinical features, diagnosis, treatment, and disposition of pneumonia in adults.

m. Describe the pathophysiology, clinical features, diagnosis, treatment, and disposition of pneumonia in patients with underlying disease processes. Discuss the pneumonia severity index as it relates to hospital admission and ICU admission.

n. Describe the pathophysiology, clinical features, diagnosis, treatment, and disposition of aspiration pneumonia.

o. Describe the pathophysiology, clinical features, diagnosis, treatment, and disposition of acute asthma and COPD exacerbations. Describe how to classify severity of an asthma exacerbation.

p. Describe the pathophysiologic classification of anemia and the initial laboratory evaluation of anemia.

Describe the evaluation of microcytic, normocytic and macrocytic anemia.

q. Discuss the pathophysiology of acquired thrombocytopenia. What are common symptoms in patients with idiopathic thrombocytopenic purpura?

r. Describe the bleeding complications, replacement therapy, and indications for hospitalization for those patients with Hemophilia A and B. What clotting factors are deficient in Hemophilia A & B?

s. Describe the classification and treatment for those patients with von Willebrand’s disease

t. Describe available blood products and recognition, management, and evaluation of acute transfusion reactions. Describe characteristics of blood products, to include typical dose and dosage effect. Describe general indications for platelet transfusion.

u. Demonstrate knowledge of the anticoagulant agents; oral, parental (heparin and low-molecular weight heparin), glycoprotein IIB-IIIA inhibitors, and fibrinolytic. Discuss absolute and relative contraindications to fibrinolytic therapy.

v. Describe the emergency treatment of bleeding complications of antithrombotic therapy.

w. Discuss the pathogenesis, clinical features, lab findings, differential diagnosis and treatment of DIC.

x. Describe the medical evaluation, diagnosis, emergency department management, and disposition of a psychiatric patient.

y. Describe the approach to the psychotic patient. What type of delusions and hallucinations are common in patients with psychotic disorders?

z. Describe the approach to the acutely agitated, suicidal patient.

aa. What is informed consent? What is important to document when a patient wants to leave the ED against medical advice? Discuss the treatment of minors in the emergency department? Be aware of EMTALA obligations. Discuss provider interpersonal behaviors that can reduce risk.

a. Clinical rotations – The EMPA Resident will complete a block rotation through the Cardiac Critical

Care, Surgical ICU, Medical ICU and Emergency Departments during the 18 months. Duties will be coordinated by the rotation preceptor. Evaluation will be through all acuity levels of patients presenting to the emergency department and the goal is to evaluate, manage, and disposition three to five patients each shift. The resident should aggressively seek procedures during clinical shifts.

b. Procedure laboratory – Monthly procedure labs will be conducted emphasizing skills required as an

EMPA.

c. Reading assignments - Emergency Medicine A Comprehensive Study Guide 9th ed., Chapters: 48-49, 51-

53, 56-59, 62, 65, 69-70, 231, 233, 235, 238-239, 286-287, 296, 303.

d.Supplemental reading - Rosen’s Emergency Medicine Concepts and Clinical Practice Fifth ed., Chapters

13-17 pages 123-155, Chapters 95-103 pages 1433-1541, Chapters 115-117 pages 1665-1714, Chapters

120-122 pages 1744-1785, Chapter 177 pages 2491-2503, Chapter 179 pages 2511-2534, Chapter 29 pages 233-240, Chapters 42-51 pages 467-737, Chapters 110-112 pages 1583-1618, Chapter 121 pages

1762-1770, Chapter 130 pages 1925-1943, Chapters 18-20 pages 155-178, Chapters 68-83 pages 938-

1234. Roberts/Hedges Clinical Procedures in Emergency Medicine Third ed. Selected journal articles may be given to each EMPA Resident to compliment the objectives listed.

e. Certification course – Sixteen hours of lecture and practical on Advanced Cardiac Life support (ACLS) and an additional twenty-four hours for ACLS instructor training are required.

f. Lectures – Twelve hours of lecture and sixteen hours of Critical Care Course will be given during the initial orientation month.

g. Grand Rounds lectures – Weekly lectures will be attended. These lectures include over ten hours on the topic of cardiopulmonary care.

5. RESOURCES AND FACILITIES: Each EMPA Resident will be provided all texts required to complete the goals and objectives as outlined in the curriculum. MEM6213 rotation shifts will be conducted at

MTF, unless otherwise specified. Grand Round lectures will be held in ED Conference room. The procedure labs will be conducted within each MTF. The Medical library is available twenty-four hours daily for research or study requirements.

6. DUTIES AND RESPONSIBILITIES OF THE EMPA RESIDENT: The duty hours during the

MEM6213 didactic section will be posted by the rotation supervisor. EMPA residents are required to report fifteen minutes prior to clinical shift to check all airway carts in the department. Duty uniform will be either

Class B or ACU’s, and hospital/black during clinical shifts or appropriate civilian attire in local civilian hospitals. Grand Round lectures attendance and the monthly procedure laboratory are mandatory. During clinical shifts, the EMPA Resident will be required to evaluate several patients per shift. Direct supervision will be present and the goal is to increase ability to manage multiple patients.

7. EMPA SUPERVISION, EVALUATION, AND FEEDBACK: The EMPA Resident will be under direct supervision of the EM3 (senior Resident) and/or the Emergency Department staff (physician, physician assistant). All patients evaluated by the EMPA Resident will be discussed and evaluated by the ED staff prior to the patient being discharged. It is also the EMPA Resident’s responsibility to ensure a Procedural Skills

Assessment is completed by the ED staff for all procedures attempted. There will be a written examination at the end of the section covering the objectives listed. The evaluation will be accomplished using Institution specific residency management software.

document. Failure to receive passing grade will result in placement on program level remediation, academic probation, extension of training, or termination from the program. At the end of each rotation, it is the residents’

9. WRITTEN EXAMINATION: There will be a written examination at the end of the section covering the objectives listed. The EMPA Residents are required to receive at least an 80% on the exam to receive the passing grade. If the residents receive less than an 80% on the end of rotation written exam, the residents will be required to retest. The highest grade the residents will receive on a retest is 80%. If they fail the retest, the residents are placed on academic probation and given a remediation plan. Failure after remediation may result

c. B+ = 87%-89% of points awarded.

Week 2 reading assignment, grand rounds

MEM6214 GASTROINTESTINAL, GENITOURINARY, OBSTETRICS, AND

GYNECOLOGY

1. DESCRIPTION: The MEM6214 section is a block consisting of gastrointestinal and genitourinary, and obstetrics and gynecologic diseases encountered in an emergency department environment

2. GOALS: GI/GU

a. Assimilate concepts of general medicine, history taking and physical examination skills to develop a systemic evaluation and differential diagnosis for patients presenting to the emergency department

b. Describe indications for consultation and surgical intervention in patients with acute abdominal pain

c. Describe the indications for admission and the criteria for discharge for a wide variety of medical conditions

d. Describe the pathophysiology, presentation, and management of diseases related to the alimentary tract

e. Describe the pathophysiology, evaluation, and treatment of acute renal failure and emergencies in dialysis patients

f. Describe the diagnosis and management of urinary tract infections, including pyelonephritis and cystitis

g. Describe the diagnosis and management of disorders of the male genitalia

h. Describe the diagnosis and management of renal calculi

i. Describe the key historical and physical examination elements in the evaluation of renal transplant patients

j. Describe the use of diagnostic imaging modalities available for the evaluation of urologic disorders

k. Demonstrate procedural skills relevant to general surgery

l. Demonstrate competency in various procedures related to the care of Emergency Medicine patients

m. Demonstrate the knowledge and skills necessary to interpret and effectively utilize laboratory and radiographic data used to assess patient pathology

3. GOALS: OBSTETRICS/GYNECOLOGY

a. Demonstrate expertise in the diagnosis and management of vaginal bleeding. Describe the physiological changes during a normal pregnancy

b. Demonstrate expertise in the diagnosis and management of emergent complications of pregnancy including the postpartum period

c. Demonstrate expertise in the management of uncomplicated and complicated labor and delivery

d. Describe the diagnosis and treatment of genital and pelvic infectious diseases

e. Demonstrate an understanding of breast and urogynecologic disorders that present to the emergency department

f. Demonstrate an understanding of the presentation and complications of gynecologic malignancies

g. Demonstrate the skill in assessing post-gynecologic procedure complications presenting…