Clerkship Program

Patient Care

Goal: Students who are able to provide patient-centered care that is appropriate and compassionate

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

• Demonstrate proper interviewing techniques (PC-1.1)
• Obtain an accurate problem-focused history and physical exam (PC-1.1)
• Develop a diagnostic and therapeutic patient management plan for the patient with both an undifferentiated complaint and a known disease process (PC-1.3, PC-1.2)
• Formulate a differential dx when evaluating an undifferentiated patient: (PC-1.3)
  • List worst case scenarios
  • Prioritize likelihood of diagnoses based on clinical findings
• Patient management skills (PC-1.2, PC-1.7)
  • Monitor the response to therapeutic intervention
  • Develop appropriate disposition and follow up plans
• Patient communication (PC-1.6, PC-1.7)
  • Educate patients on safety and provide anticipatory guidance as necessary
  • Educate patients to ensure comprehension of discharge plan
• Recognize immediate life-threatening conditions such as, but not limited to, STEMI, Stroke, high- acuity Trauma, (PC-1.4, PC-1.5)
• Interpret basic diagnostic tests such as, but not limited to labs and imaging (PC-1.3)
• Execute accurate EMR documentation appropriate to the ED (PC-1.1, ICS- 4.4)
• Initiate basic resuscitation and stabilization (PC-1.5)
• Demonstrate proficiency in the following basic skills (PC-1.3, PC-1.8)

-Basic Airway Management

-Peripheral Intravenous Access

-ECG/cardiac rhythm analysis

-Cardiopulmonary resuscitation

Goal: Students who are able to apply their broad knowledge base to patient care in the ED clinical setting.

Objectives: During the clerkship the student will have opportunity to:

• Apply diagnostic principles from years 1-3 to the ED clinical setting (KP-2.2)
• Apply evidence-based principles to patient care in the ED clinical setting (KP-2.3)

Goal: Students who are able to apply scientific evidence to patient care and accept and apply feedback for improvement of patient care practices.

Objectives: Students will demonstrate the ability to:

• Investigate a clinical question relevant to patient care through evaluation of primary research (PBL-3.1, PBL-3.4)

• Act on corrective feedback (PBL-3.3)
• Evaluate the medical literature (PBL-3.4)
• Use information technology to improve patient care (PBL-3.4)

Goal: Students who are able to effectively communicate with patients, families, faculty, staff, residents, and other students.

Objectives: Students will have opportunity to:

• Develop and  demonstrate  professional  interactions  and  effective  communication  with  ED faculty, staff and consultants (ICS-4.2)
• Demonstrate active listening skills (ICS-4.3)
• Establish a therapeutic relationship with patients and families (ICS-4.1, ICS-3)

Goal: Students who demonstrate a commitment to carrying out professional responsibilities, adhering to ethical principles, displaying sensitivity to a diverse patient population.

Objectives: Throughout the clerkship students will demonstrate:

• Respect towards patients and families whose lifestyles, culture and values may be different from their own (PRO-5.1)
• Ethical behavior, including patient confidentiality, privacy and consent (PRO-5.2)
• Reliability, by arriving on time and prepared for all required activities (PRO-5.3, PRO-7)
• Honesty and integrity in patient care (PRO-5.6)
• Professional appearance (PRO-5.7)

Goal: Students who demonstrate an awareness of the larger context of health care and understand how to effectively utilize system resources to provide optimal care.

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

• Describe the role of emergency medicine in the US health care system (SBP-6.1)
• Demonstrate understanding of limitations patients’ face due to lack of resources (SBP-6.2, SBP-6.3)
• Know when accessing social services is indicated (SBP-6.2, SBP-4)
• Describe the role of poison centers in the US healthcare system (SBP-6.1)

Goal: Students who demonstrate the ability to effectively engage as part of an inter-professional team.

Objectives: Throughout the clerkship, student should have the opportunity to:

• Develop teamwork and inter-professional communication skills during simulation activities and in the ED (IPC-7.3)

Goal: Students who demonstrate the principles required for lifelong professional growth.

Objectives: During the clerkship students will have opportunity to:

• Develop their own clinical question, identify appropriate research to answer the question and critically appraise this research, presenting their findings to fellow students (PBL3.1)
• Develop proper judgment regarding when to take responsibility and when to seek assistance with patient care, based on their current level of training (PPD-8.1)

Course expectations include showing up for all shifts, on time, appropriately attired (scrubs or business attire, no dangling hair, no open toe shoes), ready to work, with a stethoscope. When evaluating real or simulated patients, always use appropriate Personal Protective Equipment (PPE) and be respectful.

ED Shifts will be distributed between the following facilities:

• UMC of El Paso, 4815 Alameda, 915-521-7700
• El Paso Children’s Hospital, 4815 Alameda, 915-298-5443
• THOP-Transmountain Campus, 2000 Transmountain Road, 915-877-8136 (with completed credentialing on file)

If an emergency arises preventing you from working your shift or you are ill, e-mail the Clerkship Coordinator and PLFClerkhsipAbsence.com The absentee policy during this rotation allows up to 16 hours of missed shift work if the missed shifts are for excused absences (illness, residency interview or family emergency). You will be required to make up any excused absence (if more than 16 hours) to complete the rotation. Contact the Clerkship Coordinator to reschedule any shift that needs to be rescheduled for any other reason.  Should an MS-4 request changes to the schedule after being published, it is also the MS-4’s responsibility to assist in assuring all duty hour requirements/restrictions have been met.  Any shift changes should be requested a minimum of 48 hours in advance, excluding weekend hours, to ensure timely change to the schedules.

We have a strict ‘No-Show’ policy. If you do not show up for a scheduled shift or required activity without notification, you will be dropped from the course, based on a lack of professionalism and you will be required to retake the course in May to receive a PASS. It is your responsibility to know when you are scheduled to be in the ED.

You will usually be assigned to a single ED attending for each shift when you arrive in the ED.  Your attending may request you work with a Senior Resident. Typically, you are expected to act as the primary provider for the patients you see on these shifts. You will do a focused H&P, and then present the patient to the faculty with a differential diagnosis along with a diagnostic and therapeutic management plan. Each MS-4 will be assigned 98 clinical hours in the emergency department in shifts varying in length, but not more than 12 hours. You will be required to work nights and weekends. You may request up to 3 dates to be off the schedule during the rotation. Requests can be given to the Clerkship Coordinator prior to the rotation starting. If you need to make additional shift changes, you may work these out with your classmates and inform the Clerkship Coordinator of any shift swaps.  Shift scheduling is required to abide by the school’s duty hour policy. It is also required that you are available on the first and last day of the clerkship, per school policy.

All patients are to be presented to faculty before orders are written, before pelvic and rectal exams, and before any procedures are done. You are not to do any of these things without direct physician observation. You must notify and obtain approval from your faculty member for each patient you plan to pick up. If a patient appears unstable (i.e. looks really sick, has respiratory distress, or has abnormal vital signs) notify your attending or resident immediately.

Do not leave the department without advising your faculty. Expect to eat your meals in the ED, although you will be allowed to leave the department to get food from the cafeteria. There is a refrigerator and microwave oven in the ED for physician/student use.

For ED charting UMC and EPCH use Cerner. You will receive a personal login and receive training on how to use Cerner during orientation. Your note can be sent to the resident you are working with and after review they have the option to provide an attestation and addendum to your note and it will become a part of the medical record. Student documentation is not taking place at ED sites other than UMC.

On the first day of your rotation, each student will be provided with an EM Fundamentals Book.  EM Fundamentals, is a small pocket book that you can carry around with you and use as a quick reference during your shifts for major issues with guidance on treatment and disposition.

A second book provided for student use. An Introduction to Clinical Emergency Medicine by Mahadevan and Garmel is written for MS-4’s. You are encouraged to read any sections of the book you find interesting. Selected readings below reflect current national curriculum guidelines.

• Ch. 3-    Cardiopulmonary and cerebral resuscitation (read before SIM cases activity)
• Ch. 6-   Shock
• Ch. 7-   Traumatic injuries Ch. 10- Abdominal pain
• Ch. 11- Abnormal behavior
• Ch. 14- Altered mental status
• Ch. 17- Chest pain
• Ch. 21- Diabetes-related emergencies
• Ch. 30- Headache
• Ch. 34- Pelvic pain
• Ch. 37- Seizures
• Ch. 38- Shortness of Breath in Adults
• Ch. 47- Environmental emergencies

Appendix B-Common emergency procedures (read before Task Trainers activity) Appendix C- Laceration repair

Documentation is an important part of clinical practice. We require you to turn in one completed chart for Dr. Parsa to review, due on Friday of the second week of the rotation. This should be your own documentation (not part of the permanent medical record). It should be submitted in a standard typewritten format and uploaded into PLF approved on-line system. It must include the following mandatory items:

• History and physical (not exhaustive, but focused; appropriate for ED)
• ED course-Testing results with interpretation (i.e. K- 9-low). Differential diagnosis.  Therapeutic interventions with indications and reassessment, i.e.
  • 17:30- Ondansetron given for 18:00-  no  nausea,  abdomen  non-tender,  P90  BP 120/80
• Final Diagnosis
• Disposition (with treatment and follow up plan if discharged)

Your note should include what a proper ED physician’s note would include, such as one that would be dictated into a real medical record. Feedback will be provided in PLF approved on-line system on this assignment noting your documentation strengths and weaknesses. If your documentation has significant weaknesses you will be required to repeat the assignment until adequate documentation is demonstrated.

A typical ED patient may face many life challenges; these may be related to poor decisions they have made or may be related to circumstances beyond their control. These challenges may include such difficulties as substance abuse, prior criminal activity and arrests, being a victim of crime, poverty, unemployment, gender identity, lack of healthcare coverage, disability, legal problems, immigration status issues, transportation difficulties, complex close relationship issues (abuse, estrangement, etc.), or family of origin/upbringing issues (i.e. parent was an addict).

Your assignment is to identify an ED patient with a chief complaint or medical condition that suggests challenges in accessing healthcare or maintaining a healthy lifestyle and to complete a detailed social history on that patient, recounting the specific challenges they face in regard to any of the above issues. Discuss the issues relevant to them and their situation. Please attempt to find out details and specific examples of how these challenges may have affected their health and how many of these challenges are linked together. As you interview your patient, ask yourself:

1. What are the key barriers to health for this patient?
2. How are these barriers affecting this patient’s health?

For example, a gentleman with EtOH dependence may have most of the above problems, all stemming from his EtOH use. He may have tried to quit many times (ask about what he has tried, how effective it was, why it did or didn’t work). Ask about some of the other issues above, and how EtOH has affected those issues. Ask where he gets money and how he spends it, ask how he accesses healthcare (when was his last clinic visit, how beneficial was it, how did he get there, could he afford the prescriptions and ancillary testing); ask about living arrangements and family support.

Don’t ask questions as if going through a checklist, but try to do your best to put yourself in their shoes and truly understand the patient’s perspective on their struggles. Take what you have learned and write a one-page narrative including any personal reflections related to the encounter.  Sample write-ups can be accessed in PLF approved on-line system.  Dr. Parsa will review your write-up and provide written feedback in PLF approved on-line system. The assignment will need to be repeated if it is not comprehensive and completed with proper effort.

To assist in the preparation for clinical practice, each MS-4 will practice their skills in a safe, controlled educational environment in the Training and Educational Center for Healthcare Simulation (TECHS), a state-of-the art venue for teaching and testing clinical skills such as:

Ultrasound Training:

• Discuss indications for point of care ED ultrasound
• Obtain and interpret basic point of care ED ultrasound images

Task Trainers:

• Basic Airway Management
• Bag Valve Mask
• Basic Endotracheal Intubation
• Intra-Osseous Line Placement
• Lumbar Puncture
• Tube Thoracostomy
• Central Venous Catheterization

Medical Simulation Cases:

Three cases will be addressed:  (1) Adult Syncope; (2) Chest Pain; and (3) Pediatric Trauma.

All MS-4’s will be scheduled to attend both sessions. A minimum of one session must be attended. Should both sessions be missed, one session must be completed at a later date without interruption of the MS’s academic schedule or one of the following Make-Up Assignments should be completed:

• Task Trainers - Read Appendix B from Maradevan Garmel – Common Emergency Procedures and write detailed steps of one emergency procedure of your choice.

SIM EM Resident Shadow:

Each MS-4 will be required to attend one Thursday Resident SIM Case as assigned during their Emergency Medicine rotation. This shadowing experience allows the MS-4 to evaluate the day- to-day care in a structured, educational setting broadening their clinical exposure in both common and rare scenarios.

Each MS-4 will spend 2 hours at the 911 Dispatch Center where dispatchers receive calls. You do not need to bring anything. You will be able to see firsthand what happens behind the scenes.

You will also spend one 9-hour shift with an EMS ambulance crew. A Fire Station within the city will be identified. The address will be provided on your pass on the day of orientation and in Scheduler.

Each MS-4 will spend 2 hours observing operations at the West Texas Regional Poison Control. This time will be spent listening in on calls and observing how calls are managed.

MS-4’s with previous experience in the pre-hospital arena or Poison Control may request to substitute their hours with additional ED shift(s) totaling the same hours. The request should be made prior to the rotation starting to allow timely changes to be documented appropriately.

By the end of the rotation, each MS-4 is required to turn in your Procedure Log checklist and enter your procedures in OpLog documenting that you have performed a minimum of 5 procedures. Possible procedures are listed on the Procedure Log and include: IV start, blood draw, urine cath, I&D and laceration. Any number of each procedure is acceptable, as long as five have been completed.  Additional procedures not listed can be written in.   

EM Resident Journal Club is held monthly, you will be notified of the date and time.  Journal Club is optional but encouraged for those interested in EM. If you wish to attend, ask the Clerkship Coordinator to arrange the schedule accordingly.

Towards the end of your rotation, each MS-4 is required to attend the assigned CQP date and briefly present to the other students and at least one faculty. This round table style presentation should be based on a clinical question of interest to you that has arisen during the clerkship. Once you have decided on something to investigate, find a primary research article that investigates this problem. You will probably need to review several studies before finding the one you wish to present.  Do NOT choose a review article to present. You should discuss the methods and results pointing out strengths and weaknesses of the study and it’s applicability to patient care. Please identify how you located the article, (PubMed, Google, etc.) why you chose it and why the question the article addresses is important to answer.  Print and complete the top portion of your CQP assessment (found in PLF approved on-line system) and present to your faculty for their completion.

For example, if you are curious about the management of children with bronchiolitis, you could discuss an article relevant to the diagnosis of the illness (e.g. a study looking at the utility of CXR in diagnosis) or treatment (e.g. a study looking at outcomes comparing nebulized epinephrine to albuterol). These should be significant studies that are relevant to the clinical practice of emergency medicine. For the study that you will be discussing please upload into PLF approved on-line system at least 24 hours beforehand. PLF approved on-line system access will be provided to the student in your round table for review and discussion. If you have questions or wish to discuss your ideas beforehand, contact Dr. Parsa. Please review the provided presentation evaluation form for further details on what will be expected. Scores of 4-5 in each category and a final grade of High Pass will be required to be eligible for honors in the course. Each MS-4 will be allotted 15-20 minutes and question/discussion time will be encouraged after each presentation. A brief PowerPoint is required to highlight key article discussion points.

Clinical evaluations will be based on the form that you will provide to each faculty 30-60 minutes before the end of your shift. The faculty will fill it out and give it back to you to turn in. We require that you turn in all forms. This is our best way of documenting you were present in the ED for your shift. If you are missing a form we will consider that an absence that will require an explanation.  If your presence at a shift cannot be confirmed this will be considered a ‘no-show’ for the shift. We have asked all faculty members to discuss their evaluation remarks with you personally at the end of each shift. Please bring completed forms each Thursday morning, when you come to morning didactics, and give to the Clerkship Coordinator.