PEDIATRIC EMERGENCY MEDICINE ROTATION OBJECTIVES During your rotation, you will be expected to focus your learning on 5 basic topics: • Respiratory distress • Shock • Altered level of consciousness • Trauma • Infectious diseases The specific objectives within each of the above topics are outlined below.
Given the nature of emergency medicine and the short duration of the rotation as well as the sporadic nature of certain clinical presentations, it is expected that each of you will have a somewhat varied experience. To ensure that each of you meet your core objectives, it will be essential that you use the attached specific objectives to guide reading with a self-study program.
A – Respiratory Distress Knowledge/Management Objectives • Know the normal respiratory rates for children of various ages • Describe the signs and symptoms of respiratory distress in children • Define respiratory failure • Describe an approach to the following presenting complaints o Cough o Shortness of breath o Noisy breathing (stridor/wheeze) • Describe the initial approach and management of a child in significant respiratory distress • Recognize and initiate management for the following conditions o Asthma exacerbation o Croup o Bronchiolitis o Pneumonia Skills objectives • Interpret a pediatric chest x-ray
B – Shock •
• • • •
Know the normal blood pressure and heart rates for children of varying ages Describe the types of shock commonly seen in children (septic, hypovolemic, anaphylactic, cardiogenic) Describe the signs and symptoms and initial management of a child in hypovolemic shock Recognize and initiate management for the following conditions o Dehydration with shock o Septic shock o Anaphylactic shock o Hypovolemic shock secondary to blood loss
Skills objectives • Describe how to insert an interosseous needle
C – Altered level of consciousness • • • • •
Knowledge/management objectives Classify seizures by a standardized classification scheme Describe the features of a typical febrile seizure Describe the initial approach and management of: o A child who is actively seizing o A child with a decreased level of consciousness NYD Recognize the initiate management for the following conditions: o Typical febrile seizure o Atypical febrile seizure o Afebrile seizure
D – Trauma Knowledge/management objectives • Describe a general approach to the multiple trauma patient • Know how to assess the neurovascular status of the limbs • Know how to classify concussions • Know the recommendations regarding return to play after a concussion • Describe the features of non-accidental trauma in terms of history and injury patterns • Describe an approach to suspected non-accidental trauma • Evaluate and initiate management for the following conditions o Simple lacerations o Musculoskeletal trauma o Closed head injury
Skills objectives • Demonstrate ability to adequately cleanse and close a wound with both interrupted sutures and tissue adhesive • Demonstrate the ability to interpret growth plate fractures, including a basic understanding of the Salter Harris classification system • Demonstrate a thorough neurological exam in all age ranges
E – Infectious diseases Knowledge/management objectives • Recognize and initiate management for the following conditions o Otitis media o Pharyngitis o Meningitis o Viral URTI o Gastroenteritis o Urinary tract infection o Cellulitis o Sepsis
Skills objectives • Demonstrate the ability to perform an otoscopic exam on a child (including various restraing strategies) • Demonstrate the ability to perform a throat swab on a child (including various restraint strategies) • Demonstrate the ability to perform a lumbar puncture
GUIDELINES FOR GRADED RESPONSIBILITY AND RESIDENT SUPERVISION FOR PEDIATRIC EMERGENCY MEDICINE The attending physician has a dual professional responsibility: to provide appropriate patient care and to provide education for trainees. There must be careful assessment of the responsibility delegated to the trainee. The resident has a dual responsibility: to ensure that patients (and their families) for whom they are providing care know that they are in a teaching department and to keep attending physicians informed about their patients. NOTES:
1. Expectations of graded responsibility and resident supervision are governed by the staff emergency physician ultimate fiduciary responsibility for patient care and the educational requirements of appropriate teaching and meaningful evaluation based on observed performance.
2. The rate of transfer of graded responsibility and the measure of teaching and evaluation are determined by the level of training, the resident's performance to date, resident and staff negotiation of supervisory comfort level and the complexity of the patient's situation. This is a dynamic process and is often negotiated to different endpoint in every preceptor and resident assignment. 3. While clinical service is an accepted part of the training of a clinical emergency physician, preceptors must be prepared to capitalize on the educational components of service and minimize the delegation of service tasks devoid of educational merit to trainees. ATTENDING PHYSICIAN RESPONSIBILITIES It is the responsibility of the attending physician to provide appropriate supervision for residents at all times and to: 1. Ensure that the patient knows that residents may be involved in his/her care.
2. Review each chart with the resident prior to the end of the shift. This includes: • A discussion of the findings and their significance, and of patient management; • Involvement and agreement concerning major decisions relating to management; • Involvement with the planning and performance of procedures, including direct supervision when required by patient safety or requested by the trainee; • Identification of aspects of the case affording educational emphasis.
3. Be available at all times during the shift. RESIDENT RESPONSIBILITIES
It is the responsibility of every resident to: 1. Introduce yourself to the patient.
2. Inform every patient (or family) that they are in a teaching hospital and that patient care is a team approach under the supervision of the attending physician. 3. Notify the attending physician when: • A patient's condition is deteriorating • The diagnosis or management is in doubt • A procedure is planned • A patient requires admission to hospital • Prior to ED patient discharge.
4. Record in writing all contacts with consulting physicians.
PEDIATRIC HUMAN PATIENT SIMULATION SESSIONS Residents rotating through Pediatric Emergency Medicine Critical events in pediatrics are infrequent, yet patients are likely to have a good outcome if successfully managed. Although many practicing physicians will at some point be required to manage acutely ill children, very few opportunities to learn and practice the necessary skills are encountered during residency training, especially in non-pediatric training programs (family medicine, emergency medicine, surgical subspecialties, radiology, anesthesia, etc.) As such, many of these skills are taught didactically, with no opportunity for hands-on practice. These missed opportunities have a dramatic influence on physician confidence in these situations, but also allow for an increased possibility of medical error or adverse outcome. Human patient simulation is a new area of medical education that has been developed in part to fill these voids. It is now used extensively in some areas of medicine to teach and evaluate new techniques and rare events. It has already proven to be of benefit in pediatric resuscitation skills, but may also hold great potential to teach and allow practice for PGME residents from numerous disciplines in the management of acutely ill children.
In an attempt to meet this educational goal, and to provide practical experience caring for acutely ill or injured children, the Department of Pediatrics at the University of Calgary and the Alberta Children’s Hospital (ACH) have developed the KIDSIM™ Program whereby human patient simulation experiences are provided for trainees during different rotations. One of the main goals of our Pediatric Emergency Medicine (PEM) rotation is to provide experience with dealing with acutely ill or injured children. As most of you know, the experience in this area is somewhat variable based on what types of patients present to the ED during your rotation. As such, we have planned sessions on the HPS for rotating residents during their PEM rotation. You will be scheduled for 1-2 sessions during your rotation. The sessions are held in one of two places: the HPS lab located at the back end of the ED (adjacent to rooms 10 and 11) or the HPS lab in the PICU. A schedule of the sessions you are assigned to attend will be provided for you at the beginning of the rotation. These sessions are considered a mandatory part of your rotation. Please check your schedule carefully for the date and time of your sessions. We look forward to having you in the HPS lab. Please direct any questions or concerns to Dr. Vince Grant, Medical Director of KIDSIM™, the Human Patient Simulation Program at 403-955-7643.
ACH EMERGENCY RESIDENT TRAUMA ORIENTATION
Code 77 is the Trauma Team activation for ACH. o The Trauma Activation Guidelines are posted above the patch phone at the front of the ED. The RN answering the patch phone will be responsible for activating the Code 77. o The Trauma Team Composition is also posted above the patch. Please note that the only other physicians, besides the ED MD, on the team are General Surgery Resident / Staff and PICU Resident / Staff. The ED MD acts as the Trauma Team Leader (TTL) until such time as he / she deem it appropriate to hand the patient over to one of the other MD’s (most likely the admitting service MD). o As the ED Resident your role will most likely be the bedside physician. If this is the case, follow the TTL’s direction. As an extension of this role, the TTL may want you to accompany the patient to the CT scanner. The attending MD clears spinal immobilization on trauma patients. Once this is done, there is a yellow Spinal Clearance Sheet that must be filled out and sent with the patient throughout their hospital stay. This is for communication purposes to the admission units. There is a separate record to fill out for trauma patients that are being admitted: “Pediatric Trauma Team Leader History and Physical Assessment”. These are kept in the trauma room. This is used instead of the front emergency MD form. Admitting Trauma Patients: o Multiple injured patients are admitted to Trauma Surgery (08001700) or General Surgery (1700-0800). o Isolated head injuries > 1 yr old are admitted to Neurosurgery. There is an SCM orderset to be used if they are not in house. o Isolated extremity and pelvis fractures are admitted to Orthopedics. o Non-accidental trauma, Head injuries < 1 yr old, and Burns are admitted to Pediatrics. o Unit 4 is the ACH Trauma Unit. Code 88 is a code that will activate the Intensivist and OR team, including Anesthesiology. Poster of criteria is posted above the patch phones. The Pediatric Massive Transfusion Protocol (MTP) can be activated for certain criteria. There are posters in the trauma room. This is a general overview of trauma at ACH. Please contact Sherry MacGillivray, Trauma Coordinator at ACH if you have any questions. (955-7872 or pager 04957).