Table of Contents s55

University of Nebraska Medical Center

House Officer Manual 2005 - 2006 Department of Emergency Medicine

1 Table of Contents

Review of Faculty and Staff-University and Department

Program Mission Statement, Goals & Objectives

PGY 1 Goals & Objectives Emergency Medicine Rotation Anesthesia Rotation Cardiology Rotation Internal Medicine Rotation Radiology/Ultra Sound Rotation OB/GYN Rotation Ortho Rotation Trauma Rotation

PGY 2 Goals & Objectives Emergency Medicine Rotation Pediatric Surgery Rotation Neurologic Surgery Rotation PICU Rotation AICU Rotation Rural Emergency Medicine Rotation

PGY 3 Goals & Objectives Emergency Medicine Rotation Emergency Department Administration Rotation Rural Emergency Medicine Rotation Elective Rotations

Lecture Schedule and Description

Evaluation Process

Collection of Case Numbers

Research

Department, GME, & UNMC Policies

Monthly Schedule & Duty Hour Policies

Vacation, Meeting, & Sick Time Policies

Harassment & Complaint Policy

House Officer’s Role in M3, M4, and off service resident Education

Billing Information

Medical Records

Additional Program Information

2 Abbreviations and Acronyms

3 The University of Nebraska Medical Center

Hospital Administration

Harold M. Maurer, MD, Chancellor William O. Berndt, PhD, Vice Chancellor for Academic Affairs Don Leuenberger, Vice Chancellor for Business & Finance Robert D. Bartee, Executive Assistant to the Chancellor John Russell, Executive Director Human Resources Yvette Holly, Executive Director Info. Technology Services Nancy Woelfl, PhD, Director McGoogan Library of Medicine Sandra Goetzinger-Comer, Director Public Affairs

Colleges, Hospital, Clinics/Institutes

James O. Armitage, MD, Dean College of Medicine Irene G. Klintberg, PhD, Executive Associate Dean Rodney S. Markin, MD, PhD, Associate Dean, Clinical Affairs, President University Medical Associates Glenn A Fosdick, MHA, Associate Dean for the Health System Mary C. Haven, MS, Associate Dean, School of Allied Health Professions Robert S. Wigton, MD, Associate Dean, Graduate Medical Education John B. Windle, MD, Associate Dean, Continuing Medical Education Stephen B. Smith, MD, Associate Dean, Ambulatory Services Jeffrey W. Hill, MD, Associate Dean, Admissions, Students & Multicultural Affairs Gerald F. Moore, MD, Associate Dean, Curriculum Ira Fox, MD, Associate Dean, Research and Development Clarence T. Ueda, Pharm.D, PhD, Dean, College of Pharmacy Ada M. Lindsey, RN, PhD, Dean, College of Nursing John W. Reinhardt, DDS, Dean, College of Dentistry Kenneth H. Cowan, MD, PhD, Director Eppley Institute for Research in Cancer and Allied Diseases Bruce A. Buehler, MD, Director Munroe - Meyer Institute

4 Department Chairs

Judith K. Christman, PhD, Biochemistry and Molecular Biology William O. Berndt, PhD, Vice Chancellor for Academic Affairs Don Leuenberger, Vice Chancellor for Business & Finance Robert D. Bartee, Executive Assistant to the Chancellor John Russell, Executive Director, Human Resources Yvette Holly, Executive Director Info. Technology Services Nancy Woelfl, PhD, Director McGoogan Library of Medicine Sandra Goetzinger-Comer, Director Public Affairs Thomas H. Rosenquist, PhD, Cell Biology & Anatomy Samuel M. Cohen, MD, Pathology/Microbiology David B. Bylund, PhD, Pharmacology Irving H. Zucker, PhD, Physiology/Biophysics John Tinker, MD, Anesthesiology Michael Sitorius, MD, Family Medicine John Gollan, MD, PhD, Internal Medicine Carl V. Smith, MD, Obstetrics and Gynecology Carl B. Camras, MD, Ophthalmology Kevin Garvin, MD, Orthopedic Surgery Donald Leopold, MD, Otolaryngology Bruce A. Buehler, MD, Pediatrics James R. Anderson, PhD, Preventive & Societal Medicine David G. Folks, MD, Psychiatry Craig W. Walker, MD, Radiology Byers W. Shaw, MD, Surgery Charles A. Enke, MD, Radiation Oncology

Residency Program Directors

John Tinker, MD, Anesthesiology James Stageman, MD, Family Medicine Jeffrey Harrison, MD, Family Medicine –Rural James O’Dell, MD, Internal Medicine Joel R. Bessmer, MD, Medicine/Pediatrics Pierre Fayad, MD, Neurological Sciences Lyal Leibrock, MD, Neurosurgery Jordan Hankins, MD, Nuclear Medicine Teresa Berg, MD, Obstetrics and Gynecology Thomas Hejkal, MD, Opthalmology Michael Miloro, MD, Oral and Maxillofacial Surgery Kevin Garvin, MD and Matthew Mormino, MD, Orthopaedic Surgery and Rehabilitation Barbara Heywood, MD, Otolaryngology-Head & Neck Surgery James Gulizia, MD, Pathology John Walburn, MD, Pediatrics Perry Johnson, MD, Plastic & Reconstructive Surgery David O’Dell, MD, Primary Care 5 William Roccaforte, MD, Psychiatry Jonathan Jaksha, MD, Radiology Jon Thompson, MD, Surgery John Donovan, MD, Urologic Surgery Department of Emergency Medicine

Faculty - Academic Larry Lamberty, MD Robert Muelleman, MD Assistant Professor Professor Chief Section of Emergency Medicine Timothy Larsen, MD Assistant Professor

Michael Wadman, MD Susan MacQuiddy, MD Assistant Professor Assistant Professor Residency Program Director Lee Millward, MD Jennifer Audi, MD Assistant Professor Assistant Professor/Toxicologist Steven Seifert, MD Kristine Bott, MD Professor, Medical Director Assistant Professor Nebraska Regional Poison Center Student Clerkship Director Clarkson EM & Part-Time Lance Hoffman, MD Physicians Assistant Professor Therese Safranek, MD Assistant Program Director Charles Denton, MD Joseph Sippel, MD James McClay, MD Scott Menolascino, MD Assistant Professor Thaddeus Woods, MD Director of EM Informatics James J. Faylor

S. Marshall Longwell, MD Midlevel Practitioners Assistant Professor Michelle Sgourakis Kris Smith T. Paul Tran, MD Teresa Palmer, PA-C G. Pat Riedmann, PA-C Assistant Professor R. Dennis Rieke, PA-C

Research Director Administrative

Richard Walker, MD Laura Robinson, Manager Associate Professor Tammi Erickson, Education Facilitator Faculty – Clinical Victoria Halgren, MD Randy Leister, Administrative Instructor Support

Darrin Jackson, MD Robert Williams, Administrative Assistant Professor Support

6 Phyllis DeGeorge, Billing Specialist

Lynn Horst-Heyda, Billing Specialist

7 Emergency Medicine Residency Mission Statement

The University of Nebraska Emergency Medicine Residency Program will

Strive to produce competent, compassionate physicians who

Have achieved excellence in

Clinical practice, academic pursuits, and service to their community and region.

Participation in this program will offer

Residents the rare opportunity to help start a new program and develop new traditions.

Goals and Objectives of the Emergency Medicine Residency Program

8 House Officer First Year Rotation Descriptions

Position: House Officer I Rotation: Emergency Medicine at UNMC

The EM1 will achieve proficiency in the history and physical examination skills relevant to emergency medicine while gaining familiarity with the time management skills necessary to care for multiple patients in the acute setting. In this initial phase in training, the resident must develop an approach to the evaluation and management of common ED presentations, and the emphasis is on this process.

Goals 1. Learn the systematic approach to the evaluation of patients with urgent/emergent presentations. 2. Acquire the medical knowledge pertinent to the practice of emergency medicine. 3. Develop the interpersonal skills and professional attributes necessary to provide optimal care in the emergency department. 4. Understand the role the ED plays in the greater health care system & how the emergency physician may facilitate patient care. 5. Learn self-analysis of clinical emergency practice, utilizing information technology & scientific evidence, to improve the delivery of high quality patient care. 6. Develop the ability to facilitate the learning of others in the emergency department setting. 7. Learn the procedural skills required in the evaluation and management of a variety of urgent/emergent patient presentations.

Objectives 1. Perform an appropriate problem-focused history and physical examination for a variety of urgent and emergent presentations. 2. Demonstrate a coherent presentation of history and physical examination findings to supervising physicians. 3. Demonstrate the formulation of a complete differential diagnosis based on information obtained from history and physical examination findings for a variety of ED presentations. 4. Describe the evaluation and management of a wide range of ED presentations of undifferentiated disease. 5. Perform time-efficient patient management and begin to effectively prioritize the evaluation and management of multiple patients. 6. Demonstrate the ability to communicate with patients and their families in a compassionate, supportive manner. 7. Demonstrate the ability to effectively communicate with other healthcare providers (i.e. pre-hospital care providers, consulting physicians, and nursing staff) to optimize patient care. 8. Assist or perform important EM procedural skills, including CPR, arterial line insertion, central venous line insertion, thoracostomy, paracentesis, thoracentesis, invasive & noninvasive airway management, arthrocentesis, joint relocation, fracture reduction, & conscious sedation techniques. 9. Perform basic ED procedures, to include wound care/laceration repair, incision and drainage of subcutaneous abscesses, extremity immobilization/splinting, spine immobilization techniques, peripheral venous access, femoral and radial arterial blood sampling, and Foley catheter placement 10. Demonstrate basic EM diagnostic skills, to include ECG interpretation, laboratory analysis of metabolic derangements, bedside ultrasound, plain radiography, and cranial CT interpretation.

Supervision The PGY 1 resident will be supervised by upper level residents in EM residency program as well as by the emergency medicine faculty members.

Work Hours While on the emergency medicine rotation, the work hours will follow the ACGME Guidelines. Residents on this rotation will not be scheduled for more than 60 clinical hours per week in the emergency department and no more than 72 duty hours per week. Duty hours comprise all clinical duty time and conferences, whether spent within or outside the educational program including on-call hours.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please make all requests to Tammi Erickson a minimum of 45 days in advance to the start of your EM rotation.

Educational Responsibilities 9 Conferences EM Core Conference Orientation Lecture Series Topics in EM Conference EM Grand Rounds Journal Club Trauma Case Conference Laboratory EM Procedure Conference EM Orientation Laboratory Sessions Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000. Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia, W.B. Saunders, 1998.

Evaluation Process The EM section will receive an evaluation from supervising EM faculty for each resident using the standard EM Resident Evaluation Form via New Innovations. A review of the evaluation will occur at the six-month resident progress meeting with the EM Residency Program Director. Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

Position: House Officer I Rotation: EMS

The resident will join the pre-hospital care teams for both Omaha Fire Department and LifeNet as an active participant in patient care, performing assessments & interventions as directed by the supervising medic or nurse. EMS system administrative experience will occur through the resident’s position as assistant to the medical directors of Omaha Fire Department and LifeNet. The objectives of the EMS curriculum are to train the EM resident in accordance with the following goals as modified from the American College of Emergency Physicians’ position paper on the qualifications of EMS medical directors

Goals: Learn the principles of pre-hospital medical care and transport. 1. Learn the principles of disaster management. 2. Learn to plan for medical care at mass gatherings. 3. Demonstrate proficiency in the evaluation and management of patients in the pre-hospital setting. 4. Develop proficiency in the teaching of pre-hospital care providers. 5. Familiarity with the design and operation of EMS systems.

Objectives: 1. Experience in out-of-hospital emergency care. 2. Active involvement in the training of EMS personnel in basic life support (BLS) and advanced life support (ALS) 3. Active involvement in the medical audit process with review and critique of BLS and ALS patient care activities. 4. Education regarding the administrative and legislative process affecting the regional and state EMS systems.

Supervisor: The resident will participate in patient care & perform assessments & interventions as directed by supervising Medic or Nurse on shift.

Work Hours: This rotation will require the resident to work average between 40 and 60 hours per week. This includes scheduled ED shifts, scheduled EMS shifts, attending meetings, and education days. a. At least 1 Omaha Fire EMS squad ride alongs (8 hours)

10 b. At least 4-6 LifeNet Ride Alongs. (see below for additional details) Each LifeNet shift is 12 hours long (7a-7p). These shifts will occur Tuesdays, Wednesdays, Fridays, Saturdays, & Sundays. c. Teaching at Creighton Paramedic Center on Mondays & Thursdays (see below for additional details). d. Attendance to all OFD QA’s & Case Reviews on Mondays & Tuesdays from 3p-5p. e. The monthly LifeNet meeting on Wednesday mornings. f. You will be scheduled 1 clinical shift per week in ED while on this rotation.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please make all requests to Tammi Erickson a minimum of 60 days in advance to the start of your EMS rotation.

Call Responsibilities: While you are on this rotation, you will not be assigned to taking call.

Patient Responsibilities: Primarily you will function in the capacity as a shadow gaining progressive responsibility in performing assessments and interventions as allowed by the supervising Medic or Nurse.

Shift Responsibilities: Your responsibilities will be given to you by the supervising medic or nurse that you are scheduled to work with during that shift. These responsibilities may vary each day depending on work load and staffing.

Education Responsibilities: Conferences EM Core Conference (wk 1) EMS Meetings a. Omaha Fire EMS QA every Monday 15:00 – 17:00 at the Central Station b. Omaha Fire EMS run review every Tuesday 15:00 – 17:00 – the site varies c. Omaha Fire EMS Clarkson run reviews – site and times vary d. Omaha LifeNet monthly meeting held the 2nd Wednesday each month from 07:00 – 11:00 e. LifeNet Chart Reviews & Education meetings are held in Feb., Apr., June, Aug., Oct., Dec. f. Attend any Disaster Drills, Nuclear Safety, Bioterriorism events and other EMS related meetings. Creighton Paramedic Education Goals: This rotation is designed to orient the post-graduate emergency medicine resident physician to the field of EMS and EMS education, granting a wide range of learning opportunities to become familiar with field EMS operations and patient care, to learn about how EMS responders are trained and educated, and to participate in the education of EMS responders as lecturers and practical workshop instructors.

Objectives: Upon completion of this program, the post-graduate emergency medicine physician will be able to: 1. Describe the state of EMS and EMS response systems nationally, regionally, statewide and locally; 2. Competently develop and deliver a competent EMS lecture for a paramedic class and an EMT class; and, 3. Competently instruct paramedics in practical learning laboratories.

Program Design: It is presumed that post-graduate emergency medicine resident physician will enter the rotation with a wide range of clinical and educational backgrounds. Some physicians will likely have extensive experience as former or current paramedics, some may have been experienced registered nurses or clinical technicians, and others may have had only a minimal amount of clinical experience prior to medical school. Thus, as different physicians going through this rotation might benefit from different experiences, the maximum flexibility will be offered to design a meaningful and engaging series of experiences for each physician.

Activities:

1. Paramedic didactic classes are scheduled each Monday, 8:30 a.m. to 3:30 p.m. Paramedic practical skills sessions are scheduled each Thursday, from 8:30 a.m. to 3:00 p.m. Participation in these will be the default scheduled activity when no other experiences have been scheduled or are available. 2. At least one paramedic lecture will be prepared, delivered and evaluated. This will include development of the objectives, handouts, projections, and evaluation-testing materials.

11 3. At least five patient care scenario practical laboratory presentations will be developed and presented, including the background scenario, the learning points, the clinical findings, the diagnostic testing results, the clinical progression of the patient, and relevant follow-up information to be discussed; 4. For those who have no EMS experiences, at least one scheduled ride with a local EMS service will be scheduled within the first week of the rotation. For those with extensive EMS experience, this would remain an option available to him or her. Additional ride schedules with area EMS services may be scheduled based on perceived benefit and experiences; 5. Attendance at state, regional and local EMS administrative and training meetings will be welcomed when appropriate; 6. Participation in developing research projects will be welcomed; and, 7. Other activities proposed by the physician and approved by the Medical Director and Program Director.

Questions regarding Creighton EMS Education should be addressed directly with any of the following Bill Raynovich, NREMTP, MPH, Program Director956-4557 (pager), 651-8395 (mobile) Mike Miller, NREMTP, RN Program Coordinator 956-1394 (pager), 250-6359 (mobile) Peggy Dean, NREMTP, BS EMS Clinical Coordinator 956-6154 (pager)

Laboratory EM Orientation (lab sessions 2, 3)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw- Hill, 2000; 1-37. Rosens, Reading packet As assigned by Creighton EMS Faculty. Evaluation Process: The LifeNet Manager, Shane Mohr, Creighton EMS Faculty and EM faculty will receive an evaluation via New Innovations to complete for your performance while working with them. A review of the evaluations will occur at the six-month resident progress meeting.

Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

Position: House Officer I Rotation: Anesthesia

The resident will assume responsibility for pre-, intra-, and post-operative care of patients requiring airway management & anesthetic administration as directed by the supervising faculty or resident. The Department of Anesthesiology staff will provide supervision of all patient care & determine the appropriate level of resident involvement based on experience and demonstrated ability.

Goals: 1. Learn the principles of airway management. 2. Learn the principles of anesthetic techniques. 3. Learn the pharmacology of various drugs used in airway management. 4. Develop proficiency in airway management in the elective/OR setting. 5. Develop proficiency in various monitoring techniques/procedures in intubated/anesthetized patients. 6. Learn appropriate history and physical examination for assessment of the patient in need of airway management/anesthesia. 7. Learn to appropriately assess patients presenting with painful conditions, and provide appropriate interventions 12 Objectives: 1. Review the anatomy pertinent to airway management and mechanical ventilation. 2. Perform basic airway management techniques (i.e. bag-valve-mask ventilation, chin lift, jaw thrust, head-neck positioning, & use of upper airway adjuncts). 3. Perform oral and nasotracheal intubations on adult and pediatric patients in the OR setting. 4. Learn the indications for, and specifics of special techniques and devices utilized in the management of the difficult or failed intubation patient (laryngeal mask, lighted stylet, retrograde intubation, digital intubation). 5. Learn indications for, & pharmacology of the drugs commonly used in airway management (i.e. sedatives, induction agents, muscle relaxants). 6. Administer anesthetic agents to patients in the OR setting. 7. Learn the indications for, specifics of use, and pharmacology of various general anesthetic agents used in the OR. 8. Learn the indications of, specifics of use, and pharmacology of various local anesthetic agents. 9. Perform local anesthetic administration in a variety of patients. 10. Perform end-tidal CO2 monitoring, pulse oximetry, & aspiration techniques to confirm proper endotracheal tube position in intubated patients in the OR. 11. Perform monitoring techniques for anesthetized/mechanically ventilated patients (surface electrocardiography, capnography, pulse oximetry, esophageal stethoscope). 12. Perform central venous access in adult and pediatric patients. 13. Perform arterial catheter placement. 14. Interpret arterial blood gas measurements of mechanically ventilated patients.

Supervisor: The department of Anesthesiology Staff will provide supervision of all patient care and determine the appropriate level of resident involvement based on experience and demonstrated ability.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please contact Shelly McCaffrey a minimum of 45 days in advance to the start of your Anes. rotation. Shelly can be reached by calling her at 559-7405 or by emailing her at [email protected].

Work Hours: While on this rotation, you can expect to work on average 48 hours each week. You will arrive no later than 6:30am to the OR Board or the Main OR desk and review the cases for the day. You may address any questions with the Chief Resident at pager 888-0774.

Call Responsibilities: There will be no call responsibilities while on this rotation.

Patient Responsibilities: The resident will assume primary responsibility for pre-, intra-, & post-operative care of patients requiring airway management & anesthetic administration as directed by supervising faculty or resident.

Shift Responsibilities: You will be scheduled to work Monday – Friday from 0630-1700.

Education Responsibilities: Conferences: EM Core Conference (wk 2, 3, 4, 5, 7) Laboratory: EM Procedure Conference (mo 1, 2, 5) Assigned readings: Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 65-71, 79-111, 128-214, 251-280.

Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia, W.B. Saunders, 1998; 1-74, 82-130, 281-385, 410-442, 454-531.

13 Walls RM (ed): Manual of Emergency Airway Management. Philadelphia, Lippincot, Williams, and Wilkins, 2000; 3-81, 121-139, 205- 217.

Evaluation Process: The EM section will receive an evaluation via New Innovations from supervising Department of Anesthesiology faculty. A review of the evaluation will occur at the six-month resident progress meeting.

Position: House Officer I Rotation: Cardiology

EM residents have the opportunity to rotate on the General Cardiology and Electrophysiology Services. The latter is reserved for EM resident on an elective basis, after having completed the General cardiology rotation. The following description will describe the General Cardiology rotation; however the Electrophysiology Service functions similarly. Differences will be pointed out where appropriate.

Goals: 1. Demonstrate the ability to stabilize patients who present in cardiopulmonary arrest. 2. Develop skills in the evaluation of patients who present with chest pain. 3. Demonstrate the ability to evaluate, stabilize, treat, and arrange for appropriate disposition of patients with cardiac disease processes. 4. Demonstrate the ability to develop a differential diagnosis for patients presenting with cardiac symptomat ology (chest pain, shortness of breath, weakness, and palpitations). 5. Demonstrate skill in the interpretation of diagnostic modalities (ECG, chest x-ray and cardiac ultrasonography). 6. Develop a familiarity with cardiac pharmacologic agents. 7. Demonstrate skill at cardiac related procedures: venous line and CVP pressure monitoring, pericardiocentesis, defibrillation and cardioversion, Swan ganz catheterization, and ultrasonography. 8. Demonstrate the ability to diagnose, stabilize, and apply thrombolytic therapy to patients presenting with acute early myocardial infarction.

Objectives: 1. Demonstrate the ability to perform an appropriate history and physical examination on the patient presenting with cardiac symptomatology. 2. List items elicited from the history of patient with chest pain to suggest a risk for cardiac etiology. 3. Discuss limitations in differentiation of cardiac chest pain from non-cardiac pain in patients with risk factors. 4. Describe the pathophysiology of cardiac ischemia, acute angina chest pain, and acute myocardial infarction. 5. Describe the typical electrocardiograph findings of patients with myocardial ischemia, subendocardial infarction and myocardial and transmural infarction. 6. Discuss differential diagnosis of atypical chest pain. 7. Discuss atypical presentations for acute cardiac ischemia and myocardial infarction. 8. Discuss the sensitivity and specificity of ancillary studies for chest pain presentations including EKG, chest x-ray, cardiac enzymes, and arterial blood gases. 9. Differentiate between stable and unstable angina and outline the initial treatment of patients with unstable angina including the use of pharmacologic agents. 10. Discuss the concept of "silent" myocardial infarction and ischemia. 11. Differentiate between transmural versus subendocardial infarction. 12. Discuss the significance of acute complete atrio-ventricular block with inferior myocardial infarction versus anterior myocardial infarction.

14 13. Demonstrate knowledge of AHA recommendation for the treatment of acute ventricular fibrillation, ventricular tachycardia, asystole, pulseless electrical activity, atrial flutter and fibrillation, junctional ectopy, pre-exitation, supraventricular tachycardia, and bradycardia, sick-sinus syndrome, atrial ventricular blocks (first degree, second degree and third degree) and bundle branch blocks. 14. Describe the clinical findings of cardiogenic shock and outline therapy for cardiogenic shock. 15. Differentiate cardiogenic shock from other etiologies for shock. 16. Describe the clinical presentation for pericardial disease and outline the appropriate initial therapy and management for pericardial disease. 17. Describe the presentations for myocardial infarction and their association with vessel involvement. 18. List the indications, contraindications and complications of thrombolytic therapy for acute myocardial infarction. 19. Describe the clinical presentation, etiologies for pathophysiology of, and current therapy for acute congestive heart failure. 20. Describe the valvular anatomy of the heart and list etiologies for valvular heart disease. 21. Describe the clinical findings of a mitral valve prolapse, valvular aortic stenosis, aortic regurgitation, tricuspid stenosis, tricuspid regurgitation, and pulmonary stenosis, and discuss management of each of these valvular abnormalities. 22. List complications of prosthetic cardiac valves and appropriate emergency department management. 23. Differentiate between congestive cardiomyopathy, hypertrophic cardiomyopathy and restrictive cardiomyopathy and discuss therapy for each. 24. Define myocarditis and describe the EKG findings and acute management of myocarditis. 25. Differentiate between acute hypertensive emergencies, hypertensive urgency, and uncomplicated hypertension. 26. Discuss the indications for treatment of hypertension in the emergency department. 27. Describe the syndrome of hypertensive encephalopathy. 28. Outline the treatment for acute hypertensive emergency and differentiate treatment in the setting of thoracic aortic dissection. 29. Differentiate between primary agents for hypertensive emergency to include their advantages and disadvantages. 30. Describe the clinical presentation of acute mesenteric ischemia and discuss the inherent difficulties in the diagnosis as well as the emergency department management. 31. Discuss the pathophysiology, etiology, and overall morbidity and mortality of patients presenting with acute aortic dissection. 32. Explain the emergency department management of acute aortic dissection. 33. Differentiate between expanding, ruptured, and dissecting aortic aneurysms. 34. Describe the pathophysiology and clinical presentation for acute peripheral ischemia and outline the emergency department management.

Supervisor: During this rotation, you will be supervised by Cardiology Fellows and Staff Physicians. All admissions and consults should be discussed with the Fellow and ultimately the attending of records on call.

Work Hours: The call schedule will not exceed more than every third night, on average, and will all be home call. You will be assigned 1 weekend of home call beginning on Friday at 5:00pm until Monday at 8:00am.

Vacation Policy You are not permitted to use your vacation time while on this rotation. You may make 1 request for personal time, however, this will not be considered as vacation, therefore no change in the amount of call while on this rotation. You will be given a 4 day period off for the days of Thursday, Friday, Saturday & Sunday. Please contact Janice Fink a minimum of 60 days in advance to the start of your Cardiology rotation. Janice can be reached by calling her at 559- 9268 or by emailing her at [email protected].

Call Responsibilities: EM residents can expect approximately up to 10 home-call shifts a month. EM residents will always be on call with a fellow and staff member. The home-call schedule, on average, will not exceed more than every third night. When the EM resident is on call, he or she is on call for patients, admissions or consults to both services. They are triaged to the appropriate service the next day.

Patient Responsibilities: The resident will function as an active member of the cardiology service, performing initial evaluation of patients under the supervision of cardiology fellows and staff physicians. The average patient census is 8-15 patients. The EM 15 resident should not be responsible for more than 8-12 patients at any one time. The resident will perform history and physical examinations for patients requiring cardiology consultation in the ED and on the inpatient wards. Active participation in diagnostic work-up and treatment decision-making is expected. Residents will perform procedures under the direction of cardiology faculty as dictated by each resident’s demonstrated competency. Follow up care of discharged patients and experience in the outpatient management of various chronic conditions will occur in the clinic setting.

Shift Responsibilities: The EM resident is expected to pre-round with the cardiology fellow before a 9:00 a.m. patient conference, which takes place in the nurses’ conference room on 7 North telemetry unit. The EM residents, residents and fellow are expected to attend this meeting, during which patient management is reviewed with the nursing staff, utilization reviewers and case managers. These conferences usually last less than 30 minutes. Formal attending rounds usually begin at 10:00 a.m. on 7 North. Generally, rounds last no longer than 2 hours, depending on the patient census. The same is true for the Electrophysiology Service.

Education Responsibilities: In addition to EM education days, you will be required to attend all Cardiology didactic lectures during the rotation. EM residents must be freed from their clinical duties to attend these conferences as well as those required on Tuesday and Thursday at noon and the Internal Medicine Grand Rounds. EM residents will be given a series of pertinent articles that will be useful during the rotation on the General Cardiology and Electrophysiology Services. The didactic teaching will consist of lectures at least 2-3 hours per week. These sessions are separate from clinical patient rounding activity. Didactic teaching at the patient bedside is also performed, preferable separate from rounding, as well as too illustrates the physical examination.

The didactic series will consist of the following on a rotation basis:

1. The Cardiac Physical Examination 2. The preoperative Evaluation the Cardiac Patient for Non-cardiac Surgical Procedures 3. Current Management of Myocardial Infarction and their Complications 4. Functional Studies in the Assessment of Cardiac Diseases 5. Risk Factor Modification 6. Current Management of Heart Failure 7. Management of Valvular Disease 8. Strategies in the Prevention of Sudden Death 9. Differential Diagnosis and Management of Superventricular Arrhythmias 10. Differential Diagnosis and Management of Wide Complex Tachycardia-including VT 11. The Syncope Evaluation 12. ECG conference weekly 13. Case Management Conference

Lectures will be updated as necessary depending on the level and past experience of the EM resident. All EM residents are required to attend the ECG and Case Management conferences. The EM resident will be given a schedule of mandatory attendance conferences during their scheduled month. It is extremely helpful if the EM residents supply Janice Fink with any personal preferences for dates not to be scheduled due to personal commitment during the rotation prior to the month on the rotation to schedule the lectures accordingly.

Conferences EM Core Conferences (wk 2, 3, 4, 5, 6, 9, 10, 11), Conferences as required by the Cardiology section. Laboratory EM Procedure Conference (mo 3, 8) Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 39-49, 102-118, 169-214, 215-228, 239-242, 341-441. Evaluation Process: The EM section will receive evaluations via New Innovations from the Department of Cardiology’s faculty. A review of the evaluation will occur at the six-month resident progress meeting.

Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will 16 outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

Position: House Officer I Rotation: Internal Medicine

The resident will participate in the medical evaluation and management of each assigned patient admitted to the internal medicine service from the ED or hospital clinics as well as patients requiring consulting evaluation in the ED or on the inpatient wards. Resident responsibilities for each assigned patient will include initial history and physical examination, differential diagnosis, and diagnostic work-up and treatment planning. All patients evaluated by the resident will be presented to internal medicine faculty.

Goals: 1. Assimilate general concepts of internal medicine, history taking and physical examination skills to develop a systemic evaluation for patients presenting to the emergency department. 2. Learn the pathophysiology, presentation, and management of diseases related to the alimentary tract. 3. Develop knowledge of the pathophysiology, presentation, and management of common hematologic diseases. 4. Master the understanding of the components of the immune system, and the disorders of hyper- and hypofunction of the immune system. 5. Know the major systemic infectious disorders, their diagnosis and treatment. 6. Learn the pathophysiology, evaluation, and treatment of renal disorders. 7. Develop knowledge of the etiologies, manifestations, and treatment of endocrine and metabolic disorders. 8. Master an understanding of the diseases of the respiratory system, including pathophysiology, evaluation, and treatment.

Objectives: 1. Demonstrate appropriate history taking skills for all patients presenting to the emergency department. 2. Demonstrate the ability, based on the history acquired, to do an immediate assessment and initial stabilization, followed by a complete directed examination. 3. Combine the knowledge defined in the objectives below with the history and physical examination, to develop an appropriate differential diagnosis for all presentations. 4. Demonstrate knowledge of the causes, presentation, and management of esophageal problems. 5. Describe the etiologic agents, pathophysiology, and management of infectious diarrhea. 6. Demonstrate the ability to evaluate, manage, and appropriately disposition patients with gallbladder and liver disorders. 7. Demonstrate knowledge of the presentation, diagnosis, and management of obstructive lesions of the alimentary tract. 8. Demonstrate the ability to perform intubation procedures of the alimentary tract, including, but not limited to, NG tube insertion and anoscopy. 9. Describe the presentations, work-up, and appropriate treatment of patients with inflammatory processes of the alimentary tract. 10. Demonstrate familiarity with the evaluation, treatment, and appropriate disposition of patients with gastrointestinal bleeding. 11. Demonstrate knowledge of the proper evaluation and treatment of the patient with sickle cell disease. 12. Describe the appropriate steps in the assessment and treatment of the patient with bleeding disorders. 13. Demonstrate knowledge in the work-up, treatment, and appropriate disposition of the patient with anemia. 14. Demonstrate understanding of the appropriate use of transfusions of blood components, including diagnosis and treatment of transfusion reactions. 15. Demonstrate familiarity with the mechanism and manifestations of immune compromise, including that caused by infection with HIV. 16. Discuss and be able to differentiate non-AIDS causes of immune hypofunction. 17. Discuss the manifestations, initial treatment, and appropriate disposition of patients with rheumatologic and autoimmune diseases. 18. Demonstrate understanding of the work-up and treatment of patients with hypersensitivity reactions, including transplant rejection. 17 19. Demonstrate knowledge of the concepts of cellular and humoral immunity and the proper use of immunizations in patients presenting to the emergency department. 20. Demonstrate familiarity with the manifestations of, evaluation for, and treatment of bacterial infections, especially including gonorrhea, syphilis, tuberculosis, and tetanus. 21. Describe the diagnostic criteria for, and the treatment of, toxic shock syndrome. 22. Know the characteristics of sepsis in different age groups. 23. Demonstrate knowledge of the appropriate initial treatment of the patient with possible sepsis. 24. Demonstrate knowledge of the vector, predisposing factors, clinical course, work-up, and treatment of rickettsial diseases. 25. Discuss the manifestations of, treatment of, appropriate disposition for, and immunization (when appropriate) of patients with viral infections. 26. Demonstrate knowledge of the time course, vectors, and treatment of the more common protozoal diseases. 27. Demonstrate familiarity with the causes, presentation, initial management and disposition of patients with glomerular disorders. 28. Describe the common etiologic agents, and appropriate work-up and disposition of patients with infections of the renal system. 29. Discuss the common causes, metabolic manifestations, treatment (including dialysis) and disposition of patients with renal failure. 30. Describe the common complications of dialysis therapy and how they manifest in patients presenting to the emergency department. 31. Define the etiologies, and demonstrate understanding in the evaluation and treatment of patients with acid/base disorders. 32. Demonstrate understanding of the etiologies, manifestations, and treatment of fluid and electrolyte abnormalities. 33. Discuss the manifestations, work-up, treatment, and disposition of patients with disorders of glucose metabolism. 34. Demonstrate understanding of the common endocrine abnormalities, especially regarding presentation, initial evaluation and management, and disposition. 35. Discuss acute treatment for patients presenting with disorders of severe malnutrition. 36. Demonstrate knowledge in the etiologic agents causing, presentation and evaluation, and disposition of patients with infections of the respiratory system. 37. Describe the etiology, manifestation, and treatment of patients with acute and chronic airway disease. 38. Discuss the predisposing factors, presentation, and appropriate treatment of patients with pulmonary embolus. 39. Demonstrate knowledge of the potential presentation, work-up, treatment and appropriate disposition of patients with chest masses. 40. Demonstrate knowledge of the presentation, work-up, treatment, and disposition of patients with chronic granulomatous disease. 41. Demonstrate knowledge of the appropriate evaluation of patients with abnormalities of the lymphatic system. 42. Demonstrate knowledge of the presentation, treatment, and disposition of patients with malignancies of the hematopoietic system. 43. Demonstrate understanding of the etiologies, diagnosis, and treatment of adult respiratory distress syndrome and multisystem organ failure.

Supervisor: The EM resident will be supervised by the Internal Medicine Faculty Members

Duty Hours: 1. There are four general medicine inpatient services comprised of one staff, one supervisory resident, and two interns. 2. Each team takes call every fourth night. 3. One intern must stay overnight in the hospital for each call night and the other intern must be available until 10:00 p.m. 4. Call is 24 hours in length (8:00 a.m. – 8:00 a.m.) with up to 6 hours afterward to round and complete patient care responsibilities. 5. The team not post-call or pre-call is on “short call” which is from 8:00 a.m. – 6:00 p.m. Monday- Thursdays and 8:00 a.m. – 4:00 p.m. on Friday. There is no short call team on the weekends or holidays. The short call team takes admissions to be determined by the supervisory resident of the on call team. 6. On the day before call the team does not take admissions and may leave after completing rounds, patient care responsibilities, conferences, etc.

18 7. The team members are responsible for determining which team members will round on weekend days when the team is not on call. Each member of the team must average at least one day off per week.

Call Responsibilities: 1. Complete evaluation of patients admitted to general medicine and consultations including complete H&P to be both dictated and written and formulation of a plan with the guidance of the supervisory resident. 2. Admission of patients to the geriatric service to be managed by the geriatric service the following morning. 3. Care of all patients on the general medicine and geriatrics services. 4. Response to all code blue situations.

Vacation Policy You are permitted to use your vacation time while on this rotation. There is a limit of 2 week days and 2 weekend days with a total of 4 dates maximum while on this rotation. Please contact the Chief Resident, Brian Ward via email a minimum of 60 days in advance to the start of your IM Wards rotation. The coordinator for Internal Medicine is Robin Jaeckel, she can be reached by calling her at 559-6488 or by emailing her at [email protected].

Patient and Shift Responsibilities: Resident responsibilities for each assigned patient will include 1. Initial history and physical examination, differential diagnosis, and diagnostic work-up and treatment planning. 2. Care of patients admitted by the General Medicine services and medicine subspecialty services with general medicine assuming attending responsibility and consultative support from the appropriate service. 3. Daily work rounds. 4. Daily attending rounds. 5. Supervision and teaching of medical students. 6. Consultations to other services. 7. Selective reading.

Educational Responsibilities: In addition to attending the EM education days, you must attend the following Internal Medicine educational activities: 1. Morning report Mon – Fri, 10:00 a.m. - 11:00 a.m. Each day there is an assigned team whose responsibility it is to present a case. 2. Twice weekly noon conferences Tuesdays and Thursdays 3. Grand rounds each Friday at noon 4. Monthly resident seminar at 5:30 p.m. Tuesday evening

Conferences EM Core Conferences (wk 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 25, 26, 33, 34, 35, 36)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 341-668, 943-1056, 1327-1500.

Evaluation Process: The EM section will receive an evaluation via New Innovations from supervising Department of Internal Medicine faculty. A review of the evaluation will occur at the six-month resident progress meeting.

Position: House Officer I Rotation: Radiology and UltraSound 19 The resident will learn the performance and interpretation of ultrasonography under the supervision of senior radiology residents and faculty. The resident will attend the over-read session with the faculty radiologist each morning. This rotation requires self study during down time. It is recommended that residents concentrate on developing their research while on this rotation.

Goals: 1. Develop skill in interpretation of various diagnostic studies. 2. Develop skill in performing and interpreting ultrasound examinations of the abdomen and pelvis. 3. Learn the interactions between emergency medicine and radiology that facilitate patient care and evaluation.

Objectives: 1. List the indications, technique, contraindications, and complications of the imaging procedures utilized in the assessment of the ED patient, to include plain radiography, computerized tomography scanning, magnetic resonance imaging, angiography, and ultrasonography. 2. Demonstrate proficiency in the interpretation of plain radiographs and cranial computerized tomography. 3. Demonstrate proficiency in the performance and interpretation of emergency ultrasonography in the evaluation of the patient with thoracoabdominal trauma. 4. Develop an understanding of the quality assurance issues held in common with the ED.

Supervisor: The resident will learn work under the supervision of senior radiology residents and faculty.

Call Responsibilities: There are no call responsibilities while on this rotation.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please contact the coordinator a minimum of 45 days in advance to the start of your rotation. The coordinator for Radiology is Tina Clifton, she can be reached by calling her at 559-1018 or by emailing her at [email protected].

Shift Responsibilities: You will arrive to radiology at 8:00am to begin interpretation as directed by the chief radiology resident and supervising faculty.

Educational Responsibilities: Conferences EM Core Conferences (wk 47) Laboratory EM Procedure Conference (mo 9) Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 1967-1992.

Evaluation Process: The EM section will receive an evaluation via New Innovations from supervising Radiology Faculty. A review of the evaluation will occur at the six-month resident progress meeting.

20 Position: House Officer I Rotation: Obstetrics and Gynecology

The resident will function as an intern on the OB/GYN service with primary responsibility for performing the initial evaluation of patients presenting to labor and delivery. Procedural competence will develop through increasing responsibility for normal vaginal deliveries during the course of the month as determined by OB/GYN faculty.

Goals: 1. Develop expertise in the diagnosis and management of emergent complications of pregnancy. 2. Develop expertise in the management of uncomplicated and complicated labor and delivery. 3. Develop expertise in the management of sexual assault. 4. Learn the principles of management of gynecologic and obstetrical trauma. 5. Learn diagnosis and treatment of genital and pelvic infectious diseases. 6. Develop expertise in the diagnosis and management of abdominal pain in females. 7. Develop expertise in the diagnosis and management of vaginal bleeding.

Objectives: 1. Demonstrate ability to correctly perform a complete gynecologic exam. 2. Discuss the differential diagnosis and demonstrate ability to evaluate and treat patients with vaginal discharge. 3. Discuss the differential diagnosis and demonstrate ability to evaluate and treat patients with pelvic pain. 4. Discuss the differential diagnosis and demonstrate ability to evaluate and treat vaginal bleeding in pregnant and non-pregnant women. 5. Discuss the differential diagnosis and demonstrate ability to evaluate and treat patients with dysmenorrhea. 6. Demonstrate ability to evaluate and treat patients with genitourinary infections including PID, UTI, STD, TOA, and vaginitis 7. Describe the symptoms and differential diagnosis of toxic shock syndrome. 8. Demonstrate ability to perform perinatal and neonatal resuscitations. 9. Describe the relative effectiveness and complications of various contraceptive methods, including post-coital douche, coitus interruptus, condoms, diaphragm, rhythm method, oral contraceptives, injectable hormonal agents and IUD. 10. Demonstrate ability to evaluate and manage the care of patients with suspected ectopic pregnancy. 11. Discuss the signs, symptoms and treatment of placenta previa. 12. Discuss the signs, symptoms and treatment of abruptio placenta. 13. Discuss the signs, symptoms and treatment of preeclampsia and eclampsia. 14. Discuss the normal stages of labor and the time course for each. 15. Demonstrate ability to determine the APGAR score and discuss the significance of different values. 16. Define the following according to ACOG guidelines: rape, statutory rape, sexual molestation, and deviant sexual assault. 17. Demonstrate ability to evaluate and treat sexual assault victims, including evidence collection, appropriate patient counseling and pregnancy prevention. 18. Discuss the differential diagnosis and demonstrate ability to diagnose and treat genital ulcerations. 19. Discuss the pathophysiology, differential diagnosis, signs, symptoms and treatment of ovarian torsion. 20. Discuss the management of trauma during pregnancy. 21. Discuss the indications for perimortem caesarian section and describe the technique. 22. Demonstrate ability to perform uncomplicated full-term deliveries. 23. Demonstrate ability to manage patients with hyperemesis gravidarum. 24. Discuss the diagnosis and treatment of complicated labor including premature rupture of membranes, premature labor, failure to progress, fetal distress, and ruptured uterus. 25. Describe the management of complicated deliveries, including prolapsed cord, uncommon presentations, dystocia, uterine inversion, multiple births and stillbirth. 26. Demonstrate ability to diagnose and manage postpartum complications including retained products, endometritis and mastitis. 27. Discuss RH incompatibility and the role of rhogam in pregnant patient with vaginal bleeding. 28. Describe the presentation a patient with hydatidiform mole. 39. Describe the classification scheme for abortion.

Supervisor: While on the OB/GYN service, you will be supervised by the senior resident and or the faculty member covering the labor & delivery unit during your shift.

Duty Hours: 21 You will be scheduled for a maximum of 80 hours on average per week during your OB/GYN rotation. Call will not be more than 1 in 3 on average and EM residents will receive at least, on average, 1 complete day off from any shift or educational responsibilities each week.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please contact the coordinator a minimum of 60 days in advance to the start of your rotation. The coordinator for OB/GYN is Nicole Bussey, she can be reached by calling her at 559-6160 or by emailing her at [email protected]

Call Responsibilities: You will take in house call on average 1 in every 3 nights on average per week.

Patient Responsibilities: Your responsibilities are – but not limited to: While on L&D, you will see the patients and write notes as assigned by your upper level supervising resident who has placed your initials next to the patient name on the board in the MD interaction room. During the day you will see outpatients in the triage area, as well as, monitor your patients in labor. You will also be responsible for the postpartum patients you saw in the morning and any thing else that was specifically checked out to you by the outgoing intern. You will dictate D/C’s and op notes for deliveries and circumcisions. You must attend the weekly Perinatal conference.

Educational Responsibilities: Conferences EM Core Conference (wk 2, 19, 20, 40) EM Orientation (session 5) Any conferences required by the service

Laboratory EM Orientation (lab session 6)

Evaluation Process: The EM section will receive an evaluation via New Innovations from supervising Department of Obstetrics and Gynecology faculty for each resident.. A review of the evaluation will occur at the six-month resident progress meeting.

Position: House Officer I Rotation: Orthopedic Surgery

The resident will serve as an intern on the orthopedic service providing initial evaluation of emergency department consults and clinic patients. The resident will perform needed procedures (reductions, relocations, and immobilization) on ED and clinic patients under the direction of orthopedic faculty or senior residents. Operating room experience will occur as dictated by patient volume and resident staffing needs, but the treatment of ED patients will take precedence.

Goals: 1. Develop relevant history and physical exam skills. 2. Learn use of the diagnostic imaging modalities available for the evaluation of orthopedic disorders. 22 3. Develop skill in the evaluation and management of musculoskeletal trauma. 4. Develop skill in the diagnosis and treatment of inflammatory and infectious disorders of the musculoskeletal system. 5. Learn principles of acute and chronic pain management in patients with musculoskeletal disorders.

Objectives: 1. Develop ability to correctly perform a history and physical in patients with musculoskeletal disorders. 2. Demonstrate ability to correctly order and interpret radiographs in patients with orthopedic injuries. 3. Demonstrate knowledge of standard orthopedic nomenclature. 4. Demonstrate knowledge of appropriate aftercare and rehabilitation of orthopedic injuries. 5. Demonstrate knowledge of the differences in pediatric and adult skeletal anatomy and indicate how those difference are manifest in clinical and radiographic presentations. 6. Demonstrate ability to apply orthopedic devices, including compressive dressings, splints and immobilizers. 7. Demonstrate skill in performance of the following procedures: fracture/dislocation immobilization and reduction, arthrocentesis, extensor tendon repair. 8. Demonstrate ability to prioritize and manage the treatment of orthopedic injuries in multiple trauma patients. 9. Describe the presentation of patients with inflammatory and infectious disorders and demonstrate ability to diagnose and treat them. 10. Demonstrate ability to diagnose and treat soft tissue foreign bodies. 11. Describe the presentations, complications, diagnosis, management and prognosis of patients with human and animal bites. 12. Describe the presentations, complications, diagnosis and management of compartment syndromes. 13. Demonstrate ability to provide regional anesthesia, including hematoma blocks, Bier blocks and radial, ulnar, median, axillary, posterior tibial and sural nerve blocks. 14. Discuss the dosages, indications, contraindications and side effects of standard analgesic and sedative agents used to treat patients with acute orthopedic trauma and demonstrate skills in their use. 15. Discuss the dosages, indications, contraindications, side effects and relative potency of standard oral analgesics used in treatment of patients with musculoskeletal disorders. 16, Discuss the differential diagnosis, historical features, physical and examination findings of patients with low back pain. 17. Demonstrate ability to recognize and treat soft tissue infections involving muscle, fascia, and tendons. 18. Describe diagnosis and treatment of overuse syndrome. 19. Describe how to evaluate and preserve amputated limb parts. 20. Demonstrate knowledge of joint injuries, evaluation and grading of joint injuries, treatment of joint injuries and prognosis. 21. Discuss evaluation and treatment of soft tissue injuries such as strains, penetrating soft tissue injuries, crush injuries, and high pressure injection injuries.

Supervisor: The resident will perform needed procedures (reductions, relocations, and immobilization) on patients under the direction of orthopedic faculty or senior residents.

Duty Hours: You will be scheduled for up to 80 duty hours per week. You can expect your day to be from 7:00 – 5:00, Monday – Friday. There will be home call while on this rotation that will be on average 1 night in 3 with 1 day off completely from clinical or educational activites.

Call Responsibilities: You will not be on call greater than on average 1 in every 3 days with a full day away from all duty and educational activities. Your call will begin after you are out of surgery or clinic and will end the next morning at 7:30am.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please contact the coordinator a minimum of 60 days in advance to the start of your rotation. The coordinator for Orthopaedics is Geri Miller who can be reached by calling her at 559-2258 or by emailing her at [email protected]

Educational Responsibilities: Conferences EM Core Conferences (wk 42, 43, 44)

23 Laboratory EM Procedure Conferences (mo 2, 11) EM Orientation (lab session 2, 3)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 251-280, 309-339, 905-918, 1739-1905.

Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia, W.B. Saunders, 1998; 772-946.

Evaluation Process: The EM section will receive an evaluation via New Innovations from supervising orthopedic faculty for each resident. A review of the evaluation will occur at the six-month resident progress meeting.

Position: House Officer I Rotation: Trauma

The resident will serve as a first-year house officer on the trauma service, including the primary responsibility for performing the primary and secondary survey and necessary interventions on all patients evaluated by the trauma team under the direct supervision of the trauma chief resident. The resident will participate in the care of patients requiring OR interventions at the discretion of the trauma attending. The resident will also assume primary responsibility for the ongoing inpatient care of the trauma patient.

General Objectives 1. Manage a variety of surgical conditions in an emergency setting. 2. Demonstrate knowledge of patient stabilization, transport, and physician-to-physician communication in an emergency situation. 3. Demonstrate ability to evaluate & effectively manage all acute or life-threatening conditions, including major trauma in emergency settings. 4. Demonstrate knowledge of disaster management, including role of triage; & display ability to apply this knowledge to emergency setting.

Competency-Based Knowledge Objectives: 1. Complete coursework & testing to obtain Basic & Advanced Cardiac Life Support (BLS & ACLS), Advanced & Trauma Life Support 2. Describe the initial management of the injured patient(s) in the following stages of care: a. Care in pre-hospital setting including BLS b. Triage in emergency department. c. Serve as team leader and member during ATLS d. Coordinate patient transport to tertiary facility 3. Outline the basic principles of triage in the emergency department, including: a. Immediate treatment b. Ambulatory treatment c. Delayed treatment d. Expectant treatment e. Psychiatric considerations 4. Explain priorities for diagnosis &/or assessment of illness/injury for patients presenting to the ED, keeping the following issues in mind: a. Discuss requests for diagnostic studies comparing the urgency of the need to know with: 24 (1) The time required to obtain results (2) Potential danger to unstable patient (3) Quality of information obtained if a stat procedure compromises preparation of the patient b. Compare need for provision of expedient, cost effective work-ups against appropriateness of using the emergency setting for extensive work-ups at the risk of over utilizing limited resources.

5. Explain the ATLS protocol for the emergency resuscitation and stabilization of a seriously ill or injured patient: a. Cite working knowledge of the ABC's of resuscitation b. Define the essentials of AMPLE history (Allergy, Medications, Past illnesses, Last meal, Events of illness/injury) c. Define the essentials of the Primary and Secondary Surveys 6. Describe the considerations for establishing an airway appropriate to the patient's condition, including: a. Nasal trumpets/nasopharyngeal airway b. Bag-mask assistance c. Endotracheal tube d. Surgically Created Airways (cricothyrotomy-needle or tube)

7. Describe the typical case scenarios for the following life-threatening problems requiring appropriate urgent/emergent action: a. Multiple system trauma b. Shock (cardiogenic, neurogenic, septic, and hypovolemic) c. Traumatic neurological injuries 1. Head injury without altered consciousness 2. Head injury with altered consciousness, including deteriorating mental status 3. Subarachnoid/subdural hemorrhage 4. Penetrating head trauma d. Chest injuries (penetrating and blunt) e. Abdominal and pelvic injuries (penetrating and blunt) f. Vascular injuries (penetrating and blunt) g. Myocardial infarction 1. Complicated (with congestive heart failure [CHF], hypotension, dysrhythmia) 2. Uncomplicated h. Pulmonary embolus i. Diabetic ketoacidosis and other metabolic derangements 1. Hyper- and hypo- kalemia 2. Hyper- and hypo- natremia 3. Hyper- and hypo- calcemia j. Gastrointestinal bleeding k. Pancreatitis l. Ectopic pregnancy m. Phlebitis n. Burns, including inhalation injury o. Poisoning p. Hypothermia

8. Describe the principles of evaluation and management for the following less-serious problems: a. Drug abuse and suicide attempts b. Seizures/coma c. Facial injuries 1. Lacerations of face and scalp 2. Fractures of facial bones and jaw 3. Epistaxis d. Pneumonia e. Cardiac versus other chest pain f. Acute abdominal pain g. Hand injuries h. Long bone fractures

9. Discuss the principles of evaluation and management for the following common minor problems: a. Laceration evaluation 25 b. Tetanus prophylaxis c. Wound treatment d. Surgical repair of wounds e. Appropriate dressings f. Soft tissue infections g. Headache h. Eye, ear, nose, and throat infections i. Bronchitis j. Gastroenteritis k. Hemorrhoids l. Wildlife injuries (animal bites, insect and marine envenomations) m. Follow-up instructions

10. Explain the indications and appropriate methods for: a. Peritoneal lavage b. Insertion of chest tubes c. Pericardiocentesis d. Suprapubic catheter insertion e. Central line insertion f. External/transvenous pacemaker placement g. Cricothyrotomy h. Rapid rewarming BAIR Hugger, CAVR (Continuous arterial venous rewarming)

11. Recommend ways in which the ED physical environment can be adapted to better meet the special needs of elderly patients. Discuss these problems: a. Little privacy or confidentiality b. Poor lighting c. High ambient noise level d. Lack of adequate communication and/or reassuring dialogue

12. Analyze the medicolegal responsibilities of the physician in the field as an accepting physician coordinating transport.

13. Define the requirements for informed consent in the emergency setting: a. Life-threatening conditions b. Minor surgery c. Patients who are minors d. Patients unable to provide informed consent (non compis mentis) 1. Amnesia for event 2. Drug or alcohol use 3. Dementia

14. Summarize significant steps in the examination for and treatment of dental/oral emergencies with which a general surgeon should be familiar: a. Toothache b. Gingival bleeding (gingivitis, periodontitis, HIV-related hemorrhagic conditions) c. Buccolingually displaced tooth or teeth d. Dental or periodontal abscess or fistulous tract e. Cellulitis, including Ludwig's Angina f. Peritonsillar abscess (Quinsy)

Competency-Based Performance Objectives: Junior Level: Under the guidance and supervision of more senior residents, attending surgeons, or emergency department attendings: 1. Perform triage of emergency trauma patients. 2. Establish emergency stabilization of the traumatized patient via the following precautions: a. Fracture management/stabilization b. Cervical spine protection c. Prevention of hypothermia 26 3. Assess patients presenting emergency conditions using the appropriate diagnostic protocol. 4. Prioritize requests for diagnostic studies based on need to know and the time required to obtain results. 5. Establish the following airways: a. Perform bag-mask ventilation b. Insert nasopharyngeal or oropharyngeal airways c. Perform endotracheal intubation (oro- and nasopharyngeal) d. Perform a cricothyrotomy 6. Establish access to the central venous system. 7. Assist with acute resuscitation procedures as indicated. 8. Discuss patient's condition and future care with family. 9. Provide appropriate treatment for non-emergency problems presenting to the emergency department.

Under the guidance and supervision of senior residents, attending surgeons, or emergency department attendings: 1. Function as a surgical consultant, assessing and developing differential diagnoses and discussing recommendations with senior resident or attending. 2. Ascertain the severity of injury and identify patients requiring operative intervention. 3. Perform emergency diagnostic and therapeutic procedures such as: a. Peritoneal lavage b. Insertion of chest tubes c. Pericardiocentesis d. Suprapubic catheter insertion e. Central line insertion f. External/ transvenous pacemaker g. Insertion of intracranial pressure monitoring device 4. Perform minor surgical procedures such as: a. Drainage of abscesses b. Wound closure c. Removal of foreign bodies d. Wound debridement e. Bladder catheterization

5. Perform emergent dental procedures prior to referral to a dentist, oral surgeon, or maxillofacial prosthodontist, including: a. Examination and recommendation of palliative treatment for toothache b. Reinsertion of avulsed tooth c. Recognition and stabilization of fractured tooth/teeth d. Alleviation and/or prescription preparation for abscess or fistula e. Diagnosing and immediately managing cellulitis, especially extending to the neck 6. Explain patient's condition and proposed therapy to his/her family and obtain appropriate informed consent. 7. Discuss management options with the patient and his/her family. 8. Recommend further diagnostic and/or radiographic studies to clarify diagnosis and focus patient management. 9. Communicate the importance of injury prevention to patients, patient families, and staff in the quest for control of trauma as a disease of modern society.

Supervisor: The resident will serve under the direct supervision of the trauma chief resident.

Duty Hours: While on the Trauma rotation, you can expect to work approximately 70-80 hours per week with 2 in-house call nights per week and one day off per week.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please contact the coordinator a minimum of 60 days in advance to the start of your rotation. The coordinator for Trauma is Bree Graham, she can be reached by calling her at 559-5510 or by emailing her at [email protected]

Call Responsibilities: When on call on a non-trauma night the resident will cover all in house trauma patients in the ICU and on the floor. In addition, they will answer any questions from the outpatients through the call center and see and evaluate all consults. On trauma nights, in addition to the above responsibilities, the resident on call will also respond to all traumas in the ER, triage the patient, stabilize, and follow the patient throughout their trauma evaluation. (Senior residents will be on hand at all times for assistance and supervision on Trauma nights.) 27 Educational Responsibilities: Conferences EM Core Trauma Conferences (wk 6, 40, 41)

Laboratory EM Procedure Conference (wk 1, 3, 4, 6, 7, 8, 9)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 97-111, 215-228, 247-250, 1281-1302, 1609- 1738.

Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia, W.B. Saunders, 1998; 57-74,148-172, 264-280, 308-385, 426-442, 659-678, 733-742. Evaluation Process:

The EM section will receive an evaluation via New Innovations from attending Trauma Service physicians. A review of the evaluation will occur at the six-month resident progress meeting.

House Officer Second Year Rotation Descriptions

Position : House Officer II Rotation : Emergency Medicine

The EM2 will evaluate and treat unselected ED patients presenting to NHS-University ED. The EM2 will continue to present H&P findings for all patients to EM faculty, but in a more concise and focused manner. Increasing responsibility for management decisions, critical procedures, and multiple-patient care will take individual resident growth and abilities into account, but all EM2 residents will grow in these areas.

Goals 1. Learn the systematic approach to the evaluation of patients with urgent/emergent presentations. 2. Acquire the medical knowledge pertinent to the practice of emergency medicine. 3. Develop the interpersonal skills and professional attributes necessary to provide optimal care in the emergency department. 4. Understand the role the emergency department plays in the greater health care system and how the emergency physician may facilitate patient care. 5. Learn self-analysis of clinical emergency practice, utilizing information technology and scientific evidence, to improve the delivery of high quality patient care. 6. Develop the ability to facilitate the learning of others in the emergency department setting. 7. Learn the procedural skills required in the evaluation and management of a variety of urgent/emergent patient presentations.

Objectives 1. Demonstrate the time-management skills necessary to effectively evaluate and manage multiple patients in the acute setting. 2. Present history and physical examination findings in a concise manner emphasizing information pertinent to the immediate diagnostic plan and management options to supervising EM faculty as well as consulting physicians 3. Develop the communication and leadership skills necessary to effectively direct patient care in the acute setting. 28 4. Develop the capacity to become an advocate for the patient to insure appropriate care in the ED and after admission or discharge. 5. Develop the capacity to serve as a resource to junior residents and medical students in the ED. 6. Gain proficiency in important EM procedural skills, to include CPR, arterial line insertion, central venous line insertion, thoracostomy, paracentesis, thoracentesis, invasive and noninvasive airway management, arthrocentesis, joint relocation, fracture reduction, and conscious sedation techniques. 7. Gain proficiency in basic EM diagnostic skills, to include ECG interpretation, laboratory analysis of metabolic derangements, bedside ultrasound, plain radiography, cranial CT interpretation.

Supervisor: HO II residents will be supervised by the emergency medicine physician(s) in the emergency department.

Duty Hours: While on the emergency medicine rotation, the work hours will follow the ACGME Guidelines/RRC for EM. Residents on this rotation will not be scheduled for more than 60 hours per week seeing patients in the emergency department and no more than 72 duty hours per week. Duty hours comprise all clinical duty time and conferences, whether spent within or outside the educational program including on-call hours.

Vacation Policy You are permitted to use your vacation time while on this rotation. Please make all requests to Tammi Erickson a minimum of 60 days in advance to the start of your EM rotation.

Educational Responsibilities: Conferences EM Core Conference EM Orientation Lecture Series Topics in EM Conference Trauma Case Confernece EM Grand Rounds Journal Club EM Radiology Conference

Laboratory EM Procedure Conference EM Orientation Laboratory Sessions

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000.

Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia, W.B. Saunders, 1998.

Evaluation Process: The EM section will receive an evaluation from supervising EM faculty for each resident using the standard EM Resident Evaluation Form via New Innovations. A review of the evaluation will occur at the six-month resident progress meeting with the EM Residency Program Director. Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

Position: House Officer II Rotation: Neurosurgery

The resident will assume the responsibilities of an intern on the neurosurgery service with primary responsibility for initial evaluation of ED patients requiring neurosurgical consultation. The rotating resident will participate in therapeutic interventions at the discretion of senior neurosugery residents and attending faculty. The resident will also provide ongoing care to admitted patients. 29 Goals: 1. Learn the anatomy, pathophysiology, presentation, and management of common neurologic disorders and injuries. 2. Develop skill in the performance of a screening and detailed neurological evaluation. 3. Develop skill in the use and performance of diagnostic procedures in the evaluation of neurological disorders. 4. Effectively utilize radiologic studies to diagnose neurological disease or injury. 5. Diagnose, stabilize and provide initial treatment of injuries and diseases of the brain, spinal cord, bony spine, peripheral nerves, vascular structure, and carotid structure. 6. Learn how CSF shunts function and learn to evaluate patients with possible shunt malfunction.

Objectives: 1. Demonstrate a brief and a complete neurological history and examination on patients with various levels of consciousness, including trauma patients. 2. Demonstrate knowledge of neuroanatomy and application of this knowledge in the neurological examination to localize neurological disorders. 3. Demonstrate the ability to recognize and manage cerebrovascular ischemic disorders, seizure disorders, headache, spinal cord compression, shunt malfunction, neurological infections, and neurological inflammatory states. 4. Demonstrate the ability to recognize and manage cranial nerve disorders, pseudotumor cerebri, normal pressure hydrocephalus, and peripheral neuropathy, peripheral nerve compression. 5. Demonstrate skill in the initial evaluation and management of blunt and penetrating traumatic injuries of the CNS. 6. Describe initial management of fractures, subluxations, and dislocations of the spine. 7. Demonstrate the ability to recognize and manage acute cerebrovascular and spinal cord disorders that are amenable to neurosurgical intervention. 8. Describe the main classifications of headaches and state the doses, indications, and contraindications for agents used to manage each of these types of headaches. 9. Describe the indications, techniques, and contraindications for neurological imaging procedures including plain radiographs, computerized tomographic scans, magnetic resonance imaging, tomography). 10. Demonstrate accurate interpretation of neurological imaging studies including plain radiographs and computerized tomographic scans. 11. Demonstrate skill in the performance and interpretation of spinal fluid studies. 12. Discuss the indications, contraindications, and dosages of agents used to treat neurological infections in pediatric and adult populations. 13. Demonstrate spinal immobilization techniques. 14. Demonstrate ability to recognize and manage spinal cord compression due to non-traumatic causes. 15. Describe the indications and techniques for control of intracranial pressure. 16. Perform Lumbar Puncture

Supervisor: The Chief Resident will be available either in house or via home call.

Duty Hours: You will be assigned to 1 in 3 Home Call. All duty hours will comply with the ACGME’s 80-week.

Point of Contact for Day 1 on service: Call chief pager 888-1865 a few days before this rotation begins.

Vacation/Requests for time off: You may take up to 5 days off + 2 weekend days during your 1 month rotation with NeuroSurg. All requests must be emailed to either the coordinator Kelly Deveny, who can be reached at 9-9605 or [email protected] or the Chief Resident, Brad Bowdino at [email protected]. Educational Responsibilities: Conferences EM Core Conferences (wk 35, 36, 40, 41) Weekly M&M or Grand Rounds every Wednesday 8am Neuro Radiology Conf every Tuesday 7AM

Laboratory 30 EM Orientation (lab session 3)

Evaluation Process: The EM section will receive an evaluation via New Innovations from attending Neurosurgery faculty for each resident. A review of the evaluation will occur at the six-month resident progress meeting.

Position : House Officer II Rotation : PICU

The rotating resident will assume primary responsibility for the initial assessment and stabilization of critically ill patients admitted to the PICU from the floor or ED under the supervision of attending pediatric critical care specialists. The resident will perform all necessary procedures at the discretion of attending faculty. The resident will also provide ongoing daily care to all admitted patients.

Goals 1. Develop skill in infant/pediatric resuscitation. 2. Develop skill in performance of appropriate pediatric history and physical exam, including general growth and development, assessment and knowledge of current immunization requirements. 3. Learn the etiologies, significance, and treatment of fever and infection in the child. 4. Learn the manifestations and significance of abdominal related complaints in the child. 5. Learn the etiologies and treatment of neurologic emergencies in the child. 6. Learn the physiology and derangements of fluid and electrolyte management in children. 7. Learn the specific problems of pediatric trauma victims. 8. Learn the manifestations and treatment of pediatric cardiac abnormalities. 9. Learn the pathophysiology, etiologies, and treatment of respiratory disorders of children. 10. Learn the pathophysiology, etiologies, and treatment of common serious endocrine and hematologic disorders of children. 11. Learn the common dermatologic diseases and dermatologic manifestations of systemic diseases in children

Objectives 1. Demonstrate correct airway management including pediatric endotracheal intubation. 2. Demonstrate ability to obtain and utilize intravenous access including venipuncture, intraosseous needle placement, and administration of appropriate dose of emergency medications. 3. Demonstrate knowledge of the significance of fever in children of various ages, and the ability to perform an adequate assessment including Yale Observation Score of the febrile child. 4 Demonstrate knowledge of common infectious diseases of childhood, including appropriate work-up and treatment of meningitis, sepsis, pneumonia, urinary tract infection, and bacteremia. 5. Demonstrate ability to properly perform a pediatric lumbar puncture. 6. Demonstrate knowledge of the pathophysiology and manifestations of common and/or serious diseases of the gastrointestinal tract and abdominal cavity of children, including gastroenteritis, intussusception, volvulus, Meckel's, anaphylactoid purpura, and appendicitis. 7. Discuss the differential and preliminary work-up of abdominal masses found in the pediatric patient. 8. State the appropriate management of children with seizures, both febrile and afebrile.

31 9. Demonstrate familiarity with the diagnosis and management of Reye's syndrome, Hemmorhagic Shock, & Encephalopathy Syndrome. 10. Demonstrate knowledge of hydrocephalus, its differential, treatment and the management of neurologic shunt problems. You will also discuss management of Intracranial Hypertension. 11. Calculate fluid and electrolyte requirements of a dehydrated child. 12. Demonstrate knowledge of the significance and correct treatment of various patterns of burns in pediatric patients. 13. Interpret a series of pediatric EKG's, showing awareness of the normal physiologic differences from adult EKG's. 14. Discuss the common pediatric dysrhythmias, their diagnosis and treatment. 15. Discuss the types of congenital cyanotic and noncyanotic heart disease, their complications and treatment. 16. Demonstrate ability to read pediatric chest x-rays. 17. Discuss the differential diagnosis of chest pain in children and adolescents, noting differences from adults, and demonstrating knowledge of proper work-up and treatment. 18. Discuss the differential of congestive failure in the pediatric patient and demonstrate knowledge of appropriate treatment. 19. Discuss the anatomy and physiology of the respiratory tract in children. 20. Demonstrate correct performance of peak expiratory flow measurement, pulse oximetry and end-tidal CO2. 21. Discuss management of patients with upper airway infection suspected of having epiglottitis 22. Correctly interpret soft tissue lateral neck x-rays in children. 23 Discuss the etiologies and demonstrate correct management of children with lower and upper airway diseases including asthma, bronchiolitis, cystic fibrosis, pneumonia. 24. Demonstrate correct management of the pediatric patient with diabetes and/or diabetic ketoacidosis. 25. Demonstrate knowledge of the etiologies of anemia in children and the appropriate diagnostic evaluation. 26. Demonstrate knowledge of the differential diagnosis and work-up of the jaundiced child. 27. Discuss the differential diagnosis and work-up of the child with evidence of a bleeding disorder. 28. Demonstrate knowledge of the differential diagnosis and evaluation of children with petechiae. 29. Demonstrate knowledge of pediatric facial and orbital infections and their treatment. 30. Discuss the causes of neonatal shock and demonstrate the ability to perform and infant resuscitation, including endotracheal intubation and insertion of an umbilical venous catheter. 32. Discuss shaken Infant/Child Abuse/Organ Donation and Ethical issues in the PICU patient, and demonstrate knowledge of the proper legal steps and ability to support the family. 33. Discuss the differential diagnosis and acute treatment of the weak infant and child, including polio, botulism and the Landry-Guillain-Barre syndrome. 34. Demonstrate knowledge of the evaluation and treatment of children with diarrheal illness. 35. Demonstrate knowledge of the common poisonings of childhood and their treatments. 36. Manage the care of a child with immersion/drowning. 37. State the differential diagnosis of a child with upper or lower GI bleeding, and discuss the evaluation and treatment. 38. Discuss the differential diagnosis and work-up of renal failure or anuria in children. 39. Demonstrate ability to evaluate children with syncope and discuss its differential diagnosis. 40. Discuss the signs, symptoms, treatment and complications of Kawasaki disease. 41. Demonstrate ability to evaluate and treat a child with altered mental status and interpret a pediatric cranial CT scan.

Supervisor: The rotating resident will function under the supervision of attending pediatric critical care specialists.

Duty Hours: Not to exceed the Duty Hours rule set by the RRC

Educational Responsibilities: Conferences Attend EM Core Conferences every Thursday morning from 8:00 am to 2:00pm. (wk 2, 3, 4, 5, 21, 22)

Laboratory EM Procedure Conference (mo 5)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 57-71, 109-111, 749-786, 802-899. 32 Point of Contact for Day 1 on service: The Pediatric Intensivist on Clinical Service. PICU Phone # 955-4200, PICU Resident # 955-7926.

Vacation Policy: There will be no vacation allowed while on this rotation. .

Evaluation Process: The EM section will receive an evaluation via email from supervising pediatric faculty for each resident. A review of the evaluation will occur at the six-month resident progress meeting.

Position : House Officer II Rotation : AICU

The resident will assume the clinical responsibilities of a second-year resident, performing the initial evaluation of patients admitted to the adult intensive care unit and participating in diagnostic work-up and management planning. The performance of necessary procedures will take place at the discretion of the attending critical care faculty and under the supervision of the critical care fellow or faculty. On-call time will allow for further experience in evaluation and management of critically ill patients presenting to the ED.

Goals: 1. Develop the ability to rapidly evaluate, diagnose, stabilize, and disposition critically ill patients. 2. Learn respiratory, cardiovascular, renal and neurologic physiology and the pathophysiology of trauma, toxins, shock, sepsis, cardiac failure, and respiratory failure that affect critically ill patients. 3. Learn the principles of medical instrumentation and hemodynamic monitoring and utilize them in the care of critically ill patients. 4. Learn the indications and develop the technical skills needed to perform diagnostic and therapeutic interventions in critically ill patients. 5. Learn the rational use of laboratory, radiographic and other diagnostic tests in the management of critically ill patients. 6. Understand the etiologies and pathophysiology of cardiac arrest. 7. Learn to recognize the dysrhythmias associated with cardiac arrest and their treatment. 8. Learn the American Heart Association recommendations and develop skill in the performance of standard resuscitative procedures. 9. Learn the principles of pharmacotherapy and the routes and dosages of drugs recommended during cardiac arrest and following resuscitation. 10. Learn the indications for withholding and terminating resuscitation.

Objectives: 1. Demonstrate ability to rapidly perform history and physical exams in critically ill patients. 2. Demonstrate the ability to perform the following procedures: oral endotracheal intubation, nasotracheal intubation, cricothyrotomy, needle thoracostomy, tube thoracostomy, central intravenous placement, swan ganz placement, transvenous cardiac pacing, arterial line placement, ABG, and foley catheterization. 3. Demonstrate the ability to use and interpret data from ECG monitors, ECGs, cardiac outputs, hemodynamic

monitoring, arterial blood gases, pulse oximetry, end tidal CO2 monitors and respirators. 4. Describe the dosages, indications and contraindications of pharmacologic interventions for shock, cardiac failure, dysrhythmias, sepsis, trauma, toxins, respiratory failure, hepatic failure, renal failure, and neurologic illnesses. 5. Demonstrate the ability to manage a patient on a ventilator. 33 6. Demonstrate appropriate judgment in the management of critically ill patients. 7. Demonstrate appropriate prioritization of diagnostic and therapeutic interventions in critically ill patients. 8. Demonstrate ability to diagnose and treat shock, sepsis, fluid and electrolyte abnormalities, cardiac failure, cardiac dysrthmias, renal failure, hepatic failure, and toxicologic emergencies. 9. Demonstrate an understanding of the appropriate use of consultants in critically ill patients. 10. Demonstrate an understanding of the ethical and legal principles applicable to the care of critically ill patients. 11. Demonstrate knowledge of the various etiologies of cardiac arrest and the corresponding therapeutic approaches. 12. Demonstrate knowledge of the factors affecting blood flow, oxygen delivery and oxygen consumption during cardiac arrest. 13. Demonstrate ability to recognize dysrrhythmias associated with cardiac arrest and knowledge of ACLS protocols for their treatment. 14. Demonstrate ability to manage the airway during cardiac arrest, including bag-valve-mask ventilation, endotracheal intubation, cricothyroidotomy, and recognition of the obstructed airway. 15. Demonstrate ability to perform external closed chest cardiopulmonary resuscitation. 16. Discuss the dosages, indications and contraindications for pharmocologic therapy during cardiac arrest and following resuscitation. Demonstrate knowledge of the techniques for drug administration including peripheral and central venous, endotracheal, intraosseous and administration. 17. Demonstrate ability to safely perform internal and external defibrillation. 18. Demonstrate understanding of "Do not resuscitate" orders, advance directives, living wills and brain death criteria.

Supervisor: All activities while on this service will be supervised by the critical care Faculty/Fellow including any necessary procedures.

Duty Hours: Duty hours while on this rotation will comply with the ACGME Guidelines

Vacation Policy Vacation requests will not be approved while on this rotation due to patient needs. You will be allowed to have 4 days total off during this rotation to comply with RRC requirements. This rotation allows one weekend off, and a weekend day off during 2 other weeks.

Educational Responsibilities: Conferences EM Core Conferences (wk 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 27, 28, 29, 30)

Laboratory EM Procedure Conference (wk 1, 3, 7, 8)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 39-49, 76-250, 341-496, 1057-1226, 1231-1242, 1303-1306, 1330-1352, 1365-1370, 1392-1399, 1409-1414, 1440-1449.

Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must

34 be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

Position: House Officer II Rotation : Rural Emergency Medicine

The Community/Rural EM rotation will allow the resident to experience non-urban EM practice, as well as daily life in a rural environment. During the month, the resident will live in Scottsbluff, Nebraska in an apartment provided by the University of Nebraska Section of EM. The Community/Rural EM rotation will follow the same educational objectives as for the EM2 or EM3 NHS-University ED rotations, but will emphasize the following aspects of EM practice unique to the rural ED

Goals: 1. Learn the systematic approach to the evaluation of patients with urgent/emergent presentations. 2. Acquire the medical knowledge pertinent to the practice of emergency medicine. 3. Develop the interpersonal skills and professional attributes necessary to provide optimal care in the emergency department. 4. Understand the role the emergency department plays in the greater health care system and how the emergency physician may facilitate patient care. 5. Learn self-analysis of clinical emergency practice, utilizing information technology and scientific evidence, to improve the delivery of high quality patient care. 6. Develop the ability to facilitate the learning of others in the emergency department setting. 7. Learn the procedural skills required in the evaluation and management of a variety of urgent/emergent patient presentations.

Objectives: 1. Demonstrate the evaluation and management of patient presentations more common in the rural setting (i.e. machinery trauma). 2. Describe the evaluation and management of the illnesses and injuries typically resulting from agricultural activities. 3. Interact with rural health care providers, including primary care providers, EMS personnel, and nursing home personnel. 4. Describe the limitations imposed on healthcare providers serving rural populations and the role the ED plays in assisting with healthcare delivery (i.e. distance from care, limited resources, limited diagnostics, transportation, etc.). 5. Experience the clinical practice of an ED serving in a rural community. Supervisor: The resident will provide initial evaluation and management of unselected adult and pediatric patients presenting to non-urban ED, under the supervision of a adjunct EM faculty. The resident will present all patients to EM faculty, and discuss diagnostic work-up and management. The level of resident responsibility for patient care will depend on demonstrated ability as determined by supervising EM faculty on-site. Senior residents will assume the role of junior staff, essentially performing all patient care and administrative duties for the ED under the direct supervision of EM faculty. During this month, the resident will also function as assistant medical director for EMS in the region, providing clinical oversight, EMT instruction, and administrative duties.

Duty Hours: While on the emergency medicine rotation, the work hours will follow the ACGME Guidelines. Residents on this rotation will not be scheduled for more than 60 hours per week seeing patients in the emergency department and no more than 72 duty hours per week. Duty hours comprise all clinical duty time and conferences, whether spent within or outside the educational program including on-call hours.

Educational Responsibilities: Residents rotating at Regional West Medical Center ED will attend all conferences provided by the Emergency Medicine Residency Program through teleconferencing. Residents will be excused from clinical duties for conference attendance.

Evaluation Process: The EM section will receive an evaluation via email from supervising EM Faculty in Scottsbluff for each resident. A review of the evaluation will occur at the six-month resident progress meeting.

35 Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

36 House Officer Third Year Rotation Descriptions

Position: House Officer III Rotation : Emergency Medicine

The EM3, after the initial two months of the senior year in the program, will begin to assume the role of ‘junior attending’, based on the individual resident’s skills and abilities as determined by supervising EM faculty. The EM3 will perform initial H&P on unselected ED patients and present all patients to EM faculty, as in the previous years of training, but the presentation will include only brief, pertinent information and the resident will assume primary responsibility for developing and implementing a diagnostic/treatment plan. EM faculty will continue to see all patients, but the level of involvement will continue to decrease and only certain elements of the H&P will receive attention. The EM3 will also serve as a resource to more junior residents and medical students, providing informal consultations in the ED.

Objectives: 1. Gain proficiency in time management skills, demonstrating the ability to effectively evaluate and manage multiple patients with varying acuity of presentation. 2. Gain mastery in one or two areas of EM practice and serve as a resource to other physicians. 3. Develop the ability to direct the operation of the ED as a whole, to include triage of multiple critically ill patients, supervision of junior residents and medical students, interaction with nurse management, and interaction with consulting staff. 4. Perform the role of team leader in the resuscitation of critically ill patients. 5. Serve as a resource for junior residents in the clinical setting. 6. Serve as patient advocate to insure appropriate care in the ED, on the in-patient wards, and in the community. 7. Develop the capacity to effectively manage work-related stress and recognize physician impairment risks. 8. Gain mastery of important EM procedural skills, to include cardiopulmonary resuscitation, arterial line insertion, central venous line insertion, thoracostomy, paracentesis, thoracentesis, invasive and noninvasive airway management, arthrocentesis, joint relocation, fracture reduction, and conscious sedation techniques. 9. Gain mastery of EM diagnostic skills, to include ECG interpretation, laboratory analysis of metabolic derangements, bedside ultrasound, plain radiography, cranial CT interpretation.

Supervisor: While on the EM rotation, you will be supervised by your immediate attending physician.

Shift Responsibilities: While on this rotation, you can expect to work approximately 19 shifts per month. Residents who are chiefs will receive a compensation of shift reduction.

Educational Responsibilities: Conferences EM Core Conference EM Orientation Lecture Series Topics in EM Conference EM Grand Rounds Journal Club EM Radiology Conference 37 Laboratory EM Procedure Conference EM Orientation Laboratory Sessions

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000. Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 3rd ed. Philadelphia, W.B. Saunders, 1998.

Position: House Officer III Rotation : Emergency Department Administration

The EM3 will serve as assistant medical/clinical director for the month of the rotation with primary responsibility for all continuous quality improvement activities. Each resident will assist in the development, implementation, and evaluation of a CQI project during the rotation. The resident will attend the monthly unit-based council meeting and will receive assignments from the issues discussed.

Goals: 1. Learn basic principles of leadership and administration. 2. Develop an understanding of quality improvement and risk management programs and their application to the operation of an emergency department. 3. Develop an understanding of the function of emergency medicine within the institution and its relationship with other departments. 4. Develop an understanding of the function of accrediting agencies and their relationship with emergency medicine.

Objectives: 1. Discuss the following concepts as they relate to Emergency Medicine: credentialing, career development, recruitment, budgeting, health care financing, managed care, personnel management, public relations, marketing, hospital administration, practice management, contracts, work schedules. 2. Discuss cost containment as relates to Emergency Medicine. 3. Discuss JCAHO requirements relating to the Emergency Department with emphasis on staffing, equipment and supplies, facility, quality assurance and patient transfer regulations. 4. Discuss hospital and Emergency Department administrative organization.

Supervisor: While on this rotation, you will be supervised by the Section Chief and the Clinical Medical Director

38 Shift Responsibilities: While on this rotation, you will act administratively as directed by the Section Chief and the Clinical Medical Director.

Educational Responsibilities: Conferences EM Core Conference (wk 1)

Assigned readings Salluzzo RF, Mayer TA, Strauss RW, Kidd P (eds): Emergency Department Management Principles and Applications. St. Louis, Mosby, 1997; 3-117, 121-150, 173-178, 463-531, 543-633, 717-733.

Position : House Officer III Rotation : PICU

The rotating resident will assume primary responsibility for the initial assessment and stabilization of critically ill patients admitted to the PICU from the floor or ED under the supervision of attending pediatric critical care specialists. The resident will perform all necessary procedures at the discretion of attending faculty. The resident will also provide ongoing daily care to all admitted patients.

Goals 1. Develop skill in infant/pediatric resuscitation. 2. Develop skill in performance of appropriate pediatric history and physical exam, including general growth and development, assessment and knowledge of current immunization requirements. 3. Learn the etiologies, significance, and treatment of fever and infection in the child. 4. Learn the manifestations and significance of abdominal related complaints in the child. 5. Learn the etiologies and treatment of neurologic emergencies in the child. 6. Learn the physiology and derangements of fluid and electrolyte management in children. 7. Learn the specific problems of pediatric trauma victims. 8. Learn the manifestations and treatment of pediatric cardiac abnormalities. 9. Learn the pathophysiology, etiologies, and treatment of respiratory disorders of children. 10. Learn the pathophysiology, etiologies, and treatment of common serious endocrine and hematologic disorders of children. 11. Learn the common dermatologic diseases and dermatologic manifestations of systemic diseases in children

Objectives 1. Demonstrate correct airway management including pediatric endotracheal intubation. 2. Demonstrate ability to obtain and utilize intravenous access including venipuncture, intraosseous needle placement, and administration of appropriate dose of emergency medications. 3. Demonstrate knowledge of the significance of fever in children of various ages, and the ability to perform an adequate assessment including Yale Observation Score of the febrile child. 4 Demonstrate knowledge of common infectious diseases of childhood, including appropriate work-up and treatment of meningitis, sepsis, pneumonia, urinary tract infection, and bacteremia. 5. Demonstrate ability to properly perform a pediatric lumbar puncture.

39 6. Demonstrate knowledge of the pathophysiology and manifestations of common and/or serious diseases of the gastrointestinal tract and abdominal cavity of children, including gastroenteritis, intussusception, volvulus, Meckel's, anaphylactoid purpura, and appendicitis. 7. Discuss the differential and preliminary work-up of abdominal masses found in the pediatric patient. 8. State the appropriate management of children with seizures, both febrile and afebrile. 9. Demonstrate familiarity with the diagnosis and management of Reye's syndrome, Hemmorhagic Shock, & Encephalopathy Syndrome. 10. Demonstrate knowledge of hydrocephalus, its differential, treatment and the management of neurologic shunt problems. You will also discuss management of Intracranial Hypertension. 11. Calculate fluid and electrolyte requirements of a dehydrated child. 12. Demonstrate knowledge of the significance and correct treatment of various patterns of burns in pediatric patients. 13. Interpret a series of pediatric EKG's, showing awareness of the normal physiologic differences from adult EKG's. 14. Discuss the common pediatric dysrhythmias, their diagnosis and treatment. 15. Discuss the types of congenital cyanotic and noncyanotic heart disease, their complications and treatment. 16. Demonstrate ability to read pediatric chest x-rays. 17. Discuss the differential diagnosis of chest pain in children and adolescents, noting differences from adults, and demonstrating knowledge of proper work-up and treatment. 18. Discuss the differential of congestive failure in the pediatric patient and demonstrate knowledge of appropriate treatment. 19. Discuss the anatomy and physiology of the respiratory tract in children. 20. Demonstrate correct performance of peak expiratory flow measurement, pulse oximetry and end-tidal CO2. 21. Discuss management of patients with upper airway infection suspected of having epiglottitis 22. Correctly interpret soft tissue lateral neck x-rays in children. 23 Discuss the etiologies and demonstrate correct management of children with lower and upper airway diseases including asthma, bronchiolitis, cystic fibrosis, pneumonia. 24. Demonstrate correct management of the pediatric patient with diabetes and/or diabetic ketoacidosis. 25. Demonstrate knowledge of the etiologies of anemia in children and the appropriate diagnostic evaluation. 26. Demonstrate knowledge of the differential diagnosis and work-up of the jaundiced child. 27. Discuss the differential diagnosis and work-up of the child with evidence of a bleeding disorder. 28. Demonstrate knowledge of the differential diagnosis and evaluation of children with petechiae. 29. Demonstrate knowledge of pediatric facial and orbital infections and their treatment. 30. Discuss the causes of neonatal shock and demonstrate the ability to perform and infant resuscitation, including endotracheal intubation and insertion of an umbilical venous catheter. 32. Discuss shaken Infant/Child Abuse/Organ Donation and Ethical issues in the PICU patient, and demonstrate knowledge of the proper legal steps and ability to support the family. 33. Discuss the differential diagnosis and acute treatment of the weak infant and child, including polio, botulism and the Landry-Guillain-Barre syndrome. 34. Demonstrate knowledge of the evaluation and treatment of children with diarrheal illness. 35. Demonstrate knowledge of the common poisonings of childhood and their treatments. 36. Manage the care of a child with immersion/drowning. 37. State the differential diagnosis of a child with upper or lower GI bleeding, and discuss the evaluation and treatment. 38. Discuss the differential diagnosis and work-up of renal failure or anuria in children. 39. Demonstrate ability to evaluate children with syncope and discuss its differential diagnosis. 40. Discuss the signs, symptoms, treatment and complications of Kawasaki disease. 41. Demonstrate ability to evaluate and treat a child with altered mental status and interpret a pediatric cranial CT scan.

Supervisor: The rotating resident will function under the supervision of attending pediatric critical care specialists.

Duty Hours: Not to exceed the Duty Hours rule set by the RRC

Educational Responsibilities: Conferences Attend EM Core Conferences every Thursday morning from 8:00 am to 2:00pm. (wk 2, 3, 4, 5, 21, 22)

Laboratory 40 EM Procedure Conference (mo 5)

Assigned readings Tintinalli JE, Kelen GD, Stapczynski JS (eds): Emergency Medicine: A Comprehensive Study Guide, 5th ed. New York, McGraw-Hill, 2000; 57-71, 109-111, 749-786, 802-899.

Point of Contact for Day 1 on service: The Pediatric Intensivist on Clinical Service. PICU Phone # 955-4200, PICU Resident # 955-7926.

Vacation Policy: There will be no vacation allowed while on this rotation. .

Position : House Officer III Rotation : Rural Emergency Medicine

The Community/Rural EM rotation will allow the resident to experience non-urban EM practice, as well as daily life in a rural environment. During the month, the resident will live in Scottsbluff, Nebraska in an apartment provided by the University of Nebraska Section of EM. The Community/Rural EM rotation will follow the same educational objectives as for the EM2 or EM3 NHS-University ED rotations, but will emphasize the following aspects of EM practice unique to the rural ED:

The resident will provide initial evaluation and management of unselected adult and pediatric patients presenting to non-urban ED, under the supervision of a adjunct EM faculty. The resident will present all patients to EM faculty, and discuss diagnostic work-up and management. The level of resident responsibility for patient care will depend on demonstrated ability as determined by supervising EM faculty on-site. Senior residents will assume the role of junior staff, essentially performing all patient care and administrative duties for the ED under the direct supervision of EM faculty. During this month, the resident will also function as assistant medical director for EMS in the region, providing clinical oversight, EMT instruction, and administrative duties.

Objectives:

41 1. Demonstrate the evaluation and management of patient presentations more common in the rural setting (i.e. machinery trauma). 2. Describe the evaluation and management of the illnesses and injuries typically resulting from agricultural activities. 3. Interact with rural health care providers, including primary care providers, EMS personnel, and nursing home personnel. 4. Describe the limitations imposed on healthcare providers serving rural populations and the role the ED plays in assisting with healthcare delivery (i.e. distance from care, limited resources, limited diagnostics, transportation, etc.). 5. Experience the clinical practice of an ED serving in a rural community.

Supervisor: You will be supervised by the attending EM physician in the Scottsbluff ED.

Educational Responsibilities: Residents rotating at Regional West Medical Center ED will attend all conferences provided by the Emergency Medicine Residency Program through teleconferencing. Residents will be excused from clinical duties for conference attendance.

Evaluation Process: The EM section will receive an evaluation via email from supervising EM Faculty in Scottsbluff for each resident. A review of the evaluation will occur at the six-month resident progress meeting.

Residents will meet with an EM faculty advisor & residency director at six-month intervals to review their progress in training. The review will include all EM & off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback & guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. The EM education office will collect and track data obtained from this form. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account. Breakfast. All EM residents will be assigned a faculty evaluation form at the ends of their EM rotations for each UNMC EM faculty member. These evaluations must be completed by the due date listed with the notification of the evaluation due or fines may be docked from the CME account.

Position : House Officer III Rotation : Electives

This rotation will be decided by each individual resident under the direction of his or her advisor. This may be taken as a campus rotation in another department or may be used as your research month.

Supervisor: If you are in another department for your elective rotation, you will follow their guidelines regarding supervision. Should you designate your elective months to research, your supervisor will be the residency director and your advisor.

Duty Hours: As stated by ACGME Guidelines for that specialty. Should you designate your elective months to research, your duty hours will be not greater than 60 per week and a total of 12 hours per week of educational conferences.

Call Responsibilities:

42 As required by the department of the elected rotation. There will be no call responsibilities should you opt for a research elective.

Patient Responsibilities: As required by the department of the elected rotation. There will be no patient responsibilities should you opt for a research elective.

Shift Responsibilities: As required by the department of the elected rotation. There will be no shift responsibilities should you opt for a research elective.

Educational Responsibilities: EM Core Conference

Evaluation Process: The EM section will receive an evaluation via new innovations from the elected rotation’s program director or supervising faculty. A review of the evaluation will occur at the six-month resident progress meeting.

In the event that the elective was designated to research, you will need to meet with your advisor to discuss the progress that has been made in your research so that your advisor may obtain a grade of pass or fail for the rotation.

43 Lecture Schedule and Description Each resident must attend at least 90% of all lectures scheduled for EM Education. You will be allowed to have a maximum total of 3 tardies per year. A tardy will be awarded if you make it to the meeting within the first 15 minutes of the meeting. Should you arrive after 15 minutes of the beginning of the lecture, you will not be given credit for attendance at that lecture hour.

EM Orientation Lectures Lectures taking place during the month of July each year are required for all EM interns, PGY II’s & III’s are invited to all lectures. The orientation lectures are designed to cover a variety of subjects that will help prepare you for your initial year in the emergency department.

The EM Core Conferences These lectures will take place each Thursday morning from 8:00am - 2:00. These are mandatory for all emergency medicine residents and attendance will be taken each week by each resident signing the lecture attendance book each week. Off service residents rotating in the ED will cover the Wednesday night shift as well as the day shift on Thursdays so that all EM residents can attend Thursday morning didactics.

EM Grand Rounds EM Grand Rounds will be scheduled intermittently throughout the year. Dr. Wadman will have a speaker scheduled for this event or will designate a core faculty member to schedule a speaker.

M&M Presentation’s M&M’s will be presented every Thursday for a total of 1 hour and 30 minutes. Interns will be asked to present at M&M in the second half of their intern year. A schedule has been created so that each intern presents on the 1st Thursday of each month. 2nd year EM residents will rotate presenting at M&M on the 2nd Thursday of each month. 3rd year EM residents will rotate presenting at M&M on the 3rd Thursday of each month. Faculty members will continue presenting all M&M’s taking place on all other Thursdays not assigned to residents.

Journal Club Journal Club will be held the 4th Thursday of each month. Each resident will choose an article of interest and have it approved by their mentor or Dr. Tran. Each resident will be assigned a month to present their article. The article must be submitted to Tammi Erickson a minimum of 1 week (7 days) prior to the presentation. Tammi will distribute the article to all EM faculty and other EM residents as well as placing a copy in the presenting resident’s portfolio.

There are many criteria that you can use to select articles for presentation, but generally articles are selected based on "well built clinical questions." That in essence is one major goal of evidence-based medicine. Please use the template that for presenting that Dr. Tran gave in the EBM lecture when presenting articles at journal club during your Orientation month of lectures. You may request "Evidence Based Medicine" by Hackett. After you have performed your Journal Club presentation, please fill out the journal club form that an EM staff Assistant will give you as part of journal club assignment.

Evaluation Process The EM section will receive evaluations from each department you rotate through for each of the 3 years of your residency. While you are on the emergency medicine service each faculty member that you have worked with will provide an evaluation using the standard EM Resident Evaluation Form provided by the Section of EM. A review of the evaluation will occur at the six-month resident progress meeting.

Each resident will meet with an EM faculty advisor and the residency director at six-month intervals to review their progress in training. The review will include all EM and off-service evaluation forms available at that time. Any resident with deficiencies will receive immediate feedback and guidance in correcting all identified problems. A written plan will outline the remedies agreed upon by the resident and the EM and off-service faculty. Residents will submit a Rotation Evaluation Form via New Innovations following each off-service rotation and the EM education office will collect and track data obtained from this form. EM residents will be required to perform evaluations on the EM faculty members after they have completed a rotation in EM. Direct resident feedback on rotations may also take place at the six-month progress meeting or at the monthly Resident Breakfast.

Collection of Case Numbers New Innovations software will be the web-based database for tracking your emergency room patients during your 3 years of residency. You will have the option of entering information via computer or by using a hand held device. All 44 resident interns will receive training of this software program during orientation month in July. Support for this program can either be obtained from Tammi Erickson or by emailing the company directly. You are encouraged to enter your cases on a weekly basis to keep current and accurate.

Research While in residency, you will be required to present a research project. You are expected to work on this project during the first two years of residency and presenting during your third year before graduation. You will discuss your research project’s progress every six months during your evaluation meeting with your advisor and program director.

Department, GME, & UNMC Policies University of Nebraska Medical Center policies can be viewed at the following web-site address: http://info.unmc.edu/ The Department of Surgery and Section of Emergency Medicine are both required to abide by these policies and procedures at all times.

Each July of your residency here at the University of Nebraska Medical Center, you will receive a House Staff Manual from Graduate Medical Education. You are responsible for the contents of this manual as well. You may access this handbook on line at www.unmc.edu/gme/HOStaff_Manual.pdf

Monthly Scheduling Guidelines Shift in the emergency room will be as follows: Day: 07:00-17:00 Evening: 11:00-21:00 Swing: 17:00-03:00 Nights: 21:00 – 07:00

ACGME DUTY HOUR GUIDELINES: ”As a minimum, resident shall be allowed 1 full day in 7 days away from the institution and free of any clinical or academic responsibilities, including planned educational experiences. While on duty in the emergency department, residents may not work longer than 12 continuous scheduled hours. There must be at least an equivalent period of continuous time off between scheduled work periods. A resident should not work more than 60 scheduled hours per week seeing patients in the emergency department and no more than 72 duty hours per week. Duty hours comprise all clinical duty time and conferences, whether spent within or outside the educational program, including all on-call hours.”

First year residents will be scheduled for approximately 21 ten hour shifts each month, second year residents will be scheduled for approximately 20 ten hour shifts each month and all third year residents will be scheduled for approximately 19 ten hour shifts. The Administrative Chiefs will be given a shift compensation working a total of 18 ten hour shifts each month. All schedules created will follow the ACGME’s Duty Hour Guidelines as indicated above.

Vacation Request, Meeting Request, and Sick Time Policies As stated verbatim in the house officer contract:

6. Vacations: The house officer shall have four weeks (twenty working days) of paid vacation per year provided that such vacation days shall not include more than eight weekends. Vacation for house officers employed less than one year will be pro-rated. Up to a maximum of ten unused vacation days may be carried over and used by the house officer in the succeeding year. House officers employed for one year or more shall be reimbursed for up to two weeks (ten working days) of unused vacation time upon termination of employment. House officers may have up to five days of leave with pay for approved professional or educational meetings.

You will have the option of taking your vacation in single day requests with a maximum of 1 working week per request/per rotation. Each request for vacation must be submitted on the vacation form located in the Resident office in a binder labeled “vacation forms.” All requests must be submitted a minimum of 60 days before the start of the rotation month in which vacation is being requested.

Vacationing on off service rotations: Each rotation has its own policy regarding vacation requests. Please refer to the Goals & Objectives for each rotation to review their policy specifically. Residents are strongly encouraged to contact any upcoming rotation in which vacation time is scheduled to verify that the request was accommodated. It is the resident’s responsibility to submit

45 any specific scheduling requests to the department where the rotation is taking place. This means any personal time that you do not wish to use as vacation or EM education dates.

You will receive one week of professional meeting time each academic year. All requests must be turned into the residency program director at least 6 weeks in advance to be considered. All meetings must be approved by the residency program director. Each resident will be responsible for making their own travel & accommodation arrangements as well as submitting any forms for reimbursement from their travels if using their education fund.

You will receive 12 days of paid sick time during your first and second year of residency. You will receive 180 days of sick time after 24 months of full time employment at the University of Nebraska Medical Center. In the event that you require more than 6 weeks off during your third year of residency, you will need to meet with the residency program director to discuss making up the missed time so that you are eligible for Board Certification.

Harassment and Complaint Policy UNMC reaffirms that all women and men -- administrators, faculty, staff, students, patients, and visitors -- are to be treated fairly and equally with dignity and respect. Any form of discrimination, including sexual harassment, is prohibited. This policy is enforced by federal law and by the University of Nebraska Board of Regents policies. The UNMC Affirmative Action Officer, Jane E. Harris, Division Director of Human Resources-Employee Relations, monitors UNMC's affirmative action and non-discrimination policies According to the federal Equal Employment Opportunity Commission guidelines, sexual harassment is: “ . . . unwelcome sexual advances, requests for sexual favors, and other verbal and physical conduct of a sexual nature. . . “ when: Submission to such conduct is made either explicitly or implicitly, a term or condition of employment or educational status Submission to or rejection of such conduct is used as the basis for employment or academic decisions affecting an individual Such conduct has the purpose or effect of unreasonably interfering with one’s work or academic performance or creating an intimidating, hostile, or offensive environment

When possible, grievances should be settled within the resident’s department. If this route has been tried and no agreement is reached, the resident should come to the Graduate Medical Education Office. If there is no resolution at this point, then the resident can activate a formal grievance procedure as described in the house officer agreement or in the next section.

House Officer’s Role in M3, M4, and off service resident Education During your first year of Emergency Medicine, you will have very limited responsibilities to teaching medical students and off service residents. You can answer and advise medical students and off service residents at your comfort level and refer them to check with their supervising EM attending. During your second and third years, your responsibilities to educate your junior peers will increase. PGY II EM residents will begin taking check outs from off service interns rotation in the ED beginning in January of their 2nd year. PGY III’s role will be defined in the Education Committee Meetings.

Billing Information Because of Medicare teaching physician rules, it is imperative that each resident sign every chart. Please make a notation of the time you first saw the patient. You should try to get at least 2 past medical, family & social histories on each patient. We would like to have at least 2 ROS but 10 is better. If you do a complete ROS you may note 2 and check the box “All others reviewed and negative” If you are unable to obtain a PMH, FH, SH, or ROS please circle each individually at the bottom of the first page of the template and the reason for not being able to get this information. When documenting your physical exam circle each finding individually-not just one large circle for a bunch of normal findings. If you review the patient’s medical records, please give a small summary of your review. Please make sure all orders for albs, x-rays, EKGs and drugs are documented on the order sheet with the time and your signature. Please document all procedures thoroughly. When documenting a laceration repair please indicate how many layers of sutures were done as well as the length of each wound in centimeters. Circle your consults with the name of the consulting service and the time you called them. Please write out your final diagnoses in full-no abbreviations please. Every chart needs a plan of care documented with any prescriptions written out fully with the name of the drug, dosage and amount. Please circle differential diagnoses when indicated. PLEASE SIGN EACH CHART! Watch for new templates as the ED is constantly striving to make the template easier and more complete.

Additional Program Information 46 Salary While you are a resident here at the University of Nebraska Medical Center, you will receive a monthly paycheck. Your check will be directly deposited into your checking account at the beginning of each month. Each July, the salaries will increase at a rate determined by the State of Nebraska. The salaries for the 2005-2006 are shown below.

HO I $40,387 $3,365.58 HO II $41,882 $3,490.17 HO III $43,589 $3,632.42 HO IV $45,144 $3,762.00 HO V $46,723 $3,893.58 HO VI $48,231 $4,019.25 HO VII $50,669 $4,222.42 HO VIII $53,202 $4,433.50 HO IX $55,862 $4,655.17 HO X $58,393 $4,866.08

Annual In-Service Exam There will be an annual ABEM In-Service Exam given to all residents in the ED residency program on the 4th Wednesday in February each of the 3 years of their residency training period. This exam will serve as a measure of knowledge and deficiencies only. It will not determine the promotion of the resident into the next level of training.

Educational Fund Each resident will receive $500.00 each July during their training. This money must be used for educational purposes such as the purchase of text books, Educational CD’s and DVD’s related to your training, or as travel and hotel accommodations to and from an approved educational meeting. Should you decide to purchase any electronics, you will need to either give the product back at the end of your residency or buy it at a depreciated value. LATE FEES: Starting in July 2005, all EM residents will be eligible of receiving late fees for non completion of assigned tasks. You will be given a task such as completing an evaluation via New Innovations, Research assignment with deadline, Institutional assignments of compliance via Black Board etc. Should you not complete your assigned task by the deadline, you will receive a $10.00 late fee. You will be notified of this late fee via email from the educational support office. This fee will be subtracted from your Educational Fund. You then will have an additional week to complete the task-should you miss the 2nd deadline, an additional $10.00 will be deducted from your educational fund. Again, you will receive notification of the late fee charged to your account via the educational support office. Should no funds be available in your account, you will go into a negative balance. When your account is replenished in July, it will be less your negative balance. APPEALS PROCESS: You may appeal the charge of the late fee. You will have 10 days from notification of the late fee charge. Your appeal will be taken to the Education committee meeting for that month. The committee will approve or deny your appeal request. In the event there is not a committee meeting in any given month, your case will be held over for the next month.

Scrubs and Lab Coats You have the option of wearing your own navy colored scrubs to work. Hospital scrubs will be provided to you through a “check out” system at no charge.

The University of Nebraska Medical Center will provide each resident with 4 lab coats at the beginning of residency. These lab coats will be embroidered with the residents name and department. These coats are expected to last the entire 3 years of your interviews.

Parking The University of Nebraska Medical Center will offer on-campus parking in various different areas with various different costs. When a resident is scheduled to any shift that ends past 20:30, that resident will be allowed to park in Lot 2 Patient/Visitor for that shift. The day shift must park in their assigned lot. Parking must be renewed every 2 years in June. All interns will receive a parking hand book at the beginning of the year during GME House Officer Orientation in which they are responsible for it’s contents.

Meal Allowance Each resident will receive $6.00 for each shift scheduled in the emergency room. This meal allowance will be added to your ID badge at the beginning of each month. You will receive a meal card from GME that will allow you $5.00 per day for lunch.

Center for Healthy Living The Center for Healthy Living (CFHL) provides a variety of leisure activities in addition to fitness and wellness services for Medical Center students, faculty, staff, volunteers, alumni and their families. The CFHL includes two activity courts (for basketball, volleyball and badminton); indoor walking track; fitness studio; racquetball court; men’s and women’s locker rooms; and the Heiser strength and conditioning area. The Heiser area contains several alternatives for dynamic 47 exercise such as treadmills; step machines; rowing machine; ski-machine; bicycles, and elliptical trainers as well as options for resistive exercise, including Wynmore and Cybex weight machines and free weights. The CFHL membership includes use of all facilities as well as the following services: • Fitness classes • Fitness assessments • Exercise program design • Equipment orientation • Daily-use lockers

A variety of memberships types and lengths are offered, memberships may be purchased by cash or payroll deduction. Intramural leagues basketball, volleyball, golf and softball); Massage Therapy and Healing Touch are also available for an additional fee. (CFHL membership is not required for these services)

Child Development Center The center was established in 1991 to meet the childcare needs of parents and grandparents who are students, staff or faculty of UNMC / The Nebraska Medical Center / UMA. Children are provided a quality program designed to meet their physical, emotional, social and intellectual needs through stimulating activities in a nurturing and accepting atmosphere. This is done with sensitive, caring staff working in partnership with parents and families. Our goal is for each child to realize his or her potential in a secure and loving environment. A few of the many services we provide include: • Full time child care • Breakfast, lunch & afternoon snack • Title XX accepted-limited # spots • Open door policy-Parents welcome

We accept children ages 6 weeks through 7 years, and our operating hours are 6:00am- 6:00pm. To register, stop by and tour our facility, phone us at 559-8800 or visit our website at: http://www.app1.unmc.edu/unmcchildcare. A non- refundable fee of $25 is required for enrollment. If an opening isn’t currently available, you will be places on a waiting list.

Health and Life Insurance Benefits UNMC Benefits Office 559-4340

NuFlex Enrollment Overview: Under NUFlex you choose the level of benefits you need to cover yourself and dependents. Each year the University will provide you an allowance of NUCredits. This allowance represents a portion of the money the University spends for your benefits. This amount is paid out to you in your regular paycheck throughout the year. The dollars are taxable income, however, most benefits are paid for with pre-tax dollars. To participate in NUFlex, you must submit an enrollment form to the Benefits Office within 31 days of hire or eligibility. If you do not enroll during the 31-day period allowed, there are some restrictions as to when you may enroll for benefits.

Medical Insurance Eligibility and Insurability Provisions You are eligible for the medical coverage if you are classified as a regular employee and have an FTE of .5 or greater. Your coverage begins the first day of the month following your hire or eligibility date. If you were hired the first working day of the month, your coverage will begin that same day. An insurance application must be completed within 31 days of eligibility date. (Preexisting conditions are waived.) If not signed within 31 days, you will not have the option of coverage in the benefit plans until (1) re-enrollment period or (2) there has been a qualifying change in employment status or family status.

The current medical PPO network directory may be viewed on Central Administration’s Home Page at the following location: http://www.nebraska.edu/hr/hr benefits.html. PPO participation information may also be obtained by calling Blue Cross Blue Shield at 1-888-368-2227.

Preferred Provider – Prescription Drug The prescription drug component of the medical plan is administered by Caremark, a pharmacy benefit management specialist. This program offers you two convenient methods to fill you medication needs...in person at a participating Caremark retail network pharmacy or by mail order. Copays for the prescription drug program are based on Caremark’s formulary/Primary Drug List, which is a list of preferred brand name drugs. Listed below are the amounts you pay for each prescription purchased through a Caremark retail network pharmacy or the mail order drug program. Each covered insured will be required to establish an annual $50 prescription drug deductible. Once the deductible has been met, the applicable prescription drug copay must be paid. Prescription drug purchases may not be submitted to the major medical portion of the medical plan. You may view Caremark’s Nebraska PPO retail network directory and the Caremark 48 Dental Insurance The dental plan has been designed to pay a significant portion of the cost for checkups and to provide cost-sharing benefits for needed restorative work up to the annual maximum benefit. You may participate in the dental plan or elect no coverage. The choice that you make now will be in effect through December 31, 2003.

The current dental PPO network directory may be viewed on Central Administration’s Home Page at the following location: http://www.nebraska/edu/hr/hr/benefits.html. PPO participation information may also be obtained by calling Blue Cross Blue Shield at 1-888-368-2227.

Termination of Employment You pay for your health and dental coverage in the same month you receive coverage. Your insurance will terminate the last day of the month in which employment ceases. Under COBRA (Consolidated Omnibus Budget Reconciliation Act) Public Law 99-272 Title X, employees may continue with the group health plans at group rates plus a 2% administration charge for up to 18 months after termination. Some qualifying dependents may continue coverage up to 36 months. For more information employees should contact the Human Resource Representatives in the Benefits office. If you retire from the Medical Center, you may continue coverage with the University group.

Vision Care Insurance EyeMed Vision Care provides comprehensive vision care benefits to help ensure you and your dependents receive quality eye care from a network of professional eye care providers. Participation allows you and your dependents to obtain an eye examination, glasses, and/or contact lenses from a network provider at an affordable cost. You may participate in the vision care plan or elect no coverage. The choice that you make now will be in effect through December 31, 2003. The Nebraska EyeMed Vision Care Provider Network Directory may be viewed on Central Administration’s Home Page at the following location: http://www.nebraska/edu/hr/hr benefits.html. Network participation information may also be obtained by calling EyeMed Vision Care at 1-877-226-1115.

Reimbursement Account The Reimbursement Account provides University of Nebraska faculty and staff with a unique opportunity to pay certain eligible health care and dependent day care expenses with pre-tax dollars.

Abbreviations and Acronyms

AMA American Medical Association www.ama-assn.org

49 AHA American Hospital Association www.aha.org

AAMC Association of American Medical Colleges www.aamc.org

ABEM American Board of Emergency Medicine www.abem.org

ACEP American College of Emergency Physicians www.acep.org

ACGME Accreditation Council of Graduate Medical Education www.acgme.org

CORD Council of Emergency Medicine Residency Directors www.cordem.org

EMRA Emergency Medicine Residents’ Association www.emra.org

GME Graduate Medical Education www.unmc.edu/gme

JAMA Journal of the American Medical Association http://jama.ama-assn.org/

JCAHO Joint Commission on Accreditation of Healthcare Organizations www.jcaho.org

LCME Liaison Committee for Medical Education www.lcme.org

NBME National Board of Medical Examiners www.nbme.org

NMA Nebraska Medical Association www.nebmed.org

OMS Omaha Medical Society www.omahamedical.com

OMWCS Omaha Mid-West Clinical Society not available

NRMP National Resident Matching Program www.nrmp.org

RRC Residency Review Committee www.acgme.org/RRC/Committee.asp

SAEM Society for Academic Emergency Medicine www.saem.org