PEDS 429 PEDIATRIC EMERGENCY MEDICINE ELECTIVE
RADY CHILDREN’S HOSPITAL
UNIVERSITY OF CALIFORNIA SAN DIEGO SCHOOL OF MEDICINE
HANDBOOK
AY 2013-1014
WELCOME!
Welcome to the Emergency Care Center at Rady Children’s Hospital. Thank you for
your interest in Pediatric Emergency Medicine. We are very pleased that you will be
spending time with us and hope that your rotation will be a rewarding one. Our
attending staff and fellows are very committed to medical student education and
look forward to sharing with you their enthusiasm for this unique specialty.
Introduction
The Emergency Department at Rady Children’s Hospital is a very busy place! It is the
only Level I Pediatric Trauma Center in San Diego County and also serves areas
inland including Riverside and Imperial Counties. There are over 70,000 patient
visits per year to our Emergency Department with complaints ranging from acutely
life-threatening to benign. There are a variety of providers who work as a team in
the Emergency Department to provide care for all of these patients including
pediatric emergency medicine physicians, pediatricians and nurse practitioners.
The Rady Children’s Emergency Department is divided into two main sections. The
Main Emergency Department (ED) also known as “the front” is divided into Exam
rooms (1-10), Procedure rooms (6-8), the Observation area (rooms 11-16) and
Trauma/Resuscitation. The Intermediate Care (IC) area includes all exam rooms
from 17-36. In general, sicker patients are roomed in the ED such as those who
require continuous cardiopulmonary monitoring, procedural sedation, present with
acute psychiatric issues or other complicated complaints or have a complex medical
history. The IC area sees patients that are usually less acutely ill but a large number
of work ups and procedures are performed here as well.
Overview of the Rotation
Students will provide care for patients in the Emergency Department under the
direct supervision of Pediatric Emergency Medicine and Pediatric attendings. The
Emergency Department offers ample opportunities to hone pediatric history taking,
physical exam and common procedural skills in an acute care environment through
direct patient contact, one-on-one bedside teaching, didactic teaching and directed
reading.
Schedule
Shifts are 8 or 9 hours in length depending on the area of the ED and include
mornings, afternoons and nights. Each student will be scheduled for 15 shifts over
the 4 week rotation.
On-line access for the student schedule is available at
www.amion.com
password: radyedres
Punctuality and Attendance
Professionalism dictates that students arrive on time for scheduled shifts and
mandatory conferences. If illness or a personal emergency prevents you from
working or if you will be more than 10-15 minutes late please call the ED at 858966-8800 AND e-mail Dr. Jennifer Weglowski at jweglowski@rchsd.org and
Richelle Belen at rbelen@rchsd.org or Sammie Hail at shail@rchsd.edu as soon as
reasonably possible.
You are expected to make up missed hours and shifts.
If you need to change your schedule please speak to Dr. Weglowski and Richelle
Belen or Sammie Hail to assure that there are no conflicts with other student or
resident schedules.
Professional Appearance
Please ensure that all clothing is professional and appropriate for the work
environment. Students are expected to be dressed in neat clothes or clean scrubs
and a white coat. No open toed shoes! Students must wear ID badges at all times.
Professional Behavior
Students should identify themselves to patients and families as medical students or
student doctors.
Please treat every patient and their family as you would hope to be treated. Students
are encouraged to communicate to the families the plan of care in the emergency
department and what they can expect during their stay. This helps to ease parental
and patient anxiety and is simply good care.
All students have had HIPPA training and are expected to protect patient specific
information and avoid discussing patients in front of other families.
Many funny, amazing, terrible and adorable things happen in a pediatric Emergency
Department. However, you are strongly encouraged to avoid discussing patients
outside of the department.
Any reports of unprofessional behavior are taken very seriously and will be taken to
the Dean of Students at the School of Medicine.
Departmental Cleanliness
We are responsible for cleaning up after ourselves so remove and dispose of sharps
(but don’t re-cap the needles) after procedures and place objects back in their
proper place when done using them. Don’t know where it goes? Just ask!
Seeing Patients
Patients are seen according to acuity (a numerical grade of 1-5, from most to least
serious), then in order of time in the room. If you are unsure which patient should
be seen next please ask the attending physician. Please avoid the temptation to pick
and choose patients as all patients offer a valuable learning experience.
Charting/Computer Access
All charting in the Emergency Department is done on Epic. Students are given a
tutorial in computer order entry and electronic charting prior to the start of the
rotation. The link to the tutorial will be sent to you along with this handbook and
other introductory material prior to the start of the rotation. Once the necessary
paperwork has been received by the GME office here, a login and password will be
issued to students by Sammie Hail.
Students are able and encouraged to enter patient orders into EPIC. All orders,
charts, and discharge instructions must be co-signed by the attending. Once the
plan of care has been determined with the attending please communicate this to the
patient’s nurse so orders can be performed in an expeditious manner.
Students are expected to complete all of their charts including a section on medical
decision making prior to leaving at the end of their shift.
Educational Opportunities
Prior to the rotation, we encourage you to identify any specific goals you would like
to accomplish or experiences you would like to have and review them with the
attendings and fellows at the start of your shifts so your time in the Emergency
Department can be maximized. In the past when students expressed a particular
interest in areas such as orthopedics, surgery, ophthalmology, etc. we have tried to
facilitate those experiences whenever possible.
Conferences
There are three mandatory conferences. If you are already scheduled to work you
will be excused from the unit to attend and the hours spent in conference will count
towards your hours for the day.
The first Wednesday of the month from 11:00am to 2:00pm students and residents
attend the division Morbidity and Mortality conference, Radiology rounds and Child
Protection rounds in MOB 407B.
There is an educational conference for the residents, fellows and medical students
on the second Wednesday of each month from 7:30am to 10:30am also in MOB
407B. This includes fellow lectures, case presentations and board review.
The third Wednesday is a fellow-directed Mock Code in the trauma bay in the ED
followed by a lecture (location TBA)
Evaluations
Students are required to have approximately 10 evaluations completed by the ED
attendings. Each time you work with a new attending, please activate or add the
attending on OASIS. These evaluations will need to be completed as part of the
requirement to receive credit for this course. Obviously the more evaluations
you collect the more balanced and accurate your final evaluation will be.
You are also strongly advised to evaluate the attendings and fellows with whom you
work on OASIS.
The quality of student charting/history and physical exam weighs heavily in the
final evaluation of performance. Students are encouraged to keep track of
particularly interesting cases and examples of what they feel is their best work to
share with the primary attending.
Students are strongly encouraged to take responsibility for their patients by being
the primary contact for the patient and family during their stay, reporting
laboratory and radiology results to the attending and speaking with consultants and
the admitting team when needed.
In Conclusion
The variety of patient complaints and pace of work in the Emergency Department
makes for a unique pediatric experience. Please do not hesitate to ask questions. We
want you to have fun and learn all you can while you are with us.
If you have any questions or concerns please let us know. We would love to hear
your ideas of how to make the rotation even better.
General Information
Contacts
Dr. Jennifer Weglowski
Director Medical Student Education
Division of Pediatric Emergency Medicine
Clerkship Director PEDS 429
jweglowski@rchsd.org
858-966-8036
Richelle Belen and Sammie Hail
PEDS 429 Course Administrators
radyedres@rchsd.org
858-966-8036
Main ED number: 858-966-8800 (24 hours a day, 7 days a week)
Additional information about the rotation including classic articles may be found at
the below link:
http://www.rchsd.org/professionals/emergencymedicinerotation/index.htm
Other good resources for the rotation include the following, all of which can be
found in the Emergency Department and Hospital Library:
Pediatric Emergency Medicine Secrets, 2e by Steven M. Selbst MD and Kate
Cronan MD (pocket handbook)
Textbook of Pediatric Emergency Medicine (Textbook of Pediatric Medicine
(Fleisher)) by Gary R. Fleisher and Stephen Ludwig, 6th ed. (classic text)
Nelson Textbook of Pediatrics: 19e by Robert M. Kliegman MD, Bonita M.D.
Stanton MD, Joseph St. Geme and Nina F Schor MD PhD (classic text)
Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: 6e by Basil J. Zitelli MD,
Sara C McIntire MD and Andrew J Nowalk MD PhD (photos galore)
Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of
Childhood and Adolescence, 4e by Amy S. Paller MD and Anthony J. Mancini MD
Red Book: 2012 Report of the Committee on Infectious Diseases (Red Book Report
of the Committee on Infectious Diseases) by Larry K. Pickering MD FAAP, Baker,
David W. Kimberlin MD FAAP and Sarah S. Long MD FAAP
Web sites such as Up To Date and Medscape.
GENERAL OBJECTIVES
1. Develop a logical, efficient approach to the assessment of the ill pediatric
patient.
2. Practice the principles of rapid cardiopulmonary assessment.
3. Learn the concepts of triage and prioritization of patient care.
4. Perform and hone procedures necessary to resuscitate and stabilize pediatric
patients.
5. Build knowledge base and technical skills needed to accurately diagnose and
treat pediatric emergencies.
6. Practice effective communication skills with patients, families, ED staff and
consultants.
7. Improve documentation and note writing skills, particularly medical decision
making and formulation of differential diagnoses.
8. Learn when certain pediatric problems should be admitted and when they
can be safely sent home.
EDUCATIONAL OBJECTIVES
1. Initial evaluation
a.
Become familiar with the triage process
b.
Be able to perform a rapid cardiopulmonary assessment.
c.
Be familiar with what vital sign values should trigger an
immediate evaluation.
2. Life support
a.
Become proficient in the airway management of a pediatric
patient including both basic and advanced airway skills.
b.
Learn how to lead a resuscitation effort.
c.
Evaluate and treat a child with potential trauma.
d.
Learn how to evaluate and treat shock.
3. Allergy
a.
Understand the presentation, treatment, and complications of
asthma.
b.
Learn to manage a child with anaphylaxis.
4. Child abuse
a.
Know the most common presentations of physical and sexual
abuse.
b.
Understand differentiation of non-accidental and accidental
bruising.
c.
Be familiar with reporting laws.
d.
Know the indications for head ct and skeletal survey in a
potential non-accidental trauma.
5. Dermatology
a.
Know how to recognize and treat drug reactions, contact
dermatitis, fungal infections, lice, and scabies.
b.
Understand what is a petechial/purpuric rash in addition to
the differential and treatments for these rashes.
6. Endocrine
a.
Recognize and treat DKA.
b.
Diagnose and manage hypoglycemia
7. Gastroenterology
a.
Develop a differential for abdominal pain based on
presentation/age/sex.
b.
Understand approach to upper and lower GI bleeding.
c.
Assess and treat various stages of dehydration secondary to
vomiting and diarrhea.
d.
Manage and treat intestinal obstruction/hernias.
8. Gynecology
a.
Understand and treat dysfunctional uterine bleeding
b.
Evaluate and treat vaginal discharge/vaginitis.
c.
Management of PID.
9. Hematology
a.
Manage sickle cell crisis and sickle cell patient with fever.
b.
Develop an assessment for acute onset bleeding/bruising.
c.
Manage hemophiliacs with trauma.
d.
Manage fever and neutropenia.
10. Infectious disease
a.
Evaluate and treat patients with multiple infectious etiologies.
b.
Develop an approach to the assessment and treatment of the
febrile infant and toddler.
c.
Manage animal bites.
11. Neurology
a.
Manage febrile seizures
b.
Approach to a patient with altered mental status.
c.
Approach to first time seizure and status.
d.
Evaluate possible vp shunt obstruction.
e.
Assess and treat headaches.
12. Opthalmology
a.
Learn vision screening and basic visual exam skills.
b.
Learn to evaluate and treat corneal abrasions, hyphema,
conjunctivitis, and ocular foreign body.
13. Orthopedic
a.
Form an approach to the evaluation of a limping child
b.
Manage nursemaid’s elbow.
c.
Diagnosis and treatment of fractures/sprains.
14. Pain Management
a.
Use of different pain management techniques
b.
Understand different types of procedural sedation.
c.
Understand use of local anesthetics.
15. Psychiatric
a.
Learn how to treat a suicidal or violent patient.
16. Pulmonary
a.
Recognize and treat respiratory failure
b.
Evaluate and treat patients with aspiration, foreign body
ingestion, dpneumothorax.
17. Urology
a.
Evaluation and treatment of testicular pain.
b.
Hematuria evaluation
c.
Balanitis and phimosis treatment
d.
Manage and treat renal failure
18. Toxicology
a.
Manage the child with ingestion of unknown substance.
b.
Recognize and treat specific ingestions/poisonings.
19. Trauma
a.
Become familiar with primary and secondary survey for a
trauma patient.
b.
Understand how to evaluate and treat a child with specific
traumatic injuries.
PROCEDURES
Students will have the opportunity to learn, observe and perform the
following procedures in the ED as long as the attending is present and agrees
that the procedure is necessary.
1. Arterial puncture/arterial line.
2. Abscess aspiration/ incision and drainage.
3. Local anesthesia administration.
4. Digital block.
5. Foreign body removal from soft tissue, ear, nose, mouth, and eye.
6. Suturing.
7. Paronychia drainage.
8. NG placement/gastric lavage.
9. Burn dressing.
10. Wound irrigation.
11. Peripheral IVs. (with the nurses)
12. Intubation.
13. Lumbar puncture.
14. Conscious sedation.
15. Nursemaid’s elbow reduction
16. Fluorescein staining of cornea.
17. Eye irrigation with Morgan lens.
18. Ring and fishhook removal.
19. Incarcerated hernia reduction.