PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
SECTION 8: EMERGENCY MEDICINE
This section has been reviewed and approved by the Chief, Division of Emergency Medicine
as well as the Program Director, Internal Medicine Residency Program at Prince George’s
Hospital Center.
________________________
Chief, Division Of Emergency Med
I.
______________________________
Program Director, Residency Program
Overview
Emergency medicine involves the evaluation and care of acute illness and injuries that
require intervention within a limited time span. It is defined by a time interval rather than
by a particular organ. Some conditions may be encountered in office practice, others in
acute care settings. Regardless of the setting, the general internist should be able to
manage common emergency conditions and provide consultation and management for a
variety of acute serious illness.
Prince George’s Hospital Center has a busy emergency department that caters to the
population in the Washington D.C. metropolitan area. Being the only Trauma Center
(Level 2) it plays an important role in the care of injured patients in the community. The
Emergency Room has attached a walk in clinic to evaluate patients with minor problems.
The Emergency Department physicians have subspecialty training in Emergency
Medicine. This includes the faculty of George Washington University. Medicine
Residents from the Internal Medicine Residency Program at Prince George’s train side
by side with these residents under the supervision of the George Washington University
Faculty as well as other ER physicians.
Senior residents (PGY 2 and 3) spend 1-2 months in rotation in the Emergency
Department (ED) for direct care and MAO duty. Supervision in the ED is by Attending
physicians Department of Emergency Medicine or a Faculty of George Washington
University. Residents from George Washington University Emergency Medicine
Residency Program rotate through the Emergency Room at Prince George’s Hospital
Center. Residents perform initial evaluations of adult and adolescent patients presenting
to the ED with undifferentiated medical and minor surgical problems. Quick decisionmaking is important in this setting. All patients are presented to an Emergency Medicine
Attending who then sees the patient to verify history and physical findings. Medicine
resident and Emergency Medicine Attending together develop a diagnostic and
therapeutic plan. If a patient is to be admitted to the medicine service, the resident also
calls the patient’s Internal Medicine Attending and discusses the case with them. While
in the ED, Internal Medicine residents work side by side with emergency medicine
residents from George Washington University.
It is imperative that residents learn to recognize life-threatening situations and are able
to initiate resuscitation. By the end of the emergency room rotation residents become
familiar with airway management (bag-valve mask and intubation), augmentation of
circulation, hemorrhage control, neck and limb stabilization, as well as stabilization of the
acutely poisoned patient. Residents are encouraged to perform many procedures
including intubations, central lines and lumbar punctures under the direct supervision of
an attending.
There are areas of patient care unique to Emergency Medicine. These areas include
prehospital care, environmental issues, and toxicology. Residents learn to evaluate
when a patient is in danger and how to manage the more common toxic ingestions.
These include tricylclic antidepressants, acetaminophen, salicylates, and alcohol, among
others. Also, residents learn to manage disease and injury form environmental causes
including bites and stings, burns, hyper- and hypothermia, near drowning, and lightning.
Due to recent changes in our country’s health care system, the ED physician’s role in
patient care has been expanded. It is necessary to coordinate patient care with the
services of the various insurance companies and HMOs. As a result, communication
with the patient and his/her insurance provider is critical in terms of providing follow-up
care, patient transfers and admissions to the hospital. While in the ED residents learn
how to acquire appropriate inpatient and outpatient consultations and referrals, and how
to provide cost-efficient care.
During the rotation, residents have to manage several patients at the same time.
Residents will learn to triage patient care based upon the severity of their illnesses.
Residents must notify attendings immediately of any patient that is critically ill, follow-up
on all x-rays and laboratory results. Resident responsibilities are detailed under Section I
of the Resident Handbook.
Of particular importance is early recognition and initiation of therapy in certain life
threatening conditions like
 Acute myocardial infarction
 Pulmonary embolism
 Dissecting aortic aneurysm
 Abdominal aortic aneurysm
 Meningitis
 Subarachnoid hemorrhage
 Spinal cord compression
 Mesenteric ischemia
 Ruptured ectopic pregnancy
 Acute arterial occlusion
II. Principle Teaching Methods
This consists of frequent encounters with the Emergency Room attendings. The principle
teaching and learning activity during the Emergency Medicine rotations is direct patient
care activity working one-on-one with the Emergency Medicine attending staff.
Emergency medicine attending staff and credential Emergency Medicine residents in the
ED; these procedures may include: suturing of lacerations, placement of central venous
and arterial lines, immobilization and supportive bandaging of soft tissue orthopedic
injuries, and incision drainage of abscesses, resuscitation of critically ill patients with
fluids, chemical and mechanical means.
The residents have regular conferences in the Emergency Room itself where they
present assigned topics. Residents have access to MD Consult and other internet
learning resources in the Emergency Room itself. In addition, each year the Internal
Medicine residency program devotes conferences to common medical emergencies
under the core lecture series. These conferences assure that all residents receive formal
instruction regarding all common medical emergencies.
Residents will be required to attend the 3:00pm lectures held in the ER on the days they
are on the day shift. The ER attending will assign residents topics for presentation and
their performance during these sessions will be used in part to assess their medical
knowledge.
The residents will also have to interpret a minimum of 3 - 7 common diagnostic tests
(like chest X rays etc) during their rotation. A logsheet with this requirement is present at
the end of this section . Resident must print out a double sided copy of the logsheet at
the beginning of rotation and carry it with them during the rotation. Residents are
required to have attendings sign off on these diagnostic test requirements as they get
completed. This logsheet must be turned in to the internal medicine program coordinator
at the end of the rotation to as requirement for successful completion of the rotation.
All Procedures (like central line placements, intubations) must be logged in the
procedure logbook provided at the start of the academic yaer and must be signed off by
the attending and then entered into new innovations.
The ER attendings will also conduct mini CEX on residents every Tuesday evening shift
III. Strengths and Limitations
The Emergency Department faculty consists of physicians with a strong commitment to
patient care and resident education. The patient and disease exposure is very broad and
typical of a community-based hospital. On site cardiac or trauma surgery adds to the
wealth of experience at Prince George’s Hospital Center. Ability to interact with residents
from George Washington University is also a plus. This provides a unique experience for
residents in a community-training program.
IV. Goals and Objectives
Legend for Learning Activities
Learning Venues
1. Direct patient care: supervised by attending physician
2. Conference presentations in the ER
3. Self Study
4. Core Department of Medicine Lecture Series
Evaluation Methods:
A. Attending evaluation
B. Direct clinical observation
C. Peer evaluation
D. Nurses evaluation
E. In-Training examination
F. Procedures done
The principle educational goals for Emergency Medicine rotation are listed by ACGME core
competencies:
Competency: Patient Care
Effectively perform initial evaluation and management
of patients with medical emergencies and minor
surgical emergencies
Effectively assess patients’ need for hospital
admission and appropriate level on inpatient use
Know indications for common emergency department
procedures and perform these procedures with proper
technique
Competency: Medical Knowledge
Expand clinically applicable knowledge base of the
basic and clinical sciences underlying the care of
patients with medical and minor surgical emergencies
Access and critically evaluate current medical
information and scientific evidence relevant to medical
and minor surgical emergencies
Competency: Practice-Based Learning and
Improvement
Identify and acknowledge gaps in personal knowledge
and skills in the care of patients with medical and
minor surgical emergencies
Develop real-time strategies for filling knowledge gaps
that will benefit patients with medical and minor
surgical emergencies
Competency: Interpersonal Skills and
Communication
Communicate effectively with patients and families in
a stressful ED environment
Communicate effectively with physician colleagues in
the ED and members of other health care professions
to assure timely, comprehensive patient care
Communicate effectively with primary care physicians
regarding the care of their patients in the ED
Communicate effectively with consulting residents and
attendings from specialty services whose assistance
is needed in the evaluation or management of
patients in the ED
Communicate effectively with colleagues when
signing out patients
Competency: Professionalism
Behave professionally towards patients, families,
colleagues, and all members of the health care team
Competency: Systems-Based Practice
Understand and utilize the multidisciplinary resources
necessary to care for patients in the ED
Collaborate with other members of the health care
team to assure comprehensive care for patients in the
Learning Venues*
1
Evaluation Methods
A, B, C
1
A, B, C
1
A, B, F (Enter
procedures in new
innovations system)
ALL
A, E
ALL
A, E
ALL
A, B,C, E
ALL
A, B,C, E
1
A, B, C, D
1
A, B, C, D
1
A, B, C, D
1
A, C, D
1
A, C, D
1
A, C, D
*
1, 3
A, C, D
1,3
A, C, D
ED
Facilitate the safe and timely transfer of admitted
patients form the ED to the appropriate inpatient
setting
Use evidence-based, cost-conscious strategies in the
care of patients with medical and minor surgical
emergencies
1
A, D
1, 3, 4
A
V. Educational Content
A. Cardiovascular
1) Recognition and Management of:
 Acute or chronic congestive heart failure
 Arrhythmias
 Cardiopulmonary arrest
 Chest pain, stable and unstable angina, myocardial infarction
 Hypertension, hypertensive emergencies
 Shock
 Syncope
 Unstable thoracic or abdominal aortic aneurysms
2) Perform/order, interpret and understand indications for:
 EKG
 Chest X ray
 ABG
 Role of thrombolytics
 ACLS
 Temporary pacemaker
 Emergency cardioversion
 Intubations
 Mechanical ventilation (invasive, non-invasive)
B. Dermatology
1) Cutaneous ulcers
2) Rash
C. Assault
1) Learn to diagnose, the medico-legal requirements and follow appropriate
management plan
 Domestic Violence
 Sexual abuse
 Trauma
2) Suturing of minor lacerations
D. Endocrine and Metabolic
1) Diagnose and manage:
 Acute complications of hyperthyroidism, hypothyroidism
 Addisonian crisis

Diabetes mellitus, hypoglycemia, hyperglycemia, diabetic ketoacidosis
2) Hyperthermia and hypothermia
3) Order and interpret appropriate tests
 ABG
 Chemistries
 Thyroid function
E. Gastroenterologic
1) Diagnose and initiate management of
 Acute abdomen
 Acute diarrhea
 Acute liver failure
 Acute pancreatitis
 Ascites
 Bleeding
 Bowel obstruction
 Gallstones, cholecystitis
 Nausea and vomiting
2) Order/ perform and interpret appropriate tests
 CT scan
 Chest Xray
 Abdominal ultrasound
 NG tube aspration
 Stool studies, hemoccult test
 Abdominal paracentesis and fluid analysis
 Pancreatic enzymes, liver function tests
F. Hematologic
1) Diagnose and initiate management of:
 Acute complications of sickle cell disease
 Anemia, leukopenia, thrombocytopenia
 Easy bruising, purpura, ecchymosis
 Polycythemia, leukocytes, thrombocytosis
2) Order and interpret appropriate tests
3) Recognise patients in blast crises and arrange for transfer to tertiary care facility
G. Infectious Diseases
1) Diagnose and initiate management of:
 Active tuberculosis
 Encephalitis
 Herpes simplex infection
 Herpes zoster infection
 HIV infection (including infectious complications)
 Meningitis
 Otitis externa media









Pharyngitis
Pneumonia, bronchitis
Prostatitis, urethritis, epididymitis
Sepsis
Sexually transmitted diseases
Sinusitis
Upper respiratory infection
Urinary tract infection, pyelonephritis
Viral hepatitis
2) Follow appropriate infection control protocols
3) Order and interpret appropriate tests
 Cell counts and cultures
 Vaginal wet preparation
 Lumbar puncture and CSF fluid analysis
 Chest X ray, CT scans
H. Neurologic
1) Diagnosis and initial management of
 Coma
 Head trauma
 Headache
 Seizure
 Transient ischemic attack, stroke, subarachnoid hemorrhage
 Overdose, poisoning
 Cord compression
2) Order appropriate tests and consults
3) Understand indications and techniques of airway management if required
I.
Ophthalmologic
1) Diagnose and initiate treatment
 Acute loss of vision (painful and painless)
 Red eye
 Foreign body, trauma (minor)
2) Perform appropriate tests:
 Slit lamp examination
 Fundoscopy
J. Otolaryngologic
1) Management of :
 Epistaxis
 Ear pain
 Vertigo
 Otitis externa, media
2) Syringing for wax impaction
K. Pulmonary
1) Diagnosis and initial management of:
 Acute respiratory failure
 Asthma exacerbation
 Chronic obstructive pulmonary disease exacerbation
 Pneumothorax
 Pulmonary embolism, deep venous thrombosis, phlebitis
 Severe airway obstruction- foreign body
 Pneumonia, pleural effusion
 Cavitary lung lesions
2) Indication and/or interpretation of
 Mechanical ventilation (invasive, non-invasive), oxygen therapy
 ABG
 VQ scan
 Spiral CT scan, chest x ray
L. Renal
1) Understand causes and management of complications of
 Acute renal failure
 Chronic renal insufficiency
 Renal colic, kidney stones
 Fluid -Electrolyte, acid-base disorders
2) Understand the indications of emergency hemodialysis
M. Rheumatologic and Orthopedics
1) Diagnosis and management of
 Acute arthritis (including gout, septic arthritis)
 Back pain
 Vasculopathies and their exacerbations and complications
 Strains, sprains and fracture
2) Understand the indications for Arthrocentesis, imaging studies and vasculitic
work up and interpret results
N. Obstetrics and Gynecology
1) Diagnosis and appropriate management of:
 Ruptured ectopic pregnancy
 Miscarriages, threatened abortions
 Complications of pregnancy
 Pelvic inflammatory disease
 UTIs
 Vaginal bleeding, pelvic mass
 Sexual assault, domestic violence, substance abuse
VI. Reading Resources
Residents have access to books in the Emergency Room and the library as well as
Internet access to Pubmed/ MEDLINE, MDConsult and Up To Date in the emergency
room. Residents are encouraged to call Poison Control and obtain information regarding
various poisons on a case-by-case basis. Resources available include but are not
limited to:
A.
B.
C.
D.
E.
F.
G.
H.
I.
Emergency Medicine – Judith Tintinalli, 3rd edition
Emergency Medicine: Concepts and Clinical Practice – Rosen, Barkin
Harrison’s Principles of Internal Medicine – ed. Braunwald et al.
Medical Toxicology – ed. Ellenhorn, 2nd edition
Diagnostic Radiology in Emergency Medicine – Rosen et al.
Clinical Procedures in Emergency Medicine – Roberts, Hedges, 3rd edition
Atlas of Clinical Dermatology – du Vivier, 2nd edition
Journal of Emergency Medicine
The following few selected articles as supplements.
Emergency Medicine supplement articles1. Mokhlesi B. Adult toxicology in critical care. Part I: General approach to the intoxicated
patient. Chest, Feb 2003; 123(2): 577-592
2. Mokhlesi B. Adult toxicology in critical care. Part II: Specific poisonings. Chest, Mar
2003; 123(3): 897-922
3. Kales SN. Acute chemical emergencies. NEJM, Feb 19, 2004; 350: 800-8
4. Kosten TR. Management of drug and alcohol withdrawal. NEJM, May 1, 2003; 348:
1786-95
5. McDonagh DL. Assessing the patient with suspected stroke. Emerg Med, Mar 2002; 3243
6. Li F. Neuroimaging for acute ischemic stroke. Emerg Med, Jan 2007; 9-26
7. Brott T. Treatment of acute ischemic stroke. NEJM, Sep 7, 2000; 343: 710-722
8. Tofteland ND. Subarachnoid hemorrhage. Hosp Phys, May 2007; 43(5): 31-41
9. Arce D. Recognizing spinal cord emergencies. Am Fam Phys, Aug 15, 2001; 64(4): 631638
10. Liebmann O. Evaluating the patient with altered level of consciousness. Emerg Med, Feb
2006; 35-42
11. Burke P. Diagnosing and stabilizing acute neuropathies. Emerg Med, Jan 2004; 15-27
12. Lowenstein DH. Status epilepticus. NEJM, Apr 2, 1998; 338: 970-976
13. Banh KV. Identifying and managing cerebral concussion. Emerg Med, Oct 2006; 12-19
14. Haydel MJ. Indications for computed tomography in patients with minor head injury.
NEJM, July 13, 2000; 343: 100-105
15. Kucik CJ. Management of epistaxis. Am Fam Phys, Jan 15, 2005; 71(2): 305-311
16. Bakes K. Clinical assessment of vision loss. Emerg Med, Nov 2005; 14-24
17. Fine MJ. A prediction rule to identify low-risk patients with community acquired
pneumonia. NEJM, Jan 23, 1997; 336(4): 243-250
18. Aceves SS. Evaluating and treating asthma. Emeg Med, Apr 2005; 20-29
19. Alexander JL. Assessing and managing exacerbations of COPD. Emerg Med, Mar 2007;
20-26
20. Harrison BP. Evaluating and managing pneumothorax. Emerg Med, Oct 2005; 18-25
21. Bono MJ. Cyanosis. Emerg Med, Sept 2005; 45-48
22. Baden EY. Hypertensive emergencies: are you prepared? Emerg Med, May 2006; 20-32
23. Golding J. Acute heart failure: an evidence based approach. Emerg Med, Jan 2007; 16-26
24. Mueller C. Use of B-type natriuretic peptide in the evaluation and management of acute
dyspnea. NEJM, Feb 12, 2004; 350: 647-654
25. Clark DS. Acute chest pain: when is it life-threatening? Emerg Med, Oct 2006; 20-31
26. Weber JE. Validation of a brief observation period for patients with cocaine associated
chest pain. NEJM, Feb 6, 2003; 348: 510-7
27. Zimetbaum PJ. Use of the electrocardiogram in acute myocardial infarction. NEJM, Mar
6, 2003; 348: 933-40
28. Wang K. ST-segment elevation in conditions other than acute myocardial infarction.
NEJM, Nov 27, 2003; 349: 2128-35
29. White MJ. Troubleshooting acute abdominal pain - Part I. Emerg Med, Jan 2002; 34-42
30. White MJ. Troubleshooting acute abdominal pain – Part II. Emerg Med, Feb 2002; 16-27
31. Buresh CT. Unusual causes of recurrent abdominal pain. Emerg Med, May 2006; 11-18
32. Tilman K. Interpreting abnormal liver function tests. Emerg Med, May 2005; 31-38
33. Rockey DC. Gastrointestinal bleeding. Gastroenterol Clin N Am, 2005; 34: 581-588
34. Paulson EK. Suspected appendicitis. NEJM, Jan 16, 2003; 348:236-242
35. DeLashaw M. Managing anorectal complaints. Emerg Med, May 2006; 44-50
36. Adrogue HJ. Management of life-threatening acid-base disorders, Part I. NEJM, Jan 1,
1998; 338: 26-34
37. Adrogue HJ. Management of life-threatening acid-base disorders, Part II. NEJM, Jan 8,
1998; 338: 107-111
38. Meehan P. Responding to electrolyte abnormalities. Emerg Med, March 2005; 33-38
39. Kini S. Acute diabetic complications. Emerg Med, Oct 2006; 44-51
40. Playe SJ. Recognizing adverse reactions to antibiotics. Emerg Med, June 2006; 11-20
41. Van de Beek D. Community-acquired bacterial meningitis in adults. NEJM, Jan 5, 2006;
354: 44-53
42. Thielman NM. Acute infectious diarrhea. NEJM, Jan 1, 2004; 350: 38-47
43. Ryan ET. Illness after international travel. NEJM, Aug 15, 2002; 347: 505-516
44. Gerdes MS. Cutaneous eruptions accompanied by fever. Emerg Med, May 2005; 39-45
45. Coker K. Sepsis. Emerg Med, Feb 2007; 33-40
46. Bossard S. When to suspect pelvic inflammatory disease. Emerg Med, Feb 2004; 45-50
47. Devine AS. 10 common genitourinary emergencies in men. Emerg Med, Aug 2006; 1828
48. Klahr S. Acute oliguria. NEJM, Mar 5, 1998; 338: 671-675
49. Bono MJ. How to recognize and manage sickle cell crisis. Emerg Med, Dec 2005; 39-42
50. Buddin DA. Recognizing emergent dermatologic conditions. Emerg Med, Mar 2004; 2635
51. Singer AJ. Evaluation and management of traumatic laceration. NEJM, Oct 16, 1997;
337: 1142-48
52. Lemonick DM. Conducting medical clearance of the psychiatric patient. Emerg Med,
Mar 2006; 10-19
PRINCE GEORGE’S HOSPITAL CENTER
INTERNAL MEDICINE RESIDENCY PROGRAM
EMERGENCY MEDICINE LOGSHEET
RESIDENT NAME______________________________________________
PGY LEVEL_______________
ROTATION MONTH_____________
* Residents must personally prepare and review the wet mount and KOH slides and have their
interpretation signed off by the ER laboratory personnel.
TEST
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
CXR
CT SCAN
(HEAD/
CHEST/
ABDO)
WET
MOUNT* &
KOH STAIN
EKG
FINDINGS
CSF
FINDINGS
RESIDENT NAME:
TEST
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
MR#
Interpretation of result by
resident (diagnosis)
Comment by supervising
attending (correct/not,
missed findings etc)
SIGNATURE of
Supevising attending &
DATE
CXR
CT SCAN
(HEAD/
CHEST/
ABDO)
WET
MOUNT* &
KOH STAIN
EKG
FINDINGS
ABG
FINDINGS