The Children Mercy Hospital by MikeJenny


        Pediatrics Residency Program- University of Kansas Medical Center
          General Emergency Department- KU Medical Center (PL1)
     Pediatric Emergency Department- Children’s Mercy Hospital (PL2&3)

EXPECTATIONS (1,2,3,4,5,6)
    Basic pediatric knowledge gained during medical school and general pediatric rotations.
    Ability to take an accurate, concise history which should include:
            Chief complaint
            Pertinent history related to the chief complaint
            Past medical, birth & surgical history
            Medications, allergies & immunizations
            Social history
            Family history
            Pertinent developmental and diet histories
    Ability to perform an accurate directed physical examination for various age levels.
    Ability to present the patient concisely including:
            Physical exam
            Differential diagnosis, working diagnosis and final diagnoses
            Treatment plan- initial and final
    Ability to develop a working treatment plan and follow it
    Ability to express different viewpoints and treatment plans for the pediatric patient
    Interest in working as part of a medical care team
    Facilitate the learning of students and other healthcare professionals
    Consistently maintain accurate, timely, and legally appropriate medical records including:
            Detailed procedure notes for procedures done in the ED
            Accurate, timed record of all medications and fluids given
            Results of any diagnostic studies available at the time of discharge/transfer
            Condition on discharge or transfer from the ED
    Basic patient/parent-physician communication skills
    Enthusiasm for learning more about the care of pediatric emergencies.
    Gentleness and kindness for all our patients and their families
    Understand the epidemiology of the patient population from which the patients come
    Deliver timely care to the patient and their family
    Appreciate the costs to patients and the health care system in the delivery of ED care
    Prescription writing skills and ability to use available references to calculate drug doses
    Provide discharge instructions, written and verbal in a form understandable to the caretaker
    Communicate effectively in writing and by phone with referring and primary physicians

GOAL 1: General Objectives for the Pediatric Emergency Medicine rotation
       1. Develop a logical, efficient approach to the assessment of the ill pediatric patient
       2. Learn to multitask and prioritize patient care
       3. Become adept at procedures needed to resuscitate and stabilize pediatric patients
       4. Expand knowledge and technical skills through the management of various pediatric
          patients through direct patient care and self-directed study
       5. Learn how to deal with families under stress
       6. Develop skills of telephone communication
GOAL 2: EMS-C System (APA Goal 6.1)
Understand the basic principles of emergency medical services for children, including the
role of the primary care provider, pre-hospital care systems, and regional trauma systems.

  A. Describe the organization of emergency medical systems in the area, including:
         1. Pre-hospital care: access, training, and limitations of providers; transportation
             systems, the effect of time/distance on response.
         2. Availability of trauma centers and other centers capable of providing care for
             critically ill children.
         3. Facilities for inter-hospital transport.
         4. How to arrange transport to another facility (including timing with respect to patient
             condition, appropriate mode of transport, and communication between facilities).
         5. Disaster preparedness: the role of the pediatrician in preparing for and responding to
  B. Explain the unique medical-legal issues in providing emergency care, including:
         1. Caring for patients with no financial support.
         2. Consent for urgent medical care of minors including special circumstances (e.g.,
             rape, abuse, substance abuse, STDs).
         3. Refusing emergency care.
         4. Obligations of the emergency physician to provide/arrange follow-up care.
         5. Physician responsibilities and COBRA regulations regarding inter-hospital patient
         6. Medical examiner/coroner cases.
  C. Describe the equipment, staff training, and reference material needed to ensure office
     preparedness for emergencies.

GOAL 3: Resuscitation and Stabilization- ED (APA Goal 6.2)
Understand how to rapidly assess, resuscitate, and stabilize a critically ill or injured child in
the Emergency Department (ED) setting. (1,2,3,5)

  A. Rapidly assess urgent patients:
      1. Recognize respiratory failure and/or shock.
      2. Formulate a diagnosis quickly, especially with respect to conditions, which may need
              respiratory or cardiovascular support or an immediate intervention
      3. Assist in evaluating and stabilizing a child with multiple trauma.
  B. Establish and manage airway for infants, children, and teens.
  C. Identify priorities for vascular access, establish access, and perform fluid resuscitation.
  D. Demonstrate proficiency at cardiopulmonary resuscitation:
      1. Obtain certification as a provider of Pediatric Advanced Life Support.
      2. Direct resuscitation efforts in mock codes and in actual emergency situations.
      3. Understand the pharmacology of the drugs used in resuscitation.
GOAL 4: Common Signs/Symptoms and Conditions, Diagnostic Testing,
Monitoring and Therapeutic Modalities- ED (APA Goals 6.3,6.4, 6.5, 6.6)
Understand how to evaluate and manage common signs and symptoms in infants, children,
and adolescents presenting to the ED and urgent care center. Understand how to manage
common illnesses and injuries presenting emergently. Demonstrate an ability to discuss these
conditions and their management with patients and their families. Understand how to use
and interpret laboratory, imaging studies, and other commonly used diagnostic procedures
in the emergency setting. Understand the costs to both the patient and the health care system
involved in managing emergent conditions. Understand the application of physiologic
monitoring and special technology and treatment in the ED setting. Recognize evolving
diagnostic modalities and treatments based on appraisal of the current medical literature.

  For the symptoms/signs and emergent conditions:
     a. Perform an appropriate problem-oriented history and physical examination.
     b. Formulate a differential diagnosis, with appropriate prioritization, recognizing patients
          with possible life-threatening conditions.
     c. Formulate and carry out a plan for assessment and management.
     d. Describe indications for admissions to the ward, PICU or for transfer to another facility.
     e. Arrange appropriate follow-up.

  For the emergent conditions listed:
     a. Discuss the pathophysiologic basis of the disease or injury.
     b. Discuss and implement initial rapid assessment and stabilizing treatment, including
          specialized examinations when indicated (e.g., pelvic, forensic exam).
     c. Make a decision regarding discharge from the ED, admission, or transfer.
     d. Discuss the appropriate use of consultants and the role of the generalist in management.

  For the lab and xray studies:
     a. Explain the indications and limitations and be aware of age-appropriate normals.
     b. Recognize cost utilization issues.
     c. Independently interpret the results in the context of the care of the specific patient.

  For the monitoring techniques and special treatments in the list below:
     a. Discuss indications, contraindications, and complications.
     b. Demonstrate proper use of technique or treatment for children of varying ages
     c. Interpret results of monitoring based on method used, age, and clinical situation.

       1. Develop a differential diagnosis based on information available
       2. Learn the appropriate use of follow-up for patients seen in the ED
       3. Learn how to use consultants to assist in the evaluation and management of a patient
       4. Learn how to interact with primary care physicians (PCP)
       5. Ability to manage at least 2 patients at a time

Evaluation and Treatment of Children With:

       1. Respiratory: asthma, bronchiolitis (wheezing), URI, pneumonia, croup/epiglot1itis
       2. Infectious disease: sinusitis, fever. otitis media, pharyngitis, meningitis, rule-out sepsis,
           cellulitis, impetigo, common viral exanthems (chickenpox, Roseola), UTIs
       3. GI/GU: vomiting/diarrhea,GE reflux, abdominal pain, gastritis, GI bleeding
       3. Trauma: minor trauma, closed head injury, lacerations, fractures, nursemaid's elbow,
       4. child abuse/neglect, suspected sexual assault, burns
       5. Hem/Onc: sickle cell disease with vaso-occlusive crisis and/or fever, fever/neutropenia
       6. Neurology: seizures. altered mental status, seizure with fever
       7. Dermatology: contact dermatitis, eczema, and ringworm. diaper rash, head lice
       8. Toxicology: ingestions, exposures
       9. Allergy/Pulmonology: allergic reactions
       13. Ortho/Rheumatology: limp
       14. Surgical: acute abdominal pain, hernia

Ability to Perform:

       apply leads for cardiac monitor        venipuncture                  arterial blood gas
       pulse oximetry                         lumbar puncture               throat culture
       blood pressure monitoring              simple wound closure          simple splints
       bag-valve-mask                         chest compressions            visual acuity
       foreign body removal- nose, ear        incision and drainage of abcess
       fluoroscein stain of eyes              pelvic exam with cultures/PAP smear

Ability to Interpret:
X-ray: CXR, Salter-Harris classification of fractures
Labs: CBC, electrolytes. BUN, creatinine, glucose, ABG/VBG, CSF, UA, blood & urine cultures

   1.   Develop an evaluation plan based on the differential diagnosis.
   2.   Develop a treatment plan base on the results of the evaluation.
   3.   Implement an appropriate follow-up plan including use of community physicians, specialty
        clinics, and other health care agencies.
   4.   Understand the importance and technique of communication with the PCP of ED patients.
   5.   Use automated systems for information retrieval.
   6.   Develop an understanding of the use of emergent Vs urgent Vs routine consults in the care
        of the ED patient.
   7.   Learn how to use available resources to manage poison calls and other toxicological
Evaluation and treatment of children with:
   1.  Disease states on PL-1 list
   2.  Respiratory: failure/arrest
   3.  Cardiac: dysrhythmias, heart failure, congenital heart lesions
   4.  Infectious diseases: uncommon, complicated, or serious infections such as HIV-related
       disease and other immunocompromised infections, osteomyelitis, joint infections,
   5. Heme/Onc: anemia, neutropenia, solid tumors, blood dyscrasias, disorders of coagulation
   6. Rheumatology: vasculitis, other collagen vascular diseases, Kawasaki's, HSP
   7. Adolescent: suicide, PID, pregnancy, violence, delinquency, substance abuse
   8. Renal: hemolytic uremic syndrome, renal failure, obstructive uropathies, hypertension,
       nephrotic syndrome, nephritis, electrolyte abnormalities
   9. Endocrine: DKA, hypoglycemia, CAH
   10. Surgical: acute abdomen, major trauma, intussusception, pyloric stenosis, bowel
       obstruction, genitourinary tract emergencies such as testicular torsion
   11. Neurology: status epilepticus, headache, ataxia
   12. Ortho: septic joint, toxic synovitis, slipped capital femoral epiphysis, Legg-Perthes,
       developmental hip dysplasia
Ability to perform:
        all procedures for PL-1             intermediate wound closures
        foreign body removal                digital block
        gastric lavage                      oral ETT intubation
        NG placement                        interosseus access
Ability to interpret:
X-rays: learn normal appearances of epiphyses and apophyses and age related normal variants,
skeletal survey, c-spine films, and CT head
Labs: learn developmental changes

        1. To be able to care for a more complicated patient and teach another resident or student
            while doing so
        2. To recognize and teach others about classic and standard pediatric findings and
        3. Learn how to establish and maintain an efficient flow of patients throughout the ED
        4. Become comfortable leading resuscitations in the ED
        5. Understand the importance of and to develop communication skills with referring
            physicians and to know and when to ask for Attending assistance in the cases
        6. Understand the objectives and mechanism of the triage system of patients
        7. Be able to make independent decisions and manage complicated patients while
            recognizing your limitations
        8. Ability to manage multiple patients at one time
Evaluation and Treatment of Children With:

   1. Disease states on PL-l and PL-2 objective lists
   2. Cardiopulmonary arrest
   3. Transplant patients: fever, rejection
   4. Psychiatric illness
   5. Complex social problems
   6. Endocrine: Thyroid disease, Addisons disease and other uncommon endocrine disorders
   7. Envenomation

Ability to Perform:

        all procedures for PL-l and PL-2                      complex lacerations
        nailbed injuries                                      sedation-all forms
        defibrillation/cardioversion (chemical or electrical) central lines


GOAL 5: Teamwork and Consultation- ED (APA Goal 6.8)
Understand how to function as part of an interdisciplinary team in the ED. (3,5)

  1. Participate effectively in the patient care team (nurses, clerical staff, financial workers,
  attending physicians, trauma team/surgeons, residents, respiratory therapists, social workers,
      A. Explain the skills and limitations each team member brings to the team care process in
          the ED.
      B. Work effectively with these various team members.
      C. Demonstrate good communication skills, and appreciation and respect for the
          contribution of each team member to the care of ED patients.
      D. Serve as a team member and leader in urgent situations.
  2. Use consultants appropriately and communicate effectively with them.
  3. Serve as pediatric consultant to primary care providers and specialists who manage children
  in the ED.
GOAL 6: Patient Support and Advocacy-ED (APA Goal 6.9)
Understand how to provide sensitive support acutely to patients and families of children and
adolescents with acute illness and injury, and arrange for on-going support and/or
preventive services if needed. (1,2,3,4,5,6)

    1. Listen to concerns of patients and families; assign a team member to provide information
and support in emergencies.
    2. Deal with families of injured or seriously ill patients in a non-judgmental, culturally
sensitive manner, which conveys a warm, caring attitude.
    3. Identify problems and risk factors in the child and family, even outside the scope of this
visit, and appropriately intervene or refer (e.g., need for preventive or social services, care for
unrelated problems).
    4. Be able to deal with the "difficult" parent and child.
    5. Demonstrate sensitivity and skills in dealing with death and dying in the ED.
    6. Explain and be sensitive to the role of the primary care physician in providing on-going
support and continuing care; effectively communicate with both referring physicians and the
child's regular doctor.
    7. Enlist the parents' aid in the care of the child after discharge; teach them skills they will
    8. Describe problems of indigent families seeking acute care
    9. Identify strategies that might prevent or reduce morbidity for common problems presenting
to the ED in one's community.

GOAL 7: Financial Issues and Cost Control- ED (APA Goal 6.10)
Understand key aspects of cost control, billing, and reimbursement in the ED setting. (1,3,6)

     1. For diagnostic and therapeutic interventions in the ED, identify the general cost range, and
utilize these interventions appropriately, with appreciation for how the expense impacts on the
medical outcome, family, the service unit, and managed care providers.
     2. Select prescription medications with sensitivity to cost issues.
     3. Practice appropriate utilization of consultants.
     4. Participate in billing/managed care routines required of providers in the ED facility, showing
attention to detail, accuracy, and appropriate documentation.
     5. Describe general principles about typical insurance coverage for emergency care (e.g., types
of services covered; required notification of managed care provider); discuss how coverage may
differ for ED versus urgent care centers/sites.
     6. Be sensitive to the financial status of patients; be willing to refer to appropriate agencies if
assistance is needed.
     7. Discuss legal and ethical obligations to patients seen in the ED which impact on service, and
thus cost of care.
     8. Discuss cost implications of admission, extended observation in the ED, and admission to
observation bed status.
GOAL 8: Expectations of residents rotating on a 1-month ED rotation

Clinic attendance: PGY 1- shifts as assigned in the KUMC ED (General ED)
                   PGY 2 or 3- shifts as assigned in the CMH ED (Pediatric ED)

Didactic experiences:   An orientation guide to the CMH ER will be given to all
                  PGY 2 or 3 residents rotating to CMH.
                        At CMH, conferences are held on the 2nd Wednesday of
                  each month from 10:30am-1:30pm and the 3rd Wednesday of the
                  month from 10:00am-12:00pm in the Emergency Medicine
                  conference room.

Other educational experiences:

TOOLS: Faculty evaluation (1,2,3,4,5,6)
       Participation in patient care and quality of performance (1,2,3,4,5,6)
       Procedure cards (1,2)
       Patient logs (1,2,3,4,6)

Key: 1) Patient care                    4) Practice Based Learning & Improvement
     2) Medical Knowledge                      5) Professionalism
     3) Interpersonal/communication skills     6) Systems Based Practice

Preliminary Revision Fall 2008
        Anticipate further revision of KU ED G&O as the ED prepares for their own residency

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