RVH Orientation for New Residents
Welcome to the RVH Emergency Department! The RVH celebrated its 100th birthday in 1993 and has had a functioning Emergency Department since opening. The original location was just off University Street, its entrance being under the bridge to the Montreal Neurologic Institute. Many renovations later, the ED is now located in the Centennial Pavilion and is divided into 5 treatments areas; acute care (ACA), minor care (MCA), resuscitation room, transitional care (TCA) and psychiatry.
The RVH is a major referral center, with an annual census in 2007 of just under 34000 patients (of which over 9000 arrived by ambulance and around 5000 were admitted), and has active Cardiology (including cardiac catheterization), Transplant and Oncology divisions, which gives us a more complicated, sicker patient population compared to that of many other hospitals. Also, we are joined to the Montreal Neurological Institute and therefore see a considerable number of their patients presenting with complex neurological or neurosurgical problems. The RVH is also the primary site for Obstetrics and Gynecology at the MUHC. This all makes for a varied and interesting patient population, although trauma patients (other than minor ones) are seen at the Montreal General Hospital.
The RVH ED is one of the MUHC base hospitals for the Emergency Medicine Royal College Residency Program. About half of the attending physicians on staff are Royal College trained Emergency specialists; others are family physicians with extra training or many years experience in Emergency Medicine. All the attending physicians have a clear commitment to Emergency Medicine, although some hold additional fellowships, for example in Sports Medicine, Toxicology, and Intensive Care.
EVALUATIONS
Your final in-training assessment will be based on feedback from each attending you work with on each shift. Feedback is an important tool for learning; to get the most out of it you should identify goals for yourself at the beginning of each shift, and reflect on what you learned from each case. When you start each shift, pick up a blank patient and procedure log, and fill in your name, the attending’s name, and your goal(s) for the shift. Keep track of the patients you see on the front of the sheet (including the points learned from each patient), and log your procedures on the back. At the end of the shift, go over the log with your attending (you may choose to keep a copy for your records as well). Although most feedback will happen throughout the shift, as you review cases, the attending should spend a few minutes at the end to discuss your overall performance, to help you identify goals for the next shift, and to solicit feedback from you on the teaching you received. The patient/procedure log will help provide material for this discussion. You may keep the log and use it to guide your reading.
Evaluations are done electronically through the one45 system. The evaluations to be filled include:
- A daily evaluation of the resident (by the staff)
- A daily evaluation of the staff (by the resident)
- Evaluation of the daily lecture (by all in attendance)
- End of rotation feedback from you
Before the end of each shift, log on to the one45 system at:
https://one45stage.is.mcgill.ca/app/
You will find this as either a desktop icon or under “favourites” on all the computers in the department. Once logged in, select “choose a new form to complete”. For your daily evaluation, select “Emergency Medicine MUHC-RVH daily resident evaluation of staff”, then choose the name of the attending you are working with and the date, then submit. The attending will receive your blank evaluation in his or her “to do box”, and you will receive a blank staff evaluation form in yours. The process is the same for evaluating the daily lecture, but note that there is one form for lectures given by residents, and another for lectures given by staff – please choose the appropriate form depending on who is teaching that day.
If you have any difficulty accessing the site or you have any questions about the system, please contact the MRES Administrator by email at mresone45.med [at] mcgill.ca or by phone (514) 398-5227.
There are a small number of attending staff who have not yet been added to the one45 system. If you work with one of those attendings, you will have to given them a paper copy of the daily feedback form. These can be found on the wall just outside the conference room. The attending will return the form to the resident supervisor.
Goals and Objectives for Off-Service Residents
The principal objective of the Emergency rotation, regardless of your sub-specialty field, is to expose you to a large variety of presentations of varying degrees of acuity. Often, the patient’s presenting problem will be outside the realm of your specialty, and so you may feel that you have nothing of value to learn from the case. Not so. As a practicing physician, patients will present to you with problems of all kinds, so it is important to learn a basic approach to the so-called “cardinal presentations” (e.g. fever, weakness, dizziness, abdominal pain, shortness of breath, etc). Furthermore, in your career you will likely be called upon, from time to time, to deal with an urgent situation. For example, the patient who faints in your waiting room, or the patient who develops an anaphylactic reaction to a medication you have just administered. A good grounding in the “ABC”s of Emergency Medicine will serve you well on these occasions.
The Emergency Rotation will also expose you to a less traditional method of data gathering than you would employ elsewhere. Often the history cannot be obtained directly from the patient because of altered mental status or language barrier, and at times the urgency of the presentation demands that treatment be initiated before history taking has been completed. One of the goals of the rotation is thus to enable you to recognize the severity of a patient’s illness and prioritize their care appropriately.
Another skill you will develop in the Emergency Department is “multitasking”. You will learn how to manage several patients simultaneously, remaining alert to any changes in the status of patients waiting for tests or consultants, and intervening when needed.
The number of patients waiting to be seen also places pressure on the physician to work quickly; thus, in the ED you are expected to improve the speed and efficiency of your work. This applies not only to history-taking and the physical examination, but also to your ability to generate a pertinent differential diagnosis, to document clearly, and to present the case in an organized and coherent manner.[1] Rapid decision-making is one of the cornerstones of Emergency Medicine. In this rotation you will learn to make rational and cost-effective choices with respect to ordering tests, initiating treatment, and arranging disposition or follow-up.
During your rotation you may have the opportunity to learn and practice many medical procedures, including suturing, lumbar puncture, peripheral and central venous access, airway management, procedural sedation, fracture/dislocation reduction, casting, and abdominal paracentesis (to name a few). Before being permitted to perform any procedure on a patient, however, you will have to demonstrate to the attending physician your understanding of the indications, contraindications, technique, and complications associated with it, and you must be able to obtain informed consent from the patient. As the opportunities to practice procedures may be few, it is strongly recommended that you read up on these prior to starting the rotation; otherwise you may miss out on an important learning opportunity.
Nowhere in the hospital is teamwork more important than in the Emergency Department. A single staff physician may be responsible for as many as forty sick patients at a time; unless he or she can work well with the team of highly trained nurses, clerks, social workers, and consultants, disaster will arise. You will need to integrate into this team in order to function in the department. Good communication skills and respect for your coworkers are critical.
Certain medical problems fall within the expertise of emergency physicians in particular: resuscitation, toxicology, and environmental illnesses are examples. You should take advantage of this brief opportunity to learn more about these conditions from people who are expert in these areas.
You may have your own set of goals and objectives depending on the stage in your training, past experiences, and the needs of your residency. We encourage you to share these expectations with us so that we may help you to meet them during your rotation.
In summary, the goals and objectives of the emergency rotation, in CANMEDs format, are:
MEDICAL EXPERT:
q Recognize the unstable patient and initiate treatment of the “ABC”s
q Develop an approach to the cardinal presentations
q Gain knowledge in certain subspecialty areas of Emergency Medicine
q Learn and practice some common emergency department diagnostic and therapeutic procedures
COMMUNICATOR
q Gather data efficiently, document it clearly, and present it coherently
COLLABORATOR
q Function as a member of the ED team
MANAGER
q Investigate and treat emergency department patients in a rational, cost-effective way
q Manage several patients simultaneously
HEALTH ADVOCATE
q Recognize the biopsychosocial factors that modify disease and intervene when appropriate
SCHOLAR
q Critically appraise sources of medical information relevant to Emergency Medicine
PROFESSIONAL
q Practice medicine ethically, consistent with the obligations of a physician
TEACHING
We start with the premise that you are adult learners and as such are responsible for your own education. This means that you are expected to read around the cases you see and spend extra time on those that are unfamiliar to you. In other words, you are expected to develop a responsible amount of knowledge about cases from all areas of medicine – not just in your specialty. Indeed this is perhaps the only rotation where you will see patients covering all areas of medicine as well as the whole spectrum of a given disease (e.g. mild congestive heart failure to cardiogenic shock). It is our hope that by the end of the rotation you will be comfortable with the initial assessment of any patient with any complaint, and be able to decide whether the patient is sick and requires immediate intervention or can wait for further evaluation.
15h00 Teaching
A formal teaching session will be held in the Emergency conference room, Mondays through Fridays at 15h00 and attendance is compulsory for all residents on the schedule that day (unless on nights or if it conflicts with your protected teaching time or clinic). The attending physician coming on in the acute care area at 16h00 will teach the session, which should last about 45 minutes.
These lectures are meant to cover the major areas of emergency medicine and a list of the topics and the teacher can be found on the bulletin board outside the conference room. Please take a moment to fill out an evaluation form for each lecture (through one45) so that we can improve the quality from month to month.
Emergency Medicine Rounds
Each Wednesday, from 8h30 to noon, lectures on a variety of Emergency Medicine topics are presented by EM residents and staff, as well as visitors from other specialties. These sessions are not mandatory for off-service residents, but you are welcome to join us if you are not scheduled to work. A schedule of the locations, times, and topics will be posted on the bulletin board outside the conference room. Usually the first Wednesday of the month will be held at the JGH, the third Wednesday is for EM residents only, and the other two Wednesdays are at the RVH in room M3.30. Exceptions often occur, so please check the schedule.
The last Wednesday of each rotation, at 18h30, we hold a journal club meeting at the Thomson House, with a dinner provided (not sponsored by industry). This is both a relaxed, pleasant social event, and an opportunity to review the techniques of evidence based medicine and stay up-to-date on the latest literature. Off-service residents are welcome to attend but this is not mandatory. If you plan to attend, please ask Gillian Frontin to email the articles to you.
Reading
A collection of review articles from the Emergency Medicine literature, related to the 15h teaching topics, is available on CD for all rotating residents.
Located in the acute care nursing station, the ED reference library includes texts on Emergency Medicine, Internal Medicine, Toxicology, and Orthopedics. The internet is also accessible at several stations and is connected to the McGill server so you can access UpToDate (www.uptodate.com), PEPID, Medline, and McGill’s library of online medical journals.
Clinical Teaching Unit Residents (CTU)
Those residents and students rotating through our department in period 3 this year will benefit from the presence of the CTU residents, senior Emergency Medicine residents scheduled to do clinical teaching. This resident’s role is to review cases with you, show you interesting cases other than your own, and provide case-based and bedside teaching as well as give two of the 15h00 lectures.
Direct Supervision of Cases
On an ad-hoc basis, when there is a “plus doc” available in the evening and ED congestion is not too great, this physician will spend some time one-on-one with a resident or student for direct supervision teaching. This involves the attending silently observing the trainee as he or she takes a history and does a physical exam, followed by case discussion and detailed feedback on all aspects of data gathering and interpretation, and case management. Direct supervision will also replace 15h00 teaching when only one trainee is in attendance.
Reviewing Cases
Most of the teaching that goes on in the ED is case-based and occurs at the time that you review the case with the attending physician, or at the patient’s bedside. These discussions may involve the elements of patient history, physical, differential diagnosis, investigation, or treatment plan, or may focus on other CanMEDs roles (aspects of communication, collaboration, advocacy, scholarship, or professionalism). The attending should provide relevant feedback and brief teaching points based on the problem presented. To get the most out of this experience, you are encouraged to ask for feedback on the specific elements of the evaluation that you felt were more difficult. For example, you may have been confused by the history, or were unsure how to properly examine a joint, or did not understand the approach to investigating the complaint. For this reason the staff will ask that you have written up the chart before you present the case as this gives you time to organize your thoughts and also allows them to check the documentation at the same time. However, if you should see a patient who you feel needs immediate treatment (e.g. unstable vital signs, altered mental status, severe pain), please notify the staff at once, and continue the evaluation while the attending helps you stabilize the patient’s status.
Do not forget to reassess your patients! A good rule of thumb is to quickly reassess each patient you have seen before picking up a new patient – this may involve rechecking the vital signs (did that fluid bolus bring down the heart rate?), inquiring about adequacy of analgesia, looking for a response to therapy (is the patient less short of breath after that dose of furosemide?), checking any xray or lab results that have come back, or finding out if the consultant has seen the patient yet (and what did they recommend?). Please write a note (with date and time) each time patient is reassessed if there has been any change or if results have come back.
DOCUMENTATION: THE ED CHART
As you are no doubt aware, the MUHC still uses cumbersome hand-written paper charts. We are all familiar with the frustration of not being able to read our colleagues’ handwriting, or discovering that key information is missing or that the rationale for treatment decisions is unclear. You should strive to create a document that is helpful to the next doctor to see the patient. It is also essential that all notes and orders be dated and timed, and signed by both resident and attending. Only standard dark blue and black, waterproof ink are acceptable for writing in the medical record.
History
The patient history should be complete yet concise. It is important to balance the inclusion of all relevant data without being overly wordy. Stay focused on the chief complaint. Point form and commonly used acronyms are useful methods of documenting. Pertinent negatives should be included (this means negatives that help you to exclude or prioritize diagnoses from your differential list), but an exhaustive review of systems need not be. Elements of the past medical history that have no bearing on the present illness should be excluded (e.g. ACL repair from 1990 in a patient presenting today with abdominal pain). On the other hand, some elements of the PMH are so important that they belong in the patient identification section (e.g. liver transplant in 2003). Write legibly, organize your notes logically, and use the back of the sheet if needed.
Remember that the patient is the one with the disease so whenever possible take the history from him or her, not the family member, and then use other sources to fill in the blanks. When patients cannot give history or seem unreliable you may have to call family members or nursing/group home personnel. Be a detective! Sometimes you can get lots of useful information by looking for medic-alert bracelets, calling the patient’s pharmacy, reading the triage nurse note, and looking at the old chart. Use all available sources of information when needed. Request a translator if there is a language barrier.
Physical Examination
The physical exam should be as complete as warranted. This means that, for example, in an isolated ankle injury in a young person with nothing on history to suggest any additional problems, an exam limited to the lower limb may be justifiable. On the other hand, an elderly patient presenting with ankle injury after a fall will need a thorough exam to determine why they fell. In all cases, the patient should be adequately undressed to permit an appropriate examination. For most patients, this means completely undressed (except undergarments); for isolated extremity injuries, the rule of thumb is that you need to examine the joint above and below the injury, and you need to be able to compare to the other side.
Gynecologic/breast exams and detailed neurological exams are only necessary if the history suggests the problem may lie in these areas. Please tell the attending before doing gynecologic exams (which must be done with a female nurse or physician in attendance).
Do not document anything you did not do. For example, it is common to see “CN II – XII normal” when in fact the cranial nerve exam was not that complete.
Differential Diagnosis
The differential should include a well-prioritized list of the most serious and most likely probable diagnoses (not a page out of Harrison’s textbook). When the patient presents with multiple problems, a separate differential for each problem may be indicated if a common diagnosis is not apparent. Coming up with a well-organized differential diagnosis is one of the most challenging problems in emergency medicine; you will have lots of opportunity to practice this during your rotation.
Documentation of your “impression” is the most important part of the patient’s chart, yet is often the least well done in the ED. This is where you consider the differential diagnosis and explain the clinical reasoning behind your work-up and management decisions. Do not skimp on this section! Fill this out before you review the case, as it will force you to work through the problem on your own. You can always revise your note after discussing the case. When revising a note, it is important not to black out anything that has been written; instead, you can add an addendum, or cross out the incorrect portion (so that it is still legible) and initial the change.
Investigation and Plan
Testing is expensive and increases the patient’s length of stay, so you will be expected to justify every test you order. This doesn’t mean that warranted tests won’t be ordered, but they should be limited to those that will change patient management in the emergency department (some tests may be needed non-urgently; those can be booked as outpatients as long as appropriate follow-up is also arranged). Remember that some tests cost more than others. For example, a portable chest x-ray costs more than a regular chest x-ray and gives you much less information so if the patient is stable enough to go to radiology, then wait. Often there is more than one acceptable treatment for a given condition. When equally effective alternatives exist, it is preferable to choose the less expensive one. To avoid confusion and cut costs it is also preferable to use generic rather than brand names of drugs.
Writing orders
Cases must be reviewed with the attending physician before initiating treatment. Of course, when patients require immediate management, you should ask the attending MD to come to the bedside.
All orders for investigations, fluids, medications, care instructions, and consultations are done electronically (through MedUrge). You will receive training for this system at the start of the rotation.
Correctly entered orders must include type of diet (or NPO), investigations (laboratory and radiographic), IV fluids, acute treatments (including analgesia), as well as the patient’s usual medications. Be very careful to obtain an up-to-date and accurate list of the usual medications and doses (you may need to contact the patient’s pharmacy to do this) and consider the possibility of drug interactions when you prescribe anything new. Some of the usual medications may need to be put “on hold” while in the ED (e.g. if the patient is dehydrated, their diuretic might need to be held).
Radiographic test requests must be accompanied by a brief history and a specific question. This has been shown to increase the accuracy of the radiologist’s interpretation. It is also important to record your own interpretation (on the Inteleviewer system) so that the radiologist will know to alert us when we miss an important finding.
In minor care, you must indicate whether the patient may return to the waiting room pending results (preferred, as this frees up space) or if they should be left on a stretcher in the hallway. Always consider whether the patient requires isolation – most such cases will be picked up by the triage nurse, but this is not guaranteed.
Out-patient prescriptions, like all orders, must be clearly legible, dated, signed and the MD’s name must be written clearly with their licence number. Also remember that a properly written prescription includes the name of the medication, dose, route of administration, frequency, AND DURATION. Also indicate the number of refills (write “no refill” if none). We get many calls from pharmacies regarding illegible or incomplete outpatient prescriptions so please be vigilant.
Consultations in the Emergency Department
Consulting other services should only be done after the case has been discussed with the staff emergency physician you are working with. An appropriately filled out consult request includes a brief summary of the problem and a precise question or specific request. Consults are entered into MedUrge, then the unit coordinator will page the service and read your consult over the phone. The consultant may need to speak to you if they have questions, usually concerning the urgency of the consult. “STAT” consults should always be discussed over the phone.
Internal Medicine
Internal Medicine provides a consult service that is based in the ED. The IM attending staff is known as “the gatekeeper”. The gatekeeper works from 08h00 to 18h00. A second year internal medicine resident covers the service from 21h00-08h00 most nights. The gatekeepers are responsible for all internal medicine consults and ongoing care for patients awaiting a bed on one of the medical wards. However, as long as the patient is in the ED, the emergency physician shares some responsibility for their care and should periodically reassess these patients as well.
Psychiatry
There is a six-bed unit located between the acute and minor care areas. The unit is staffed from 9h00 to 23h00 by an attending psychiatrist and a resident. There is also a psychiatric nurse on duty from 8h00 to 23h00; overnight there is a nurse or PCA. Patients who are currently being followed by the Allan Memorial Psychiatric staff or resident clinics might be directly seen by psychiatry when they arrive in the ED with a psychiatric complaint. Psychiatric care on the island of Montreal is sectorized by postal code. If a patient requires a non-urgent psychiatric referral, the psychiatric nurse can help you arrange for this in the appropriate sector hospital.
Often the ED physician will be asked to see a psychiatric patient for “medical clearance”. This is a term to be avoided, as it implies that it is possible for the EP to exclude all possible medical problems in the patient. Rather, the role of the EP is to assess whether there is a current active medical condition that requires stabilization or treatment, either before or during a psychiatric admission. Most of the time, this can be accomplished with a well-done history and physical exam. Laboratory tests should be guided by these findings, and often may not be necessary at all.
Orthopedics
There is no orthopedic consult service at the RVH (orthopedics is based at the MGH). However, patients with orthopedic problems still present to the RVH ED and are evaluated and treated by the emergency physician. Patients requiring admission or urgent orthopedic consultation are transferred to the MGH after discussing with the orthopedic service. For the others a consult must be filled out to the attention of Dr Berry, and will be faxed to his office at the MGH by the unit coordinator. The consults will be triaged, and the patient will be called for their appointment. Make sure the patient’s correct phone number is on the consult.
Obstetrics and Gynecology
Obstetrics and Gynecology patients are assessed in the ED and consultation is made as needed. Pregnant patients past 20 weeks gestation go directly to the Case Room for evaluation unless they have a problem unrelated to their pregnancy. The Case Room may send them back to the ED for further assessment if no obstetrical cause is deemed to be present. A Case Room nurse is available to assist in fetal monitoring in the ED. Remember that after 12 weeks of gestation, the fetal heart rate is an essential vital sign; the obstetrical doppler is located in the minor care clean utility room. All pregnant patients with vaginal bleeding must have a type and screen done unless they are on record in the RVH blood bank or have a blood donor card that proves they are Rh positive. All pregnant patients with vaginal bleeding and who are Rh negative must receive Rho (D) immune globulin (RhoGAM).
Geriatrics
A geriatric liaison nurse is based in the department Monday to Friday 7:30 to 15:30 and will assess patients over the age of 65 if requested. If a patient requires a geriatric admission or urgent consultation he/she will arrange for the geriatrician on call to see the patient. He/she can also be of invaluable help to link with community services such as CLSC or Nursing Home to arrange disposition of elderly patient. On weekends, geriatrics consults are handled by the internal medicine gatekeeper.
Social services
A team of social workers have their office in the back of minor care. They are available to help the treating team in solving psychosocial issues such as helping someone find a place to stay, finding money to pay for medications, or providing grief counseling. They will see patients of all ages.
Unit coordinators
There is one unit coordinator in each of the acute, minor, and transitional care areas (except overnight, when there is only one UC on duty for the department). They are responsible for paging consultants, ordering tests and handling all results coming in the ED. Ask the UC to page a consultant for you rather than doing it yourself – this frees you to walk away from the phone and see another patient while you are waiting for the consultant to respond.
Patient Care Attendants
PCAs are resource people working in the ED. They can help with a lot of situations including “code white” (for aggressive or agitated patients), getting patients dressed or undressed, helping with gait assessments, or taking patients to the bathroom.
Transfers to and from other Hospitals
Oftentimes patients are brought by ambulance to our hospital even though they are followed elsewhere by a specialist or have been recently admitted to another institution. When this happens we are responsible to stabilize the patient, investigate their chief complaint, and initiate treatment. If an admission is deemed necessary, a request for “appartenance” to the other institution is faxed. Appartenance must be accepted if the patient has been followed regularly by a specialist in the last year or has been admitted in the past six months (visits to the ED without admission do not count). Sometimes patients who do not meet these criteria are accepted by a specialty service, in which case the patient must be admitted to that service upon arrival (if the transfer is deemed urgent, the patient may be cared for in the emergency department until a bed is available).
Patient Satisfaction
Patients and their families often are not sure what to expect from their visit to the ED, or may have unrealistic expectations regarding timeliness of investigations and treatment, desire for urgent specialty consultation when this is not indicated, and so on. It is important to learn what these expectations are so that they can be directly addressed, which will improve satisfaction.
Always make sure the patient understands your role in the department and knows that you will be discussing their case with the physician in charge. It is important to give patients an idea of how long they will wait for things to happen, but you should always overestimate these times (note that the average length of stay in our department is 20 hours). It would not be unusual, for example, for a CT scan ordered at 9h00 to be done only at 18h00.
The key to patient satisfaction is good communication. In addition to managing expectations, this also includes giving them the opportunity to ask questions, and providing clear discharge instructions and plans for follow. Note that attaching a specific diagnosis to the patient’s chief complaint is often not possible in the ED. In such cases, it is important to explain that serious diagnoses have been excluded, that symptoms will be managed with (treatment x), and that follow-up is in place in case the symptoms do not resolve.
Never discharge a patient without first discussing with the attending in charge. In almost all cases, the attending will see the patient with you before he or she leaves.
Dress Code
It is recommended to wear scrubs in the emergency department. If you choose to wear street clothes, please dress comfortably but professionally. Use your judgment, but in general this means no jeans, no midriff-baring t-shirts, and no open-toe sandals. Do not, however, wear a tie. Ties are fomites for disease transmission and also serve as a noose when a psychotic patient has decided to strangle you. Wear a clean lab coat over your clothes. Please refer to the MUHC dress code policy. NEVER wear scrubs outside of the hospital.
Well-being in the Emergency Department
The emergency department is a hectic environment with a fast pace of work. The demands of shiftwork, the acuity of illness, the volume of patients and overcrowding, dealing with difficult or even violent patients, the noise, and the constant interruptions all contribute to a high-stress workplace. Finding ways to cope with these challenges is essential to prevent burnout.
We do our best to schedule your shifts in a clockwise rotation (a day shift is never scheduled after an evening shift) and to avoid “clumping” of shifts. Meeting the exact needs of every resident is not always possible; at times you may have an E shift followed by a C shift (but never an A shift) or you may face up to 6 shifts in a row.
The schedule may not be under your control, but other factors are. Regular exercise, good nutrition (minimizing caffeine and alcohol intake), and adequate sleep is the typical formula for managing stress. During a shift, be sure to drink plenty of water and take a short break to eat halfway through. Consider bringing your own food: it saves time and is usually better for you (and tastier) than what you can buy in the cafeteria. On night shifts, don’t forget that you will need to eat “lunch” somewhere around 3 am.
Occasionally, conflicts with attendings or nursing/paramedical staff can lead to additional stress. Most of these situations can be avoided by treating our colleagues with respect and acknowledging their skills and expertise. However, should problems arise that you are not easily able to resolve on your own, please feel free to bring these up with your attending or the residency education coordinators.
Oh yes, and one final thought: PLEASE WASH YOUR HANDS!
Take care of yourself, and contact us if you have any problems during the rotation.
Christine Meyers
Residency Education Coordinator
[1] To learn more about presenting your cases efficiently, please refer to: Davenport C, et al. The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme. ACADEMIC EMERGENCY MEDICINE 2008; 15:683–687