Emergency Department
Goals and Objectives
The goal of the MGH Emergency Department rotation is to develop the ability of residents to triage, evaluate and manage children with a broad range of medical and surgical problems with varying levels of acuity. The rotation is based in an urban referral pediatric emergency department designated as a level I pediatric trauma center. Patients will include those aged birth to 19 years who live in the area, as well as those referred to this tertiary care hospital emergency department for higher levels of care. First, second and third year residents will all participate in this rotation. The residents will work closely with other team members, including other pediatric residents, emergency room attendings, subspecialists, nurses and support staff to triage and care for patients who present to the pediatric emergency room. The objectives of this rotation are designed to further the residents’ development of competency in the following six areas:
I. Patient Care
II. Medical Knowledge
III. Practice-Based Learning and Improvement
IV. Interpersonal and Communication Skills
V. Professionalism
VI. Systems-Based Practice
I. Patient Care
Residents will take an active role in triage and the rapid assessment of urgent patients.
They will work closely with a multidisciplinary team led by surgical and emergency department staff in the immediate stabilization of a child with multiple trauma.
Residents will care for patients from the time of admission to the ED until discharge or admission to the intensive care unit or pediatric ward.
Residents will perform a problem-focused history and physical for each patient. After evaluating the patient, they will formulate a differential diagnosis and plan appropriate diagnostic and therapeutic interventions, in consultation with the emergency department attending.
Through thoughtful review of diagnostic results and reassessment of the patient during treatment, residents will determine need for admission or readiness for discharge to home.
At all times, it is the residents’ responsibility to educate and work with the patient and family, maintaining a strong therapeutic alliance.
As medically indicated, residents will perform appropriate diagnostic and therapeutic procedures after obtaining informed consent from the patient and/or family. Residents will document procedures in the chart and in their personal logbooks. On this rotation, these may include:
- arterial puncture
- bladder catheterization / suprapubic aspiration
- burn debridement
- endotracheal intubation
- intraosseous line placement
- intravenous catheter placement
- laceration repair/wound management
- lumbar puncture
- nasal wash
- nasogastric tube placement
- procedural sedation and pain management
- suturing and wound care
- splinting/casting joints
- venipuncture
During this rotation, residents are expected to further develop their proficiency in the following areas related to the acute care of children:
- cardiopulmonary resuscitation
- initial evaluation and resuscitation of critically ill patients
- management of shock
II. Medical Knowledge
Residents will draw from the wide range of medical and surgical problems requiring treatment in a referral pediatric emergency and trauma department in order to broaden their understanding of the presentation of complex disease processes. In developing a differential diagnosis, the resident will demonstrate his ability to apply analytical thinking to the clinical situation.
The patient population at this city-based referral center includes patients with general pediatric medical and surgical problems, as well as those with complex, rare, or multi-organ system disease or trauma.
During this rotation, it is expected that residents will manage patients diagnosed with, but not limited to:
- Burns
- Cardiac arrest
- Dehydration/Electrolyte disturbances
- Fever
- Fractures
- Respiratory distress/Respiratory failure
- Seizures
- Sepsis
- Suicidal ideation/attempts
- Toxic Ingestions/Poisonings
- Trauma (including MVA, spinal cord injury, intentional, self-inflicted)
III. Practice-Based Learning and Improvement
In caring for patients, residents will utilize a broad range of published medical information readily available through web-based resources. It is expected that decisions about patient care will be evidence-based.
Residents will review cases seen overnight under the supervision of the ED attending, with the pediatric ED attending in the morning.
The medical director of the Pediatric ED reviews the charts of all patients who return for care within 72 hours of discharge. The management of individual cases is then reviewed with providers, including the resident, to assess areas where improved care might have led to another outcome.
All residents will take an active role teaching third year Harvard and visiting medical students rotating through the emergency department.
IV. Interpersonal and Communication Skills
Residents will work closely with emergency department, radiology, surgery and subspecialty attendings, as well as emergency department nurses, social workers, orthopedic technicians, and support staff.
Residents will document the patient’s care in the ED chart which will become part of the patient’s permanent medical record.
Residents will communicate with primary care physicians about their patients at the time of referral to the ED, as well as at the time of discharge or admission to the hospital.
Residents will provide feedback to students and attendings on an ongoing basis throughout the rotation, completing written evaluations at the completion of the rotation. Similarly, they will receive regular verbal feedback and a final written evaluation from the attending staff that will be placed in their permanent record. Residents will use constructive feedback to guide their efforts in ongoing learning and self-improvement.
V. Professionalism
Residents will interact with an extremely ethnically and socio-economically varied patient population that is treated in this busy referral emergency department. Patients will include those living in local communities, as well as those referred or transferred to MGH because of acuity or complexity of illness.
Patients will be cared for independent of their ability to pay for services.
Residents will provide compassionate, empathic and culturally sensitive communication with parents. They will be particularly sensitive to the unique situation of parents of critically ill children. They will demonstrate sensitivity and responsiveness at all times to patient and parent culture, gender, sexual orientation and disabilities.
Maintenance of patient confidentiality will be of highest priority.
Residents will at all times demonstrate ethical and professional behavior. During this rotation, in particular, residents will deal with families struggling with issues around uncertainty of diagnosis and prognosis, as well as life-threatening illness.
Residents will obtain informed consent for procedures and interventions.
VI. Systems-Based Practice
Residents are expected to provide high quality, but cost-effective health care.
Follow-up care will be facilitated by the residents, including referral for community services when appropriate.
Residents will utilize the Cambridge Health Alliance asthma registry for all patients treated in the CHA who present to the ED with asthma symptoms. This database is designed to maximize therapy for patients with asthma, providing updated visit and medication histories.
Residents work with the Massachussets Sexual Assault Nurse Examiner (SANE) program in evaluating victims of sexual assault aged 12 and older.
At all times, residents will act in accordance with the legal mandate in the Commonwealth of Massachusetts to report any suspicions of child abuse or neglect, being familiar with the process by which such suspicions are reported. The MGH Child Protection Consultation Team will be a unique resource for residents working in the complex referral atmosphere of this rotation
