Objectives

• Through repeated clinical exposure, the student will refine and demonstrate the skills necessary to provide for the efficient and safe evaluation/management of patients presenting to the emergency department with a wide spectrum of patient-declared emergencies. Use of a daily, formative feedback process between preceptors and students will assist in this process.
  
  
• Through teaching rounds, clinical exposure and independent use of selected learning resources, the student will obtain and demonstrate a knowledge of common medical and surgical emergencies, including their epidemiology, pathophysiology, clinical features, investigation and management (see specific cognitive objectives).
  
  
• The student will demonstrate, through his/her daily work, an ability to interact with patients, their families and other health care providers in a professional, compassionate and efficient manner.
  
  
• Through clinical experience and specific hands-on teaching sessions, the student will develop and demonstrate an ability to perform a variety of medical and surgical procedures appropriate to the practice of emergency medicine (see specific procedural objectives).
  
  
• Students will develop, through clinical experience, an appreciation of the physical, social and economic issues that are to be considered in determining appropriate patient treatment and disposition. Students must demonstrate clinically an ability to make good economic use of available hospital and community services.
  
  
• Clinical exposure and independent use of learning resources will allow the student to develop and demonstrate the ability to interpret emergency laboratory reports, particularly plain radiographs, electrocardiograms and arterial blood gases.
  
  
• Specific exposure to the roles of the emergency department discharge planning nurse, social worker and psychiatric assessment team will allow the student to understand their function in patient assessment, care and disposition.

Approach to Symptom-Based Diagnosis

The student must demonstrate an ability to address the following general complaints in terms of appropriate emergency department evaluation, investigation, management and disposition:

1. Chest pain
2. Shortness of breath
3. Abdominal pain
4. Depressed or altered level of consciousness/coma
5. Syncope
6. Fever of unknown origin (various age groups)
7. New-onset headache
8. Trauma
9. Poisoned or intoxicated patient
10. Domestic violence
11. Vaginal bleeding - pregnant or non-pregnant patient

The student must demonstrate a knowledge and understanding of the pathophysiology, clinical features, diagnosis, management and disposition of the following systemic emergencies:

1. Cardiovascular
   
   
   1. Acute ischemic heart disease, including unstable angina and acute myocardial infarction. In particular, this must include an ability to interpret patterns of ischemia and infarction on EKG, an understanding of the utility of laboratory investigation in the emergency diagnosis of IHD, and a working knowledge of the emergency management of acute infarction.
   2. Acute ischemic heart disease, including unstable angina and acute myocardial infarction. In particular, this must include an ability to interpret.
   3. Acute congestive heart failure, including its common precipitants, emergency management and criteria used for determining disposition.
   4. Common cardiac dysrhythmias, including acute atrial fibrillation, paroxysmal atrial tachycardia, complete heart block, ventricular fibrillation and ventricular tachycardia.
   5. (e) Deep venous thrombosis and pulmonary embolism.
   
   
2. Respiratory
   
   
   1. Acute exacerbations of asthma and COPD, emphasizing emergency management and the criteria used in determining disposition (including bedside spirometry).
   2. Community-acquired pneumonia
   3. Anaphylaxis and upper airway obstruction
   4. Spontaneous pneumothorax
   
   
3. Gastrointestinal
   
   
   1. Acute upper and lower GI bleeding
   2. Biliary colic, cholecystitis, ascending cholangitis, pancreatitis
   3. Acute diarrhea with an emphasis on differential diagnosis and infectious etiologies
   
   
4. Genitourinary
   
   
   1. Urinary tract infection - upper and lower
   2. Renal colic, including interpretation of intravenous urogram
   3. Testicular pain and/or swelling
   4. Sexually-transmitted disease
   5. Pelvic inflammatory disease
   
   
5. Musculoskeletal
   
   
   1. Minor extremity trauma, including fractures and dislocations of digits, ankle sprains, minor ankle fractures, soft tissue injuries of the knee, Colles fractures, boxer's fractures, radial head fractures, shoulder dislocations, humeral neck fractures
   2. Acute monarticular arthritis
   3. Acute lower back pain, emphasizing routine management. Students must be able to recognize more ominous patterns of disease, including cord compression, cauda equina syndrome.
   4. Cervical spine injuries
   
   
6. Toxicology
   
   
   1. Acute stabilization, decontamination, recognition of the common toxidromes
   2. Specific overdose management, including salicylates, acetaminophen, tricyclic antidepressants and sedative hypnotics
   
   
7. Neurology
   
   
   1. Migraine headache, including relevant pharmacology and emergency treatment options
   2. Common stroke syndromes
   3. New onset and established seizure disorders
   
   
8. Environmental Emergencies
   
   
   1. Hypo- and hyperthermia
   2. Electrical injury
   3. Smoke inhalation and CO intoxication
   4. Thermal burns - emphasis on outpatient management
   
   
9. Pediatric Emergencies
   
   
   1. Fever of unknown origin - approach by age group
   2. Pediatric asthma
   3. Croup and epiglottitis
   4. Vomiting and diarrhea - including rehydration therapy
   5. Common upper respiratory infections - otitis media, pharyngitis

The student is expected to have an organized approach to interpreting the following laboratory investigations and be able to identify common and critical abnormalities:

1. Plain chest and abdominal radiographs
2. Radiographs of the axial skeleton and extremities
3. Electrocardiogram
4. Dipstick and microscopic urinalysis
5. Arterial blood gases
6. Serum electrolytes, including specific abnormalities such as hyper/hypokalemia, hyper/hypoatremia and the anion gap.
7. Complete blood count

The possible range of different procedures encountered in the emergency department is extensive. The following procedures have been categorized as essential, desirable or optional to the emergency department experience of a clinical clerk.

Essential skills are skills fundamental to the practice of emergency medicine, which occur with sufficient frequency that all clerks might reasonably expect to practice them during a one-month rotation. Desirable skills may also be considered fundamental skills and should be practiced, if possible. However, all students may not encounter these skills during the rotation. All clerks must demonstrate a proficiency in the performance of all the essential skills during the rotation. Some skills, if not encountered clinically, may be reviewed as demonstrations and simulations (marked with *).

Where appropriate, students should be introduced to the concept of "painless procedures" through the use of local anaesthetic agents and conscious sedation.