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Objectives to direct the training of emergency medicine residents on off-service rotations: Surgery, part 3
The Journal of EmergencyMedicine, Vol 14, No 1, pp 99- 104, 1996 Copyright 8 1996 Elsevier ScienceInc. Printed in the USA. All rights resewed 0736-4679/96 $15.00 + 90
ELSEVIER
SSDI 0736-4679(95) 02050-o
Education
OBJECTIVES TO DIRECT THE TRAINING OF EMERGENCY RESIDENTS ON OFF-SERVICE ROTATIONS: SURGERY, Mary Jo Wagner, MD, FACEP,* Major John M. Wightman, MD, and Glenn C. Hamilton, MD, MSM, FACEM, FAcPt
MEDICINE PART 3
MA, FAcEP,t
*Department of Emergency Medicine, Saginaw Cooperative Hospitals, Inc., Saginaw, Michigan tDepartment of Emergency Medicine, Wright State University School of Medicine, Dayton, Ohio Reprint Address: Glenn C. Hamilton, MD, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401-0927
0 Abstract-This is the 36th and final article in a series of objectives to direct emergency medicine resident experienceson off-service rotations. An understanding of the principles of surgical diagnosis and treatment is an essential component of the practice of emergency medicine. Emergency medicine residents rotating on surgical services require specific objectives to maxbnize their learning potential, emphash early patient assessment,identify the possible need for surgery, and gain a basic understand& of definitive management. This article approaches surgical problems from the presenting complaint. It concludes with procedures not covered in the goals and objectives for traumatology.
is on presenting symptoms that may require surgical intervention. Procedures commonly performed on a general surgery rotation are also addressed. Utilization of these goals and objectives will allow both resident and preceptor to identify those learning opportunities and experiences which would best prepare the future emergency physician. Increasing the knowledge of rotating emergency medicine residents in fundamental surgical principles can improve and maintain the important patient care-based relationship between emergency medicine and general surgery.
Cl KeywoMucation; medical; graduate; emergency medicine; objectives; residency; surgery
CONTENTS The numbering system in this article corresponds to topics found in the Core Content for Emergency Medicine (1).
INTRODUCTION
22.0 Presentations and Symptoms 22.1.28 Hypotension 22.1.32 Poisoning 22.1.38 Shock 22.1.45 Weight loss 22.3.4 Hemoptysis
This is the 36th and final article in a series of goals and objectives published beginning in 1989. These objectives can enhance the learning process of residents on offservice rotations. It is the third of three parts covering essential aspects of surgical practice that may be applied in the emergency department (ED). The primary focus
Education is coordinated by Mary Ann Illinois, Chicago, Illinois
Cooper,
MD,
99
of Mercy Hospital and Medical Center, the University of
M. J. Wagner et al.
100
22.4.1 Abdominal pain 22.4.8 Abdominal distention 22.4.1 1 Dysphagia 22.4.16 Hematemesis 22.4.17 Hematochezia 22.4.18 Hematuria 22.4.19 Jaundice 22.4.20 Melena 22.4.21 Nausea and Vomiting 22.4.25 Rectal pain 23.3 Diagnostic Procedures 23.3.5 Nasogastric intubation 23.3.8 Portable ultrasound 23.3.9 Proctoscopy and anoscopy 23.4 Genital and Urinary Procedures 23.4.1 Bladder catheterization 23.4.1.1 Foley catheters 23.4.1.2 Suprapubic catheterization 23.6 Hemodynamic Techniques 23.8 Thoracic Procedures 238.5 Thoracostomy 23.9 Other Techniques 23.9.3 Incision and drainage (I&D) 23.9.4 Intestinal tube insertion 23.9.7 Sengstaken-Blakemore tube insertion 23.9.8 Skin grafts 23.9.9 Suture techniques 23.9.11 Wound management and bandaging techniques 23.9.12 Excision of thrombosed hemorrhoids 23.9.13 Foreign body removal
GOALS AND OBJECTIVES 22.0 Presentations and Symptoms 22.1.28 Hypotension 1. Define hypotension. What is the pathophysiology of shock and how is it different from hypotension? 2. What is the amount of blood volume lost needed to cause mild, moderate, and severe hypotension? 3. List four nonpharmaceutical mechanisms to correct hypotension. References: (2) pages 452, 1187-8, 1622, & 1938; (3) pages 37-40; (4) pages 8-13. 22.1.32 Poisoning 1. Aside from patients with intentional overdoses, toxic bezoars are most likely found in what type of patient?
2. What is the best technique to diagnose possible cocaine poisoning due to “body packing”? 3. List two indications for surgical removal of drug filled balloons from the gastrointestinal (GI) tract. References: (2) pages 331-2; (3) page 835; (4) page 240. 22.1.38 Shock 1. List the most sensitive signs of shock found on physical examination. 2. List two of the most accurate noninvasive measurements for monitoring a patient in shock. 3. Name the most accurate invasive measurements useful for monitoring a patient in shock. 4. Compare the presentation, evaluation, and therapeutic differences between traumatic shock, septic shock, neurogenic shock, and cardiogenic shock. 5. Name at least three different pharmaceutical treatments for shock, and explain their mechanisms of action. References: (2) pages 163-72; (3) pages 34-56; (4) pages 8-13. 22.1.45 Weight loss 1. List the two most common causes of surgically related weight loss. 2. What are the results of prolonged undernutrition, and what is their relationship to healing in the surgical patient? 3. What percentage of weight loss of original body weight is significant? What percentage is life-threatening? 4. Total parenteral nutrition is used for patients with significant weight loss. In which patients has this been studied and found to be definitively helpful; probably helpful; possibly helpful? References: (3) pages 128-30; (4) pages 364-72. 22.3.4 Hemoptysis 1. What is the definition of massive hemoptysis, and what are the two basic modalities used to treat it? 2. List the advantages of each bronchoscope (flexible and rigid) for use in the control of massive hemoptysis. 3. What is the most common cause of severe hemoptysis? 4. Hemoptysis is a rare clinical manifestation of aortic dissection. What are the two possible causes of this bleeding?
Objectives-Surgery,
101
Part 3
References: (2) pages 1289-91 & 1386; (3) pages 1699, 1734; (4) pages 627-31. 22.4.1 Abdominal pain 1. Differentiate the neuro-anatomical basis for somatic, visceral, and referred pain. 2. Choose the appropriate findings that define an acute abdomen. 3. Delineate the useful diagnostic information obtainable in the patient with abdominal pain by each of the following : a. Ultrasonography b. Computed tomography c. Nuclear medicine d. Endoscopy 4. List the six most common causesof abdominal pain requiring emergent or urgent surgical intervention. 5. What amount of free air must be present from a perforated viscus to be detected on a plain film of the abdomen? 6. List at least six nonsurgical causes of abdominal pain. 7. List the four most common causes of abdominal pain in patients over 70 years old. 8. List the four most common causes of abdominal pain in patients under 2 years old. References: (2) pages 1498-1514; (3) pages‘736-55; (4) pages 34-42. 22.4.8 Abdominal distention Abdominal distention is a complaint of patients with a bowel obstruction. Distention is present if the obstruction is distal to what point? List the three factors involved in the development of abdominal distention due to ascites. Identify the two principles of surgical management for intractable ascites. Abdominal distention in the postoperative period is often causedby depression of the normal propulsive activity of the GI tract, Select the time period after surgery during which gastric and colonic peristalsis return. References: (3) pages 312-3, 750-2, & 1030-5. 22.4.11 Dysphagia 1. Define dysphagia and differentiate this from odynophagia and globus hystericus. 2. List the three phases of swallowing and name at least three pathologic processesthat may affect each phase.
3. What modalities are used to image or visualize the neck and chest area to diagnose dysphagia? 4. Discuss the surgical treatment of cricopharyngeal and esophageal motor abnormalities. References: (2) pages 1583-8; (3) pages 663-6; (4) pages 83-95. 22.4.16 Hematemesis 1. Identify the two diagnostic procedures of most benefit in determining the presence and site of ongoing upper gastrointestinal (UGI) hemorrhage. 2. Contrast the immediate medical and surgical management of UGI hemorrhage due to PUD and esophageal varices. 3. Select the mortality rate of UGI bleeding and identify three high risk groups of patients. 4. Select the three most common causesof UC1 bleeding. Name at least three other causes of hematemesis. 5. Choose the three types of patients with hematemesis that should be considered for emergent surgical exploration. What percentage of patients with hematemesis require surgical intervention? Name at least four surgical operations used in a patient with an UGI bleed. List the late complications seen after patients have had surgery for an UGI bleed. References: (2) pages 1515-32; (3) pages 770-81; (4) pages 60-7. 22.4.17 Hematochezia 1. Assuming a rapid GI transport time, select the amount of UGI blood necessary to cause red blood to be passed per rectum. 2. List the six most common causesof lower gastrointestinal (LGI) bleeding. 3. Name at least two causesof hematochezia that may require surgical consultation in each age group: neonates, infants (to 1 year old), and children (l- 12 years old). 4. In addition to proctoscopy and anoscopy, name the four diagnostic modalities available in the ED to determine the presence or extent of LGI hemorrhage prior to surgery. 5. List three treatments for persistent LGI bleeding.
M. J. Wagner et al.
102
References: (2) pages 1515, 1519, & 1522-3; (3) pages 912-5; (4) pages 96-104. 22.4.18 Hematuria 1. List the four most common causes of hematuria in the adult population. 2. Name at least six modalities for visualizing or evaluating the urinary tract for hematuria. 3. Identify the surgical procedures used for evaluation and treatment of hematuria. 4. Identify the causes of pseudohematuria (red urine without microscopic evidence of WCs). 5. What are the indications for admission of a patient with hematuria secondary to nephrolithiasis? References: (2) pages 1885, 1899-1911, & 1914-6; (3) pages 1436-8, 1441-2, 1446-7, & 1452-5; (4) pages 673-80. 22.4.19 Jaundice 1. Describe the indications for use of the following diagnostic procedures in a patient with jaundice: a. HIDA (hepatoiminodiacetic acid) scan b. ERCP (endoscopic retrograde cholangiopancreatography ) c. PTHC (percutaneous transhepatic cholangiograNY) 2. List the three laboratory values that are generally abnormal in a jaundiced patient with cholestatic disease. 3. Select three liver disorders that can causejaundice. 4. Name the three types of disorders leading to postoperative jaundice after surgery that do not involve the liver or biliary tract. References: (2) pages 1601-9 & 1611-9; (3) page 314; (4) pages 68-73. 22.4.20 Melena 1. Choose the minimum amount of UGI blood necessary to cause melena. 2. Identify the process that causes the stool to turn melanotic. 3. Write the criteria for admission in a patient with a history of melena but only trace-positive blood in brown stool on presentation. References: (2) pages 1519 & 1527-8; (4) pages 96104.
22.4.21 Nausea and vomiting Identify three therapeutic methods of relieving a patient’s symptoms of nausea and vomiting. The symptoms of nausea and vomiting occur at specific times in patients with different etiologies of abdominal pain. Identify those differences that allow a physician to make a more accurate diagnosis of a patient by this history. List four surgically correctable causes of vomiting in newborns and infants. References: (2) pages 512-3; (3) page 738; (4) pages 74-82. 22.4.25 Rectal pain
1. Select three causes of pain in the anus or rectum that are easily identifiable on rectal examination. 2. Choose the most common treatment modalities for hemorrhoids and rectal fissures. 3. Delineate the difference in history, clinical findings, and treatment between a perianal, ischiorectal, submucosal, supralevator, and ilionidal abscess. 4. Choose the possible treatments for fecal impaction. 5. Name at least three nonsurgical techniques for removal of rectal foreign bodies. In which casesmust these be treated surgically? References: (2) pages 1658-72; (3) pages 962-8: (4) pages 44-51. 23.3 Diagnostic Procedures 23.3.5 Nasogastric intubation 1. List three gastrointestinal disorders in which nasogastric intubation is used routinely as a therapeutic procedure. 2. Identify the common complications of nasogastric intubation. 3. Perform nasogastric intubation on at least three human patients. Reference: (5) pages 640-9. 23.3.8 Portable ultrasound 1. List the three principle findings on ultrasound that are diagnostic of gallbladder disease. 2. Name at least four causesof thickening of the gall bladder wall not associated with cholecystitis. 3. Match the advantages and disadvantages of using ultrasound to diagnose abdominal aortic aneurysms in the emergency department. 4. Select whether unclotted blood (e.g., hemoperitoneum) is echogenic or anechoic on ultrasound.
Objectives-Surgery,
103
Part 3
5. List at least three anatomical locations that might be visualized on ultrasound where free fluid collects in the abdomen. 6. Identify the usual amount of free flowing fluid that is needed in the peritoneal cavity to visualize on ultrasound. 7. Describe the appearance of an inflamed appendix as seen on ultrasound. Reference: (7) pages 41-65, 86-104, & 135-7. 23.3.9 Proctoscopy and anoscopy 1. List the indications and contraindications for anoscopy in the surgical patient. 2. Identify the landmarks seenwhen performing anosCOPY. 3. Perform anoscopy on at least three patients. Reference: (5) pages 696-8.
3. Perform tube thoracostomy on at least one patient for nontraumatic indications. 4. Delineate the steps for chest tube removal and thoracostomy closure. Reference: (5) pages 133-49. 23.9 Other Surgical Techniques 23.9.3 Incision and drainage (I&D) 1. List the indications and contraindications of incision and drainage of a cutaneous abscess. 2. Identify the subsetof patients who should be treated with antibiotics in addition to the I&D of their abscess. 3. Perform an I&D of a cutaneous abscesson at least one patient. Reference: (5) pages 591-6 & 603-10. 23.9.4 Intestinal tube insertion
23.4 Genital and Urinary Procedures 23.4.1 Bladder catheterization 23.4.1.1 Foley catheters 1. List the indications for placement of an indwelling catheter. 2. Prepare the equipment, identify the landmarks, and describe the catheterization of a female patient. 3. Name five difficulties of insertion of a catheter in a male patient. 4. List four techniques to remove a nondeflating balloon. 5. Perform indwelling catheterization on at least two female and two male patients. Reference: (5) pages 867-74. 23.4.1.2 Suprapubic catheterization 1. List the indications and contraindications of suprapubic catheterization. 2. Prepare the equipment, identify the landmarks, and describe the placement of a suprapubic catheter. Reference: (5) pages 875-80. 23.6 Hemodynamic Techniques (see objectives from reference 6-Traumatology) 23.8 Thoracic Procedures 23.8.5 Thoracostomy 1. List the indications of thoracostomy in a nontraumatic patient. 2. Prepare equipment and identify landmarks for tube thoracostomy.
1. List the indications and contraindications for intestinal tube insertion. 2. Prepare the equipment and delineate the steps for replacing a transabdominal feeding tube. Reference: (5) pages 667-72. 23.9.7 Sengstaken-Blakemore tube insertion 1. List the indications and contraindications for use of a Sengstaken-Blakemore tube. 2. Name the three most common complications during the use of a Sengstaken-Blakemore tube. References: (2) page 1526; (5) pages 649-55. 23.9.8 Skin grafts (see objectives from reference 6Traumatology ) 23.9.9 Suture techniques (see objectives from reference 6-Traumatology ) 23.9.11 Bandaging techniques (see objectives from reference 6-Traumatology ) 23.9.12 Excision of thrombosed hemorrhoids 1. List the indications and contraindications of excision of thrombosed hemorrhoids. 2. List the postoperative care for a patient in whom a hemorrhoid has been excised. 3. Prepare the equipment, identify the landmarks, and describe the excision of a thrombosed hemorrhoid. Reference: (5) pages 704-7. 23.9.13 Foreign body removal (see objectives from reference 6-Traumatology)
104
M. J. Wagner et ai.
REFERENCES I. American College of Emergency Physicians, American Board of Emergency Medicine, Society for Academic Emergency Medicine. Core content for emergency medicine. Ann Emerg Med. 1991;20:920-34. 2. Rosen P, Barkin RM, Braen GR, et al., eds. Emergency medicine: concepts and clinical practice, 3rd ed. St Louis: Mosby-Year Book; 1992. *3. Sabiston DC, ed. Textbook of surgery: the biological basis of modem surgical practice, 14th ed. Philadelphia: WB Saunders; 1991.
* Books and article to be included in resident briefcase.
4. Hamilton GC, ed. Presenting signs and symptoms in the emergency department: evaluation and treatment. Baltimore: Williams & Wilkins; 1993. *5. Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine, 2nd ed. Philadelphia: Saunders; 1991. *6. Wightman JM, Hamilton GC. Objectives to direct the training of emergency medicine residents on off-service rotations: Traumatology, Part 3. .I Emerg Med. 199.5;13:407- 14. *7. Heller M, Jehle D. Ultrasound in emergency medicine. Philadelphia: WB Saunders; 1995.
ELSEVIER
SSDI 0736-4679(95) 02050-o
Education
OBJECTIVES TO DIRECT THE TRAINING OF EMERGENCY RESIDENTS ON OFF-SERVICE ROTATIONS: SURGERY, Mary Jo Wagner, MD, FACEP,* Major John M. Wightman, MD, and Glenn C. Hamilton, MD, MSM, FACEM, FAcPt
MEDICINE PART 3
MA, FAcEP,t
*Department of Emergency Medicine, Saginaw Cooperative Hospitals, Inc., Saginaw, Michigan tDepartment of Emergency Medicine, Wright State University School of Medicine, Dayton, Ohio Reprint Address: Glenn C. Hamilton, MD, Department of Emergency Medicine, Wright State University School of Medicine, Post Office Box 927, Dayton, OH 45401-0927
0 Abstract-This is the 36th and final article in a series of objectives to direct emergency medicine resident experienceson off-service rotations. An understanding of the principles of surgical diagnosis and treatment is an essential component of the practice of emergency medicine. Emergency medicine residents rotating on surgical services require specific objectives to maxbnize their learning potential, emphash early patient assessment,identify the possible need for surgery, and gain a basic understand& of definitive management. This article approaches surgical problems from the presenting complaint. It concludes with procedures not covered in the goals and objectives for traumatology.
is on presenting symptoms that may require surgical intervention. Procedures commonly performed on a general surgery rotation are also addressed. Utilization of these goals and objectives will allow both resident and preceptor to identify those learning opportunities and experiences which would best prepare the future emergency physician. Increasing the knowledge of rotating emergency medicine residents in fundamental surgical principles can improve and maintain the important patient care-based relationship between emergency medicine and general surgery.
Cl KeywoMucation; medical; graduate; emergency medicine; objectives; residency; surgery
CONTENTS The numbering system in this article corresponds to topics found in the Core Content for Emergency Medicine (1).
INTRODUCTION
22.0 Presentations and Symptoms 22.1.28 Hypotension 22.1.32 Poisoning 22.1.38 Shock 22.1.45 Weight loss 22.3.4 Hemoptysis
This is the 36th and final article in a series of goals and objectives published beginning in 1989. These objectives can enhance the learning process of residents on offservice rotations. It is the third of three parts covering essential aspects of surgical practice that may be applied in the emergency department (ED). The primary focus
Education is coordinated by Mary Ann Illinois, Chicago, Illinois
Cooper,
MD,
99
of Mercy Hospital and Medical Center, the University of
M. J. Wagner et al.
100
22.4.1 Abdominal pain 22.4.8 Abdominal distention 22.4.1 1 Dysphagia 22.4.16 Hematemesis 22.4.17 Hematochezia 22.4.18 Hematuria 22.4.19 Jaundice 22.4.20 Melena 22.4.21 Nausea and Vomiting 22.4.25 Rectal pain 23.3 Diagnostic Procedures 23.3.5 Nasogastric intubation 23.3.8 Portable ultrasound 23.3.9 Proctoscopy and anoscopy 23.4 Genital and Urinary Procedures 23.4.1 Bladder catheterization 23.4.1.1 Foley catheters 23.4.1.2 Suprapubic catheterization 23.6 Hemodynamic Techniques 23.8 Thoracic Procedures 238.5 Thoracostomy 23.9 Other Techniques 23.9.3 Incision and drainage (I&D) 23.9.4 Intestinal tube insertion 23.9.7 Sengstaken-Blakemore tube insertion 23.9.8 Skin grafts 23.9.9 Suture techniques 23.9.11 Wound management and bandaging techniques 23.9.12 Excision of thrombosed hemorrhoids 23.9.13 Foreign body removal
GOALS AND OBJECTIVES 22.0 Presentations and Symptoms 22.1.28 Hypotension 1. Define hypotension. What is the pathophysiology of shock and how is it different from hypotension? 2. What is the amount of blood volume lost needed to cause mild, moderate, and severe hypotension? 3. List four nonpharmaceutical mechanisms to correct hypotension. References: (2) pages 452, 1187-8, 1622, & 1938; (3) pages 37-40; (4) pages 8-13. 22.1.32 Poisoning 1. Aside from patients with intentional overdoses, toxic bezoars are most likely found in what type of patient?
2. What is the best technique to diagnose possible cocaine poisoning due to “body packing”? 3. List two indications for surgical removal of drug filled balloons from the gastrointestinal (GI) tract. References: (2) pages 331-2; (3) page 835; (4) page 240. 22.1.38 Shock 1. List the most sensitive signs of shock found on physical examination. 2. List two of the most accurate noninvasive measurements for monitoring a patient in shock. 3. Name the most accurate invasive measurements useful for monitoring a patient in shock. 4. Compare the presentation, evaluation, and therapeutic differences between traumatic shock, septic shock, neurogenic shock, and cardiogenic shock. 5. Name at least three different pharmaceutical treatments for shock, and explain their mechanisms of action. References: (2) pages 163-72; (3) pages 34-56; (4) pages 8-13. 22.1.45 Weight loss 1. List the two most common causes of surgically related weight loss. 2. What are the results of prolonged undernutrition, and what is their relationship to healing in the surgical patient? 3. What percentage of weight loss of original body weight is significant? What percentage is life-threatening? 4. Total parenteral nutrition is used for patients with significant weight loss. In which patients has this been studied and found to be definitively helpful; probably helpful; possibly helpful? References: (3) pages 128-30; (4) pages 364-72. 22.3.4 Hemoptysis 1. What is the definition of massive hemoptysis, and what are the two basic modalities used to treat it? 2. List the advantages of each bronchoscope (flexible and rigid) for use in the control of massive hemoptysis. 3. What is the most common cause of severe hemoptysis? 4. Hemoptysis is a rare clinical manifestation of aortic dissection. What are the two possible causes of this bleeding?
Objectives-Surgery,
101
Part 3
References: (2) pages 1289-91 & 1386; (3) pages 1699, 1734; (4) pages 627-31. 22.4.1 Abdominal pain 1. Differentiate the neuro-anatomical basis for somatic, visceral, and referred pain. 2. Choose the appropriate findings that define an acute abdomen. 3. Delineate the useful diagnostic information obtainable in the patient with abdominal pain by each of the following : a. Ultrasonography b. Computed tomography c. Nuclear medicine d. Endoscopy 4. List the six most common causesof abdominal pain requiring emergent or urgent surgical intervention. 5. What amount of free air must be present from a perforated viscus to be detected on a plain film of the abdomen? 6. List at least six nonsurgical causes of abdominal pain. 7. List the four most common causes of abdominal pain in patients over 70 years old. 8. List the four most common causes of abdominal pain in patients under 2 years old. References: (2) pages 1498-1514; (3) pages‘736-55; (4) pages 34-42. 22.4.8 Abdominal distention Abdominal distention is a complaint of patients with a bowel obstruction. Distention is present if the obstruction is distal to what point? List the three factors involved in the development of abdominal distention due to ascites. Identify the two principles of surgical management for intractable ascites. Abdominal distention in the postoperative period is often causedby depression of the normal propulsive activity of the GI tract, Select the time period after surgery during which gastric and colonic peristalsis return. References: (3) pages 312-3, 750-2, & 1030-5. 22.4.11 Dysphagia 1. Define dysphagia and differentiate this from odynophagia and globus hystericus. 2. List the three phases of swallowing and name at least three pathologic processesthat may affect each phase.
3. What modalities are used to image or visualize the neck and chest area to diagnose dysphagia? 4. Discuss the surgical treatment of cricopharyngeal and esophageal motor abnormalities. References: (2) pages 1583-8; (3) pages 663-6; (4) pages 83-95. 22.4.16 Hematemesis 1. Identify the two diagnostic procedures of most benefit in determining the presence and site of ongoing upper gastrointestinal (UGI) hemorrhage. 2. Contrast the immediate medical and surgical management of UGI hemorrhage due to PUD and esophageal varices. 3. Select the mortality rate of UGI bleeding and identify three high risk groups of patients. 4. Select the three most common causesof UC1 bleeding. Name at least three other causes of hematemesis. 5. Choose the three types of patients with hematemesis that should be considered for emergent surgical exploration. What percentage of patients with hematemesis require surgical intervention? Name at least four surgical operations used in a patient with an UGI bleed. List the late complications seen after patients have had surgery for an UGI bleed. References: (2) pages 1515-32; (3) pages 770-81; (4) pages 60-7. 22.4.17 Hematochezia 1. Assuming a rapid GI transport time, select the amount of UGI blood necessary to cause red blood to be passed per rectum. 2. List the six most common causesof lower gastrointestinal (LGI) bleeding. 3. Name at least two causesof hematochezia that may require surgical consultation in each age group: neonates, infants (to 1 year old), and children (l- 12 years old). 4. In addition to proctoscopy and anoscopy, name the four diagnostic modalities available in the ED to determine the presence or extent of LGI hemorrhage prior to surgery. 5. List three treatments for persistent LGI bleeding.
M. J. Wagner et al.
102
References: (2) pages 1515, 1519, & 1522-3; (3) pages 912-5; (4) pages 96-104. 22.4.18 Hematuria 1. List the four most common causes of hematuria in the adult population. 2. Name at least six modalities for visualizing or evaluating the urinary tract for hematuria. 3. Identify the surgical procedures used for evaluation and treatment of hematuria. 4. Identify the causes of pseudohematuria (red urine without microscopic evidence of WCs). 5. What are the indications for admission of a patient with hematuria secondary to nephrolithiasis? References: (2) pages 1885, 1899-1911, & 1914-6; (3) pages 1436-8, 1441-2, 1446-7, & 1452-5; (4) pages 673-80. 22.4.19 Jaundice 1. Describe the indications for use of the following diagnostic procedures in a patient with jaundice: a. HIDA (hepatoiminodiacetic acid) scan b. ERCP (endoscopic retrograde cholangiopancreatography ) c. PTHC (percutaneous transhepatic cholangiograNY) 2. List the three laboratory values that are generally abnormal in a jaundiced patient with cholestatic disease. 3. Select three liver disorders that can causejaundice. 4. Name the three types of disorders leading to postoperative jaundice after surgery that do not involve the liver or biliary tract. References: (2) pages 1601-9 & 1611-9; (3) page 314; (4) pages 68-73. 22.4.20 Melena 1. Choose the minimum amount of UGI blood necessary to cause melena. 2. Identify the process that causes the stool to turn melanotic. 3. Write the criteria for admission in a patient with a history of melena but only trace-positive blood in brown stool on presentation. References: (2) pages 1519 & 1527-8; (4) pages 96104.
22.4.21 Nausea and vomiting Identify three therapeutic methods of relieving a patient’s symptoms of nausea and vomiting. The symptoms of nausea and vomiting occur at specific times in patients with different etiologies of abdominal pain. Identify those differences that allow a physician to make a more accurate diagnosis of a patient by this history. List four surgically correctable causes of vomiting in newborns and infants. References: (2) pages 512-3; (3) page 738; (4) pages 74-82. 22.4.25 Rectal pain
1. Select three causes of pain in the anus or rectum that are easily identifiable on rectal examination. 2. Choose the most common treatment modalities for hemorrhoids and rectal fissures. 3. Delineate the difference in history, clinical findings, and treatment between a perianal, ischiorectal, submucosal, supralevator, and ilionidal abscess. 4. Choose the possible treatments for fecal impaction. 5. Name at least three nonsurgical techniques for removal of rectal foreign bodies. In which casesmust these be treated surgically? References: (2) pages 1658-72; (3) pages 962-8: (4) pages 44-51. 23.3 Diagnostic Procedures 23.3.5 Nasogastric intubation 1. List three gastrointestinal disorders in which nasogastric intubation is used routinely as a therapeutic procedure. 2. Identify the common complications of nasogastric intubation. 3. Perform nasogastric intubation on at least three human patients. Reference: (5) pages 640-9. 23.3.8 Portable ultrasound 1. List the three principle findings on ultrasound that are diagnostic of gallbladder disease. 2. Name at least four causesof thickening of the gall bladder wall not associated with cholecystitis. 3. Match the advantages and disadvantages of using ultrasound to diagnose abdominal aortic aneurysms in the emergency department. 4. Select whether unclotted blood (e.g., hemoperitoneum) is echogenic or anechoic on ultrasound.
Objectives-Surgery,
103
Part 3
5. List at least three anatomical locations that might be visualized on ultrasound where free fluid collects in the abdomen. 6. Identify the usual amount of free flowing fluid that is needed in the peritoneal cavity to visualize on ultrasound. 7. Describe the appearance of an inflamed appendix as seen on ultrasound. Reference: (7) pages 41-65, 86-104, & 135-7. 23.3.9 Proctoscopy and anoscopy 1. List the indications and contraindications for anoscopy in the surgical patient. 2. Identify the landmarks seenwhen performing anosCOPY. 3. Perform anoscopy on at least three patients. Reference: (5) pages 696-8.
3. Perform tube thoracostomy on at least one patient for nontraumatic indications. 4. Delineate the steps for chest tube removal and thoracostomy closure. Reference: (5) pages 133-49. 23.9 Other Surgical Techniques 23.9.3 Incision and drainage (I&D) 1. List the indications and contraindications of incision and drainage of a cutaneous abscess. 2. Identify the subsetof patients who should be treated with antibiotics in addition to the I&D of their abscess. 3. Perform an I&D of a cutaneous abscesson at least one patient. Reference: (5) pages 591-6 & 603-10. 23.9.4 Intestinal tube insertion
23.4 Genital and Urinary Procedures 23.4.1 Bladder catheterization 23.4.1.1 Foley catheters 1. List the indications for placement of an indwelling catheter. 2. Prepare the equipment, identify the landmarks, and describe the catheterization of a female patient. 3. Name five difficulties of insertion of a catheter in a male patient. 4. List four techniques to remove a nondeflating balloon. 5. Perform indwelling catheterization on at least two female and two male patients. Reference: (5) pages 867-74. 23.4.1.2 Suprapubic catheterization 1. List the indications and contraindications of suprapubic catheterization. 2. Prepare the equipment, identify the landmarks, and describe the placement of a suprapubic catheter. Reference: (5) pages 875-80. 23.6 Hemodynamic Techniques (see objectives from reference 6-Traumatology) 23.8 Thoracic Procedures 23.8.5 Thoracostomy 1. List the indications of thoracostomy in a nontraumatic patient. 2. Prepare equipment and identify landmarks for tube thoracostomy.
1. List the indications and contraindications for intestinal tube insertion. 2. Prepare the equipment and delineate the steps for replacing a transabdominal feeding tube. Reference: (5) pages 667-72. 23.9.7 Sengstaken-Blakemore tube insertion 1. List the indications and contraindications for use of a Sengstaken-Blakemore tube. 2. Name the three most common complications during the use of a Sengstaken-Blakemore tube. References: (2) page 1526; (5) pages 649-55. 23.9.8 Skin grafts (see objectives from reference 6Traumatology ) 23.9.9 Suture techniques (see objectives from reference 6-Traumatology ) 23.9.11 Bandaging techniques (see objectives from reference 6-Traumatology ) 23.9.12 Excision of thrombosed hemorrhoids 1. List the indications and contraindications of excision of thrombosed hemorrhoids. 2. List the postoperative care for a patient in whom a hemorrhoid has been excised. 3. Prepare the equipment, identify the landmarks, and describe the excision of a thrombosed hemorrhoid. Reference: (5) pages 704-7. 23.9.13 Foreign body removal (see objectives from reference 6-Traumatology)
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REFERENCES I. American College of Emergency Physicians, American Board of Emergency Medicine, Society for Academic Emergency Medicine. Core content for emergency medicine. Ann Emerg Med. 1991;20:920-34. 2. Rosen P, Barkin RM, Braen GR, et al., eds. Emergency medicine: concepts and clinical practice, 3rd ed. St Louis: Mosby-Year Book; 1992. *3. Sabiston DC, ed. Textbook of surgery: the biological basis of modem surgical practice, 14th ed. Philadelphia: WB Saunders; 1991.
* Books and article to be included in resident briefcase.
4. Hamilton GC, ed. Presenting signs and symptoms in the emergency department: evaluation and treatment. Baltimore: Williams & Wilkins; 1993. *5. Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine, 2nd ed. Philadelphia: Saunders; 1991. *6. Wightman JM, Hamilton GC. Objectives to direct the training of emergency medicine residents on off-service rotations: Traumatology, Part 3. .I Emerg Med. 199.5;13:407- 14. *7. Heller M, Jehle D. Ultrasound in emergency medicine. Philadelphia: WB Saunders; 1995.