- Email: [email protected]
Objectives to direct the training of emergency medicine residents on off-service rotations
Printed in the USA ??CopyrIght 0 1989 Pergamon Press plc
TheJournal of Emergency Medicme. Vol. 7, pp 535-545, 1989
OBJECTIVES
TO DIRECT THE TRAINING OF EMERGENCY RESIDENTS ON OFF-SERVICE ROTATIONS
Glenn C. Hamilton,
MD, FACEP,
FACP,*
MEDICINE
Clifton A. Sheets, M&t and Mark A. Eilers, MD*
“Chair and Program Director, TResidency Coordinator, and *Education Coordinator, Department of Emergency Medicine, Wright State University, School of Medicine, Dayton, Ohio Reprint address: Glenn C. Hamilton, MD, Department of Emergency Medicine, WSUSOM, P.O. Box 927, Dayton, OH 45401
0 Abstract- Up to SO%of the 36 months of resident training in emergency medicine may be on off-service rotations. The experience on these rotations can lack educational content and opportunity pertinent to emergency medicine. The resident rarely has readily available and structured guidance to optimize training in terms of the anticipated needs of the specialty. In response to this problem, the authors have written curricula containing subject content listings, objectives, and supplied references for 16 off-service rotations. A plan for implementing the materials and an example from the obstetrics-gynecology rotation is given. After 12 months’ experience, the authors have subjective responses from residents and off-service program directors that support the value of this information. Positive reports include: Residents having a better understanding of faculty expectations, improved “consistency of experience,” residents appreciating the added attention, improved performance, and expanded reading efforts. One expressed concern is “too much to read .” The project continues to evolve. 0 Keywords-resident; rotation
should also teach residents the principles of another specialty as it interfaces with emergency medicine. Unfortunately, the experience often falls short of these goals, and the content and process of this important training remains out of the emergency medicine program director’s control. Despite multiple meetings with the off-service course director, emergency medicine program directors eventually accept that despite written outlines and assurances, much of the clinical information and experience supplied to emergency medicine residents is decided by nonemergency-medicine specialists. Those physicians may or may not understand or care why an emergency resident is rotating on their service or be able to identify those areas pertinent to emergency medicine. Though one may teach many topics from the emergency medicine perspective in a didactic curriculum, the clinical experience must reinforce the classroom. As Sir William Osler noted: “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” (1). To remedy this situation and to respond to the Resident Review Committee for Emergency Medicine special requirements section on curriculum, the faculty of the Department of Emergency Medicine, Wright State University School of Medicine, began a graduate medical education project in late 1985. The project was to create a curriculum for emergency residents on each off-service rotation. The curriculum would contain four elements: 1) a content listing, 2) objectives for each content topic, 3) an implementa-
education; objectives; off-service;
INTRODUCTION
Off-service rotations account for up to 50% of graduate education time in emergency medicine residencies. Optimally, they allow the clinical course of specific diseases to be observed, and help establish responsibility for the clinical decisions made in the emergency department. Important professional relationships are established that can form the basis for trust that is essential in our world of practice. This
~
Education -Features articles focusing on the training of emergency physicians and the administration of residency programs. This section of JEM is coordinated by Mary Ann Cooper, MD, Mercy Hospital and Medical Center, Division of Emergency Medicine, University of Illinois, Chicago.
RECEIVED:13 February 1989; RECEIVED:5 A ril 1988; FINALSUBMISSION ACCEPTED:21 L arch 1989 535
0736-4679/89 $3.00 + .OO
536
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
tion strategy, and 4) an evaluation and feedback mechanism for both residents and faculty. The project is not complete, but the content listing, objectives for each content topic, and preliminary responses on implementation were thought sufficient to warrant publication as a guide and aid to other program directors working on the same problem.
Computer Science at Wright State University and continues to be tested. 5. *Feedback: Resident comments on the quality of the information have been solicited. Comparisons will be made with resident performance scores on off-service rotations before and after implementing the briefcases. Scores on the computer examination will be tallied and returned to the resident. *These two materials are under development.
MATERIALS 1 Content listing: The content list includes patient complaints, factual information, and procedures appropriate for the rotation. The content is derived from a departmental revision of the recent Core Content for Emergency Medicine (2). 2. Objectives: Each topic in the content list has one or more objectives. The number of objectives reflects the degree of importance or complexity of the subject. The objectives are written in the format recommended by Robert Mager in “Preparing Instructional Objectives” (3). This includes identifying the conditions, performance, and criteria for acceptable performance for each objective. 3. Implementation: It is assumed that the emergency medicine residents, rather than off-service faculty, will respond to objectives defining the “important information” to learn on a specific rotation. Therefore, the content and objectives are referenced to selected textbooks and literature supplied to the residents in a briefcase for each rotation. The briefcase contains an explanatory page outlining how to use the materials, the content, the objectives, and the references. Each is picked up and dropped off at the beginning and end of each rotation. A tally is kept and reminders given if materials are not obtained or returned in a timely manner. Each resident integrates the material into the educational experience as he or she deems appropriate. 4. *Evaluation: nYo questions are written for each objective, and placed in a computer test-generating program. The program allows an examination to be taken up to nine times without duplication of questions or question sequence. A “percentage random” selection choice is available allowing the test author to have certain key questions repeated on each examination. The program supplies immediate feedback by listing the objectives from which the questions that are missed were derived. The performance on the examination before, during and after, the rotation can be tallied. Also, it can be related to minimal, moderate, or extensive use of the briefcase materials. The computerized exam was written in conjunction with the Department of
METHODS A retreat was held in 1986 to educate the faculty in writing objectives, to develop content lists for offservice rotations, and to produce a sample of objectives for one rotation. After distribution of the materials from the retreat, a team of one faculty and two residents spent one-half day writing a first draft for one of 16 off-service rotations. Two revisions, including references, were developed by each faculty member under the guidance and review of an Objective Task Force made up of three faculty. Final editing, textbook selection, referencing, and assembly of briefcases was performed by the Objectives l&k Force. Testing of the briefcase material on selected rotations was done throughout 1987 and revisions based on resident comments made. By January 1988, briefcases were available for all 16 rotations. Over the course of the year, comments were collected on the quantity and quality of the information in the briefcases. In December 1988, the objectives and references were revised in response to this “field trial.”
RESULTS At this incomplete stage, it is difficult to be precise about the impact of this project. We have found several benefits: 1. The residents are not as educationally isolated from emergency medicine while on off-service rotations. 2. The residents have been pleased with the guidance. They subjectively feel better about their grasp of pertinent facts from an off-service rotation. 3. The residents are pleased that this much effort has been directed toward them. 4. Course directors of off-service rotations have commented serially and positively on the results of our effort. They note that the residents are more assured of “what they want” out of a rotation and aggressive in obtaining it.
537
EM Objectives for Off-Service Rotations
A repeated concern was whether there was sufficient time to adequately review the objectives and references. As the project proceeded this concern diminished.
DISCUSSION This is an introduction to a study that remains unfinished. The full evaluation package and feedback mechanism have not been implemented. The influence of these objectives will take several classes of residents and an ongoing computation of computer examination results, off-service evaluations, and performance on the American Board of Emergency Medicine In-Service and Certifying Examinations. While proceeding, the authors thought it useful to share the work completed to date: the content listing, objectives, and references for 16 off-service rotations. This information could supply the base for developing an off-service curriculum and be modified to suit another residency program’s needs. The curriculum for the Obstetrics and Gynecology rotation follows as part of this paper. In future issues of the Journal, the following rotations will be outlined: Administration Anesthesiology
Cardiology Critical Care* Dermatology Emergency Medical Services* Ear, Nose, and Throat General Internal Medicine General Surgery Hand Surgery Pulmonary Neurology Ophthalmology Orthopedics Pediatric-Inpatient Pediatric-Outpatient *Not considered off-service in our residency, but curriculum written and briefcase used.
SUMMARY After detailing its rationale and organization, we have presented an incomplete project. The authors believe two elements of the project, the content and referenced objectives, will benefit those in emergency medicine needing educational objectives for off-service rotations. This information will be presented as a Medicine. series in the Journal of Emergency Progress in the project will be included in the series as new developments occur.
REFERENCES 1. Osler W. Osler, the Teacher. Johns Hopkins Hospital Bulletin, 1919, Vol. 30. 2. Hamilton CC, Lumpkin JR, Tomlanovich MC, Krome RL, Wiegenstein J. Emergency medicine core content. Ann Emerg
Med. 1986;15:853-62. 3. Mager RF. Preparing instructional objectives. 2nd ed. Belmont, CA: Pitman Learning, Inc; 1984:1-22.
OBSTETRICS
16.1.5 16.1.6 16.1.8 16.1.11 16.1.12 16.1.13 16.1.14
AND GYNECOLOGY ROTATION*
3.0 CARDIOVASCULAR 3.6.2.3
DISORDERS
Toxic Shock Syndrome
16.0 UROGENITAL
DISORDERS
16.1 Presentations/Considerations
16.1.1 16.1.3 16.1.4
Numbers
16.3 Obstetric
Abnormal Vaginal Bleeding Discharge Dysmenorrhea
coincide
with departmentally
tent in Emergency Medicine.
Dyspareunia Dysuria Foreign bodies Incontinence Neoplasia Pelvic Pain Premenstrual Syndrome
16.3.1 Contraception 16.3.2 Pregnancy, Uncomplicated 16.3.3 Pregnancy, Complicated revised Core Con-
16.3.3.1 Ectopic Pregnancy 16.3.3.2 Abortion 16.3.3.2.1 Threatened
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
538
OBSTETRICS AND GYNECOLOGY ROTATION OB/GYN OBJECTIVES* .
16.3.3.2.2 Inevitable
16.3.3.2.3 Incomplete 16.3.3.2.4 Septic 16.3.3.2.5 Missed 16.3.3.3 16.3.3.4 16.3.3.5 16.3.3.6
3.0 CARDIOVASCULAR
Premature membrane rupture Abruptio Placenta Placenta Previa Toxemia
16.3.4 Delivery 16.3.4.1 Normal 16.3.4.2.1 16.3.4.2.2 16.3.4.2.3 16.3.4.2.4
Presentation Dystocia Prolapsed Cord Caesarean Section
16.3.5 Postpartum tions
hemorrhage/infection/complica-
DISORDERS
3.6.2.3 Toxic Shock Syndrome 1. List 4 case definition criteria for toxic shock syndrome (TSS) 2. List 3 components of the pathophysiology of TSS. 3. List at least 5 signs of symptoms of TSS. 4. Name 5 components of the differential diagnosis of TSS. Reference: Pernoll and Benson, Chapter 38. 16.0 UROGENITAL DISORDERS Evaluative 16.1 Presentations/Considerations
16.5 Genital-Female
16.1.1 Abnormal Vaginal Bleeding
16.5.1 Dysfunctional Uterine Bleeding 16.5.2 Sexual Assault 16.5.3 Infections
1. Be able to evaluate vaginal bleeding as outlined in the “Approach To” manual. Include historical and physical examination features as well as differential diagnosis and proposed therapeutic regimens.
16.5.3.1 16.5.3.2 16.5.3.3 16.5.3.4 16.5.4 16.5.5 16.5.6 16.5.7
Bartholin abscess Cervicitis Endometritis Salpingitis
Thbo-Ovarian Abscess Vulvo-Vaginitis Ovarian Cysts Ovarian Torsion
16.1.3 Discharge 1. List four components of the history, five components of the physical examination, a three part differential diagnosis and a suggested therapy for a patient with vaginal discharge as outlined in the “Approach to” manual. 16.1.4 Dysmenorrhea
16.6 Trauma 16.6.1 Principles of Emergency Care 16.6.2 Specific organ Injury
1. For a patient with dysmenorrhea list the four components in the history and physical exams, a four component differential diagnosis and treatment regimen for each.
16.6.2.3 External Genitalia 16.6.2.4 Vagina/Uterus
Reference: Pernoll and Benson, Chapter 33.
1.6.3 Trauma in Pregnancy
16.1.5 Dyspareunia
16.7 PROCEDURES
1. Given a patient presenting with dyspareunia be able to elicit five components of the history, six components of the physical examination and to formulate at least a five component differential diagnosis for the patient. List appropriately related therapeutic modalities.
16.7.1 General Procedures 16.7.2 Culdocentesis 16.7.3 Delivery of Newborn 16.7.3.1 16.7.3.2 16.7.3.3 16.7.3.4
Normal Delivery Breech Delivery Perimortum Caesarean Section Caesarean Section
16.7.4 Dilatation and Curettage (D&C)
Reference: Pernoll and Benson, Chapter 60. *Numbers coincide with departmentally tent in Emergency Medicine.
revised Core Con-
539
EM Objectives for Off-Service Rotations
16.1.6 Dysuria
1. Be able to perform the history, physical examination, and formulate a differential diagnosis including a prioritized treatment plan for a patient with dysuria as outlined in “Approach to” manual. 16.1.8 Foreign bodies
the following: a. post coital douch b. coitus interuptis c. condoms d. diaphragm/vaginal inserts e. rhythm method f. oral contraceptives g. hormonal contraception by injection h. morning after pill (DES) i. IUD
1. The resident will be able to elicit the pertinent history, perform a physical examination and procedures indicated in a patient with vaginal foreign bodies.
Reference: Pernoll and Benson, Chapter 32.
Reference: Pernoll and Benson, Chapter 41.
16.3.2 Pregnancy, Uncomplicated
16.1.11 Incontinence
1. Given a 26-year-old female patient, G2 Pl, ABO, at 26 weeks gestation, list the changes found in the following organs or physiology. Uterus-blood supply, size, position :: Breasts-size, function C. Hematologic system-sedimentation rate, RBC mass, total plasma volume d. Cardiovascular-blood pressure, pulse rate rate, FRC e. Respiratory-respiratory f. GI -stomach position and function, appendix position, intestinal mobility GU - bladder capacity, ureter, renal function :: Endocrine - FSH, LH, thyroid hormone, TBG, T3, T3 uptake i. Musculoskeletal - lordosis, increased mobility of sacroiliac joint and sacroccygeal joint, demineralization. of uterine j. Abdominal physical exam-height fundus expected, vital signs pregnancy diagnoses.
1. Given a patient with urinary incontinence, be able to elicit a history, appropriate physical examination, establish a differential diagnosis, and list a prioritized treatment plan for evaluation as outlined in “Approach to” manual. 16.1.12 Neoplasia 1. Given a patient presenting with potential gynecologic neoplasia outline the appropriate historical features that need to be elicited, the appropriate physical examination, a differential diagnosis (that would include at least 5 possibilities), and a diagnostic and therapeutic approach. Reference: Pernoll and Benson, Chapter 46-48. 16.1.13 Pelvic Pain 1. The resident should be able to perform an appropriate history, physical exam, establish a five part differential diagnosis, and outline a prioritized treatment plan as outlined in “Approach to” manual. 16.1.14 Premenstrual
Syndrome
1. Given a patient with premenstrual syndrome the resident will be able to elicit a history, perform a physical examination, establish a brief differential diagnosis and list initial therapeutic and diagnostic regimen. Reference: Pernoll and Benson, Chapter 33 and Roberts and Hedges COGNITIVE 16.3 Obstetric 16.3.1 Contraception 1. List four indications for birth control. 2. List the risks (if any) and effectiveness of each of
Reference: Pernoll and Benson, Chapter 7. Reference: Pernoll and Benson, Chapter 5. 2. List the treatment each of the following disorders at a) 8 weeks pregnant (first trimester) versus b) 36 weeks pregnant (third trimester). 1. UT1 2. a) Pharyngitis b) Penicillin allergic 3. Pneumonia 4. Cellulitis 5. Pulmonary embolus 6. Otitis media 7. Hyperemesis 8. URI Reference: Pernoll and Benson, Chapter 19, 63. 3. Identify the physiology and suggested therapy for each of the following common complaints of pregnancy:
540
a. pica b. urinary frequency c. vaginal infections 1. Gardnerella Vaginalis 2. Trichomoniasis 3. Candidiasis d. varicose veins e. edema f. joint pain, backache and pelvic pressure g. leg cramps h. breast soreness i. discomfort in the hands 4. Identify the risks associated with each of the following in pregnancy: a. cigarette smoking b. alcoholic beverages c. douching d . immunication e. exercise f. travel 16.3.3 Pregnancy, Complicated 16.3.3.1 Ectopic Pregnancy 1. In a suspected ectopic pregnancy, categorize the influence of each of the following twenty-six items on determining the diagnosis of ectopic pregnancy. Categories are very likely, somewhat likely, unlikely or not helpful: 6 weeks amenorrhea :: 24 weeks amenorrhea C. use of a diaphragm d. IUD e. left lower quandrant pain f. acute sudden onset of pain vaginal bleeding !: previous pelvic surgery i. previous episode of pelvic inflammatory disease/salpingitis j. breast tenderness, increasing fatigue k. right lower quandrant pain 1. CVA tenderness m. diffusive abdominal pain n. suprapubic tenderness right or left adnexal tenderness 0. P* cervical motion tenderness q. adnexal mass r. vaginal bleeding urine pregnancy negative, serum pregnancy S. positive t. pregnancy test negative U. no fluid obtained on culdocentesis V. straw colored fluid obtained on cultocentesis
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
w. 5 cc’s nonclotting blood obtained x. 5 cc’s clotting blood obtained on culdocentesis y. ultrasound with no gestational sack seen in uterus with positive pregnancy test z. ultrasound showing gestational sack in adnexae 2. Given a patient with suspected ectopic pregnancy, list at least five prioritized other potential diagnostic possibilities. 3. List in order the five primary steps to the stabilization and resuscitation of a hypotensive female with suspected ruptured ectopic pregnancy. Reference: Pernoll and Benson, Chapter 12. 16.3.3.2 Abortion 1. Define spontaneous abortion 2. Define complete abortion 3. For each of the following identify three major components that contribute to spontaneous abortion. a. First trimester ovulatory factors b. Second trimester of maternal factors c. Systemic disease d. Immunologic disorders e. Toxic factors f. Uterine defects g. Psychic and emotional factors h. Trauma 4. Define at what point falling or abnormally low plasma levels of beta HCG are predictive of spontaneous abortion. 5. Identify the utility of ultrasonography in diagnosing impending spontaneous abortion. 6. Identify at least four other ,entities that comprise a differential diagnosis of spontaneous abortion. 7. Identify three complications of spontaneous abortion. 8. Define under what condition oxytocics should (for example oxytocin) be used in the treatment spontaneous abortion. Contrast this with ergot preparations and D&C. 16.3.3.2.1 Threatened abortion 1. Define threatened abortion with respect to clinical signs, symptoms and status of the fetus and cervix. 16.3.3.2.2 Inevitable abortion 1. Identify at least four of the six criteria that characterize inevitable abortion. 2. Identify how many of the above criteria are necessary to fit the definition of inevitable abortion. 16.3.3.2.3 Incomplete abortion
541
EM Objectives for Off-Service Rotations
1. Define incomplete abortion with respect to clinical signs and symptoms and fetal findings. 16.3.3.2.4 Septic abortion 1. Define septic abortion and identify its clinical signs and symptoms including pelvic findings and systemic symptoms. 2. Identify the circumstance under which abdominal hysterectomy should be considered as the treatment of choice for septic abortion. 16.3.3.2.5 Missed abortion 1. Define missed abortion 2. Identify three clinical signs and symptoms of missed abortion. 3. List two differential diagnoses for missed abortion. 4. Outline a treatment plan for missed abortion. 16.3.3.3 Premature membrane rupture 1. List five predisposing factors for premature rupture of membranes. 2. Identify three conditions precipitated by premature rupture of membranes. 3. List the seven components of the sterile speculum examination. 4. List four signs and symptoms of amnionitis. 5. Identify three conditions under which urgent intervention is necessary in patients with premature rupture of membranes. Reference: Pernoll and Benson, Chapter 14. 16.3.3.4 Abruptio Placenta 1. List five predisposing factors for abruptio placenta. 2. Write a description of the pathophysiologic events involved in abruptio placenta. 3. List five signs or symptoms consistent with abruptio placenta. 4. List at least four differential diagnoses for third trimester of vaginal bleeding. 5. Categorize the utility of each of the following tests in the setting of abruptio placenta: a. hemoglobin b. platelet count c. prothrombin time d. partial thromboplastin time e. ultrasound 6. Identify under what conditions are expectant, vaginal delivery, or Caesarian section intervention indicated in the treatment of a patient with abruptio placenta. Reference: Pernoll and Benson, Chapter 22.
16.3.3.5 Placenta Previa 1. List the three predisposing factors of placenta previa. 2. List the three components of the pathophysiologic process of bleeding in placenta previa. 3. Identify the cardinal sign of placenta previa. 4. List the timing, findings, and accuracy of an ultrasound examination in the patient with placenta previa. 5. Identify under what conditions expectant, vaginal delivery, or caesarian section delivery are indicated in the treatment of placenta previa. Reference: Pernoll and Benson, Chapter 22. 16.3.3.6 Toxemia 1. List the criteria necessary to diagnose: a. preeclampsia b. eclampsia 2. List two components of the pathophysiology of toxemia as it affects each of the following: a. Central nervous system b. ophthalmologic c. pulmonary d. cardiovascular e. hepatic f. renal g. hematologic h. endocrine 3. List the three cardinal symptoms or signs of toxemia. Include diagnostic criteria for each. 4. Identify the three goals in management of severe preclampsia. 5. Identify the loading and maintenance doses of magnesium sulfate in preclamptic blood pressure control. What are the physiologic endpoints? 6. Identify therapeutic agent selection, loading and maintenance dose for seizure control and control of blood pressure in eclampsia. 7. List at least three indications for delivery in patients with preeclampsia or eclampsia. Reference: Pernoll and Benson, Chapter 18. 16.3.4 Delivery 16.3.4.1 Normal 1. Identify the three stages of normal labor and the time course for each. 2. Identify the essential information gathered in the initial examination with regards to: a. abdominal exam b. fetal heart tones c. contractions d. vaginal exam
542
3. Correlate
4.
5.
6. 7.
8.
9.
the station of the presenting fetal part with anatomic location, i.e. crowning, -2 centimeter, + 3 centimeters. Identify the criteria needed to diagnose each of the following vaginal delivery presentations: a. LGA b. LOP c. RMP d. breech e. brow f. transverse List the cardinal events in each of the following phases of the second stage labor. a. engagement b. flexion c. descent d. internal rotation e. extention f. external rotation Identify criteria necessary for the performance of an episiotomy. List the five components of the immediate postpartum care of: a. the infant b. the mother List the five components of the APGAR score, and given these components in a real infant, be able to calculate and interpret the significance of the score Define and outline treatment for each of the following tears of the perineum. a. first degree b. second degree c. third degree d. fourth degree
Reference: Pernoll and Benson, Chapter 8. 16.3.4.2 Abnormal Labor and Delivery 1. Define each of the following: a. precipitous labor b . prolonged labor c. arrested labor Reference: Pernoll and Benson, Chapter 24. 16.3.4.2.2 Presentation 1. Define each of the following: a. frank breech b. complete breech c. footling breech 2. Briefly outline a technique for assistance in sterile vaginal delivery of breech presentation. 3. In the management of a breech delivery list at least 5 criteria needed for successful:
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
a. vaginal delivery b . caesarean section delivery Reference: Pernoll and Benson, Chapter 23. 16.3.4.2.1 Dystocia 1. Define shoulder dystocia and identify three potential causes. 2. List five complications of shoulder dystocia. 3. Describe two techniques for shoulder dystocia management. Reference: Pernoll and Benson, Chapter 23. 16.3.4.2.3 Prolapsed Cord 1. Define: a. overt cord prolapse b. fundic prolapse presentation c. occult prolapse 2. Identify four causes of prolapsed cord. 3. Name four components of the management of: a. overt cord prolapse b. occult cord prolapse c. fundic presentation Reference: Pernoll and Benson, Chapter 23. 16.3.4.2.4 Caesarean Section 1. See Procedural Section. 16.35 Postpartum tions
hemorrhage/infection/complica-
1. Define postpartum hemorrhage. 2. For each of the following causes of postpartum hemorrhage identify the frequency, predisposing cause, diagnoses and treatment: a. uterine atony b. obstetric laceration c. retained productions of conception d. coagulation defects 3. Define uterine eversion and list three predisposing conditions. 4. Name two methods of treatment for uterine eversion. 5. Identify the pathophysiology, diagnosis and treatment of each of the following as a postpartum complication: a. endometritis b. septic pelvic thrombophlebitis c. wound infection d. mastitis e. amnionic fluid embolus f. puerperal sepsis Reference: Pernoll and Benson, Chapters 29 and 58
543
EM Objectives for Off-Service Rotations
16.5 Genital - Female
16.5.1 Dysfunctional
Uterine Bleeding
1. Define and list at least two etiologies and therapies for each of the patterns of vaginal bleeding: a. dysmenorrhea b . menorrhagia c. metrorrhagia d. hypomenorrhagia e. polymenorrhagia f. menometrorrhagia g. oligomenorrhagia h. post coital bleeding 2. Define dysfunctional uterine bleeding. 3. List two etiologies and therapies for dysfunctional uterine bleeding in each of the following: a. adolescent women b. young women c. premenopausal women 4. Define postmenopausal bleeding. 5. List the three etiologic classes of postmenopausal bleeding and their therapies. Reference: Pernoll and Benson, Chapter 33. 165.2 Sexual Assault 1. Define the following according to ACOG guidelines: a. rape b. statutory rape c. sexual molestation d. deviant sexual assault 2. In suspected rape: a. name the laboratory/crime lab specimens that should be collected in each case b. give the significance of a positive acid phosphate test c. List two medical therapies for preventing pregnancy d. give the timing and logic of medical follow-up care (include laboratory work to be performed) Reference: Pernoll and Benson, Chapter 61. (see 16.4.9) 16.5.3 Infections 16.5.3.1 Bartholin abscess 1. Identify the anatomic location of Bartholin’s glands. 2. Name three most common infecting organisms of Bartholin’s gland cysts. Reference: Pernoll and Benson, Chapter 34. 16.5.3.2 Cervicitis
1. Identify at least three signs and symptoms of cervicitis 2. Identify the two most common etiologies of cervicitis and the appropriate antibiotic therapy for each. 3. Identify the influence of cervicitis on PAP smear testing. Reference: Pernoll and Benson, Chapter 35. 16.5.3.3 Endometritis 1. Define and list at least three signs and symptoms of each: a. metritis b. endometritis 2. List the two most common auaerolsis and aerobic bacterial isolater from postpartum endometritis. 3. Given a patient with suspected postpartum endometritis, identify three acceptable antibiotic therapies. Reference: Pernoll and Benson, Chapter 29. 16.5.3.4 Salpingitis 1. Identify at least four clinical signs and symptoms of salpingitis. 2. Identify at least five risk factors for pelvic inflammatory disease (PID) or salpingitis. 3. Given a patient with pelvic pain, state the criteria for the diagnosis of PID/salpingitis according to the American College of Obstetrics and Gynecology (ACOG). Reference: OB and Gynecology, June 83 (61): 114. 4. Define the three clinical stages of PID (1. uncomplicated, 2. complicated, 3. ruptured tubo-ovarian abscess) and match with the ACOG approved medical-surgical therapy. 5. List CDC approved antiotic regimens for PID for: a. uncomplicated PID b. complicated PID Reference: OB and GYN. Jan. 83, (61) 114. 16.5.4 lbbo-Ovarian
Abscess (TOA)
1. Given a 22 year old nulliparous, sexually active female who uses an IUD for contraception: a. name three risk factors for TOA b. name criteria for surgery c. name three complications of TOA’s. Reference: Pernoll and Benson, Chapter 38. 16.5.5 Vulvo-Vaginitis (see 16.1.3) 1. Match the following vulvar infections with the antibiotic drug of choice.
544
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
a. tinea cruris b. erythrasma (C. minutissium) c. scabies d. crab lice e. folliculitis f. pinworms Identify therapy for the following vaginal infection for A) an 18 yo allergic to PCN, B) a 24 yo, 2 months pregnant, and C) a 35 yo allergic to sulfa: i) nonspecific vaginitis ii) monilliasis iii) trichomonaisis iv) mucopurulent cervicitis Given a patient with a single, large, painful human genital wart (Condyloma acuminatum) be able to: a. identify the lesion by its appearance b. describe three modes of therapy c. state the associated cancer risk 4. For genital herpes (Herpes Simplex, Type #), identify the: a. incubation period b. period of infectivity c. signs and symptoms of primary infection, secondary eruption d. culture and laboratory methods of diagnosis e. medical therapy options Reference: Pernoll and Benson, Chapter 34. 165.6 Ovarian Cysts 1. List three potential etiologies for acute abdominal pain in a patient with a known six centimeter solitary ovarian cyst. 2. List at least two diagnostic modalities for the above. Reference: Pernoll and Benson, Chapter 37. 165.7 Ovarian Torsion 1. List two risk factors for ovarian torsion. 2. List three signs and symptoms of ovarian torsion. 3. Identify at least three components of a differential diagnosis of ovarian torsion. 4. Outline currently accepted medical/surgical therapy for ovarian torsion. Reference: Pernoll and Benson, Chapter 37. 16.6 Trauma 16.6.1 Principles of Emergency Care 16.6.2 Specific organ Injury 16.5.2.3 External Genitalia 1. Outline a conservative
labial hematoma.
therapeutic
approach to a
2. List two indications for surgical intervention labial hematoma.
in a
Reference: Pernoll and Benson, Chapter 3 1. 16.5.2.4 Vagina/Uterus 1. In a 2 centimeter posterior vaginal laceration that does not extend into the rectum: a. select appropriate suture material b. name appropriate anesthesia and anesthestetic techniques c. identify appropriate suture technique Reference: Pernoll and Benson, Chapter 3 1. 16.6.3 Trauma in Pregnancy 1. Given a near term pregnant female who has been severely traumatized: a. name three ways to prevent uterine compression of venous return (supine hypotensive syndrome) b. state the earliest sign of fetal distress c. state four criteria for peritoneal lavage d. state the criteria for site selection for peritoneal lavage 2. Given a near term pregnant female who has been severely traumatized, and is hypotensive, categorize the use of the following as a) indicated and safe, b) indicated with some maternal/fetal risk, c) contraindicated. a. ephedrine blood pressure support b. epinephrine blood pressure support c. uterine displacer d. elevation of right side 15-20 degrees e. MAST Trousers f. uncrossmatched blood g. peritoneal lavage h. culdocentesis Reference: Buchshaum, H. “Trauma in Pregnancy”Selected Optional Reading 16.7 PROCEDURES 16.7.1 General Procedures
Pelvic Examination-given an actual adult of pediatric patient be able to perform a complete pelvic examination. This will be confirmed. (Examined by an attending.) To include examination under anesthesia. Cervical and Vaginal Smear Interpretation-be able to collect and interpret cervical and/or vaginal smear material for a) clue cells, b) trichomoniasis, and c) white cells with intracellular diplococci, sperm and KOH prep for pseudohyphae. 16.7.2 Culdocentesis
545
EM Objectives for Off-Service Rotations
1. Perform a culdocentesis under observation of either the OB/Gyn resident, attending or emergency department physician. Identify the indications and contraindications of the procedure, (see also 16.3.3.1 Ectopic pregnancy). Reference: Roberts and Hedges, Chapter 52.
emergent or elective caesarean section assist the resident or attending physician in performing at least three caesarean sections. References: Approach Hedges, Chapter 50.
To Manual and Roberts and
16.7.3 Delivery of Newborn
16.7.4 Dilatation and Curettage (D&C)
16.7.3.1 Normal Delivery
1 Assist on dilatation and curettage (D&C) - given a patient requiring a dilatation and curettage assist the attending or physician perform a dilatation and curettage.
1. An uncomplicated full term pregnancy-be able to deliver the fetus and placenta. Examine for complications, (i.e., lacerations or extension of episiotomy. 16.7.3.2 Breech Delivery 1. Assist or observe delivery of breech presentation infant. 16.7.3.3 Perimortum Caesarean Section 1. Given a morbund, near term mother state the circumstances that might lead to a perimortum Caesarean section. 2. Given the above circumstances, outline the procedure techniques and time course to completion. Reference: Pernoll and Benson, Chapter 27. 16.7.3.4 Caesarean Section 1. Assist on C-Section-given
a patient requiring an
OBSTETRICS AND GYNECOLOGY ROTATION REFERENCES (IN BRIEFCASE) 1. Pernoll ML, Benson RD (eds). Current obstetric and gynecologic diagnosis and treatment, 6th ed. Connecticut: Appleton and Lange; 1987. 2. Berkowitz RL, Couston DR, Mochizulski TK. Handbook for prescribing medications during pregnancy, 2nd ed. Boston: Little, Brown and Company; 1986. 3. Approach to presenting signs and symptoms in the emergency department. Located at: Department of Emergency Medicine, Wright State University, Dayton, OH. 1987. 4. Roberts JR, Jedges JR. Clinical procedures in emergency medicine. Philadelphia, WG Saunders; 1985. 5. Buchsbaum H. Trauma in pregnancy. Philadelphia: WB Saunders; 1979. 6. Specific Papers a. Hager WD, Eschenbach DA, Spence MR, Sweet RL. Criteria for diagnosis and grading of salpingitis. OB&GYN. 1983;61: 113.
TheJournal of Emergency Medicme. Vol. 7, pp 535-545, 1989
OBJECTIVES
TO DIRECT THE TRAINING OF EMERGENCY RESIDENTS ON OFF-SERVICE ROTATIONS
Glenn C. Hamilton,
MD, FACEP,
FACP,*
MEDICINE
Clifton A. Sheets, M&t and Mark A. Eilers, MD*
“Chair and Program Director, TResidency Coordinator, and *Education Coordinator, Department of Emergency Medicine, Wright State University, School of Medicine, Dayton, Ohio Reprint address: Glenn C. Hamilton, MD, Department of Emergency Medicine, WSUSOM, P.O. Box 927, Dayton, OH 45401
0 Abstract- Up to SO%of the 36 months of resident training in emergency medicine may be on off-service rotations. The experience on these rotations can lack educational content and opportunity pertinent to emergency medicine. The resident rarely has readily available and structured guidance to optimize training in terms of the anticipated needs of the specialty. In response to this problem, the authors have written curricula containing subject content listings, objectives, and supplied references for 16 off-service rotations. A plan for implementing the materials and an example from the obstetrics-gynecology rotation is given. After 12 months’ experience, the authors have subjective responses from residents and off-service program directors that support the value of this information. Positive reports include: Residents having a better understanding of faculty expectations, improved “consistency of experience,” residents appreciating the added attention, improved performance, and expanded reading efforts. One expressed concern is “too much to read .” The project continues to evolve. 0 Keywords-resident; rotation
should also teach residents the principles of another specialty as it interfaces with emergency medicine. Unfortunately, the experience often falls short of these goals, and the content and process of this important training remains out of the emergency medicine program director’s control. Despite multiple meetings with the off-service course director, emergency medicine program directors eventually accept that despite written outlines and assurances, much of the clinical information and experience supplied to emergency medicine residents is decided by nonemergency-medicine specialists. Those physicians may or may not understand or care why an emergency resident is rotating on their service or be able to identify those areas pertinent to emergency medicine. Though one may teach many topics from the emergency medicine perspective in a didactic curriculum, the clinical experience must reinforce the classroom. As Sir William Osler noted: “To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” (1). To remedy this situation and to respond to the Resident Review Committee for Emergency Medicine special requirements section on curriculum, the faculty of the Department of Emergency Medicine, Wright State University School of Medicine, began a graduate medical education project in late 1985. The project was to create a curriculum for emergency residents on each off-service rotation. The curriculum would contain four elements: 1) a content listing, 2) objectives for each content topic, 3) an implementa-
education; objectives; off-service;
INTRODUCTION
Off-service rotations account for up to 50% of graduate education time in emergency medicine residencies. Optimally, they allow the clinical course of specific diseases to be observed, and help establish responsibility for the clinical decisions made in the emergency department. Important professional relationships are established that can form the basis for trust that is essential in our world of practice. This
~
Education -Features articles focusing on the training of emergency physicians and the administration of residency programs. This section of JEM is coordinated by Mary Ann Cooper, MD, Mercy Hospital and Medical Center, Division of Emergency Medicine, University of Illinois, Chicago.
RECEIVED:13 February 1989; RECEIVED:5 A ril 1988; FINALSUBMISSION ACCEPTED:21 L arch 1989 535
0736-4679/89 $3.00 + .OO
536
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
tion strategy, and 4) an evaluation and feedback mechanism for both residents and faculty. The project is not complete, but the content listing, objectives for each content topic, and preliminary responses on implementation were thought sufficient to warrant publication as a guide and aid to other program directors working on the same problem.
Computer Science at Wright State University and continues to be tested. 5. *Feedback: Resident comments on the quality of the information have been solicited. Comparisons will be made with resident performance scores on off-service rotations before and after implementing the briefcases. Scores on the computer examination will be tallied and returned to the resident. *These two materials are under development.
MATERIALS 1 Content listing: The content list includes patient complaints, factual information, and procedures appropriate for the rotation. The content is derived from a departmental revision of the recent Core Content for Emergency Medicine (2). 2. Objectives: Each topic in the content list has one or more objectives. The number of objectives reflects the degree of importance or complexity of the subject. The objectives are written in the format recommended by Robert Mager in “Preparing Instructional Objectives” (3). This includes identifying the conditions, performance, and criteria for acceptable performance for each objective. 3. Implementation: It is assumed that the emergency medicine residents, rather than off-service faculty, will respond to objectives defining the “important information” to learn on a specific rotation. Therefore, the content and objectives are referenced to selected textbooks and literature supplied to the residents in a briefcase for each rotation. The briefcase contains an explanatory page outlining how to use the materials, the content, the objectives, and the references. Each is picked up and dropped off at the beginning and end of each rotation. A tally is kept and reminders given if materials are not obtained or returned in a timely manner. Each resident integrates the material into the educational experience as he or she deems appropriate. 4. *Evaluation: nYo questions are written for each objective, and placed in a computer test-generating program. The program allows an examination to be taken up to nine times without duplication of questions or question sequence. A “percentage random” selection choice is available allowing the test author to have certain key questions repeated on each examination. The program supplies immediate feedback by listing the objectives from which the questions that are missed were derived. The performance on the examination before, during and after, the rotation can be tallied. Also, it can be related to minimal, moderate, or extensive use of the briefcase materials. The computerized exam was written in conjunction with the Department of
METHODS A retreat was held in 1986 to educate the faculty in writing objectives, to develop content lists for offservice rotations, and to produce a sample of objectives for one rotation. After distribution of the materials from the retreat, a team of one faculty and two residents spent one-half day writing a first draft for one of 16 off-service rotations. Two revisions, including references, were developed by each faculty member under the guidance and review of an Objective Task Force made up of three faculty. Final editing, textbook selection, referencing, and assembly of briefcases was performed by the Objectives l&k Force. Testing of the briefcase material on selected rotations was done throughout 1987 and revisions based on resident comments made. By January 1988, briefcases were available for all 16 rotations. Over the course of the year, comments were collected on the quantity and quality of the information in the briefcases. In December 1988, the objectives and references were revised in response to this “field trial.”
RESULTS At this incomplete stage, it is difficult to be precise about the impact of this project. We have found several benefits: 1. The residents are not as educationally isolated from emergency medicine while on off-service rotations. 2. The residents have been pleased with the guidance. They subjectively feel better about their grasp of pertinent facts from an off-service rotation. 3. The residents are pleased that this much effort has been directed toward them. 4. Course directors of off-service rotations have commented serially and positively on the results of our effort. They note that the residents are more assured of “what they want” out of a rotation and aggressive in obtaining it.
537
EM Objectives for Off-Service Rotations
A repeated concern was whether there was sufficient time to adequately review the objectives and references. As the project proceeded this concern diminished.
DISCUSSION This is an introduction to a study that remains unfinished. The full evaluation package and feedback mechanism have not been implemented. The influence of these objectives will take several classes of residents and an ongoing computation of computer examination results, off-service evaluations, and performance on the American Board of Emergency Medicine In-Service and Certifying Examinations. While proceeding, the authors thought it useful to share the work completed to date: the content listing, objectives, and references for 16 off-service rotations. This information could supply the base for developing an off-service curriculum and be modified to suit another residency program’s needs. The curriculum for the Obstetrics and Gynecology rotation follows as part of this paper. In future issues of the Journal, the following rotations will be outlined: Administration Anesthesiology
Cardiology Critical Care* Dermatology Emergency Medical Services* Ear, Nose, and Throat General Internal Medicine General Surgery Hand Surgery Pulmonary Neurology Ophthalmology Orthopedics Pediatric-Inpatient Pediatric-Outpatient *Not considered off-service in our residency, but curriculum written and briefcase used.
SUMMARY After detailing its rationale and organization, we have presented an incomplete project. The authors believe two elements of the project, the content and referenced objectives, will benefit those in emergency medicine needing educational objectives for off-service rotations. This information will be presented as a Medicine. series in the Journal of Emergency Progress in the project will be included in the series as new developments occur.
REFERENCES 1. Osler W. Osler, the Teacher. Johns Hopkins Hospital Bulletin, 1919, Vol. 30. 2. Hamilton CC, Lumpkin JR, Tomlanovich MC, Krome RL, Wiegenstein J. Emergency medicine core content. Ann Emerg
Med. 1986;15:853-62. 3. Mager RF. Preparing instructional objectives. 2nd ed. Belmont, CA: Pitman Learning, Inc; 1984:1-22.
OBSTETRICS
16.1.5 16.1.6 16.1.8 16.1.11 16.1.12 16.1.13 16.1.14
AND GYNECOLOGY ROTATION*
3.0 CARDIOVASCULAR 3.6.2.3
DISORDERS
Toxic Shock Syndrome
16.0 UROGENITAL
DISORDERS
16.1 Presentations/Considerations
16.1.1 16.1.3 16.1.4
Numbers
16.3 Obstetric
Abnormal Vaginal Bleeding Discharge Dysmenorrhea
coincide
with departmentally
tent in Emergency Medicine.
Dyspareunia Dysuria Foreign bodies Incontinence Neoplasia Pelvic Pain Premenstrual Syndrome
16.3.1 Contraception 16.3.2 Pregnancy, Uncomplicated 16.3.3 Pregnancy, Complicated revised Core Con-
16.3.3.1 Ectopic Pregnancy 16.3.3.2 Abortion 16.3.3.2.1 Threatened
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
538
OBSTETRICS AND GYNECOLOGY ROTATION OB/GYN OBJECTIVES* .
16.3.3.2.2 Inevitable
16.3.3.2.3 Incomplete 16.3.3.2.4 Septic 16.3.3.2.5 Missed 16.3.3.3 16.3.3.4 16.3.3.5 16.3.3.6
3.0 CARDIOVASCULAR
Premature membrane rupture Abruptio Placenta Placenta Previa Toxemia
16.3.4 Delivery 16.3.4.1 Normal 16.3.4.2.1 16.3.4.2.2 16.3.4.2.3 16.3.4.2.4
Presentation Dystocia Prolapsed Cord Caesarean Section
16.3.5 Postpartum tions
hemorrhage/infection/complica-
DISORDERS
3.6.2.3 Toxic Shock Syndrome 1. List 4 case definition criteria for toxic shock syndrome (TSS) 2. List 3 components of the pathophysiology of TSS. 3. List at least 5 signs of symptoms of TSS. 4. Name 5 components of the differential diagnosis of TSS. Reference: Pernoll and Benson, Chapter 38. 16.0 UROGENITAL DISORDERS Evaluative 16.1 Presentations/Considerations
16.5 Genital-Female
16.1.1 Abnormal Vaginal Bleeding
16.5.1 Dysfunctional Uterine Bleeding 16.5.2 Sexual Assault 16.5.3 Infections
1. Be able to evaluate vaginal bleeding as outlined in the “Approach To” manual. Include historical and physical examination features as well as differential diagnosis and proposed therapeutic regimens.
16.5.3.1 16.5.3.2 16.5.3.3 16.5.3.4 16.5.4 16.5.5 16.5.6 16.5.7
Bartholin abscess Cervicitis Endometritis Salpingitis
Thbo-Ovarian Abscess Vulvo-Vaginitis Ovarian Cysts Ovarian Torsion
16.1.3 Discharge 1. List four components of the history, five components of the physical examination, a three part differential diagnosis and a suggested therapy for a patient with vaginal discharge as outlined in the “Approach to” manual. 16.1.4 Dysmenorrhea
16.6 Trauma 16.6.1 Principles of Emergency Care 16.6.2 Specific organ Injury
1. For a patient with dysmenorrhea list the four components in the history and physical exams, a four component differential diagnosis and treatment regimen for each.
16.6.2.3 External Genitalia 16.6.2.4 Vagina/Uterus
Reference: Pernoll and Benson, Chapter 33.
1.6.3 Trauma in Pregnancy
16.1.5 Dyspareunia
16.7 PROCEDURES
1. Given a patient presenting with dyspareunia be able to elicit five components of the history, six components of the physical examination and to formulate at least a five component differential diagnosis for the patient. List appropriately related therapeutic modalities.
16.7.1 General Procedures 16.7.2 Culdocentesis 16.7.3 Delivery of Newborn 16.7.3.1 16.7.3.2 16.7.3.3 16.7.3.4
Normal Delivery Breech Delivery Perimortum Caesarean Section Caesarean Section
16.7.4 Dilatation and Curettage (D&C)
Reference: Pernoll and Benson, Chapter 60. *Numbers coincide with departmentally tent in Emergency Medicine.
revised Core Con-
539
EM Objectives for Off-Service Rotations
16.1.6 Dysuria
1. Be able to perform the history, physical examination, and formulate a differential diagnosis including a prioritized treatment plan for a patient with dysuria as outlined in “Approach to” manual. 16.1.8 Foreign bodies
the following: a. post coital douch b. coitus interuptis c. condoms d. diaphragm/vaginal inserts e. rhythm method f. oral contraceptives g. hormonal contraception by injection h. morning after pill (DES) i. IUD
1. The resident will be able to elicit the pertinent history, perform a physical examination and procedures indicated in a patient with vaginal foreign bodies.
Reference: Pernoll and Benson, Chapter 32.
Reference: Pernoll and Benson, Chapter 41.
16.3.2 Pregnancy, Uncomplicated
16.1.11 Incontinence
1. Given a 26-year-old female patient, G2 Pl, ABO, at 26 weeks gestation, list the changes found in the following organs or physiology. Uterus-blood supply, size, position :: Breasts-size, function C. Hematologic system-sedimentation rate, RBC mass, total plasma volume d. Cardiovascular-blood pressure, pulse rate rate, FRC e. Respiratory-respiratory f. GI -stomach position and function, appendix position, intestinal mobility GU - bladder capacity, ureter, renal function :: Endocrine - FSH, LH, thyroid hormone, TBG, T3, T3 uptake i. Musculoskeletal - lordosis, increased mobility of sacroiliac joint and sacroccygeal joint, demineralization. of uterine j. Abdominal physical exam-height fundus expected, vital signs pregnancy diagnoses.
1. Given a patient with urinary incontinence, be able to elicit a history, appropriate physical examination, establish a differential diagnosis, and list a prioritized treatment plan for evaluation as outlined in “Approach to” manual. 16.1.12 Neoplasia 1. Given a patient presenting with potential gynecologic neoplasia outline the appropriate historical features that need to be elicited, the appropriate physical examination, a differential diagnosis (that would include at least 5 possibilities), and a diagnostic and therapeutic approach. Reference: Pernoll and Benson, Chapter 46-48. 16.1.13 Pelvic Pain 1. The resident should be able to perform an appropriate history, physical exam, establish a five part differential diagnosis, and outline a prioritized treatment plan as outlined in “Approach to” manual. 16.1.14 Premenstrual
Syndrome
1. Given a patient with premenstrual syndrome the resident will be able to elicit a history, perform a physical examination, establish a brief differential diagnosis and list initial therapeutic and diagnostic regimen. Reference: Pernoll and Benson, Chapter 33 and Roberts and Hedges COGNITIVE 16.3 Obstetric 16.3.1 Contraception 1. List four indications for birth control. 2. List the risks (if any) and effectiveness of each of
Reference: Pernoll and Benson, Chapter 7. Reference: Pernoll and Benson, Chapter 5. 2. List the treatment each of the following disorders at a) 8 weeks pregnant (first trimester) versus b) 36 weeks pregnant (third trimester). 1. UT1 2. a) Pharyngitis b) Penicillin allergic 3. Pneumonia 4. Cellulitis 5. Pulmonary embolus 6. Otitis media 7. Hyperemesis 8. URI Reference: Pernoll and Benson, Chapter 19, 63. 3. Identify the physiology and suggested therapy for each of the following common complaints of pregnancy:
540
a. pica b. urinary frequency c. vaginal infections 1. Gardnerella Vaginalis 2. Trichomoniasis 3. Candidiasis d. varicose veins e. edema f. joint pain, backache and pelvic pressure g. leg cramps h. breast soreness i. discomfort in the hands 4. Identify the risks associated with each of the following in pregnancy: a. cigarette smoking b. alcoholic beverages c. douching d . immunication e. exercise f. travel 16.3.3 Pregnancy, Complicated 16.3.3.1 Ectopic Pregnancy 1. In a suspected ectopic pregnancy, categorize the influence of each of the following twenty-six items on determining the diagnosis of ectopic pregnancy. Categories are very likely, somewhat likely, unlikely or not helpful: 6 weeks amenorrhea :: 24 weeks amenorrhea C. use of a diaphragm d. IUD e. left lower quandrant pain f. acute sudden onset of pain vaginal bleeding !: previous pelvic surgery i. previous episode of pelvic inflammatory disease/salpingitis j. breast tenderness, increasing fatigue k. right lower quandrant pain 1. CVA tenderness m. diffusive abdominal pain n. suprapubic tenderness right or left adnexal tenderness 0. P* cervical motion tenderness q. adnexal mass r. vaginal bleeding urine pregnancy negative, serum pregnancy S. positive t. pregnancy test negative U. no fluid obtained on culdocentesis V. straw colored fluid obtained on cultocentesis
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
w. 5 cc’s nonclotting blood obtained x. 5 cc’s clotting blood obtained on culdocentesis y. ultrasound with no gestational sack seen in uterus with positive pregnancy test z. ultrasound showing gestational sack in adnexae 2. Given a patient with suspected ectopic pregnancy, list at least five prioritized other potential diagnostic possibilities. 3. List in order the five primary steps to the stabilization and resuscitation of a hypotensive female with suspected ruptured ectopic pregnancy. Reference: Pernoll and Benson, Chapter 12. 16.3.3.2 Abortion 1. Define spontaneous abortion 2. Define complete abortion 3. For each of the following identify three major components that contribute to spontaneous abortion. a. First trimester ovulatory factors b. Second trimester of maternal factors c. Systemic disease d. Immunologic disorders e. Toxic factors f. Uterine defects g. Psychic and emotional factors h. Trauma 4. Define at what point falling or abnormally low plasma levels of beta HCG are predictive of spontaneous abortion. 5. Identify the utility of ultrasonography in diagnosing impending spontaneous abortion. 6. Identify at least four other ,entities that comprise a differential diagnosis of spontaneous abortion. 7. Identify three complications of spontaneous abortion. 8. Define under what condition oxytocics should (for example oxytocin) be used in the treatment spontaneous abortion. Contrast this with ergot preparations and D&C. 16.3.3.2.1 Threatened abortion 1. Define threatened abortion with respect to clinical signs, symptoms and status of the fetus and cervix. 16.3.3.2.2 Inevitable abortion 1. Identify at least four of the six criteria that characterize inevitable abortion. 2. Identify how many of the above criteria are necessary to fit the definition of inevitable abortion. 16.3.3.2.3 Incomplete abortion
541
EM Objectives for Off-Service Rotations
1. Define incomplete abortion with respect to clinical signs and symptoms and fetal findings. 16.3.3.2.4 Septic abortion 1. Define septic abortion and identify its clinical signs and symptoms including pelvic findings and systemic symptoms. 2. Identify the circumstance under which abdominal hysterectomy should be considered as the treatment of choice for septic abortion. 16.3.3.2.5 Missed abortion 1. Define missed abortion 2. Identify three clinical signs and symptoms of missed abortion. 3. List two differential diagnoses for missed abortion. 4. Outline a treatment plan for missed abortion. 16.3.3.3 Premature membrane rupture 1. List five predisposing factors for premature rupture of membranes. 2. Identify three conditions precipitated by premature rupture of membranes. 3. List the seven components of the sterile speculum examination. 4. List four signs and symptoms of amnionitis. 5. Identify three conditions under which urgent intervention is necessary in patients with premature rupture of membranes. Reference: Pernoll and Benson, Chapter 14. 16.3.3.4 Abruptio Placenta 1. List five predisposing factors for abruptio placenta. 2. Write a description of the pathophysiologic events involved in abruptio placenta. 3. List five signs or symptoms consistent with abruptio placenta. 4. List at least four differential diagnoses for third trimester of vaginal bleeding. 5. Categorize the utility of each of the following tests in the setting of abruptio placenta: a. hemoglobin b. platelet count c. prothrombin time d. partial thromboplastin time e. ultrasound 6. Identify under what conditions are expectant, vaginal delivery, or Caesarian section intervention indicated in the treatment of a patient with abruptio placenta. Reference: Pernoll and Benson, Chapter 22.
16.3.3.5 Placenta Previa 1. List the three predisposing factors of placenta previa. 2. List the three components of the pathophysiologic process of bleeding in placenta previa. 3. Identify the cardinal sign of placenta previa. 4. List the timing, findings, and accuracy of an ultrasound examination in the patient with placenta previa. 5. Identify under what conditions expectant, vaginal delivery, or caesarian section delivery are indicated in the treatment of placenta previa. Reference: Pernoll and Benson, Chapter 22. 16.3.3.6 Toxemia 1. List the criteria necessary to diagnose: a. preeclampsia b. eclampsia 2. List two components of the pathophysiology of toxemia as it affects each of the following: a. Central nervous system b. ophthalmologic c. pulmonary d. cardiovascular e. hepatic f. renal g. hematologic h. endocrine 3. List the three cardinal symptoms or signs of toxemia. Include diagnostic criteria for each. 4. Identify the three goals in management of severe preclampsia. 5. Identify the loading and maintenance doses of magnesium sulfate in preclamptic blood pressure control. What are the physiologic endpoints? 6. Identify therapeutic agent selection, loading and maintenance dose for seizure control and control of blood pressure in eclampsia. 7. List at least three indications for delivery in patients with preeclampsia or eclampsia. Reference: Pernoll and Benson, Chapter 18. 16.3.4 Delivery 16.3.4.1 Normal 1. Identify the three stages of normal labor and the time course for each. 2. Identify the essential information gathered in the initial examination with regards to: a. abdominal exam b. fetal heart tones c. contractions d. vaginal exam
542
3. Correlate
4.
5.
6. 7.
8.
9.
the station of the presenting fetal part with anatomic location, i.e. crowning, -2 centimeter, + 3 centimeters. Identify the criteria needed to diagnose each of the following vaginal delivery presentations: a. LGA b. LOP c. RMP d. breech e. brow f. transverse List the cardinal events in each of the following phases of the second stage labor. a. engagement b. flexion c. descent d. internal rotation e. extention f. external rotation Identify criteria necessary for the performance of an episiotomy. List the five components of the immediate postpartum care of: a. the infant b. the mother List the five components of the APGAR score, and given these components in a real infant, be able to calculate and interpret the significance of the score Define and outline treatment for each of the following tears of the perineum. a. first degree b. second degree c. third degree d. fourth degree
Reference: Pernoll and Benson, Chapter 8. 16.3.4.2 Abnormal Labor and Delivery 1. Define each of the following: a. precipitous labor b . prolonged labor c. arrested labor Reference: Pernoll and Benson, Chapter 24. 16.3.4.2.2 Presentation 1. Define each of the following: a. frank breech b. complete breech c. footling breech 2. Briefly outline a technique for assistance in sterile vaginal delivery of breech presentation. 3. In the management of a breech delivery list at least 5 criteria needed for successful:
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
a. vaginal delivery b . caesarean section delivery Reference: Pernoll and Benson, Chapter 23. 16.3.4.2.1 Dystocia 1. Define shoulder dystocia and identify three potential causes. 2. List five complications of shoulder dystocia. 3. Describe two techniques for shoulder dystocia management. Reference: Pernoll and Benson, Chapter 23. 16.3.4.2.3 Prolapsed Cord 1. Define: a. overt cord prolapse b. fundic prolapse presentation c. occult prolapse 2. Identify four causes of prolapsed cord. 3. Name four components of the management of: a. overt cord prolapse b. occult cord prolapse c. fundic presentation Reference: Pernoll and Benson, Chapter 23. 16.3.4.2.4 Caesarean Section 1. See Procedural Section. 16.35 Postpartum tions
hemorrhage/infection/complica-
1. Define postpartum hemorrhage. 2. For each of the following causes of postpartum hemorrhage identify the frequency, predisposing cause, diagnoses and treatment: a. uterine atony b. obstetric laceration c. retained productions of conception d. coagulation defects 3. Define uterine eversion and list three predisposing conditions. 4. Name two methods of treatment for uterine eversion. 5. Identify the pathophysiology, diagnosis and treatment of each of the following as a postpartum complication: a. endometritis b. septic pelvic thrombophlebitis c. wound infection d. mastitis e. amnionic fluid embolus f. puerperal sepsis Reference: Pernoll and Benson, Chapters 29 and 58
543
EM Objectives for Off-Service Rotations
16.5 Genital - Female
16.5.1 Dysfunctional
Uterine Bleeding
1. Define and list at least two etiologies and therapies for each of the patterns of vaginal bleeding: a. dysmenorrhea b . menorrhagia c. metrorrhagia d. hypomenorrhagia e. polymenorrhagia f. menometrorrhagia g. oligomenorrhagia h. post coital bleeding 2. Define dysfunctional uterine bleeding. 3. List two etiologies and therapies for dysfunctional uterine bleeding in each of the following: a. adolescent women b. young women c. premenopausal women 4. Define postmenopausal bleeding. 5. List the three etiologic classes of postmenopausal bleeding and their therapies. Reference: Pernoll and Benson, Chapter 33. 165.2 Sexual Assault 1. Define the following according to ACOG guidelines: a. rape b. statutory rape c. sexual molestation d. deviant sexual assault 2. In suspected rape: a. name the laboratory/crime lab specimens that should be collected in each case b. give the significance of a positive acid phosphate test c. List two medical therapies for preventing pregnancy d. give the timing and logic of medical follow-up care (include laboratory work to be performed) Reference: Pernoll and Benson, Chapter 61. (see 16.4.9) 16.5.3 Infections 16.5.3.1 Bartholin abscess 1. Identify the anatomic location of Bartholin’s glands. 2. Name three most common infecting organisms of Bartholin’s gland cysts. Reference: Pernoll and Benson, Chapter 34. 16.5.3.2 Cervicitis
1. Identify at least three signs and symptoms of cervicitis 2. Identify the two most common etiologies of cervicitis and the appropriate antibiotic therapy for each. 3. Identify the influence of cervicitis on PAP smear testing. Reference: Pernoll and Benson, Chapter 35. 16.5.3.3 Endometritis 1. Define and list at least three signs and symptoms of each: a. metritis b. endometritis 2. List the two most common auaerolsis and aerobic bacterial isolater from postpartum endometritis. 3. Given a patient with suspected postpartum endometritis, identify three acceptable antibiotic therapies. Reference: Pernoll and Benson, Chapter 29. 16.5.3.4 Salpingitis 1. Identify at least four clinical signs and symptoms of salpingitis. 2. Identify at least five risk factors for pelvic inflammatory disease (PID) or salpingitis. 3. Given a patient with pelvic pain, state the criteria for the diagnosis of PID/salpingitis according to the American College of Obstetrics and Gynecology (ACOG). Reference: OB and Gynecology, June 83 (61): 114. 4. Define the three clinical stages of PID (1. uncomplicated, 2. complicated, 3. ruptured tubo-ovarian abscess) and match with the ACOG approved medical-surgical therapy. 5. List CDC approved antiotic regimens for PID for: a. uncomplicated PID b. complicated PID Reference: OB and GYN. Jan. 83, (61) 114. 16.5.4 lbbo-Ovarian
Abscess (TOA)
1. Given a 22 year old nulliparous, sexually active female who uses an IUD for contraception: a. name three risk factors for TOA b. name criteria for surgery c. name three complications of TOA’s. Reference: Pernoll and Benson, Chapter 38. 16.5.5 Vulvo-Vaginitis (see 16.1.3) 1. Match the following vulvar infections with the antibiotic drug of choice.
544
Glenn C. Hamilton, Clifton A. Sheets, Mark A. Eilers
a. tinea cruris b. erythrasma (C. minutissium) c. scabies d. crab lice e. folliculitis f. pinworms Identify therapy for the following vaginal infection for A) an 18 yo allergic to PCN, B) a 24 yo, 2 months pregnant, and C) a 35 yo allergic to sulfa: i) nonspecific vaginitis ii) monilliasis iii) trichomonaisis iv) mucopurulent cervicitis Given a patient with a single, large, painful human genital wart (Condyloma acuminatum) be able to: a. identify the lesion by its appearance b. describe three modes of therapy c. state the associated cancer risk 4. For genital herpes (Herpes Simplex, Type #), identify the: a. incubation period b. period of infectivity c. signs and symptoms of primary infection, secondary eruption d. culture and laboratory methods of diagnosis e. medical therapy options Reference: Pernoll and Benson, Chapter 34. 165.6 Ovarian Cysts 1. List three potential etiologies for acute abdominal pain in a patient with a known six centimeter solitary ovarian cyst. 2. List at least two diagnostic modalities for the above. Reference: Pernoll and Benson, Chapter 37. 165.7 Ovarian Torsion 1. List two risk factors for ovarian torsion. 2. List three signs and symptoms of ovarian torsion. 3. Identify at least three components of a differential diagnosis of ovarian torsion. 4. Outline currently accepted medical/surgical therapy for ovarian torsion. Reference: Pernoll and Benson, Chapter 37. 16.6 Trauma 16.6.1 Principles of Emergency Care 16.6.2 Specific organ Injury 16.5.2.3 External Genitalia 1. Outline a conservative
labial hematoma.
therapeutic
approach to a
2. List two indications for surgical intervention labial hematoma.
in a
Reference: Pernoll and Benson, Chapter 3 1. 16.5.2.4 Vagina/Uterus 1. In a 2 centimeter posterior vaginal laceration that does not extend into the rectum: a. select appropriate suture material b. name appropriate anesthesia and anesthestetic techniques c. identify appropriate suture technique Reference: Pernoll and Benson, Chapter 3 1. 16.6.3 Trauma in Pregnancy 1. Given a near term pregnant female who has been severely traumatized: a. name three ways to prevent uterine compression of venous return (supine hypotensive syndrome) b. state the earliest sign of fetal distress c. state four criteria for peritoneal lavage d. state the criteria for site selection for peritoneal lavage 2. Given a near term pregnant female who has been severely traumatized, and is hypotensive, categorize the use of the following as a) indicated and safe, b) indicated with some maternal/fetal risk, c) contraindicated. a. ephedrine blood pressure support b. epinephrine blood pressure support c. uterine displacer d. elevation of right side 15-20 degrees e. MAST Trousers f. uncrossmatched blood g. peritoneal lavage h. culdocentesis Reference: Buchshaum, H. “Trauma in Pregnancy”Selected Optional Reading 16.7 PROCEDURES 16.7.1 General Procedures
Pelvic Examination-given an actual adult of pediatric patient be able to perform a complete pelvic examination. This will be confirmed. (Examined by an attending.) To include examination under anesthesia. Cervical and Vaginal Smear Interpretation-be able to collect and interpret cervical and/or vaginal smear material for a) clue cells, b) trichomoniasis, and c) white cells with intracellular diplococci, sperm and KOH prep for pseudohyphae. 16.7.2 Culdocentesis
545
EM Objectives for Off-Service Rotations
1. Perform a culdocentesis under observation of either the OB/Gyn resident, attending or emergency department physician. Identify the indications and contraindications of the procedure, (see also 16.3.3.1 Ectopic pregnancy). Reference: Roberts and Hedges, Chapter 52.
emergent or elective caesarean section assist the resident or attending physician in performing at least three caesarean sections. References: Approach Hedges, Chapter 50.
To Manual and Roberts and
16.7.3 Delivery of Newborn
16.7.4 Dilatation and Curettage (D&C)
16.7.3.1 Normal Delivery
1 Assist on dilatation and curettage (D&C) - given a patient requiring a dilatation and curettage assist the attending or physician perform a dilatation and curettage.
1. An uncomplicated full term pregnancy-be able to deliver the fetus and placenta. Examine for complications, (i.e., lacerations or extension of episiotomy. 16.7.3.2 Breech Delivery 1. Assist or observe delivery of breech presentation infant. 16.7.3.3 Perimortum Caesarean Section 1. Given a morbund, near term mother state the circumstances that might lead to a perimortum Caesarean section. 2. Given the above circumstances, outline the procedure techniques and time course to completion. Reference: Pernoll and Benson, Chapter 27. 16.7.3.4 Caesarean Section 1. Assist on C-Section-given
a patient requiring an
OBSTETRICS AND GYNECOLOGY ROTATION REFERENCES (IN BRIEFCASE) 1. Pernoll ML, Benson RD (eds). Current obstetric and gynecologic diagnosis and treatment, 6th ed. Connecticut: Appleton and Lange; 1987. 2. Berkowitz RL, Couston DR, Mochizulski TK. Handbook for prescribing medications during pregnancy, 2nd ed. Boston: Little, Brown and Company; 1986. 3. Approach to presenting signs and symptoms in the emergency department. Located at: Department of Emergency Medicine, Wright State University, Dayton, OH. 1987. 4. Roberts JR, Jedges JR. Clinical procedures in emergency medicine. Philadelphia, WG Saunders; 1985. 5. Buchsbaum H. Trauma in pregnancy. Philadelphia: WB Saunders; 1979. 6. Specific Papers a. Hager WD, Eschenbach DA, Spence MR, Sweet RL. Criteria for diagnosis and grading of salpingitis. OB&GYN. 1983;61: 113.