Pediatric Emergency Medicine

Rotation Director:

Name: Beech Burns, MD

Email: burnsb@ohsu.edu (preferred method of communication)

Office: CDRC-west

Phone: 503-347-2045

Overview:

This rotation provides direct clinical experience working in the pediatric emergency department. Residents will complete an emergency department rotation three times during their training, once during each year.

Rotation goals and objectives:

    • Residents are expected to come prepared to see a wide variety of patients, from true emergencies to perceived emergencies

    • Residents will have the opportunity to learn the following during their rotations:

      • Care for the undifferentiated disease

      • Work effectively with a multidisciplinary team in a busy clinical setting

      • Learn to multi-task patients (primarily in the 2nd and 3rd year)

      • Procedure skills including splinting, suturing, LP, and intubation. Residents will also complete an RN procedure shift ½ day

      • Manage minor pediatric trauma

Prior to the start of the rotation:

    • Residents MUST watch this brief orientation video (19 minutes)

    • Look at the ED specific amion to confirm your shifts (amion.com, password “ohsu” -->emergency department. From there you can look at your name just as you would in the pediatric amion)

      • Please notify the peds chiefs if there is any discrepancy in your schedule compared to the peds amion

First day of the rotation:

    • Come prepared by having watched the above orientation video

    • Please arrive to the pediatric emergency department (located on the 8th floor of the main hospital) 30 minutes prior to the start of your shift time on your first day to ensure adequate orientation time.

    • Make sure you are in the correct context (Emergency Dept HRC). From there you can click “ED peds and reception” to see the pediatric patients

    • Assign yourself to new patients. Please note the legend at the top of the track board will help remind you of the colors (bright red is ready to be seen by a provider)

      • You must first sign-in (Hit “sign-in” at the top of the track board screen) – be sure to change your contact # (the yellow phone you’re holding) and your current role

      • Once you are signed in, you can right click on a patient and hit “assign me”

    • Notes should be done using NOTEWRITER function and shared so that the attending can edit if needed

Resident Expectations:

    • Residents are expected to complete notes promptly after the completion of their shift. For admitted patients, the note should be completed no more than 12 hours after the shift concludes

    • Traumas: Residents have the opportunity to participate in pediatric traumas. These take place on the adult side and residents should touch base with the pediatric ED attending prior to the trauma arrival as one provider will also need to stay on the pediatric side to continue managing patients

    • Staffing: Residents will staff each patient with the attending. The attending must see each patient prior to discharge from the ED. Staffing time and style is attending dependent, but please note that in the busy ED especially, residents may have the opportunity to begin work-up, anticipatory guidance, consults, etc prior to attending discussion depending on the resident comfort level and attending preference

    • Patient load: Residents will see multiple patients at one time and will practice management of patients simultaneously. Residents are expected to sign-up for any type of patient that comes into the unit

    • At the end of the shift: Residents should be aware of time and how many patients they are carrying toward the end of their shift. Residents should wrap up as much as possible, this means sometimes staying a little late to wrap up patient care. Patients with ongoing care/work-up can be signed out to the oncoming resident or discussed with the attending but MUST have a hand-off to a provider prior to leaving.

General Schedule:

    • Residents work a combination of the following 8 hour shifts. As above, the schedule is found under the ED amion

      • 10a-6p

      • 3p-11p

      • 6p-2a

    • Please note: If a co-resident is ill during one of the shifts, the emergency department moves to a two shift system. You may be asked by the peds chiefs or EM chiefs to adjust your schedule to help accommodate this change. The two shift schedule is typically:

      • 12pm-8pm (if you are the 10am-6pm or 3pm-11pm resident you may be asked to move to this time slot)

      • 6pm-2am (if you are the 3pm-11pm resident and the 6p-2a resident is sick you may be asked to move to this time slot)

    • On average, first year residents will work 12 shifts, 2nd year residents will work 8 shifts (with vacation also occurring during this block), and 3rd year residents will work 12 shifts. This exact number will vary among residents

    • Once during your rotation, residents will also participate in an RN procedure shift. This will be from 5p-9p. During this time, the resident will be paired with the nursing staff to participate in procedures such as lab draws, IV placement, and bladder catheterization. The procedures shift resident will not perform procedures that other residents have an opportunity to complete as part of their clinical care (such as LP or abscess drainage). Residents will also not have other clinical care responsibilities as they are on a separate shift from the regularly scheduled hours as above.

If you are going to be absent for all or part of a day:

    • Please contact (page or text) chief on call as soon as possible. A verbal exchange must happen with the chief on call because you may need to contact other individuals.

    • Any resident missing more than 2 days (or 4 half days) may be required to make up the difference at a future date at the discretion of the rotation director, chiefs, and program leadership.

    • Please see “general schedule” above regarding adjusted schedules when any resident is sick

Resident Resources, Helpful Tips, and Reading List:

Box Folder

ALTE/BRUE:

Tieder JS, Bonkowsky JL, Etzel RA, et al. “Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants”. Pediatrics. May 2016; 137(5)

Asthma:

Keeney GE, Gray MP, Morrison AK, et al. “Dexamethasone for acute asthma exacerbations in children: a meta-analysis”. Pediatrics. March 2014; 133(3): 493-9

Bronchiolitis:

Corneli HM, Zorc JJ, Mahajan P, et al. “A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis” NEJM. July 2007; 357(4): 331-338

Ralston SL, Lieberthal AS, Meissner HC, et al. “Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis”. Pediatrics. Nov 2014; 134(5): e1474-e1502

Fever:

Ishimine P. “Risk stratification and management of the febrile young child”. Emerg Med Clin of North Amer. Aug 2013; 31(3):601-26

Levine DA, Platt SL, Dayan PS, et al. “Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections”. Pediatrics. Jun 2004; 113(6):1728-34

Orthopedics/Fractures:

Davidson AW. “Rock-paper-scissors”. Injury. Jan 2003; 61-3.

Seizures:

Szlam S, Meredith M. “Shake, rattle, and roll: an update on pediatric seizures”. Pediatr Emerg Care. Dec 2013; 29(12): 1287-91

Sepsis/Shock:

Carcillo JA, Davis AL, Zaritsky A. “Role of early fluid resuscitation in pediatric septic shock”. JAMA. 1991; 266: 1242-45

Sedation:

Beach ML, Cohen DM, Gallagher BS, et al. “Major adverse events and relationship to Nil per os status in pediatric sedation/anesthesia outside the operating room”. Anesthesiology. 2016; 124:80-88

Fernanda-Bellolio M, Puls HA, Anderson JL, et al. “Incidence of adverse events in pediatric procedural sedation in the emergency department: a systematic review and meta-analysis”. BMJ Open. 2016.

Trauma:

Holmes JF, et al. “Identifying children at very low risk of clinically important blunt abdominal injuries”. Ann Emerg Med. 2013; 62(2):107-116

Kupperman N, et al. “Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study”. Lancet. 2009; 3(374):1160-70.

Urinary Tract Infections:

Hoberman A, Wald ER, Hickey RW, et al. “Oral versus initial intravenous therapy for UTI in young febrile children”. Pediatrics. 1999. 104:79-86.

Subcommittee on UTI, Steering Committee on QI. “Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months”. Pediatrics. Sept 2011; 128(3): 595-610