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Emergency Medicine Residency Program
Director
Background The Department of Emergency Medicine at HCMC was established in 1971. One of the main tasks of the department was to institute a residency program in Emergency Medicine. In 1972, the HCMC Emergency Medicine Residency Program was established making it the second residency program available in the United States, and thus one of the oldest emergency medicine residencies in the country. Beginning with two residents and one academic faculty more than 30 years ago, the program today has 33 residents and 24 full and part-time academic emergency medicine faculty. Hennepin County Medical Center is a 416 bed, county-owned facilty and Minnesota's first Level 1 Trauma Center. Hennepin County Medical Center Hennepin County Medical Center opened as a city Hospital in 1887, and has been in continuous operation ever since. The original hospital opened with 61 beds, 4 nurses, 1 matron, 1 handyman, 1 faculty, 2 interns, and had a daily charge of $.89 per day! The Emergency Department In 1999 the entire Emergency Department was renovated and expanded, creating 45 examination rooms and 4 spacious stabilization rooms with state-of-the-art equipment. This renovation included the installation of a dedicated CT scanner, a complete digital medical imaging system and finished the transition to an entirely paperless department with computerized charting. All clerical, nursing and physician workstations have dedicated computer access and the department maintains more than 20 computers on wheels (COWS). A mixture of county and private ED experiences guarantees our residents exposure to a variety of patients. With a large and diverse patient population, the clinical experience our residents receive is outstanding. We have a strong commitment to research. Some of our most recent projects include cutting-edge studies in procedural sedation, airway management, ultrasound and issues of social and educational importance in medicine. Here is our 2009-2010 Annual Report. Program Goals and Philosophy We will advance the quality of emergency care by contributing new knowledge and skills obtained through active biomedical research and innovation in the practice of Emergency Medicine. Highlights of the Emergency Medicine Residency First, see this brochure to find out why Minneapolis-St. Paul is a great place to live. Click here to discover some of the reasons that we have a great quality of life. There is a thriving artistic community (dance, theatre, museums, music), with more theatre per capita than any city in the U.S. except New York. It is among the best cities for biking, most literate and educated cities, has dozens of lakes, and the Mississippi River Valley, all with running and biking trails (see this map), a 35k Nordic ski trail in the city limits, Easy access to the North Shore of Lake Superior and the Boundary Waters, scores of beautiful State Parks. Unlike places where the snow and ice melt to slush and mud, Winter is actually fun here: there’s hockey, ice skating on 47 free outdoor rinks, Nordic skiing (scores of parks for this), sledding, the luminary loppet, broomball. If you just can’t make friends with the Winter, there is the Skyway system that keeps you out of it and all the aforementioned arts. For 15 years in a row, US News and World Report has listed HCMC among 150 hospitals as one of “America’s Best Hospitals.” The Financial status of our public hospital is outstanding. Thanks to strong financial stewardship and highly efficient delivery of high quality health care, in 2009, HCMC received 5% of its revenues from county property taxes, far less than most other public safety net hospitals in the U.S. (average 12%, maximum 48%). Minnesota has one of the highest insurance rates in the country, so that almost all patients have some ability to pay, ensuring financial stability. Leadership. Our chief, Dr. Joseph Clinton, had been a leader in EM for 35 years, was the president of ABEM when we became a primary specialty board in 1989 and has made our ED into a leading department in the hospital, locally and nationally. You will be assured of high respect and status as an EM resident at HCMC and be a more than equal member of any inpatient team you work on. See here for more on Joe Clinton. Assisting Dr. Clinton in leadership is Dr. Douglas Brunette (Assistant Chief and Medical Director for the Emergency Department) and Dr. William Heegaard (Assistant Chief of Business Affairs and Outreach Activities) Our leadership in EM is exemplified by Dr. Louis Ling, who is past president of SAEM and ABEM and past or current chair, founding member, or board member of nearly every important national and local medical education committee in existence. See here for a list of some of Louis’ more important past and present positions. Experience. The HCMC EM residency was started by Dr. Ernie Ruiz, a surgeon, in 1972, the earliest year of any EM residency. Dr. Clinton continued as residency director in the 1980’s, followed by Dr. Doug Brunette. Under Dr. Marc Martel, the residency developed further and he has now passed that on to Dr. Richard Gray, who is supported by Associate Director Dr. Eric Gross and Assistant Director Dr. Danielle Hart. Electronic Health Record. The Emergency Department, which has had a fully electronic medical record since 2001, is now fully integrated with Epic, HCMC’s electronic medical record system, which was introduced in 2007. Computerized physician order entry, real-time nurse charting during critical stabilization cases and utilization of Dragon Speech Recognition software for physician dictation directly into Epic are examples of the leadership the Emergency Department has demonstrated in advancing the utility of Epic. Dr. Doug Brunette is the departmental liaison for Epic and serves on the Epic Physician Champion Committee. Collegial Teamwork. There is a long tradition of cooperative, non-hierarchichal teamwork among providers and ancillary staff of all levels, fostering excellent communication, low anxiety and great patient care. New Simulation Center. Dr. Danielle Hart has fully integrated a high fidelity simulation curriculum into EM residency training. The new interdisciplinary simulation & education center (HCMC-ISEC) is currently under construction. This will be a state of the art simulation facility, ultimately comprising 10,000 square feet on the downtown campus. The first phase of this project is projected to open in the summer of 2012 and will include 5,000 square feet of simulation space. This will enable the learners to participate in high fidelity human patient simulation cases, task trainer / procedural skill trainer activities and standardized patient encounters. Virtual reality is included in future plans for the simulation center. Dr. Hart has spoken locally, regionally, nationally and internationally on simulation topics. See below for further information on the new simulation center. Cardiology and ECG training. Hennepin Heart Center has a full cardiac and cardiac surgery service. Door to Balloon time is among the best in the country, with a mean 56 minutes, largely due to our prehospital cath lab activation. We were the first hospital in Minnesota to start therapeutic cooling for cardiac arrest. As described below, our EMS system has unsurpassed cardiac arrest survival. Dr. Stephen Smith, of Dr. Smith’s ECG Blog and author of the textbook The ECG in Acute MI, is one of the nation’s leading experts on the ECG in Emergency Medicine. He is also editor of another ECG textbook and of many textbook chapters on the ECG in Emergency Medicine, as well as articles on the use of troponin in the diagnosis of ACS. He is on the Editorial Board of AEM journal as a Cardiology Decision Editor. Here is a link to the curriculum of our 34-hour resident electrocardiography course taught by Dr. Smith. Ultrasound. Dr. Rob Reardon is one of the world’s leaders in emergency ultrasound and is director of ultrasound in the Emergency Department as well as director of the ultrasound fellowship. His fellows have gone on to lead ED residency ultrasound programs all over the country. Dr. Dave Plummer has long been involved with ultrasound teaching and research and is another leader in the field. We offer incredible bedside ultrasound training for all residents. Because the HCMC ED has incorporated ultrasound for 26 years, all faculty are proficient. We are the only ED program with an emergency ultrasound technologist (Liberty Caroon) dedicated to teaching residents the spectrum of ultrasound use both didactically and at the bedside. We have 12 ultrasound machines, wireless capture of images and video and mounted machines in critical care and pelvic rooms. Here is a link to our ultrasound fellowship; all the fellowship benefits apply to resident training as well. Here is a link to Rob’s Ultrasound Manual; he is also an instructor in the Emergency Ultrasound Course. See our formal ultrasound curriculum here. Here is a link to some of our research in ultrasound. Liberty and Dr. Reardon work with the interns for two full days (16 hours) at the start of the residency, at which time residents attend 8 lectures and gethands- on experience. Then, interns are scheduled with Liberty for a 1/2 day during their toxicology month. Every month, for 1 hour, Liberty and others conduct an interactive ultrasound session for all residents to learn proper transducer placement and manipulation to optimize ultrasound images and to review unique cases. There are multiple other venues for ultrasound, including stabilization room conference. For the G3's, we offer an elective one month ultrasound rotation in advanced ultrasound imaging with the option to obtain their RDMS (Registered Diagnostic Medical Sonographer). You may create ultrasound presentations and place them on our outstanding educational web site, www.hqmeded.com. You will learn: Trauma, Intrauterine Pregnancy, AAA, Cardiac, Biliary, Urinary Tract, DVT, Soft-tissue/musculoskeletal, Thoracic, Ocular, Procedural Guidance and, in addition, many more cutting edge applications. Procedure lab. This unique lab (truly unique, as it is found nowhere else), developed by our founder and former chief, Dr. Ernie Ruiz, has operated continuously since 1977. You will work one on one with a faculty member for 6 hours, practicing 50 different procedures, once in each year of your residency. Among the procedures learned is skull trephination (which is taught in no other EM residency, and makes a difference in saving lives), cricothyrotomy, thoracotomy, pericardiotomy, cardiac wound repair, internal cardiac “massage” and defibrillation, internal transvenous cardiac pacing, suprapubic catheter placement, retrograde intubation, and more. Airway. Drs. John McGill and Rob Reardon are the leaders of our airway program. There are 400 intubations per year in the ED, all of which are video recorded for purposes of QA, teaching and research. Enabled by the technical expertise of Dr. Scott Joing, the department uses movement detection to trigger the recording of every airway intervention, from multiple vantage points, as well as laryngeal views using the CMAC videoscope. Particular strengths of EM airway teaching include focus and expertise in use of the bougie and the ILMA. We are also one of the few training programs with sufficient faculty experience to effectively teach nasotracheal intubation. The department's long term commitment to the advancement of emergency airway management is evidenced by it being the first EM department to publish articles on cricothyrotomy, use of paralytics, fiberoptic intubation and use of ILMA in the ED. The department has authored the primary airway chapters in Roberts and Hedges (the best known procedural text in EM) since its inception 30 years ago. Dr. Rob Reardon is an instructor in the Difficult Airway Course. Trauma Care. Hennepin County Medical Center became Minnesota's first Level I Trauma Center in 1988. HCMC was recently re-verified as an adult Level 1 Trauma Center and verified as a Pediatric Level I Trauma Center in 2010. As an emergency medicine resident you will manage all airways within the emergency department. You will direct the initial stabilization of all trauma patients. We have a respectful and cooperative relationship with our trauma surgeon colleagues. As our Department’s first Chief, Dr. Ernest Ruiz (both a practicing surgeon and emergency physician) emphasized since the inception of the ED, outstanding trauma care requires exceptional Emergency Medicine stabilization and seamless transfer of care to our surgical colleagues. In short, it takes a team which receives strong institutional support to deliver outstanding trauma care. We have this kind of teamwork at HCMC and we will provide you with the best EM trauma care training in the nation. Hyperbaric Medicine. Under the leadership of Dr. Cheryl Adkinson, a grand new hyperbaric medicine facility will be opening at HCMC in April 2012. Three multiplace (walk-in) chambers with state-of-the-art critical care capabilities will allow the Division of Hyperbaric Medicine to carry on, uninterrupted, the 50 year tradition of providing 24/7 hyperbaric oxygen treatment to the sickest of the sick in the state of MN and bordering states. EM residents are directly involved with the care of emergency hyperbaric patients, as is our fellow in the ACGME certified Undersea and Hyperbaric Medicine fellowship. Critical Care experience. HCMC has a very high volume of critically ill patients andphenomenal patient care outcomes in both our ED and ICUs. You will rotate in the Medical ICU as an intern and as a G2 you will be the responsible resident, taking the same role as a 3rd year medical resident. Our weekly Critical Care Conference is an amazing multispecialty conference that focuses on Stabilization Room cases. It is so popular that scores of physicians watch it online from all over the state and country. As a 3rd year resident, you will run all critical cases and present the chosen ones at this conference. Publications/Research. Dr. James Miner, prolific author of scores of articles and developer of the research associate (RA) program at HCMC, is the director of research and is supported by the former director, Dr. Michelle Biros (member of the Institute of Medicine and former 10 year editor-in-chief of Academic Emergency Medicine). In 2009-2010, our 22 faculty totaled 198 publications: 94 peer-reviewed works, 50 abstracts, and 54 chapters and books. There is a wide variety of Emergency Medicine research being conducted here; the principal focus of our collective efforts is in critical care, with principal investigators focusing in the areas of tissue perfusion monitoring, ventilatory monitoring, ultrasound evaluation, airway management, cardio-pulmonary resuscitation, pain management and sedation, brain injury, diagnosis and management of acute coronary syndromes. Other areas of research in our department include multiple areas of toxicology, healthcare disparities, the treatment of asthma, soft tissue infections, cocaine intoxication, the management of agitated delirium and the medical aspects of law enforcement. Our investigators work together using the research associates and our department’s strong research infrastructure to collaboratively accomplish high quality research. Here is a link to the Research Associate Program. We are the only non-university hospital to have an SAEM-accredited research fellowship program. Here is a link to research we’ve done in the past 30 years and past 10 years. Stroke Center. The ED and Neurology have developed a strong clinical and research collaboration, led by Dr. Michelle Biros, our neurology liaison. We have an integrated stroke team and stroke fellowship program and receive many stroke transfers. In 2010, we activated 253 stroke codes and for the 40 patients who received tPA for stroke in 2010, we had a mean Door to Needle Time of 49 minutes (only 7% of hospitals have mean times less than 60 minutes). We perform invasive stroke therapy for those who do not reperfuse or whose time of presentation is beyond the tPA window. We are a national leader in study enrollment and have developed outreach research and clinical protocols with many of our referral hospitals in our effort to improve the care of Minnesota patients with neurological emergencies. Pain and Procedural Sedation. The Emergency Department at HCMC performs a variety of research in the areas of Procedural Sedation and Pain Management. Our research has lead to the development and enactment of several novel protocols that improve patient comfort and experience. This is one of Dr. Jim Miner’s areas of research concentration and it has led to our state of the art practice in pain management. Pediatrics. Dr. Albert Tsai, trained in both EM and pediatrics, heads our pediatric program, which includes the Pediatric ED, with priority placement of pediatric patients to specific beds and play areas, pediatric certification in Advanced Pediatric Life Support/Pediatric Advanced Life Support for nursing and medical staff, dedicated pediatric nursing and medical director (Dr. Tsai) of Pediatric Emergency Medicine. We network with Twin Cities area pediatric hospitals and Pediatric Emergency Medicine practitioners through monthly education conferences. We have comprehensive critical care capabilities with a dedicated space in the critical care area of the ED and in-house intensive care units for neonatal, trauma (including burns) and medical, as well as designation as a Pediatric Level I Trauma Center by ACS. Finally, we offer a pediatric selective at the University of Minnesota, where you will see many rare pediatric conditions. International Medicine. Dr. Stephen Dunlop completed a 2-year fellowship in international medicine and runs a great international program. During this 2 year fellowship, Dr. Dunlop completed a Masters in Public Health focusing on Healthcare in the Developing world, a Certificate of Knowledge in Clinical Tropical Medicine and Travelers’ Health from the American Society of of Tropical Medicine and Hygiene and just returned from a 6 month assignment as Director of Outpatient Services at Arusha Lutheran Medical Centre in Tanzania. While there, Dr. Dunlop was tasked with improving the efficiency of the 50,000 visit per year Urgent Care. A number of our EM residents have rotated there with Dr. Dunlop this past year and have had a wonderful experience. We are thrilled to report that this opportunity will remain available to future residents. Toxicology. Hennepin County Medical Center is home to the Hennepin Regional Poison Center, which provides Poison Control for the states of Minnesota, North Dakota and South Dakota. The Hennepin Regional Poison Center takes over 80,000 calls per year from both health care professionals and the public. Dr. Jon Cole, Medical Director of the Poison Center is actively engaged in Toxicology Research. At the 2011 North American Congress of Clinical Toxicology, he presented 18 abstracts, participated in the CPC case competition and won for best case presentation, presented the number one abstract during the Platform Sessions and was awarded the Outstanding Young Investigator Award for the meeting. All in his first year! Prehospital/EMS. Dr. Brian Mahoney leads this division. The best measure of the complete efficiency of an EMS system is its cardiac arrest survival. No EMS system has a higher survival to discharge rate than ours, with an Utstein number of 49% (44 of 89 patients with witnessed ventricular fibrillation arrest survived in calendar year 2010). Overall survival of 17% is the highest in the nation among systems with at least 300 calls per year. Here is a link to our overall cardiac arrest data and here is a link to the Cares Agency Data for comparative Cardiac Arrest survival numbers. Here is some recent research by our team of cardiac arrest researchers, including Dr. Keith Lurie (an electrophysiologist who has joined our department) and Dr. Mahoney. Here is a list of Dr. Lurie’s publications in the last 8 years. Disaster Preparedness. HCMC is the leader in statewide disaster management under Dr. John Hick, a national and international leader who has published dozens of articles on disaster management. Here is a description of HCMC’s extensive role and experience in disaster preparedness. Other Teaching
Fellowships: Hyperbaric Medicine (ACGME), Toxicology, Ultrasound, Research, International Medicine, EMS. Tactical Medicine: Dr. Jeffrey Ho is EMS Fellowship trained and is a fully sworn and licensed peace officer. He has a unique perspective of applying clinical medicine in street situations. He is the Medical Director for a Fire Department EMS service, a county sheriff's office and for TASER International, Inc. He has prior operational experience with the US military and an urban SWAT Team. He now leads a cadre of researchers studying human effects of TASER devices and physiology involving law enforcement usage of force. His group received the prestigious 2010 Research Award from the International Association of Chief's of Police organization.
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