22101 Moross Rd., Detroit MI 43286

(313) 343-8797 sjhemergency@gmail.com

Selectives & Electives

Introduction

Welcome to the PGY‐3 Emergency Ultrasound Elective! This elective is designed for senior residents with a strong interest in emergency ultrasound and those considering pursuing an ultrasound fellowship after completion of residency. The purpose of this elective is to ensure competency in core emergency ultrasound applications, as well as to further delve into more advanced applications, such as Doppler, Echocardiography, and procedural based ultrasound techniques.

While the ultrasound elective is designed to improve your skills as a sonographer, we do ask that you also serve as a mentor to interns, medical students, and any off-service rotating residents who may wish to learn more about ultrasound. The capability to teach and instruct junior residents on ultrasound technique and applications is an important and invaluable component to your own learning.

We are excited to have you on board for the next several weeks! Please let us know what we can do to make this month enjoyable and valuable for you. As always, we will do our best to tailor the elective towards your own personal goals and objectives. Looking forward to scanning with you!

Goals and Description of the Rotation

The goal of this elective is better enhance your understanding of ultrasound physics, knobology, and more importantly, improve your proficiency in both core and advanced emergency ultrasound applications.

1. Competency in core emergency ultrasound applications:
A. Physics/Instrumentation
B. Cardiac
C. Lung
D. Biliary
E. Aorta
F. eFAST/FAST
G. Genitourinary (Renal and Scrotal)
H. OB/GYN (First Trimester Pregnancy)
I. Deep Venous Thrombosis
J. Ocular
K. Procedural
L. Soft Tissue and Musculoskeletal

2. Utilization and basic understanding of advanced emergency ultrasonography applications including Doppler, Echocardiography, and ultrasound guided procedures.

3. Completion of 300 scans during 4-week elective or 150 scans during 2-week elective (Mandatory). These scans should be logged into New Innovations by the completion of the elective.

4. Attendance at weekly Senior Ultrasound Shift, Friday 9am-5pm (Mandatory).

5. Attendance at monthly Wayne State University medical student ultrasound didactic lecture (Mandatory).

6. Attendance at weekly QA session, Monday 9am-12pm (Mandatory).

7. Self-administered test covering all core modalities (Mandatory).
• Please go to http://www.emsono.com/acep/ACEP_EUS_Exam.html
• Complete the tests for all modalities. Print your scores. If you fail the test, please try again. Print and email test scores for all modalities once completed. This is due on the last day of your rotation.

8. Ultrasound based case write up to be submitted to an online journal.
• 2-Week Elective (Optional)
• 4-Week Elective (Mandatory)

Ultrasound Rotation Details

Getting Started

Senior ultrasound electives may be scheduled as either a 2 or 4 week elective. Please contact the Ultrasound Faculty 1 week prior to the start of your rotation. Please also notify Barbara Martens via email of the planned dates for your elective.

Week 1 Orientation

Meet with one of the ultrasound faculty members during the first several days of your elective for orientation. We will cover the schedule over the course of the 2-4 week elective, as well as basic knobology, probe selection, core competencies to be covered, and how to save images to both the machine and a USB drive.

Scanning

The scanning schedule is typically Monday-Friday from 9am-5pm. You are not expected to work on the weekends or holidays. If, however, you are unable to complete a scanning shift during the week, you will be expected to complete the shift during a weekend day. Try to coordinate your scanning time alongside ultrasound faculty clinical shifts. You will also be expected to attend all senior ultrasound scanning shifts on Friday 9am-5pm at one of three clinical sites: St. John Hospital, Detroit Receiving Hospital, or Sinai Grace Hospital.

Study Submission

Please save your scans to a USB drive for weekly QA review.

Competency Assessment

In order to assess your competency in the core Emergency Ultrasound exams, we will evaluate your performance in several areas:

1. Assessment of Ultrasound Technique
• Direct Observation by Ultrasound Faculty
• Review of selected static and dynamic scans

2. Assessment of Image Interpretation

3. Self-Administered Test covering core competencies
• http://www.emsono.com/acep/ACEP_EUS_Exam.html

Other Resources

The following are some great resources that you should utilize and review during your elective month. The resources below will guide you through actual examination technique, as well as provide examples of abnormal pathology. Please review at your convenience.

1.General:
• http://www.sonoguide.com
• http://www.ultrasoundpodcast.com
• http://www.sonospot.com
• http://www.ultrasoundoftheweek.com

2. Echocardiography:
• http://web.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Main_Page
• http://www.vhlab.umn.edu/atlas/echocardiography-tutorial-video/index.shtml

3. Musculoskeletal:
• http://www.med.umich.edu/radiology/mskus/index.html

4. Procedural Skills:
• https://vimeo.com/mikestone

Contact Information

Dr. Leonoard Bunting, Ultrasound Director:
Email: Leonard.Bunting@stjohn.org
Phone Number: (248) 420-7680

Dr. Ashley Sullivan, Associate Ultrasound Director
Email: Ashley.Sullivan@stjohn.org
Phone Number: (317) 413-3995

Barbara Martens, Department of Emergency Medicine
Email: barbara.martens@stjohn.org
Phone Number: (313) 343-8797

Attachments
• Monthly Calendar (Updated Regularly)
• Emergency Ultrasound Guidelines – 2008
• Emergency Ultrasound Standard Reporting Guidelines
• Emergency Ultrasound Imaging Criteria Compendium (PDF)

Welcome to your EMS Rotation!

My name is Robert Dunne and I will be your rotation director for this fun and exciting 2-4 week experience in Pre-Hospital Emergency Medicine.

you can reach me by email at rkdunne@comcast.net

my cell phone is 248-894-4997

Instructor(s): 
Robert B Dunne MD, WSU EMS fellowship director
Marc Rosenthal DO, WSU Associate EMS fellowship director

EMS Faculty:
Erin Brennan MD

Stefanie Wise MD

EMS Fellow:
Vesta Anilus MD

Length: 2-4 week(s)

Level of Training: MS-4, PGY-2, PGY-3, or  PGY-4

Rotation Goals:
To provide Emergency Medicine Residents and Interested Students with exposure to the Detroit Area EMS system.
Participating with paramedics and EMT’s in ambulance run
Observation and participation at EMS base station.
To develop an appreciation for field conditions, time, personnel and equipment constraints on paramedic personnel.
To share our expertise in Emergency Medicine with pre-hospital personnel.
To facilitate a “team relationship” with paramedic personnel.
To participate in training of EMS personnel and health care providers in pre-hospital care of those requiring immediate medical care.
To understand the challenges and pitfalls of “On-Line” medical direction.
 
Resident Responsibilities:
The requirements of the EMS rotation during the EMS rotation are divided into (5) major categories:

(1) EMS Ride-Alongs: Participating in a total of 3 (three) full 8-hour days during the course of the week directly observing and, when appropriate, participating in the care of patient’s as they are assessed and transported by EMS personnel. Your responsibilities will be dictated by the EMS personnel you rotate with but will generally included:
a. Observation of EMS personnel and assisting when requested
b. Keeping patient logs and turning these in to Dr Dery and Renee Day at the Emergency Medicine Residency office.
Scheduling your EMS Ride-A-Long Shifts: YOU will be responsible to contact the agencies listed below at LEAST (1) week (seven days) in advance to make sure that there is a crew available on that day to have you as a ride-a-long. Please contact one of the agencies below to schedule your EMS Day:
Detroit Fire Department –
HART medical Ambulance -
Universal Ambulance -

Dress code: Casual dress is fine (Khaki and polo’s) or you can wear hospital issued scrubs but blue jeans and T shirts are NEVER acceptable nor do they represent the professional impression that we try to maintain. We are guests of the Fire Departments and we are representing their department while we are there.

Meals: The on-duty crews will typically ask you at the beginning of the shift of you brought your own food or if you are planning to eat with them. Bring Lunch and or money.

Duties: Discuss with your assigned crew what they want you to do on scene. Remember, your safety always comes first!
Evaluations: please bring a Shift Evaluation form with you to your EMS Day. You will need to have a member of your crew sign your evaluation form in order to get credit for your (8) hour shift. This form will need to be turned in the rest of your materials at the end of the rotation.

(2) Base Station Observation at St John Hospital Emergency Department to gain a better understanding of the overall function of the city wide EMS system and radio communication as the “On-Line” Medical Control.  Review the DEMCA protocols. www.demca.org

(3) NIMS Training modules.  This a FEDERAL requirement for all EM trained residents to complete. This is an introduction course in the Federal Incident Command Structure. At times of a mass casualty incident or chaos, there must be a simplistic and universal system to know “who is in charge” and who to report to within the Emergency Department and our surrounding community. At completion of this on-line training program, a certificate of completion will be mailed to you and should be turned into the EMS faculty advisor for placement in your permanent file.

Click here for the FEMA NIMS ICS 100 course (look on the right side of the page; FIRST, locate the heading on the right under TAKE THIS COURSE and click on the link immediately below; after you are done taking the coursework, you can look just underneath to the next heading entitled TAKE FINAL EXAM; click the link to take the test online)

Click here for the FEMA NIMS ICS 200 course (look on the right side of the page; FIRST, locate the heading on the right under TAKE THIS COURSE and click on the link immediately below; after you are done taking the coursework, you can look just underneath to the next heading entitled TAKE FINAL EXAM; click the link to take the test online)

Click here for the FEMA NIMS ICS 700 course (look on the right side of the page; FIRST, locate the heading on the right under TAKE THIS COURSE and click on the link immediately below; after you are done taking the coursework, you can look just underneath to the next heading entitled TAKE FINAL EXAM; click the link to take the test online)

incident (MCI); Discuss the real-time implementation and use of the incident-command system (ICS); Identify failure in communication between the EMS and Police response; Identify how best to use the resources “on-scene”
TIME: The anticipated time to complete this assignment is 45 mins.

(4) Assigned Readings: You will need to look at several different articles and journals during the course of this rotation. I am basing these reading on the Core Content of an EMS Fellowship published by the Journal of Prehospital Care (you can read this information by clicking here).

The required readings are listed below. You will be able to access these files from either this website directly, by clicking on weblinks that will open in a different page, or be available in the department for you to review on your own time.
Handbook for EMS Directors (published from FEMA): click here
Legal Aspects of CPR (from LegalAspects of EM): LegalAspects – CPR
Legal Aspects of C-Spine (from LegalAspects): CLICK HERE
Legal Aspects of Trauma article (from LegalAspects): click here
HEMS vs Ground Transport article (from JAMA, 2012): click here
Disaster Medicine Core Content article (from Annals of EM, 2012): click here
Terminating CPR (from NAEMSP Position Statement): click here
Safe Handoff’s between Ground & Air Teams (from AMPA, 2012): click here
EMTALA article from The Sullivan Group: Click here to download the PDF
Pre-Hospital Refusals (from Prehospital Emergency Care): click here
Tintinalli JE, Kelen GD, Stapczynski JS (eds).  Emergency Medicine: A Comprehensive Study Guide, 6 th ed. New York, McGraw-Hill,
Chapters    
Emergency Medical Services
Pre-hospital Equipment and Adjuncts
Air Medical Transport4     
Neonatal and Pediatric Transport
Mass Gathering
Disaster Medical Services
Cardiopulmonary Resuscitation in Adults
Neonatal Resuscitation in Emergencies
Pediatric Cardiopulmonary Resuscitation
Newer Resuscitative Techniques
Initial Approach to Trauma

(5) EMS lecture.  During the EMS week, the resident will prepare a lecture or interactive discussion that will be provided to the EMS personnel with whom you are interacting with during your week long rotation.  Alternatively, select individuals may be asked to prepare a lecture that will be provided as part of the biannual ED-EMS city-wide symposium or develop material to be added to the checktheleads.com website.

Talks given to EMS should be at an appropriate level for EMS personnel with the ultimate goal to share an Emergency Medicine perspective on typical presenting complaints and management techniques that will be encountered in the pre-hospital setting.
All materials MUST be reviewed and approved by EMS faculty prior to distribution.

(6) Administration Meetings with Faculty. You will be expected to assist and attend any EMS and Team meetings during your rotation. These can include:
Agency Meetings
Physician Advisory Board Meetings
Detroit Fire Department Meetings
Medical Control Authority Meeting/Training
Special Response Team Meeting/Training

REQUIRED FORMS – you should print these off and keep them with you
Evaluation Form
Log Form

EMS Selective Rotation Schedule:
You will need to discuss any major changes to this rotation schedule with the EMS faculty liaison PRIOR to the beginning of the rotation. Here is a typical 2 week’s schedule:
Monday: (8 hours total)
Base Station Observation –
DEMCA Protocol Test
Tuesday: (8 hours total)
Possible Meetings (4hrs) AND/OR
EMS Ride-a-long (8 hrs)

Wednesday: (8 hours)
Preparation for EMS lecture/discussion
NIMS Training modules (ICS 100, 200, 700 – print off the certification forms please)
Thursday: (8 hours)
EMS Ride-A-Long (8 hrs)
Friday: (8 hours)
EMS ride-along
Possible give the EMS lecture/discussion (#5 above) to the on-duty crew

Immediate responsibilities:
The week before the start of the rotation, the resident is to contact the Emergency Medical Service contact individual at one of the above facilities to arrange the time and the place where you will be doing your Ride-Alongs and EMS education
At the conclusion of the rotation, the resident will give a copy of the presentation provided to the EMS personnel to the EMS faculty liaison who will be in charge of the resident’s final rotation evaluation.
It is strongly recommended that you review all assigned reading material prior to      starting the rotation, especially Tintinalli Chapters 1-6.
Should there be any difficulties in starting the rotation, the resident must contact the training site’s Emergency Medicine leadership office
The resident is responsible for completing the Emergency Medical Services Work Sheet found below and turning this into the Emergency Medicine Residency administrative offices within 10 day from the end of the rotation.
The resident will be responsible for completing an electronically generated evaluation form that will be sent via email during their final week of a rotation. This will be used to provide the Emergency Medicine leadership with feedback on the value of this rotation.
 
Emergency Medical Services Goals and Objectives
Goals
Learn the organizational structures of various emergency medical services (EMS)
Learn the educational requirements and skill levels of various EMS providers.
Learn principles of EMS system operations.
Learn basic principles of disaster management.
Learn principles of prehospital triage and emergency medical care.
Learn medicolegal principles relating to EMS.
Objectives
Demonstrate effective communication with patients, their families, and professional associates (*ICS).
Demonstrate respect, compassion, and integrity (*PR).
Demonstrate the ability to perform an appropriate history and physical exam in the EMS patient (*PC)
Demonstrate the ability to develop an appropriate differential diagnosis and treatment plan (*MK).
Demonstrate appropriate clinical decision making skills (*PC).
Understand the pathophysiology of typical injuries and diseases as encountered in the prehospital setting (*MK)
Learn the principles of adult and pediatric resuscitation in the prehospital setting (*PC).
Demonstrate procedural skills that are technically proficient with level of training (*PC)
Learn the basic resources available for the care of the EMS personnel used on an ambulance (*SBP).
Learn the appropriate information resources (i.e., textbooks, handbooks, online resources, etc.) available for care of patients that may be utilized by EMS personnel. (*PBL).
Actively participate in prehospital care (*PC).
Actively participate in EMS systems administration (*SBP)
Demonstrate an ability to use the EMS communication system (*SBP).
Provide initial and continuing education to all levels of EMS personnel (*ICS, PBL).
Demonstrate an understanding of medicolegal liability issues relating to EMS (*CBP).
Participate in EMS continuous quality improvement (*ICS,PBL).
Demonstrate understanding of appropriate use for ground and air medical services (*SBP)
Review local EMS prehospital care protocols (*SBP)
Demonstrate an understanding of basic concepts of disaster management
Demonstrate an understanding of the importance of- and methods for medical  control in EMS systems (*SBP).
Discuss the differences in education and skill level of various EMS providers (*SBP,MK).
Describe common environmental, toxicologic, and biological hazards encountered in the prehospital care setting (*MK).
Discuss injury control strategies (*MK).
(* Denotes core competency area: PC-patient care, MK-medical knowledge, ICS-interpersonal and communication skills, PR-professionalism, SBP-systems based practice, PBL-practiced based learning and improvement)

Toxicology: Educational Goals and Objectives

Description of Rotation: Toxicology is an integral part of the daily practice of emergency medicine, critical care and pediatrics. This one-month rotation combines a variety of didactic techniques (e.g. lecture, small group discussion) with direct patient care, both at the bedside, and through the Children’s Hospital of Michigan Regional Poison Control Center. Rotators include medical students, residents, pharmacists, and fellows. Depending on the month, students will have the opportunity to go on 1 or 2 field trips to the Detroit Zoo and Botanical Gardens.

Patient Care

Goal: To develop the skills required to recognize and manage both acute and chronic poisonings in adults and children.

Objectives:
Be able to take an appropriate history and physical with respect to overdose/poisoning
Be able to identify specific toxidromes
Be familiar with routine testing involved in the care of the poisoned patient
Understand stabilization and treatment priorities
Daily inpatient rounds will be made on poisoned patients in the DMC hospitals and the student will accompany the toxicology fellow(s) and/or clinical consultants when consultations are being provided

Medical Knowledge

Goal: To develop a deep understanding of pharmacokinetics, pharmacodynamics, toxicokinetics, adverse drug events, pathophysiology of severe poisonings and the diagnosis and management thereof

Objectives:
understand the pathophysiology induced by selected toxins.
develop a basic understanding of toxicokinetics.
predict and recognize the clinical manifestations of specific poisonings.
understand the rationale behind the various methods of decontamination, enhanced elimination, and antidote utilization
understand the appropriate utilization of the toxicology laboratory
develop clinical skills required to recognize both occupational and environmental poisoning
Complete the end-of-rotation 100 question multiple choice test

Practice-Based Learning and Improvement

Goal: To be able to critically appraise the toxicology literature and apply it appropriately to poisoned patients

Objectives:
To select and present an article from a peer-reviewed journal that pertains to toxicology and understand it’s conclusion, strengths, limitations and generalizability
To create a literature-based review of a specific clinical question or topic by the end of the rotation
become familiar with reference resources, evaluate their merit and help develop approaches for responses to both telephone and patient consultation

Systems Based Practice

Goal: To develop an awareness of the services of the Poison Control Center and how it operates to meet the needs of the public and the medical community.

Objectives:
become familiar with the epidemiology of poisoning and the role of various agencies in the management, prevention, and treatment of poisoning
participate in other roles of the poison control center including community outreach and drug abuse education
participate in hospital call follow-up so that the student understands the data required when physicians contact the Poison Center and the epidemiology of national risk assessment and data collection
The student will meet daily with the Poison Center staff and review important exposures that are being managed through the poison control center

Professionalism

Goal: The rotator is expected to conduct his or herself in a manner befitting of a consultant and to advocate for the best care possible of the patients he/she is asked to evaluate

Objectives:
Perform prompt patient evaluation
Establish good rapport and communication with primary team
Establish good rapport and communication with patients and their families
The rotator will strive to attain the highest levels of professionalism with respect to duty, accountability, altruism and excellence

Interpersonal and Communication Skills

Goal: The rotator will be able to communicate findings and recommendations both with the primary team and the patient/family.

Objectives:
Explain to the patient and/or family what clinical effects have occurred and should be anticipated, how we plan on treating the exposure, and what, if any, long-term effects can occur.
develop the skills necessary to counsel patients and families regarding poison prevention in the home environment
Develop communication skills to interact with the primary team with the appropriate rationalization for the recommendations

Teaching Methods

Teaching methods include direct patient care, patient rounds, role modeling, video recording of patient encounters and didactic and multidisciplinary conferences. Residents are assigned patients and given progressive responsibility based on their level of training and knowledge.

Logistics

This is a one month rotation that meets at the Children’s Hospital of Michigan Regional Poison Control Center. A significant portion of the first month will consist of orientation lectures and patient care experiences to help the resident to be prepared to care for patients in the inpatient setting. The resident is also required to attend a half day academic conference weekly.

Location:
Primary:
Rotation Supervisor: Andrew King
Typical hours: 8AM – 4PM

Assessment Method (Program Evaluation)

Residents will complete an evaluation of the experience at the end of the rotation. There is also a 100 question test at the end as well

Assessment Method (Residents)

Final evaluation of the resident will be done by the faculty. The form used is the rotation evaluation form unique to the PCC. Residents receive ongoing feedback from the faculty during the rotation. Residents are asked to document any procedures as described in the Procedure Documentation Policy in the Residency Manual.

There are no formal examinations. In the event of a failing performance, an appropriate remediation program, including possible repetition of the rotation, will be fashioned by the program director with input from the faculty.

Level of Supervision

Residents are supervised by the faculty on a direct supervision or indirect with direct supervision immediately available basis.

Contact George Delgado for more information.

george.delgado@stjohn.org

Contact Dr. Patricia Nouhan for more information.

patricia.nouhan@stjohn.org

Introduction

Welcome to the PGY‐3 Community EM Elective. This elective is designed for senior residents with a desire to experience community emergency medicine prior to graduation. The purpose of this elective is to develop the skills and knowledge to work outside of a large academic hospital, where resources are inherently limited.

Site

St. John River District Hospital, East China, Michigan

Goals and Objectives (in ACGME format)

Patient Care

Goal: To develop the skills required to treat adults and children in a community hospital setting.

Objectives:
Be able to take an appropriate history and physical
Be able to perform the appropriate patient work-up including diagnostic tests and imaging in a resource limited environment
Be able to identify indications for transfer to a higher level of care
Be able to prioritize and stabilize multiple patients in a single-physician coverage emergency department

Medical Knowledge

Goal: To develop a medical knowledge base for clinical decision making and differential diagnosis building specifically in the community hospital setting without readily available subspecialty consultants.

Objectives:
Be able to create an appropriate differential diagnosis
Be able to identify and treat life-threatening medical problems in a resource limited environment

Practice-Based Learning and Improvement

Goal: To be able to critically appraise the emergency medicine literature and apply it appropriately to patients in the community hospital setting.

Objectives:
Be able to use current medical literature to provide evidence-based care

Interpersonal and Communication Skills

Goal: To develop the skills required to effectively communicate findings with consultants, nursing and the patient.

Objectives:
Be able to communicate effectively with the patient the risks and benefits of procedures and diagnostic tests, as well as relevant diagnoses
Be able to communicate effectively with specialty consultants in the community hospital setting
Be able to demonstrate compassion, respect and empathy with the patient population encountered
Be able to create effective documentation in the electronic medical record in a timely and efficient manner
Be able to work as an effective team member in a novel environment

Professionalism

Goal: To demonstrate respectful and appropriate behavior, attire, and communication as a medical provider towards members of the medical staff and facility staff and to the patient.

Objectives:
Be able to arrive on time for shift
Be able to perform duties in a timely manner
Be able to dress in an appropriate and cleanly manner

Systems Based Practice

Goal: To develop an understanding of the function and capabilities of an emergency department in a community hospital setting.

Objectives:
Be able to utilize effectively consultants and other resources unique to the community hospital setting
Be able to disposition patients who have more consistent access to primary care providers
Be able to demonstrate cost-effective and high-quality care to patients in a community hospital setting

Contact Information

Dr. Ronald Thies, Director of Emergency Services, St. John River District Hospital

Email: ronald.thies@stjohn.org