NMCSD Rotation Gouge

Please contact the Rotation Director and Rotation Coordinator at least 3-4 weeks prior to the start of the rotation. For inpatient NMCSD rotations, onboarding emails may be sent to your military email first. It is a good idea to email them directly to ask for schedule requests ahead of time. 

Recommended Apps for rotations: 

• WikEM: wikipedia for EM workups and procedures  

• MDCalc: suggested favorites NIH stroke scale, HEART, MELD, Wells, PESI

• MobilEM: Con: costs money Pros: works offline, all EMRA books included (ABx, PEM, Pain meds, Tox, Ortho, Vents, etc) 

• Suture, Nerve Block, Fracture Apps: all related to WikEM app. All free. Direct recommendations and instructions. 

• AOCD Dermatology App: Free. All derm diseases and diagnoses. 

• PediStat: Con: costs money. Pro: pretty much pocket Broselow tape with all med management for peds by weight/height.

NMCSD Cast Room

Check In:

This rotation is 3 weeks. You do not need to check in prior to the start date. On the first day of the rotation, show up to the Ortho Cast Room around 0730. The best way to get there is to walk into the Ortho clinic (opposite side of the pharmacy from the ED) and head to the Cast Room Intern workroom (go down the hall left of the check-in desk and it will be on the left with a label next to the door). There will be at least a third year resident during the day who will orient you; ask for a template consult note and dot phrases to use for the rest of the rotation. 

What to Expect: 

Patients start showing up around 0800. The patients are, for the most part, following up to have casts removed or replaced, alignment checked, preop or walk ins from the ED for casting, reduction or arthrocentesis. Most of them will also have imaging of some sort performed before or during the visit, so review previous images and the new to see how alignment may have changed or if healing is progressing appropriately.

When the clerk writes the patient's initials one the white board in the workroom, put your initials next to the patients and go to the numbered bed. When doing the exam, they REALLY only want to know about the injured/surgical site and nothing else; do not bring a stethoscope. On each patient and when able (as in not obstructed by splint/cast), test for fracture or surgical site pain with palpation, test sensation and range of motion, and check for strength. If there was a surgical site, check for erythema, induration, and drainage. Depending upon the length of time from the procedure, you may have to remove sutures or staples and pull surgical pins. Occasionally you will do arthrocentesis for suspected septic joint and you will likely do many hematoma blocks (they don’t use ultrasounds). The residents are good about walking you through these procedures.

Important things to include in your note besides the usual H&P are interval imaging updates, current phone number, smoking status (especially pre op), hand dominance, and if active duty what they’re job includes (admin, MARSOC, etc). Try to take some time to learn about the injury each patient has and common indications for orthopedists to operate because the attending will drop by to staff the patients before lunch and after clinic closes in the afternoon. They may ask some questions about the injury patterns, though they will not expect you to know everything that an Ortho intern would know. The majority of the time on the rotation, you will leave around 1600-1800, although some have consistently left at 1400. You will not work weekends. You wear scrubs every day. 

Wednesday afternoons are Orthopedics academics; they start at 1300 and are optional. Most lectures are specialized for orthopedics and not directed for the ED environment. Thursday mornings, you will go to EM academics as regularly scheduled, and you do not need to go back to cast room afterwards unless requested by the resident. 

NMCSD ED Ultrasound

Check In:

The ultrasound rotation is a two week block spent in the NMCSD Emergency Department solely performing ultrasounds on patients. LCDR Decker and Dr Siefert run this rotation. Together, they head up the ultrasonography portion of the residency curriculum and review every ultrasound performed in the department. Two weeks before the scheduled start date, send LCDR Decker or Dr. Siefert an email. You can drop by his office to discuss the expectations and requirements for the US block. 

What to Expect:

Interns will work seven, four hour shifts over the course of the two weeks and must perform at least seventy-five scans. Each exam counts as a separate scan, and should be logged as such. Scan multiple organs on the same patient, such as performing a FAST exam, RUQ scan, bilateral renal scans, and aorta scan all on one person. Do not forget to perform scans prior to procedures, like measuring an abscess, or body parts that are often overlooked in terms of ultrasound, such as the eyes (haha... get it), or musculoskeletal system.

Interns are required to schedule time in the OBGYN clinic for prenatal ultrasounds and Cardiology clinic for echocardiograms during the two week period for a four hour period in each location. 

Interns will shadow the ultrasound techs in the Radiology Department on two 4-hour shifts. Log all of the ultrasounds performed, even those done in OBGYN or Cardiology, under LCDR Decker.

At the end of the rotation, you will have a test-out session, usually with Dr Siefert, during which you will perform a couple of different ultrasound exams with him and explain what you have learned over the course of the two weeks. This can include specific findings or signs on ultrasound and what they mean, normal or abnormal parameters, or even which probe is used for certain exams and why. Do not stress about this too much, as it is very informal and the vast majority of people do fine.

Contact Information:

Echocardiogram suite:

• Lopez is the echo ultrasound technician and best to either stop by his office or text/call him to find a time that works, (210-426-2544)

Anesthesia Department

• To set up a day with the anesthesia regional block team, call the anesthesia phone number at 619-453-6694. 

• You may not get to perform blocks if there is an anesthesia resident also on the team, but still good to learn from observing and talking through the anatomy of the blocks with the attendings. If you are bored in between blocks, feel free to practice US guided IV's in the pre-op area or ultrasound patient's for fun, just make sure to tell the patient that you are not diagnosing, only practicing your ultrasound skills. 

Radiology US clinic: 

• It is best to walk up to the second floor and ask to speak with Ricky who will help guide you in which days are best to come in depending on how the schedule looks. All of the ultrasound technicians are very helpful and love to teach. 

Fetal Assessment Clinic:

• You can either walk over the clinic and set up a time or you can email Dr. Victoria Fratto, victoria.m.fratto.civ@health.mil.

Electives

Interns have one block of elective time. The world is your oyster as long as you are working, learning, and it gets approved by ACRs. 

Prior residents have done: research, ophthalmology, cards ekg, radiology, EMS, MUC courses. If you’re interested in something else, you just have to make contact with them and clear it with us. 

You can take leave during elective. If you are staying within the local area, you do not need to take leave on elective. However, keep in mind that if someone on a Balboa or ICU block gets sick/injured/cannot work for more than a day, you can get called in to cover. 

For scheduling and confirming your chosen elective, email Dominique and ACRs with your selection and rotation dates for confirmation.

MUC Courses:

• • List of All MUC Courses *note class level specific*: MUC Courses

  • Additional courses announced in ACR newsletter with contact information 

EKG:

• • Contact CDR Landa

  • knlandaponi@gmail.com

EMS:

• • Contact Dr. Farah 1 month prior to rotation with your rotation dates: 

    • Dr. Jennifer Farah 

UCSD Base Hospital Medical Director

Medical Director, Chula Vista Fire Department

Associate Fellowship Program Director, Emergency Medical Services

jlfarah@health.ucsd.edu

• • Curriculum and Requirements: EMS Curriculum

Research:

• Email ACRs and Dominique with your chosen research project and project information. 

Other Elective Options:

• Dermatology

• ENT

• OMFS

• Ophthalmology

  • Typical hours 0800-1300 in the clinic getting reps at basic eye exam.

• Radiology: POC: roberta.m.vigil.civ@mail.mil, 619-532-6755