During residency, you will rotate through many ERs and various specialties, the exact details are fluid, but the core blocks and block durations are constant. As an NMCP EM resident, you will spend the majority of your time in our ER and in the surrounding community ERs, but the remainder of your rotations are electives or off-service blocks. During internship, you only work one or two months in the ER, everything else is off-service, but this ratio changes as you progress through residency. By your final year, you will spend half of the academic year in the ER, so if you feel that you do not get enough ER exposure as an intern, don’t worry, your time will come. Specific rotation gouge for each of these locations is found on the residency website.
NMCP EM. During NMCP ER blocks, I recommend that residents focus primarily on learning to manage large volumes of patients efficiently. The five different EMRs that must be utilized simultaneously during a shift can complicate matters, but if you can work efficiently in our ER, you can do it anywhere. You will also encounter a large number of pediatric patients and female OB/GYN complaints, so you will become a master of the kiddos and the pelvis. This is also our home academic ER, so the staff actually care about your education and will teach you, enjoy this and maximize this time. Pick their brains about the nuances of their practice, absorb as much as possible and craft your own patterns accordingly.
Outside EM. The predominantly low acuity at our own institution necessitates frequent outside rotations at civilian ERs. These months are the highlights of residency due to the high acuity, the procedures, and the independence allowed. Many of these ERs do not have their own residency programs, so the staff attendings frequently offer you intubations, central lines, chest tubes, and other procedures. This allows them to continue seeing new patients, and you get more experience with EM critical care – a win win situation. Once they trust you, they allow significant independence, which is awesome during 3rd and 4th year, but is somewhat intimidating during your first few years. So ask questions and actively seek their help if needed. I recommend that residents not focus on volume during these rotations. Focus on cherry picking high acuity patients – that is why you are there. If you continue crushing patients like you do at NMCP, then a trauma or a resuscitation will arrive and you will be unavailable, so leave some bandwidth free for critical patients and procedures. This may feel awkward at times since we are trained to aggressively see new patients, but get over it. You need critical patients, and you will see them at these outside ERs. Maximize those opportunities. Rumors of NMCP becoming a trauma center are circulating (although these rumors were ongoing when I was an intern seven years ago), and we recently opened the gates to civilian ambulance runs, so hopefully the acuity at NMCP will improve. But until then, proceed as per above.
Trauma. We rotate one month of internship and one month of EM2 across the water at Sentara Norfolk General Hospital (SNGH), the Level 1 trauma center for the region. We previously rotated a third month at SNGH during EM3, but recently transitioned to a hospital near Chicago to get a different trauma experience. During these months, you will see a lot of blunt force trauma and occasionally penetrating trauma. You will serve as a part of the trauma team, have various rounding and floor duties, and respond to the trauma bay whenever the PA system announces an incoming trauma. You will learn bread and butter trauma assessment and management, and through the sheer volume of patients evaluated, the ATLS algorithm will become second nature. Unfortunately, as junior EM residents, you will rarely be involved in the big picture decision making, this is delegated to the senior surgical resident running the service. So focus on making trauma evaluation instinctual, perform as many procedures as possible, and then exercise these skills during your next EM rotation.
Focus on making trauma evaluation instinctual, perform as many procedures as possible, and then exercise these skills during your next EM rotation.
You will also spend two months at Riverside Regional Medical Center and one month at the University of Florida, Shands, in Jacksonville. At Riverside, a Level 2 trauma center, you will manage the traumas with the ER attending and the nursing staff. This is phenomenal for your leadership development, especially during the last few years of residency. During EM3 and EM4, completing one more month of trauma at Norfolk General as a cog in the wheel of the trauma team is not necessarily furthering your education nor preparing you well for your future practice, so the management independence and decision making experiences offered at a smaller trauma center matures you much more as an EM physician. During the month at Shands, you will run the resuscitation unit and manage all of the trauma activations. This is a phenomenal experience. You will see severe traumas without the volume of SNGH, and you will be involved significantly in management and decision making. After all of these months of trauma and the variety of experiences at different locations, you should feel very confident in caring for traumas independently at whatever ER you eventually practice.
ICU. The critical care rotations were some of my favorite experiences, especially at Norfolk General. You will spend a month in the SNGH ICU as a junior resident and another month as a senior EM resident. As the senior resident, you will manage the ICU overnight alone with an intern and occasionally with another resident. The independence and management experience is incredible. You will also respond to codes in various areas of the hospital, and occasionally run them. Everything in the General ICU is your responsibility, and you will frequently manage very sick patients that require all of your accumulated experience. The critical care fellows are on call overnight and are always available, but they respond from home and you should be able to handle most scenarios without them. During the days, you will round as a part of the ICU team and receive excellent teaching from the attendings and fellows. Overall, these ICU months are invaluable experiences that will ultimately make you a much better EM physician.
In the ER, airway is king, and we must be the wizards of difficult, bloody, vomitus, young, old, and traumatic airways.
Anesthesia. Spending time with the anesthesiologists and intubating patients in the controlled setting of the OR is likely the singular most important experience for a budding EM resuscitationist. In the ER, airway is king, and we must be the wizards of difficult, bloody, vomitus, young, old, and traumatic airways. These months at NMCP and Riverside will make you competent and possibly even good at intubating. During my rotation, I primarily performed direct laryngoscopy (DL), which solidified many of the microskills associated with intubating and paved the way for future success with video laryngoscopy (VL) – which I found incredibly easy after DL. Make the most of these experiences, I found that airways are earned, not given – discuss the cases with the anesthesiologists and CRNAs, introduce yourself to the patients and help prepare them for the OR, find the optimal rooms and operations for potential intubations, and perform well early so that they trust you with future airways. Much of your success during these months depends on your personal motivation. Overall, these rotations are foundational to your airway success in EM.
Toxicology. This is easily the most popular month in our residency, this rotation during fourth year is simply amazing. During the day, you will follow up on patients whose providers consulted the NYC Poison Center, digest lectures from toxicology gurus – including Dr. Lewis Goldfrank, and discuss various toxicology topics as a group. During the evenings and weekends, you are free to explore New York City in all of its glory. The work room is in the New York City Poison Center directly across the street from Bellevue Hospital on the East Side of Manhattan Island. From there, it is a short walk or subway ride away to most of the excitement of New York City, and the restaurants are everywhere and incredible.
Electives. These can be amazing months, let your imaginations run wild. Some residents complete courses in Mountain Medicine and Cold Weather Medicine. Some pursue rotations in specialties that will make them better EM physicians – pediatrics anesthesia, ophthalmology. Others spend the month in ERs close to their homes. So think big, do something interesting, do something that you may never have the chance to do again in your career.
Global Health. This program is a phenomenal opportunity for those interested in global health. This is a funded scholarship tract for 1-2 residents per year, and those involved have traveled to Vietnam, Hawaii, India, participated in humanitarian missions on the USNS Comfort, and assisted in teaching various courses at Harvard and in Washington DC.
Others. You will also complete rotations in General Surgery, Internal Medicine, Orthopedics, and Obstetrics. During these rotations, learn everything that you can from our consultant colleagues about their specialties and their practices, then incorporate those lessons learned into your own practice in the ER to make you a better EM physician, colleague, and informed consulter. Learn what they want when they are consulted, each have their own peculiar wishes and practices. The better you learn their nuances, the better your relationship with your consultants will be. Often, you will perform their duties yourself in small Navy and rural civilian ERs, and refer the patients to them in the outpatient setting. So learn as much as you can before you are on your own.