Emergency Ultrasound Fellowship

Our emergency ultrasound fellowship is a one-year fellowship accredited by Emergency Ultrasound Fellowship Accreditation Council (EUFAC), with unique opportunities in bedside transesophageal echocardiography (TEE), regional nerve blocks, original research, and resident and medical student education. 

Clinical Work: Fellows will be expected to perform 70-80 hours of clinical duties per month. Clinical work is divided between Kaweah Health Medical Center and the nearby community emergency departments. Kaweah Health Medical Center is a designated level 3 trauma center, as well as stroke and STEMI receiving center. Fellows will supervise residents while working clinically at Kaweah Health.

Teaching: Fellows will also lead weekly QA and teaching sessions with residents and medical students rotating through our ultrasound rotation, with additional opportunities for teaching at our local medical school and regional symposia and conferences.

Research: All fellows will participate in clinical research during their fellowship year. Each fellow is required to launch a new research project during their fellowship, with fellows to present research projects at national and regional conferences during the year.

Administration: By the end of fellowship, fellows are expected to become experts on the billing and documentation for bedside point-of-care ultrasound. Our site has partnered with SonoSite in developing Synchronicity, a new middleware used for documenting and billing for ultrasounds performed in the emergency department. Fellows will be involved in further development as well as optimizing site-specific workflow. 

Compensation: As a Vituity physician partner, clinical hours worked during fellowship will contribute towards Vituity partner advancement, with compensation being comparable to the typical attending rate. There is an additional educational stipend that may be used for purchase of equipment, educational material, and conference travel. 

For any questions regarding our fellowship, feel free to reach out to Fellowship Director, Dr. John Hipskind, at jhipskin@kaweahhealth.org.  

Faculty

  • John Hipskind, MD, FACEP FPD-AEMUS – Fellowship Director
  • Dana Thompson, MD – Associate Fellowship Director
  • Michael Niechayev, MD – Assistant Fellowship Director 

Past Fellows

  • Matthew Henschel, DO
  • Tyler Mitchell, DO
  • Nolan Page, DO
  • Michael Niechayev, MD, MBA

Society of Clinical Ultrasound Fellowships

EUFAC – Accrediting Advanced Emergency Ultrasound Fellowships

Advanced Emergency Medicine Ultrasonography Fellowship Program Requirements

POCUS Research

  • Effect of Implementing and ED-based Ultrasound-guided Procedure Team on Hospital Length of Stay (PI Niechayev)
  • Financial impact of a TEE program at hospitals (PI Hipskind)
  • Superficial cervical plexus blocks (I have a rough draft PICO FINER)
  • Serratus plane blocks (I have a rough draft PICO FINER)
  • Efficacy of PENG block in pubic rami fractures
  • Clavi-pectoral block (ACEP News, Feb 24) for clavicle fractures
  • POCUS Case Studies
    • Retinal edema as a false positive for retinal detachment
    • Hepatic Artery Hemorrhage
    • Non-infectious Fournier’s Gangrene


Ultrasound Rotation Information

The expectations, goals and objectives for your rotation are found on New Innovations.

Prior to Day #1: Email Krystal Guzman (knourie@kaweahhealth.org) your cell phone number.

Pre-Scanning Checklist

Daily:

  • Check Room 44 to ensure machine is ready (see below), it is clear of all non-ultrasound related items, the closet is fully stocked with sheets, washcloths, gel and other items as shown to you during orientation.
  • Check to ensure there is a unit in Zone 2 hallway, Room 20, and Zone 5.  Make sure all machines are plugged in and clean. Check under “Work Lists” to ensure all studies are archived, i.e. no red or yellow checkmarks by the file. 
  • Introduce yourself to ALL APCs, residents and attendings.  Look at the tracking board for clinical cases.  Also do educational exams to acquire normal sonoanatomy knowledge and ensure they all have a MR# and performer assigned.

Machine Maintenance:

  •  Remove everything but the pink top endocavitary wipes and 3 full bottles of gel from the ultrasound unit trays.  Stock gel from “Medical Storage Staff Only” room between Zones 2 & 3. Code is 123.  Check the cabinet in Room 20 for two endocavitary and one TEE probe (If missing, contact sterile processing at x2457 and text the US faculty).  If an ultrasound unit ever shows an error message, text a photo of it and the machine number to Matt Howard or his cell 804-1040.
  • Check the locked cabinet (2215) in Room 44 to insure all 2 BiQ and iPads are there.
1. For a registered patient with an order, find the order in the Xporte “patient list”.   Select it. Next, scan your ID badge short bar code.  Scan the patient.
2. For a non-registered patient, first scan your barcode.  Next, scan the patient.  After the patient is registered, scan the patients Q code.
3. Interpret the images in the worksheet section of the machine, assign it to your attending, and select “End Exam” or
4. Interpret the images in Sonosite Synchronicity, assign the interpretation to your attending and select “End Exam”.  

Tips for a Great Rotation

1. Review the Program-Specific Rotation Information section below to see what your program requires.
2. Prioritize specialty specific ultrasound guided procedures, e.g. nerve blocks for analgesia in central lines, hip fractures or rib fractures; nerve blocks for fracture and dislocation reduction; abscess and effusion drainage; joint aspiration; 
3. If possible, review prior or subsequent imaging like CT or comprehensive (radiology) performed ultrasounds.
4. If asked to perform an exam you are not familiar with, tell the requesting resident or attending that you will get the machine and patient ready to be scanned together with them supervising and teaching you.  Do not do scans by yourself if you are not familiar with that exam.  

5. Schedules are due by the end of the first day.  

6. Set up your Body Works Eve account in Sim lab.  David will help.  Do cases there on Thursdays after QA sessions.
7. POCUS 101:  Complete all modules (save VEXUS, Nerve Blocks and Foresight Exam for last due to their more advanced nature).  Focus on those with your clinical interest in mind.
8. Prepare for QA sessions (generally 12:30 to 14:00) by saving your own cases.
9. At the beginning of your shift, after machine maintenance, introduce yourself to the ED attendings, residents and APPs so they can help you get cases…don’t be shy!
10. Most cases are clinically indicated and require an order in Cerner First Net.  The only difference with an educational (non-clinically indicated study) is that these are not ordered.  If you have an exam and the worksheet shows “UNK 000……” it is lacking a medical record number.  If unable to correct, text me the info and I will reset the ED note.
11. The dedicated POCUS Room (44) is for diagnostic POCUS exams only.  If you see it being used for other purposes and do not feel comfortable asking the clinician to perform the exam elsewhere, text me and I will have a discussion with them (keeping your name confidential).
12. As you progress through the rotation,  push yourself to work faster and be more efficient.
13. Review your speciality specific SDOT as faculty may elect to evaluate you using these as the standard.
14. Interested in a deep dive into critical care applications?  Check out https://www.acep.org/emultrasound/subcommittees/critical-care-emergency-ultrasound
15. Want to see the latest updates from ACEP regarding POCUS?  Check out:   https://www.acep.org/emultrasound/newsroom/

Program-Specific Rotation Information

Transitional Year Goals & Objectives

Family Medicine Goals & Objectives

AAFP POCUS Curriculum

Anesthesiology Goals & Objectives

ACGME Anesthesiology

Trauma Anesthesiology

EM PGY1 G & O

ACEP EUS Policy Statement Clinical Guidelines (April 23)

 

General Surgery Goals & Objectives

Shift Schedule

Special Topics

ACEP TEE Policy  

Virtual TEE

Course in Basic TEE

www.5minsono.com

TEE: Heartworks Advanced

ACEP: TEE in Cardiac Arrest

ED TEE Credentialing Form

ED TEE Standarized Assessment

TEE Help Sheet

TEE indications, privileges, and procedure

Normal Cardiac Anatomy and TEE Imaging Planes

5 Minute Sono

Mike Stone Vimeo

Highland EM Ultrasound

NYSORA 

Ultrasound Guided Nerve Block procedure note

Checklist for Ultrasound Guided Nerve Blocks 

Apps: 

AnSo Pro

Nerve Block App  

UW Medicine Nerve Block App

ACEP Policy – Appropriate Use Criteria for Handheld-Pocket US Devices

US Guided subclavian line

POCUS CPT and RVU

POCUS Links

Cardiovascular ICU Selective/Elective

Teaching Chief: Kartheek Nagappala MD

Description: Advanced Cardiovascular Critical Care rotation will allow residents to further develop their skills, knowledge and attitudes obtained during their previous rotations, specifically expanding on their critical knowledge to patients that are post cardiac surgery, major vascular surgery, and critically ill due to compromise of their cardiovascular system. The rotation will involve 21-22 12-hour shifts, similar to the EM core ICU experience. 

Availability: Generally available year-round and will occasionally share the experience with an Anesthesia co-rotator.

Scheduling: Schedule to be made by the rotator with final schedule approval by the teaching chief

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Community Emergency Medicine Elective

(PGY-3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Palliative Care Selective/Elective

Teaching Chief: Ryan Howard MD

Description: The Palliative Care Selective or Elective is a 2- or 4-week inpatient rotation designed to expose the rotator to all aspects of inpatient palliative care. Residents will work alongside the palliative director and/or the palliative fellow along with the interdisciplinary palliative team throughout the rotation. The goal is to provide either PGY2 or PGY3 residents with an immersive clinical experience to learn more about inpatient palliative services.

Availability: Generally year-round, those interested in applying to Palliative Fellowship get precedence on the rotation as space is limited

Scheduling: M-F, 8am-5pm, with call shifts if required/desired per Dr. Howard

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Intro and Advanced Pharmacology Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD and Savannah Lail PharmD

Description: A 2 or 4-week rotation where the resident works and learns alongside the ED pharmacists on assigned shifts. The Pharmacology rotation is designed to provide training concerning the application of pharmacology knowledge, pharmaceutics, drug information, medication safety, communication skills, critical thinking, pathophysiology, and therapeutics to the care of patients in an emergency department setting. The advanced rotation is for those who have already had the introductory Pharmacology rotation experience.

Availability: Generally year-round, but must contact PharmD teaching chief prior to choosing the rotation to ensure availability. 

Scheduling: Variable shifts, 10-shifts per rotation, to be assigned by PharmD teaching chief

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Pulmonary and Ventilator Management Selective/Elective

Teaching Chief: Leland Beggs MD

Description: This is a 4-week rotation based in the ICU, CVICU and ED. Residents will work side-by-side with designated respiratory therapists as well as core faculty physicians. The goal of this rotation is to focus solely on vent management and non-invasive ventilation techniques in patients with a wide variety of disease processes. Residents will be expected to manage vent settings for intubated patients in the ED, ICU and CVICU. Residents on service should gain an in-depth understanding of the events surrounding intubation, including strategies in pre oxygenation as well as the various drugs used for RSI and post intubation sedation. In addition, they will learn when to initiate, and how to manage non-invasive ventilation.

Availability: Generally year-round

Scheduling: M-F, 6am-4pm

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Radiology Selective/Elective

(Two-week experience) 

Teaching Chief: Ashkan Shahkarami MD

Description: The two-week Radiology rotation will provide the resident with an opportunity to learn normal and abnormal radiographic anatomy, recognize radiographic findings of common diseases, understand the indications for commonly ordered imaging studies, and learn the appropriate use of IR procedures. The goal of the rotation is to help the resident become competent in the use of imaging in the evaluation and treatment of disease.

Availability: Generally year-round, but must contact teaching chief before choosing the rotation to ensure availability

Scheduling: M-F, 8am-4pm, or as adjusted by the Radiology attending

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Wilderness Medicine Selective/Elective

Teaching Chief: Various

Description: The one-week wilderness medicine selective is offered twice a year at Kaweah Health, usually once in the Spring and once in the Fall/Winter. If not available during the allocated selective/elective block, previous residents have participated in 4-week experiences in Utah and Redding, CA. Experiences are variable and depend on the chosen course, so for this one touch base with Dr. Sukhija to see what is feasible both locally and away.

Availability: Highly variable, see description above

Scheduling: Highly variable

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Emergency Medicine Admin Selective/Elective

Teaching Chief: Kona Seng DO and Khoa Tu MD

Description: This is 2-4-week rotation in conjunction with the Department of Emergency Medicine Medical Director. The purpose of the ED Administration rotation is to provide an understanding of the administrative components of EM clinical services and operations. This will allow early exposure to ED administration to determine if the resident is interested in the administration and business of emergency medicine. The EM residents will attend all assigned meetings and participate in administrative projects. 

Availability: Generally year-round, will share the rotation with the PGY3 on their core admin rotation

Scheduling: M-F, 9-5pm, or as adjusted by the teaching chiefs

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Patient and Physician Advocacy and Street Medicine Selective/Elective

Teaching Chief: Kunal Sukhija MD, Omar Guzman MD, Lori Winston MD

Description: The Advocacy 2- or 4-week rotation is designed to be a self-directed customizable experience that will provide immersion into various aspects of physician and patient advocacy. The resident will be able to participate in local, state-wide, and national (schedule permitting) advocacy efforts while simultaneously learning about effective strategies to engage community leaders, legislators, and the local constituency. The rotation will offer experiences in both the legislative and community advocacy (the latter will be based in the Street Medicine program). 

Availability: Generally year-round, however certain months tend to be better given the yearly CMA, AMA, CalACEP, ACEP schedules. Touch base with Dr. Sukhija prior to choosing this elective in order to ensure you can get the individualized experience you desire.

Scheduling: Highly variable depending on advocacy events and meetings, Street Medicine tends to hold its events on Friday

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Performance and Quality Improvement (PI/QI) Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD

Description: The Performance Improvement (PI)/Quality Improvement (QI) selective rotation will provide exposure to ongoing PI and QI efforts at KDHCD and provide opportunities for the PGY2 or PGY3 EM resident to become involved in PI/QI projects on an individual, departmental, or institutional level. The resident will join the Emergency Medicine PI director in the regular duties of chart review, M&M conference coordination and presentations, and committee meeting attendance as appropriate. It also offers time for the resident to work on their PI/QI project as part of residency graduation requirements. 

Availability: Generally year-round

Scheduling: Variable depending on meetings and current on-going projects

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Public Health Elective (PGY3 only)

(PGY3 only)

Teaching Chief: Karen Haught MD MPH, Tulare County Public Health Director

Description: This is a 4-week rotation with the Tulare Public Health Department designed to expose the rotator to all aspects of public health. Residents will work alongside the Tulare Public Health Director and/or the epidemiologist throughout the rotation. The goal is to provide PGY3 residents exposure to the role of the local public health department in the community. Residents will be expected to work at the Tulare Public Health Department and contribute to a community health project of the resident’s choice.

Availability: Generally year-round, though an interested resident should first contact Dr. Haught prior to selecting this experience (Dr. Sukhija will help you with contact information)

Scheduling: M-F, 9-5, though historically it’s been less than this as independence is given to work on the resident’s chosen project

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Research Selective/Elective

Teaching Chief: Chris Patty DNP, Director of Research

Description: The goal of the resident research rotation (2 or 4 weeks) is to improve the resident’s understanding of how new knowledge is created and translated into practice.  At the end of the rotation, the resident will present a deliverable which demonstrates ACGME competencies in knowledge development and translation. Many residents choose this rotation in order to work on their chosen Scholarly Activity as part of residency graduation requirements. 

Availability: Generally year-round, the resident must contact the director of research 4-weeks prior to the rotation in order to state deliverables and set up the rotational requirements.

Scheduling: Variable, generally self-directed independent work

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Simulation and Education Selective/Elective

Teaching Chief: Kim Sokol MD

Description: This is a 4-week rotation includes developing simulation scenarios, teaching simulation-based educational sessions, and assisting in daily operations in the simulation center. The rotation’s purpose is to develop skills associated with teaching. The rotation will provide an introduction to simulation with multiple adjuncts such as high and low-fidelity mannequins, task trainers, and the use of standardized patients.  A basic understanding of simulation-based education and debriefing will be taught along with basic principles associated with adult education. The resident must choose teaching shifts as their clinical experience.

Availability: Generally year-round

Scheduling: Variable, to be determined with the teaching chief prior to the rotation start date

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Teaching Elective with Dr. Stanley

(PGY3 only)

Teaching Chief: Michael Stanley DO

Description: This 4-week rotation is a highly-desired advanced elective rotation for PGY3 EM residents. It is intended only for those residents who are serious about improving their ability to teach AND lead. This rotation is as much about leadership as it is about teaching because both utilize the same skill sets. Residents will gain knowledge in effective communication techniques while learning about the underlying psychology of teaching, learning, and leadership.

Availability: Generally year-round

Scheduling: 12 10-hour shifts to be scheduled in accordance with Dr. Stanley’s clinical schedule, along with didactics (also to be scheduled with Dr. Stanley prior to the start date). If Dr. Stanley has less than 12 shifts, then the remainder can be completed with either Dr. Oldroyd, Dr. Sokol, or Dr. Alexeeva.

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Advanced Ultrasound Selective/Elective

Teaching Chief: John Hipskind MD

Description: This 4-week rotation is designed to augment the resident’s diagnostic (and therapeutic) skills in relation to the ultrasound, and to explore more advanced US modalities such as TEE. The resident will gain experience with nerve blocks, enhanced approaches to the core EM ultrasound studies, and explore novel ways to use the ultrasound in the ED setting. They will work alongside the teaching chief as well as the ultrasound fellows.

Scheduling: The expectation is to be scanning daily M-F, with weekends off. Due to PGY1 EM rotators and the popularity of this selective/elective, there may be many residents on rotation, and thus scheduling must be in conjunction with Mia Zavinovich and Dr. Hipskind prior to the start of the rotation. 

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International & Global Medicine Elective

(PGY3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Patient Callbacks and PBLI form

Patient callback instuctions - complete 12/block when you are on the emergency medicine service

PBLI form - complete 4/year to reflect & self-evaluate your patient care

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