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The Clinical Experience

The LAC+USC Formula
Rotations
Specialty Courses

The LAC+USC Formula

At the heart of the LAC+USC program is an unparalleled clinical experience. Our formula for optimizing learning involves the interplay of four unique factors: a philosophy that places residents at the center of patient management, a concentration of patients with high acuity, departmental and resident autonomy, and a full spectrum of presenting pathologies.

Emergency medicine is different than other specialties. In addition to primary patient care skills, the emergency physician must be able to provide simultaneous care to multiple ill and injured patients. From the very beginning of their training, residents are provided an opportunity to learn how to prioritize the management of multiple patients within a system that is designed specifically for that purpose. As residents advance through the program, they are given progressively more responsibility for the overall patient flow through the department, until their senior year, when they are charged with the responsibility of the entire clinical department. This process takes place under the supervision of an experienced faculty whose primary function is to supervise and teach, allowing the residents the independence to develop into confident, seasoned practitioners.

Acuity

The acuity of patients presenting to LAC+USC Medical Center and our affiliated private facilities (which are all designated trauma centers) is very high. At LAC+USC, which has one of the largest censuses in the nation, patients are stratified by acuity into different clinical areas. To ensure a concentrated resident experience in the care of the most severely ill and injured patients, midlevel providers are utilized to staff the lower acuity areas of the clinical department.

Autonomy

The Department of Emergency Medicine at LAC+USC and the USC School of Medicine was the first autonomous academic department in our specialty. For nearly four decades, our departmental status has enabled us the ability to provide our residents a level of access to patient care and procedures that can be found at few other institutions. All aspects of patient care, including airway and trauma management, procedural analgesia and sedation, bedside ultrasound, and critical decisions relating to patient disposition, are under the control of the emergency medicine residents under the supervision of emergency medicine faculty.

Pathology

The breadth of patient pathology presenting to LAC+USC is truly astonishing. The role of LAC+USC as a central referral center ensures a steady stream of patients from throughout the County and beyond that require the services and expertise of a tertiary academic center. Not only do residents have an opportunity to manage the most complex medical and traumatic resuscitations, they have a robust experience in areas not commonly encountered in community hospitals, such as acute presentations of tropical diseases and the full spectrum of law enforcement related and forensic pathology.

Rotations

PGY1 Year

In 2009 the LAC+USC Emergency Medicine Residency began transitioning to a PGY1-4 format. For the 2011 application cycle, it will accept 16 categorical candidates (PGY 1-4) how will begin their training at LAC+USC during their internship year. Additionally however, for the 2011 application cycle, 1 advanced position (PGY2-4) candidates will also be accepted. The advanced position candidate will be required to do a preliminary  or transitional PG 1 year and subsequently join during their PGY2 year to complete a 2-4 program. For these advanced position candidate, the intern year should consist of a broad-based inpatient experience in areas such as internal medicine, surgery, obstetrics & gynecology, and pediatrics. Elective time in Emergency Medicine will be valuable as well. A true transitional year is preferred, but preliminary medicine or surgery years are also acceptable.

PGY2 Year

The PGY2 year is designed to provide supervised experience in the management of all the commonly encountered non-critical illnesses and injuries that make up the spectrum of Emergency Medicine practice, with emphasis on the development of the procedural skills requisite to each of the specialty areas.

PGY3 Year

The PGY3 year provides supervised experience in the recognition and management of the major critical clinical entities which present to an Emergency Department and promotes an even higher level of competence and confidence in non-critical patient management.  Training also continues in other pertinent medical specialties.

PGY4 Year

The PGY4 year is designed to provide for the continued refinement of independent clinical judgment and the development of sophistication in both critical and non-critical patient management; to promote the development of academic, teaching, research, managerial and administrative skills; and to provide opportunities for training in areas of highest interest.  Its purpose is to produce emergency physicians who can practice at the highest level of clinical Emergency Medicine and who can integrate all aspects of Emergency Medicine into a balanced professional career.

Specialty Courses

Special courses of particular importance to Emergency Medicine Residents are given at specified times throughout the training period and include:

PGY-2 Orientation Program:

An extensive two week program designed to give the incoming resident an introduction to the philosophy and practice of Emergency Medicine, an orientation to departmental policies and operations, and a brief orientation to clinical areas in the DEM. The Orientation Program includes:

• Seminar on Symptom-Based approach to EM
• Introduction to Clinical Areas
• Base Station Operations Course
• ACLS Provider Course
• Suture/Splinting/Casting Workshops
• Procedure Lab

Advanced Trauma Life Support (ATLS)

Sponsored by the American College of Surgeons, ATLS is given to all residents in the PGY-2 year, usually in October.

Emergency Medicine Trauma Management Course

The DEM sponsors a comprehensive Trauma Management Course presented in two separate sessions, two days each. Part 1 (given in the fall of the PGII year) consists of the American College of Surgeon's ATLS Provider Course. Part 2 (given at the end of PG II year) expands on concepts learned in ATLS and covers all the surgical subspecialties such as eye, and ENT, trauma, burns, electrical and radiation injuries, etc., as well as trauma in the geriatric, pediatric and OB patient.

Pediatric Advanced Life Support (PALS) Provider Course

A 16 hour course given on two consecutive Tuesdays (usually in April of the PGY-2 year) covering the most commonly encountered life-threatening conditions affecting the pediatric population. The course covers ACLS protocols, fluid resuscitation, sepsis/fever work-ups, and respiratory emergencies. Formal PALS certification is provided upon successful completion of the course.

Advanced Cardiac Life Support (ACLS) Instructor's Course

Given to all EM residents at the end of the PGY-2 year, the course follows Amercian Heart Association guidelines but has been extended to include a special workshop on medical teaching techniques.

Base-Station Operations Course

The Base Station at LAC+USC is the busiest of the 20 Los Angeles County Base Stations with 22,801 base station runs in 2004. It is the primary base station for 20 LAFD units, one LA County squad, and two private sectors (the cities of Vernon and Monterrey Park). LAC+USC is one of only four Level I trauma centers in Los Angeles County and, due to its open catchment area, is also the designated trauma center for the San Gabriel and Antelope Valleys.

The Base-Station Operations Course is given to PGY-2 residents during the 2 week orientation in July. After completion of an additional one week training session during the first half of the PGY-2 year, all PGY-2 residents will be certified to answer and direct paramedic base station calls in Los Angeles County.

Advanced Pediatric Life Support (APLS)

A 16 hour program which builds upon PALS and is more tailored to the expertise needed for EM practice. Toxicology and trauma topics (not covered in PALS) are introduced, and a highly qualified pediatric and EM faculty present the material.

Hyperbaric Chamber Course

A special course presented by Dr. Jeff Sipsey, Director of the Hyperbaric Chamber on Catalina Island, designed for Emergency Medicine residents interested in Recompression Medicine.

The Department of Emergency Medicine has responsibility for providing medical support for the Hyperbaric Treatment Chamber on Catalina Island. This large, multi-person facility is dedicated to the acute treatment of diving injuries and handles 40-50 calls per year. While this is not a formal part of the EM resident's curriculum, interested residents will have the opportunity to go through an initial basic course in hyperbarics and subsequently participate in treatment of diving injuries. This represents a unique opportunity for interested residents to obtain training and experience in a field of medicine not generally accessible to most physicians.

The USC Catalina Hyperbaric Chamber is 24 feet long, 9 1/2 feet in diameter and has two locks. The size of the Chamber allows the possibility of treating multiple patients simultaneously (to date, the maximum number of patients treated simultaneously is four) and allows room to perform CPR and Advanced Life Support for patients who arrive in cardiac arrest. The Chamber facility is an extension of the L.A. County/USC Medical Center Emergency Room and is part of the countywide Medical Alert Center (MAC). Funding for the Chamber comes from L.A. County and donations from dive clubs, dive boat operators, fund raising activities and other generous contributors.

Emergency Medicine: A Critical Appraisal

This consists of a comprehensive 20 hour course based on Emergency Medical Abstracts in co-sponsorship with the California and Florida Chapters of ACEP. The course has been specifically adapted for our Emergency Medicine Residents.

Introductory Emergency Ultrasound Course (PGY-2)

The DEM has had an active ultrasonography program since 1993 and has 8 ultrasound machines for Emergency Department use. All residents receive ultrasound training as part of the core Emergency Medicine Training Program. Incoming PGY2 residents receive an introductory 16 hour course each fall. This course curriculum is based on published guidelines and covers the following topics:

• Basic Physics
• Pelvic sonography
• Trauma ultrasound
• Echocardiography
• Biliary ultrasound
• Renal ultrasound
• Aorta ultrasound
• Central line insertion
• Musculoskeletal Applications

The residency curriculum allows graduating residents to exceed the national SAEM training guideline of 40 hours of education and 150 ultrasound examinations. Many residents continue on to complete the RDMS (Registered Diagnostic Medical Sonographer) certification program. Departmental expertise has helped develop emergency ultrasound both nationally and internationally, including Canada, Australia, New Zealand, and Ghana. The DEM is actively involved in national committees and task forces addressing the future of bedside ultrasound in Emergency Medicine. Research in emergency ultrasound is growing. The DEM is an active participant in ultrasound research and has completed many projects including emergency applications of: renal ultrasound, foreign body ultrasound, pediatric trauma ultrasound, central line insertion, echocardiography, and ultrasound training requirements.

Advanced Emergency Ultrasound Course

The DEM offers a one-day course to all residents covering advanced applications of emergency ultrasonography. Examples of topics covered in the past include:

• Retinal Detachment
• Deep Venous Thrombosis
• Advanced Echocardiography
• Central Venous Pressure Monitoring
• Chest Ultrasound
• Testicular Ultrasound
• Advanced Pelvic Ultrasound

Gorgas School of Tropical Medicine

Cadaver Lab

Residents have the opportunity to spend time in a cadaver lab, doing dissections and performing many of the core emergency medicine procedures such as chest tube insertion, intraosseous line placement, central line placement, cricothyrotomy, open thoracotomy, and venous cutdowns. Supervised by Dr. Leonardo Rodriguez, this experience is very highly rated by residents.

Simulation Center

Under the direction of Dr. Manon Kwon, the simulation center houses 2 adult mannequins and 2 pediatric mannequins. Residents spend afternoon sessions at regularly scheduled intervals throughout the residency.