A Job Within a Job: Residency Rotation Director

In conjunction with the PEMFellows.com Blog I’ve authored a post on what it means to be a Residency Rotation Director, a role that I inhabit at Cincinnati Children’s Hospital Medical Center.

At the risk of getting analogical, there are many hats in the haberdashery of a Clinical Educator. Many institutions specify that faculty do more than provide clinical care. Though the classic triple threat triumvirate of clinical, research, and education serve as guideposts for how we should spend our time it is important to recognize that within these categories there are quite a few roles and positions that faculty can choose to occupy. One of those roles is the residency rotation director.

Near the end of my first year as a faculty physician I assumed this role within the Division of Emergency Medicine at Cincinnati Children’s Hospital Medical Center. My career interests education focused, and I felt that this would allow me to gain valuable experience in a position of leadership. I also saw a need to refine our curriculum and overhaul the evaluation process for our residents on the Emergency Medicine rotation. This role has come to define my niche within my Division and I’m now seen as “The Resident Guy” and have been able to get involved in a number of valuable initiatives.

What do they do?

The rotation director is a liaison between the residency program leadership (program directors), the departmental faculty and the residents themselves. Their specific duties may include rotation orientation, curriculum development, evaluation, conflict mediation, scheduling, mentoring and more. It can be challenging to balance these many duties with a busy clinical schedule. Staying organized and making good use of one’s administrative assistant’s talents are essential. The role comes with a bit of baggage in terms of scheduling meetings, and thus developing overall goals in accordance with Emergency Medicine and Residency leadership is incredibly important in making sure that your time is goal-oriented and well spent.

How do you become one?

Ask. Seriously, that’s it. The ACGME specifies that each residency rotation have a faculty member who is responsible for the oversight of the aforementioned tasks. First, you can find out who is responsible for this role in your department. As faculty you are responsible for charting your career path. If you are interested in a career in education or leadership this can be a great way to get your feet wet. When interviewing for a faculty position, it can be helpful to consider whose job you want. Not that you’re looking to depose anyone – but more specifically who has a role that you’d like to have in the future, and what do you need to do to learn more about it and get involved. Make it clear that you’d like to be next in line for the role, and talk openly and honestly with your interviewer and arrange to meet with the current rotation director.

Tell me more about the specific responsibilities?

Curriculum Development

This role entails determining not only the schedule for lectures and other learning opportunities, but also making sure that your residents are learning what they are supposed to be learning. Familiarize yourself with the rotation goals and objectives as specified by the residency program as well as the American Board of Pediatrics content specifications. Make sure that the residents are learning during and after their shifts. For me this involves both canvassing them for feedback in person and collecting structured feedback after our educational sessions. You might also think about including online modules or websites into your curriculum. You could start your own, or direct them to blogs such as PEMBlog.com and PedEMmorsels.com.

Our residents have eight hours of protected time per month for learning during which I was able to secure attending coverage. Our educational sessions include a mix of didactic lectures, hands on procedure training and in situ simulations. I am responsible for the overarching content, and recruit faculty contributors based on their interests and areas of expertise. I attend all of the lectures and serve as the Master of Ceremonies and color commentator.


Milestones, milestones, milestones… Since all programs now have to evaluate using the Pediatric Milestones familiarize yourself with not only the original criteria, but also your institution’s plan for evaluation. The Pediatric Milestones represent no less than a paradigmatic shift in how residents are evaluated. They are based on a continuum of clinical behaviors that develop throughout training. For example, senior residents should be able to make autonomous decisions for straightforward problems. If they don’t know how to manage an asthmatic for instance, you should be concerned that they have not developed sufficiently mature illness scripts. Other residents may struggle specifically with prioritization or dealing with consultants. You can learn more about the Milestones here.

Many institutions use a system such as MedHub or New Innovations for evaluation and thus the infrastructure may already be in place. Not only will you have jurisdiction over how the residents are evaluated, but you will also be responsible for assuring that faculty complete their evaluations on time. Many institutions have evaluation completion compliance built into their faculty roles and responsibilities. You’ll be responsible for reviewing the resident evaluations and developing a plan to intervene when residents are having particular difficulties during the rotation. My main goal is to make sure that the summative rotation evaluations impact the residents in a meaningful fashion.

Conflict mediation

There are times when residents have issues that impact patient safety, satisfaction or the care team in general. In addition to investigating the situation and discussing the issues with all involved parties, you may also be responsible for mediation. This can be a challenging yet rewarding part of the job and it really contributes to the professional development of your trainees.

Do I have to join any committees? I love committee meetings!

Your institution will have a Curriculum Competency Committee (name subject to variance of course). This committee is a group comprised of residency leadership (program directors and chief residents) as well as the individual faculty residency rotation directors. During regular sessions you will discuss important issues germane to the residency program at large, and biannually meet to discuss the progress of every resident in accordance of the pediatric milestones across all of their rotations. It would not surprise you to learn that residents that struggle in the high volume, fast paced ED might also struggle in the ICU, but conversely could thrive in a primary care clinic. The next time that resident returns to the emergency department, have a plan for their ongoing evaluation and improvement.

Any other benefits?

Sure! If you are interested in educational research there may be no better local pipeline than the role of rotation director. You’ll have extensive contact with program leadership, who can serve as mentors as well as residents themselves. My role also allowed me to partner with other similarly focused Pediatric Emergency Medicine educators and we published our resident education focused work last year in Academic Emergency Medicine. As previously noted, your time is valuable. This role often comes with protected time (time “bought down” from clinical responsibilities). It is important to know and/or estimate how many hours per week you spend on the role. I have had to consider the following when making my case for protected time:

  • Time spent on education including planning, attending and presenting lectures
  • Time spent reviewing evaluations
  • Regularly scheduled meetings

Can I ask you some more questions?

Absolutely. You can contact me on Twitter @PEMTweets, via my homepage bradsobolewski.com or by leaving a comment on this post.

The post A Job Within a Job: Residency Rotation Director appeared first on PEM Blog.

Automated urinalysis measurement compared with the traditional dipstick method

And so it is with great lament and crocodile tears that we have reached the end of my series on the top ten articles presented at the recent AAP NCE in San Diego. It took me a bit of time to get there, but I think that the journey was worth it. Look for a compilation post in the near future.

Automated Urinalysis and Urine Dipstick in the Emergency Evaluation of Young Febrile Children

Kanegaye JT, Jacob JM, Malicki D. Pediatrics, 2014
Links PubMed Pediatrics

The bottom line

Automated urinalysis is probably as good as dipstick testing for the diagnosis of urinary tract infections

What they did

The authors recruited a convenience sample of 342 children <48 months who had urethral catheterization performed. Automated urinalysis (like what is done for CBC) and traditional dipstick testing were performed and receiver operating characteristic (ROC) analyses were performed and diagnostic indices were calculated for dipstick and automated cell counts at different cutpoints.

  • 12% had bacteria ≥50 000/mL on culture
  • The areas under the receiver operating characteristic curves were:
    • Automated white blood cell count 0.97
    • Automated bacterial count 0.998
    • POC leukocyte esterase 0.94
    • POC nitrite 0.76
  • Automated leukocyte counts ≥100/μL was 86% sensitive and 98% specific
  • Automated bacterial counts ≥250/μL was 98% sensitive and 98% specific
  • A urine dipstick with ≥1+ leukocyte esterase or positive nitrite was 95% sensitive and 98% specific

What you can do

  • Know that automated urinalysis can be faster that dipstick and may be coming to an ED near you
  • Existing data supports the use of automated urinalysis, but its not for everybody, especially given the cost

The post Automated urinalysis measurement compared with the traditional dipstick method appeared first on PEM Blog.

Should you supply a salty solution for bronchiolitis symptoms?

Continuing onward with the next in the top ten articles presented at the recent AAP NCE in San Diego is a study of the use of hypertonic saline (HTS) in bronchiolitis. I’ll stray a bit form the usual format in that this paper was presented in a point counterpoint fashion. I’ve also posted on this topic previously as a part of my Bronchiolitis! series (yes, the exclamation point is intentional).

Nebulized hypertonic saline for bronchiolitis: a randomized clinical trial

Wu S, Baker C, Lang ME, Schrager SM, Liley FF, Papa C, Mira V, Balkian A, Mason WH. JAMA Pediatrics, 2014

Links PubMed JAMA Pediatrics

Nebulized hypertonic saline for bronchiolitis in the emergency department: a randomized clinical trial

Florin TA, Shaw KN, Kittick M, Yakscoe S, Zorc JJ. JAMA Pediatrics, 2014

Links PubMed JAMA Pediatrics

The bottom line

Hypertonic saline might help reduce the risk of admission in bronchiolitis, but then again it might not.

What they did

Wu and colleagues performed a RCT over 3 consecutive bronchiolitis seasons and recruited a convenience sample of patients <24 months old with bronchiolitis. from March 1, 2008, through April 30, 2011. 211 patients were randomized to HTS and 197 to saline. They received each treatment up to 3 times. All patients were premedicated with albuterol. The main outcome was hospital admission. Additional outcomes included length of stay for admitted patients, and Respiratory Distress Assessment Instrument score.

  • The authors reported that the HTS group had lower odds of admission. HTS was 28.9% compared with 42.6% in the NS group (aOR=0.49 [95% CI, 0.28-0.86])
  • There was no significant difference in the respiratory distress score in either group
  • Length of stay was marginally shorter for HTS but not significant

Meanwhile Florin et al performed a RCT comparing HTS versus normal saline. 62 patients between 2 and 24 months of age (31 in each arm) with their first episode of bronchiolitis were randomized to placebo or HTS, with the primary outcome being respiratory distress at 1 hour after administration. The included patients were enrolled after they had been suctioned and received albuterol and were determined to still have respiratory distress. They also assessed  vital signs, oxygen saturation, hospitalization, physician clinical impression, parental assessment, and adverse events.

  • They noted that 1 hour after treatment the HTS improved less versus placebo (HTS, −1 [interquartile range, −5 to 1] vs saline placebo, −5 [interquartile range, −6 to −2]; P = .01)
  • They saw no significant differences in heart rate, oxygen saturation, hospitalization rate, or other outcomes
  • This study was limited by small numbers and a single trial of HTS
  • It is also uncertain as to what effect (if any) the albuterol had on these patients

What you can do

The post Should you supply a salty solution for bronchiolitis symptoms? appeared first on PEM Blog.

PEM Currents faces parotitis

With the recent influenza epidemic you may have also seen a rise in the number of cases of parotitis. This should not be a surprise, as acute parotitis is usually viral, self-limited and treated with supportive measures – just like the flu! Learn more by listening to this edition of PEM Currents, which is all about acute parotitis.

Check it out on iTunes

Or listen via the streaming music player right here on the blog:

The post PEM Currents faces parotitis appeared first on PEM Blog.

Just give the antibiotics already (for sepsis)!

Let’s check out another in the  top ten articles presented at the recent AAP NCE in San Diego. This study examined the relationship between time to antibiotics and morbidity and mortality in pediatric sepsis.

Delayed Antimicrobial Therapy Increases Mortality and Organ Dysfunction Duration in Pediatric Sepsis

Weiss, Scott L. MD, Fitzgerald, Julie C. MD, PhD, Balamuth, Fran MD, PhD, Alpern, Elizabeth R. MD, MSCE, Lavelle, Jane MD, Chilutti, Marianne MS, Grundmeier, Robert MD, Nadkarni, Vinay M. MD, MS, Thomas, Neal J. MD, MSc. Critical Care Medicine, 2014

Links PubMed Critical Care Medicine

The bottom line

Early administration of antibiotics in sepsis reduces mortality.

What they did

The authors performed a retrospective observational study of 130 children treated for severe sepsis or septic shock. Some definitions:

  • Severe sepsis: Sepsis-induced organ dysfunction or tissue hypoperfusion (hypotension, elevated lactate, or decreased urine output)
  • Septic shock: Severe sepsis plus persistent hypotension despite the administration of IV fluids


They reviewed data for several outcomes related to sepsis mortality and morbidity and noted the following:

  • Median time to first antibiotics was 140 minutes and 177 minutes for appropriate antibiotic
  • Each one hour delay from sepsis recognition to antimicrobial administration increased mortality. It was statistically significant at >3 hours with mortality OR=3.92 (95% CI, 1.27-12.06) for initial antibiotic and 3.59 (95% CI, 1.09-11.76) for appropriate antibiotic
  • Naturally, odds of mortality were greater when illness severity was favored in – OR=4.84 (95% CI, 1.45-16.2) and 4.92 (95% CI, 1.30-18.58) for more than 3-hour delay to initial and first appropriate antimicrobials, respectively
  • Finally, delaying antibiotics >3 hours was associated with a longer period of organ-failure (16 days for <3 hours vs 20 days for > 3 hours, p = 0.04).

What you can do

  • Even if you are only somewhat suspicious for sepsis GIVE ANTIBIOTICS ASAP!
  • Consider broad spectrum agents appropriate for the patient population including gram positive and negative coverage (ceftriaxone + vancomycin for instance)
  • Even if you aren’t sure that it’s sepsis – or may just SIRS – GIVE ANTIBIOTICS ASAP!
  • When taking a referral from an outside hospital assure that antibiotics are given prior to transfer if at all possible

The post Just give the antibiotics already (for sepsis)! appeared first on PEM Blog.

A better way to perform a needle thoracostomy

Sure, you could just jam a 14 gauge angiocath into the intercostal space and listen for the whoosh of air that may and may not come… But why not try this method, which takes a few seconds longer to set up, but gives you better feedback and allows you to temporarily close the system in preparation for a formal chest tube.

The post A better way to perform a needle thoracostomy appeared first on PEM Blog.