Medical Student

Emergency Medicine Ultrasound

Orientation Packet
 WELCOME TO UC Irvine Emergency Medicine Ultrasound Elective

We are glad you are here! Please take the time to review the contents of this packet. We hope this information enables you to
have a positive clinical experience at UC Irvine Health and UC Irvine School of Medicine. Please utilize this packet as a reference
throughout your elective.

Elective Description

Students will be required to complete enough clinical shifts to perform a minimum of 75 bedside ultrasounds on ED patients. The
elective director is Chris Fox, MD. During your elective you will learn proper ultrasound techniques and interpretation of bedside
ultrasound. Indications for ED ultrasound, limitations, knobology, and image acquisition will be emphasized. The following
applications of ED ultrasound include: cardiac, gallbladder, renal, aorta, testicular, endovaginal, FAST, deep vein thrombosis, and
ultrasound guided procedures. All students will get the opportunity to perform most of these ultrasounds. Students will be
required to keep a log of ultrasounds performed, and follow up on confirmatory studies obtained. All ultrasounds performed are
recorded. Students will be required to attend the 3-hour quality assurance (QA) session held each week by one of the following
MD's: Chris Fox, MD, Shadi Lahham, MD or an ultrasound fellow, at which time the ultrasound scans performed in the ED will be
reviewed. During the QA sessions, the students will learn to interpret normal ultrasound findings, pathology and image quality/
technique. In addition, if there are Clinical Foundation sessions scheduled during your rotation you will be required to instruct
First and/or Second year medical students the art of Ultrasound with hands on training. Clinical Foundation sessions will be held
on BOTH Tuesdays and Thursdays with a mandatory training session held on Tuesday morning. The Clinical Foundation sessions
will be held throughout the year at the UCI Medical School Campus. Students will be notified of dates in advance.
ATTENDANCE is mandatory for all QA clinical foundation sessions (if applicable) and ournal club (if applicable)

Elective Activities

* There will be a small orientation held on the first QA meeting at the start of your elective block.
* Please make sure you read through this document (Emergency Ultrasound Elective course Guide pdf) prior to your first ED shift.
* Bring your home identification badge; UCI will also provide an access badge.
* Please pick up your badge directly from Dr. Fox his office is located at 333 City Tower Blvd. West, Orange, CA 92868.
On the 6th floor of City Tower Suite 640.
* Return badge to Dr. Fox prior to your last day at UCI. EA E N TE D N T ET N ACCE AD E YOU
FAIL THE ELECTIVE!
* A minimum of 75 bedside ultrasounds completed in the ED per week. You are able to perform multiple ultrasound exams on
one patient (FAST scan, gallbladder, thyroid, DVT, etc.).
* Please revie Dr Fox s podcasts on itunes before you start your ultrasound scans
Go to iTunes -> search for "Fox Ultrasound" a collection of his podcasts will appear, choose Emergency Ultrasound on the top left.

* To get the most out of the elective, try to come in every (week)day and get involved with any patients with potential
pathology.
* After some practice, you can offer to do the FAST exam on trauma patients. There is an ultrasound machine in each of the
trauma bays.
* The ED Observation unit is a great place to do a bunch of scans because the patients are stable and ususally waiting for hours
for a specific test/intervention.
* Keep log of all ultrasound completed; record videos
* It is recommend to keep a hand written log of your ultrasounds with notes on the patient's presenting symptoms since you wil
not have access to their charts.
* Attend weekly QA meetings -- You will be given QA dates in advance in your welcome email
* Attend Tuesday morning Clinical Foundations (CF) ultrasound training sessions (if applicable)
* Teach M1/M2 Clinical Foundations of Ultrasound on Tuesday and Thursday afternoons (if applicable)
* Attire is professional clothes or scrubs WITH WHITE COAT
At t e end of t is ultrasound rotation t e student ill be able to
1. Understand the basics of ultrasound
2. Recognize indications for an ED bedside ultrasound.
3. Perform bedside ultrasound of the heart, abdomen, pelvis, and extremities.
4. Obtain classic “windows” of each of the above bedside applications in a timely fashion.
5. Read and interpret limited ED bedside ultrasounds.

TRANSPORTATION

* Fly into John Wayne (Orange County) airport

* Car -- it is highly recommended that you have a car to get between undergraduate (main campus) and medical center
(20-25 minute drive).

Shuttles (https // parking uci edu/AT/modes/shuttles cfm)

Campus-to-campus shuttle during the day
Need UCI identification
Leaves from Admin circle (by the “flag pole”) or Lot 80 (by the medical school)

Parking at the UC Irvine Medical Center/City Tower

https://www.parking.uci.edu/parking/publicInfo/survivingwithoutacar.pdf
Parking permit(s)
Zone 2 student permit ($70/month) can be used on the medical school campus and in the Crystal Cathedral lot
by the medical center/hospital.
If working a weekend shift, park in UCI Dawn Way parking structure and then show parking permit to
attendent when leaving for free parking.
If working a late shift (last shuttle leaves hospital for Crystal Cathedral at 8:45pm), talk to Transportation office
about parking in the lot across Chapman Ave.
If parked in Crystal Cathedral lot, leaving after 8:45pm and don’t feel comfortable walking, you can call Security
and have them drive you to your car.
Can also get weekly guest pass at the UCI Dawn Way parking structure for 2 week rotators. Passes cost $12 per
week and may be purchased in the parking office or the parking kiosk in the patient/visitor parking structure.

Parking at UC Irvine School of Medicine (Main Campus)

You can find a pay station on Lot 83. 4 hour parking permit is $7.00 and an all day parking permit is for $10.00
UCI Transportation Shuttle Service: https://www.parking.uci.edu/AT/modes/shuttles.cfm
UCI School of Medicine -- Medical Education Campus: http://www.ultrasound.uci.edu/contact-us.asp
 Housing
* I would recommend trying to find housing close to the hospital campus in Orange, since that is where you will be
working most often
* Rotating Room (rotatingroom.com) may have some options if you are looking early enough
* If you are trying to find housing last minute, consider contacting Cindy Hughes (cindy.hughes@icha.uci.edu) - Rental
Consultant/Community Service Coordinator, Irvine
* Campus Housing Authority: Usually only has housing options near undergraduate/main UCI campus

Ultrasound Resources
* External recommendations (per Dr. Robert Huang)
EMSono - requires subscription
Sonoguide - website. Free
Introduction to Bedside Ultrasound 1 and 2 by Mallin and Dawson - on itunes/iBooks. Free (right now;
apparently can cost $1-2). Best resource

* UCI recommendations (per Dr. Fox and Dr. Lahham)

Google “UC Irvine ultrasound podcast fox” to access free UCI ultrasound podcasts
Podcasts open in iTunes U
Titled “Ultrasound in MedEd” (MS1 through MS4)
UCI Emergency Medicine Lectures from iTunes (files also open in iTunes U)
UCI ultrasound iBooks - Genitourinary Ultrasound :https://itunes.apple.com/us/book/introduction-to-genitourinary-
ultrasound/id1088135854?mt=11
Cardiac Ultrasound: https://itunes.apple.com/us/book/introduction-to-cardiac-ultrasound/id1024752536?
ls=1&mt=11 2
Ocular Ultrasound: https://itunes.apple.com/us/book/introduction-to-ocular-ultrasound/id1088138183?mt=11 Abdominal
Ultrasound: https://itunes.apple.com/us/book/introduction-to-abdominal-ultrasound/id1037939208?mt=11
FAST Scan: https://itunes.apple.com/us/book/introduction-to-fast-scan/id1046079411?mt=11

Statement of Diversity

The University of California Irvine values diversity and inclusion. We are committed to a climate of mutual respect and full
participation. Our goal is to create learning environments that are usable, equitable, inclusive and welcoming.

If there are aspects of the instruction or design of this course that result in barriers to your inclusion or accurate assessment or
achievement, please notify the instructor as soon as possible.

Students with a disability that may impact their ability to learn and/or perform in the School of Medicine are also welcome to
contact the Disability Services Center to discuss a range of options to removing barriers in the course, including accommodations.

The center may be contacted at www.disability.uci.edu or 949-824-7494.

HOSPITAL ACCESS BADGES

You will sign-out a temporary access badge on your orientation day (same day as scheduled QA date) with Dr. Fox directly or his
assistant Cecile Nguyen cecilen@uci.edu. You will need to wear this badge at all times together with your medical school badge.
A UCIMC access badge will allow you access to hospital, staff elevators, unit doors, and staff lounges.

PLEASE NOTE:
There will be a $25 fee for any lost or misplaced access badges. If you do not return your
access badge or submit the fee we will not release your grades and there will be a hold
placed on your evaluation.

DRESS CODE
UC Irvine SOM approved scrubs (dark green with SOM logo and not outside scrubs). Must wear white coat with scrubs.
Visiting students can use matching scrubs from their institution, with white coat, and school ID badge.
No hoodies.

CELLPHONE USE
Must be on silent or vibration mode at all times
Limit personal use to break and lunch periods in non-patient care areas
No cell phone photography of patients is allowed
NO TEXTING!

HAND HYGIENE
Use soap and water – scrub at least 15 seconds.

When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body
fluids
Before eating
After using a restroom
After care of a patient on “Spore Precautions” or after contact with the patient’s 
environment in the “Spore Precautions”
room

Use alcohol-based hand rub – rub hands, covering all surfaces, until hands are dry

Before having direct contact with patients

Before donning PPE
Before inserting indwelling urinary catheters, peripheral vascular catheters or other 
invasive devices
After contact with a patient’s intact skin (when taking vitals, lifting patient, etc.)
 CODES AND PAGING
Dial extension 6123 and report Code (state the color) and its location (Building, Unit, and Bed Number).

Paging system: dial 9-506-pager number

Call Back: extension you are calling from, then # key

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA)

Do not take any portion or copies of the patient chart out of the medical center for any reason. No paperwork with patient
identifying information leaves the hospital.

END OF ROTATION EVALUATION

We value your feedback! You are required to evaluation the rotation to let us know how we can improve. Visit EM End of Rotation
Evaluation. Your responses are anonymous.

FINAL GRADES
Final grades are typically submitted within 4 weeks of the end of your rotation.
Please ensure you have completed all requirements (rotation attendance, assignments, documentation, evaluations, returning of
badges, etc.) to allow for timely processing of your final grade.
Questions regarding final grades should be directed to Dr. Fox.
External and International students, please have your school send the evaluation forms directly to the Ultrasound Coordinators.

Ultrasound Elective Contact Information

Director of Emergency Director of Instructional Ultrasound Coordinators

Medicine Ultrasound Ultrasound Nora Perez-Moreno nperezmo@uci.edu
Shadi Lahham, MD Chris Fox, MD Brenda Nash
slahham@uci.edu jfox@uci.edu nashb@uci.edu

Thank you, we hope you will enjoy your clinical experience with the
Department of Emergency Medicine!
Emergency Medicine Ultrasound )HOORZVKLS -- FAQ’s

1. When and where do I show up on the first day of the IHOORZVKLS?

Report to the ED department of the UC Irvine Medical Center (UCIMC) located at 101 The City Drive South Orange, CA
92868 and let the attending physicians and residents there know that you are on the ultrasound IHOORZVKLS and ask if
they have any good scans for you to perform. If they say no (unlikely) then ask if you can scan any of their patients.

2. How many scans do I have to do?

You are required to complete 100() scans per week. This sounds like a lot but it is actually not very time intensive. In a
single patient from head to toe you can do ocular, thyroid, carotid, brachial plexus, lung, cardiac, FAST, renal, biliary,
bowel, aorta, DVT, and musculoskeletal. That is 13 scans. If you just do 5 scans per patient you will be done with your
numbers after  patients. Performing multiple scans on the same patient is advisable from a time
perspective but remember that it is not about the numbers. It is better to perform scans that answer a clinical question in
your mind. Does the patient with shortness of breath have pulmonary edema or CHF? Does the patient with leg edema
have a DVT? Go into the room with a question in your mind. Perform the scan to answer the question then go ahead and
add on more scans for practice.

3. What are my responsibilities during this IHOORZVKLS?

You must attend all ultrasound QA sessions (MANDATORY)

You must attend and teach at all WHDFKLQJsessionsLIDSSOLFDEOH
You must attend journal club meetings if one they are scheduled during your
IHOORZVKLS. You must complete all of your scans on your own schedule.

4. Where is the location for QA?

1st Location -- most likely

always held here):
333 City Tower Blvd. West,
Orange, CA 92868.
th
On the 6 floor of City Tower
Suite 640 in the ED conference
room.

If you get lost please contact

Jennifer Holford at 714.456.8934.

nd
2 Location – very rarely
Main UCI campus Medical
rd
Education Building #836, 3 floor
Room 3105

http://www.ultrasound.uci.edu/cont
act-us.asp
Saving Good Quality Clips and Images

ALL MUST BE CLIPS, unless measurement/interpretation/M mode

Interpretation – tell us what you saw. Each scan you do needs an interpretation
(e.g. if you scanned the gallbladder and the aorta on the same person, both
need an interpretation). You should type you interpretation on the screen after
you last clip and save a still image of it.

Keep in mind that we only want you recording if you think you’re getting adequate images. If
you’re not satisfied with you image, neither are we, so don’t record it. Instead do what you
need to in order to get better images: use a different technique, use a different probe, use a
different frequency, change the patient’s position, push harder with the probe, grab an
ultrasound fellow, attending or resident and ask for help.

AORTA: 2 Clips: Transverse and longitudinal - SX to iliacs.

Normal <3cm outer wall to outer wall. If dilation or if diameter >3cm, look
for clot. Save transverse still with measurement of widest area

ECHO: Clips: 3 out of 4 views (below). Eval for effusion/tamponade,

contractility; CARDIAC settings on US.
-Subxyphoid 4 chamber: flatten probe under xiphoid process
-Parasternal long: left anterior chest wall; indicator toward left hip (abdominal
settings) or right shoulder (cardiac settings); also evaluates aortic root/descending aorta
-Parasternal short: left anterior chest wall; indicator toward right hip (abdominal
settings) left shoulder (cardiac settings); evaluates LV contractility -
Apical 4 chamber: at PMI; under nipple indicator to pt’s right (abdominal
settings) left (cardiac settings); evaluates RV size in relation to LV (great for evaluation of
Pulmonary Embolus)

EFAST: 4 Views: 4 Clips: anterior mid clavicular lung views, RUQ, LUQ, SUBX (or PSL),
PELVIS:
- View entire kidney by fanning through it; make sure to get clips of the inferior pole of both
kidneys; view entire heart (do not fan); evaluate for fluid above and below diaphragm when
viewing RUQ and LUQ
- Slow fanning thru diaphragm-liver-kidney/spleen-kidney/pelvis space
- Make sure you view PELVIS in both transverse and sagittal plane – when viewing in the
sagittal plane, make sure you evaluate the recto-uterine pouch (pouch of Douglass) and the
retrovesicular space (between the bladder and the uterus) in women and the recto-vesicular
space in men

E-FAST: 6 views (bilateral chest + 4 FAST views): ant chest wall 2nd IC space; indicator
toward pt’s head, need bilateral clips of lung sliding/comet tails (M-Mode option)
GALLBLADDER: 2 clips: fan thru transverse & long GB; adjust depth prn
- Evaluate for stones, pericholecystic fluid, ant wall thickening, CBD diameter
- Normal GB: length 7-10cm/ width 2-4cm
- Normal GB anterior wall: 3mm; CBD: 5 mm (+1 for each decade>50y)

TRANSABDOMINAL PELVIS: 2+ Clips (fanning thru region,

if large bladder and too bright likely need to decrease gain to avoid posterior acoustic
enhancement)
- Uterus: sagittal & transverse + bilateral ovaries attempt
- Live IUP: gestational sac (5.5weeks), yolk sac, fetal pole
- Cardiac activity/ rate (with M mode – DO NOT USE DOPPLER)
- gest age: GS, CRL, BPD, FL (optional) - Do a FAST as part of your ectopic evaluation

ABDOMEN (SPECIAL): Clips of anatomy with both transverse &

longitudinal views (pyloric stenosis, intussusceptions, etc)

BLADDER VOLUME: Clips preferred/stills OK: Suprapubic transverse (2

measurements) and sagittal view (1 measurement) - 3 measurements and
calculation of volume (0.5 x L x W x D)
CHEST/THORAX: Clips: Bilateral views. If evaluating for CHF/PNA/ARDS:
check for multiple B lines (aka greater than 3) on multiple views on each side of the chest (8
total chest quadrants evaluated).

DVT: Clips preferred/stills OK if split screen of non-compressed vs

compressed region - compress every 1cm for the length of 5cm for both in
femoral and popliteal (up to trifurcation) regions

IVC: Clips preferred: subxyphoid view (longitudinal) showing IVC entering

RA with respiratory variations; visualize IVC size; sniff test option (make
sure it is NOT the aorta). Normal 1.5-2.5cm with <=50% variation

MSK/SoftTissue: Clip of relevant findings in multiple (at least 2) views.

Look for fracture, cellulitis, abscess, joint effusion, lymph nodes, foreign body

ORBITAL: Clips: bilateral orbits in transverse and longitudinal; linear

probe; fanning thru orbit;
-shows optic nerve, retina, vitreous, lens, anterior chamber, pupil muscle
contraction:
- Optic nerve sheath diameter (ONSD) measured 3mm from retina; norm <5mm. Linear
relation to intracranial pressure (ICP), can use to evaluate for changes in ICP in real time.

RENAL: 3 views: clips: transverse and long kidney PLUS bladder

-Normal kidney length 9-12cm; left lower than right
-Evaluate for cysts, masses, hydronephrosis, stones, bladder general size

RLQ (appendicitis): Linear probe at area of pain; Clips of compression/

incompressibility/evidence of free fluid. Appendix should be compressed between psoas and
abdominal wall muscles - views with Color (looking for the “ring of fire”) encouraged.

TESTICULAR: Clips: Transverse/long/coronal of each testicle - with/without

Color Doppler.

MISC: Get at least 2 (transverse, long) views; interpret image

PROCEDURAL: Clips preferred/stills OK – for fluid localization

(thoracentesis/paracentesis/abscess); Vascular access: must show CLIP of guide wire catheter
or needle in vein