Emergency Ultrasound Section Newsletter - April 2010 - Vol 14, #2
Gerardo Chiricolo, MD, FACEP, RDMS
The section leadership has been well apprised of the recent editorials published in Emergency Medicine News regarding emergency ultrasound and the previous work of our section. Please rest assured that we will be responding as we have a well thought-out strategic plan (both short-term and long-term). The section leadership appreciates your concern as well as the massive amount of emotional but rational responses. Please feel free to respond to Emergency Medicine News independently if you so desire. Please contact me directly for any particular questions, comments, or concerns.
With that out of the way, there has been a lot of activity within the section that I would like to share with all of you. All of our subcommittees have been hard at work and I am going to take this time to point out a few.
Major concerns are refusal to credential emergency physicians to perform emergency ultrasound and continued denials of reimbursement by a major insurance carrier in a couple of states. The section leaders (past and present) have been working closely with PaACEP and MACEP in an effort to overcome these obstacles. I urge all section members to be vigilant in their respective states for any political issues that may arise. Please contact Dr. Paul Sierzenski and myself with any issues or concerns that may arise.
The Industry subcommittee has been developing templates for a more consistent and uniform workflow and for developing a formal relationship between the college and IHE. A spinoff group, the Minimum Reporting Standards subcommittee has done a considerable amount of work in a short period of time. The reporting templates for each exam type have been completed and are being refined.
The Accreditation subcommittee is in the development phase of this labor-intensive project. There are a ton of legal issues that need to be addressed. There are a ton of administrative materials that need to be developed including but not limited to operational guidelines and reviewers manuals. Then there are the details of advertising and promotion. We will continue to work hard in making this a reality.
The Ultrasound Fellowship subcommittee has convened and updated the fellowship guidelines, which should be available very soon. There are several changes but of note the minimum number of scans recommended for successful completion of a fellowship was raised from 800 to 1,000. Another important note is how time spent scanning outside of the emergency department will be held. Although it is noted that there are very few circumstances where a fellow might benefit from scanning with other specialties, such time should not be counted toward the number of examinations performed in the ED. Focused clinical emergency ultrasound is vastly different from comprehensive consultative ultrasound and therefore should be treated as a separate distinct experience.
Many of you have noticed a change in the layout of the ultrasound information found on the ACEP website. Invaluable resources and materials have been made available to all members. Whether you are looking to start an ultrasound presence at your institution or you have an established ultrasound division but need further guidance, the community subcommittee has done a phenomenal job of getting this data out to all of you. A special thanks to Dr. Tillotson and his crew for such dedication and hard work.
I would like to thank all of the section members for their time and energy and hope to continue on this pace for the rest of the year.
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Mark Ault, MD FACEP
Bradley T. Rosen, MD MBA FHM
Cedars-Sinai Medical Center
Los Angeles, CA
Ultrasound has become the established standard for central line placement by physicians, and it is now being increasingly touted for use by nurses and paramedics for peripheral IV access. However, reports have been conflicting about its utility for peripheral IV starts. We offer for historical perspective our data from the time we ramped up the use of portable ultrasound for PICC placements. Our experience with ultrasound for PICC placement strikingly mirrors the challenges faced today for routine peripheral access. Both of these point-of-care applications involve difficult vascular targets, which are often very small and sometimes adjacent to other neurovascular structures. Successful deployment of the applications also requires overcoming the inertia of entrenched practice patterns.
We acquired our first ultrasound machine (a Site Rite® II from Dymax Corporation, Pittsburgh, Pa) in 1999, 9 years after the advent of our Procedure center at Cedars-Sinai Medical Center in Los Angeles. By that time we had a very busy PICC service and had placed over 6000 PICCs without ultrasound. We were proud of our 98% success rate. However, drilling down into that data revealed a cutdown rate of 31%. Point-of-care ultrasound was in its infancy at that time and so naturally we were a bit skeptical: Our feelings were that, even though cutdowns were invasive and caused scarring, we had refined our skills over the years and had come to accept the incidence of cutdowns as a natural cost of doing business.
We nevertheless agreed to give the ultrasound a try, and we implemented it on an elective basis to be used at the discretion of the physician. We were already routinely collecting and analyzing all of our insertion and outcomes data, and after several months we reviewed our experience with the ultrasound. As it turned out, it didn't take us long to embrace the "magic" of ultrasound, and our cutdown rate dropped to less than 10%. In addition, we were pleased to note that we had successfully established percutaneous access in 25 patients that had previously required cutdowns. We discovered additional advantages of real-time ultrasound use including: Better selection and location of vascular targets, avoiding thrombosed and anatomically unfavorable vessels, and achieving more precise placement of local anesthetic prior to percutaneous needle placement.
Importantly, we noted a significant learning curve before the full benefits of ultrasound were achieved, as demonstrated by our gradual decline in cut-down rates over the 1 1/2 year adoption period (Figure 1).
The preponderance of published literature, as well as our own extensive experience over the past 12 years, strongly supports the use of real-time ultrasound guidance for all kinds of vascular access…ranging from PICCs to central lines to peripheral IVs and arterial lines. Equally important, however, is the need for significant training and experience before optimal technical expertise can be achieved. We present this data not to discourage ultrasound use by nurses, paramedics, or physicians for peripheral access; rather, to promote the need for sufficient training, patience, and persistence in utilizing this technique in order to achieve the full advantage of this invaluable technology.
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Lawrence A. Melniker, MD, MS, FACEP
Immediate-Past Chair, EUS Section
As the Chinese proverb states: we live in interesting times – but are our times really more interesting than bygone days? I think we can make the argument that they are!
Prior to Osler, medical assessment was predominantly an auditory-visual art and science - physicians "listened to" and "looked at" their patients and drew conclusions from their sounds and appearances. Some practitioners used olfaction and "smelled out" diagnoses. Occasionally, body fluids were "tasted." What was occurring below the skin remained a mystery. William Osler is considered the father of "physical diagnosis." He brought our sense of touch into the process of evaluation and so palpation became integral to the multisensory physical examination – "Use your five senses; learn to see, learn to hear, learn to feel, learn to smell…" (No reference to tasting found). Adding palpation, the eliciting of tenderness by applying pressure or causing tissues to vibrate and move abruptly allowed inferences of internal pathological states. However, actual visualization of the inner workings of the body and the changes occurring during disease states remained the purview of post-mortem dissection and evaluation. This began to change in the latter part of the 19th century.
With widespread use of the microscope, the concept of cellular building blocks and the microbiological world came into focus. By the end of the 1800’s, medical science had the stethoscope, endoscope, ophthalmoscope, and X-rays to peer into the body - the electrocardiogram entered the scene in 1903. These devices heralded a new era in medical science by affording clinicians the ability to peer inside the patient. There was considerable resistance to the use of these new technologies with leading cardiologists continuing to place their ears against patients’ chests. Many felt that only specially trained clinicians should use the devices; unregulated use would lead to chaos.
Medical diagnosis certainly experienced a renaissance in the last century – as did medical therapeutics. By the mid-20th century, x-rays, computerized tomography, sonography, radioisotope scanning, and, finally, magnetic resonance imaging provided unprecedented visualization of internal organs without invading the integument. These modalities started in Departments of Radiology, the traditional providers; but have now moved beyond to others areas and specialties. Technological advances have led to bigger and better machines and, subsequently, higher resolution. The one difference has been sonography, where advances in digital circuit technology have led to smaller, but better devices. Today, sonographs are no more than transducers attached to computers with some form of screen. Many of us have power computers clipped to our belts or nestled in a pocket or purse.
Herein lies clinical sonography’s implications for bringing Osler’s genius to the next level. Sonography brings imagery of internal organs and structures to the bedside to compliment the senses we use in our physical assessment of the patient. Harvey described the circulatory system, Osler gave us the method to feel the "point-of-maximal-impulse," while Laennec facilitated listening to S1 & S2; clinical sonography allows us to look at the heart and its environs and provides manifold more information in real-time at the point-of-care. Likewise, not all pulsatile masses are abdominal aortic aneurysms and not all AAAs produce palpable pulsations; some "gallbladder attacks" are just biliary colic, while others result from cholecystitis necessitating surgical intervention; wheezing can result from bronchospasm or be due to excess lung water; and soft tissue infections can be simple cellulitides or contain fluid collections requiring incision & drainage. These are just a few examples of the potential for clinical sonography to add to our senses and differentiate the proper course of action. In addition, the "blind approach" applied to many procedures should be left on the scrap heap of history, where it belongs. For the safety of our patients and the efficiency of completing interventions on the first attempt, clinical sonographic assistance should be the standard of care. In the near future, we will not be able to defend not using this technology.
So what lies ahead in the future? Can you imagine a world in which ionizing radiation is exclusively used for oncologic treatment and not for diagnostic purposes - a place where everything outside of bone is imaged by sonography and the interior of bones by MRI? Starting at the head and flowing down to the toes: the applications of clinical sonography seem limited by our vision and imagination. All layers of the integument; ligaments, tendons, muscles, and the cortex of bone; arteries and veins; solid organs; and hollow viscus (once properly flushed of gaseous contents) – all of the tissues and structures can be sonographically assessed. Specifically, the potential of musculoskeletal ultrasound is amazing. Extrapolating from government databases, over 2 million primary and follow-up x-rays conducted annually at a cost of hundreds of millions of dollars for information that may be accurately obtained without ionizing radiation by employing sonography. Obtaining competency in head-to-toe scanning will take time and effort.
The Food and Drug Administration is planning to initiate a process of regulating and mitigating patient exposure to radiation, mainly diagnostic applications – the timeline for this oversight has not been determined. So where should we begin to realize this dreamy future? We can debate this question, but I believe the "low lying fruit" are 2 organs – the kidneys in adults and the appendix in children. Looking back at older editions of Tintinalli’s or Rosen’s textbook, under renal colic there were 3 indications for imaging: solitary kidney, obstruction with pyelonephritis, and intractable pain (not otherwise explained) – and no mention of stone size. Then, along came the "Stone Scan," renal CT, and everyone got one or several. Repeated Ovid or Pubmed searches for evidence that an emergency physician needs to know stone size have consistently led to zero prospective or substantive retrospective studies. In contrast, multiple investigations have supported the positive predictive value of appendiceal ultrasound and a tiered evaluation starting with history and physical examination, followed by ultrasound, and CT only used when H & P and US are equivocal.
Finally, on average, x-rays are billed at approximately twice, CTs are 5-10 times higher, and MRs are 10-20 times more than the charges for clinical sonography scans. Therefore, the potential savings to the healthcare system may well run in the billions. It is essential that we conduct cost-benefit and efficiency trials to confirm the many potential benefits of clinical sonography as soon as possible.
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Lawrence A. Melniker, MD, MS
WINFOCUS has had a very dynamic year. In addition to starting the new publication, Critical Ultrasound Journal, the organization has begun hosting International Consensus Conferences and plans are being made for the 6th World Congress in October 2010 in Rome, Italy and the WCU7 in September 2011 in New Delhi, India.
The Critical Ultrasound Journal, under Editor-in-Chief Michael Blaivas, MD, published 2 issues in 2009. It contains sections for Acute & Trauma Surgery, Anesthesia & Critical Care, Disaster & Tactical medicine, Echocardiography in Intensive Care, Education & Organization, Emergency Medicine, Evidenced Based Medicine, Lung & Pleural Ultrasound, Neonatology & Pediatrics, Obstetrics & Gynecology, Prehospital Care (EMS/HEMS), Primary Health Care & Scarce Resource Medicine, Remote Care & Sports Medicine, and Telemedicine & Technology. Each year, contributions for these sections will produce a robust resource for best practices, educational tools, competency assessment, and principles for the advancement of clinical sonography in all settings.
In November 2009, the 1st International Consensus Conference on Pleural & Lung Ultrasound was convened. The first meeting was in Bologna, Italy and, while the debate was robust, there was far more consensus than controversy. In December, the conferees completed a second round of voting on principles and, currently, the Coordinating Committee is completing the bibliography and scoring process. The second meeting will be in May in Pisa, Italy and the consensus document will be finalized in October at the 6th World Congress.
The next installment will be the 1st International Consensus Conference on Ultrasound Assistance of Vascular Access with the initial meeting in June 2010 in Amsterdam, Netherlands. It is expected that this conference’s consensus document will also be finalized at WCU6. Other Consensus Conferences will be planned, resulting documents published in the CUJ, and all supporting material made available through the WINFOCUS website.
On March 18, 2010, WINFOCUS representatives presented the use of clinical sonography at the United Nations in New York City as part of the InfoPoverty Program. InfoPoverty is a group dedicated to ending extreme poverty in the world through high-tech, low-cost solutions and, in the context of medical imaging, clinical sonography exemplifies that mission. Last year, the concept of clinical sonography was presented to delegates in New York and via closed circuit transmission in Milan, Italy. This year a practical hands-on presentation is planned.
Finally, it is a great pleasure to announce the 2011-2012 President-Elect of WINFOCUS, Tomislav Petrovic, MD, of Paris, France. Tomi was the Chair of the Organizing Committee for WCU3 in 2007 held in Paris and has been a terrific contributor to the WINFOCUS mission since its inception. He will succeed Michael Blaivas at the end of his term.
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Over the past year members of the emergency ultrasound community have organized to design and build a network focusing on point of care ultrasound. The ultimate goal was to create a network that can answer questions about the benefits (and limitations) of EPs performing real time ultrasound on their patients. This sustained effort led to the creation of the Real-time Emergency Assessment with Sonography: Outcomes Research Network (REASON). After several meetings and discussions over the past year a steering committee was identified, and an initial proposal was accepted to a new research meeting organized at NIH called the US Critical Injury and Illness Trials Group (USCIIT group). Thanks to the efforts of Romolo Gaspari, MD at UMASS and several other individuals, our group received very positive feedback after presenting at the NIH meeting. In fact REASON seemed to be one the better organized projects at the Society of Critical Care Medicine follow-up conference and the feedback we received will hopefully position the group to obtain funding and make REASON a reality.
Trial 1 will evaluate the use of point of care ultrasound in cardiac arrest patients. The group hopes to offer insight into whether a heart with no activity stands any chance of restarting again or are EPs simply pursuing an un-winnable battle. We hope to validate prior work built by many pioneers of emergency medicine ultrasound. One central coordinating site (UMass) and 7 regional leadership sites (Carolinas Medical Center, N. Shore U. Hospital, Washington U., Highland General, Mass General, Christiana Care HS, U. of Ottawa) were chosen from over 25 competitive applicants. The final protocol is being fine tuned and a call for local sites will be distributed shortly. In addition the REASON operational guidelines and infrastructure are being finalized and will be presented formally to the ultrasound community likely at the SAEM national meeting.
Every attempt is being made to make this project open and transparent, and it is imperative that anyone willing, able, and wanting participate both in this initial trial and any future endeavors. This is an exciting project and we all look forward to achieving great things as an emergency ultrasound community.
If you are interested in participating, please email me back with the following information: your name, phone number, email address, affiliation, method of recording your cardiac images, estimated % of faculty or staff that use ultrasound during cardiac resuscitation, and a statement that you are interested in being considered as a local site for REASON. I will re-contact you with additional information once decisions on local sites have been made. If you know of any other interested parties (other sites or critical care departments), please forward this information.
I look forward to working with you. Please feel free to email me directly with any questions.
Thank you for your interest.
Romolo Gaspari, MD, PhD, FACEP
Director, Division of Emergency Ultrasound
REASON Steering Committee
Srikar R. Adhikari, MD, University of Nebraska Medical Center
Romolo Gaspari, MD, PhD, FACEP, University of Massachusetts
Vicki Noble, MD, FACEP, Massachusetts General Hospital
Larry Melniker, MD, MS, RDMS, FACEP, New York Methodist Hospital
Christopher Raio, MD, RDMS, FACEP, North Shore University Hospital
Dan Theodoro, MD, RDMS, Washington University School of Medicine in St. Louis
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FDA NEWS RELEASE
For Immediate Release: Feb. 9, 2010
Media Inquiries: Peper Long, 301-796-4671, firstname.lastname@example.org
Consumer Inquiries: 888-INFO-FDA
The U.S. Food and Drug Administration today announced an initiative to reduce unnecessary radiation exposure from three types of medical imaging procedures: computed tomography (CT), nuclear medicine studies, and fluoroscopy. These procedures are the greatest contributors to total radiation exposure within the U.S. population and use much higher radiation doses than other radiographic procedures, such as standard X-rays, dental X-rays, and mammography.
CT, nuclear medicine, and fluoroscopic imaging have led to early diagnosis of disease, improved treatment planning, and image-guided therapies that help save lives every day. The FDA continues to support a strong dialogue between patients and physicians over the medical necessity and risk associated with these types of imaging studies.
However, like all medical procedures, CT, nuclear medicine, and fluoroscopy pose risks. These types of imaging exams expose patients to ionizing radiation, a type of radiation that can increase a person’s lifetime cancer risk. Accidental exposure to very high amounts of radiation also can cause injuries, such as skin burns, hair loss and cataracts. Health care decisions made by patients and their physicians should include discussions of the medical need and associated risks for each procedure.
"The amount of radiation Americans are exposed to from medical imaging has dramatically increased over the past 20 years," said Jeffrey Shuren, M.D., J.D., director of the FDA’s Center for Devices and Radiological Health. "The goal of FDA’s initiative is to support the benefits associated with medical imaging while minimizing the risks."
While there is some disagreement over the extent of the cancer risk associated with exposure to radiation from medical imaging, there is broad agreement that steps can and should be taken to reduce unnecessary radiation exposure.
For example, the radiation dose associated with a CT abdomen scan is the same as the dose from approximately 400 chest X-rays. In comparison, a dental X-ray calls for approximately one-half the radiation dose of a chest X-ray. Both diagnostics serve important, sometimes critical, public health needs.
Through the FDA’s regulatory oversight of medical imaging devices, such as CT scanners, and through collaboration with other federal agencies and health care professional groups, the FDA is advocating the adoption of two principles of radiation protection: appropriate justification of the radiation procedure and optimization of the radiation dose used during each procedure.
"Working together," said Shuren, "the FDA and other organizations hope to help patients get the right imaging exam, at the right time, with the right radiation dose."
The three-pronged initiative the FDA is announcing will promote the safe use of medical imaging devices, support informed clinical decision-making, and increase patient awareness of their own exposure.
The FDA intends to issue targeted requirements for manufacturers of CT and fluoroscopic devices to incorporate important safeguards into the design of their machines to develop safer technologies and to provide appropriate training to support safe use by practitioners. The agency intends to hold a public meeting on March 30-31, 2010, to solicit input on what requirements to establish.
Examples could include a requirement that these devices display, record, and report equipment settings and radiation dose, an alert for users when the dose exceeds a diagnostic reference level (the optimal dose for most patients), training for users, and a requirement that devices be able to capture and transmit radiation dose information to a patient’s electronic medical record and to national dose registries.
In addition, the FDA and the Centers for Medicare and Medicaid Services are collaborating to incorporate key quality assurance practices into the mandatory accreditation and conditions of participation survey processes for imaging facilities and hospitals. These quality assurance practices will improve the quality of oversight and promote the safe use of advanced imaging technologies in those facilities.
The FDA recommends that health care professional organizations continue to develop, in collaboration with the agency, diagnostic radiation reference levels for medical imaging procedures, and increase efforts to develop one or more national registries for radiation doses.
A dose registry would pool data from many imaging facilities nationwide, capturing dose information from a variety of imaging studies. This registry will help define diagnostic reference levels where they do not yet exist, validate levels that do exist, and provide benchmarks for health care facilities to use in individual imaging studies.
In a bid to empower patients and increase awareness, the FDA is collaborating with other organizations to develop and disseminate a patient medical imaging history card. This tool, which will be available on the FDA’s Web site, will allow patients to track their own medical imaging history and share it with their physicians, especially when it may not be included in their medical records.
Additional information on this initiative may be found at:
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Vivek S. Tayal, MD, FACEP
- QA - If you are a credentialed emergency ultrasound provider, there is no need for a routine over-read by another EM physician, except as specified by your US QA plan. The ACEP Emergency Ultrasound Guidelines suggest that you sample ultrasound exams of credentialed physicians for QA purposes (eg, sampling rate lower than 100%). In 2001, we had used the figure of sampling 10% of US exams of credentialed providers, but in the 2008 Guidelines the rate was not specified as the there are many variables including how often that procedure is done by the group or by the provider, and the importance of the study in that specific ED or hospital. However, we encourage timely quality QA with attention to technical, interpretative, and outcome feedback
- Who does QA - Another common misconception is that the physician doing QA has to be fellowship trained. Any credentialed emergency physician is who is willing to pay attention to the QA process for emergency ultrasound could provide that service within your group.
- Billing - there is no connection between billing for either the technical or professional fee and the need for an over-read if you are credentialed. The over-read process (QA process) is for quality improvement, risk management, educational, and credentialing purposes.
- Billing if not credentialed - While typically not prohibited, generally providers should be credentialed before billing. This is the situation where an over-read by a credentialed emergency physician may contribute to an even, consistent system for billing emergency ultrasound as new or novice providers train and then meet credentialing standards within their hospital.
- Who should report and when - Whether it is a physician or a technician is performing the ultrasound exam, a final interpretation examination report should be written, dictated, or digitally completed into the medical record by the interpreting physician. If the final interpretation report is not available immediately, a preliminary US exam note should be written in the chart by the tech or physician. Since the paradigm for emergency ultrasound is typically physician performed and interpreted, most of the time physicians will be dealing with the documentation.
There are other aspects of ultrasound reimbursement guidance in the Emergency Ultrasound Coding and Reimbursement Update-2009, https://www.acep.org/workarea/downloadasset.aspx?id=33280Additional US info on www.acep.org, keyword - ultrasound.
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ACEP is a living entity which needs new ideas to keep it healthy and viable in the 21st century. Many College members introduce new ideas and current issues to ACEP through Council resolutions. This may sound daunting to our newer members, but the good news is that only takes two ACEP members to submit a resolution for Council consideration. In just a few months the ACEP Council will meet and consider numerous resolutions.
ACEP’s Representative Council, the major governing body for the College, considers resolutions annually in conjunction with Scientific Assembly. During this annual meeting, the Council considers many resolutions, ranging from College regulations to major policy initiatives thus directing fund allocation. For 2010, the Council has 330 Councillors: ACEP members representing chapters, sections, EMRA, and AACEM.
This Council meeting is your opportunity to make a resounding impact by setting our agenda for the coming years. Topics such as the direct election of the president-elect, or working with the Emergency Nurses’ Association on staffing models, grew directly from member resolutions submitted to the Council. If you have a hot topic that you believe the College should address, now is the time to start writing that resolution.
I’m ready to write my resolution
Resolutions consist of a descriptive Title, a Whereas section, and finally, the Resolved section. The Council only considers the Resolved when it votes, and the Resolved is what the Board of Directors reviews to direct College resources. The Whereas section is the background, and explains the logic of your Resolved. This should be short, focus on the facts, and include any available statistics. The Resolved section should be direct and include recommended action, such as a new policy or action by the College.
There are two types of resolutions: general resolutions and Bylaws resolutions. General resolutions require a simple majority vote to pass, while Bylaws resolutions require a two-thirds majority. When writing Bylaws resolutions, list the Article number and Section from the Bylaws you wish to alter. Then, in the resolution, you should show the current language, and bold your suggested new language while striking through the suggested edits. See the ACEP Web site article, "Guidelines for Writing Resolutions," (https://www.acep.org/aboutus.aspx?LinkIdentifier=id&id=23188&fid=1576&Mo=No&taxid=112439) which further details the process and offers tips on writing a resolution.
I want to submit my resolution
It takes at least two members to submit a resolution, or a Chapter or Section may submit a resolution. If the resolution comes from a Chapter or Section, then a letter of support from the President of the Chapter or Chair of the Section is required. The Board of Directors or an ACEP committee can also submit a resolution. The Board of Directors must review any resolution from an ACEP committee, and usually reviews all drafts at their June meeting. Bylaws resolutions pass through the Bylaws committee for review and suggested changes. These changes and suggestions are referred back to the author of the resolution for consideration. One may submit a resolution by mail, fax, or email. Resolutions are due at least 90 days before the Council meeting. This year the deadline is June 29, 2010.
Debating the resolution
Councillors receive the resolutions prior to the annual meeting along with background information from ACEP staff. Discussion often occurs on the Council electronic list serve prior to the Council meeting. At the discretion of the Speaker, non-Councillor resolution authors may be added to the Council e-list serve upon request.
At the Council meeting, the Speaker and Vice-Speaker divide the resolutions into four reference committees. The reference committees meet and hear testimony on each resolution. You, as the author of your resolution, should attend the reference committee that discusses your resolution. Reference committees allow for open debate and unlimited testimony, and participants often have questions best answered by the author. Afterwards, the reference committee summarizes the debate and makes a recommendation to the Council.
The Council then meets to discuss all the resolutions. Each reference committee presents each resolution, providing a recommendation and summary of the debate to the Council in writing and on the podium, and then the Council debates each resolution. Any ACEP member may sit in the back and listen to the Council debate whether a Councillor or not. If you wish to speak directly to the Council, you may request to do so in writing to the Speaker before the debate. Include your name, organization affiliation, issue to address, and the rationale for speaking to the Council. Alternatively, you may ask your Chapter or Section for alternate Councillor status and permission for Council floor access during debate. Chapters and Sections often have alternate Councillor slots and encourage the extra participation.
The Council’s options are: Adopt the resolution as written; Adopt as Amended by the Council; Refer to the Board, the Council Steering Committee, or the Bylaws Interpretation Committee; Not Adopt (defeat or reject) the resolution; or Postpone.
Hints from Successful Resolution Authors
- Present your resolution prior to submission to your Chapter or Section for sponsorship on the Council floor. This way, they can give advice and assistance.
- Consider the practical applications of your resolution. A well-written resolution that speaks to an important issue in a practical way passes through the Council much more easily.
- Do a little homework before submitting your resolution. The ACEP web site is a great place to start. Does ACEP already have a policy on this topic? Has the Council considered this before? What happened?
- Find and contact the other stakeholders for your topic. They have valuable insight and expertise. Those stakeholders may co-sponsor your resolution.
- Attend debate concerning your resolution in both reference committee and before the Council. If you cannot attend, prepare another ACEP member to represent you.
I need more resources
Go to ACEP’s Web site, www.acep.org. Pick the "Member Center" drop list, then "Leadership," and click on "Council." There you will see a link to the "Guidelines for Writing Resolutions" article. All authors should review this article prior to writing their resolution. Additionally, there is information about the Council Standing Rules, Council committees, and Councillor/Alternate Councillor job descriptions. Of special note, there is a link to Action on Past Resolutions. Under this link are .pdf documents dating back to 1998 summarizing each resolution and what has occurred with each of them. You can review past actions, or keep track of what happens once your resolution passes.
Well, get to it
Writing and submitting Council resolutions keeps our College healthy and vital. A Council resolution is a great way for College members to speak to the leaders of the College and the Board of Directors. Even if your resolution does not pass, the College will debate the topic and consider its ramifications. Additionally, other members may have resources or suggestions to address your issue. I encourage you to take advantage of this opportunity and exercise your rights as part of our Emergency Medicine community. Dare to make a difference by submitting a resolution to the ACEP Council.
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Schuster K, Lofthouse R, Moore, C, et al. Pulseless Electrical Activity, Focused Abdominal Sonography for Trauma, and Cardiac Contractile Activity as Predictors of Survival After Trauma. J Trauma. 2009; 67: 1154-57.
Reviewer: Christopher Angemi, DO
Objective: To evaluate if the absence of cardiac activity on pericardial FAST (pFAST) exam in a trauma patient presenting or progressing into pulseless electrical activity (PEA) was indicative of an unsalvageable patient.
Methods: This was a retrospective review of patients presenting in PEA or progressing to PEA during initial trauma resuscitation at a level I trauma center from Jan 2006 – Jan 2009. Extended FAST exam was performed by senior (PGY 3-4) residents trained in ultrasound under the direct supervision of credentialed attending physicians. The images were then reviewed by an ultrasound trained physician who was blinded to the outcome to confirm the findings on the medical record. Additional data collected included mechanism of injury, age, pFAST findings, vital signs, resuscitation time after pFAST, CPR in the field, and outcome.
Results: There were 28 patients enrolled in this study, of which 25 presented in PEA and 3 developed PEA during resuscitation. 12 out of the 28 had organized cardiac activity on pFAST. 5 patients regained a pulse during resuscitation, all of which had cardiac activity on pFAST. Cardiac activity yielded a statistically significant predictive value for a return to pulse but not for survival past resuscitation. None of the patients without cardiac activity on pFAST regained a pulse. Only 3 patients survived past resuscitation however two died in the operating room and one in the ICU. The absence of cardiac activity was 69% sensitive and 100% specific for not regaining a pulse.
Discussion: This study demonstrates that lack of cardiac activity on pFAST in the traumatic patient presenting in or developing PEA during resuscitation has a poor outcome. Those with cardiac activity have a statistically significant chance for a return to pulse and may represent a chance for survival. Limitations include a small sample size and possible bias if the patient had no cardiac activity thereby limiting longer resuscitative efforts. The authors contend future use may extend into the prehospital setting as to limit utilization of resources.
Chandra A, Mastrovitch T, Ladner H, et al. The Utility of Bedside Ultrasound in the Detection of a Ruptured Globe in the Porcine Model. West J of Emerg Med. 2009. 10(4)263-66.
Reviewer: Christopher Angemi, DO
Objective: The objective is to evaluate the emergency physician’s ability to detect a ruptured globe in an ex-vivo porcine model. Secondly, to evaluate if ultrasound increases ocular pressure with and without a 1mm clear plastic shield.
Methods: Emergency medicine residents and attending physicians had a 15 minute training lecture then measured 18 porcine eyes randomized as normal, ruptured, or complete vitreous hemorrhage using a linear array transducer. They were not able to visualize the eyes as they were covered in gelatin to simulate periorbital edema in the post traumatic eye. After the initial study, ocular pressure was measured with a pressure sensor in normal eyes both with and without a 1mm shield.
Results: The author’s report difficultly of participants in the study noting opposite findings verbal then documented on the questionnaire. The study resulted in a sensitivity of 79% and a specificity of 51% in a merged data set. In the unmerged data set using only normal and a ruptured globe the sensitivity was 64% and specificity 71%. Intraocular pressure was increased by 5% using minimal pressure for adequate visualization and 17% at maximal amount of pressure obtaining imaging. There was no measureable intraocular pressure change with the clear plastic shield. The authors reported no change visual quality with the shield.
Discussion: It is difficult to extrapolate the data given the participants’ confusion on documentation. Interestingly, residents training in an ultrasound elective fared better than those that did not have an ultrasound elective. The use of a clear plastic shield did not increase the intraocular pressure in ex vivo porcine model, which is a concern in the ruptured eye of unknown consequence. The authors state that the shield did not affect image quality but offer no objective support of this in the study. In both data sets the sensitivity is too low to rule out a globe rupture. Therefore authors conclude it is unlikely to replace other imaging modalities.
Bierig SM, Jones A. Accuracy and Cost Comparison of Ultrasound Versus Alternative Imaging Modalities, Including CT, MR, PET, and Angiography. J Diag Med Sono. 2009;25:138.
Reviewer: Gillian Baty, MD, RDMS
Methods: This was a literature review to collate data on accuracy/efficacy and cost of US versus other imaging modalities. This review looked at studies published in the last 5 years that were available through MEDLINE comparing US versus other imaging modalities in several specialties and applications. No other specifics were given for methods.
Results: Under the heading of OB/Gyn, authors conclude that current practice of US as preferred initial imaging for pregnancy, as well as bleeding in early pregnancy, is justified. They also state that US is preferred for perimenopausal & postmenopausal bleeding, as well as initial evaluation of uterine tumors. Within Abdomen, studies are cited that US is best for AAA screening, endoscopic US in gallbladder disease has cost benefits, US is more accurate than MR for gallbladder wall thickening (94% vs 71%), US is comparable to CT and MRI in evaluation of adrenal masses, US is an alternative to colonoscopy because of high sensitivity and specificity (reportedly 100%) for colon cancer, and US should be considered for IBD serial evaluations because of similar accuracy, less radiation and cost as compared to CT or MRI. Vascular US had similar sensitivity and specificity to CT for venous thromboembolism, and they recommend using US over MR or CT because of limited availability and cost. In patients with peripheral arterial disease, US had higher cost effectiveness at a lower cost per quality-adjusted life year than MR, CT or angiography. The authors found MR to be only slightly better than US to assess need for carotid endarterectomy with a disproportionate increase in cost. In Cardiac, they mention that US has been shown to save $900 per patient for patients presenting to the ED with chest pain. They also remarked on the advantages of stress echo over SPECT, angiography and exercise EKGs. The last point is that TEE has equal accuracy to CT and MR in the evaluation of aortic dissection, with the benefit of better timeliness. In Emergency, they find better accuracy of US over CXR for lung contusion, equal accuracy to CT in lung contusion, equal accuracy to CT in pneumothorax, more information on extension of disease than CXR in pneumothorax, and then, in closing mention that US correlates well to MR in evaluation of meniscal tears. Within Disease Diagnosis and Cancer, they touch on evaluation of other MSK problems, hyperparathyroidism, and cancer staging. Their overall conclusions are that the use of US compared to alternative imaging methods is more cost-effective in the diagnosis and management of patients.
Discussion: It is not clear from the methods that there was a thorough, unbiased review of the majority of available evidence to support the conclusion. The authors certainly bring together some interesting and salient studies, but the lack of an immediately logical basis for the headings underlines the haphazard quality. Bafflingly, within the field of Emergency, there is no mention of FAST exams or procedural uses, certainly two applications with a plethora of studies.
Bottom line: This review seems to use current practice as justification for current practice, with the exception of a smattering of studies that support this practice. It’s possible that the authors didn’t detail their more rigorous methods in the paper, but the paper as published does not provide that evidence.
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