Emergency Ultrasound Section Newsletter - January 2007, Vol 11, #1
From the Chair
Robert Jones, DO, RDMS, FACEP
10 Years Later
"Mr. President, I rise to speak about the use of ultrasound imaging by emergency physicians. October 2006 marks the 10-year anniversary of the establishment of the American College of Emergency Physicians, ACEP, Section of Emergency Ultrasound, which actively encourages research and training of emergency physicians in the use of emergency ultrasound. October 15, 2006, celebrates Emergency Ultrasound Day.
As a trauma surgeon, I spent many days and nights serving the emergency department. Emergency ultrasound, defined as the use of ultrasound imaging at the patient's bedside, is a critical component of quality emergency medical care. Ultrasound imaging enhances the physician's ability to evaluate, diagnose, and treat patients in the emergency department. It provides immediate information and can answer specific questions about the patient's physical condition, such as determining whether a presenting patient has thoracic and abdominal traumas, ectopic pregnancy, pericardial effusion, and many other conditions.
High-quality emergency care is dependent on rapid diagnostic tools, enhanced safety of emergency procedures, and reduced treatment time. Imaging technology has greatly improved quality of care and made invasive medical procedures safer.
Emergency physicians are trained in the use of imaging equipment during their residency as well as continuing medical education courses. Hospital privileges further validate this training.
Emergency ultrasound has moved outside the hospital due to its compact nature. In fact, emergency ultrasound technology is helpful onsite during military and disaster medical care. It has served in the care of America's brave military troops during both the Gulf and Iraq wars. Also, emergency ultrasound was used to care for patients last year after Hurricane Katrina and will be helpful in responding to other disasters and mass casualty events.
Mr. President, I congratulate the work of the ACEP Section of Emergency Ultrasound. It has increased awareness of the contribution and value of emergency ultrasound in the medical care of emergency patients, survivors of disasters, and our military forces serving at home and abroad. Research in this field should continue to be encouraged to allow the adaptation of critical technologies to continually improve the quality of emergency care."
- Senator William Frist
It is now official; October 15th is "Emergency Ultrasound Day." The above words were spoken by Senator William Frist, a cardiac surgeon, on the Senate floor to honor the work of this section and the field of emergency ultrasound. Last year's chair, Paul Sierzenski MD, with the assistance of the ACEP Washington office staff, requested that the US Congress proclaim a national "Emergency Ultrasound Day."
Senator Frist did an excellent job of describing to Congress what our section is all about. In the last 10 years, our section and its members have always been there to advance emergency ultrasound in both hospital and non-hospital settings. Emergency physicians have been leaders in using ultrasound in times of military conflict and in times of natural disasters. Emergency physicians are now leading the way in incorporating bedside ultrasound into medical school curriculums.
I would like to begin my first newsletter article by thanking those who worked so hard to get the section and the field of emergency ultrasound to where it is today. Despite all the internal and external pressures, both the section and field of emergency ultrasound have made incredible advancements over the past ten years. Unfortunately, we can't just sit back now and relax since there is still a lot of work to be done. The issues of credentialing, accreditation, billing and resident education are still far from being resolved. My goal for the next year, like Paul's goal last year, is to represent the needs of our section members, promote the growth of the section and the field of emergency ultrasound, and protect the work that has already been accomplished.
It is now more important than ever that section members get involved. In order for this section to continue to grow and to successfully represent the diverse needs of the emergency ultrasound community, it will require the work of more than one or two individuals. Everyone within this section has something to contribute. You don't have to be the director of an emergency ultrasound program at a major medical center in order to contribute. If you have an interest in emergency ultrasound and you use it in your practice, then you have something to say and to contribute.
Last month I sent out an email to section members asking if they wanted to participate in the following subcommittees: coding/reimbursement, community practice, education/practice standards (to be combined with SAEM interest group), medical student education, and industry input. It is not too late to join if you are interested. I want these subcommittees to provide the framework within the section. Future newsletters will provide you with updates on subcommittee achievements.
I want to emphasize that the section is open to participation from and meant to benefit all members, not just a select few. I was concerned in New Orleans when several members approached me and commented that they felt the section was becoming much too specialized and was only meeting the needs of fellowship-trained individuals. If we look back at the major accomplishments within the section, it should be apparent that this is far from the truth. ACEP Policy Statements, such as the 2001 Guidelines and the 2006 Emergency Ultrasound Imaging Criteria Compendium, were designed to meet the needs of all section members, not just the few who complete fellowships.
Recently, leaders within the section had been meeting with leaders from AIUM to create a joint FAST exam document. After numerous revisions, it seemed that significant progress had been made and the final document would be just around the corner. However, at the last minute, AIUM changed the agreed upon document and replaced ACEP's ultrasound criteria with their own. Requiring emergency physicians to obtain 100 hours of CME and perform 300 exams in order to be able to perform a FAST exam at the bedside would clearly not benefit our section members and the document was rejected. This demonstrates to me that the external conflicts are still present and more importantly, it demonstrates to me that our ultrasound section is fighting to meet the needs of all members.
I want to wish all of you the happiest and healthiest new year and thank you for all you do for our patients and specialty.
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Robert Jones, DO, RDMS, FACEP
For those present at the ACEP section meeting in New Orleans, I think it is safe to say that the discussion regarding emergency medicine residency ultrasound competency requirements was very entertaining. Individuals from all sides entered into the discussion. From the resident perspective, it was felt that not all residency programs are providing quality instruction in emergency ultrasound. From the residency faculty perspective, it was felt that attempting to enforce competency requirements would be difficult at this time. From the community director perspective, it was felt that many graduating residents are not proficient in the use of bedside ultrasound.
Obviously, this problem is multifaceted and a single solution won't work here. It is true that there are some residencies that provide little instruction to its residents in emergency ultrasound. However, there are some residencies with excellent ultrasound programs that turn out residents that lack competency in the basic emergency ultrasound skills. Believe it or not, not all EM residents embrace emergency ultrasound. For further proof of this, I would encourage you to read or re-read the article by Lisa Mills, MD from the September 2006 section newsletter, The Sound of a Hurricane. It literally took Hurricane Katrina to jumpstart their ultrasound program. Lets face it, when you are tired (as most residents are) and you have a trauma surgeon standing 5 feet away from you and a waiting CT scan machine just 50 feet away, do you really want to perform that FAST exam? So what is a community director looking for a graduate to lead an ultrasound program to do?
It is my opinion that the answer lies deeper than the 40 ultrasounds required by the RRC to graduate or the 150 ultrasounds required by ACEPEmergency Ultrasound Guidelines. The ACGME has recognized that competency can't be guaranteed just because a resident met a certain number. The ACGME Outcome Project, "Educating Physicians for the 21st Century", looks at developing competency-based curriculums, not numbers-based curriculums. This applies to all aspects of medical education, not just emergency ultrasound.
If you are looking for someone who is "competent" in emergency ultrasound, then you must dig deeper than the numbers. You need to ask the right questions! It is important to first of all know how the resident used ultrasound in his or her practice during residency. For some residents, ultrasound is incorporated into their daily practices and the skills are developed over the course of the residency. For others, ultrasound is nothing more than another "thing" to accomplish during residency, and it seems like it becomes more of a sprint to get 150 ultrasounds during their ultrasound month or during the last few months of their residency program. Personally, nothing excites me more than helping a third year resident get "those last damn 50 scans" in June because their new job will require them to meet the criteria found in ACEP's Emergency Ultrasound Guidelines. Which graduating resident would you want?
Next, specifically ask the residency director or the ultrasound director questions that will help you to understand the applicant's competency level. The ACEP Policy Statement, Emergency Ultrasound Imaging Criteria Compendium, is an excellent resource since it clearly identifies both primary and extended applications of the focused examinations. For example, during a focused gallbladder examination, can the individual only find large stones or can he or she identify sonographic findings of cholecystitis? During a focused 1st trimester examination, can the individual only identify an obvious IUP or can he or she identify subtle findings of both intrauterine and ectopic pregnancies? The list could go on here but hopefully you get the point.
As an educator, hearing the discussions at the section meeting made me more aware that I need to state in letters something more useful than they received ultrasound training in the following areas and completed the following number of studies. I would encourage others to do the same and provide more useful guidance to our colleagues in the community.
The issue of competency affects all of us: residents, educators and community-based physicians. For the field of emergency ultrasound to continue advancing, we will need to lay the foundation for competency-based curriculums. The medical imaging industry is adopting the model of practice accreditation and payers are demanding this as a cost containment and quality of care strategy. In order for us to successfully come to the plate here, we are going to have to have these issues addressed. I would encourage you to become involved in the section and join one of the subcommittees. You won't regret it.
Emergency Ultrasound Fellowship Guidelines, Information Paper
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Werner SL, Smith CE, Goldstein JR, et al. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med. 2006 Sep 30. Article in Press (Epub ahead of print).
Reviewer: Seric Cusick, MD
Methods: This was a prospective, randomized, controlled study. Eligible patients were adults undergoing elective surgery requiring intubation. Exclusion criteria were a history of difficult intubation, abnormal airway anatomy, aspiration risk factors, and esophageal disease. Thirty-three patients were enrolled. After induction of anesthesia and neuromuscular blockade, the anesthesiologist placed the endotracheal tube in the trachea and esophagus in random order with direct laryngoscopy. During the intubations, a high-frequency, linear transducer was placed transversely on the neck at the suprasternal notch. Two emergency physicians, blinded to the order and performance of the intubations, independently recorded the location of the endotracheal tube according to the real-time ultrasonographic image. A 2-by-2 table was used to calculate sensitivity and specificity of the emergency physicians' ability to detect placement of the endotracheal tube.
Results: For each physician, the sensitivity for identifying the first intubation as tracheal was 100% (95% confidence interval [CI] 77% to 100%) with a specificity of 100% (95% CI 82% to 100%). One endotracheal tube was unintentionally placed twice in the esophagus, but both tube placements were identified as esophageal by the emergency physicians.
Discussion: Emergency physicians currently have multiple available modalities to confirm proper endotracheal tube placement - each with inherent limitations. Previous evaluations of sonographic determination of endotracheal position have assessed the presence or absence of lung sliding or diaphragmatic movement upon ventilation. Additionally, Ma G, Hayden SR, Chan TC, et al evaluated direct visualization of intubation in cadavers and demonstrated excellent sensitivity and specificity (Acad Emerg Med. 1999;6:515). The current investigators report equally impressive results in a smaller sample size of patients undergoing elective procedures with no predictive factors for difficult intubation when evaluated by two skilled ultrasonographers. This self-described pilot study offers promising results and suggests this technique may be of clinical utility if validated utilizing physicians with varied ultrasound training while enrolling a heterogeneous patient population.
Tayal VS, Neulander M, Norton J, et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann Emerg Med. 2006 Sep 22. Article in Press (Epub ahead of print).
Reviewer: Seric Cusick, MD
Methods: We conducted a prospective, blinded observational study on adult ED patients with suspected intracranial injury with possible elevated intracranial pressure. Exclusion criteria were age younger than 18 years or obvious ocular trauma. Using a 7.5 MHz ultrasonographic probe on the closed eyelids, a single optic nerve sheath diameter was measured 3 mm behind the globe in each eye. A mean binocular optic nerve sheath diameter greater than 5.00 mm was considered abnormal. Cranial CT findings of shift, edema, or effacement suggestive of elevated intracranial pressure were used to evaluate optic nerve sheath diameter accuracy.
Results: Fifty-nine patients were enrolled in the study. Average age was 38 years, and median Glasgow Coma Scale score was 15 (interquartile 6 to 15). Eight patients with an optic nerve sheath diameter of 5.00 mm or more had CT findings that correlated with elevated intracranial pressure. The sensitivity for the ultrasonography in detecting elevated intracranial pressure was 100% (95% confidence interval [CI] 68% to 100%) and specificity was 63% (95% CI 50% to 76%). The sensitivity of ultrasonography for detection of any traumatic intracranial injury found by CT was 84% (95% CI 60% to 97%) and specificity was 73% (95% CI 59% to 86%).
Discussion: Previous multidisciplinary literature suggests sonographic measurement of the optic nerve sheath diameter (ONSD) may be useful as a predictor of increased intracranial pressure (ICP). This observational study provides the largest series to date evaluating the sensitivity and specificity of the ONSD for the detection of acutely increased ICP. The authors use a well described technique and report a sensitivity of 100% for detecting elevated ICP. The low prevalence of patients with elevated ICP places the lower limit of the 95% CI at 63%. It is important to note, that cranial CT findings consistent with elevated ICP - rather than invasively measured intracranial pressures - served as the comparison standard. This data corroborates earlier reports by Michael Blaivas, MD, RDMS, FACEP; Daniel L. Theodoro; and Paul Sierzenski, MD, FACEP. (Acad Emerg Med. 2003;10:376-381) and, if reproduced in larger cohorts, may provide health care providers in varied settings with a tool to noninvasively exclude elevated intracranial pressure.
Wang R, Snoey E, Clements, RC, et al. Effect of head rotation on vascular anatomy of the neck: An ultrasound study. J Emerg Med. 2006;31(3):283-286.
Reviewer: Matt Solley, MD
Introduction: The head is often rotated to the side opposite of the approach taken for an internal jugular vein (IJV) central line. For example, when placing a right IJV central line, the head is often rotated to the patient's left to allow better visualization of the neck anatomy as well as move the chin out of the way to allow more room to access the IJV.
Methods: This is a prospective study with convenience sample enrollment looking at the effect of head rotation on the relationship of the carotid artery (CA) to the IJV. Any patient in the emergency department was eligible for inclusion - patients were not necessarily planning to receive a central line. Patients were excluded if they had cervical spine disease, were hemodynamically unstable, or unable to consent. Subjects were placed into 15 degrees of trendelenberg and underwent evaluation of the right side neck anatomy with a Sonosite Titan linear transducer. The relationship of the CA to the IJV was evaluated at zero, 45 and 90 degrees of leftward head rotation. The main outcome measures were the overlap between the CA and IJV as well as the distance between the center-point of the IJV and the nearest border of the CA.
Results: As the head is rotated to the left, there is an increase in overlap between the CA and IJV. At the apex of the anterior sternocleidomastoid triangle, there is a mean overlap of 29% at zero degrees of head rotation, 42% at 45 degrees of rotation, and 72% at 90 degrees of rotation. Similar findings were noted at the base of the triangle. In regards to the CA-IJV distance, there is a decrease in distance as the head is rotated to the left. At zero degrees of rotation, there are 8 mm and 10.3 mm (base and apex) distance between, while at 90 degrees of rotation there is only 3mm and 1 mm distance (base and apex) separate the two vessels.
Discussion: When placing an IJV central line, practitioners often erroneously assume that the CA and IJV lie side by side in the neck, with the IJV lying lateral to the CA. This study shows that this is not the case, but rather that there is overlap between the CA and IJV, with the CA located in a postero-lateral position. Further, this study shows that as the head is rotated to the opposite side to allow easier access to the anatomy, the overlap increases and the margin of safety decreases Those familiar with real-time ultrasound-guided central line placement appreciate the tenting of the IJV as the needle attempts to penetrate the IJV lumen. It is possible, especially in hypotensive patients, to visualize the IJV tenting in real time and yet advance the needle tip through the IJV and into the posterior-lying CA, with the first flash of blood in the syringe being arterial instead of venous. This is a rare occurrence when using ultrasound guidance, however one may conjecture that there could be an increased incidence of this complication with an increase in CA-IJV overlap. As demonstrated by these authors, vessel overlap increases as the head is rotated to the left for a right-sided approach. It would seem prudent to rotate the head to move the chin out of the way, but limit the rotation as much as possible when placing an IJV central line to decrease potential vessel overlap and increase the margin of safety.
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Experts in the Shadows
Mike Blaivas, MD, RDMS
Past Chair (2004-2005), ACEP Ultrasound Section
It never ceases to amaze me how difficult it is for some of our colleagues to admit or even recognize consciously that we may be the ultrasound experts in a particular application in the hospital. Really, this is no different than what emergency medicine has faced, and still does, with issues like airway management and trauma resuscitation, among others. I think sometimes it is just too painful for the old guard of medicine, surgery and radiology to admit we may have something to offer that no one else has. This is only human nature, of course. Here are two examples that remind me emergency ultrasound is not the "red headed stepchild" that our opponents, and our own colleagues, make us out to be.
Some time ago, in a hospital far, far away, a colleague of mine got a call from the medical ICU to help with placement of an arterial line. In the past we had tried to work with our old MICU director to teach ultrasound but got nowhere. Through side channels we had heard that he considered it insulting that emergency physicians would be teaching him and his colleagues anything and the MICU folks tried to introduce ultrasound themselves, without any formal training. It is important to note that this was nothing any of us heard directly, so may have been just a rumor. While we used to get calls from the MICU on a regular basis to put in difficult central lines, this had stopped. Thus, we were surprised to get this call but not the circumstances around it. The MICU had a young obese male patient on a ventilator with possible sepsis. They had difficulty getting cuff blood pressures on him for some time and he was slowly deteriorating. The ICU team did not know exactly how to manage the patient; he was very edematous on top of being obese, since they could not even palpate his pulses. The MICU residents, fellows and staff had tried multiple times to place an arterial line. Every possible site had been tried and there were hematomas everywhere. After about a day of this the ICU contacted surgery, they also tried multiple times, but failed. According to the ICU, radiology was then contacted but was unable to help at the patient's bedside. Finally, as the patient was visibly doing worse, someone thought of emergency medicine and that we actually used ultrasound at bedside for vascular access in more difficult patients than any one else.
Upon arrival to the MICU with the Sonosite in hand it was clear that this was going to be a difficult task. It took my colleague about half an hour to get an arterial line in. He fed the line into a vessel that was in spasm from previous attempts that day, and even though he could see the line in the lumen of the artery there was never a pressure obtained. He then successfully placed it in another location and finally got some blood to flow. However, before a reading could be made an ICU nurse accidentally pulled the arterial line out. So he spent another half hour placing a line, finally getting one into the right brachial artery. This time no one pulled it out and a reading came up. It showed profound hypotension, but shortly afterward the patient coded. Despite all this my colleague, nor any of us, ever got a thank you for the MICU for helping. Nor was there any recognition that they should have called us right away, not after wasting an entire day.
Here is another example, one that had a better outcome. Again, a long time ago, in a hospital far, far away, at the beginning of a night shift I got a call from a plastic surgeon on call for "face." A small outside ED was seeing a patient who presented with severe throat and neck pain and fever. He could not move his head and had difficulty swallowing due to pain. A CT of the head and neck revealed a para-vertebral abscess, according to my plastic surgeon. He said he tried to turf this to ENT or facial surgery but since he was on call they would not take it. He simply said that I could call him into the ED after the patient arrived but he would not be of any help since he was not even sure what the radiologist had described. The patient arrived an hour later and was obviously uncomfortable. I decided to take a look at the CT prior to starting the calls to various surgical services to see who would be able to help me in the middle of the night. On CT I saw the abscess, it looked like a peritonsillar abscess (PTA), but much deeper. It occupied quite a bit of space but was isolated and did not involve or track into other important structures. This was actually a deep retropharyngeal abscess. I had a thought, why not drain it like a PTA, under ultrasound. I gave the patient IV antibiotics, toradol and a half hour later a topical anesthetic for his throat.
He was so stiff he could not move his head away from me and was also determined to let me get a good look at whatever this was. Using a sheathed endocavity transducer I located the abscess then tried to get at it with an 18-gauge needle, like I normally do for PTAs. Not even close, the abscess was so deep I could not get into it. I was at a loss and asked a nurse for help. She brought me a 14-gauge, 5 inch IV catheter. This would reach. Much of the needle went in (without the catheter) and got to the abscess with direct ultrasound visualization the entire time. I had to change syringes three times as I only brought ten milliliter ones. In total, I got out 22 milliliters of green pus. When I started to pull the needle out with the final syringe the patient came with it. I actually had to tug the needle out of him. After that I thought he might hit me rather than thank me. Instead he moved his head from side to side swallowed, rotated his head some more and said "ok, I am ready to go now." Needless to say I kept him all night for another two doses if IV antibiotics. He left and did fine on oral antibiotics. At the end of my night shift I got a call from the plastic surgery attending asking what had happened with the patient. When I explained he simply said "ok" and hung up. A half hour later an ENT attending called me. They said that plastics had called them last evening and they would have been happy to help once their clinic opened. I thanked them very much and let them know about what had transpired. The attending was shocked to learn that we regularly drain PTAs under ultrasound and that ultrasound could be used to diagnose and guide drainage of PTAs at all. I heard an earful of how I was going to be invited to their grand rounds to give lectures and I should present at their meetings and so on. Needless to say, there were never any grand rounds or lectures given or any meetings presented at. Surely, when the morning coffee took effect, ENT realized they would be getting education from an emergency physician, unthinkable.
Whether you work in a hospital where your skills are recognized and appreciated or in one where you are only called upon quietly, as a last resort, you can be sure that using ultrasound can make a difference to your patients one at a time and to you.
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Ultrasound Section Co-Winner of 2006 Outstanding Web Page Award
Paul Sierzenski MD, RDMS, FACEP
ACEP Section of Emergency Ultrasound
Congratulations to Past-Chair, Michael Blaivas, MD, RDMS, FACEP; Web page Co-administrators David Bahner MD, RDMS, FACEP; and Gary Quick MD; web page contributors, and the Ultrasound Section as the co-winners of the 2006 Outstanding Web Page Award.
The contributions by Section membership and the commitment of our leadership highlight the value that the Ultrasound Section web page provides to our Section members and to the College at-large.
Dr. Blaivas represented the Ultrasound Section at the Leadership Awards Luncheon held at Scientific Assembly on October 16, 2006.
Congratulations to all who participated and continue to support the Ultrasound Section web page.
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The Ultrasound Garden
Gary Quick, MD, FACEP
As I stand in the midst of my garden this chilly, brilliantly sunny winter afternoon, my hands work the tasks of preparing the garden for the coming spring. My thoughts however, are contemplating a paradigm comparing my garden to the development and productivity of the Section of Emergency Ultrasound.
The garden lies snow-sealed in a dormant state during winter. One task which prudent, experienced gardeners tackle during the winter months is that of soil supplementation. If one gardens in a location of heavy clay soil, supplementation with organic material will enhance soil porosity, allowing plants to more deeply root. If the plot is tended in an area of high soil acidity, then amendment with small amounts of wood ash or lime will return the soil pH toward a more neutral reading. Most garden plants like a pH slightly on the acid side, approximately 6.8-6.9 on the pH meter scale.
Retracing the history of my garden involves going back in time to the decision to build a garden in a certain location. In my case, previous gardeners had laid out the plot, broken the ground initially and tilled the soil to a suitable degree of softness. They had provided for weed control by sinking railroad ties lengthwise as borders for the garden's sections. Each spring the present gardener occupant planted seeds and seedlings in the hope of harvesting a yield of produce including green beans, corn, potatoes, peppers, onions, tomatoes and okra. With proper tending, nutrition and moisture, the garden usually yielded an acceptable crop for the gardener's table.
I inherited the garden 14 years ago, when we moved to our present home. After one growing season, I recognized that the garden had been developed on a clay pan resulting in packed soil and poor drainage and minimal porosity. Now, after 14 years of regularly supplementing the garden soil with shredded leaves, grass clippings, coffee grounds and fireplace ashes, the soil is soft and crumbly. Turning a shovel of soil at any time during the year shows a soil teeming with earthworms and soil arthropods. The volume of supplements has filled over 500 outdoor trash bags over time.
Our Emergency Ultrasound section has proceeded through similar steps to reach our current status. Some of our predecessors and colleagues broke ground for the Section garden; others tended to tilling the initial hardpan to provide for the first crops. Emergency sonographers tended to planting and cultivating, complete with weed control to protect the young but developing plot. The harvests have been slim on occasion, but the trend has been to increasing bounty received from the plot.
At this time we find ourselves vigorously amending the soil of the Ultrasound Section to improve its suitability for growth of emergency ultrasound activity. Recent events would seem to indicate that the soil is becoming conducive to new growth. The harvest is beginning to build. Please note that Dr. Dan Theodore, SAEM Interest Group Chair, has received an NIH K-12 grant in support of emergency ultrasound research. Drs. David Bahner and Mike Blaivas are running for an AIUM Board of Directors position; this is evidence that our AIUM connection is growing. (AIUM members please remember to vote, and non-AIUM members, please consider joining AIUM to help build the connection.) The proclamation of October 15th as Emergency Ultrasound Day by Senator Frist noting the training of emergency physicians in bedside sonography and encouragement to emergency ultrasound helps round out the picture of the new bounty of harvest from the ultrasound garden. The process of harvest involves many hands. Find a way to involve yourself with the Section. Join a committee or research project. Enhance your skill as a bedside sonographer or write an article or case report for the Section newsletter. At least find a way to supplement the soil and you will be contributing to the Section's soil enrichment plan.
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SOAP Update December 2006
Lawrence A, Melniker, MD, MS
Prospective Observational Trial of Vascular PLUS for Suspected DVT: The Fourth Sonography Outcomes Assessment Program (SOAP-4) Trial (E. Leibner)
This prospective, observational cohort study assessed the accuracy of emergency physician diagnosis of proximal DVT in the ED using a simplified compression technique. Results will presented to the SAEM Annual Meeting in 2007.
Prospective Observational Trial of a Lung and Cardiac PLUS-Inclusive Protocol for the Evaluation of Acute Dyspnea in the Emergency Department (M. Del Rios Rivera)
This is a prospective observational trial to assess the predictive value of a PLUS-inclusive evaluation protocol for dyspneic patients in the ED. Results will be submitted to the SAEM Annual Meeting in 2007
Randomized Controlled Trial of PLUS-Assistance of Pediatric Peripheral Intravenous Access (M. Sharma)
This trial assesses the effect of the availability of PLUS-assistance for the placement of peripheral IVs in pediatric patients. This trial will be completed by January 2007 and the results will be presented to the 2007 ACEP Scientific Assembly.
Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with Acute Chest Pain in the Emergency Department
New York State ECRIP Grant - $120,000
Prospective Observational Trial of Inferior Vena Cava Caliber, Variability, and Indices in Healthy Pediatric Patients
Trials in Development
Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with TIA and CVA in the Emergency Department
Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with Syncope in the Emergency Department
Comparative Trial of Common Carotid Intima Media Thickness Assessment with Coronary Angiography, Cardiac Computerized Tomography, and Cardiac Magnetic Resonance Imaging
Prospective Observational Trial of Sonographic Confirmation of Endotracheal Tube Placement in the Emergency Department
Prospective Observational Trial of Sonographic Confirmation of Endotracheal Tube Positioning in the Critical Care Setting
The coordinating center for the Sonography Outcomes Assessment Program, the Division of Clinical Ultrasonography of the Department of Emergency Medicine at New York Methodist Hospital, is seeking applicants for a newly-created Associate Directorship position. The Associate Director will have educational responsibilities in the EM residency and the Ultrasonography Research Fellowship; and be active in SOAP trials. Eligible candidates must be fellowship-trained or have at least 3 years experience coordinating an ED ultrasonography program. Please forward a letter of interest and CV to email@example.com.
Happy Holiday and a Happy New Year!
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Emergency Ultrasound Section Meeting Minutes - 2006 Scientific Assembly
Sunday, October 15, 2006
10:30 - 12:30pm
Room 395, Ernest N. Morial Convention Center
Attending all or part of the meeting were the section leaders and 120 members and guests.
Board Liaison; David Seaberg, MD, FACEP
Staff Liaison: Marilyn Bromley, RN
Call to Order
· EUS Clinical Guidelines
· Community EUS Working Group
· RRC-EM EUS Competency update
· Section grant update
· World Congress US in Emergency & Critical Care
· Section Newsletter Report
· Webpage update
Clinical Lecture "Ultrasound Evaluation of Pediatric Fracture" by James W. Tsung, MD
Ultrasound Management Course report
AIUM Liaison Report
Induction of Chair elect
Major Points Discussed
Paul Sierzenski, MD, FACEP welcomed everyone to meeting. He reported on the piece submitted by Senator William Frist in the senate report extolling the benefits of the emergency ultrasound and congratulating the section on its 10th anniversary. This piece will be featured in an upcoming edition of ACEP News and will sent to every section member.
Dr. Seaberg provided a brief report from the Council meeting and congratulated the section on the fine work and significant contribution to the College.
Dr. Sierzenski reported that the section had met its goal of membership exceeding 500 this year. The Board approved the policy "Emergency Ultrasound Imaging Criteria Compendium." It is now on the Web site and available to all members.
There was lively discussion on the Residency Review Committee- Emergency Medicine (RRC-EM) ultrasound competency requirements. Concern was expressed that with the RRC no longer mentioning a number of ultrasounds required in this training that residents training would be lacking. Daniel F. Danzl, MD, FACEP, of the RRC spoke to the fact that program directors should make sure their residents are adequately trained to use ultrasound and that the current number of 40 may not be sufficient to achieve this purpose. Several spoke about their experiences in trying to find recent graduates that were trained in the use of ultrasound and found that many of the individuals interviewed had no idea how to use emergency ultrasound equipment or perform an ultrasound exam. The president of Council of Emergency Medicine Residency Directors (CORD) asked that those concerned about the quality of the training in residency program provided contact her. One resident reported that she was forced to find ultrasound education on her own as the director of the program did not have an interest in this and did not provide training for the residents in this program.
Michael Blaivas, MD, FACEP, discussed issues surrounding accreditation in emergency ultrasound. Of particular note was push by insurance companies to deny payment because they did not view the emergency physicians as 'accredited' to be reimbursed for emergency ultrasound services provided. The section continues to monitor this situation and will be working on that issue this year and presenting their findings with a recommendation to the Board of Directors on the direction the College should take on this issue.
Because Beatrice Hoffman, MD could not attend, Dr. Blaivas reported on the section grant and noted that the CD was being readied for dissemination.
Dr. Blaivas also provided a report on the success of the World Congress US in Emergency & Critical Care.
Dr. Sierzenski, on behalf of Gary Quick, MD, FACEP, reported on the success of the newsletter and the award given to the section for an excellent Web page.
James W. Tsung, gave the educational lecture on ultrasound evaluation of the pediatric fracture. Dr. Tsung noted how the beneficial ultrasound was in the physician exam and provided examples of how an injury to the growth plate is better seen using ultrasound than a flat plate x-ray.
Dr. Sierzenski, informed the section that there would be a focus on the recruitment and needs of the resident. He called for those in the section wishing to provide leadership and mentoring to residents to contact the section leaders.
Vivek Tayal, MD, FACEP, reported that although the Ultrasound Management Course was a resounding success a decision had been made not to hold it this year and instead the faculty was working on putting many of the materials used in the lectures in a compendium for ACEP members interested in how to set up and manage and ultrasound program in their facility.
Dr. Tayal reported on the work done with AIUM and the progress made. He noted that a position on the AIUM board of directors was created for an emergency physician and that Drs. Bahner and Blaivas would be running for that seat. Although it appeared that there would be agreement between AIUM and ACEP on the FAST exam guidelines at the last AIUM meeting it became apparent that this would not happen.
Robert A. Jones, DO, FACEP, gave a brief presentation on the difference between credentialing and privileging. He encouraged attendees to know the appeals process for their hospital and those managed care companies contracted with the hospital. He encouraged those having problems to remind the hospitals that the JCAHO process for credentialing allows for emergency ultrasound. The audience was encouraged to participate in the medical staff bylaws committees or find allies on this committee, and work with hospital administration and state chapters in an effort to insure that emergency physicians can offer emergency ultrasound in the ED.
Dr. Sierzenski noted that the due to the lack of time the information on the billing would be emailed to the membership at a later date. Also the ultrasound reimbursement paper will be updated this year.
A slate of officers was presented and nominations from the floor were called for. Hearing no nominations the slate of officers was elected by acclamation.
Dr. Jones presented a certificate of appreciation to Dr. Sierzenski for all his work he did on behalf of the section this year.
The meeting adjourned at 12:50pm.
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Quality Course at Spring Congress
If you are an ED administrator, the Quality person, or just a practicing clinical physician or nurse, you are involved in quality to an extent. If you are not practicing quality emergency medicine, you will probably be out of business soon so ignore this brief article. Quality is something we all want to do and it is something our patients demand. So why doesn't quality happen all the time?
The Quality Improvement and Patient Safety Section is offering the first of it's kind "Quality Course" at this year's Spring Congress in San Diego on April 25, 2007, from 2:30 to 6:30pm. If you are registered for the Spring Congress, there is no additional charge. Who should take this course? Anyone working in ED Quality, new graduates, nurses, and anyone who wants to learn how not to end up on the wrong end of a quality review. There will be four one-hour sessions in the afternoon of day two of the Spring Congress. The format will be:
- The Case Review
- Data Collection and Analysis
- Fixing Systems to Improve Outcome
- Panel Discussion on Proven Success Stories
The lectures will be case-based and practical. We all get plenty of lectures on theory and error reduction. This course is designed to be practical and hands on. When you leave you should be able to design an ED Quality Program or re-tool an already existing one. We have commitments from some of the best and brightest in the College as faculty. Please send along your Quality people, nurses, physicians, and mid-level providers. All are welcome.
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