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Emergency Ultrasound Section Newsletter - January 2008, Vol 12, #1

Emergency Ultrasound Section

circle_arrow From the Chair
circle_arrow Critical Care Liaison
circle_arrow SOAP Update December 2007
circle_arrow Continuous Quality Management and Expanding the Use of Clinical Sonography: Paradigm Shift to Enhance Quality of Care and Patient Safety – An Introduction
circle_arrow Journal Watch – January 2008
circle_arrow A Critical Look at the "Revised" Cochrane Review of Trauma Ultrasound
circle_arrow From the Editor’s Desk--Clinician-Performed Sonography
circle_arrow WINFOCUS
circle_arrow Case Report--Acute Painless Unilateral Vision Loss
circle_arrow Resolution 32(07)
circle_arrow Meeting Minutes


Newsletter Index


Emergency Ultrasound Section

 

 

From the Chair

Vivek S. Tayal, MD, FACEP

Dear Fellow Ultrasound Section Members:

For my first Chair’s message I would like to update the Section on activities so far, and give you a few notable newsworthy events that affect our field.

On the positive front:

  1. ACEP and AIUM did reach agreement on a FAST guideline. You saw my separate email regarding this agreement earlier in November. Again, this joint guideline took 3 years to hammer out and reach agreement. It is based on the ACEP US Imaging Criteria – Trauma. Our section leadership had the foresight to plan for negotiations with AIUM, and come up with our own descriptions of our EUS exams. In addition to all the ACEP US Section members who were involved, I think we need to credit the new President of AIUM, Josh Copel MD, for pushing the process especially on the AIUM side to a positive conclusion. I think this will help emergency physicians in their political battles in their hospitals. As the prototypic "emergency" ultrasound exam, the FAST, was recognized by an interdisciplinary national society. In addition the agreement recognizes our ACEP guidelines and recognizes the limitations of the emergency exam in regards to location, image retention, and documentation.

  2. The overuse of CT scanning was a topic of national interest this week as a review article came out in the New England Journal of Medicine. Obviously this is a perfect segue way to the safe and possible increased use of ultrasound for emergency conditions. Of course, there were a lot of ridiculous statements floating out in the news media, suggesting the "ERs" order a CT scan on everyone who has abdominal pain. So ACEP had to confront that issue first. But our media subcommittee and I are working with ACEP public relations to see if we can get our message out about the use of ultrasound by emergency physicians in emergency conditions. Consequently, this is a great time for you, our section, to play the US Card - "No ionizing radiation, yet bedside, sophisticated, immediate technology to improve the care of our patients."

    On the negative side:

  3. I will quote directly from a report from Erik Ridley, writing for a radiology trade newsletter named "Aunt Minnie " on November 26, 2007,

    1. "Despite recent attempts by emergency medicine (EM) physicians to secure a major role for their specialty in emergency department (ED) ultrasound and x-ray studies, radiologists still retain overwhelming control over the exams, according to a presentation Monday at the 2007 RSNA meeting.

      "Given their low level of experience at formally interpreting ultrasound and x-ray, it seems unlikely that EM physicians can achieve the necessary competence to take responsibility for these studies in the future," said presenter Dr. David C. Levin of Thomas Jefferson University Hospital in Philadelphia.

      To determine whether EM physicians had increased their role in these studies in recent years, the researchers examined the national Medicare Part B Physician/Supplier Procedure Summary Master Files for 2001 through 2005.

      Using Medicare place-of-service codes, they selected all noncardiac ultrasound and all x-ray studies performed in EDs on the Medicare fee-for-service population. All global and professional component claims were tabulated, and the researchers used Medicare's physician specialty codes to identify all studies interpreted and billed by EM physicians, radiologists, and other physicians. Noncardiac ultrasound studies increased 60% between 2001 and 2005, reaching 448,675 exams, Levin said. Of these, radiologists interpreted 393,897 (87.8%), while EM physicians only handled 4195 (0.9%).

      "I have to qualify that by saying that we don't know how many times they informally looked at the ultrasound exam or practiced doing ultrasound exams, and so on and forth," Levin said. "But the fact of the matter is, if you're interested in looking at who is the physician of record, who dictates the report, and who takes the responsibility for that examination in the ER, it's less than 1% of the time (that it's the emergency physician). If you look at their 2005 volume … that is less than the output of one single ultrasound machine."

      In 2001, EM physicians performed 0.3% of noncardiac ultrasound studies, while radiologists handled 91.3%. In 2005, vascular surgeons and other surgeons interpreted 17,206 (3.8%) and 14,578 (3.2%), respectively.

    2. Our side of this report –

      Obviously this speaks volumes about the specialty of radiology. First, this study only queried Medicare, which is not the majority payor in most markets. Second, these are only billed ultrasounds. I know most emergency physicians are just starting to bill, much less getting their US program going. Third, it is always about the bill with radiology. Fourth, the source is Thomas Jefferson’s Dept of Radiology, a very unfriendly department towards emergency physicians performing ultrasound. Frankly, if we are not billing Medicare in large numbers, then we are not the problem of the financial drain of imaging. Medicare and other payors should pay attention to CT, MRI, and other specialties that are above the 0.9% rate for EM. However, we have to get our specialty going with education, implementation, practice, and finally billing of ultrasound in the ED. Why bother? We should make the effort to secure payment because positive gain is important for the future stability and growth of our US programs and our EDs. Hospitals, appropriately, do not like zero revenue. We need every Section member to push ultrasound in their region now. It will take months and years to get where we need to be, and waiting is not an option.

    Section activities

    We had a conference call with all the subcommittee chairs in November where I laid out the agenda for the year, and we discussed some items. Here are the subcommittees, chairs, and some basic goals. I renamed the certification taskforce "Subspecialty options" because of confusion with the word "certification." I am not sending out the complete list of subcommittee members because I am still recruiting section members to help, so please email me at vtayal@carolinas.org. Be involved!

    Reimbursement
    Chair – Steve Hoffenberg, MD
    Objectives

    1. Create, develop, and submit new ultrasound codes for non-traditional ultrasound applications like soft-tissue and pulmonary, working with the Coding and Nomenclature Advisory Committee and the Reimbursement Committee of ACEP
    2. Revision of the Reimbursement paper to match the US Imaging Criteria

    Accreditation
    Chair – Jerry Chiricolo, MD, FACEP
    Objectives

    1. Coordinate with ACEP regarding responses to legislative and third party accreditation proposals
    2. Create a document for government and third-party entities emphasizing our existing structure
    3. Create and develop a tiered fall-back plan regarding accreditation

    Industry communications
    Chair – Chris Moore, MD
    Objectives

    1. Revise the ACEP US Section to Industry on optimal characteristics of an emergency US machine
    2. Revise the letter to all US manufacturers urging them to participate with the ACEP US Section and Scientific Assembly.

    Community Practice
    Chair – Robert J. Tillotson, DO, FACEP
    Objectives

    1. Develop a program and materials that will assist any Emergency Department or Emergency Physician with the planning and implementation of Ultrasound into their department.*
      1. "Model credentialing documents and sample presentation"*
    2. Survey of emergency departments 2008 regarding practice of emergency ultrasound*
    3. Working Database of emergency ultrasound practice *
    4. Create a working list of Emergency Ultrasound preceptorships where community physicians can train under supervision*
    5. Advise the Section leadership regarding ACEP clinical guidelines with the goal of facilitating the efficient and safe implementation of Ultrasound into the practice of Emergency Medicine in the community hospital.
    6. Coordinate with Residency subcommittee of Section regarding residency competency
      1. Numbers of procedures/studies guidelines
      2. Competency and competency assessment Tools
      3. Similarity to standard "practice track."
    7. Educational Focus on the training of the Emergency Physician practicing in the community setting
      1. Develop Training guidelines and recommendations based on the Ultrasound Compendium that can be used by State Chapters, individuals and private companies in the consistent introductory training of practicing Emergency Physicians.
      2. Solicit input from community practicing Emergency Physicians for training needs specific to the community based practice.
    8. Develop guidelines, format and models for state chapter sponsored courses to assist in the development of these courses at the state level.
      1. These courses should prepare the practicing physician for credentialing and certification if required in the future.
      2. National ACEP should be a resource and assist in course development.

    Media/Gov Relations
    Chair – Paul Sierzenski, MD
    Objectives

    Residency Education
    Chair – Dan Theodoro, MD
    Objectives

    1. Develop a definition of working definition of competency that integrates residency training and community training
    2. Develop a "universal" model curriculum of essentials for EM residency (document)

    Medical Student Education
    Chair – Mike Stone, MD
    Objectives

    1. Develop a "universal" core curriculum for a one month rotation in emergency US for medical students
    2. Develop goals and possibly a module (lecture/ practical teaching labs) for integration of emergency ultrasound into the one month rotation of medical students in emergency medicine during their 3rd or 4th year
    3. Develop a guide to integration of ultrasound (especially emergency US) into the 4 year curriculum of medical schools

    US Section Web Page
    Chair – Thomas Mailhot, MD
    Objectives

    1. Clean up and improve the US Section web page on the ACEP web page
    2. Work to a members only area for the US section
    3. Increase teaching and US reference materials on the web page.

    Military Emergency Ultrasound
    Chair - Rob Blankenship, MD
    Objectives

    1. Describe in white paper the use of ultrasound in the battlefield setting

    International Emergency Ultrasound
    Chair – Dan Price, MD
    Objectives

    1. Describe unique aspects of ultrasound for international health care and missions

    Critical Care in Emergency Ultrasound
    Chair - Anthony Dean,MD
    Objectives

    1. Liaison internally and externally with emergency physicians, critical care physicians and others regarding common applications, policities, and politics of ultrasound

    Subspecialty Future Organization
    Chair – Resa Lewis, MD
    Objective

    1. Investigate and present to the Section at the annual meeting in Chicago an overview of subspecialty and certification issues in emergency ultrasound with a emphasis on the pros and cons of different US certification models in other specialties.

    US Management Course
    Chair – Troy Foster, MD
    Objectives

    1. Coordination and direction of the US Management course with ACEP staff (Marilyn, Julie Dill, and others)
    2. Revisions to the curriculum
    3. Consideration of CME
    4. Publicity for the course

    Okay, there are a lot of committees but this is one method of getting section members involved and empowered. These committees will serve the section this year and possibly into the future. Not every subcommittee will produce something every year, but they all have basic objectives. They almost all have experienced former Section chairs or US leaders to help mentor them for future leadership growth. In the next newsletter, I hope to have some discussion of critical definitions such as credentialing, certification, and accreditation.

    Please email your thoughts, opinions, and desire to serve the section on subcommittees.
    Vivek S. Tayal, MD, FACEP
    Chair, ACEP Section on Emergency Ultrasound 2007-2008
    vtayal@carolinas.org


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    Critical Care Liaison

    Michael Blaivas, MD, FACEP, RDMS

    Our colleagues in critical care come from multiple backgrounds, but all have as urgent a need for point of care ultrasound as we do in the emergency department. When compared, our ultrasound practice spectrums are almost identical with the exception of pelvic ultrasound. Recently we have seen a huge surge in interest among critical care physicians in point of care ultrasound in North America. Although their European counterparts have helped pave the way for point of care ultrasound over the last two decades, many of the same hurdles and turf barriers that have plagued us for years have also kept critical care physicians here from adopting the technology. This is however in the past. The recent publications of two supplements by the journal Critical Care Medicine on point of care ultrasound and echocardiography in critical care settings have signaled an explosive expansion of critical care ultrasound.

    Interest in education is skyrocketing as it is in emergency medicine and critical care societies are reacting by organizing courses and taskforces on ultrasound education. The Society of Critical Care Medicine (SCCM) is holding multiple educational events on ultrasound during their national meeting this coming February in Hawaii. They have also invited Dr. Luca Neri, the founder and first president of WINFOCUS to speak about the creation of a critical care ultrasound curriculum. Involvement in these societies and activities is critical for emergency medicine. Our colleagues face the same barriers and challenges from traditional imaging providers and regulators that have kept so many of our patients from benefiting from point of care ultrasound. Together, we are more likely to influence a change for the positive and breakdown barriers based on profit instead of patient care.

    One of the biggest topics we are discussing with our colleagues is not just the development of educational proceeding and curricula but also the need to lobby at a national level against traditional imaging providers who seek to monopolize a technology for profit and leave patient needs in the distant background. Unlike ACEP, no critical care society has reached a high level of organization in ultrasound and they are still not ready to tackle legislative and policy issues. However, we are working jointly to change that. Increased interaction between emergency medicine and critical care physicians at SCCM and AIUM will lead to joint positions and increased progress. The next year is likely to see continued growth in critical care ultrasound development and organization and the ACEP Ultrasound Section stands ready to lend advice, policies, expertise and reports of painful lessons learned to our critical care colleagues interested in ultrasound. The two most important upcoming meetings where ACEP Ultrasound Section members will have a chance to sit down and speak with critical care ultrasound leaders will be in February at the SCCM meeting in Hawaii and also the AIUM Emergency and Critical Care Ultrasound Section meeting in San Diego, during the AIUM annual assembly in March.

    What can you do at the grass roots level? Work with your critical care teams and physicians. You may be able to offer valuable practical, educational and political experience in your hospital and help our colleagues utilize point of care ultrasound to their full potential for the benefit of their patients.

     


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    SOAP Update December 2007

    Lawrence A, Melniker, MD, MS, FACEP
    Director, Sonography Outcomes Assessment Program

    Completed Trials:

    • Randomized Controlled Trial of PLUS-Assistance of Pediatric Peripheral Intravenous Access  (M. Sharma & L. Melniker)

      This trial assesses the effectiveness of the availability of PLUS-assistance for the placement of peripheral IVs in pediatric patients. This trial was completed by April 2007 and the results were presented at the 2007 SAEM Annual Meeting.

    New Trials

    • Prospective Observational Trial of Common Carotid Intima Media Thickness Assessment in the Evaluation of Patients with Acute Chest Pain in the Emergency Department

      This trial is evaluating the predictive value of PLUS measurement of the intima-media thickness (IMT) of the carotid arteries in ED patients with suspected Acute Coronary Syndrome. It will completed in the Fall 2008 and assess the predictive value of IMT, using the resultant calculated vascular age, both as an independent variable and in conjunction with multiple cardiac biomarkers.
    • Prospective Observational Trial of Inferior Vena Cava Caliber, Variability, and Indices in Healthy Pediatric Patients: Generating a ‘Growth Curve’ for IVC.

      This trial will enroll a cohort of healthy children ages 2-12 and assess the size of the inferior vena cava during a normal state of hydration. The measurement will be used to generate an IVC "growth curve." Once validated, the growth curve will be employed prospectively on a cohort of undifferentiated patients presenting to the ED with varied hydration states. The first phase will be completed in the winter of 2008.

    • 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

      These two studies will use similar methodologies as the current IMT trial in suspected acute coronary syndrome; they will begin in the spring of 2008.

    Trials in Development

    • Comparative Trial of Sonographic Assessment of Inferior Vena Caval Filling with Central Venous Pressure Manometry in Suspected Sepsis, Severe Sepsis, and Septic Shock
    • 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
    • Randomized Controlled Trial of PLUS for Dyspnea in the Emergency Department

    Institutions interested in any of the trials planned or in development may contact me directly at: lam900@nyp.org.

     


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    Continuous Quality Management and Expanding the Use of Clinical Sonography: Paradigm Shift to Enhance Quality of Care and Patient Safety – An Introduction

    Lawrence A. Melniker, MD, MS, FACEP
    Vice Chairman for Quality Improvement
    Department of Emergency Medicine
    New York Methodist Hospital

    Several representatives of the Emergency Medicine community had the great fortune of participating in the 1st World Congress on Ultrasound in Emergency & Critical Care Medicine in June 2005. When we arrived, many referred to what we did as "Emergency Ultrasound" or "Emergency Medicine Ultrasound," but the last night, a few of us were discussing the Congress and decided - we were wrong!

    We realized that what we do with ultrasound machines in the ED is a large slice of a pie called "Clinical Sonography" or "Clinician-performed Sonography." It represents nothing less than an historic paradigm shift in how we clinically assess our patients. Resistance has been and will continue to be stiff, just as the generalization of the stethoscope was resisted 100 years ago; but the technological cat is out of the bag and running – the shift is stoppable! My daughter, Haley, is 3 years old; should she decide to follow our footsteps into medicine, I believe she may never own a stethoscope, but she will have a "Personal Sonographic Assistant."

    Those of us in Emergency Medicine who use Clinical Sonography are right in the middle of this transition and have a responsibility to promote this transformation. Some will develop innovative ways to use sonography; others will conduct research to confirm its effectiveness; many will teach our colleagues how to perform and integrate sonography into the clinical decision-making process; but all must use this technology to improve quality of care and promote patient safety.

    For many reasons, this last point – quality and safety – while always on our minds, must be our verbal and written mantra in all aspects of our promotion of Clinical Sonography. Whenever possible, the description of each application should be articulated in the context of better and safer care; the rollout of new techniques should be presented as quality improvement and/or patient safety initiatives; research protocols and grant applications should include indicators of quality of care, both positive and negative, to facilitate a discussion of patient safety enhancement; and teaching opportunities, including lectures, demonstrations, and hands-on skill labs should be broadly laced with the available evidence of enhancement of quality of care and patient safety.

    These dual emphases are critical to incorporate in our dialog because continuous quality management is a "hot topic." We face an expanding list of CMS, JC, and ORYX indicators; audits for appropriate and timely treatment are facts of life; and Pay-for-Performance is right around the corner. Our challenge -- Where does Clinical Sonography fit in these manifold and complex processes?

    Furthermore, the traditional providers of imaging services expend less energy today trying to stop us from purchasing machines and using them; instead, they promulgate the false notion that we provide substandard training and imaging, for which we should not be reimbursed. They are lobbying lawmakers for the authority to credential us and accredit our imaging practices. Therefore, we also must demonstrate the quality of our teaching, performance, and interpretation of Clinical Sonography. Finally, we will fight any attempt by any other specialty to govern the practice of emergency medicine. See the ACEP Council Resolution, the Performance and Interpretation of Imaging Studies Protection Plan, submitted by the Ultrasound Section and published in this newsletter.

    This is the first in a series of articles on the importance of the relationship between Continuous Quality Management and Clinical Sonography. Any members of the Section with questions or concerns they would like addressed in future articles may contact me at lam9004@nyp.org and contributing articles may be forwarded to the newsletter editor at gquick@pol.net.

     


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    Journal Watch – January 2008

    Various Authors

    Reviewer: Lisa Mills, MD

    Warshak CR, Eskander R, Hull AD, et al. Accuracy of ultrasonography and magnetic resonance imaging in the diagnosis of placenta accreta. Obstet & Gynecol. 2006;108(3 Pt 1):573-581.

    Objective: The objective of this study was to "determine the precision and reliability of ultrasonography [US] and magnetic resonance imaging (MRI) in diagnosing placenta accreta."

    Methods: Researchers conducted a chart review to identify patients with suspected placenta treated in from 2000 – 2005. The findings on US and MRI were compared to the operative or pathology report.

    Results: The researchers reviewed 453 charts.  39 cases of placenta accreta were identified. US was performed in all (39/39) women with placenta accreta and identified 77% (30/39). US correctly ruled out placenta accreta in 96% (398/414). The sensitivity of US was 77% and the specificity 96%. Only 42 women in the study had MRI performed. MRI identified 88% (23/26) of cases and correctly ruled out placenta accrete in 100% (14/14) cases. MRI sensitivity and specificity were 88% and 100%, respectively.

    Conclusion: The authors conclude that a 2 step approach to diagnosis of placenta accreta with US followed by MRI in indeterminate cases "will optimize diagnostic accuracy."

    Comment: Placenta accreta is a rare condition in which the placenta invades the uterus to varying degrees. Intrapartum and post-partum hemorrhage complicate the delivery in these cases. Emergent hysterectomy at times is the only means to stop the bleeding. The incidence of placenta accreta has increased with the increased number of Cesarean deliveries and pregnancy following myomectomy. In the setting of a precipitous delivery, the emergency physician (EP) has few options but to deliver the child and deal with the complications as they arise. The ability to suspect or predict placenta accreta may allow the EP to prevent a fatal outcome in the mother by calling in the general surgeon, if an obstetrician is not emergently available. This article re-inforces the benefit of a focused surveillance US in the setting of a precipitous delivery to identify fetal lie and placenta location and anatomy.

    _____________

    Reviewer: Lisa Mills, MD

    Shippey SH, Bhoola SM, Royek AB, et al. Diagnosis and management of hepatic ectopic pregnancy. Obstet & Gynecol. 2007;109(2 Pt2):544-546.

    Case Report: A pregnant woman presented with abdominal pain, an empty uterus, and an adnexal mass by ultrasound (US). The patient underwent laparoscopy and removal of an ovarian teratoma. There was no evidence of pregnancy in the pelvis by laparoscopy. The patient’s quantitative hCG continued to rise. The patient underwent a curettage of the uterus, but no products of conception were found in the uterus. An US of the abdomen and subsequent MRI showed an 11 week live fetus on the liver. The ectopic pregnancy was successfully terminated with intra-fetal injections of methotrexate and potassium.

    Comment: This case reinforces the limitations of US. US does not always provide a diagnostic image in the case of ectopic pregnancy. Although nearly 99% of adnexal masses in ectopic pregnancy are found to be the pregnancy, there are these unique cases in which an ectopic mass is an incidental finding. When performing US or reviewing the report of the radiologist, it is important to delineate the structure of the adnexal mass as accurately as possible.

    _____________

    Reviewer: Thompson Kehrl, MD

    Chen L, Kim Y, Santucci KA. Use of ultrasound measurement of the inferior vena cava diameter as an objective tool in the assessment of children with clinical dehydration. Acad Emerg Med. 2007;14(10):841-845.

    Introduction: Dehydration in the pediatric ED population is a common clinical presentation. Recognition of dehydration is important, as it can lead to shock and death. Conversely, overtreatment can lead to morbidity as well. Clinical determination of dehydration (as defined as >5% change in body weight) is difficult. Laboratory testing is expensive, time-consuming, and is neither sensitive nor specific. The use of ultrasound to estimate inferior vena cava (IVC) diameter as an indicator of volume status has been used in pediatric patients receiving hemodialysis as well as in adult patients with acute blood loss. The authors set out to determine if IVC diameter was correlated with clinical dehydration. The aorta is less distensible that venous structures and has been shown to have a more constant diameter despite hypovolemia. The authors hypothesized that the ratio between the IVC and aorta may be valuable in determining volume status in pediatric patients with clinical signs of dehydration.

    Methods: Pediatric patients determined to be clinically dehydrated and in need of IV hydration by pediatric emergency attending staff between 6 months and 16 years of age were enrolled. Study patient diagnoses were broad and included but were not limited to gastroenteritis, UTI, and hyperemesis gravidarum. For each study subject, an age, weight, and height matched patient with minor complaints and no signs of dehydration was enrolled. Patients with acute blood loss were excluded. Transverse images of the abdominal aorta and IVC were taken with a curvilinear probe, with care not to compress abdominal structures. Maximum aortic diameter during systole and maximum IVC diameter during expiration were obtained over several respiratory/cardiac cycles. Repeat measurements were taken after IV fluids were administered in study patients.

    Results: 36 pairs of patients were enrolled aged 9 months to 16 years. IV fluids were obtained to study patients with an average volume of 20 mL/kg. Mean aortic diameter did not significantly change after IV fluid administration in study subjects, with a mean change of 0.03 cm. IVC diameter did significantly change after IV fluid administration, with a mean difference of 0.27 cm (95% CI 0.24-0.32). The IVC/Aorta ratio also significantly increased after IV fluid administration in study subjects, with a mean change of 0.34 cm (95% CI 0.29-0.39). Compared to age and size matched controls, prehydration ratios were significantly lower, with mean ratios 0.75 versus 1.01 with a mean difference of 0.26 (95% CI 0.18-0.35). Notably, there was no difference in ratio of IVC to Aorta in euvolemic children of all ages with a mean of 1.01 and a standard deviation of 0.15.

    Discussion: Using ultrasound to aid in the decision to administer intravenous fluids to pediatric patients with signs of dehydration is potentially very useful in the clinical setting. This is a small pilot study showing that in children clinically diagnosed with dehydration, the ratio of IVC diameter to abdominal aortic diameter was lower in age/size matched asymptomatic children and that this ratio increased after the administration of IV fluids. The ratio of IVC / Aortic diameter also remained similar across ages in the control subjects. This is potentially very useful as data analysis could lead to a standardized mean value that might allow for broader use of this ratio; however, more data is needed as the numbers included in this study are low. Limitations of this study are numerous. The study contains a small number of subjects which the author relates to difficulty matching age/size matched controls. Only two scanners were used and inter-rater reliability was not calculated, one being a medical student with limited ultrasound training. A longitudinal study with measurements taken during dehydration as well as during euvolemia with a set temporal separation is needed. Of note, this study includes only patients who are felt to be clinically dehydrated and in need of IV fluid administration. As noted above, the sensitivity and specificity of clinical judgment are not optimal. As such, the "gold standard" for this study then becomes somewhat suspect. Another treatment group in the form of patients felt to be dehydrated but not in need of IV hydration would be interesting. One of the benefits of this study design, as noted by the authors, is that patients with dehydration from various different pathologic causes were included, potentially broadening its applicability. In summary, the authors show that IVC/Aortic diameter may be useful in the assessment and treatment of pediatric patients with dehydration.

    _____________

    Reviewer: Justin P. Morris DO

    Resnick JR, Cydulka R, Jones R. Comparison of two transducers for ultrasound-guided vascular access in long axis. J Emerg Med. 2007;33(3):273-276.

    Method: This study population included 4th year medical students, Emergency Medicine residents, attending physicians, nurses, and off-service residents rotating through the emergency department. To be included in the study a person must have had less than three ultrasound-guided vascular access procedures. Participants were given a 20 minute tutorial demonstration video regarding ultrasound-guided vascular access. Subjects were asked to find a vein in the short axis first and rotate the probe to long axis. Vascular access was then attempted with an 18 gauge needle. This procedure was performed for both the linear (5-10 MHz) and curvilinear (4-7 MHz) transducers. Participants were asked to evaluate the difficulty of using both probes on a 10 point Likert scale with 10 designated as most difficult. Time to needle entry was also recorded which included repeated surface breaks and needle redirects. All attempts were conducted on a peripheral vessel model.

    Results: A total of 24 subjects were enrolled. Degree of difficulty, needle redirects, surface breaks, and time to needle entry were all found to be statistically significant in favor of the curvilinear transducer over the linear transducer.

    Discussion: These conclusions and results can only be applied to the Sonosite ultrasound machines with C11 and L38 transducers. Subjects were asked to comment on their experience and those who favored the curvilinear probe commented it was adventageous to see the needle early rather than later compared to the linear probe. The advance visualization of the needle allowed for earlier adjustments and a higher first attempt success. In contrast, those who preferred the linear probe concluded the true angles created by the linear probe, provided a straight line appearance and more anatomically correct visualization. The only other advantage addressed by using the long axis is actual determination of length of the catheter in the vein. The study was inconclusive for determining an actual advantage for early detection of the needle provided by a curved array transducer vs. the more anatomical correct angles provided by a linear array transducer. No conclusions were drawn due to the study being conducted in the artificial models rather than actual data from attempted access of live patients.

    _____________

    Reviewer: Clifford J. Fields, DO

    Hernandez C, Shuler K, Hannan H, et al. C.A.U.S.E.: Cardiac arrest ultra-sound exam - A better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. 2007. Article in Press. (Epub ahead of print)

    Methods: Literature review followed by the proposal, based on the authors’ opinions, for a specific protocol using ultrasound to guide resuscitation in cardiac arrest patients not suffering from a primary arrhythmogenic cardiac arrest.

    Results: The authors review the literature supporting emergency physician success in using ultrasound to evaluate patients for cardiac tamponade, hypovolemia, pulmonary embolus, and tension pneumothorax. They also review the literature on the prognosis of patients with ulrasonographically-documented asystole. The authors then propose incorporating ultrasound into the resuscitation of non-arrhythmogenic cardiac arrest patients using a specific algorhythm using two ultrasound views of the thorax to diagnose or exclude these conditions. The first image recommended to obtain is a four-chamber view of the heart to check for cardiac tamponade, pulmonary embolus and hypovolemia. If neither is present, the next view recommended is a sagittal view of the thorax in the second intercostal space and the midclavicular line looking for signs of a pneumothorax.

    Discussion: Evaluation and treatment of the patient in non-arrhythmogenic cardiac arrest is challenging in that the underlying cause of the arrest needs to be determined and treated immediately. Unfortunately, the diagnosis of the important reversible causes of cardiac arrest is difficult clinically for multiple reasons. Hernandez and colleagues in this article demonstrate through a literature review that emergency physicians can readily diagnose these conditions by ultrasound. They also propose a simple, rational, ultrasound-based approach to diagnose these conditions. The proposal seems perfectly reasonable and may lead to improved care in this subset of patients. The recommendations can be easily implemented at institutions already using bedside emergency sonography without any additional resources and little to no interference in the resuscitation process. The skills required are either already possessed or easily acquired by most emergency physicians. The recommendations will need to be studied prospectively in detail to see if they do indeed improve outcomes.

     


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    A Critical Look at the "Revised" Cochrane Review of Trauma Ultrasound

    William T. Hosek, MD, MBA, FACEP
    Johns Hopkins University

    The Cochrane review of trauma ultrasound was first published in February of 20051. The objective of the analysis was to assess the impact (efficiency & effectiveness) of ultrasound in blunt abdominal trauma algorithms. The analysis combined results from four studies2-5 and concluded that ultrasound had no statistically significant impact on mortality, CT scan use, laparotomy or DPL rates. Additionally, the authors implied that use of ultrasound might be reducing CT use at the expense of patient survival. However, as detailed in a recent letter to the editor in the Annals of Emergency Medicine6, these conclusions were based upon incorrect data and poor study assignment.

    Several changes to the Cochrane review were subsequently made in the fall of 2007. The Navarrete-Navarro study 4 was dropped from and the Melniker study 7 was added to the analysis. In addition, several data points were corrected in the CT and DPL analyses. Despite these changes, the Cochrane review again concluded that there is "insufficient evidence to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma."8 Unfortunately, this "revised" Cochrane analysis is plagued by new problems that are just as significant as the original ones. Laparotomy data from the Boulanger study 3 and mortality data from the Melniker study 7 are incorrectly reported. Valuable endpoint data (time to operative care, hospital length of stay and total charges) from the Melniker study were excluded from the analysis. Finally, data regarding DPL rates are excluded from the conclusions and never discussed.

    When these mistakes and omissions are taken into account, the studies actually show that ultrasound does, in fact, have a positive impact in the evaluation of patients with torso trauma. Diagnostic time, time to operative care, CT use, total charges and hospital length of stay are all reduced when ultrasound-based clinical pathways are used. In addition, diagnostic peritoneal lavage has been replaced, in large part, by ultrasound. All of these benefits are observed without any adverse effect on mortality or laparotomy rates. While further studies regarding trauma ultrasound are needed to improve upon clinical pathways as they exist today, the beneficial impact of ultrasound thus far should not be discounted. 

    References:

    1. Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews. 2005, Issue 2. Art. No.: CD004446. DOI:10.1002/14651858.CD004446.pub2.
    2. Arrillaga A, Graham R, York JW, et al. Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. The American Surgeon. 1999;65:31-35.
    3. Boulanger BR, McLellan BA, Brenneman FD, et al. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma. 1999;47(4):632-637.
    4. Navarrete-Navarro P, Vazquez G, Bosch JM, et al. Computed tomography vs. clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma-a cost analysis approach. Intensive Care Med. 1996;22:208-212.
    5. Rose JS, Levitt MA, Porter J, et al. Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized trial of ultrasound in trauma. J Trauma. 2001;51:545-549.
    6. Hosek WT, McCarthy ML. Trauma ultrasound and the 2005 Cochrane Review. Ann Emerg Med. 2007;50(5):619-620.
    7. Melniker LA, Evan L, McKenney, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: The first sonographic outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235.
    8. (Revised 2007) Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD00446. DOI:10.1002/14651858.CD004446.pub2.

     


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    From the Editor’s Desk--Clinician-Performed Sonography

    Gary Quick, MD, FACEP

    Mr. Smith (an alias) presented to the ED with exertional dyspnea which had progressed to chest tightness over a 2-week course. He had experienced no weight gain but his exercise tolerance allowed him to walk only 15-20 feet before becoming severely winded. He reported a single episode of congestive heart failure 2 years previous to this visit and gave no history of symptomatic angina, COPD or asthma. On physical examination I found 2+ pitting pretibial edema and a few bibasilar rales. His EKG showed normal sinus rhythm with a rate of 82 bpm and a chest x-ray showed moderate cardiomegaly with bilateral hilar prominence and moderate interstitial edema. His brain naturiouretic peptide (BNP) was measured at 270 (normal 0-200). I made the diagnosis of congestive heart failure based upon his past history of CHF, his current physical findings compatible with CHF. His radiographic and lab finding corroborated CHF.

    Based upon his dyspnea, which seemed disproportionate to the severity of his presumed CHF, and his real but minimal supporting data for CHF, including a generous cardiac silhouette on x-ray, and because the ultrasound machine was easily accessible, I performed a limited cardiac echo exam. I was mildly shocked to find a 3.5 cm.circumfer-ential pericardial effusion with a freely swinging heart accompanying right ventricular, right atrial and left atrial diastolic collapse indicative of tamponade physiology, despite his blood pressure of 140/80 mm Hg and pulse of 84 bpm. I put down the probe and walked to the phone to call my interventional cardiology back-up who promptly took the patient to cath lab for drainage of 1.2 L. bloody effusion and performance of a pericardial window.

    The point of this case is that bedside ultrasound makes a difference in care of real patients, and we must find ways to introduce clinician-performed sonography into every ED in this country. I know that 10 years ago I would have missed the effusion on my patient, and I am willing to wager against the average emergency physician making the diagnosis of pericardial effusion with tamponade in a patient like mine even today in most emergency departments. Dr. Melniker is right on the mark in reminding us of the improved quality of care and safety which clinical sonography brings to ED patient care. These twin themes as measured in objective quality reviews will greatly strengthen the case for clinician-performed sonography.

    I have some experience in helping to develop an electronic medical record (EMR). One major difficulty with most EMR’s is that they are not programmed by physicians and thereby suffer greatly in translation through a programmer into the actual EMR software application. If a physician programs an EMR, one has a much better chance of producing a record that works like physicians think. Clinician-performed sonography carries much the same weight of opportunity. A knowledgeable physician takes the probe and in a matter of minutes confirms or disproves his clinically based differential diagnosis with much more speed and accuracy than having to work through a sonographic interpreter. I do certainly admit that sonographic technicians will always exceed my skill level in acquiring images on a consistent basis, but I know what I am looking for when I take the probe. That knowledge level is the essential difference afforded by clinician-performed sonography.

    Dr. Tayal has outlined an ambitious and comprehensive detailing of US Section activities which we are going to move forward on many fronts. Pick an area in which you have interest or ability and join in with the subcommittee of your choice. Although we are still few in number by commonly applied parameters such as our radiology colleagues measure influence, we are present on the front line of patient care. In that position we can continuously advocate for improved patient care and patient safety. As I wrote some years ago when the hockey player Mario Lemieux was asked how he managed to score so many points, he responded, "I skate to where the puck will be." We should embrace that counsel and skate to where the ultrasound puck will be.

     


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    WINFOCUS

    Michael Blaivas, MD, FACEP, RDMS

    WINFOCUS stands for "World Interactive Network Focused on Critical Ultrasound." WINFOCUS, the vision statement says it all: "Improving Emergency and Critical Care Medicine by incorporating Point of Care Ultrasound into Clinical Practice." If only all of our own colleagues supported this in emergency medicine at the grass roots level. What started as an ambitious vision for a method to bring clinical ultrasound experts together from around the globe has grown into an international society. The dream began in Milan, Italy with Dr. Luca Neri. Trained as an emergency surgeon and intensivist, Dr. Neri is an emergency physician and part of an emerging new specialty in Italy. In a region of the world where medical imaging decisions are driven less by high dollar profits for traditional imaging providers, ultrasound at the bedside not only made sense but also was more easily accepted.

    The first meeting of about 250 clinical ultrasound zealots occurred in Milan, Italy three and a half years ago and was an eye-opener for all in attendance. The First World Congress on Ultrasound in Emergency and Critical Care Medicine exposed the breadth of emergency ultrasound activity around the world. Those of us from the United States realized that to the rest of the world "emergency ultrasound" meant ultrasound use in an emergency or urgent situation, and many of those practicing it were not emergency physicians. Thus, emergency ultrasound was a concept that was not tied to a location.

    The Second World Congress took place in New York and generated more interest, especially from critical care physicians, as they were discovering ultrasound on this side of the pond. The Third World Congress was recently held in Paris and was a tremendous success. Generating a large attendance increase over the previous years and bringing in people from all over the world. This was also the first world congress under the new international society, WINFOCUS, which was officially inaugurated in Paris. The Paris meeting featured not only multiple educational and scientific sessions but also the introduction of clinical ultrasound guidelines. These guidelines are being developed to assist sonologists in setting up their point of care ultrasound practices and to standardize emergency and critical care ultrasound applications. Several regional sections of WINFOCUS were also discussed including one for Italy, China, India and Brazil. The WINFOCUS Board of Directors also decided to undertake the creation of regional centers of clinical ultrasound excellence where clinicians from large regions could train and major research projects could originate. The two first regional centers will likely be India and Brazil.

    Although brand new, the society is already gaining wide acceptance around the world as the only one representing solely clinicians interested in emergency and critical care ultrasound. One of the biggest new developments is the invitation of WINFOCUS members to present at a United Nations (UN) meeting in Geneva, Switzerland this July on how ultrasound can improve the care provided in under-developed areas of the world in which imaging modalities such as CT and MRI are impractical and even plain x-rays may not be possible due to lack of reliable electrical connections and requirement for great mobility to serve a dispersed population. In cooperation with the UN and sponsorship from equipment manufacturers, WINFOCUS is hoping to spread ultrasound wherever point of care diagnosis can make a difference in a patient’s care. The first project has already begun and is being run in Madagascar. A recent visit from WINFOCUS representatives and United Nations staffers launched the first point of care educational program there. In addition, WINFOCUS was recently invited to present at a recent United Nations meeting in Rwanda where dozens of regional ministers and many UN ambassadors and staffers were in attendance. WINFOCUS is being asked to help integrate point of care ultrasound into some the most underserved regions of Africa.

    The next world congress on ultrasound in emergency and critical care medicine will be held in Porto Alegre Brazil this March 5th through 8th and will see presentations of multiple lectures from around the world as well as scientific posters and discussions. This is an opportunity for ultrasound novices and aficionados alike to interact with colleagues of multiple different specialties from around the globe. This is also a chance to get involved in teaching and research collaboration with physicians and other medical personnel from all over South America. Please check the WINFOCUS website (http://www.winfocus.org/ ) for more information and to sign up to attend the Congress or become a member.

     


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    Case Report--Acute Painless Unilateral Vision Loss

    Dana Sajed, MD
    Michael B. Stone, MD, FACEP

    A 53 year-old female presented to the emergency department with acute, painless vision loss in her left eye. She described the feeling as a black spot blocking most of the visual field in her left eye. She denied headache, jaw claudication, scalp tenderness, neurological deficit or recent trauma to the head, face or eyes.  The patient’s medical history was significant for non-insulin dependent diabetes mellitus, hypertension and hyperlipidemia. Further ophthalmologic history revealed that the patient had previously undergone pan-retinal photocoagulation (PRP) therapy for bilateral proliferative diabetic retinopathy.

    The patient’s vital signs on presentation were as follows: blood pressure 118/64, pulse 93, respiratory rate 18, oral temperature 98.4°F and pulse oximetry of 98% on room air. A finger-stick glucose measurement was 217 mg/dL. The physical exam revealed a well appearing African-American woman who appeared her stated age, in no acute distress. Ophthalmic exam showed intact extra-ocular motion, equally round and reactive pupils with consensual accommodation and response; applination tonometry showed intraocular pressures of 14 mmHg and 15 mmHg in the right and left eyes, respectively. Visual acuity was noted to be 20/60 in the right eye and 20/400 in the left eye. A slit lamp examination revealed bilateral clear and deep anterior chambers with no corneal defects. Fundoscopy without dilatation showed the right optic disc as sharp without obvious neovascularization, and the macula was noted to have exudates. The left optic disc and macula were poorly visualized.

    A bedside ocular ultrasound was performed with a 10-5 MHz linear array probe and revealed a thickened, irregularly contoured hyperechoic lesion in the vitreous space adjacent to the macula [Fig 1]. No obvious detachment of the retina was noted. The ultrasonographic findings, as well as the patient’s history and physical exam were consistent with the diagnosis of a macular vitreous hemorrhage. The patient was then seen by the ophthalmology consultant in the ED, whose dilated fundoscopic exam revealed vitreous hemorrhage and a large fibrovascular tuft which encompassed a majority of the posterior pole of the retina. Diffuse macroaneurysms and scattered retinal scarring consistent with the previous history of PRP therapy were also noted. The patient was discharged home with rapid follow up arranged in the Ophthalmology/Retina Clinic. Subsequent chart review indicates that the patient was seen in clinic with some resolution of her symptoms, and was scheduled for further PRP therapy 3 weeks following her initial visit to the Emergency Room.

    0108visionloss
    Figure 1

    The overall incidence of vitreous hemorrhage in the US population is estimated to be approximately 7 cases per 100,000.1 The hemorrhagic fluid spreads through the gelatinous vitreous and often obscures the optic disk. This leads to the chief complaint of visual loss of varying degrees, often including a description of "black rain" or smoky haze in the visual field2. The most common causes of vitreous hemorrhage are proliferative diabetic retinopathy, vitreous detachment with or without retinal tear and trauma. Less frequent causes include retinal microaneurysm, hemorrhage secondary to central retinal vein occlusion, age related macular degeneration, vascular tumors and subarachnoid hemorrhage (Terson syndrome).1,3

    Physical examination of the eye in vitreous hemorrhage is often unreliable as the retina, and fundus in particular, may be obscured by blood.4 In this case, ultrasound is a reliable tool for further diagnosis, and may reveal other pathology not seen on initial exam, such as retinal tear or detachment, traumatic hematoma or mass lesion.3,4 The use of ultrasound in the management of diabetic retinopathy with vitreous hemorrhage has shown to accurately predict the prognosis of patients with intraocular blood.5,6 Furthermore, the use of bedside ocular ultrasound by emergency physicians has been shown to accurately diagnosis and expedite care in both traumatic and non-traumatic ophthalmologic pathology.7,8

    Therapy for vitreous hemorrhage depends on the underlying cause. In retinal tear or detachment, laser therapy or scleral buckle surgery is usually indicated. Most cases are treated conservatively with close observation in the few weeks following presentation, which allows for some spontaneous resolution of the hemorrhage, although this may be a very slow process. In patients with diabetic retinopathy, early PRP has been shown to be beneficial.9 Patients refractory to this therapy or with persistent vitreous hemorrhage may require surgical vitrectomy.9

    Vitreous hemorrhage is a frequent cause of painless vision loss, and should certainly be considered in the differential diagnosis of the patient with diabetes or known retinopathy. In this case, the patient’s presentation and use of bedside ultrasound led to rapid recognition of the pathology in question and aided in management in conjunction with ophthalmology consultation. The use of this modality for diagnosis and therapeutic decision-making may prove even more valuable in institutions where ophthalmology consultation is not readily available.

    References:

    1. Spraul CW, Grossniklaus HE: Vitreous hemorrhage. Surv Ophthalmol. 1997 Jul-Aug; 42(1): 3-39.
    2. Bedi DG, Gombos DS, Ng CS, et al. Sonography of the eye. AJR Am J Roentgenol. 2006;187(4):1061-1072.
    3. Vote BJ, Membrey WL, Casswell AG.. Vitreous haemorrhage without obvious cause: national survey of management practices. Eye. 2005;19(7):770-777.
    4. Rabinowitz R, Yagev R, Shoham A, et al. Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage. Eye. 2004 Mar;18(3):253-256.
    5. Capeans C, Santos L, Tourino R, et al. Ocular echography in the prognosis of vitreous haemorrhage in type II diabetes mellitus. Int Ophthalmol. 1997-1998;21(5):269-75.
    6. Kocabora MS, Gulkilik G, Yilmazli C, et al. The predictive value of echography in diabetic vitreous hemorrhage. Int Ophthalmol. 2005;26(6):215-219.
    7. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799.
    8. Blaivas M. Bedside emergency department ultrasonography in the evaluation of ocular pathology. Acad Emerg Med. 2000 Aug;7(8):947-50.
    9. Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA. 2007 Aug 22;298(8):902-16.

     


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    Resolution 32(07)

    This resolution was adopted by the Council and the Board.  Formal notification was received that the resolution has been assigned to the Ultrasound Section. Also, please note the second resolve requires the Board to submit a "comprehensive" report to the 2008 Council.

    AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

     

    RESOLUTION: 32(07)  
    ACTION: Council:  ADOPTED
      Board:    ADOPTED
    SUBMITTED BY: Emergency Ultrasound Section
    SUBJECT: Emergency Ultrasound Credentialing and Accreditation

    WHEREAS, Credentialing is an endorsement by an institution that an individual practitioner has met certain hospital-based standards; and

    WHEREAS, Accreditation is an affirmation by an outside agency that a facility or institution, or component thereof, has met certain agency-based standards; and

    WHEREAS, Credentialing and accreditation are well-established standards by both governmental and non-governmental payors; and

    WHEREAS, Insurers are now relying more heavily on credentialing and accreditation as a requirement for reimbursement; and

    WHEREAS, The imposition upon the specialty of Emergency Medicine of any accreditation programs developed, offered, and/or governed solely by other specialties represents a clear and present danger to the  independence of the practice of Emergency Medicine; and

    WHEREAS, Accreditation programs developed and offered by the American Institute of Ultrasound in Medicine, the American College Radiology, or other specialty-associated groups, which are used or proposed for use by third-party payors and Medicare for the performance and interpretation of imaging studies provided by emergency physicians are extremely unfriendly to Emergency Medicine and, specifically, harm the ability of emergency physicians to use emergency ultrasound, a core skill; therefore be it

    RESOLVED, That ACEP, in cooperation with all established College liaisons and relationships with other medical specialty societies, the American Medical Association, the Alliance for Specialty Medicine, the Coalition for Patient-Centric Imaging, and other interested parties actively and fully opposes the imposition upon the specialty of Emergency Medicine of any accreditation programs developed, offered, and/or governed solely by other specialties; and be it further

    RESOLVED, That the Board of Directors of ACEP submit a comprehensive report to the Council at the 2008 Council Meeting regarding the adoption and execution of a strategic plan to address the long- and short-term accreditation issues relating to the performance and interpretation of imaging studies and, specifically, emergency ultrasound.

    This resolution was submitted by the Ultrasound Section to the ACEP Council.

    The Council adopted Resolution 32(07) on October 7, 2007

    BOARD ACTION: The Board adopted Resolution 32(07) on October 11, 2007.

    RESOLVED, That ACEP, in cooperation with all established College liaisons and relationships with other medical specialty societies, the American Medical Association, the Alliance for Specialty Medicine, the Coalition for Patient-Centric Imaging, and other interested parties actively and fully opposes the imposition upon the specialty of Emergency Medicine of any accreditation programs developed, offered, and/or governed solely by other specialties; and be it further
    RESOLVED, That the Board of Directors of ACEP submit a comprehensive report to the Council at the 2008 Council Meeting regarding the adoption and execution of a strategic plan to address the long and short-term accreditation issues relating to the performance and interpretation of imaging studies by emergency physicians and, specifically, emergency ultrasound.

    Action: Assign to the Ultrasound Section for development of a strategic plan.

     


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    Meeting Minutes

    American College of Emergency Physicians

    Emergency Ultrasound Section Meeting
    Monday, October 8, 2007
    11:30 - 2:00pm
    Cirrus, Sheraton Seattle


    MINUTES

    Participants
    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

    Agenda

    Call to order/Introductions
    Didactic Session 1 - Use of Ultrasound in Iraq
    Section Report

    1. Membership/subcommittees
    2. Grant Update
    3. Accreditation
    4. ACEP Website
    5. ASE Hand-held guidelines
    6. Section Newsletter
    7. ACEP U/S Management Course
    8. ACEP-GE Ultrasound Course
    9. WINFOCUS
    10. SOAP Trial Update
    11. SCHIP bill/CARE bill
    12. Reimbursement update
    13. Liaison Reports
      1. AIUM Dr. Tayal
      2. Critical Care---- Dr. Blaivas
    14. Didactic Session 2 - Vertical Medical School Ultrasound Curriculum, Dr. Cook
    15. Officer Elections
    16. Installation of Chair-elect
    17. Adjourn ACEP Ultrasound Section meeting
    18. Begin SAEM Ultrasound Interest Group (UIG) meeting

    Major Points Discussed

    Robert A. Jones, DO, FACEP, welcomed everyone to the meeting and provided a report on what the section had accomplished this past year.

    Rob Blankenship, MD, FACEP, gave an outstanding presentation on the use of emergency ultrasound in Iraq. He indicated the ultrasound machine was the single best piece of equipment he had. He presented slides on the multiple uses of ultrasound in a war zone. He said it was ideal for checking shrapnel wounds.
    Emergency Ultrasound Section meeting minutes, October 8, 2007
    Page 2

    Beatrice Hoffman, MD, provided an update on the section grant. There was great interest in the sophistication of the presentation of the material. It was felt that this would not only have significant value to medical students, but all members of the section. Once the production of the material on CD has been completed, each section member will receive one. It was suggested that this product would be something that the College could offer to members through the bookstore and possibly even be used for a CME product.

    Michael Blaivas, MD, FACEP, addressed the issue of accreditation and why it may become necessary for the College to address this issue. He noted the Council Resolution asking the College to develop a plan regarding accreditation/certification was passed.

    Dr. Blaivas provided information on WINFOCUS. This is a multi-specialty organization international organization focused on the use of ultrasound in critical and emergent care. He also provided an update on the work underway with critical care community.

    The SOAP Trail Update was given by Lawrence A. Melniker, MD, FACEP.

    Paul R. Sierzenski, MD, FACEP, reported on the actions currently underway to address credentialing of physicians to perform emergency ultrasound found in the SCHIP and CARE bills before Congress. It was reported that thus far the College and several other specialty associations have been successful in blocking this requirement in the bills.

    Vivek S. Tayal, MD, informed the section that the College Board of Directors approved the joint FAST guidelines presented by AIUM and ACEP. He noted this project was many years in the making.

    Thomas P. Cook, MD, FACEP, presented the work on the vertical medical school ultrasound curriculum.

    Stephen Hoffenberg, MD, FACEP, provided a brief update on reimbursement issues and in particular what was being done to address various third party payers that try to limit what physicians can use emergency ultrasound.

    Officer elections were held.

    Lawrence A. Melniker, MD, FACEP Chair elect
    Gary Quick, MD, FACEP Secretary/Newsletter Editor
    Vicki E. Noble, MD, FACEP Councillor
    Rajesh N. Geria, MD Alternate Councillor

    ACEP’s Ultrasound Section meeting was adjourned.

    SAEM’s Ultrasound Special Interest Group held a brief meeting where an update on SIG projects was provided.


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    This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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