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Emergency Ultrasound Section Newsletter - May 2008, Vol 12, #2

  Emergency Ultrasound Section

circle_arrow From the Chair
circle_arrow ACEP Ultrasound Section Industry Roundtable Subcommittee Update
circle_arrow AIUM Update
circle_arrow A Primer on Credentialing, Certification and Accreditation with Implications for Emergency Ultrasound
circle_arrow WINFOCUS 4th World Congress on Ultrasound in Emergency and Critical Care Medicine
circle_arrow AIUM 2008, San Diego 3/12-3/16/2008
circle_arrow More Storms on the Horizon: The FAST Cochrane Review
circle_arrow Emergency Medicine Graduate Competency -- It’s not just a Numbers Game anymore
circle_arrow Case Report
circle_arrow Journal Watch – April 2008


Newsletter Index


Emergency Ultrasound Section

 

 

From the Chair

Vivek S. Tayal, MD, FACEP
vtayal@carolinas.org

To Fellow Section members:

We have had a busy, exciting spring in the emergency ultrasound world! Between the public events, conferences and section subcommittee work, the members of the ACEP Ultrasound Section have been very active.

As many of you know, the public events include the Council of Residency Directors (CORD) consensus conference on the issue of residency ultrasound training, the California Technology Assessment Forum (CTAF), the WINFOCUS World Congress, and the AIUM meeting. We will cover those later in the newsletter, but let me say that a tremendous amount of work has gone into preparing and contributing to these conferences by section members.

In addition, our section subcommittees have been meeting by conference call and have been very active in creating processes that will contribute later in the year.

CORD US consensus conference
Ultrasound leaders, residency directors, and others met at the Council of Residency Directors (CORD) US Consensus Conference on March 3, 2008 in New Orleans. The background to this conference was that in 2006-2007, US leaders had a discussion with the RRC-EM regarding the minimum number of total ultrasound exams (40) for all applications, which many felt was inappropriately low, not in concert with specialty-specific guidelines, and injurious to the specialty in regards to realistic residency training standards. The RRC responded by changing the US requirement from a number to a required competency, the only procedure which every residency has to show their plan for procedural competency. Since many residencies still struggled with US education, the CORD Board, led in this initiative by Sarah Stahmer, MD, FACEP, supported this year’s theme to the CORD consensus conference as US competency.

Daniel L. Theodoro, MD, Chris C. Raio, MD, and Saadia Akhtar, MD, were the coordinators of discussion groups on the curriculum. Through weeks of discussion on a separate blog, consensus statements were drafted and then discussed formally on March 3. The conference went very well with interesting and meaningful discussion.

Though we wait for the final editions, the ACEP Ultrasound section subcommittee on residency education had input into the draft. Final wording, applications, and the number of examinations expected for graduating residents were all commented on by ACEP leaders to coordinate with current and future ACEP emergency ultrasound guidelines.

I suspect this will give a big boost to ultrasound education. Having all 1000+ emergency medicine residents each year graduate having the life-saving ultrasound applications under their belt can only accelerate the integration of ultrasound into typical emergency medicine practice here in the United States. And once you get ultrasound in your ED, ultrasound fever spreads like faster than influenza!

CTAF
As many of you saw through my email on the list-serve, the ACEP section represented by former Section Chair, Diku P. Mandavia, MD, FACEP, testified in front of the California Technical Advisory Forum (CTAF), a medical review and appropriateness commission set up by Blue Shield, on March 5, 2008 on the issue of hand-held echocardiography. The CTAF appropriateness criteria is extremely demanding including only randomized controlled trials as pro forma qualifying evidence for use and payment. We realized that the implications of a Blue shield group issuing an edict that hand-held echocardiography encroached on our subspecialty, and possibly carried implications for future issues with payors. This happened in 2003 with Medicare, where one carrier used another carrier’s payment decision. And what happens in California does not stay in California. It rolls across the country in lock-step, and is often very hard to undo even with a significant effort at the national level.
The section was alerted to the imminent review in mid-February. A group including Steve Hoffenberg, MD, FACEP, Paul Sierzenski, MD, FACEP, Marilyn Bromley, and I forged response letters to posted draft testimony, and a literature review was given to CTAF. ACEP President Linda Lawrence supported the effort to send Dr. Mandavia to the conference. Many of you may have contributed to that literature review. Several conference calls of preparation occurred, but frankly our expectations were that our ability to testify to the Forum may have been only a formality and the decision that there was insufficient evidence for hand-held echocardiography would be made.
As you know, Dr. Mandavia testified in a fairly contentious hearing but won the day out in a very close decision with the Forum deciding to table the issue indefinitely. As I said in my email to the Section, this was a stunning, overwhelmingly incredible decision against all odds. The fruits of this effort will be consolidated so that the members, the Section, and ACEP can use the lessons for future battles.

WINFOCUS
Though others will describe the WINFOCUS meeting in the section newsletter, I know that a tremendous effort by Fernando Silva and the WINFOCUS team led by Mike Blaivas, MD, FACEP, and many others resulted in a fantastic meeting in Brazil.

AIUM
The annual meeting of AIUM took place in San Diego on March 12-15, 2008. Chris Moore, MD, RDMS, RCMS, FACEP and Dr. Blaivas did a great job organizing the second annual precourse on the critically ill patient, and there were excellent categorical and scientific sessions on emergency and critical care. Drs. Moore and Blaivas ran the AIUM Ultrasound section meeting with planning for future meetings discussed. In regards to further ACEP interactions with AIUM, we have let AIUM leaders know that we are interested in further collaboration on other ultrasound guidelines. In addition further contacts regarding reimbursement and non-traditional specialties were discussed.

US Section Subcommittees
The ACEP Section this year has widened in regards to subcommittees to allow participation in section business, help broaden opinion regarding issues in emergency US, and spread the workload more broadly to accomplish the completion of Section goals. With apologies to anyone left out by accident, the following is a listing of the subcommittees and the work this quarter. The committee chairs are listed first.

Reimbursement – Drs. Steve Hoffenberg, Jessica Resnick, Tom Asher, Mila Felder, Bret Nelson and Eitan Dickman have had a conference call with discussion of revision of the reimbursement paper. Further discussion regarding new codes and possible initiation of those processes were discussed. The most current edition of the reimbursement paper will be revised and further information regarding codes for certain new emergency ultrasound applications will be investigated.

Accreditation – Dr Jerry Chiricolo, Larry Melniker, Paul Sierzenski, Mike Blaivas, Vicki Noble, Anthony Dean, Vivek Tayal, Andrew Sama. A conference call was held with discussion of the past threats of outside accreditation, timing of any new threats, possible solutions including internal solutions from ACEP. An external manual for payor and regulators was discussed as well as internal accreditation. Issues regarding accreditation including a hand out for payors with emphasis on quality and standards, possible partners for accreditation, and final internal accreditation solutions if pressed were discussed. Members were given assignments.

Industry Roundtable – Drs. Chris Moore, Peter Kumasaka, Rich Limperos and Jim Hwang are redoing the ACEP letter to industry on the attributes of the optimal machine. Other possible activities at Scientific Assembly are being discussed, including a session for industry during the management course.

Community Practice – Drs. Bob Tillotson, Bob Jones, Evelyn Cardenas, Mike Roshon, Geoffrey Renk, Mike Pallaci, Mike Blaivas, Greg Snead, Irving Westney, Mike Overfield, Rita Sweeney, and Jim Fedinec also have had a conference call to discuss some of the following objectives. Some of them you have seen, and some are in creation phase. They have discussed the following projects: model credentialing documents and sample presentation, survey of emergency departments 2008 regarding practice of emergency ultrasound, and construct a working Database of emergency ultrasound practice creating a working list of Emergency Ultrasound preceptorships where community physicians can train under supervision, and develop training guidelines. 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 will develop guidelines, format and models for state chapter- sponsored courses to assist in the development of these courses at the state level.

Residency- Drs. Dan Theodoro, Chris Raio, Sarah Stahmer, Srikar Adhikari, Sandy Werner, Mike Petersen, and Keith Boniface have had a conference call prior to the CORD consensus conference discussing the imminent CORD consensus conference and applications that should be considered mandatory versus highly recommended. Also other categorizations were discussed.

Medical Student - Drs. Mike Stone, Chris Fox, Tom Cook, Phil Perera, Beatrice Hoffman had a conference call was held to discuss the objectives including a medical student curriculum, question data bank, and strategic moves for getting US into the curriculum of medical students. A section grant was proposed during this call.

Critical Care - Drs. Anthony Dean, Mike Blaivas, Anthony Weekes, Keith Boniface had a conference call to discuss the political issues with coordinating with critical care, the ACEP section on critical care, and cooperative research.

Web page - Drs. Tom Mailhot, Dave Bahner, Beatrice Hoffman, and Diku Mandavia are working with the ACEP webmaster to improve and organize the ACEP US web page.

US management course - Drs. Troy Foster, Bret Nelson, Raj Geria, and I are organizing the next management course for Sunday, October 26 as a full day course. Expect more exciting details to come out soon.

Subspecialty development - Drs. Resa Lewiss, John Kendall, Mike Roshon, Deepak Chadwani, Jerrica Chen, Sonali Ruder, Paul Sierzenski and I have been given assignments for research into this long-range topic of how to develop the subspecialty with many of the options available to us.

Military - Drs. Rob Blankenship, Rob Ferre, and Sam Mehta are members of this subcommittee on how the military is using and advancing emergency US in their practice.

International – Drs. Dan Price and Darryl Macius are members of this subcommittee on how emergency US is being used in international field work.

Pediatric - Drs. Jim Tsung and Jay Levy are members of the newest subcommittee, and are looking to liaison with the AAP and Pediatric section of ACEP

If any other section member would like to join any subcommittee or do anything creative, call or email me. Many hands make the work go faster.

2008 Emergency US Guidelines

As you know, we are planning to revise the 2001 Guidelines this year. I have been busy organizing subcommittees in the hope that they will create much of the substance to the Guidelines. We are looking at new ways of categorization while still having clarity to the outside world on what we do. We are definitely going to add applications to our core list. In addition, we hope to coordinate several EM initiatives, like the CORD conference, LLSA, etc in the guidelines. You can expect quality measures in the guidelines that may mesh with our goals like accreditation.

I encourage you to write to me regarding your desires and wishes for the 2008 guidelines.

Conversion of Abstracts to Published Manuscripts
I encourage everyone who has published abstracts in the last few years to take the time to get those abstracts turned into published manuscripts (I am one of worst offenders on this issue). There has been some fantastic scientific work done with emergency ultrasound, yet until the manuscript is published it is not acknowledged formally. It will help our cause, improve our image, and allow other researchers to build new projects on the legs of your work.

Upcoming Meetings
SAEM 2008 Annual Meeting (May/June 2008) – We will have a Section meeting after the SAEM US Interest Group meeting, but we are waiting for word on the day. I will work with Dr. Gaspari and Raio in regards to a social event or evening.

ACEP Scientific Assembly 2008 (Oct 2008) – We are already at work on the details for our section meeting. Due to the extensive work of our section, most of the meeting will be a working business meeting with lots of updates on what is going on with Emergency US. I hope to have one short didactic session as well. Obviously elections will be held, and we hope to resurrect awards. You definitely want to attend this Section meeting.

I look forward to your emails and communications. This is a great time for emergency ultrasound, and we want you and your energy in the Section.

 

 


 

 

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ACEP Ultrasound Section Industry Roundtable Subcommittee Update

Chris Moore, MD, RDMS, RDCS, FACEP

The Industry Roundtable is a subcommittee of the ACEP Ultrasound Section and seeks to improve the interface between emergency physicians and ultrasound manufacturers to better convey the needs we have, now and in the future, for equipment and services. In 2002, a letter to industry was drafted that detailed many of these needs. Much has changed since then—better images, improved reporting and image management options, more companies interested in the emergency medicine market. However, gaps still exist between what is possible and what is available.

Members of the committee this year include Peter G. Kumasaka, MD; Richard Limperos, MD; and James Q. Hwang, MD. At this point we are still in the process of redrafting this letter, which we intend to present to industry representatives before or at the ACEP Scientific Assembly meeting in Chicago this October. In particular, we are working to provide guidance on standardized reporting packages, image management systems and workflow solutions (both front and back end) that are increasingly available on dedicated emergency department systems.

We are investigating the possibility of broad industry sponsorship of the Emergency Ultrasound Management Course, to be held in Chicago, with improved opportunities for networking and dedicated time for focused discussion of equipment issues with key stakeholders. If you would like to be involved with this committee please email chris.moore@yale.edu.

 

 


 

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AIUM Update

Chris Moore, MD, RDMS, RDCS, FACEP

Thanks to all who attended the AIUM meeting in San Diego this March, especially to those dedicated few who were able to attend the World Congress (and even New Orleans) in the same month! It was a successful conference and marked the end of my tenure as AIUM section chair. A few parting words and a call to action as I leave…

I remember thinking how far away 2008 was when I accepted the position of Secretary of the Emergency Ultrasound Section at the American Institute of Ultrasound in Medicine (AIUM) meeting in Montreal in the spring of 2003. Now as I end my term as Chair of the Emergency and Critical Care Ultrasound Section, 2003 seems a long time ago. We have made progress with the AIUM, perhaps not as much as we, or they, would like, but progress nonetheless. We expanded the section to include critical care physicians and greatly expanded the course offerings from and for emergency physicians. Growth in membership has not been at the exponential rate the AIUM had hoped for but has been steady nonetheless. We have gotten to know who is who, how it works, and are more and more an expected presence at committee meetings. We have a member on the Board, David P. Bahner, MD, FACEP. After years of struggle we agreed on focused abdominal sonography for trauma (FAST) guidelines, with the not insignificant concession from AIUM that specialty specific guidelines for training are acceptable for this exam.

However, as we move forward we need to continue, and perhaps redouble, our efforts to stay involved with this organization. Why? On an individual level I continue to learn more at AIUM than any other meeting about ultrasound – its application, its history, and lessons from other specialties that have learned to use it. But in a larger sense the need for emergency physician involvement in what is the major U.S. multispecialty organization for ultrasound has never been more essential. Changes are brewing-- at the presidential level, within the economy, and within medical care and reimbursement. A multispecialty organization has a lot more legitimacy than a single specialty organization when questions of competency and quality of care (and their direct descendent, reimbursement), come to the forefront. No doubt ultrasound will live on in the ED to some extent whether it is reimbursed or not. But without appropriate reimbursement it will begin to whither in the community, and if reimbursement is cut off it will be like seeing a tree that is starting to bloom die back from the branches. Increasing our involvement with AIUM does not guarantee that this will not happen, but it improves our chances to be at the table if it does.

There are currently a bit over 70 emergency physicians out of 7,000 total members at AIUM, just over 1%. The bright side is that most of these emergency physicians are quite active in attending the meeting. But AIUM would like to see it closer to 700. This is a lot, since most emergency physicians at AIUM are pretty hardcore ultrasound fellows and their directors. Becoming more of a presence is feasible, but will take some effort. Resident membership is only $25 per year -- I would hope that anyone reading this far in the newsletter who is, or who knows, a resident could recruit a few, if not a lot. AIUM will be in New York next year, certainly now the epicenter for Emergency Ultrasound training, and I hope we can show them what a force we can be. I hope we can also reach out to our Critical Care colleagues to ally with us in this.

Thank you for your support over the last few years. Ultimately it is my hope that the ultrasound directors and fellows at both academic and community programs, emergency medicine residents with an interest in ultrasound, and the occasional community emergency physician who gets the ultrasound bug will join with the growing critical care ultrasound community to provide a more formidable force at AIUM, and to create an atmosphere for learning and an environment for collaboration as we face the tough political challenges ahead.

 


 

 

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A Primer on Credentialing, Certification and Accreditation with Implications for Emergency Ultrasound

Vivek S. Tayal, MD, FACEP
Chair, ACEP Section of Emergency Ultrasound

A common question that is raised in recent Section affairs is the following: What is the difference between Credentialing, Certification and Accreditation and how is the ACEP Section addressing these processes? As you read this article, realize that many members have special sensitivity regarding these issues, and we need to be tolerant and open to a discussion regarding these issues. Also I wish to acknowledge my adoption of some language from the American Institute of Ultrasound in Medicine (AIUM) Ultrasound Practice Forum in Baltimore, MD in 2007.

Credentialing
Credentialing is a process of a hospital or health care system granting a practitioner an ability to perform a certain procedure or act in a certain capacity. For ultrasound, this is the hospital granting privileges to an emergency physician to perform emergency ultrasound.

Based on the American Medical Association (AMA) 1999 House of Delegates resolution 802 which suggested that hospital credentialing committees use specialty-specific guidelines for the granting of privileges in ultrasound by different specialties, ACEP established specialty-specific guidelines to empower emergency physicians to perform emergency ultrasound.

  1. Advantages - Emergency physicians can gain education and training through residency or through appropriate hands-on introductory US courses with subsequent training exams to apply for hospital privileges. It does not require a separate certificate or merit badge, and does not require the whole department to be approved or accredited by a 3rd party. Ultrasound is treated like any other procedure for an emergency physician by delineation on a procedure list. The local politics that members go through to establish a program and obtain privileges establish a local standard of care that establishes buy-in from the hospital and medical staff.
  2. Disadvantage - The emergency department has to apply for privileges to allow their members to gain those ultrasound credentials. Each department has to fight a political battle, which can be ugly at times, to gain those credentials. Physicians may have to reapply when they move to different hospitals. There may be an uneven level of ability regarding competency with some skilled physicians and some with no ability yet.

Certification
Certification is a process of documenting that an individual has passed requirements including certain examinations including oral, written, or practical examinations. Certification is generally granted for a limited period of time and the certified individual must meet further requirements to retain certification. For example, ABEM or AOBEM, ARDMS, and NBE would be examples of certifying bodies that may produce certification.

  1. Advantage – Certification is specific to an individual, portable, and corresponds to the professional component of ultrasound, typically interpretation (though sonographer certification is about performance). It produces a uniform level of competence nationwide. Institutions can rely on the certifying body for competency review.
  2. Disadvantage -This makes ultrasound a separate procedure outside the envelope of the emergency medicine practice body of knowledge. All 30,000 emergency physicians will not be taking US certification tests outside of recertifying ABEM or ABOEM exam questions. Certification may slow or reduce the growth of the incorporation of emergency US into emergency practice. The RDMS certification process, though an enabling tool for gaining credibility, does not fit the paradigm and knowledge-base of emergency ultrasound. In addition, relying on sonographer or another specialty’s certifying bodies is a dangerous precedent for emergency medicine, that could expand to many other emergency medicine procedures. This process is costly and adds to the endless list of "stamps of approval" emergency physicians must satisfy.

Accreditation
Accreditation is the attestation by an outside agency that a practice, laboratory, department, organization or institution or has met certain standards. It looks at the practice in addition to the personnel and equipment. It is often touted by third parties like HMOs, payors, and quality organizations as necessary to ensure "quality." It is usually time limited and not portable to other related parts of the organization or where a certain physician may practice. It may correspond to the "technical component" of the ultrasound exam. It has may have implications for payment of ultrasound exams.

  1. Advantages -This evaluates the whole practice and assures a uniform level of practice among providing entities. The public can rely on this process for some basic level of quality and standards.
  2. Disadvantages -Emergency physician practice is not a "lab" or a "practice" per se outside the practice of emergency medicine. Hospital EDs already have to meet JCAHO standards. The fit for EM is very poor, as we are not a laboratory nor do we do ultrasound exams on elective outpatients. Emergency ultrasound does not fit into the model of sonographer/technical and physician/interpretation combo versus the bedside sonologist paradigm. In terms of growth of the use of ultrasound in emergency medicine, accreditation does not work well with a procedure in which physicians are ramping up over a period of years. Cost is also another impediment for the growth of emergency ultrasound. The associated accreditation costs for our practices based on the AIUM, ASE or ICL criteria are ridiculous, costing thousands of dollars, with probably minimal chance of successful accreditation.

So What?
Accreditation has been pushed by several payors, including United Healthcare and Medicare, as the way to limit the growth of imaging costs in the name of quality. This has rapidly been adopted by our erstwhile antagonists in organizations such as ACR and ASE, who believe this is a great way to cut out emerging specialties that will not participate in their designated structure.

Certification has not been pushed as vigorously, but with the growth of fellowships, many feel an US pathway that recognizes expertise in the field would be appropriate for growth and recognition of what seems to be an obvious subspecialty.

What is the ACEP Section doing about these processes?

Credentialing – ACEP will continue to use credentialing based on specialty-specific guidelines to empower all our emergency physicians to learn, use, and expand the use of ultrasound in their practice. We have produced guidelines in 2001, and will update them in 2008. We have Ultrasound Imaging Criteria that describe those examinations. This process has been successful in getting non-trained emergency physicians to some basic level, and works in the community and academic hospitals where many emergency physicians have to learn US outside of residency. And up to this point, residency training in emergency ultrasound has been uneven and variable, so credentialing has leveled the field at the local departmental level.

Certification – After many conversations I have had with many of you, I realized that this issue was going to be a significant long term issue that will confront both the experts in the field and the specialty of emergency medicine. Based on the philosophy that an open discussion is better than hidden discussions in back rooms, I decided to create a subcommittee of the Section to research the many options and models out there for subspecialty development or certification. In case you are unaware, there are many models that other specialties and subspecialties of emergency medicine have created including the ABEM sub-board Toxicology, an independent Board like Echocardiography, the ARDMS physician board-like Vascular, the Neurology model, the sonographer ARDMS model, the Ob/Gyn model, the Surgery verification model and others. Our use and knowledge model is fairly unique, though critical care and others may fit with us in the future. There is no pressing need for us to act this year, and accreditation is a much more imminent threat than the need to develop a plan for subspecialty development. Dr. Resa Lewiss chairs this subcommittee, and her subcommittee will present at the October US Section meeting a presentation of some of the options for the future.

Accreditation – The ACEP US section notes that our resolution regarding accreditation was passed by the ACEP council in 2007. We now have the responsibility back from ACEP to develop a plan to address accreditation. We have a subcommittee chaired by Dr. Jerry Chiricolo to address this issue:
Our plan so far:

  1. Develop a primer that can be given to payors, regulators, and legislators educating them about the field of emergency ultrasound, our guidelines, and our quality standards.
  2. Develop quality standards based on the preexisting guidelines and imaging criteria.
  3. Develop a possible fallback ACEP Emergency Ultrasound accreditation program.
  4. Liaison with other like-minded specialties for future joint programs.

I strongly believe that we in emergency ultrasound should take a path that is developed and regulated by our specialty. I have seen how other organizations and other specialties have tried to take advantage of us, and we can be assured of the same with ultrasound, to our detriment. I do encourage working cooperatively with other organizations, but not subscribing to their bureaucracy.

In emergency ultrasound, we are going to have to confront these issues and solve them to continue successfully implementing ultrasound into emergency practice. Understanding these definitions are critical to the choices we will have to make in the next few years, so please consider the issues, listen and research the options, and weigh-in with your opinions.

 


 

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WINFOCUS 4th World Congress on Ultrasound in Emergency and Critical Care Medicine

Resa E. Lewiss, MD

The 4th World Congress on Ultrasound in Emergency and Critical Care Medicine was held in Porto Alegre, Brazil from March 5-8, 2008.

WINFOCUS (World Interactive Network Focused on Critical Ultrasound) became a formal non-profit society in May 2007. In 2005, organizers for the first world congress, held in Milan lay the groundwork for the structure of an international critical ultrasound society to serve healthcare professionals managing critical patients or working in critical scenarios eg, pre-hospital, remote and limited resource areas, disaster and military arenas. Subsequent congresses [New York (2006) and Paris (2007)] highlighted critical ultrasound education, research and practical education for health care providers at all levels. WINFOCUS uniquely acts as an international society centralizing research and education on critical ultrasound.

Dr. Luca Neri an emergency surgeon and critical care specialist from Milan, Italy is the current president of WINFOCUS. Dr. Michael Blaivas, an emergency physician currently practicing in Georgia, is the incoming president for 2008-2009

Brazil was chosen as the first country in the developing world to hold the World Congress because it is a center of development of medical knowledge for Latin America. At once in need for improvement in basic healthcare, it is a key developing focus for scientific and technological development in many industries.

For 12 years, Porto Alegre has offered the first residency training in emergency medicine in Brazil, following the creation of SAMU (Serviço de Atendimenfo Móvel de Urgência) de Porto Alegre in collaboration with the French SAMU. This pre-hospital unit was the model for the development of the entire system in the country, which currently covers 926 cities and nearly 93 million people. Porto Alegre also hosted the First National Emergency Medicine Congress in September 2007.

Topics for the pre- congress courses in Brazil included: Introduction to Critical Ultrasound for Doctors, Introduction to Critical Ultrasound for Medical School, Introduction to Critical Ultrasound for Nurses/Paramedics, Introduction to Critical Ultrasound for Healthcare Managers

Experts from all over the world presented didactic lectures and hands-on education for basic and advanced level practitioners. Emphasis was placed on the utilization of point of care ultrasound on critical patients in critical environments, enhancing clinical decision making and problem solving in most triage, diagnosis, treatment and monitoring scenarios. Real-time simulation workshops demonstrated the effectiveness of the ultrasound- enhanced ABCDE management in trauma care and advanced cardio-respiratory life support situations. (See Neri L, Storti E, Lichtenstein D. Toward an ultrasound curriculum for critical care medicine. Crit Care Med. 2007 May;35(5 Suppl):S290-304.)

Particular focus was placed on "primary ultrasound". Primary ultrasound is intended to be a primary, sustainable, acceptable tool that is incorporated into the primary health care communities. Such scarce resource rural communities comprise two thirds of the current world population.

Planning for the 5th WINFOCUS world congress is under way for September 2009 in Sydney, Australia.

 


 

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AIUM 2008, San Diego 3/12-3/16/2008

David P. Bahner, MD, RDMS, FACEP

The AIUM has a storied history and yet the story has more chapters to be told in the near and distant future. Can emergency medicine become a force in this organization? Many believe so, as the passion of its practitioners is strong and will continue to grow as the message of focused bedside ultrasound gets across to more clinicians.

 

Medical Board Certification  Number   % of Total
Membership

 % of Physician
Membership

 OB/GYN  2137  29% 49%
 Diagnostic Radiology  1413  19%  33%
 MFM  909  12%  21%
 Other  201  3%  5%
 Internal Medicine 155   2%  4%
 Reproductive Endocrinology  153 2%  4%
 Nuclear Medicine  115  2%  3%
 Surgery  101  1%  2%
 Pediatric Radiology  84  1%  2%
 Emergency Medicine  78  1%  2%
 Critical Care Medicine  2  < 1%  < 1%


         
         
    

 

 

 

 

 

 

 

 

  • Total Membership in the AIUM as of December 31, 2007 = 7294 members
  • A total of 1216 new members in 2007 (17% of total membership)
  • A new benefit of membership is free online J Ultrasound Med CME beginning in 2008

        *Adapted and addended from AIUM Secretary Report submitted 2/26/2008*

Emergency Medicine Course offerings and activities at the AIUM 2008

Preconvention Course: Bedside US in the Critically Ill and Injured Patient 3/12/2008
AIUM Emergency and Critical Care Section Meeting 3/12/2008
Hands on Course: Procedural US in the Critically Ill and Injured Patient 3/13/2008
Meet the Professor: TEE and TTE use in Resuscitation-Mike Blaivas MD 3/13/2008
Categorical Course: Topics in Emergency and Critical Care US Part 1. 3/14/2008
Meet the Professor: Lung US in Critically Ill Patients-Dan Lichtenstein 3/15/2008
Categorical Course: Topics in Emergency and Critical Care US Part 2. 3/15/2008
Just Images: Emergency and Critical Care Ultrasound 3/15/2008
Scientific Sessions: Emergency Ultrasound 3/15/2008

Additionally there were committee meetings where emergency medicine was represented on the Clinical Standards Committee, Membership Committee, CME Committee and notably the Board of Governors among others. The AIUM has made significant strides to incorporate emergency ultrasound into its Annual convention and this was the most conspicuous presence of EM at the AIUM witnessed in the last 7 years.

 

 


 

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More Storms on the Horizon: The FAST Cochrane Review

Lawrence A. Melniker, MD, MS, FACEP

In 2005, the Cochrane Database of Systematic Reviews published a manuscript critical of the use of the FAST exam. The review was updated in the fall of 2007. The reference remains: Stengl D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Review. In the original review, the stated objective was the assessment of the "efficiency and effectiveness" of ultrasound-inclusive evaluative algorithms in patients with suspected blunt abdominal trauma (BAT). In the 4 trials with 1037 patients reviewed, the primary outcome measures explored were mortality, CT, and DPL use, and laparotomy rates. Little or no benefit was seen and the conclusion was that "there is insufficient evidence from randomized controlled trials to justify promotion" of FAST in patients with BAT.

The Section leadership recognized in 2005 that while the review used rigorous methods, it appeared that one or more serious flaws plagued the first manuscript and, regrettably, still infect the update. First, basic power calculations suggest that reliability measuring a mortality difference would require several thousand patients rendering the first outcome measure inappropriate given the sample size. Second, published literature (Arrillaga, Boulanger, Rose and the SOAP-1 trial included in the update) had shown significant reductions in CT and DPL use, when FAST is used. Finally, finding no difference in laparotomy rates in study and control patients in an RCT (Boulanger, Rose and SOAP-1) means the assignment groups were well matched – strength of these studies.

The authors of the Cochrane Review were contacted and invited at our expense to debate this matter at the 2nd World Congress on Ultrasound in Emergency and Critical Care Medicine, June 11-14 in New York City. Dr. Stengel and 2 co-authors came to WCU-2 and were debated during the Opening Session by Drs. Dulchavshy, Kirkpatrick and myself. The discussions were robust and there was considerable parrying back and forth. Finally, Dr. Stengel recommended further research and exploration of developing an International FAST Registry, while we recommenced expanding the FAST inputs to the National Trauma Data Bank of the American College of Surgeons. Also discussed were:

A post-hoc analysis of the SOAP-1 trial, of the 69 study arm patients with blunt torso trauma, the FAST using a hemoperitoneum score (developed and validated by McKenney et al, at the University of Miami’s Ryder Trauma Center) correctly identified all patients needing OR and cleared all patients not requiring OR. Of interest, there were no nontherapeutic laparotomies and Ct identified no other patients with intra-abdominal injuries requiring operative intervention.

A literature review using the same Cochrane methodologies. Out of 114 articles screened, five contained prospectively derived data with FAST results, each patient’s disposition and final diagnoses, and a description of all cases considered false negatives or false positives. Of the 1550 patients, 295 (19%) went to the OR. There were a total of 3 legitimately bad calls made based on the FAST, all involving inadequate scans.

Conclusion: The FAST exam with a valid hemoperitoneum score is a nearly perfect test for predicting a need for operative intervention in patients with suspected BAT. Sadly, the Cochrane Update corrected none of the deficiencies of the first review and, in fact, compounded them with new errors and misrepresentations. Mortality remained the primary outcome variable, included incorrect mortality figures from SOAP-1, and remained completely useless. Use of CT and DPL analyses excluded SOAP-1 or any other new data and again concluded no reduction in use of other tests.

Analysis of reduction in diagnostic time did not include SOAP-1 data, our primary outcome variable, and again concluded no benefit.

Analysis of critical care unit use, total hospital length-of-stay, and cost-effectiveness excluded SOAP-1 or any other new data and again concluded no benefit.

Finally, the update stated that attempts to contact SOAP-1 investigators were unsuccessful, without mention of our face-to-face meetings in New York City. We will report on future communications with Dr. Stengel, et al. and the Cochrane Library.

 

 


 

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Emergency Medicine Graduate Competency -- It’s not just a Numbers Game anymore

Daniel Theodoro, MD, RDMS

In response to objections from several leaders in the Emergency Ultrasound (EMUS) community, the Residency Review Committee (RRC) agreed to eliminate language requiring exposure to a minimum of 40 ultrasounds during residency. In its place, the RRC requires program directors to develop a method to demonstrate competency of ultrasound skills, track whether residents meet educational objectives, and address gaps in proficiency. The requirement departs from what most graduates experienced during their residency training. In general, the Council of Emergency Medicine Residency Directors (CORD) prefers to move away from using numbers for proactive, "assessment driven" methods of asserting competency of Emergency Medicine skills (ask your local academic ED attending about "SDOTS" for more on that subject). For the ultrasound community, it means there is an opening to set standards and assist in guiding EMUS education into the future.

In response to the new RRC recommendations, CORD set aside time at their annual academic assembly to discuss resident ultrasound education. The consensus conference had three objectives: define the ultrasound curriculum, recommend methods to implement an emergency medicine ultrasound program during residency, and finally, develop mechanisms to test competency. Several leaders of the emergency medicine ultrasound community descended on New Orleans to openly discuss and develop a document with the hope that residencies adopt the recommendations. The document is undergoing final revisions so the purpose of this report is to provide a brief summary of the issues discussed.

The number of EMUS applications continues to grow. However, most experts agreed that mandatory competency among a few applications demanded special attention. The group agreed that FAST, cardiac, aorta, transabdominal and transvaginal applications pertaining to women’s health issues and procedural ultrasound topped the list. All agreed residencies should guarantee competency in a core ultrasound skill set that contributes significantly in critical, life-threatening scenarios emergency physicians encounter in everyday practice.

Creating and implementing an ultrasound program in every Emergency Medicine residency is crucial for disseminating the core skill set. Numerous educational demands during residency complicate a "one size fits all" approach. Currently there is great variability among the programs. Nonetheless, attendees felt that residencies should devote block hours specifically to ultrasound. Perhaps most controversial, experts felt that residencies should require 50% of core faculty to demonstrate competency in the near future. The "competent core" would ensure timely resident feedback, expose residents to at least 150 ultrasounds in core applications, and work towards standardizing a national curriculum across residency programs. See the finished product for all the fine details!

Numerous practitioners in both academic and community environments conveyed concern regarding the competency of recent graduates. The complex nature of ultrasound technical, interpretive, and integrative skills require numerous tools to gauge the level of proficiency. Most experts felt that a practical exam focusing on technical aspects of core applications as well as standardized exams focusing on image interpretation should be developed to both guide ultrasound programs and assess the level of competency among residents. New employers could count on assessments at the end of residency that convey the graduate’s level of performance upon graduation.

In general the meeting moved forward on many ideas and allowed current experts to make recommendations in the form of a "white paper." It is important to note for both educators and future employers that these recommendations will not populate the already exhaustive requirements the RRC places upon residency programs. The goal is to provide a "tool kit" for programs implement at their institution. Our expectation is that residency programs migrate towards these recommendations over time and passively make these recommendations the standard of ultrasound education across the country. If you would like to comment on or stay tuned to the developments leading up to the final drafts of recommendations, please find them at http://groups.google.com/group/emusconsensus.

 

 


 

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Case Report

Turandot Saul, MD

A 72 year old male presented to the Emergency Department with lower abdominal pain and inability to urinate for 12 hours. He had also noticed a foul smell to his urine and watery diarrhea for several weeks. His past medical history was significant for prostate cancer for which he had had radioactive seed implantation 3 years prior to presentation. His vital signs were stable and he was afebrile. His physical examination was remarkable for mild suprapubic tenderness, lower abdominal distension and leakage of fluid from the anus during rectal examination. A low frequency curvilinear probe was utilized to examine the kidneys and bladder.

0408TurandotCaseStudyFig1
Image1 – Right kidney

 

 

 

 

 

 

 

 


Longitudinal view. The hypoechoic or dark area centrally represents a collection of fluid in the renal pelvis. This suggests mild hydronephrosis.

 

0408TurandotCaseStudyFig2

Image 2 – Left kidney

 

 

 

 

 

 

 

 

 

 

Longitudinal view. Mild hydronephrosis of the left kidney is similarly appreciated. Bilateral hydronephrosis is suggestive of obstruction distal to the ureters.

 

0408TurandotCaseStudyFig3
Image 3 – Bladder

 

 

 

 

 

 

 

 

 



Sagittal image of the bladder with an adjacent hypoechoic fluid filled viscous consistent with the rectum. The fluid filled areas are connected by a rectovesical fistula.

Diagnosis: Rectovesical Fistula

Passage of a Foley catheter returned feculent urine.  The patient was started on broad-spectrum antibiotics and the Urological service was consulted for further evaluation and management.

Rectovesical fistulas are a rare clinical entity. They can occur as a complication of inflammatory bowel disease or perirectal abscesses, but they most frequently occur as complications of prostate cancer or iatrogenically during transurethral resection of the prostate and other ablative procedures.1 Symptoms can include recurrent urinary tract infections, watery diarrhea, pneumaturia or fecaluria.2 The diagnosis can be confirmed by a voiding urethrogram, CT scan or cystoscopy. Management varies patient to patient. Conservative management includes urinary diversion and antibiotics with varying success rates from 25-50%.1 If the fistula does not close after 3-6 months it is unlikely that it will and the patient may undergo fistulectomy. This is a challenging surgical procedure that can fail if the fistula is large, or if it is in an area that has been previously irradiated.3

References:

  1. Sotelo R, Mirandolino M, Trujillo G, et al. Laparoscopic repair of rectourethral fistulas after prostate surgery. Urology. 2007; 70(3):515-518.
  2. Wein AJ, Kavoussi LR, Novick AC, et al eds. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders-Elsevier; 2007.
  3. Gozen AS, Teber D, Moazin M, et al. Laparoscopic transvesical urethrorectal fistula repair: A new technique. Urology. 2006; 67(4):833-836.

 

 


 

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Journal Watch – April 2008

Various Authors

Reviewer: Gillian Baty, MD, MPH

Soldati G, Testa A, Sher S, et al. Occult Traumatic Pneumothorax: Diagnostic Accuracy of Lung Ultrasonography in the Emergency Department.Chest. 2008; 133:204-211.

Methods: This was a prospective, observational study of consecutive conscious, spontaneously breathing adult patients with blunt chest or multiple trauma at two hospitals in Italy over a 17-month study period. Exclusion criteria included need for immediate chest decompression, hemodynamic instability, subcutaneous emphysema, chest injuries incompatible with ultrasound, or inability to consent. Two ultrasound-experienced emergency physicians scanned patients using a protocol that included multiple views of the bilateral chest with convex probes. They determined absence of "sliding lung" sign or "comet tail" artifacts or presence of "lung points" as evidence of pneumothorax and made an estimate as to extent. All enrolled patients received supine antero-posterior chest radiography (CXR), bedside ultrasound (US), and spiral computed tomography of the chest (CT). One of several radiologists reviewed the CXR for presence of PTX, and CT for extent, using the following categories: a) <1 cm, b) >1 cm isolated anteriorly, and c) large enough to extend laterally past the coronal plane. CT was used as the gold standard.

Results: There were 109 patients enrolled: 65 isolated chest trauma and 44 multiple trauma. 23 patients had a CT diagnosis of traumatic PTX, including 2 bilateral (25 total PTXs). CXR revealed 13 (52%), 12 were radiooccult. Of the radiooccult, 5 were judged miniscule by CT. US detected 23 of 25 PTXs and had one false positive. The 2 false negatives were both miniscule and in the left paracardiac region. US had a sensitivity of 92%, specificity of 99.4%, PPV 95.8% NPV 98.9%, and accuracy of 98.6%. In comparison, CXR had a sensitivity of 52% and specificity of 100%. US was able to delineate the lateral limit within approximately 2 cm. All radiooccult PTXs were either miniscule or anterior and US identified 10 of these (83%). Mean time for US evaluation was <3 minutes per side.

Discussion: The role of ultrasound in detecting pneumothorax has been well-established in multi-disciplinary literature. Few studies have characterized the diagnostic accuracy in radiooccult pneumothoraces and in determining their extent. In the supine trauma patient, air in the pleural space tends to collect in the paracardiac and anterior costodiaphragmatic recesses. Although CXR is performed routinely in the initial evaluation of a trauma patient, and is often the basis for chest decompression prior to CT scan, it is insensitive for pneumothoraces. Some pneumothoraces, even radiooccult ones, can progress to tension pneumothorax prior to CT interpretation, particularly if positive-pressure ventilation (PPV) is used. Early diagnosis may decrease morbidity and mortality associated with less-controlled chest-tube placement and need for chest decompression prior to PPV. US also offers a potential study for following the evolution of a pneumothorax without incurring more ionizing radiation load. This prospective study provides good evidence that in experienced hands, lung US may approach CT for diagnostic accuracy in pneumothorax.

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Reviewer: Keith S. Boniface, MD

Nomura JT, Leech SJ, Shenbagamurthi S, et al. A Randomized Controlled Trial of Ultrasound-Assisted Lumbar Puncture. J Ultrasound Med. 2007; 26:1341-1348.

Methods: This study was a prospective, randomized, double blinded study assessing the utility of ultrasound in lumbar puncture. A convenience sample of adults was enrolled. An elegant method of marking best site for puncture by both ultrasound landmark (UL) and palpation landmark (PL) was created utilizing a marker whose mark was only visible using an ultraviolet light; a unique symbol was utilized for marking both UL and PL on patients. PL was marked by the person performing the LP, using the standard external landmarks. UL was marked by a blinded investigator by first locating midline in transverse plane with a linear probe (lower frequency curved array in obese patients), then rotating to sagittal plane, and finally by marking the interspinous space. A blinded investigator used a visible marker to mark the site (either UL or PL) selected by randomization, and LP then proceeded through the marked location. The patient’s height and weight, length of procedure, # of attempts, ultimate success or failure of procedure, presence of traumatic tap (>400 RBCs in tube 1), ease of procedure on a visual analog scale (VAS), and patient comfort on VAS were recorded.

Results: 46 patients were enrolled over a 1 year period: 22 randomized to PL and 24 to UL. UL was significantly more successful, with a relative risk of success of 1.32 (1.01-1.72). UL was unsuccessful in 1/24 patients, and PL was unsuccessful in 6/22 patients. No significant difference was found in length of procedure, # of attempts, likelihood of traumatic tap, ease of procedure, or patient discomfort. In patients with BMI > 30, UL had a relative risk of success of 2.33 compared with PL with the confidence intervals crossing one (0.99-5.49), showing a trend toward increasing success with UL in obese patients.

Discussion: Lumbar puncture is a procedure that can be incredibly frustrating (for all involved) when it does not go well. Given the increasing prevalence of obesity, the traditional palpation technique for finding landmarks has become more difficult. This nicely designed study demonstrates that a static, external marking technique utilizing ultrasound can improve the likelihood of a successful LP. The chance of success with UL was 2.33 times that of PL, although the study was limited by the small number of obese patients enrolled, and as a result was underpowered to demonstrate a statistically significant improvement in the success of the procedure using UL. This study adds to a growing body of literature supporting the use of this easy to learn ultrasound localization technique as an adjunct to the performance of lumbar puncture.

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Reviewer: Mary Ann Edens, MD, FACEP

Kurtz A. Mirror image artifact mimicking a carotid artery dissection. JDMS. 2008; 24:26-29.

Case Report: A man in his mid-70’s was referred for sonography of his carotid arteries after experiencing right-sided numbness and weakness. On ultrasound, intraluminal echogenic linear echoes were visualized in both the transverse and longitudinal planes. The patient was referred on for carotid artery dissection despite having an MRA from 2 days prior to the sonogram that was negative. On further review of the studies, what was originally thought to be a dissection was actually a mirror image artifact of the IJV wall.

Comment: This case reinforces the importance of considering the possibility of a sonographic artifact when encountering something unexpected on an image. Mirror image artifacts are created because the ultrasound machine assumes that the sound beams are sent out and then return by the same path when actually the beams encounter the object at an angle other than 90 degrees and because of reflection actually take longer to return to the transducer. The machine then interprets the structure to be deeper than it actually is. This artifact can be eliminated by reducing the power, changing the color gain or changing the angle of insonation. Importantly in the above case, the artifact could also be eliminated by manually compressing the IJV while performing the scan. This would eliminate the linear echoes that were the source of the artifact.

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Reviewer: Roxana Yoonessi, MD, JD
Faculty Mentor: Tim Jang, MD

Fox JC, Hunt MJ, Zlidenny AM, et al. A retrospective analysis of emergency department ultrasound for acute appendicitis.West J Emerg Med. 2007; 8(2): article 2.


Objective: To determine whether emergency physicians already skilled in other areas of ultrasound could identify appendicitis by bedside ultrasonography.

Methods: This was a retrospective registry-based cohort study. This study evaluated bedside ultrasounds of the right lower quadrant performed by experienced emergency physician ultrasonographers, defined as those trained in basic areas of ultrasonography, including biliary tree, aorta, kidney, and others. Experience varied from residents having performed 50 scans to registered ultrasound practitioners. No clinical decisions were based on the ultrasounds. No specialized instruction on right lower quadrant ultrasound was given. Confirmatory testing was required for inclusion in the form of either (1) radiology performed right lower quadrant ultrasound, (2) CT scan with PO and IV contrast, or (3) surgical pathology report. ED ultrasound was performed prior to other radiologic testing. The sole diagnostic criterion for appendicitis on ED ultrasound was a noncompressible RLQ structure at least 6 mm in length. ED ultrasound was performed using graded progression and a 5-7 MHz linear probe.

Results: Emergency physicians performed 155 RLQ ultrasounds that qualified for data analysis. Ultrasounds were performed on 91 adults, 64 children, 70 males, and 85 females. Prevalence of appendicitis was 45%.  In 27/155 cases, the ED ultrasound yielded a true positive, for a sensitivity of 39% (95% CI 28-52%), based on comparison with surgical pathology. There was a true negative result in 77/155 cases for a specificity of 90% (95% CI 81-95%), based on comparison with radiology ultrasound or CT. False positive results occurred in 9 (6%) of cases, based on comparison with CT scan and surgical consult. Accuracy of ED ultrasound was 66% (95% CI 59-74%). Positive predictive value was 75% (95% CI 57-87%) and negative predictive value was 65% (95% CI 55-73%).

Discussion: Acute appendicitis is a common diagnosis in the emergency department. Increased morbidity and mortality is associated with perforation of the appendix, which is, in turn, related to waiting times to diagnosis. Early diagnosis is desirable in this condition. This study appears to suggest that bedside ultrasound does not add meaningfully to ED evaluation of acute appendicitis. However, interpretation of these results is limited by the small number of enrolled patients and high interoperator variability among the physicians performing bedside ultrasound. One earlier study examined training emergency physicians in GI ultrasound and evaluated their accuracy in appendicitis exams. That study yielded a sensitivity of 96.4% and a specificity of 67.6%, with a 72% prevalence of appendicitis. Given the high prevalence and extensive training, these numbers likely represent a maximum in terms of accuracy of ED ultrasound examinations for appendicitis. The current study likely represents a more reliable assessment of accuracy of ED ultrasound for appendicitis, suggesting that it is much more complex and difficult than other exams such as the FAST exam. Limitations included lack of blinding to patients’ clinical presentation, marked interoperator variability, and use of only one criterion to establish a positive result for appendicitis on ED ultrasound. The study could be improved by enrolling more patients, evaluating data by operator characteristics, and evaluation of characteristics that contributed to greater accuracy in evaluation. A prospective study to examine whether a feasible regimen of emergency physician training could yield sufficient accuracy in RLQ ultrasound for diagnosis of acute appendicitis is currently underway.

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Reviewer: Jehangir Meer, MD, FACEP

Shiver SA, Blaivas M. Acute lower extremity pain in an adult patient secondary to bilateral popliteal cysts.J Emerg Med. 2008; 34 (3):315–318.

Case Report: A 24 year old female presented with bilateral lower extremity pain for one week, described by the patient as dull and intermittent. There was no history of trauma or fever. On physical exam she appeared well and in no distress, with normal vital signs. She had good distal pulses in her legs and no clinical evidence of joint effusion or erythema. She had mild fullness noted in the left popliteal fossa. An ED bedside ultrasound was performed which was negative for DVT but showed bilateral popliteal (Baker’s) cysts without rupture.

Comments: This case demonstrates ED ultrasound diagnosis of bilateral popliteal cysts, which are much rarer than the unilateral cysts usually seen. As emergency physicians perform more lower extremity studies to rule out DVT, they will not infrequently find other pathology, such as popliteal cysts. This case demonstrates a rare finding of bilateral popliteal cysts, and allowed the patient a quick and safe disposition after lower extremity DVT was ruled out.

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Reviewer: Carlos E. Cao, MD, MPH

Fox JC, Cusick S, Scruggs W, et. al. Educational assessment of medical student rotation in emergency ultrasound.West J Emerg Med. 2007;8(3): 84-87.

Introduction: The authors of this study set out to see if medical students could learn and retain ultrasound skills in a two or four-week elective.

Methods: This was a prospective study. Over a 19-month period, 45 medical students taking the UC Irvine ultrasound elective were enrolled to take the same blinded (to scores and answers) 35-question exam on the first and final days of their rotation covering the primary applications of emergency ultrasound. The same blinded test was mailed out six months later to retest the students and was completed by 34 students. Lastly, a control group of 9 students who did not take the elective took the same exam two times, 4 weeks apart.

Results: Forty-five students were enrolled (25 on two-week electives and 20 on four-week). There was found to be no statistical difference in pre-elective test scores (p=0.688). Both the two-week students (72% vs. 46%, p<0.005) and the four-week (81% vs. 47%, p<0.005) post-test scores improved after the elective. As expected the four-week post-test score was significantly better than the two-week (81% vs. 72%, p=003). When comparing the six-month follow-up scores, there was improvement of both groups, two-week (69%), four-week (77%) for p<0.0005. There was also an improvement when comparing the six-month follow-up scores of four week group to 2-week group (77% vs. 69%, p=0.008). There was no statistical improvement in the control group.

Discussion: This study does have significant limitations noted by the authors: more motivated students taking the four-week elective and actually completing the six-month follow-up exam, not testing for ability to acquire accurate images (often the most difficult part), and performing the study at one site. However, this study does demonstrate an ability of medical students to improve and retain information from a short two to four-week elective. More importantly this study poses the possibility of relatively short, focused training being effective in training current Emergency Physicians (who were not ultrasound trained) already in practice.

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Reviewer: Amy M. Caron, MD

Friese RS, Malekzadeh S, Shafi S, et al. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture.J Trauma. 2007; 63(1):97-102.

Methods: This was a retrospective study intended to determine the sensitivity and specificity of FAST for the detection of hemoperitoneum in adult trauma patients with pelvic fractures who were considered high-risk for hemorrhage. All patients had at least one of the following risk factors for hemorrhage: age 55 years or greater, systolic blood pressure 100 mmHg or less, or an unstable pelvic fracture pattern. Relevant cases at a Level I trauma center from November 2003 to February 2005 were included. All patients had a FAST exam performed by a PGY-3 resident (who had been trained and tested in FAST, and was supervised by an attending physician). After FAST was performed, included cases had a follow-up abdominopelvic CT or laparotomy used as the "gold standard" to confirm or exclude the presence of hemoperitoneum.

Results: The study group consisted of 96 patients; FAST exam was positive for 13 of these patients (14%). Thirty-one (32%) patients had a false-negative FAST, with hemoperitoneum found either on CT or at laparotomy. Sensitivity of FAST for hemoperitoneum was 26%, and specificity was 96%.

Discussion: This retrospective study adds to previous data (Ballard et al, J Am Coll Surg. 1999;189:145–150), supporting the idea that FAST can be unreliable in diagnosis of hemoperitoneum in patients with pelvic fractures. The study goes beyond previous work to suggest that FAST is poor even in patients at high-risk for hemorrhage. One limitation of this study is that time between FAST and CT is not taken into account in the analysis; there may have been significant expansion of hemoperitoneum during this period. Other limitations include using residents in training to perform FAST exams, and the relatively small sample size. Additionally, the clinical relevance is questionable given that an unstable patient with a pelvic fracture is likely to have an extraperitoneal bleed related to the fracture (rather than a hemoperitoneum). The study makes a convincing case to obtain additional imaging in FAST-negative patients with pelvic fractures, but the idea needs to be expanded further by performing a larger prospective study.

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Reviewer: Edidiong N. Ikpe, MD, MPH and Timothy Jang, MD (Faculty Mentor)

Scruggs W, Fox JC, Potts B, et al. Accuracy of ED bedside ultrasound for identification of gallstones: Retrospective analysis of 575 studies.West J Emerg Med. 2008; 9(1):1-5.

Introduction: This study examines the accuracy of bedside ultrasound in predicting gallstones when performed and interpreted by emergency physicians (EPs) in the emergency department (ED).

Methods: This was a retrospective observational study. The investigators reviewed emergency department right upper quadrant (RUQ) ultrasounds performed by EPs over a 3 year period. The ultrasounds were performed by EPs of varying levels of clinical experience, including emergency physicians-in-training. There were also variable levels of ultrasound expertise among the EPs, from ultrasound-certified physicians to those with very limited ultrasound experience. Of the 2,321 RUQ ultrasounds recorded, they excluded all cases lacking valid patient identification, adequate images, documented bedside interpretation or video recording. Of the 1,690 remaining cases, they analyzed only those which also had ultrasounds performed and interpreted by radiology. Using the radiology read as the gold standard for detecting cholelithiasis, the sensitivity and specificity of ED bedside interpretation were determined as were the positive and negative predictive values of ED ultrasound.

Results: 2,321 gallbladder ultrasounds were conducted by EPs during the study period. 631 (27%) of the scans were excluded based on the aforementioned exclusion criteria, mostly for lack of video recording (n=272, 12%) or for poor image quality (n=219, 9%). Of the remaining 1,690 scans, only 575 (34%) had radiology ultrasounds and were, therefore, included in the analysis. EPs diagnosed gallstones in 332 of the 575 patients (57.7%) while radiologists diagnosed gallstones in 344 of the patients (60%). ED bedside interpretation was 88% sensitive and 89% specific. The positive predictive value of ED ultrasound for cholelithiasis was 91% and negative predictive value was 83%.144 out of 2,321 (6%) of bedside ultrasound examinations were deemed inadequate for interpretation by EPs versus only 8/575 (1.4%) for radiologists.

Discussion: The ability to accurately identify gallstones is an essential skill. As the authors elucidate, millions of patients present annually to US with gallstones. With gallstones presenting in approximately 95% of cases of acute cholecystitis, identifying gallstones with a non-invasive, quick and relatively inexpensive test would be ideal. This study demonstrates that EPs of varying levels of ultrasound experience may be able to accurately perform scans which depict gallstones and actually identify these scans as positive for gallstones in their interpretations. The study distinguishes itself from similar studies by its larger sample size. It uses physicians in all levels of training and still demonstrates high levels of sensitivity and specificity, supporting the accuracy of ED RUQ ultrasound even in training programs. While the study is promising, there are a few limitations to consider. First, there is potential for selection bias as there is no way to discern why certain patients were sent for radiology ultrasound while others were not. Additionally, the chronology of the ultrasounds is unclear, specifically the question of whether certain ED ultrasounds were performed and interpreted before or after the radiology read. While the varying levels of experience attest to the facility of ED ultrasound, it is important to know if there was any correlation of ultrasound experience with the findings, perhaps a sub-analysis to the discern whether more experience engendered better sensitivity and specificity. Furthermore, while detection of gallstones is significant, ultimately it is the identification of cholecystitis which would warrant prompt surgical evaluation. This study does not support or investigate the ability of ED physicians to detect cholecystitis. Therefore, even if EPs can identify gallstones, a vast majority of patients will still need repeat scans if there is any suspicion of infection, regardless of the EP interpretation. Finally, it is notable that almost 10% of studies were inadequate.

Implications: In general, this study adds to the existing body of ED ultrasound literature. With further investigation, perhaps even including studies which attempt to detect cholecystitis, ED RUQ ultrasound may ultimately reach a point where it matches the gold standard, facilitating prompt disposition and improving patient care.

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Reviewer: Andrew Liteplo, MD, RDMS

Tayal VS, Bullard M, Swanson DR, et al. ED endovaginal pelvic ultrasound in nonpregnant women with right lower quadrant pain. Am J Emerg Med. 2008; 26:81-85.

Objective: To evaluate the effect of emergency physician-performed endovaginal ultrasound (EVUS) on diagnostic decision making in non-pregnant women with right lower quadrant (RLQ) pain.

Methods: This was a prospective, interventional convenience sample of non-pregnant women with significant RLQ pain in whom both appendicitis and adnexal pathology were strongly considered. Exclusion criteria were age younger than 17, hemodynamic instability, a clear identifiable diagnosis, pregnancy, recent gynecologic or abdominal surgery (within 2 weeks), or a history or appendectomy or right salpingectomy or oophorectomy. A group of 5 clinicians (emergency physicians and physician assistants) who were already familiar with pelvic ultrasound received additional training, specifically on measurement of pelvic organs. A 5-8 MHz endovaginal probe was used. Physicians were asked pre and post EVUS about their probability of disease, consultation, differential diagnoses, and management. An EVUS was considered abnormal if there was a large cystic structure >4 cm, multitissue dense structure, tubal dilation, uterine enlargement or mass, or peritoneal fluid past the uterine body.

Results: Forty patients were enrolled in the study. Ovaries were statistically significantly larger in patients with a positive ED EVUS.Patients with a positive ED EVUS (12) had a mean decrease in the probability of medical (20%) and surgical (14%) disease, and an increase in the likelihood of gynecologic disease (24%). With a negative ED EVUS (28), there was an increase in the likelihood of surgical disease (5%) and a decrease in the likelihood of gynecologic (19%) and medical (3%) disease. There was minimal change in consultation and management. 75 % of patients received CT scans.

Discussion: This study evaluates the effect of ED EVUS on patient diagnosis and management. Not surprisingly, the authors discovered that physicians’ suspicions for a gynecologic etiology of pain are increased when the pelvic US is positive, and decreased when negative. There was minimal effect on consultation and further imaging--the authors attribute this to a shift in practice patterns to an era when "CT of the abdomen and pelvis became more popular and routine, almost replacing both gynecologic and surgical consultation." They also mention that while many physicians "considered the ED EVUS useful, it could not eliminate the use of CT to identify appendicitis." The study is limited by its lack of randomization and sample size. Generalizability may also be an issue, as the physician-sonographers were already experienced with pelvic sonography before receiving additional training for the study. The authors conclude that the limitations "preclude any definite recommendation of the use of pelvic ultrasound." However, the study does demonstrate that ED EVUS changes physician diagnostic decision making in non-pregnant women with RLQ pain. Even if this study was not powered to show a difference in management, ED EVUS is still a valuable non-radiating tool and can provide complementary information to the physical exam.

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Reviewers: Michael Woo, MD and Amy Caron, MD

Yanagawa Y, Sakamoto T, Okada Y. Hypovolemic shock evaluated by sonographic measurement of the inferior vena cava during resuscitation in trauma patients.J Trauma. 2007;63:1245-1248.

Methods: This was a prospective study to determine any correlation between IVC diameter and adequate fluid resuscitation in trauma patients with shock. The study took place at a Level 1 trauma center in Japan between June 2004 and May 2006. Patients were included if systolic blood pressure was less than 90 mmHg and presented during the day. Patients were excluded if blood pressure did not respond to fluid resuscitation. All patients presented within 2 hours of injury and received no fluid resuscitation or analgesics during this period. The IVC was measured just below the diaphragm in the hepatic segment in the expiratory phase on presentation and again once the blood pressure normalized after fluid resuscitation.

Results: 30 patients were enrolled and divided into a transient responder group (n=17) defined as having a second episode of shock after leaving the emergency room and a responder group (n=13) in which the blood pressure remained stable. There were no differences between these groups with respect to systolic blood pressure, heart rate, base excess and hemoglobin. On initial arrival there was no difference in IVC diameter between the two groups (6.1 ± 0.6 mm and 6.9 ± 0.7 mm, respectively). After resuscitation there was a significant difference (p<0.01) in the IVC diameter between the transient responders (6.5 ± 0.5 mm) and the responders (10.7 ± 0.7 mm). There was also a significant difference (p<0.05) in the change in IVC diameter after fluid resuscitation between the transient responders (?0.4 ± 0.6 mm) and the responders (?3.1 ± 0.5 mm). Survival rate was higher in the responder group (100%) vs. the transient responder group (70%, p<0.05). 14 patients from both groups had abdominal CT and results of IVC measurement with CT vs. ultrasound were compared with a correlation coefficient of 0.703 (p<0.01).

Discussion: This study builds upon the existing literature of using the IVC diameter as a marker of hypovolemia in trauma patients. What is unique about this study is using the IVC diameter as a marker of adequacy of resuscitation in the trauma patient. Limitations include the small sample size, lack of information regarding the duration of resuscitation, or the use of any medications which may have affected blood pressure. This study suggests that a small IVC diameter after fluid resuscitation indicates inadequate fluid resuscitation and may be more sensitive than blood pressure. If reproduced in a larger trial, sonographic measurement of IVC diameter will be very helpful in determining the need for ongoing resuscitation of the trauma patient.

 

 


 

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