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Emergency Ultrasound Section Newsletter - November 2009, Vol 14, #1

Emergency Ultrasound Section

circle_arrow From the Chair
circle_arrow 2008-2009: The Year in Review
circle_arrow Journal Watch
circle_arrow Emergency Ultrasound Management Course 2010
circle_arrow The 2009 - 2010 Section Grant Cycle Began November 9
circle_arrow Emergency Ultrasound Award presented to Dr. Patrick S. Hunt
circle_arrow Updating Preceptorships
circle_arrow EUS Applications Explode! Or Is It a Dud?
circle_arrow SonoSite Introduces SonoAccess: An Innovation in the Delivery of Ultrasound Education
circle_arrow "Hennepin County Medical Center, Palmetto Health, and Ultrasonix Medical Corp. to present preliminary results of Emergency Ultrasound workflow and data management study at ACEP assembly in Boston"
circle_arrow Annual Meeting Minutes


Newsletter Index


Emergency Ultrasound Section

 

 

From the Chair

Gerardo Chiricolo, MD, FACEP, RDMS

It was great seeing so many of you at the Scientific Assembly in Boston.  I am excited about the upcoming year and believe we can make a big impact for our specialty.  As my first message to the section I would like to provide an update on some important issues. Additionally, I would like to make you aware that the section has 15 subcommittees that are devoted to various aspects of emergency ultrasound eg, community practice, critical care, reimbursement, etc.  Please see more details on the committees elsewhere in the newsletter.  The subcommittee chairs would welcome your participation.  

The major issues involve the political arena.  First there is accreditation.  Just as a refresher there are vast differences between credentialing, certification, and accreditation.  (See extensive article by Dr. Tayal in US Section Newsletter summer 2007)  Credentialing is a local phenomena that should follow national guidelines, at the hospital level, where a credentialing committee attests to a physician’s overall qualifications and grants him/her privileges regarding aspects of patient care and procedures.  Certification is where an entity would provide a written attestation confirming a skill-set.  There is no ultrasound certification for the emergency physician, as ACEP’s membership has avoided merit badges and because ultrasound is imbedded into the core curriculum for all emergency physicians.  There is a technologist certification (registered diagnostic medical sonographer or RDMS).  That certifies that you are able to obtain images but not interpret or clinically act on them!  There is board certification for the practice of emergency medicine via ABEM.  Accreditation is where an entity acknowledges a practice or department for their quality of work.  It ensures that quality, safe, and appropriate ultrasounds are being performed.  There is no one existing accrediting body that can accredit our practices.  The American College of Radiology cannot attest to the quality of focused echocardiograms for example.  The American Institute of Ultrasound in Medicine (AIUM) cannot evaluate a department that performs focused ultrasound examinations including extremity vascular studies and echocardiography.  The ACEP board has approved for us to create our own governing process, an "ACEP Ultrasound Accreditation System" so to speak.  Why is this important for us to move forward with this?  Because the government is focused on ancillary testing and legislation has been put forth for reimbursement for such testing be linked to accredited practices only.  Third party payors will most certainly tag along.  Ultrasound has avoided the list so far but most experts will tell you that it’s only a matter of time.  We should have the website with application process up by early 2010.  We will keep you informed of the process. 

Next we have appropriateness criteria.  With the focus on healthcare spending and the overutilization of ancillary testing, the government has keen interest in decreasing the expenditure for unnecessary ultrasound examinations.  This is not new territory as the ACR, ACC, and ACCF have all put forth appropriateness criteria for many clinical scenarios and examinations.  Our liaisons to the government and the section leadership believe this is a necessary step in order to control our own destiny.  If we don’t develop these standards ourselves then others will place the standards upon us.  It is better if we define this ourselves. We are currently formulating template criteria and will also keep you all abreast of any significant advancement. 

The industry subcommittee, led by our fearless Dr. Chris Moore, has a tremendous task ahead of it.  We will be standardizing minimum ultrasound reporting and we will also be exploring the possibilities of working with the IT folks making reporting with imaging streamlined with the EMR. 

The pediatric subcommittee has taken on new leadership with Dr. Jason Levy at the helm.  We are discussing the possibilities of formalizing the pediatric ultrasound applications used by EM physicians and PEDS EM fellows.  

The community subcommittee and its chair Dr. Bob Tillotson will be focused on "packaging" all relevant informational material for all of our colleagues looking to establish an ultrasound presence, improve on their ultrasound capabilities, or initiate billing practices. 

Various members of all the subcommittees will be aiding the section in accomplishing all the above objectives. 

Again, we could use the help.  Please contact me or any member of the subcommittees that interest you in order to get involved.  There is a lot of work to be done.  I look forward to hearing from you. 

Thanks,
Jerry


    

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2008-2009: The Year in Review

Lawrence A. Melniker, MD, MS, RDMS, FACEP

Thank you all again for the opportunity to serve as Chair of the ACEP Emergency Ultrasound Section for this past year and congratulations to Gerardo Chiricolo on advancing to the Chair’s position. I look forward to Jerry’s energetic leadership and working closely with him to achieve his goals for the Section this year. It was a remarkable year! 

The year began with endorsement by the ACEP Board of Directors of the development of an Accreditation System for Emergency Departments using clinical ultrasound in their practices. This is a critical step for the College. With the exceptional leadership of Jerry, this process has moved forward with accreditation criteria defined and the Online Accreditation System ready to "go live" soon. This year the Council passed a resolution, which was approved by the Board, to make it the policy of the College to fight any requirement for an Emergency Physician or practice to obtain credentialing or "sign-off" from other specialties to conduct examinations or procedures defined with the scope of practice of Emergency Medicine. The Executive Director of ACEP, Dr. Dean Wilkerson, speaking at the recent Scientific Assembly, specifically noted and thanked the Section for its service to the College; as well as, promoting and protecting the integrity of our specialty. 

Several committee and subcommittees of the Section were very active this year and our liaisons with other organizations continue to bear considerable fruit. The committee chairs have actively recruited and mentored newer members to leadership roles in their committee, which was an important Section annual goal. The specialty of Critical Care has become a prominent partner in our quest to develop and promote Clinical Ultrasound in this country and throughout the world. Our International EM subcommittee has several members teaching extensively in other countries and on faculty of WINFOCUS and other National Congresses. We continue to reach out to our Community Practice brethren by promoting the development of proficiency of skills and the management of data to assist in the continuous quality improvement process. The Industry Communications Committee once again conducted an Industry Roundtable to promote the development of minimum standards for reporting and image archival, which was well attended in Boston. Media and Government Relations Committee continues to be spearheaded by Paul Sierzenski, who provided a briefing on proposals at the National and State levels. Paul would like volunteers from each State to survey their legislature’s activities – please contact him or Section leadership. Dr. Stone presented the report on Medical Student Education, including an introduction to the product of our latest Section Grant – an Online Emergency Ultrasound Examination System, which can be found at www.sunysono.com/acep/exam.html. Our colleagues in the Military are near completion of a White Paper on tactical applications of emergency ultrasound and hope to develop a working dialogue with the "diasterologists." Dr. Tsung reported on expanding interest and opportunities to teach our pediatric emergency medicine colleagues. Finally, the webpage committee reported on the hugely popular acep.org/sonoguide, which has several new sections in development. 

In August, I had the honor of representing the College at the American Board of Radiology Foundation summit on "overutilization" of imaging services. Much to my delight, the participants and speakers were not hostile to clinician-performed ultrasound and they freely admitted that the American College of Radiology lacked the expertise to assess the proficiency of clinical specialists using an array of applications. The speakers insisted there was overutilization of imaging services and provided evidence of 3 principal drivers for the phenomenon: "self-referral," their catch-phrase for imaging provided by non-radiologists; "defensive medicine," related to the expectation of preventing litigation by ‘taking a picture;’ and "inappropriate use," lack of an evidentiary-basis for ordering an imaging service – a function of inadequate education of clinicians. They attributed 5-10% of imaging budget to each of these drivers. Recommended was promoting evidence-based medicine in the form of "appropriateness criteria" for imaging, medical malpractice reform, and limitations on "self-referral." 

The summit included a dinner meeting with Robert Kocher, MD, Special Assistant to the President of the United States, who was well aware of clinical ultrasound and its benefits for our patients. In fact, his concern was that clinical ultrasound would become so widely used eventually it would become a substantial budgetary concern. He has requested data from the Section on the cost-effectiveness of clinical ultrasound. All members with such data or developing such data are strongly encouraged to contact the Section leadership. 

It was an exciting year on the international front. The United Nations sponsored a meeting in March for the InfoPoverty Working Group. InfoPoverty’s goals include the eradication of severe poverty through the use of low-cost technology and clinical ultrasound is one of the modalities to promote this goal. The audience was curious and intrigued by a presentation by our own Anthony Dean, MD. The potential benefits from high-tech, low-cost imaging by portable ultrasound in austere locations was apparent to the policymakers in attendance. They were eager to learn more and see this technology in action. 

Over the Labor Day weekend, the 5th World Congress on Ultrasound in Emergency & Critical Care Medicine (WCU5) was held in Sydney, Australia. Once again it was a highly successful and fascinating experience. Discussions were held with the leadership of the World Federation of Societies for Ultrasound in Medicine and Biology, which held their annual meeting in Sydney just prior to WCU5. A consensus is developing on the vital role of clinical ultrasound in the future of medicine and how collaboration between clinicians and imaging specialists can facilitate this paradigm shift in physical examination and disease management. 

Over Thanksgiving weekend, the 1st International Consensus Conference on Pleural & Lung Ultrasound will be held in Bologna, Italy, which will lead to the development of Clinical Guidelines for the use. This is an important step in erecting the second pillar of the WINFOCUS structure – to promote evidence-based medicine and research collaboration. Go to www.winfocus.org to keep track of this multifaceted process. 

I have just completed my 20th year in emergency medicine and reaching this milestone as your Section Chair was a great honor. When I started in EM, I felt the specialty was in its late childhood, beginning its adolescence; and now it is a young adult – ready to reach its prime. Our role in the development and expansion of clinical ultrasound has made living through this maturation period all the more stimulating. I look forward to many more years of clinical practice facilitated by ultrasound at the bedside and researching better ways to employ it. Clinician-performed ultrasound has the potential to change the world as we know it and emergency medicine will remain a leader in its promulgation in the United States and beyond. 


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Journal Watch

Various Reviewers

Reviewer:  Christopher Angemi, DO.  Emergency Medicine Ultrasound Fellow, Harbor-UCLA

Gaarder et al. Ultrasound performed by radiologist – confirming the truth about FAST in trauma. J Trauma. 2009; 67 (2): 323-329. 

Purpose: Gaarder et al discussed the wide range of sensitivity of the FAST exam to detect free fluid that has been cited in published literature.  Furthermore, the authors point out the lack of FAST studies performed in patients who present to the emergency department hemodynamically unstable.  In this study the authors determined the sensitivity and specificity of FAST to detect hemoperitoneum in potentially hemodynamically unstable patients based on objective hemodynamic parameters available early during resuscitation. 

Method: This study was a prospective observational study done at a single major European trauma center which admits approximately 500 patients annually with injury severity score >15.  The study period was defined as May 2005 to June 2006.  The institutional trauma registry was queried for inclusion criteria of: 

  • age 7 years or older admitted to the trauma service after trauma team activation
  • Deemed potentially unstable by either one or multiple of the following initial hemodynamic parameters:
    • systolic blood pressure < 90 mmHg
    • pulse rate >120
    • base deficit >8. 

FAST exams were performed on all patients during trauma activation as an adjunct to the primary survey. Exams were performed by residents with training in general and emergency ultrasound including FAST (mean 3.4years; range 1-6.5 years training) with at least 6 weeks supervision by experienced radiologist.  Ultrasound results were interpreted by the radiologist on call. Results were compared with one following standards: computed tomographic scan, diagnostic peritoneal lavage, exploratory laparotomy, or observation.  

Results: A total of 104 patients were enrolled. There were 75 true negative exams, 10 false negatives, 16 true positives, and 3 false positive studies. The sensitivity of was 62%, specificity 96%, with a positive predictive value of 84% and a negative predictive value of 89%. 

Discussion: FAST exam is one of the initial screening tools in evaluation of the trauma patient. The low sensitivity in hemodynamically unstable patients is concerning. Limitations include the lack of experience for the reporting sonographer. Though the mean PGY year of the residents was 3.4, the authors did not report the number of exams done by the specific sonographer. The sensitivity could have been lower because if less experienced sonographers in, terms of number of exams, had false negatives. Hertzberg et al determined that involvement in 200 or fewer cases during training is not sufficient to gain competency. Another factor affecting the sensitivity could have been that sonographers maybe more likely to call a positive FAST based on the severity of the trauma patient. 5 of the 10 false negatives had therapeutic laparotomies however one had bleeding for pelvic fractures and one from bowel mesenteric laceration. FAST has limited diagnostic ability in these areas. This paper re-demonstrates that a negative FAST exam does not rule out intra-abdominal injury.  

Reference: Hertzberg, BS, et al. Physician training requirements in sonography: how many cases are needed for competence? AJR Am J Roentgenol. 2001 Apr;176(4):1075-6. 

_____________ 

Reviewer: Michael Woo, MD, RDMS 

Gaarder C, Kroepelien CF, Loeeke R, et al. Ultrasound Performed by Radiologists – Confirming the Truth About FAST in Trauma. J Trauma. 2009;67(2):323-327.

Methods: This was a prospective observation study to determine the accuracy of FAST in hemodynamically unstable patients in a trauma centre in Oslo, Norway. FAST was performed on all trauma team activations at the discretion of the trauma team leader by predominantly radiology residents with at least 6 weeks experience in ultrasound in the diagnostic imaging department. There is radiology coverage 24/7 for all trauma activations. For the period of May 2005 to June 2006, investigators retrospectively identified trauma patients who were unstable defined as an initial SBP <90, pulse rate >120 or base deficit >8. FAST results were then compared in this group of patients with DPL, CT, laparotomy, or observation.

Results: The study group consisted of 104 patients. 66% were male with a mean age of 31. The mechanism of injury was due to motor vehicle crashes in 69% of patients. Mean SBP was 111 ± 30, pulse rate 117 ± 21,  and base deficit 5.8 ± 4.9. Mean ISS was 24 ± 16 and mortality was 11%. 20.1% of the patients went for laparotomy. The sensitivity and specificity of the FAST exam was calculated as 62% and 96%, respectively.

Discussion: The sensitivity was low in this study compared with previous studies in hemodynamically unstable patients. This could be explained by several limitations. The investigators used other parameters besides SBP including pulse rate or base deficit. In addition they only used the initial values as markers of instability with the mean results all being above their set parameters. Comparison was also made with DPL that should not be considered a gold standard. The investigators even report that the FAST was a false negative in two cases as a result of a positive DPL, but subsequent CT revealed no intra-abdominal injuries. Serial FAST exams were not performed which could have improved the sensitivity. False negative cases included a pelvic fracture, small bowel, and renal injury that are known limitations of the FAST exam. The patients included in the study were severely injured with a mean ISS of 24. The investigators report that all 8 patients who remained hemodynamically unstable after positive FAST underwent laparotomies while the other 8 positive FAST scans became hemodynamically stable and underwent CT.

Bottom line: FAST does not replace CT. Patients with hemodynamic instability despite resuscitation with a positive FAST should be strongly considered to have a laparotomy.  The challenge is defining hemodynamic instability as a decision to go to CT or to go to laparotomy. In the era of permissive hypotension, hemodynamic instability may be even more difficult to define. 

_____________

Reviewer: Lisa D Mills, MD, FACEP 

Brown HL. Trauma in pregnancy. Obstet Gynecol.  2009;114(1):147-160 

This is an edition of the "Clinical Expert Series" of the journal.  This is apparently the opinion of the author. 

The author discussed the common mechanisms of injury, intentional violence and motor vehicle collisions, and the unique maternal anatomy related to injury.  The author discussed prehospital and emergency evaluation of the pregnant patient.  The author suggested that all appropriate radiologic imaging should be performed on pregnant patients.  One sentence mentioned that MRI and ultrasonography "have not been associated with adverse fetal effect."  The author recommended utilizing US to facilitate  diagnostic peritoneal lavage to assess for free fluid.   The author recommends the utilization of Obstetric consultation liberally to assist physicians in the management of pregnant patients with trauma. 

Discussion:  This expert opinion on trauma fails to discuss the use of ultrasonography in the evaluation of the pregnant trauma patient, except to mention that it can facilitate the performance of DPL and that it is not associated with adverse fetal effects.  There is no discussion of utilization to ultrasound as a primary tool in the approach to trauma in pregnancy.  There is no synthesis of modern trauma concepts and their application in pregnancy in this article. 

______________

Reviewer: Lisa D Mills, MD, FACEP 

Dashe JS, McIntire DD, Twikler DM. Effect of maternal obesity on the ultrasound detection of anomalous fetuses. Obstet Gynecol. 2009;  113(5):1001-1007. 

Objective:  The objective is to estimate the effect of maternal habitus on detection of fetuses with major structural anomalies during second-trimester ultrasound.

Methods:  This is a retrospective cohort study of all patients referred for an anatomic survey ultrasound between the 18-24th week of pregnancy.   

Results:  11, 210 studies spanning 5 years were reviewed.  Based on body mass index (BMI) approximately 1/3 of patients were normal body habitus, overweight, and obese.  The average age was 27 +/- 6.7 years.  The patients were predominantly Hispanic (86%) with 10% Black, 2% Caucasian, and 2% reported as other.  The authors found that there was a statistically significant decrease in the sensitivity of ultrasound to detect fetal anomalies with increased BMI.  The risk for undetected fetal anomaly rises from 0.4% in normal BMI to 1.0% in obesity. 

Conclusion:  The authors conclude that the limitation of ultrasound in obese patients should be acknowledged and presented to patients as a limitation of the study. 

Discussion:  Obesity is a commonly acknowledged limitation of ultrasonography.  One radiologist, Raul Uppot, MD, has even reported the impact of obesity on the number of inadequate radiologic studies performed as Massachusetts General Hospital.  (AJR 2007; 188:433-440.)  However, little is published to quantify the impact of obesity on the adequacy of a particular study.  This serves to reinforce common knowledge.  There is little data to guide the clinician.  One can argue that the image itself leads the physician in determining the adequacy of the study.  However, there is no literature to guide the physician in an informed discussion with the patient. 

_______________

Reviewer:  Christopher Angemi, DO.  Emergency Medicine Ultrasound Fellow, Harbor-UCLA 

Kendall JL, Faragher J, Hewitt GJ, et al. Emergency Department Ultrasound is not a Sensitive Detector of Solid Organ Injury. West J Emerg Med.2009;10(1):1-5. 

Two of the known limitations of Focused Assessment with Sonography for Trauma are detecting the source of hemoperitoneum and ability to detect solid organ injury (SOI).  

Methods : In this prospective cohort study performed by emergency physicians, Kendall et al measured the sensitivity, specificity, positive and negative predictive values of ultrasound for liver and spleen injury. A convenience sampling of blunt abdominal trauma patients from July 1998 – June 1999 who had a FAST exam and underwent CT had a second ultrasound exam to detect liver or spleen injury prior to CT. All physicians performing this exam had an introduction course with additional instruction on views to assess for liver or spleen SOI. The radiologist interpreting the CT scans were blinded from the secondary ultrasound results.

Results: 152 patients were enrolled in this study. Of the 9 liver injuries found by CT only 1 was detected by ultrasound. There were 4 false positives. The sensitivity and specificity for liver injuries were 11% and 98% respectively. There were 10 spleen injuries found by CT and 8 of these were identified by ultrasound. There were 3 false positives. The sensitivity and specificity of ultrasound to detect splenic injury was 80% and 99% respectively.

Discussion: Ultrasound is known to play a limited role when evaluating for solid organ injury. There are several limitations in this study including, a 10 year old date set, older equipment, a "convenience" sample group, and limited experience in the sonographer for detecting SOI. Also the initial FAST exam may have biased the secondary ultrasound for SOI. Perhaps more research is needed with newer equipment, blinding the sonographer from the initial survey and FAST, and training to detect SOI. Ultrasound remains limited for evaluation of SOI. 


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Emergency Ultrasound Management Course 2010
Monday, September 27th, Las Vegas
Pre-course to 2010 ACEP Scientific Assembly

Is emergency ultrasound something that you have wanted to get into your department but have been unable to achieve? The solution is the ACEP Emergency Ultrasound Management Course. If you have a physician who is your ultrasound director or coordinator, this would be the perfect course to send them to get your program up and running. 

The topics range from the role of the director, to specifics of machine purchase, and a very thorough explanation of billing. The speakers are the national experts that have been successful in implementing emergency ultrasound programs. As a new addition to the course in 2010, we will have small breakout group discussions with many experts so bring your questions and challenges from your own institutions! The course includes a well-written syllabus of the lectures for reference. 

Registration and specifics of location, as well as price, TBA


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The 2009 - 2010 Section Grant Cycle Began November 9!

The ACEP Board awards up to $25,000 annually to section grant applicants.

Click here for applications and information for applying for a Section Grant. https://www.acep.org/acepmembership.aspx?id=31962

The E-mail deadline for Letters of Intent is February 15, 2010

Contact Susan Morris (smorris@acep.org) or your section liaison with questions. 


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Emergency Ultrasound Award presented to Dr. Patrick S. Hunt

On October 5, 2009, Patrick S. Hunt, MD, MBA, FACEP, won the Emergency Ultrasound Award for outstanding contributions to the field of Emergency Ultrasound. Pat has been an active leader in ultrasound education at the international, national, regional and local levels for many years. He is on the faculty of the EM residency at Richland Memorial Hospital, Columbia, S.C. His service to the emergency ultrasound community includes creation of the Ultrasound Image Bank and chairing of the SAEM Image Bank; as well as, development and management of the Emergency Ultrasound Fellowship web page. Pat is a member of the ACEP Emergency Ultrasound Section-Subcommittee on Accreditation and has led the effort to develop the Online Accreditation System and webpage. His continued tireless effort to promote emergency ultrasound through education and advanced data management processes are a lesson and benefit to our entire community. Congratulations, Pat, for your outstanding contributions to emergency ultrasound! 


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Updating Preceptorships

Vivek S. Tayal, MD, FACEP

We are updating the US preceptorship list. A preceptorship is a program that allows visiting attendings physicians (community or academic), residents, or others to rotate with a certain person or department. Please contact Greg Snead or Bob Tillotson .  


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EUS Applications Explode! Or Is It a Dud?

Michael B. Heller, MD, FACEP*

It has become routine to read that the uses of Emergency Ultrasound are "exploding" or that the number of applications of EUS is "ever-expanding." But is it really? I think not. Almost 15 years ago I co-authored a book on Emergency Ultrasound that was based on the premise that EUS had only 6 "primary" applications and that the other uses were either uncommon enough or insufficiently accurate to play an important role in a clinician’s practice. With only one possible exception (DVT, and I’m not so sure of that), I believe that is still true. 

Consider, for a moment, the "newer" applications of EUS that we read so much about. EUS to determine intracranial pressure (by measuring the width of the optic nerve)? It sounds cool but has little practical application in the ED. And the most recent studies indicate that it’s not all that accurate, certainly not good enough to consider that a normal measurement would allow the ED doc to rule out this important condition. How about the other ocular indications, intraocular foreign bodies, and retinal (and vitreous) detachment?  First of all, these are pretty rare in the usual ED and intraocular foreign bodies are usually obvious from the history and exam, not to mention the fact that CT is pretty great in diagnosing them (and the consulting eye doc will want the CT anyway). Is applying probe pressure to a partially ruptured globe so totally benign, anyway? I think so but not every ophthalmologist or textbook would agree. 

How about EUS for superficial foreign bodies in wounds? The better the study (meaning using it in actual humans rather than filet mignon or chicken breasts) confirms what you might expect. A "negative" sure doesn’t rule anything out and false positives are not so rare, either. And ET tube placement? Please. We have great ways of confirming tube placement now and the sometimes subtle difference in the in the interference pattern between a trachea without a tube in it and one with a tube in it makes this highly problematic even for people who have been doing EUS for years, myself included. Intravascular volume status (by measuring IVC size and variation)?  Sure there’s a correlation but unequivocal EUS finding are likely only in extreme cases, which are likely to be clinically evident anyway. And where it might be really useful, in kids, we haven’t been able to work out a ratio that is both sensitive and specific, and it’s not clear that such a number even exists. 

So let’s concentrate on getting the large majority of our colleagues (who are not performing EUS at all) up to speed on the 6 or 7 applications that matter and acknowledge the more esoteric applications for what they are: excellent topics for research and clinically useful only to a  relatively few EP’s in relatively uncommon situations. 

Michael Heller, MD
Director of Emergency Ultrasound
Beth Israel Medical Center
New York, NY 

*The opinions expressed in this article are those of the author. 


 

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SonoSite Introduces SonoAccess: An Innovation in the Delivery of Ultrasound Education

SonoSite Inc., the world leader and specialist in hand-carried ultrasound for point-of-care medicine, recently announced the launch of the SonoAccess™ application. SonoAccess is the first free medical iPhone™ application from an ultrasound company that provides a multimedia library of ultrasound resource materials for medical professionals.  Launched June 24, 2009, the application has since received over 12,000 downloads.  

The SonoAccess application, available on the iPhone or iPod touch® mobile digital devices, provides instructional videos, case studies and reimbursement guides for a variety of different specialties including Emergency Medicine. Users have access to over 100 clinical images and news feeds on SonoSite. In addition, users can customize their user profiles to generate a recommended list of videos specific to their specialty, as well as share videos, case studies and images with their colleagues and friends. 

"We have learned that using video works very well for teaching ultrasound-you don’t get the same impact from textbooks," says Dr. Phillips Perera, MD, FACEP, RDMS, Emergency Ultrasound Program Director at Columbia University Medical Center, New York Presbyterian Hospital, NY. "I can use SonoAccess even while teaching a resident to perform an ultrasound exam at the bedside by propping up the iPhone next to the bed and pointing out an image ‘this is the heart chamber you are looking for,’ for example." 

"The portability of SonoAccess matched with the short, bullet point education modules make this a great fit for the busy lifestyle of emergency physicians and residents," Dr. Perera said.  

With 28 instructional ultrasound videos and 17 video case studies, the SonoAccess application is one of the largest free resources of instructional videos for point-of-care ultrasound and demonstrates SonoSite’s continued commitment to education and emergency ultrasound. To download the application or to watch a demo video of SonoAccess visit www.sonosite.com/products/sonoaccess

iPhone is a trademark of Apple, Inc.  iPod touch is a trademark of Apple, Inc., registered in the U.S. and other countries. 

This article is being published in the section newsletter in appreciation for their generous support of Section.  The ideas and opinions expressed in this article are those of "SonoSite" and do not necessarily reflect the views of the section. 


 

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"Hennepin County Medical Center, Palmetto Health, and Ultrasonix Medical Corp. to present preliminary results of Emergency Ultrasound workflow and data management study at ACEP assembly in Boston"

Capture rates and compliance for Ultrasound QA, credentialing and billing has long been a challenge due to the unique workflow requirements and unpredictability of the Emergency/Trauma environment. Extensive ultrasound system keystrokes, laborious paper-driven documentation, and unreliable electronic transfer of data has resulted in lost (phantom) studies, challenges with HIPAA compliance, and ultimately, lost revenue. 

In collaboration with Palmetto Health and HCMC, Ultrasonix Medical Corporation has utilized its "OpenSONIX" technology and touch screen interface to develop specialized, user-defined system interfaces and data management software that provides seamless on-board system integration of QA, credentialing and billing information. Data can then be securely transferred wirelessly from the system for review and archived in a secure and HIPAA compliant database. Finally, the unique system interface allows for studies to be designated as "clinical" or "educational" in order to differentiate for billing and QA purposes. 

"Currently, the number of keystrokes/steps required to effectively do the ultrasound exam, submit the required data, and effectively archive for QA, billing, and over read can be 50 or more", says Thomas Cook, MD- Program Director, Department of Emergency Medicine, Palmetto Health Richland. "The goal of this study is simply to minimize the keystrokes/steps required (ideally to 15 or less), to improve compliance, create cost and workflow efficiency and provide 100% data capture for billing", added Dr. Cook. 

"Since the ability to provide standardized protocols, user-defined interfaces, and HIPAA compliant electronic data capture falls within our system capabilities, we feel obligated to provide the necessary tools to meet the requirements," says Joseph Bjorklund, Vice President, Sales North America for Ultrasonix. 

The SonixTOUCH Ultrasound System for Emergency Medicine provides seamless workflow via wireless connectivity to existing QA and Credentialing software. Integration of SonixTOUCH is currently available with the eHealthConnx Ultrasound QA and Credentialing global Portal and the SonixHUB department-specific QA and Credentialing software.

About Ultrasonix: Ultrasonix (www.ultrasonix.com) is a leading developer and manufacturer of high quality diagnostic ultrasound imaging systems. The company’s OpenSONIX ultrasound technology provides superior image quality, ease of use and clinical flexibility to adapt to the needs of a variety of specialties. Ultrasonix is a privately held company headquartered in Richmond, British Columbia with affiliate dealers in 65 countries.

This article is being published in the section newsletter in appreciation for their generous support of Section.  The ideas and opinions expressed in this article are those of "Ultrasonix" and do not necessarily reflect the views of the section. 


 

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Annual Meeting Minutes

AMERICAN COLLEGE OF EMERGENCY PHYSICIANS
Emergency Ultrasound Section
October 5, 2009
Boston, MA

MINUTES 

Participants

Approximately 245 members and guests attended the section meeting.
Board Liaison: Andrew Sama, MD, FACEP
Staff Liaison: Marilyn Bromley, RN 

Agenda

Introduction
Results of Election
American Board of Radiology Foundation Summit (Report)
Research Updates

  • Clinical Sonography Research Consortium (REASON – Real time Emergency Assessment with Sonography: Outcomes research Network)
  • EMF Ultrasound Research Grant Report
  • Carotid Intima-Media Thickness (IMT)

Section Grant – Online Examination
Subcommittee Reports
Liaison Reports
Awards – Outstanding Web Page
New Chair Comments
SAEM Meeting 

Major Points Discussed

Larry Melniker, MD, FACEP, chair of the section welcomed everyone to the meeting and announced the results of the elections. Vicki Noble, MD, FACEP, chair-elect, Gary Quick MD, FACEP, Secretary/Newsletter editor, Rajesh N. Geria, MD, FACEP becomes Councilor and Robert J. Tillotson, DO, FACEP will serve as alternate councilor for 2 years and then move to councilor. 

Dr. Melniker gave an in-depth report on the proceedings of the American Board of Radiology Foundation Summit that he attended. 

Dr. Andy Sama thanked the section for all the excellent service they provided to the College and the outstanding efforts to further the emergency ultrasound agenda in the healthcare community. 

Research updates were provided on the following:
Clinical sonography Research Consortium (REASON – Real time Emergency Assessment with Sonography: Outcomes Research Network.  Dr. Raio spoke about the utility of emergency ultrasound in cardiac arrest.  A protocol is being finalized.  Work is being done with the NIH and its ultrasound imaging and trials group. 

EMF Ultrasound Research Grant Report.  Dr. Dickman reported on emergency ultrasound being used to mitigate pain in hip fractures in the elderly. A video demonstration was provided on the ultrasound guided nerve block to provide pain relief and reduce the need for narcotics which can be poorly tolerated in the elderly. 

Carotid Intima-Media Thickness.  Dr. Melinker explained the enrolled criteria for this study. 

Section Grant – Online Examination.  Dr. Stone reported that many models had been completed for most all applications. 

Verbal presentations from subcommittee chairs were provided.  More detailed written reports will be filed in the section newsletter.

  • Accreditation – Dr. Chiricolo:  Web design for accreditation is ready for testing. 
  • Community Practice – Dr. Tillotson: materials have been developed for presentations to support emergency ultrasound in community hospitals.
  • Critical Care – Dr. Dean: Work continues with Critical Care Section and other entities involved in critical care.
  • Industry Roundtable - Dr. Moore: The meeting with vendors will focus on work flow issues.  A white paper may be developed on this issue.
  • International - Dr. Price: Issues such as what machines to use, privileging and fellowships are under discussion.
  • Media/Government Relations – Dr. Sierzenski:  Government continues to look at usage of imaging.  It would be of benefit if the section had a representative from each state that could report on activities.
  • Medical Student - Dr. Stone: Provided information in his report regarding the grant and on-line modules for testing.
  • Military and Tactical – Dr. Ferre: Create a platform for education and share ideas and research on EUS in the battlefield and in civilian disasters.
  • Pediatric – Dr. Tsung:  Difficulties encountered in the getting EUS in pediatrics, suggest a joint statement on EUS with the pediatric specialties.
  • Reimbursement-Dr. Resnick: Paper on EUS reimbursement has been completed.  Work continues with Coding and Reimbursement on EUS.
  • Safety - Dr. Nagdev: Discussed safety of the EUS equipment and noted the work currently being done on probes.
  • EUS Management Course - Dr. Foster: Planning on conducting the course next year in Las Vegas.  Currently looking at the possibility of CME for the course.
  • EUS Section Web Page – Dr. Mailhot:  EUS Section received an award for outstanding webpage.
  • Subspecialty Development – Dr Tayal: Efforts to obtain subspecialty certification have not been successful; however will continue to pursue this issue.
  • Sonoguide – Dr. Hoffman:  Number of visitors to sonoguide continues to increase, of note is the increasing number of international. The Sonoguide has been cited in the BMJ. New chapters have been written. 

Dr. Blaivas reported on the work with WINFOCUS and WCU5 and noted that the international conferences continue to do well. 

Dr. Melniker was thanked for his service to the section and Dr. Jerry Chiricolo, incoming Chair provided brief comments on his vision for the section and noted that section leaders and section subcommittee chairs would have regularly scheduled conference calls throughout the year. 

The ACEP Emergency Ultrasound Section meeting adjourned at 3:45pm and the SAEM Special Interest Group meeting convened.  

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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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