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Emergency Ultrasound Section Newsletter - September 2008, Vol 12, #3

Emergency Ultrasound Section

circle_arrow From the Chair
circle_arrow Ultrasound Section Meeting
circle_arrow Election of Officers
circle_arrow Call for Nominations to Section of Emergency Ultrasound Offices
circle_arrow Candidate – Chair-elect
circle_arrow Emergency Ultrasound Management Course 2008
circle_arrow A Saga of Our Own Editor
circle_arrow Continuous Quality Management and Expanding the Use of Clinical Sonography: Where are we and where do we go from here?
circle_arrow St. Luke’s Roosevelt Hospital, Ultrasound Division, Department of Emergency Medicine
5th Annual Regional Emergency Ultrasound Symposium
circle_arrow An Ultrasound Experience in South Africa 2008
circle_arrow Moving Beyond SOAP – Where Should Clinical Sonography Research Collaboration and Networking Go From Here?
circle_arrow ACOG Practice Bulletin
circle_arrow Director Emergency Ultrasound Opportunity in Charlotte, NC
circle_arrow Journal Watch – August 2008

Newsletter Index

Emergency Ultrasound Section



From the Chair

Vivek S. Tayal, MD, FACEP

Dear Fellow US Section members:

We have had an exciting year, and we are looking forward to an even more eventful fall. Emergency US has become a mainstream player in emergency medicine practice, emergency medicine training, medical student training, the house of medical ultrasound, the medical US industry, politics at the level of Congress, CPT coding, and within our own house in ACEP.

Ultrasound has taken on its own legs, with legitimacy less of an issue, and the issue of safety, quality, growth, and education starting to predominate. It is time to consider how to get US leaders into key leadership positions throughout EM beyond ACEP. I have considered the ACEP Board essentially US advocates since 2001.

But other organizations are stuck in the box of boundaries and legitimacy. From editorials on what emergency physicians cannot do to the unwillingness to grow the specialty to backdated policies, these organizations need US advocates at the top. A good example of how progress was made when an US advocate was at a leadership level was CORD with Dr. Sarah Stahmer. Through her and others, a consensus conference was held this year to produce a realistic, helpful agenda for educating EM residents on US. As we move forward, I urge you to volunteer and consider who is running and what they are doing for emergency ultrasound in our sister EM organizations.

The US section is a dynamic and important organization in ACEP and US. But it takes energy, commitment, and time from our members. If you put in the time and effort, you will get many rewards, tangible and intangible, throughout the year. Consider helping out.

Finally, we are in the process of updating (2008 Emergency Ultrasound Guidelines draft) and self-regulating ourselves (voluntary accreditation). If you have ideas or desires, communicate with us, we need your input.




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Ultrasound Section Meeting


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Join us at Scientific Assembly in Chicago!

The ACEP Emergency Ultrasound Section meeting has been scheduled for Monday, October 27, 2008, from 10:30 am - 1:30 pm in Room 265 of the Convention Center (McCormick Place- Lakeside Center.)

The educational portion of Scientific Assembly runs from October 27-30. We hope to see everyone there.




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Election of Officers


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The section will be holding elections for Chair-elect and Secretary/Newsletter Editor. If you have an interest in serving in either capacity, please notify Julie Dill



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Call for Nominations to Section of Emergency Ultrasound Offices

To ACEP Emergency Ultrasound Section members

This is a call for nominations (or self-nominations) for the following Officers of the Section for the year 2008-2009 to be elected at the Section meeting during Scientific Assembly in October 2008:

  1. Chair-elect (Chair term will start fall 2009)
    Two members of the section have notified us of their interest in running for the office of chair-elect. Gerardo "Jerry" Chiricolo, MD, RDMS, FACEP and Resa E. Lewiss, MD, RDMS have submitted their brief bios.
  2. Secretary/newsletter

Thus far, Dr. Gary Quick is the sole candidate for Secretary/Newsletter Editor. Dr. Quick has served the section in this capacity for several years.





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Candidate – Chair-elect

Gerardo "Jerry" Chiricolo, MD RDMS FACEP
Associate Director, Emergency Ultrasound
North Shore University Hospital
Manhasset, NY

I am an ABEM-certified Emergency Medicine physician fellowship trained in emergency ultrasonography. I am currently the Associate Director of the Division of Emergency Ultrasound at North Shore University Hospital in Manhasset, NY. I have had the privilege of learning from some of the best and most experienced in our specialty including Dr. Mike Blaivas and Dr. Dan Theodoro. I also work very closely with the chair of the SAEM ultrasound interest group, Dr. Chris Raio, who is the director of our division at North Shore. This past year I contributed to the CORD consensus document on resident education in emergency ultrasound. Among the benefits of working with these leaders was gaining the administrative experience one needs in order to effectively move into a leadership position.

ACEP and US Section Activities
I ran for the chair position last year and despite not being elected into the position my desire and interest are as strong as ever. I spent the last year working as chair of the accreditation subcommittee for the ACEP section of emergency ultrasound. In collaboration with many of the leaders in our section, developed short term and long term goals in preparation for the threat of Accreditation of ultrasound practices in our field and have implemented a corrective plan.

There are many issues that we must address, but those most critical to me are Accreditation, Reimbursement, Academic Productivity, Penetration into the community, and the Future of our section. Of upmost importance is the push from the Radiology Benefits Management linking reimbursement to accredited practices only. It is important to be proactive and set our own standards before we are forced upon the standards of other specialties. This is obviously intimately related to reimbursement for the procedures that we perform. As I mentioned above, in order for our specialty to advance, we must produce meaningful studies that demonstrate outcomes and financial benefit to patient and insurer. This can be done by increasing collaboration and developing multi-center trials. With the focus on academia, we need to improve our administrative experience and education at the resident level. As more residents are properly trained in ultrasound, more can become ultrasound directors in community settings. With proper penetration into the community our specialty will only grow stronger. Our use of ultrasound in the emergency department can develop into standard of care at all sites.

Emergency Ultrasound has progressed due to the hard work, time and effort of many dedicated members of our section. I feel capable of contributing to this progress and have the passion to do so. I look forward to working with such highly skilled and motivated members to accomplish the goals we set for the upcoming years and address any hurdles that may present.

I know of no conflicts of interest which might affect my nomination and I have no financial arrangements regarding ultrasound consultation, fees or securities owned of ultrasound manufacturers to disclose.
Candidate – Chair-elect


Resa E. Lewiss, MD, RDMS
Director of the Ultrasound Division
St. Luke's/Roosevelt Hospital Center
New York City, NY

Resa E. Lewiss, MD, RDMS, is the Director of the Ultrasound Division at St. Luke's/Roosevelt Hospital Center in New York City. She completed her residency in Emergency Medicine at the Harvard Emergency Medicine Residency in Boston. She served as one of the chief residents in her final year. She was in the first fellowship class in Emergency Ultrasound at St.Luke’s/Roosevelt and joined the core faculty upon completion. In 2004, she was named Director of the Emergency Ultrasound Division, and since 2007, she has overseen the Ultrasound Fellowship. She organizes all aspects of the Ultrasound division including credentialing faculty, educating fellows and residents, ongoing quality assessment and administration such as equipment maintenance, structuring for billing, and interactions with other departments. She believes in anticipating the trends in Ultrasound education and developments such as Global Health, Pediatrics as well as Medical Student Education. Education has been a focus of Dr. Lewiss' academic activity and she believes in the application of critical ultrasound to maximize efficient and effective patient care in developed and in developing world countries. She has taught workshops in Madagascar, Singapore, India, Italy, Israel, Philippines, Brazil and other local and international locations. As the Director of the division, she graduated the first fellow who continued onto a Pediatric EM Fellowship in 2007 and the first Pediatric EM trained physician to complete an Ultrasound Fellowship in 2008. Each year, the SLR ultrasound division has sponsored the largest annual symposium in emergency ultrasound for resident education in the country. This year's topic is Medical student education. Dr. Lewiss joined a group of her emergency ultrasound colleagues this past March at the annual CORD conference in New Orleans. She believes that this is a critical time for a unified voice in directing resident requirements for ultrasound.

ACEP and US Section activities
She is currently the director of the ACEP Ultrasound section subcommittee on subspecialty development. The purpose of this committee is to compare and contrast other subspecialty models e.g. Toxicology, Echocardiography, EMS as a means of deciding the direction Emergency Ultrasound may follow. The committee is evaluating training requirements, eligibility, certification, membership requirements, examination, organizing and approving bodies. As chair of the ultrasound section, she believes she could apply her leadership and organizational skills to further structure the subspecialty after final recommendations of the subspecialty committee. She supports colleagues in continued educational endeavors e.g. CORD consensus statement, teaching in community, academic and remote medical settings etc. As section chair she believes in the integrity of the section, supporting research, reimbursement for ultrasound and negotiating political conflicts at the national and local levels.

I know of no conflicts of interest which might affect my nomination and I have no financial arrangements regarding ultrasound consultation, fees or securities owned of ultrasound manufacturers to disclose.



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Emergency Ultrasound Management Course 2008

Are you using ultrasound in your ED? For many of us, it’s hard to imagine not using it! But often the issues regarding the ultrasound program become controversial and much more complex than learning the skill of performing and interpreting ultrasound. The ACEP Emergency Ultrasound Section is offering a course for any physician or group who needs the background to get the program up and running. This incredible course has helped many ultrasound directors and ultrasound coordinators with all aspects of creating a successful program. Taught by the experts that have led emergency ultrasound in recent years, it covers all topics from purchasing a machine to billing. This is not a hands on course for performing ultrasound, but instead the ‘how to’ course for designing your institution’s program. We have put on three previous courses with outstanding evaluations. Our fourth course will be offered this year on the day before Scientific Assembly in Chicago, Illinois. See the details below and register early.


EM US Director  M. Lambert, MD
Introductory Education J. Kendall, MD
Equipment Purchase  C. Moore, MD
Hospital Credentialing R. Jones, DO
Quality Improvements P. Hunt, MD 
Politics of EUS P. Sierzenski, MD
Continuing Program Education  B. Nelson, MD 
Community US Experience R. Geria, MD  
Creating Electives/Fellowship  C. Raio, MD  
Advanced Technology/Software M. Stone, MD
Machine Maintenance A. Dewitz, MD  
Reimbursement S. Hoffenberg, MD 
QA Session Moderators   M. Blaivas, MD and V. Tayal, MD 

The course directors intend the course to be a strong networking function for community ultrasound directors.



Sunday, October 26, 2008 
(ACEP Scientific Assembly October 27-30)

Time: 9:00 am - 5:00 pm with reception from 5:00 pm to 7:00 pm
Location: Chicago Hilton
Cost: $150 includes Resource Syllabi, Lunch, Wine and Cheese Reception 
Registration: Contact ACEP, 800.798.1822, ext. 6
Course Directors: Troy Foster, MD; Rajesh Geria, MD; Bret Nelson, MD
Senior Course Director:   Vivek Tayal, MD  



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A Saga of Our Own Editor

Vivek S. Tayal, MD, FACEP

Most of you know that Gary Quick, MD has been our secretary/newsletter editor several years. Gary had an MI earlier this year, and his story is fascinating and frightening at the same time. With his permission, I copy it below.

I underwent Thallium stress and echo in March for a bout of paroxysmal atrial fib. I had an exercise treadmill end of March to make sure flecainide for a fib was not causing prolonged QT interval. All three tests were normal. I began having chest pain in mid-March, some exertional, some rest. I thought it was non-cardiac due to the 3 normal dynamic tests. On April 18 I had an anterior MI in the ED after running steps and doing an EKG to determine if I could run a 5-K run the next day. (I had run 5-K in 25:10 2 weeks prior).

I went to cath lab and had 2 stents placed in my LAD. No bump in enzymes and EF of 62%. Went home and returned 6 days later with exertional angina. Distal stent had clotted and was re-opened in cath. I found that I had a L retroperitoneal hematoma induced at first cath. Hematoma compressed iliac vein causing DVT. Two days of bed rest and Integrelin drip resulted in massive L thigh DVT. The veins were full of Polish sausage-looking clots. I saw the US. Underwent thrombectomy that night successfully but clots recurred 2 days later. At this time the proximal stent re-clotted and bumped my enzymes and knocked my EF to 55%. There was a small apical wall segment of hypokinesia but the myocardium appeared viable.

At this point my physicians noted my platelets were 700,000 and the cardiologists did not know what to do. The cardiac surgeon presented my case individually to each of ten interventional cardiologists for their recommendation: stent, medical therapy, or CABG. 10/10 voted for bypass with the caveat that the grafts might clot due to what they presumed was a thrombotic condition of undetermined etiology. The only risk factor for me was my dad had obstructive coronary artery disease with CABG and stents. I have run competitively at 5-10 K distances for 50 years.

They grafted me with 2 IMA grafts after putting in a caval filter and kept me on Lovenox, Plavix and ASA. That was 11 days ago. Post-op 7 days I had atrial flutter one night which was treated successfully with Toprol XL at home and resolved. The next morning I continued to have pleuritic chest pain. A chest film showed post-op effusion in L chest. Tapped off 1450 cc. serosanguineous fluid. I am home; I have no ischemic pain that I recognize and have transitioned from Arixtra to coumadin and ASA. August 12 I will find out what it will take for me to begin running again based on echo and exercise testing. My bone marrow biopsy showed no positive genetic abnormalities but did show a pattern of "essential thrombocytosis." So now I take hydroxyurea BID to reduce my platelets.

One of the cardiologists making rounds said, "I have reviewed your case. You have been struck by 3 big bullets and are still alive. I don't know whether you ascribe to this, but I think the Lord has had His hand on you." To which I responded, "Chris, I ascribe! Amen!"

Gary, we are glad you are better, and hope you stay healthy.




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Continuous Quality Management and Expanding the Use of Clinical Sonography: Where are we and where do we go from here?

Larry Melniker, MD, MS, FACEP
Chair-elect, ACEP Emergency Ultrasound Section

In an earlier edition of the US Section newsletter, I discussed the vital link between continuous quality management (CQM) and the use of Clinical Sonography.  For the most part, CQM is an area of study and analysis that has been developed and promoted by regulators and administrators and, subsequently, thrust upon clinicians; often without clear definitions and instructions on how to comply.  To many clinicians the topic and the lingo employed is very foreign, but it is a language that we all must gain some familiarity with in the near future – it will not go away!

It is my goal in this coming year as Chair of the US Section, to promote a clear picture of the relationship between CQM and our expanding use of Clinical Sonography in the practice of Emergency Medicine.  For those in the Section who participate in CQM for their departments or hospitals – I will need your help and invite you to participate in painting this picture.

There are many elements of this discussion that need to be developed and will be included in a ‘White Paper’ on the enhancement of quality of care and patient safety in emergency medicine through the expanding use of ultrasound by emergency physicians.  The Section leadership is in the process of updating the ‘Emergency Ultrasound Guidelines’ first published in 2001; the authors will promote the highest quality for the provision, performance, and interpretation of Clinical Sonography in the ED.  Each aspect of training, documentation of proficiency, credentialing, quality assurance, and billing procedures will be discussed.

After updating the current bibliography and evaluating the weight of the evidence, components of the white paper will include:

What to include in lectures, demonstrations, and hands-on skill labs and description of applications to articulate how each promotes better and safer care; and CQM Program development for medical student, resident, and attending training.

New Applications:
What to include in the rollout and descriptions of new techniques and applications to present them as quality improvement and/or patient safety initiatives.

What indicators of quality of care to include in protocols and grant applications to facilitate a discussion of patient safety enhancement

Quality Assurance and Improvement:
What existing and new clinical sonography programs should include in their CQM procedures to maximize the argument that the services rendered meet the highest standards.

Billing Procedures:
What insurers and government agencies will want included in the CQM procedures to facilitate proper reimbursement for services.

There are several ways the membership can assist and promote this process. To start, members should share their experiences and insights into CQM.

What problems have arisen at your hospital due to failure to use Clinical Sonography, ie, pneumothorax related to central venous cannulation? All CVC-related pneumothoraces are reportable events in New York State. Has your institution conducted a Root Cause Analysis (RCA) of such events? De-identified RCA could be shared amongst the membership.

Can you say, "Failure Mode and Effects Analysis?" FMEA is a recent addition to the CQM lexicon. It is entails predicting an adverse event prior to its occurrence at your facility, completing a proactive RCA, and (hopefully) preventing the event from ever happening.  All facilities must produce FMEAs each year and RCAs from one institution can be reconfigured into FMEA at other sites.

Future articles will give examples of RCA, FMEA, and other helpful hints on promoting patient safety and quality of care through clinical sonography.




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St. Luke’s Roosevelt Hospital, Ultrasound Division, Department of Emergency Medicine
5th Annual Regional Emergency Ultrasound Symposium

Turandot Saul, MD
Emergency Ultrasound Fellow
St. Luke’s Roosevelt Hospital Center
New York City

On April 9, 2008, the Ultrasound Division of the Department of Emergency Medicine, St. Luke’s and Roosevelt Hospitals held its 5th Annual Regional Ultrasound Symposium.

Drs. Marina Del Rios and Resa Lewiss directed the symposium which focused on Pediatric Critical Ultrasound. Over 400 participants including residents, fellows and faculty joined from New York, New Jersey, Connecticut, Pennsylvania, Rhode Island, Massachusetts, Colorado and California.

Lei Chen, MD, Associate Professor and Associate Director of the Pediatric Emergency Medicine Fellowship at Yale University spoke on "Assessment of Intravascular Volume in Pediatric Patients." He is currently researching the inferior vena cava (IVC) to aortic diameter ratio as a measure of volume status in pediatric patients. To date, he has found that this ratio measured in dehydrated children both pre- and post-hydration is an effective marker of intravascular volume status. In this scenario, ultrasound could prove to be a non-invasive means of assessing the dehydrated child.

James Tsung, MD, MPH, Associate Professor of Emergency Medicine in Pediatrics at Bellevue/ NYU Hospital Center then discussed "Point of Care Ultrasound for Pediatric Resuscitation." Dr. Tsung instructed how to systematically incorporate ultrasound in the basic airway, breathing, and circulation algorithm in pediatric resuscitation. He began with a literature based discussion supporting ultrasound for confirmation of endo-tracheal tube placement, followed by observing lung sliding and diaphragmatic movement for evidence of breathing, and finally with limited echocardiography and ultrasound guided peripheral and central venous access to evaluate circulation.

John Kendall, MD, FACEP, Associate Professor, University of Colorado Health Science Center and Director of Emergency Ultrasound delivered a lecture on "Ultrasound in Special Populations." Dr. Kendall discussed the unique difficulties encountered in the pediatric population including size of equipment and lack of familiarity with ultrasound applications among practitioners. He included a complete literature review of recent research in areas pertinent to children with special health care needs, eg, tracheotomy tubes, feeding tubes, central venous access, and optic nerve sheath diameter as a marker of elevated intra-cranial pressure in children with ventriculo-peritoneal shunts. Dr. Kendall proposed areas for continued research in pediatric critical ultrasound such as blunt abdominal trauma, peripheral vascular access and procedural guidance.

Faculty lectures were followed by three research presentations. Adam Sivitz, MD, from Hasbro Children's Hospital presented his research on "Diagnosis of appendicitis in children", Francesca Beaudoin, MD, from Brown University presented her research on "Ultrasound and femoral nerve blocks" and Nova Panebianco, MD, from University of Pennsylvania, presented her research on "Ultrasound guidance for peripheral venous access." A moderated poster session then followed where local fellows and residents presented their current research projects on ultrasound in diagnostics, procedural guidance and treatment. Presenters included: Amit Bahl MD, North Shore University Hospital; David Begleiter MD, Jacobi Hospital; Stephanie Doniger MD, St. Luke’s Roosevelt Hospital; Tara Khan DO, New York Methodist Hospital; Alexis Langsfeld MD, St. Luke’s Roosevelt Hospital; Yiju Teresa Liu MD, North Shore University Hospital; Sohan Parekh MD, Mount Sinai Hospital; Turandot Saul MD, St. Luke’s Roosevelt Hospital; Artur Treyster MD, North Shore University Hospital; and Michael Zimmerman MD, North Shore University Hospital.




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An Ultrasound Experience in South Africa 2008

David M. Solomon, MD, RDMS, FACEP
Jonathan Wassermann, MD

Emergency medicine is a new specialty in many parts of the world. In South Africa there are four accredited emergency medicine training programs each graduating their first class in 2007. Although there is ample enthusiasm for the specialty, depending on their practice environment emergency physicians often face resistance from other services and encounter obstacles in curriculum development.

In January 2008, in an effort to promote the budding specialty, a group of six emergency medicine physicians traveled to Cape Town, South Africa with the purpose of introducing emergency ultrasound into the local emergency medicine community. The group consisted of five US trained physicians (two fellowship trained, and three with a special interest in sonography) as well as one Swedish trained physician. The trip was conceived by Dr. James "Magnum" Sadock (Kings County/SUNY Downstate Brooklyn, NY) and was organized through the international non-profit association, Emedex and the University of Cape Town Division of Emergency Medicine. We held two two-day conferences at the Stellenbosch Medical University in Cape Town. The conference consisted of morning didactics and afternoon hands-on training sessions, covering the most commonly utilized emergency ultrasound applications. In addition to this we demonstrated some of the newer applications, such as ocular, pneumothorax, and DVT evaluations, and specific procedural applications. All participants were emergency trained physicians or registrars (training in emergency medicine). The conference gathered approximately 80 physicians from all over South Africa practicing in a multitude of different environments: public, private, urban and rural hospitals, and most of the participants had never been given full access to ultrasound technology.

The common thread among the participants was a motivated desire to take time out from their usual hospital duties to learn a new modality that could potentially improve care for their patients, regardless of the fact that some would still not have access at their own institutions. In talking to the local physicians, we noted that there was a varying degree of availability for many types of diagnostic imaging equipment depending on their practice location. Some physicians practicing in rural environments told us of not having ultrasound or CT scanning directly available at all and having to call the radiologist to come in from home even to obtain X-rays. Another common comment was that the radiology department often locked up the ultrasound machine, thus isolating the machine from everyone but themselves. Interestingly, even obstetricians often do not perform their own ultrasounds, but rather utilize the radiologist to perform these exams.

Although ultrasound is a widely used modality in South Africa (as it is in the rest of the world), CT scanning is often only approved and utilized by their radiologists after an ultrasound has been performed. In the US we have become accustomed to physician-performed bedside ultrasounds as a commonplace diagnostic tool available to the emergency practitioner in most emergency departments. However, many course participants expressed apprehension for future use of emergency physician-performed bedside sonography in South Africa, given the strict monopoly of diagnostic imaging by radiology in their local health care system. This was most apparent within the public sector, as some private sector physicians already had some basic familiarity with ultrasonography, albeit without formal training. These physicians informed us that they had more autonomy to use the ultrasound within their departments, without the usual restrictions imposed by Radiology.

The attributes that make ultrasound so useful in the ED (portability, ease of repetition, lack of ionizing radiation, real time interpretation) are also attributes that make it an ideal diagnostic modality for the developing world. Although start-up costs are steep, the long term operating costs are low. In South Africa where prenatal care in urban areas is limited, many patients do not receive any fetal imaging until presentation to the emergency department. The expanded use of ultrasound for limited fetal screening in this population is ideal to help lower maternal as well as fetal mortality.

The reviews we received after the courses were overwhelmingly positive, and there was amazing enthusiasm for the use of ultrasound in the ED setting. Since the course, we have had reports of participants starting to actively use ultrasound in their practice; performing FAST exams, gynecologic exams and an AAA evaluation. It is with some reservation that we must acknowledge that due to the limitations of access, resources and local traditional practices, putting these ideas into practice may prove to be an ongoing challenge. South African Emergency Medicine as it expands, may be about to engage in one of its many growing pains; the right to provide patients with better care benefiting from the evolution of medical technology.




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Moving Beyond SOAP – Where Should Clinical Sonography Research Collaboration and Networking Go From Here?

Lawrence A. Melniker, MD, MS, FACEP
Chair-elect, Emergency US Section, ACEP

Director, SOAP
Department of Emergency Medicine
New York Methodist Hospital

The Sonography Outcomes Assessment Program (SOAP) was born in the late 1990’s to promote outcomes research in emergency ultrasound. Since its inception, it has been a fully democratic organization in which all protocols were discussed in open meetings and made available to the EUS community; all databases are accessible to the any researcher wishing to analyze them and publish their findings. Most of the work was coordinated at and benefited from intramural funding from NY Methodist Hospital, Department of Emergency Medicine.

With limited resources, SOAP has plodded along and had measurable success. With invaluable contributions from eleven Emergency Departments from around the nation, we have completed four clinical trials each with a different Principal Investigator, published six manuscripts from 5 primary authors, and had ten national and 5 international abstracts presentations. SOAP-1 produced the Paper of the Year at ACEP Scientific Assembly 2005 and now is required reading for 2008 LLSA.

Our attempts to secure extramural funding have been decidedly unsuccessful. While we have obtained funds from private foundations and New York State; applications to professional organizations, NIH and AHRQ have been rejected. Often the reviews suggested a poor understanding of the practice of emergency medicine; let alone what emergency physicians do with sonography.

The question is: where should we go from here? The serious work that needs to be done in Clinical Sonography research will require enormous resources, both financial and individual. We must take this effort to the next step and develop a formal network with the infrastructure and accountability the task necessitates and which can procure the funding required to complete the work. The leadership and members of the ACEP US Section and the SAEM US Interest Group must consider this question carefully. We should discuss it further in October in Chicago and decide no later than May, 2009 in New Orleans, whether to build upon and remake what we have [a SOAP 2.0, if you will] or begin a new research network, under the auspices of a Steering Committee established from our ranks.

Several robust Emergency Care Research Networks (ECRN) now exist, which we could pattern our group after. The critical feature is to facilitate working together towards our common goal: to demonstrate the effectiveness and efficiency of clinical sonography, and its ability to improve the quality of care and safety of our patients.




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ACOG Practice Bulletin

The guidelines below replace Practice Bulletin Number 3 published December 1998. They do not represent a significant change in standard ED approach to management of pain or bleeding in early pregnancy. Lisa D. Mills, MD, FACEP

ACOG. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-gynecologists. Obstet Gynecol. 2008;111(6):1479-1485.

ACOG recently issued updated guidelines regarding the diagnosis and management of ectopic pregnancy. In the setting of suspected ectopic, the authors continue to recommend serial ultrasonography (US) and beta human chorionic gonadotropin (bHCG) levels.

The bHCG continues to be utilized to interpret a non-diagnostic US. The authors state that the "discriminatory zone" for bHCG remains 1,500-2,000 mIU/mL. At this level, a normal, single IUP should be visualized with transvaginal US. If the bHCG is higher than the discriminatory zone and the US is indeterminate, "ectopic pregnancy is likely." The bHCG levels are elevated in multiple gestation and may be misleading.

In a patient with an indeterminate US who remains stable and without significant abdominal pain, the authors recommend that serial bHCG be followed. If the bHCG rises appropriately (53% every 48 hours), the US need not be repeated until the bHCG reaches the discriminatory zone.




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Director Emergency Ultrasound Opportunity in Charlotte, NC

Mid-Atlantic Emergency Medical Associates (MEMA), an independent, physician owned practice of 60+ physicians staffing five hospitals in and around the Charlotte area, is recruiting an Emergency Ultrasound fellowship trained EM physician to develop and be the Director of our Emergency Ultrasound Program. This will be a stipended position with dedicated administrative time.  We offer the opportunity for equal ownership in a stable local group founded on fairness and equality. We are a community practice with no academic affiliations. Our flexible rotating schedule provides maximum time for family and leisure. Compensation package includes salary, incentive based profit sharing, health, life, disability, medical liability insurance, CME, excellent 401K/profit-sharing retirement plan. Send CV, Cover Letter to Mary Lu Leatherman, Physician Recruiter, 704-377-2424,, or visit our website,  




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Journal Watch – August 2008

Various Authors

Reviewer: Brandon Backlund, MD, FACEP

Seto E, Biclar L. Ambidextrous sonographic scanning to reduce sonographer repetitive strain injury. J Diagn Med Sonogr. 2008; 24:127-135.

Methods: This study compared the quality of images generated by experienced sonographers scanning with their dominant versus non-dominant hand on healthy volunteers. Each sonographer performed both a vascular and cardiac ultrasound with a standardized number of views according to a written protocol, first with their dominant hand, and then with their non-dominant hand. The sonographers were not trained or coached in techniques for performing the exams with their non-dominant hand. Each set of images was then reviewed by 2 expert reviewers who were blinded as to which hand had been used. The sonographers also completed a questionnaire about their experience, and were videotaped and observed by the researchers during their scanning. However, no statistical analysis was performed on the data obtained; raw data only are presented.

Results: All sonographers were able to generate the required sets of images with either hand. All the vascular images were thought by the reviewers to be adequate for diagnostic use, whether they had been obtained with the dominant or non-dominant hand. The cardiac reviewers were not asked to determine whether the images were adequate for diagnostic purposes. There was disagreement between the reviewers of both vascular and cardiac images as to whether there was a difference between the images obtained with the dominant versus non-dominant hand.

Discussion: This study sought to suggest that scanning with the non-dominant hand may help reduce the incidence or improve the symptoms of repetitive strain injury related to scanning by ultrasonographers. The authors cite an incidence of musculoskeletal pain related to repetitive motions among ultrasonographers of approximately 80%, and also cite literature suggesting that using the non-dominant hand may decrease the incidence or improve the symptoms of this problem. However, this study does not adequately answer whether sonographers can perform familiar exams of sufficient quality with their non-dominant hand, given the lack of appropriate statistical analysis and missing important endpoints. Emergency physicians who perform numerous ultrasound exams may consider trying to switch hands if they are experiencing pain related to performing scans.

Reviewer: Brandon Backlund, MD, FACEP

Talavera M, Horrow M. Chronic Ectopic Pregnancy. J Diagn Med Sonogr. 2008, 24:101-103.

Methods: This is a case report of a chronic ectopic pregnancy diagnosed by ultrasound with discussion and brief review of the literature.

Results: The patient was a female in her 20’s who presented to the emergency department complaining of left lower quadrant pain of a few weeks’ duration. Her history was significant for a dilation and curettage procedure five weeks prior to her ED visit for a nonviable IUP. Her serum B-HcG in the ED was 536 mIU/mL. Transvaginal ultrasound showed a heterogeneous left adnexal mass supplied by tortuous blood vessels, consistent with chronic ectopic pregnancy. This was confirmed by MRI. Methotrexate therapy was unsuccessful, and the patient underwent laparoscopy with excision of the mass and left salpingoophorectomy.

Discussion: Chronic ectopic pregnancy is the result of a tubal ectopic pregnancy that has had repeated micro-ruptures with the resultant formation of a hematocele that may also contain trophoblastic tissue and scar tissue. By ultrasound, it appears as a vascularized adnexal mass. Case reports exist of chronic ectopic pregnancies with undetectable serum B-HcG assays, some of which have ruptured; therefore, this entity must be kept in the differential diagnosis for a female of reproductive age presenting with pelvic or lower abdominal pain, even in the face of a negative pregnancy test. The literature regarding this condition consists primarily of case reports or case series, and the reported incidence ranges between 6-28% of all ectopic pregnancies.

Reviewer: Clifford J. Fields, DO

Original article: Hernandez C, Shuler K, Hannan H, et al. C.A.U.S.E.: cardiac arrest ultra-sound exam – a better approach to managing patients in primary non-arrhythmogenic cardiac arrest. Resuscitation. 2008; 76(2):198-206.

Comment in:Resuscitation. May 2008;77(2):270

Letter #1. Drs. Murphy, Nagdev, and Sisson from the Rhode Island Hospital Department of Emergency Medicine in Providence, Rhode Island, point out that the lack of lung sliding on ultrasound does not always indicate a pneumothorax. They reference a paper by Kirkpatrick (J Trauma. 2004; 57:288-95) that documented two cases of false-positive left-sided pneumothoraces secondary to right mainstem intubation. Right mainstem intubation caused decreased aeration of the left lung leading to lack of lung sliding on ultrasound exam. They caution us to consider the possibility of a right mainstem intubation in addition to the diagnosis of a pneumothorax as the cause of a lack of lung sliding on the left.




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