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Core vs. Advanced Applications
mstone
Posted: Saturday, September 1, 2012
Joined: 9/19/2011
Posts: 21


So there are a couple of writing groups working on resident and fellow curricula for emergency ultrasound, and trying to define specific applications as "core" (eg minimum standard for graduating ED residents - graduating EM resident's ability to practice 21st century EM might be compromised without these skills) vs "advanced" (eg fellow level or at least motivated senior resident level skills - could graduate from EM residency and not be proficient at these but still be a solid ED attending). 

Everyone's barometer will differ slightly on these, but would love to start getting comments from the Section so bring it on!!!


File Attachment(s):
Core or Advanced.doc (105984 bytes)

sachita.shah@gmail.com
Posted: Tuesday, September 4, 2012
Joined: 12/28/2010
Posts: 1


Hi,

This looks good overall. I would advocate to add FHR to core OB gyn, and gestational age/head position to advanced ob gyn, and move ocular EOMI and pupillary light reflex to advanced from core. Also IVC is in advanced for echo, but core for vascular- would be good to keep it consistent, and it probably is a core skill. Just my two cents!

Thanks

Sachita 


flanniganmatt@yahoo.com
Posted: Tuesday, September 4, 2012
Joined: 2/9/2011
Posts: 3


Hi,

Thank you for starting this discussion!  It will help guide our residency programs in stressing the value or competency objectives for our graduates.

I agree with Sachita, I believe IVC should be included in the core exam list.  Likewise, I think lens dislocation and undifferentiated "posterior segment" ocular detachment (Retinal, Posterior Vitreous, Choroid) should be included in the core exam category.  It may be easier to train physicians to recognize that a detachment is present rather than learn to differentiate between posterior segment detachments as a core exam objective.

Thanks for getting this conversation started!

Matt Flannigan

Michigan State University-Grand Rapids

Assistant Ultrasound Program Director


michael.mallin@hsc.utah.edu
Posted: Tuesday, September 4, 2012
Joined: 8/24/2011
Posts: 2


Couldn't agree more regarding IVC and Optic comments by Flannigan et al. Fluid assessment and IVC should be core content as medicine in general is moving more towards noninvasive assessment of fluid status. I suspect SOC is going this direction too and it would be a shame to have a lot of graduates have to go back and learn this stuff. While IVC may have variable utility, it think it should be a core application along with fluid assessment. 

As for ocular, I am less interested in residents being able to check pupils and more interested in retinal/vetrous detachment and ONSD. I think these two areas are of significant utility in day to day EM and thus should be considered core. 

In cardiac, tamponade is currently in advanced column. This is one of the few applications that can save actual lives. I think Tamponade should be considered core. Granted it's a hard exam to be definitive, but simply recognizing RV free wall collapse is not all that hard (less sensitive, but more specific). 

Finally, Ao Dissection is not a tough thing to pick up on Ao exam and just requires the application of color/power doppler. Worthwhile and big deal if it's missed. Should probably be core too. 


toddtaylr@hotmail.com
Posted: Tuesday, September 4, 2012
Joined: 7/2/2011
Posts: 1


I also think that IVC for fluid status should be a core topic. This is just my opinion but it is a very relevant exam for our undifferentiated shock patients.   Also tamponade as well is not too difficult and something that an ER resident should have knowledge of prior to graduating.  Retinal detachment is an exam that is very easy to do and could be in core as well.  It is interesting that FB removal is under the advanced section as well.  I would think that at least FB identification should be core. 

 


slotterm@gmail.com
Posted: Wednesday, September 5, 2012
Joined: 12/13/2010
Posts: 1


This is a great discussion. 

I think basic echo/IVC, eFAST, Aorta, 1st trimester ob should definitely be among the core topics taught to residents. I think these aide emergency physicians in management of critically ill, emergent patients when they are too unstable for CT imaging and/or there is no ultrasound coverage. I would also include ocular, soft tissue/procedures as core as well. 


resalewiss
Posted: Wednesday, September 5, 2012
Joined: 5/2/2011
Posts: 3


Hi everyone:  We are really glad to hear your thoughts and please encourage people with strong opinions on this topic to post as well.  When posting, the more specific you can be, the more helpful for us in fine-tuning a consensus table.  Best, Resa Lewiss
jminardi@hsc.wvu.edu
Posted: Wednesday, September 5, 2012
Joined: 6/3/2011
Posts: 6


Trauma - would add ptx to Core

Cardiac - would add RV strain to Core (possibly immediately life saving)

Procedures - maybe central and peripheral access need not be separated, but a more general vascular access that could include arterial as well in Core

Would consider an US in Shock heading with Core and advanced applications

 

Other nonemergent, but incredibly helpful ED applications that I would add to Core:

GI - would add ascites to Core

OB/Gyn - would add fetal cardiac activity to Core

MSK - would consider joint effusions and arthrocentesis in Core as these procedures are already Core without US and US techniques incredibly useful

 

For advanced skills:

Cardiac - consider adding diastology

OB/Gyn - advanced pregnancy evaluation, AFI, BPP, placental evaluation

Aorta/Vascular - would consider iliac aneurysm, aortic graft evaluations, advanced vascular, i.e. AV fistula evaluation, pseudoaneurysm, vascular access complications

 

 


jmjacque@gmail.com
Posted: Thursday, September 6, 2012
Joined: 12/21/2010
Posts: 1


Great discussion, overall document looks good.  Here are the changes I'd make:

Cardiac: move tamponade to core because of its emergent clinical importance...see vascular on IVC discussion

Ocular: move retinal detachment to core, consider FB and lens disclocation for core (could go either way with these two) and everything else advanced

OB: add fetal heart rate by M-mode calculation to core as well as detection of fetal movement

Procedures: add pericardiocentesis to core as this is much safer under ultrasound guidance and is of emergent clinical importance, add FB removal to core, move thoracentesis and paracentesis to advanced

Vascular: move IVC to advanced....not because it is technically advanced skill per se but current evidence questions its utility except at extremes...therefore, slightly advanced in understanding its utility presently...whereas measuring fluid responsiveness by CO noninvasively (bioreactance device like NICOM or by echo criteria) is advanced skill but likely more reliable indicator of fluid responsiveness.

 

Thanks!

 

Joshua


teddydaniels
Posted: Thursday, September 6, 2012
Joined: 7/6/2011
Posts: 4


This looks good to me except the ocular ultrasound part on basic skills. Other than knowing the eye is moving what can be gleaned from this? Did I miss a paper or something?

Dan

vms0419
Posted: Thursday, September 6, 2012
Joined: 10/15/2011
Posts: 2


Thanks for opening the discussion! It's a really great list as is, and I love the recs so far. Here is my table based on mostly my personal opinion, and on my shop's Resident and Fellow curriculum. 


Virginia Stewart, MD RDMS, RDCS



CORE

Basic knobs

Primary Survey

    Pericardial fluid

    Peritoneal fluid

    Pleural fluid

Fracture

Pericardial fluid

Asystole

Global LV function

Tamponade

Fluid assessment (w IVC)

Pneumothorax

Pleural fluid

Interstitial fluid

Abdominal Aortic Aneurysm

Aortic Dissection

Hydronephrosis

Qualitative bladder volume

Gallstones

Cholecystitis

EOM movement and pupillary reactivity

IUP yes or no

Free fluid in pelvis

Central line placement

Peripheral line placement

Arterial line placement

Thoracentesis

Paracentesis

Abscess drainage

Evaluation of tubes - SPT, Gtube, Jtube, foley

Foreign body removal

Lumbar puncture

DVT evaluation - upper extremity

IVC evaluation

Abscess vs. cellulitis

Identify Lymph nodes

 

 

ADVANCED

Secondary Survey

    ICP/optic nerve sheath      

Regional wall motion

Valvular assessment

RV size and function

Cardiac output estimation


HOCM risk identification (SAM, ASH)

RVOT

Aortic levels of PSSX- identify pulmonary a

Shunt calculation

Ventricular aneurysm

Ventricular/Septal wall rupture

Identify thrombus

Identify PFO

Peds congenital stuff below

Consolidation

Ventilator management

Suprasternal approach

Coarctation

SMA/Renal artery pvl (below)

Renal parenchymal assessment

Complex vs. simple cysts

Renal Doppler

Testicular torsion, epididymitis, cysts, fracture

Liver - assessment for masses, portal venous thrombosis, hepatopedal/fugal flow

Pancreas - assessment for masses, inflammation, cysts

Spleen - assessment for size, hematoma, parenchymal changes, identify neoplasm/masses

Appendicitis

Hernia assessment

Colitis, Ileus

Diverticulitis

Pneumoperitoneum

SMA PVL

Lens dislocation

Retinal detachment

Retrobulbar hematoma

Orbital emphysema

Foreign body

Optic nerve sheath diameter

Adnexal assessment for cysts or masses

Ovarian torsion

Uterine masses

Joint aspiration

Airway confirmation

Pericardiocentesis

Evaluation of arterial insufficiency, carotid stenosis/CIMT and transcranial Doppler

Myositis

Necrotizing Fascitis

Fractures, Joint Effusions,

Tendon, ligament and

muscular Injuries

Brachial plexus, forearm

Intercostal, TAP

Femoral, sciatic, tibial

Hip evaluation

Appendicitis

Pylorus stenosis

Intussusception

Lumbar puncture

Cardiac congenital: VSD, ASD, Tet of Fallot, Transposition

Evaluation of neck masses for airway compromise

Vocal cord assessment

Eval Peritonsillar abscess

 


dmantuani@yahoo.com
Posted: Thursday, September 6, 2012
Joined: 3/27/2011
Posts: 1


My 2 cents 

Agree that detachments (PVD/retinal) should be core occular US

Keep assessment of IVC

I strongly endorse placing lung US/interstitial fluid in the core skills. Simple exam to learn that often changes clinical management. No reason at all that this should be considered an advanced skill.

Tamponade should also be included. No point in just identifying a pericardial effusion.

Would also include arterial line placement (no different skill set from PIV)

OB: FHR, basic dating/CLR/BPD/HC

Daniel Mantuani


mstone
Posted: Thursday, September 6, 2012
Joined: 9/19/2011
Posts: 21


Thanks to everyone for the comments so far. Keep 'em coming. 

Given the overall direction of comments, I would like to chime in and play Devil's advocate for a minute. We are all (obviously) extremely pro-ultrasound and I think it's natural for us to want to add more and more applications to the Core column. But as per the initial post, Core skills are those that are essential to training (cannot do without them). I think there are many ultrasound applications that are relatively easily taught/learned/performed and positively impact patient care in select situations, but do not fit this definition of Core skills. Just because something is in the Advanced column doesn't mean it couldn't be part of your (or any other) training program's Core content; it just means it doesn't have to be. 

It isn't difficult for members of our community to construct specific scenarios where bedside ultrasound could have a significant impact on patient care, but as an example I'd put forth that it is an extremely rare instance that the inability to perform an ocular ultrasound would compromise a provider's ability to deliver quality care for a given patient.  If an ED doc saw a patient with painless visual loss and an equivocal physical exam, most of us would agree that discussing it with an ophthalmologist (while not as slick as making the diagnosis themselves) would meet the standard of care. Likewise, while I agree that aortic dissection is often easily identified (and I definitely look for it in my own practice), I find it hard to argue that being able to do so at the bedside is an essential skill: if I didn't feel comfortable with that application and suspected dissection, I'd order a CTA (which wouldn't delay care b/c almost every CT surgeon wants a CTA to delineate anatomy before deciding to operate and planning their approach).

So I guess I'm saying it might be useful as an exercise to look at the table again with a different perspective: imagine that if you take something from Advanced to Core, you need to take something from Core and move it to Advanced. In other words, pretend there's a fixed # of Core skills and see if you think that trades from Core to Advanced need to happen.

Thanks!

Mike


resalewiss
Posted: Thursday, September 6, 2012
Joined: 5/2/2011
Posts: 3


In other words, imagine an EM residency without an ultrasound fellowship director or ultrasound trained faculty.  In which point-of-care ultrasound skills must a program director be sure all graduates are competent?  This minimum standard is the core skills.

Resa


phinfey@hotmail.com
Posted: Friday, September 7, 2012
Joined: 1/21/2011
Posts: 1


My thoughts as an EM PD and advanced US user:
1) Bedside US applications that allow early identification of life/limb threats should be on the core list even if they are uncommon to rare.  

2) Many bedside US exams are cool/fun to do.  If current clinical practice is working well, we do not need to add bedside US to it.  If adding US to a clinical situation results in earlier diagnosis, more accurate diagnosis, faster throughput, less pain/suffering/harm, higher patient satisfaction, then let's consider adding it to the core list. 

3) We need to keep in mind that the average community EM doc sees a different spectrum of patients than some of us on this list and has different resources.  

4) Skill retention must be considered when adding exams to the core list.  How often do you all see patients with suspected retinal detachment or hemorrhage?  How often will an EM doc perform the exam in routine clinical practice?  If the answer is not much, we should keep it off the core list 

5) Some conditions are so common that we should, in my opinion, be adding more to the core skills list.  We see patients with chest pain everyday and orders ecg's and troponin and stress tests on very low risk patients.  Why wouldn't we add wall motion assessment to the core skills list.  We would perform the exam almost everyday and it would speed throughput and allow us to identify real problems sooner.  This would offend cardiologists but that's too bad for them.  

In summary, I agree with the attached document except that more should be added to the cardiac exam core and keep eye off the core list.  

Pat Hinfey

Newark Beth Israel 

phinfey@gmail.com

 


zolopang@hotmail.com
Posted: Friday, September 7, 2012
Joined: 4/18/2011
Posts: 2


Mike-

In a community spot on Long Island, Level 1 Trauma:

Core:

 

EFAST

Central Venous Access

IUP

AAA

Cardiac

Advanced:

Renal

Gallbladder

Procedural Guidance

Ocular

DVT

etc etc


rjones@metrohealth.org
Posted: Tuesday, September 11, 2012
Joined: 7/9/2011
Posts: 1


Great Discussion.

Here are my thoughts:

Trauma:  Should include PTX here under core since dealing with eFAST exam

Cardiac:  Add IVC to Core.  Add tamponade physiology to core---agree with previous comments on this.  Add RV size to core (but not RV function-keep in advanced)

Aorta: Regarding dissection, if we are talking about it as an incidental finding that should be recognized when you are doing a AAA eval, I would say it should be core.  However, we are talking about the skill set to look at the heart, thoracic aorta (suprasternal view), etc, then I would say advanced.

Renal: Under core--I think we should change qualitative bladder volume assessment to quantitative bladder volume assessment.  Under advanced--Ureteral stone eval should be added.  Urine jet eval should be added.  I am on the fence about core vs advanced.  We teach this and would lean toward core.

Hepatobiliary: Choledocholithiais/CBD evaluation should be added under advanced.  Would like to see it under core but don't think the average graduating EM resident still struggles with CBD eval

OB-GYN: Under advanced--add adnexal evaluation for ectopic pregnancy.  Under core: add free fluid in pelvis AND RUQ.  Since core has IUP yes or no then should have abnormal IUP and ectopic pregnancy in advanced.  Agree with adding fetal heart tones to core.  Agree with 1st trimester gestational dating (MSD and CRL) to core.  Any other later gestational dating measurements should be advanced.

Procedures: Pericardiocentesis needs to be under core--truly lifesaving

Soft tissue: Under advanced would it better to change myositis to deep space infection.  I noticed in some sections very specific diagnoses are listed and it others general diagnoses listed (muscular injuries).  How specific do we want to get here and if we get specific with a certain diagnosis do we need to include all other potential diagnoses?   

 

 

 


jamesmoak@yahoo.com
Posted: Tuesday, September 11, 2012
Joined: 6/1/2011
Posts: 1


Thanks very much for getting this discussion going.  One comment and one question: 

 

-- Move pericardiocentesis to core skills. 

-- How do you use ultrasound for ventilator management?

 

James Moak, MD, RDMS

University of Virginia


resalewiss
Posted: Tuesday, September 11, 2012
Joined: 5/2/2011
Posts: 3


Could you specify?

 

For cardiac, what would be Core and what would be Advanced?

For ocular, what would be Core and what would be Advanced?

For procedures, what would be Core and what would be Advanced?

 


gasparir@ummhc.org
Posted: Wednesday, September 12, 2012
Joined: 5/1/2011
Posts: 1


I would echo Mike's comments on core vs advanced.  Stating something is core means that residencies are expected to teach it.  Another way to think of this is that a resident who does not perform a core ultrasound could be considered outside of the standard of care.

 

Thoughts on ocular - Although many programs currently teach some ocular ultrasound, it is rare to find a resident that can differentiate a retinal detachment and a vitreous detachment. I agree that it is useful but my vote is for advanced.

 

I'm interested in other's view of pancreas ultrasound included as advanced. Although we do discuss the pancreas with our fellows, I would hesitate to suggest that we teach them to think of bedside ultrasound when evaluating the pancreas for masses, inflammation or other pathology. Along a similar line, we do not teach transcranial Doppler to our fellows.  I am a little unclear how this would be implemented into an ED algorithm. I am aware that some ED physicians perform this ultrasound but I question its inclusion in this document.

 

The inclusion of "renal doppler" confuses me a little.  Are we referring to resistance indices for transplants? Arterial waveform analysis? What diagnostic algorithm are we referring to?

 

I would advocate for inclusion of placental location in 3rd trimester pregnancy in advanced.

 

I would also add "assessment for peripheral venous or arterial structural integrity (post trauma) to either soft tissue or vascular.

 

Just my thoughts-

Romolo


vtayal@aol.com
Posted: Thursday, September 13, 2012
Joined: 12/6/2010
Posts: 1


I agree with the attached document but would caution that the ACEP 2008 Guidelines were written to include some use of each of the core applications list (Trauma, Pregnancy, Aorta, Cardiac, Biliary, Urinary Tract, DVT, soft-tissue/MSK, Thoracic, ocular, and procedures).  In other words, we included these applications as we saw any emergency physician using them in their practice, whether in an sophisticated Level1 tertiary ED, or in the middle of the desert in a war, or in a rural ED with limited backup and resources.

 

My own revisions to the document are:

Cardiac - include IVC (extremes are useful for volume assessment) and RV size (See Bob Jone's comments).  This is also important because we said in the FOCUS ASE-ACEP paper that we needed this.  In shock or PEA state, which all emergency physicians deal with, a large RV should be recognized.

 

Ocular  - I would say retinal detachment and vitreal hemorrhage are the reason that ocular is in the 2008 guideline. Whether taught through simulation, image recognition, or actual ED patient, they are easily detected.  I don't really see EOMI and pupillary size as pathologic, but glad to include

 

Procedures - Philosophically, we probably should emphasize the principles of US procedural guidance,(Long axis, short axis, inplane, out of plane) and just say they apply to any procedure the emergency physician is able to do.  I agree that each procedure as some subtlities, but that can be added during didactics.

 

MSK- joint effusions and fracture lines should be primary.  I agree tendon and ligament are advanced.

 

thanks for the effort. Very important work.

Vivek

Vivek Tayal, MD

Carolinas Medical Center

 

 


loweprofile92@yahoo.com
Posted: Monday, September 17, 2012
Joined: 2/28/2011
Posts: 1


Agree with document but include IVC as basic
fi5h@aol.com
Posted: Monday, September 17, 2012
Joined: 3/31/2011
Posts: 1


This is a huge topic and is most deserving of thoughtfulness. I will try to be brief (not my nature). Our goal for “core” skills should not be an ever expanding list ofstudies and findings, but a 100% training and adoption of the most basic,frequently occurring, and clinically important scenarios.

With this in mind I think it is quite important to distinguish a special training and interest in ultrasound imaging techniques (advanced imaging) from those techniques thatshould be regarded as “core” or those with characteristics that on a day to day basis improve patient safety, efficiency, reduce the cost of care and should bein the “toolbox” of every trained emergency physician.  Core indications are not what can be done, but are what trained emergency physicians should do.

Overall the current core indications are correct in my opinion with the exception of ocular.  I believe that ocular is an advanced technique and fraught with false negatives.  The frequency of ocular complaints warranting ultrasound evaluation is a very small percentage of ED visits and often the decision for immediate consultation is based on visual acuity and history.  While this is a cool technique and with experience can provide useful data (when positive) it is a hard one to justify in the credentials committee of community EDs and even has the potential to undermine ultrasound credentialing efforts. 

The other newer categories of core indications are excellentadditions.  However not every finding within every indication constitutes a core indication. 

·        Musculoskeletal/softtissue is a must (particularly soft tissue and joint taps); tendon function and defects are advanced.

·        Thoracicis quite useful, specifically fluid and air, interstitial edema isadvanced. 

·        DVT is a solid indication that should be more broadly adopted.

·        Procedural guidance ultrasound is not a new category, but dramatically and appropriately expanding in use.  It is as core as core gets andmust be pushed ruthlessly in training programs. Emergency physicians do procedures and this is a most important use of bedside ultrasound in terms of patient safety, efficiency and comfort.  Frequently these are privileges we are already credentialed to do and US just makes them safer.  Example, guided nerve blocks. 

Final thoughts - do not let the perfect be the enemy of the good –doing solid fundamental ultrasound is good. And, don’t set our specialty up with stringent, published “expectations”that become quoted as “standard of care” in medical negligence cases.

Steve Hoffenberg


sbomann@msn.com
Posted: Monday, September 17, 2012
Joined: 3/6/2011
Posts: 1


 

Femoral nerve block should be core.

RV strain should be core.

 

ONSD is still controversial, some believing it is an artifact.

It is unlikely to ever change the management of an ED patient.

It may not belong on any serious, ACEP document just yet.

 

Just my opinion.

 

Thanks to all who have worked on this.

 

 

 

 

 



 


hminniga@iupui.edu
Posted: Monday, September 17, 2012
Joined: 10/21/2011
Posts: 1


If I understand the document sent around with the link to this blog, I am being asked what are the minimum core skills for EM residency and Fellowship training levels.

 

The document is well done.  It may extend a bit beyond what I think is doable currently for some programs.  I think the core should be defined by the concept of life threatening situations that every graduating resident needs to be skilled at.

 

I think it is essential that Cardiac, Aorta, 1st trimester and FAST exams be part of a core at the resident level.  I include all the eFAST stuff in this.  I would also include the ability to integrate a RUSH analysis in the appropriate clinical scenario.

 

Gallbladder scans are considered core for some programs, and I would like it to be a goal, but might not be realistic for all programs at the resident level.  Should be core for fellows.  Similarly, I think renal scans are easy to teach at the residency level, but are not a required part of a core.

 

Overall the document circulated does do a good job with delineating the difference between the core residency skill set and the fellow level skills, though.

Hal  Minnigan


gmbaty
Posted: Wednesday, September 19, 2012
Joined: 11/8/2011
Posts: 1


As an EUS director for several years (who does the bulk of resident EUS education) and an APD for not so many, my two cents.

I think there are three main considerations for what should be considered "core"
a) what has actually been shown to make a difference in patient care or dispo
b) what general expert consensus thinks makes a difference (where there may not be good research done yet)
c) what is reasonable to expect an average residency to teach in a 3-year curriculum

for me, these criteria
for cardiac: rule in soft signs of tamponade (i.e. e wave velocity changes and E/A ratios belong in advanced but RV/RA collapse belong in core), IVC assessment, and eyeball estimate of RV size

for ocular: rule in undifferentiated posterior segment pathology
rule out ONSD, EOM movement (does this really need to be explicitly stated anyway?) & pupillary reactivity

for procedures: rule in vascular access of all types, centeses of all types, ability to id ST fluid collections

that said, I will say it is tough to get all residents (not just the 30% or so who are gung-ho about US) up to speed in all these areas without a pretty deep EUS faculty pool, i.e. faculty who are using these scans in their daily practice and doing them with residents during shifts.

-Gillian Baty


 
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