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TEE Credentialing
pererap
Posted: Thursday, April 28, 2016
Joined: 8/31/2011
Posts: 231


Hi All,
I am looking to establish an institutional pathway for ED physicians to use TEE during resuscitations and cardiac arrest. Has anyone worked collaboratively with your anesthesia or cardiology colleagues to get credentialed in limited point of care TEE (4 or 5 views). If so, do you mind sharing your experience and/or credentialing documents?
Best,

Ross Kessler

Co-Director of Clinical Ultrasound University of Michigan


pererap
Posted: Thursday, April 28, 2016
Joined: 8/31/2011
Posts: 231


Ross,
Did anyone respond to this?  I would be interested in getting together a group of ED TEE users at ACEP to collaborate on guidance/standards for ED TEE - operations, credentialing, qa, etc... if useful, this might be separate from or added to the current acep guidelines.
I'm not sure how many departments have TEE probes in use but I know there are an increasing number of us out there.
Anyone else?
Phil

Phil Andrus, MD, FACEP

Associate Professor of Emergency Medicine

The Mount Sinai Hospital Icahn School of Medicine at Mount Sinai


pererap
Posted: Thursday, April 28, 2016
Joined: 8/31/2011
Posts: 231


Phil,

At our shop we will have access  to a TEE machine.

Initially we will be using it with all cardiac arrest patients. 
I am interested in being in this group. 


Maria O'Rourke, MD

GME Director of Emergency Ultrasound

Department of Emergency Medicine

Kaweah Delta Health Care District

400 W. Mineral King Visalia, CA  93291-6263


pererap
Posted: Thursday, April 28, 2016
Joined: 8/31/2011
Posts: 231


We have one at UCI but haven't used it yet. Very interested in next steps.  
Chris Fox
pererap
Posted: Thursday, April 28, 2016
Joined: 8/31/2011
Posts: 231


Please count me in.

Lawrence Decker, MD

Associate Professor of Military and Emergency Medicine

Uniformed Services University


pererap
Posted: Thursday, April 28, 2016
Joined: 8/31/2011
Posts: 231


Also following with interest.  While our shop doesn't have a TEE probe that I know of, the possibilities are intriguing. -b
Brendan Byrne, MD

Assistant Professor of Military and Emergency Medicine

Uniformed Services University


pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


Drs. Andrus & Kessler, 
Our ultrasound team at UIC has been entertaining this thought as well. Would love to be part of this conversation. 
Thanks, 

Pavitra Kotini-Shah, MD

Clinical Assistant Professor

Ultrasound & Resuscitation Assistant Fellowship Director

Department of Emergency Medicine

University of Illinois at Chicago


pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


We're getting one shortly and would also be interested. 
Thanks, Dasia

Dasia Esener, MD, FACEP 

Fellowship Director, Emergency Ultrasound 

Department of Emergency Medicine 

Kaiser Permanente - San Diego 


pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


At the University of Utah we have had a TEE program active for a little over 2 years. I'd be happy to share our experience.  Although I will not be at ACEP, Patrick Ockerse (Our fellowship director) will be there and could offer input in a discussion on TEE application in emergency medicine. 
Here's a few pearls I've learnt' along the way:
1) Cleaning: Cleaning was one of the biggest hurdles to implementation. High level disinfection is required and often the best way to achieve this is by piggy-backing onto an already existing program. We ended up going with our central (surgical) processing lab. Alternatives are using cardiology or anesthesias cleaning programs. If all else fails, find out who is cleaning the GI scopes. The facility should pay for cleaning as it's included in maintenance of the equipment. Start this process early, even before you have the probe. Otherwise you'll have a probe you can't use for months. 
2) Education: Obviously going to vary based on your local politics and TEE experience of Anesthesia, Cards, Critical care at your institution. We are lucky to have a close relationship with anesthesia at our institution. They also run an echo lab at an affiliated hospital. I obtained by education from them and another local critical care group and have managed to negotiate dedicated time for our fellows who are interested in advanced echo. So talk with your cardiologist and cardiac anesthesiologist. The thoracic surgery cases are a great opportunity to practice and get images. Outpatient TEEs will be harder to get your hands on.
Also, ask around and see if anyone has a simulator. If so, you're golden! Get on the simulator and practice, practice, practice. Each one of those cases can count towards credentialing (at least in my interpretation).
3) Privileging: We recently applied for and obtained global privileging for "point-of-care, limited ultrasound."  Under my interpretation, limited TEE for arrest or "peri-arrest" patients is included as "point-of-care limited ultrasound." We should get away for listing modalities to our privileging committees.  
4) Credentialing: I think this is up for interpretation. Cardiac ultrasound, is cardiac ultrasound. The images aren't much different, so do you REALLY need 25-50 MORE TEE scans after you've met your cardiac imaging criteria.? I don't think so, not for the limited views we are obtaining: ME-A4, ME-Long, Gastric Short axis, Bicaval. I think once cardiac ultrasound criteria are met 10 proctored exams (the criteria we use for procedures) is a reasonable starting point. Love to hear other's opinion on this.
5) Who to TEE? Start with intubated, cardiac arrest patients. This patient group has the greatest risk:reward ratio in my option. Additionally, I believe conceptually this will lead to less turf battles early. 

Just a few thoughts. Hopefully we can get a group together at ACEP.  Maybe a Google hangout would be a better option?  Maybe we should podcast it. 
best Mike

Mike Mallin, MD FACEP

University of Utah, Div of EM Assistant Professor of Surgery

Director Emergency Ultrasound Director of Education


pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


Thanks Mike and to everyone who responded about TEE. It definitely appears there is a lot of enthusiasm for incorporating TEE further into our practice in the ED. We are going to be working towards creating guidelines and definitions for point of care TEE within the section’s critical care ultrasound committee. If I haven’t heard from you, and you would like to be involved/collaborate, definitely let me know. For those who have already contacted me, will be in touch about next steps moving forward.
Best,
Ross
pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


I'm also a anesthesiologist here in Costa Rica, since that I and capable of use TEE in (mandatory) in cardiac surgery and also in high risk surgery (hepatic transplant).  As mentioned previously, the benefits from using this tool, are way beyond the risks in critical patients an in emergency situations.  It's learning curve is not only shorter but steeper that in the TTE cardiac echo, at least for some views (in my personal experience), the TEE will give you straight answers on patients. Downside the probe is too expensive and will last for less than 1000 scans, it will be really stuff to get that for a country such as ours. Definitely interested.

Yannis Amador

Anesthesia & Emergency Medicine

Costa Rica 


pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


Hi Ross I'm loving  the  response you are receiving on this. We tried to get this off the ground with the ImaCor  device before you started residency. Absolutely no traction. The critical care people were like "huh?".
A decade on, our specialty has its own way forward in critical care, allowing it to start defining its own agenda and practice in this field with its own  resuscitation units in the ED. (I'm sure the one that's being developed in your shop is driving this). Also nice to see how once again EUS is creating new modes of practice not just within EM, but in medicine. How cool is that?
In case they missed this thread, I am CCing Kenton and Alfred. Both have done some work with TEE. Also Mike, who was using it a decade ago.  maybe he can point you towards some of his ex fellows who are using it if if he is not continuing with it at this time. Also John, in case he thinks there's any chance of us resurrecting  this at Penn

Let me know if I can be of any help.

Anthony Dean, MD


pererap
Posted: Friday, April 29, 2016
Joined: 8/31/2011
Posts: 231


Hello all,
I wanted to share this article with you.  So often, we read confrontational statements regarding POC US from societies outside of EM.  It is heartwarming to come across something with a very positive message.  I thought this was well written.  I particularly appreciated the statement:  “There is no denying that if I were to suffer a sudden hemodynamic collapse and would wind up in an emergency department, I would want it to be one in which the emergency physicians were fully trained in POCUS (point of care ultrasound) and knew how to apply it to patient care.”
Thanks.
Mike

Michael D. Zwank, MD, RDMS, FACEP

Research & Ultrasound Director

Regions Hospital Emergency Department

Associate Professor

Department of Emergency Medicine

University of Minnesota


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