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Emergency Ultrasound

Peter’s Pet Peeves: Ultrasound Proficiency

By Peter Kumasaka, MD

Ultrasound has been used in the Emergency Department for decades, yet still many EPs are uncomfortable with performing them. And our Rebel Alliance of Emergency Medicine continues to be assailed by the Dark Side led by Darth Rader (ologist) citing poor image quality or inadequate imaging of our studies. Unfortunately, many in our Rebel Alliance, have not attained the status of a POCUS Knight, much less Master.

These POCUS Padawans may have taken a course or reviewed one of the many blogs available, but like young Luke, they need to practice using the Force before they can become a Jedi Knight. “Not think, young Padawan. Do.” We may be seduced by how cool this Force can be, but we can’t forget that we need to train AND practice it before we can consider ourselves worthy. Indeed, the training of image acquisition may be more important in becoming a POCUS Master.

Yoda would probably agree with Malcolm Gladwell in professing the 10,000 hours of focused (Pocused?) practice needed to achieve mastery. Just as the Force is inherently strong in some people, some EPs have a natural “gift” of performing US, and others have to work harder to achieve mastery. But even though the Force was strong in Luke, he still had to practice. OK, so maybe 10,000 hours is a bit excessive, but just watching a few videos or attending a lecture certainly “does not a Master make!”

So how do we encourage EPs to actively perform more studies and get their “10,000 hours”? The proliferation and abundance of filled pre-conference and US specific skills courses seems to suggest that recent EM residency grads as well as grey haired EPs feel the need to still work on their skills. At one of these conferences, the lecturer commented on running into an EP that attended his conference a year earlier. “I loved your course!” the EP commented. “Great to hear that. How are things going?” “To be honest”, the attendee replied. “I really haven’t had time to use it.” Though he took the course, he felt the time pressure of today’s busy ED. No Wait EDs. Dispo in 180 minutes. Next patient. The US machine was becoming a space occupying mass in his ED.

Overall, POCUS can speed our work up and provide, better, safer and faster care of our patients. But there is a learning curve during which time, a FAST may not be so fast. Does that prevent some from taking time to use it? “Well just come in on one of your off days and do some scanning.” And did you hear about the new POCUS application written up in last month’s journal? We should be doing those exams too!

It is so amazing to discover an unsuspected pericardial effusion and gratifying to confirm your suspicion of abdominal aortic aneurysm in seconds at the bedside. That alone SHOULD be impetus enough to get out and perform more US and become more proficient. ACEP has stated that POCUS is an essential competency for the practicing EP. The ACGME has stated that US is a core competency needed for graduation. Similarly, the ACGME lists intubation and tube thoracotomy as core competencies that EM graduates have to be able to perform. Would you accept it if an EP wasn’t proficient in intubating a patient?

There really is no argument that we EPs shouldn’t be proficient at POCUS. And with all procedures, competency comes from practice. Maybe not 10,000 hours, but we need to get our reps (repetitions) in. How do we motivate the masses of EPs already in practice to put in their reps? Maybe with baby steps? Is one scan per shift too much to ask?

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