Learning outcomes for POCUS-GIMUS

While this bootcamp is an introductory course to US in GIM, we hope to provide you with a strong foundation on which to further develop skills during your GIM training. Our overarching focus is to enhance your skill set in the use of US as an adjunct to the clinical examination and as a tool to resolve troubling bedside pathology. This set of learning outcomes is adapted from a series of resources including the Canadian Internal Medicine Recommendations and the Canadian CCUS recommendations (See ref below). We will focus on interrogating the following clinical conditions and procedures:

  • Undifferentiated respiratory failure: identification of pneumothorax and other pleural/parenchymal pathology
  • Undifferentiated hypotension and shock
  • Enhanced approach to volume status
  • Interrogating the abdomen for free fluid & enabling paracentesis.
  • Interrogating the chest for pleural effusions & enabling thoracentesis
  • Interrogating select joints for effusions to enable arthrocentesis.

Learning Outcomes

At the conclusion of this GIM u/s bootcamp, GIM trainees will be able to

Machine basics, physics and knobology

  • Identify basic physical principles required for sonographic image generation and optimization.
  • Differentiate common sonographic artifacts that may confound sonographic assessment.
  • Select appropriate imaging mode and ultrasound probe (including linear, phased-array, curvilinear) for specific clinical examinations and indications.
  • Identify key factors and best practices in safe equipment storage, infection control and maintenance.
  • Recognize limitations and scope of training for GIMUS applications.
  • The trainee must acknowledge when a particular indication or finding may require urgent or routine consultation with a more advanced echocardiographer.

Focused cardiac ultrasound

  • Acquire satisfactory trans-thoracic acoustic views including parasternal long axis, parasternal short axis, apical 4-chamber, subcostal 4-chamber and IVC view.
  • Perform a visual assessment of LV function including systolic function and describe basic quantitative measurements.
  • Perform a visual assessment of RV function and IVC including basic quantitative measurements.
  • Perform accurate visual assessment of the pericardium (vs pleural space).
  • Acquire an understanding and approach to specific conditions including severe LV dysfunction, tamponade, RV strain and cardiogenic shock.

Volume status

  • Integration of dynamic measures of the IVC, focused cardiac ultrasound and lung ultrasound assessment with a patient’s clinical evaluation of volume status.
  • Use of ultrasound to identify and evaluate the jugular venous pressure.
  • Apply an algorithmic-based approach to evaluation of volume status.

Lung and thoracic ultrasound

  • Identify and recognize basic lung artifacts essential to recognition of normal lung aeration, potential pneumothorax or parenchymal pathology: A-lines, B-lines, sliding lung, lung point, lung pulse and consolidated lung tissue.
  • Characterize limitations and false negative/positives of lung ultrasound.
  • Knowledge of the limitations of not visualizing lung sliding/B lines and other lung artifacts.
  • Identification and description of the the typical anatomic boundaries of the pleural space: diaphragm, chest wall, ribs, visceral pleura, normal/consolidated/atelectatic lung
  • Identification and description of a potential effusion including an anechoic space, spine sign, diaphragm, respiro-phasic space change, lung atelectasis and orientation of the pleural and sub-diaphragmatic space.
  • Performance of gross assessment of fluid volume (i.e. small vs moderate-large).
  • Recognition of specific limitations of ultrasonography to identify pleural fluid, such as inadequate image quality due to technical limitations, subcutaneous emphysema, hemothorax, echo-dense purulent fluid, mimics of effusion such as ascites.
  • Begin to understand the use of US in thoracentesis including identification of a site, angle, and depth for safe needle penetration and to evaluate for post-procedure pneumothorax.

Focused abdominal ultrasound

  • Identification and description of intra-peritoneal free fluid with typical anatomic boundaries: anechoic space, abdominal wall, diaphragm, liver, gallbladder, spleen, kidney, bladder, bowel, uterus, spinal column, aorta, IVC.
  • Differentiation of distended bladder from ascites in the pelvis
  • Recognition of specific limitations of ultrasonography to identify intraperitoneal fluid such as inadequate image quality due to technical limitations and bowel distension.
  • Begin to understand the use of US in paracentesis including identification of a site, angle, and depth for safe needle penetration.

Musculoskeletal ultrasound

  • Appreciate high definition musculoskeletal ultrasound as a diagnostic tool.
  • Apply the basic principals of ultrasound to musculoskeletal ultrasound evaluation and make appropriate adjustments.
  • Become familiar with normal knee sonoanatomy.
  • Demonstrate basic ability to detect moderate to large knee effusions.
  • Understand the utility of MSK ultrasound in guided MSK procedures.

Communicator

  • Communicate effectively with colleagues, patients and families with respect to bedside vs confirmatory/comprehensive imaging.
  • Communicate and document ultrasound findings appropriately within the context of patient care.

Collaborator

  • Work effectively in collaboration with specialty consulting services including cardiology and diagnostic imaging.
  • Ensure appropriate referral to comprehensive u/s studies are conducted in a timely and appropriate manner.

Manager

  • Able to manage time effectively including integration u/s with clinical practice.
  • Understand medico-legal implications and concerns regarding ultrasound in routine patient care.

Professional

  • Seek additional help if concern or possible risk with any ultrasound-based assessment or guided procedure.
  • Treat patients and colleagues with respect
  • Be accountable and responsible

References

Ma IW, Arishenkoff S, Wiseman J, et al. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med. doi:10.1007/s11606-017-4071-5.

Arntfield RT, Millington SJ, Ainsworth CD, et al. Canadian recommendations for critical care ultrasound training and competency. 2014;21(6):341-345.