It is expected that you will have read and familiarized yourself with the following document(s) PRIOR to starting your rotation.  Please report to the RAH Echo lab (across the hall from the CICU procedure room) at 8:30 a.m. on your start date after the CICU Orientation for a brief tour of the lab with one of the sonographers.  Following that, please introduce yourself to the cardiologist of the day.  If you will not be present or will be delayed on the first day, please notify the echo clerks at 780-735-6451 so they can notify the sonographers. If you have any questions or concerns, please contact the Echo rotation supervisor, Dr. Lamb at tlamb@ualberta.ca, 780-203-1536 or by pager.

Please note that there's two different orientation documents depending on the type of learner (off-service vs. cardiology)

Please review the correct orientation document

Trainees on the Echo rotation require access to ISCV, an AHS IT application used for reading Echos. If you do not already have access, please submit an access request to AHS IAM. The submission process is similar to the process detailed in the IMPAX Access Procedure instructions. For the Authorized Approver, please select either:

1. • Georgina Reid (Georgina.Reid@albertahealthservices.ca), or

   • Rachel Knezevic (Rachel.Knezevic@albertahealthservices.ca)

If you have any questions for the following, please contact:

Access:

• The Mazankowski Clinical Informatics team:

  • Mark Gajadhar Mark.Gajadhar@albertahealthservices.ca (780-407-3933)

  • Doven Mah Doven.Mah@albertahealthservices.ca (780-407-4234) 

ISCV Issues:

• AHS IT at 1-877-311-4300

• Submit a ticket at Fix Something - ServiceHub

Please do not submit a GSR on ServiceHub.

EXPECTATIONS AND RESPONSIBILITIES 

We expect you to make a reasonable effort to attend the echo lab and take part in its daily activities (0830-1630 daily), above and beyond simply reviewing cases with cardiology staff. 

The ultrasound techs are accustomed to working independently, but if they see that you are available and interested, they may ask you to review a case or a puzzling finding at the bedside, to consider the use of Definity contrast, and so forth. If you are disinterested or not available, you will miss out.  A good attitude is noticed and appreciated! 

Please leave your contact information with the communications clerk the first week, and provide support to the technologist when called upon. We do understand that you have rounds and other commitments at the UAH site as well. If you are going to be unavailable, please let the clerk know. 

The appropriate utilization of echo contrast at our site can be challenging, as echo staff are not always readily available for this task. Our sonographers are not able to give contrast independently. Your help in this regard is appreciated. 

We occasionally scan patients from peripheral hospitals and you may be asked to review the study before the patient is dismissed (in the event that the cardiologist is not immediately available). If you are not comfortable with this or feel that cardiology staff input is needed, feel free to contact us.  

Opportunities to assist with or perform pericardiocentesis arise periodically. 

We sometimes have in-house echo rounds, largely for the benefit of the technologists. You may be asked to present these rounds (typically the last Wednesday of the rotation at noon). 

Please let us know if you have questions and/or if problems arise. 

ECHO Resident Orientation - Off-Service

ORIENTATION FOR RAH ECHO ROTATION 

For ‘Off-service’ Trainees

Welcome to the Royal Alex Echo Lab! We sincerely hope that you have a positive experience. Please report to the echo lab at 8:30 each day in order to ensure that you’re able to participate in the first case of the day. Generally, it is expected that you are present in the echo lab until approximately 17:00 each day. Please introduce yourself to the sonographers and clerical staff at 8:30 on the first day – one of the sonographers will give you a brief introduction to and tour of the lab. Following this, please introduce yourself to the cardiologist of the day. It is expected that you will have read and familiarized yourself with this document prior to starting the rotation. If you have questions or concerns feel free to contact the lab director and rotation supervisor Dr. Tyler Lamb at tlamb@ualberta.ca, 780-203-1536 (cell) or 780-445-6970 (pager). 

Important Note: Regarding RAH Echo Connect Care / Philips ISCV access for viewing and reporting echos, please send an email to the individuals listed below to confirm you will be coming to the lab on rotation so they can ensure you are set up and ready to go when you start.

1. Mark Gajadhar (Mazankowski Clinical Informatics) Mark.Gajadhar@albertahealthservices.ca 

2. Alefiyah Gulamhusein (RAH US Diagnostic Imaging Manager) alefiyah.gulamhusein@albertahealthservices.ca 

3. Cc' Dr. Lamb (RAH Echo Rotation Lead) tlamb@ualberta.ca 

Primary Objective: the primary objective of this rotation is to develop a basic understanding and familiarity with echocardiography through scanning and preparing preliminary reports.

Image Acquisition: By the end of the rotation trainees should be able to acquire images adequate for determining LV and RV size and function, valvular structure and function, determining the presence or absence of a pericardial effusion, determining aortic root size and assessing the IVC. Ideally, you will be able to complete one full scan from start to finish by the end of a 4-week rotation.

Interpretation Skills: By the end of the rotation, trainees should be able to:

• Classify LV systolic function as either normal or mildly, moderately, or severely depressed

• Recognize significant RV enlargement and/or dysfunction 

• Estimate volume status on the basis of LV size and function, IVC size and collapsibility

• Correctly identify a normal versus abnormal aortic root 

• Recognize potentially significant valvular heart disease

• Recognize the difference between a physiological and mild/moderate/large pathological pericardial effusions and recognize some features suggestive of tamponade 

If you have not seen important pathologies (such as mitral stenosis, LV thrombus, vegetations, and so forth) as the rotation draws to a close, please ask for these to be demonstrated from the electronic archive. 

TEE Objectives 

• Develop a basic understanding of the complementary role of TEE in various clinical settings

• Scanning and reporting TEE studies is not a learning objective for this rotation 

Background – Scanning 

There are generally three to four technologists assigned to echo each day. Identify yourself to them and they can assist you and act in a supervisory role, according to your level of experience. Due to workflow and productivity considerations, there will be limitations on how much scanning time you have with each patient.

Daily Workflow 

The cardiologists staffing schedule changes somewhat from week to week according to CICU and ward duties, outreach clinics, holidays, and the like. The multi-colored "operations” schedule has the daily assignment and can be found in the reading room, or you can check the list by the main ultrasound desk. Each staff person has competing responsibilities, urgent TEE's and so forth, so the staff’s schedule and presence in the reading room is not consistent from day to day. In general, staff will spend the first part of their day performing and interpreting outpatient TEE’s (or sometimes stress echocardiograms) and the latter part performing inpatient TEE’s (anywhere from 0 – 2 day) and interpreting TTE’s. We encourage you to “pre-read” the echo studies prior to review with staff (generate a preliminary report). You may summarize your impressions on the patient’s echo report in the ‘conclusion’ section. This is a good way to improve your interpretive skills and gives us a sense of your knowledge level. 

Expectations and Responsibilities

• Regular attendance in the echo lab during the working hours (Monday to Friday 08:00 - 17:00 hrs)

• In general, scanning in the mornings and, depending on your progress and scanning/reading numbers, further scanning or reading only in the afternoons. Typically, the beginning of the rotation is primarily focused on scanning (and interpreting those scanned studies). Once you have become comfortable with scanning, you can switch focus to performing interpretation including on studies you have not yourself scanned 

• Reviewing transthoracic echocardiograms with staff as time permits. Typically, such review occurs in the later part of the day. As mentioned, the cardiology staff generally spend the beginning aspect of the day performing outpatient TEE’s or stress echocardiograms and may only be available in the latter part of the afternoon 

• Observing, assisting with, or performing (under supervision), echo-guided pericardiocentesis, when an opportunity arises 

• Participation in the RAH cardiology call pool (attend CICU sign-out round between 16:00 and 17:00 hours) 

Other Educational Opportunities 

• We periodically have in-house echo rounds, largely for the benefit of the technologists. These happen once every month or two on Wednesdays at noon – you are expected to attend 

• Cardiology Divisional Rounds – Thursdays at 11:30 AM, Robbins Learning Center, lunch provided – you are expected to attend

• Staff echo rounds are held 2 - 3 times per month. These usually occur on Thursday mornings at 7:00 AM in the teaching room on unit 1E – optional

• Cardiovascular surgery rounds are held every Friday at 7:00 AM. These rounds are a great opportunity to see TEE/TTE cases discussed and also provide a rich opportunity to learn about general cardiology concepts as well – optional 

Resources 

• Orientation Binder – kept in the reading room, also contains a section on Definity and agitated saline contrast 

• "Put the Probe Here” – introductory manual 

• “The Echo Manual” by J. Oh and J. Seward

• ASE guidelines: easily available by internet search. Many of the hallmark guidelines are available in the lab paper copy as part of two ring-bound ‘ASE Guidelines’ books kept in the lab

• ASE Textbook – a copy is kept in the lab

• Otto’s “Textbook of Clinical Echocardiography’ – a copy is kept in the lab

ECHO - Resident Orientation - Cardiology - Level 2

ORIENTATION FOR RAH ECHO ROTATION 

For Cardiology / Echo Trainees – Independent Reader Training Pathway 

Welcome to the Royal Alex Echo Lab! We sincerely hope that you have a positive experience. Please report to the echo lab at 8:30 each day in order to ensure that you’re able to participate in the first case of the day. Generally, it is expected that you are present in the echo lab until approximately 17:00 each day. Please introduce yourself to the sonographers and clerical staff at 830 on the first day – one of the sonographers will give you a brief introduction to and tour of the lab. Following this, please introduce yourself to the cardiologist of the day. It is expected that you will have read and familiarized yourself with this document prior to starting the rotation. If you have questions or concerns feel free to contact the lab director and rotation supervisor Dr. Tyler Lamb at tlamb@ualberta.ca, 780-203-1536 (cell) or 780-445-6970 (pager). 

The primary objective of this rotation is to gain experience and proficiency in echocardiography with a primary focus on interpretation skills. In addition, we suggest that you aim to scan one or two patients per day, though you are welcome to scan more patients if you wish to do so. A suggested approach is to start the day scanning for the first one or two cases then spend the rest of the day reporting. 

BACKGROUND - SCANNING 

There are generally three to four technologists assigned to echo each day. Identify yourself to them and they can assist you and act in a supervisory role, according to your level of experience. At least one of the techs will have a special interest and expertise in echo. When possible, it is ideal to work with one of these individuals. We have GE machines - the techs can show you how to use them. 

Please note that our site is a training center for NAIT ultrasound students. Generally, the NAIT student and supervisor will use one of our four machines. Sometimes TEE's occupy another machine, and this may reduce scanning opportunities as well. Nonetheless, we have a high volume of cases, and there are ample scanning opportunities for those willing to take the initiative. Please note that your ability to acquire adequate 2-D and Doppler images is part of your evaluation and may well be formally tested at the end of your rotation.

DAILY WORKFLOW 

The cardiologists staffing schedule changes somewhat from week to week according to CICU and ward duties, outreach clinics, holidays, and the like. The multi-colored "operations” schedule has the daily assignment and can be found in the reading room, or you can check the list by the main ultrasound desk. Each staff person has competing responsibilities, urgent TEE's and so forth, so the staff’s schedule and presence in the reading room is not consistent from day to day. In general, staff will spend the first part of their day performing and interpreting outpatient TEE’s (or sometimes stress echos) and the latter part performing inpatient TEE’s (anywhere from 0 – 2 day) and interpreting TTE’s. We encourage you to “pre-read” the echo studies prior to review with staff. You may summarize your impressions on the patient’s echo report in the ‘conclusion’ section. This is a good way to improve your interpretive skills and gives us a sense of your knowledge level. 

You are welcome and encouraged to observe some TEE studies while on rotation, and from time-to-time (at the discretion of the staff cardiologist) there may be opportunities for “hands-on” experience, particularly for those of you with a special interest (such as those going on to do an echo fellowship). However, it is not our mandate or obligation to teach TEE procedural skills to cardiology trainees outside of a formal echo training program. Pericardiocenteses are occasionally performed and are an excellent learning opportunity for you – we will make every attempt to involve you in these procedures. 

From time to time, learning opportunities arise that may not be readily available at the UAH site, and we encourage you to take advantage of these. These include mitral balloon valvuloplasty (with peri-procedural TEE) and alcohol septal ablation for HCM. Stress echo is also performed frequently at our site, and you are welcome to participate in these studies as well. 

EXPECTATIONS AND RESPONSIBILITIES 

We expect you to make a reasonable effort to attend the echo lab and take part in its daily activities, above and beyond simply reviewing cases with cardiology staff. The ultrasound techs are accustomed to working independently, but if they see that you are available and interested, they may ask you to review a case or a puzzling finding at the bedside, to consider the use of Definity contrast, and so forth. We occasionally scan patients from peripheral hospitals and you may be asked to review the study before the patient is dismissed (in the event that the cardiologist is not immediately available). If at any point you feel uncomfortable or unsure about how to appropriately advise the sonographers or feel that staff input is needed, please feel free to contact us. We frequently utilize echo contrast at our site, and we feel that residents have a valuable role with administering contrast as echo staff are not always readily available for this task. Please leave your contact information with the communications clerk the first week and provide support to the technologist when called upon. If you are disinterested or unavailable, you will miss out. A helpful and pleasant attitude will be noticed and is greatly appreciated! 

OTHER EDUCATIONAL OPPORTUNITIES 

• We periodically have in-house echo rounds, largely for the benefit of the technologists. These happen once every month or two on Wednesdays at noon – you are expected to attend and occasionally may be asked to present

• Cardiology Divisional Rounds – Thursdays at 11AM, Robbins Learning Center, lunch provided – you are expected to attend 

• Staff echo rounds are held on the first and third Thursday AM’s of each month at 7AM in the teaching room on unit 1E – you are encouraged to attend 

• Cardiovascular surgery rounds are held every Friday at 7AM. These rounds are a great opportunity to see TEE/TTE cases discussed and also provide a rich opportunity to learn about general cardiology concepts as well – you are encouraged to attend 

RESOURCES 

• ASE guidelines: easily available by internet search. Many of the hallmark guidelines are available in paper copy as part of two ring-bound ‘ASE Guidelines’ books kept in the lab

• ASE Textbook – a copy is kept in the lab 

• ‘Quick-reference’ ASE algorithm reference book – a copy is kept in the lab

• Otto’s “Textbook of Clinical Echocardiography’ – a copy is kept in the lab 

IMPORTANT NOTE – While getting your minimum reporting numbers is a necessary part of your training, please take some time to read around your cases during the days or outside work using the above resources – your overall competence in echocardiography will be dramatically better if you develop the necessary background ‘textbook knowledge’. Some of these basic principles may be tested on your Royal College Exam.