Ultrasound

Emergency Ultrasonography Program: Education, Patient Care & Research

New York-Presbyterian’s dual-campus emergency ultrasonography program seeks to provide emergency medicine and critical care providers in both the National and International arenas with the education and training in emergency ultrasonography to maximize the efficiency and safety in caring for their patients. It also strives to advance emergency ultrasonography with the application of rigorous clinical research methods

Emergency Ultrasonography Curriculum

A) Comprehensive Initial Emergency Ultrasound Course:

The emergency ultrasound curriculum will start with a full 2 day 16 hour class given during the first year of residency training. The class will cover the primary indications for emergency ultrasound as outlined by the American College of Emergency Physicians (ACEP). Residents will become adept at each of these primary uses of ultrasound through the experience of performing multiple directly supervised exams.

1. Trauma Ultrasound:

Residents will learn the standard four view focused abdominal sonography for trauma (FAST) exam in order to optimally facilitate trauma care. This exam includes the right hepatorenal, left perisplenic, suprapubic/pelvic and cardiac views. The primary goal of the FAST exam is to detect free fluid within the abdomen, pelvis and pericardial sac. Residents will also learn how to perform the newly developed expanded FAST (e-FAST) exam for evaluation of the thoracic cavity. The primary goals of the e-Fast exam are to detect pneumothorax, pleural cavity and abdominal cavity free fluid.

2. OB/GYN:

Residents will learn transabdominal and transvaginal sonographic approaches for OB/GYN sonography. The primary goal of first trimester OB/GYN sonography is the detection of intrauterine pregnancy defined as yolk sac or more. In addition, the Endo-Myometrial Mantle (EMM) must always be measured and documented (should be greater than 8mm) to evaluate for possible interstitial ectopic pregnancy. Advanced goals of first trimester OB/GYN sonography include evaluation of the adnexae and detection of ectopic pregnancy. The importance of checking for intra-abdominal and pelvic fluid with a FAST exam will also be stressed.

3. Emergency Echocardiography:

The primary goals of bedside echocardiography include the detection of pericardial effusions, cardiac standstill in the presence of cardiac arrest / pulseless electrical activity (PEA) and gross determinations of left ventricular cardiac contractility. The use of emergency bedside cardiac ultrasound to better guide appropriate care during shock states and resuscitations will be emphasized. Advanced goals of bedside echocardiography include evaluation of the heart for signs of cardiac tamponade with diastolic collapse of the right ventricle if a pericardial effusion is diagnosed. Residents will also learn how to map out pericardial effusions using sonography to determine the optimal route for emergent pericardiocentesis. Additional advanced echo techniques will also be covered during the curriculum, including determination of right ventricle strain suggestive of pulmonary embolism. Finally, residents will learn to evaluate the inferior vena cava through the respiratory cycle to gain a rough gauge of patient volume status.

4. Abdominal Aortic Aneurysms:

Training will be given in the examination of the entire abdominal aorta from diaphragm to the bifurcation of the iliac arteries. The primary goal of bedside aorta ultrasound is to recognize the presence of an abdominal aortic aneurysms defined as an aorta greater than 3 cm in diameter and iliac arteries greater than 1.5 cm in diameter.

5. Hepatobiliary:

The primary goals of bedside gallbladder sonography are the evaluation for gallbladder stones, measure the anterior GB wall (normally less than 3mm) and assessment of the sonographic Murphy's sign. Advanced goals include detection of the secondary signs of cholecystitis and cholangitis such as common bile duct enlargement (greater than 6mm) and pericholecystic fluid.

6. Genitourinary:

The primary goals of GU bedside ultrasound are the evaluation of obstructive uropathy and acute urinary retention. Both kidneys will be assessed for hydronephrosis and the assessment of bladder size. Advanced goals include evaluation for kidney stones and other renal pathologies.

7. Vascular Ultrasound:

The use of ultrasound to guide both peripheral and central venous vascular access will be emphasized. Residents will learn to use ultrasound to aid in placement of central lines in the internal jugular, subclavian and femoral veins in order to minimize the risk of these procedures to patients. Ultrasound guided peripheral venous access to the basilic and brachial veins of the arm will also be taught.

8. Thoracentesis, Paracentesis and Lumbar Puncture:

Ultrasound will be used to first detect the presence of pleural effusions and ascites amenable to a drainage procedure. Residents will then learn ultrasound guided approaches to facilitate the procedures of thoracentesis and paracentesis in order to minimize risks to the patient. Ultrasound guided lumbar puncture will also be taught.

9. Foreign Body Detection:

Ultrasound will be used to detect radiolucent foreign bodies that may be difficult to visualize with plain radiography. Ultrasound guided techniques to remove foreign bodies will also be covered in the curriculum.

10. Cellulitis and Abscess:

Residents will learn to evaluate the soft tissues for fluid collections in order to allow for better diagnosis of abscess and differentiation from cellulitis. Residents will also learn to evaluate the tonsils for peritonsillar abscess requiring drainage.

11. Deep Venous Thrombosis:

Residents will learn the limited DVT screening exam focusing on evaluation of the proximal common femoral vein, greater saphenous and superficial femoral veins down to the proximal popliteal vein down to trifurcation. Analysis of the compressibility of the vessel with direct pressure of the probe will be taught as a means to diagnose a deep venous thrombosis.

12. Musculoskeletal:

Residents will learn how to use ultrasound to analyze joints for the presence of effusions. Ultrasound guided approaches to arthrocentesis will be taught. Residents will also learn how to use ultrasound to examine tendons and ligaments for disruption/rupture. Finally, residents will be taught how to use ultrasound to diagnose fractures.

13. Ocular Ultrasound:

Residents will have the opportunity to learn ocular ultrasound with the primary goal of diagnosing posterior chamber and orbital pathology such as retinal detachment, vitreous hemorrhage, and disruptions of structures. Residents will also learn how to evaluate for increase in intracranial pressure by measuring the optic nerve sheath diameter.

14. Pediatric Applications: Residents will learn ultrasonography applied to children with a focus on abdominal pathology: appendicitis, pyloric stenosis, inguinal hernia and intussusception.

15. Other Advanced Applications:

Residents will learn basic techniques of testicular ultrasound helpful in diagnosis of pathology in this organ. Ultrasound guided nerve blocks will also be taught. Finally, the RUSH (Rapid Ultrasound in Shock) examination will be taught as a synthesis of emergency focused echocardiography, evaluation of intravascular volume status and of arterial ruptures (aortic dissection and aortic aneurysms) and deep venous thrombosis, to help determine potential causes of undifferentiated shock states. Residents will be trained to perform ultrasound guided nerve blocks.

B) Continuing Emergency Ultrasound Education / Credentialing Pathway:

Submission of Ultrasound Scans:

Residents will submit a minimum of 300 ultrasound exams for analysis to the ultrasound director. Optimally, the ultrasound exams should be divided evenly among the primary indications for ultrasound as listed above and should include both positive and negative findings. All ED exams should be followed by official studies when indicated—please make sure you discuss this with the Attending you are working with.

Ultrasound QPath will be available in both ERs - Columbia and Cornell - for residents to submit their ultrasound images for review.

Before you begin scanning a patient, the most important thing is to enter the patient's name, medical record number and your user code into the patient information screen (press the "patient" button on the right side of the keypad). Your user code is the first 3 characters of your CWID. After you scan and save clips and still images, you should then end your exam by pressing "B" or going back to the patient information screen and choosing to start a new exam. Once you have ended your exam, all clips and images you have saved will be uploaded into QPath which is on a hospital server.

QPath is accessible through the NYP apps page. The name of the QPath app is NYP Telexy. Your username and password for your QPath account are the same as your CWID and hospital password. From you QPath account, you can complete QA worksheets, submit exams for QA and then look at feedback you've received on your ultrasound images. QPath is accessible from home as long as you have VPN access.

Initial Resident QA of Submitted Ultrasound Scans:

Scans will be evaluated for proper views obtained per application (see section on Minimal Criteria) and for quality of images. If these are not met, the scans will be considered a “technically limited study” (TLS)—meaning that the images are not good enough to answer the questions set out to investigate. All scans will be tallied to assess effort but TLS scans will not count towards the prerequisite number of 300 to graduate.

Junior EM Residents Scanning Shifts:

PGY1/2 EM Residents will have one scanning shift per EM month just dedicated to scanning in the ED. Residents are encouraged to scan as much as he / she can with a minimum of 20 applications per shift. Senior residents as well as Attendings working clinically during that shift will supervise, as necessary.

Senior EM Residents Serve as Faculty for Yearly NYP Ultrasound Class:

PGY4 EM Residents will serve as faculty for the workshop portions of the Annual NY Presbyterian Emergency Ultrasound Course. They will have the chance to solidify both their ultrasound knowledge base and their teaching skills through this experience.

Emergency Ultrasound Elective:

All residents are strongly advised to complete an elective in bedside emergency ultrasound during their senior years to further improve their ultrasound skills and knowledge. Residents will work directly in the clinical areas under the direct supervision of the ultrasound faculty at Columbia and Cornell. They will also have the additional time to pursue further online ultrasound education.

Completion of Ultrasound Training is a Prerequisite to Graduation:

Residents who have not achieved the required submission of 300 “technically acceptable” ultrasound scans by the fourth year of training will be required to spend additional time in the Emergency Department performing ultrasonography. This time will be taken from the elective time available to each resident. Proficiency in ultrasound as defined by the above standards is a prerequisite for graduation from the NYP Emergency Medicine Residency.

Successful completion of the above requirements will allow for residents to receive a certification of completion as outlined by the ACEP ultrasound training criteria upon graduation from the NYP Emergency Medicine Residency. Each resident will be awarded a certificate that can be used toward hospital credentialing in bedside emergency ultrasound at their future jobs.

C) Ultrasound Lectures in Wednesday Conferences:

Continuing ultrasound education will be emphasized during the Wednesday lecture series with four dedicated ultrasound lectures given each year. These lectures will reinforce the material covered in the Annual EM Ultrasound Class as well as covering advanced topics. Review of submitted resident ultrasound scans will be included as part of the conference curriculum.

D) Web Based Ultrasound Teaching:

Free ultrasound teaching videos are now available at: www.sound-bytes.tv

Residents are encouraged to review these videos which will help solidify the ultrasound knowledge needed by residents to practice responsible and accurate bedside emergency ultrasound.

Additional sources of web-based ultrasonography education include:

ACEP Ultrasound Resources: www.acep.org/practres.aspx?id=32182

Neuraxium Ultrasound Guided Nerve Blocks: www.neuraxiom.com

Ultrasound Guide for Emergency Physicians: www.sonoguide.com/introduction.htm

Basic Ultrasound Echocardiography and Doppler for Clinicians: http://folk.ntnu.no/stoylen/strainrate/Ultrasound/

Emergency Ultrasound Exam: www.emsono.com/acep/exam.html

Sonographic Assessment of the Adnexa: www.gehealthcare.com/usen/education/proff_leadership/products/msucmeov.html

ICU Sonography: http://www.criticalecho.com

Virtual TEE: http://pie.med.utoronto.ca/TEE/TEE_content/TEE_standardViews_intro.html#quickstart

Stanford Echo in ICU: https://www.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Main_Page

Heart Gross Anatomy: http://www.rjmatthewsmd.com/Definitions/anatomy_ofthe_heart.htm

Echo by Web: http://www.echobyweb.com/htm_level2_eng/formulas&calculations.htm

Critical Ultrasound Journal: http://springerlink.com/content/121538

E) Ultrasound Research:

Residents are encouraged to consider selecting a topic in ultrasound research as their required EM Residency research project. Opportunities for emergency ultrasound research in the Adult and Pediatric Emergency Departments at NY Presbyterian will be offered. Interested residents should speak directly to the ultrasound directors.

G) Ultrasound Resources:

Residents will receive a complete syllabus from the Yearly NY Presbyterian EM Residency Ultrasound Course available as a PDF document. They can refer back to this syllabus through their training. Textbooks on ultrasound will be present in the book carts present in both the Columbia and Cornell Emergency Departments. Residents can purchase their own copies at Barnes and Noble or at the ACEP Bookstore.

The Core Textbooks for NYP EM Ultrasound will be:

-Practical Guide to Emergency Ultrasound. Karen Cosby and John Kendall.

Lippincott Williams and Wilkins. 2006.

An excellent text with many good images and helpful step by step commentary on how to perform and interpret ultrasound in the Emergency Department. This is a great resource for those interested in learning more about this exciting field. Highly recommended for residents in the NYP Emergency Medicine Residency.

-Emergency Ultrasound. O. John Ma and James R. Mateer.

McGraw Hill Publishing. 2007.

The newest textbook on emergency bedside ultrasound on the market. This is an excellent text that has been the foundation of many EM ultrasound curriculums around the country for years. Nice images with helpful commentary. Highly recommended for those interested in having an up to date text in emergency ultrasound.