For the emergency medicine and critical care physician competency in ultrasound is becoming essential.
The people I truly look up to in my specialties all recognise that bedside ultrasonography is an integral part of patient assessment.
However, the hows and whos of learning and teaching bedside ultrasonography remain a murky quagmire.
This is how I think it should be.
Every training scheme should have specialists skilled in the day-to-day use of bedside ultrasound who are equally adept in teaching these skills to others. Trainees should be expected, and should in turn demand, that they use ultrasound in their day-to-day practice and by the end of their training be proficient in diagnosing AAAs, performing eFAST scans, performing ultrasound-assisted procedures and using it to differentiate undifferentiated shock patients. Sonography skills will be meaningfully tested in Fellowship exams.
Trainees should not have to dip into their own pockets to attend expensive courses. They should not have to obtain superfluous additional certificates and qualifications. They should not have to complete meaningless logbooks (unless such logbooks are used effectively for reflection and meaningful discussion with a mentor).
In the future you won’t be an emergency medicine or critical care doctor unless you can inspect, palpate, percuss, auscultate, ultrasound and cogitate. Taking histories is integrated into our training. Examining patients is integrated into our training. Mastering ECG interpretation is integrated into our training. So must bedside sonography, and in the same way.
The real challenge is perhaps in teaching the teachers…
Perhaps FOAM can help to some extent: Ultrasound in EM.
About Chris Nickson
Couldn’t agree more!
Couldn’t agree more Chris. I’m worried what the college will come up with in regards to credentialling as well. I’m worried they will make it to prohibitive for many to successfully complete.
Costs for USS courses in Australia are certainly prohibitive and further are mostly a waste of money if you can’t apply it frequently in your practice (ie ‘you can’t do that USS, you are not credentialed’).
I’ve taken the self taught approach, whereby I have been using Dr. Christian Fox’s excellent vidcast on Emergency Ultrasound, available for free on iTunes. I would frequently watch a lecture, then go in 1 hour early to work and check out the short stay or the screen for patients awaiting CT KUBs (hydronephrosis), CHF (echo) or liver failure (positive FAST). Then check their investigations later to see how I fared.
Trying to make sure we all achieve a certain level of competence is important, but I feel that USS is often an advanced extension of my physical exam and particularly when asking something binary (ie -- effusion? ? Free fluid), can be a very useful skill in the time pressed emergency department.
Chris
Right on the money Chris! However, your logical reasoning flies in the face of the massive move towards micro-credentialing that has been happening for years. I often feel like I should have a sash to proudly display the mirad assortment of merit badges I have been issued over the years.
In my opinion many of these required courses and credentials offer little useful to the busy practicing emerg doc and are more akin to a tax paid to the planning organization. ACLS is the most glaring example, where emergency docs are forced to pay hundreds of dollars every 2 years to re-learn the basics about a subject that they know well and practice daily…
Aaron
Well said, Chris.
There are members of the ACEM Ultrasound Sub-Committee who also run their own private ultrasound training businesses. Some might say this is a conflict of interest and an obstacle to achieving the goal you have described.
Cognitive disconnect
-- unreported radiology and clinical assessment are OK to base decisions on. Both well established to have significant error rate. Neither have formal credentialing (I wouldn’t include a long case and a handful of short cases at the end of training to be in any way a substitute, and if it is then you can chuck a FAST image into the VAQ and consider USS credentialed for the new FACEM).
-- bedside USS well established to have a smaller error rate with a short learning curve (caveats: binary decision making tool e.g. presence or absence of fluid), requires formal credentialing
-- bedside USS guided CVL insertion now standard of care but does not require credentialing
CAN A DOCTOR FLY A JET PLANE?
Guys, I’m one of those geeky FACEMs who is on the ACEM US subcommittee. I also run a [free] course for my trainees, and I don’t make $ out of courses. I am speaking for myself here, NOT on behalf of my committee colleagues or anyone else.
Speaking for myself, I agree 100% that we need to break this dependence on weird extraneous courses, and that bedside US needs to become a core skill for all of us.
The key is to get the bigwigs & professors to ‘get it’. Let’s get basic ultrasound into Aussie med schools- some of them [eg Notre Dame] already do it. All interns should be able to turn on a machine, apply gel, and stick a needle into a vein under US guidance. Remember having umpteen attempts on some poor patient’s veins at 2am because you were scared of waking the med reg? BUT when people like us ask some of the other med schools to introduce this, we get knocked back. Why? Because it’s ‘not a core skill’.
Okay, so let’s get it into our specialist training programs. Bedside US training is already mandated for the UK College of EM trainees, and for US EM trainees. So at least in theory, every EM specialist from those countries can ultrasound all the things they should be able to: vessels, the heart in a cardiac arrest, trauma, and AAA. [I’ve heard the counter argument is that this is only true in theory, but seriously that sounds pretty scurrilous and a different issue and beside the point.]
The ACEM US subcommittee has been trying for years to get bedside US recognised as a core component of the ACEM curriculum: understanding the clinical context, turning on a machine, creating an image, interpreting that image and acting on it. The ACEM council & education committee & all the other college high-ups are thinking about it, and things seem to be moving in the right direction.
It all seems bloody frustrating and slow from my perspective but this is the way that the process seems to work.
BUT I just don’t agree with the angle that says ‘I don’t need to be credentialed and you should just let me get cracking with my critically ill patients’. Because US is like every other complex, operator-dependent tool out there- you have to respect the basic rules of how it works.
Not convinced? Reckon you’re immune from f***ing up with an US probe? Here are a couple of real, actual cases for you to mull over:
• A patient who nearly got their tension pneumothorax drained at a major teaching hospital… except that they didn’t have a PTX at all. They were a shocked multitrauma patient who had just been intubated in the ED, and they became hypoxic. The bedside US showed no lung sliding on the left, so SHOCK + HYPOXIA + NO LUNG SLIDING = STICK A NEEDLE INTO THAT PTX. Luckily we all realised that in fact it was a right main bronchus intubation, & withdrawing the ETT fixed the problem.
• An OG registrar who told the patient she’d miscarried because she had an empty uterus… except her pregnancy was fine, it’s just that you couldn’t see it on the transabdominal scan [the TV scan the next day was NAD].
• An ED doctor called in urology at 2am to fix the urgent torted testis… except that the testis was fine, and the Doppler scale [PRF] was set too high, so it looked spuriously like there was ‘no flow’.
• The AAA that turned out to be a fluid filled stomach.
• A patient with RUQ pain & a big gallstone on US… except they didn’t have a gallstone at all. Instead it was air in the duodenum next to the gallbladder, & it appeared to be in the GB due to a side lobe artefact.
• The ‘aortic dissection’ that wasn’t. Yep, it was another US artefact & the aorta was NAD.
• The shocked trauma patient that went to OT on the strength of a positive FAST: except that the belly was empty & the ‘fluid’ was almost certainly fat in Morison’s Pouch & the gain was set too low. [The images were never saved.] The patient suffered from delayed diagnosis and a GA & having her belly opened, and she died in ICU. Was the false positive FAST to blame? Who can say?
• The two shocked trauma patients I’ve been involved with in whom the ED specialist’s FAST was negative. BUT the bellies were both full of blood…it’s just that in each case it was clotted [not black] and completely missed by the doctor.
I have PERSONALLY been involved in all these cases [NB not in my current hospitals, for the record], and have had to do some serious mopping up, incident management, & settling justifiably angry medical colleagues who think we’re a bunch of colleagues. I have honestly seen patients suffer as a result of our scans.
And I’m just one guy.
So, on the day that bedside US becomes a core skill at med school & in our training programs, fine. We won’t need all these stupid bloody log books & extra QA systems… but until that day, we cannot simply pick up an US probe & get cracking. I honestly don’t know the best way to credential drs / ensure QA, but that doesn’t mean we simply shouldn’t try.
Remember, you actually did have a system of training & credentialing to use a stethoscope. It was called the exit exam for med school. And as a junior doctor you still got it wrong sometimes. US is more complicated, more operator dependent & more likely to F*** you up… and your patients too.
So if you are immune from the above mistakes & you already know all there is to know about US artifacts & how they can trip you up, go for it. You can probably fly a jet plane as well. I can’t.
Justin Bowra FACEM
Hi Justin,
You make some good points, although I’m not quite advocating a ‘let me fly the plane’ approach.
I wonder if the credentialing committee will be considering the use of FOAM to help gain EM USS skills? I would hate to see road blocks set up whereby credentials can only be completed if ‘Complete Course X, Y, approved by ACEM’ then ‘X amount of supervised’ followed by ‘X amount per year’.
I see FOAM being of use particularly in the learning stage -- knobology, probe position, physics and examples of +ve and -ve findings. ACEM could even recommend some of the free online courses that fit it’s standards. From there, one approach could be to setup ACEM USS credentialers who could take videos/still images from trainees and make comment, combined with a log book.
Of course, getting USS into the mainstream ie med school, early training is paramount. Making sure ACEM approved EDs have FACEMs skilled in USS will also allow for overview and teaching. Maybe some ACEM guidance to DEMTs on how to help train their trainees in the use of USS? Maybe a template for trainees to fill out when they do an USS as well?
I’m just throwing out some ideas. I understand that some formalisation of ACEM trainee USS skills is important for clinical safety, but if we create a bottleneck whereby this can only be gained by formal and expensive courses, I’m not sure we are doing our patients, or trainees a service.
To give a recent positive example as well:
1. Just 4 nights ago -- patient presented with back pain, abdo pain and collapse -- quick USS showed a 7cm aneurysm, pt. was in pain, pale. Explained to vascular surgeon on-call -- he didn’t want CT, he came in the middle of the night, I showed him my stills and he took the patient straight to OT for emergency repair.
My clinical interpretation without USS was ?AAA -- USS became an extension of my exam and affirmed it for the surgeon. I
I don’t pretend to be an USS whizz -- I wanted to go on a course in Australia but could not afford it. What I do is stick to basics (I don’t do O+G scans, chole scans) -- MSK to assist procedures (#s, haematoma blocks), EFAST and AAA. I won’t get it right 100% of the time and always interpret it with the appropriate patient history and exam, but in my experience, I’ve helped far more than I’ve hurt.
Chris
Thanks for your comment and perspective Justin.
However, I think you’ve created a bit of a straw man with the ‘I don’t need to be credentialed and you should just let me get cracking with my critically ill patients’ comment.
I’d like to see a serious attempt at building ultrasound into the framework of our training schemes -- I think as you do.
I accept that there are many cases of ‘semi’-proficient doctors going astray with ultrasound. Yet doctors also miss important diagnoses on ECGs, radiology images, examination and history as well. In fact, some of the ultrasound error examples you’ve given would no doubt have been avoided if the other aspects of patient assessment were performed properly.
As a counter point, there are likely many cases of doctors using ultrasound that unexpectedly saved the day for a patient -- however these tend not to be highlighted by QA committees.
I personally do NOT advocate doctors having a free reign to go crazy with a device they have not been trained to use. I do advocate doctors receiving this training as an integrated component of their specialty training, that doctors know their limits and work within them, and that doctors don’t forget everything else that goes into patient assessment.
Cheers,
Chris
Hi Chris
I am a die-hard ultrasound enthusiast, but have essentially had to teach myself, attended a few great short workshops to get my technique corrected and then practiced, practiced and practiced.
I think it has taken me 3 -- 4 years of continual practice to get to a point where the majority of my scans are “useful” in my clinical algorithms -- some more useful than others. I have scanned alot of people knowing that I was not going to use the data unless it was clearly positive (or negative) -- ignoring the grey as I climbed the learning curve. This is how all students / RMOs /regs should evolve their skills -- ideally in a safe, paid and supervised environment!
Justin: “US doesn’t kill people, doctors with US and no insight kill people”.
it would be foolhardy to take a history of chest trauma, auscultate and decide there is no pneumothorax… yet I see this happen! scanning them adds sensitivity. In my hands it is probably as good as a CXR, in another maybe better or worse. Depends on the quality of the images obtained, the seriousness of the scenario, the baseline characterisitcs of the workup. This is what they pay us the big bucks for -- making calls and interpreting data -- we just need to know how reliable these studies are so we can incorporate them into our “gestalt”, or more formal algoritms.
I think most of Justin’s disaster cases above would have worked out better if the clinician had recognised the inconguity of the clinical picture with the scan and either got a second opinion or done another imaging test before locking in on a plan.
Now there is a rapidly growing body of evidence for the various US modalities -- some are clearly superior to clinical exam, some superior to traditional plain film equivalents ( of course all of this relies on a basic level of US skill and interpretation nouse ) So why not use these -- the patient’s will benefit if they get accurate and more timely diagnoses or avoiding uneccesary IX / invasive tests.
Example: RIF pain in a 20 yo guy -- bedside US is +ve for appendix -- great call the surgeon, if -ve -- go for traditional Ix or watch. Only loss is a bit of time. At present all the surgeons I work with would CT first and ask later -- costs money, radiation…
However, it seems unfair to say US is unsafe due to “operator error” when we have not trained ourselves to use it appropriately. I think in 10 years this will be a moot point.
OK, re-rant over
Carry on. Casey
Hi Casey,
Been following your blog and posts on twitter with great enthusiasm.
One thing that often pops in my head when reading your posts, which is relevant to this discussion is ‘I wish I had a mentor like that during my training’.
Not trying to blow smoke, what I’m trying to say, if we, as a specialty, take USS on board, be enthusiastic about it and adopt it into our regular clinical practice then it will become the norm. It is people like you and Justin and Chris and all the others out there that will make it happen.
So from a trainee POV, thanks and keep it coming -- and I might need to apply for a rotation up north one of these days
Chris
All,
First off, I think ultrasound is a huge waste of time…….just kidding. I’d love to be the one to disagree with everyone and not pile on with the total agreement with Chris, but his points are too reasonable and well thought out. He’s obviously right that this is a basic skill. I DON’T feel comfortable with someone taking care of me or my family if they don’t have basic USS skills. When my oldest daughter had a cellulitis vs. abscess and I was on the other side of the country I had my wife wait to take her in until I knew the doc on had good skills and could evaluate without automatically cutting her. For a more recent experience I had related to this go to notapincushion.com. I’m obviously a believer that you should be proficient in this before being allowed to graduate and practice.
It does give me some satisfaction that this is yet something else that we in the U.S.A are ahead of you guys in (add to list of: invading other countries, arrogance, # of nuclear bombs, denial of global warming, and denying our population basic healthcare). We actually do define this as a “skill integral to the practice of emergency medicine” in our “Model of Clinical Practice of Emergency Medicine”. It has also been an RRC requirement of all EM residencies since 2003. Our residencies have to perform a certain number and “demonstrate proficiency”, whatever that means. The problem here, though, is that only a small % of our EM docs are residency trained since 2003. So we still have a problem with this skill getting out to the masses. Hopefully FOAM and other advances will get us all proficient sooner rather than later. The problem with ultrasound is that it really is a skill that HAS to be practiced and learned hands-on.
Not sure what the perfect solution is, but I believe we’re getting closer. Hopefully Australia will require some sort of built in ultrasound education to training programs sooner rather than later. Good luck. We’re 10 yrs into the requirement here and still only have a fraction of the docs adequately trained.
Matt
p.s. -- Sorry I didn’t go through and change some of my c’s to s’s and add random a’s and o’s (haemothorax and oesophageal) and such to translate into Australian. Hopefully this is legible….
• A patient who nearly got their tension pneumothorax drained at a major teaching hospital… except that they didn’t have a PTX at all. They were a shocked multitrauma patient who had just been intubated in the ED, and they became hypoxic. The bedside US showed no lung sliding on the left, so SHOCK + HYPOXIA + NO LUNG SLIDING = STICK A NEEDLE INTO THAT PTX. Luckily we all realised that in fact it was a right main bronchus intubation, & withdrawing the ETT fixed the problem.
Misunderstanding of algorithm. Post intubation hypoxia is a different beast from shocked hypoxia in a non ventilated patient.
• An OG registrar who told the patient she’d miscarried because she had an empty uterus… except her pregnancy was fine, it’s just that you couldn’t see it on the transabdominal scan [the TV scan the next day was NAD].
This isn’t even an ED physician. Fails to understand limitations of test (TA v TV, hCG with singletons/multis and value of serial measurements, normal algorithm for early pregnancy, zones of discrimintation).
• An ED doctor called in urology at 2am to fix the urgent torted testis… except that the testis was fine, and the Doppler scale [PRF] was set too high, so it looked spuriously like there was ‘no flow’.
Operator error is one thing, but USS for torsion?
• The AAA that turned out to be a fluid filled stomach.
Was the patient hypotensive with a clinical history suggestive of ruptured AAA? Otherwise, failure to understand algorithm.
• A patient with RUQ pain & a big gallstone on US… except they didn’t have a gallstone at all. Instead it was air in the duodenum next to the gallbladder, & it appeared to be in the GB due to a side lobe artefact.
Again, stretching the uses of ED bedside USS. Was the gallbladder wall thickened? Was there pericholcystic fluid? Was the pain reproduced with probe pressure? Otherwise, I can’t see how this would influence treatment. Did the ED doctor take the patient into the procedure room to perform an unnecessary cholecystectomy? Again, lack of understanding of the application of the tool.
• The ‘aortic dissection’ that wasn’t. Yep, it was another US artefact & the aorta was NAD.
I’m pretty unexcited about tests with anecdotal false positives. Did it influence management? Was it consistent with the clinical H&E? Did it lead to another test (CT angiogram)? Was this indicated anyway by the H&E?
For any test, we need to know sensitivity and specificity, learning curve, and context. What is the false positive rate for USS? How much training is required to get close to the top of the learning curve? TTE has Sp of ~80% and Sn of ~60% (from quick google search on one article), I expect bedside USS would be lower, which probably gets down to the ‘not clinically useful’ sort of territory.
• The shocked trauma patient that went to OT on the strength of a positive FAST: except that the belly was empty & the ‘fluid’ was almost certainly fat in Morison’s Pouch & the gain was set too low. [The images were never saved.] The patient suffered from delayed diagnosis and a GA & having her belly opened, and she died in ICU. Was the false positive FAST to blame? Who can say?
This is more like it. But blaming the FAST for her death (or implying it with the hanging questions) is disingenuous. Was is the only thing that lead to the laparotomy? Again, false positive and negatives rates are important in the bigger picture, but not necessarily for the individual. Did the institutional trauma audit find that this was responsible in the RCA? Were the false positive/negative rates for the department audited? A single point of data is nothing without context. The operator error (technical fault) contributes, but I agree you can never separate this from the overall outcome so it should still be included in the analysis.
• The two shocked trauma patients I’ve been involved with in whom the ED specialist’s FAST was negative. BUT the bellies were both full of blood…it’s just that in each case it was clotted [not black] and completely missed by the doctor.
As for last comment.
As Chris Nickson has already said, this argument is a massive strawman. The choice is not EITHER maverick ED doctors performing random scans outside of their clinical indication and then the patient being required immediately without confirmation to have a high morbidity procedure OR ED doctors having to have unreasonable and unwieldy training, accreditation and ongoing CME. His last few paragraphs sum up the situation better than I could, so ‘me too’.
Guys, I think we are all on the same page.
We know that US is a useful tool, just not the Holy Grail… and it’s high time we got this into our training program & into the med schools, then as Casey points out, our ranting will all be a historical curiosity. So get everyone you know to email the college! Let’s start a push to get this into our training program for real- not just image interpretation [some US VAQs are already coming through] but al the rest too.
In the meantime, here are the pearls I teach my trainees so they don’t stuff up too much:
If the image doesn’t match the clinical picture, turn off the machine.
If the US won’t help, don’t even turn it on.
And if in doubt, be a doctor- I was a fulltime doctor before I became a part time US nut, and I will always be better at doctoring than scanning.
Finally, as my Belfast mate Russ pointed out, ‘A fool with a stethoscope will be a fool with an ultrasound.’
No more rants from me.
JB
Some good rants here. Mine is more of a ramble.
My view is that US in ED is (or is very soon to become) a core skill. Just like ECG interpretation, just like blood gas interpretation, just like xray interpretation. As the technology advances and becomes cheaper and more readily available, every ED will have multiple machines -- and we will be expected to use them. I have noticed increasing numbers of inpatient registrars ask if we have already done a bedside ultrasound -- other specialties already look to us as being experts in certain things (resus, toxicology, management of the violent/disturbed patient, etc), and now they are seeing us as the bedside US experts. If they are starting think that US is a core skill for us, then maybe the college and our training institutions should too. We should be provided with, at least, basic training.
For trainees to be expected to pay thousands of dollars in courses is a akin to outsourcing all our other interpretive skills learning. Imagine if trainees had to suddenly spend their hard-earned cash on 6-monthly courses and refreshers on basic radiology so they could be credentialed to diagnose a Colles fracture (imagine the ortho reg response if you called them to say you have seen a patient post-FOOSH with a painful wrist, but you can’t comment on the x-ray because you haven’t got your certificate) -- this is not the case because xray skills are core knowledge (learnt at med school, taught to an advanced level in registrar teaching sessions, and honed by clinical experience). US should be the same -- introductory sessions at med school, further teaching as an HMO and registrar, with ongoing on-the-job learning.
I looked at the courses available here in Australia and decided to spend the cash on a holiday to the USA and incorporate an observership at a large tertiary ED into my holiday. I completed the same free ultrasound training program that all of their ED residents have to complete -- 2-3 weeks of didactic lectures, bedside tutes, and independent scanning (and log book completion) to gain experience in FAST, eFAST, AAA scanning, renal scanning, GB scanning, basic echo, and 1st trimester scanning. Free and fantastic. And it should be offered here in Australia.
I continue to use these skills at the bedside here. I don’t rely on my skills to be the sole diagnostic modality for my patients -- I incorporate my findings with the history and physical and construct an appropriate management plan. I always gets confirmatory scans when indicated (eg -- the 1st 7 week PV bleeder who presents at 8pm -- I confirm an IUP, check blood group, and discharge with reassurance and a plan for a formal ultrasound in the next 24 hours -- happy educated patient, happy doctor, better ED patient flow). And I always explain to the patient that my US is not a formal extensive US scan, but merely being used as a tool to help clarify my management.
I am more than happy to pay money for advanced ultrasound courses -- just like I would for an advanced airway course or an advanced ECG interpretation course. But the basics should be part of our training.
Credentials to comment:
I’ve spent the last decade learning, performing and teaching emergency and clinician-performed ultrasound. I’m well over Malcolm Gladwells “10,000-hour rule” (The Outliers).
Comment:
The comment regarding ACEM ultrasound subcommittee members who teach ultrasound having a conflict of interest is disingenuous and reflects little insight into the reality.
We can all quote anecdotes of disaster which are useful to reflect on. There are also cases where sonographers and radiologists have missed or misinterpreted scans with subsequent disaster.
Ultrasound is incredibly useful when used by clinicians with the appropriate knowledge and skill base.
In more detail:
The clinician needs to have assessed the patient fully and be asking a specific question that ultrasound can answer.
The clinician must understand the limitations and role of ultrasound in the specific scenario and must be able to integrate their findings into the diagnostic algorithm appropriately.
The clinician must have the ultrasound skills (know how to use the machine and the transducer)
The clinician must have knowledge of the range of ultrasound pathology and appearances that can occur within the area of interest.
The clinician must record and communicate the results of their scan including any uncertainty / limitations in the patient notes.
Images should be stored.
How do we ultimately achieve this:
A small proportion of the population are enthusiasts and direct their own adult learning. We can’t rely on this.
Formal training and assessment (examinations) make people study / practice and ensure they reach a predetermined adequate level of proficiency.
General ultrasound training should be integrated into medical student education as is occurring in many centres around the globe. We would trust the intern’s ultrasound assessment much as we do any other element of their clinical assessment.
Specialty specific ultrasound training should be integrated into specialty training programs and examined along the way. Standardised education requirements, scope of practice, reports etc should be established by the specialty college.
What about now?
A big issue, people trust an “ED specialist’s” opinion, but in the land of ultrasound many of these have not necessarily reached an acceptable level of proficiency.
I don’t really care about whether people do a brief course, a university course, a logbook, a period of supervised scanning, whatever -- as long as at the end they fulfil the requirements listed in the “in more detail:” section above.
To ensure this my personal feeling that there should be a single standardised test of competence that would then credential people.
The test should include:
A standardised summative practical assessment like this EFAST summative assessment
An MCQ covering the clinical and ultrasound knowledge base
An image interpretation quiz covering the common and uncommon appearances of various relevant pathologies
Cheers
James
Hi all,
Thanks to everyone who has taken the time to comment here. I’m not prone to rants, but I think this is an important issue and I hoped to stimulate a worthwhile discussion on an open forum where everyone could take part.
Overwhelmingly I think we’re in agreement on the major points -- that bedside ultrasound is important, and we need it to be a core part of our training.
I certainly value the perspective of people like James Rippey and Justin Bowra who have been flying the flag for ED ultrasound, have come up against a few brick walls in their time and have gone a long way to breaking them down so that ultrasound is increasingly seen as part of our weaponry.
The bottom line is we have to get good at whichever parts of bedside sonography we actually do. The challenge is how to achieve this.
Chris
If you can’t get the training locally, then doing courses is a good thing. Even when you are proficient with bedside US, there is plenty to get out of courses. Yes, the basics should be acquired during your training, but there is always more you can learn, and there are some good external courses (and some bad ones) out there.
The additional external US qualifications such as CCPU or DDU, carry a significant credibility factor and should be considered, especially if you plan to teach ultrasound to colleagues.
Shouldn’t it just be integrated into high school human sciences and then every appropriate part of every anatomy lesson and then each and every Ultrasound-relevant part of your clinical skills training?
Shouldnt it be considered the new stethescope?
Shouldn’t we be making ourselves obsolete as the intern rocks up with 7 years of probe handling experience and says (in appropriately up to date slang) “check this out!” and we all go back to learning from our students?
A wise man once foretold of a CATCH 22 for ultrasound
1. You can’t be allowed to use it unless you are good enough
2. You can’t be good enough unless you are allowed to use it
I have no formal training -- and learn by doing…ultrasound should be taught in medical school as we once learned to wield a stethoscope
Mike, sums up my frustrations as a trainee exactly
I really appreciated this post and all the comments so far. v useful for my own viewpoint on this as a formal educator.
Clearly there are four categories of clinician performed bedside USS in my mind.
DOGS BALL OBVIOUS vs NOT
TIME CRITICAL LIFE SAVING vs NOT
The FOAMEd revolution has changed the learning landscape for bedside USS. The Americans are the clear leaders here and legends like Matt Dawson and Mike Mallon are the pioneers .
I have no doubt that anyone can learn the DOGS BALL OBVIOUS USS category very simply. I work with remote midwives who do dating first trimester scanning without any formal credentialling extra to their midwifery qualification. I do the same. Its easily repeatable and with good clinical decision skills, is very safe. Although it is not how I learnt my USS skills, I believe via FOAMEd and good mentoring, any clinician can gain safe and competent DOGS BALL OBVIOUS USS competency
The NOT categories are not time critical nor obvious and I think formal elective scans should be ordered for them. For me, that means sending my pregnant patients a few hundred kilometres via plane for their second trimester morphology scan, or fetal echo. For the woman with pelvic mass , ditto.
For clinicians who want to gain competency in the NOT cAtegories I totally support the notion of formal assessment process.
but really where emergency USS shines is in the time critical resuscitation decision making process.
I personally believe in this category a USER BEWARE system of self regulation is reasonable. Peer review and learning should be acceptable standard. Just like it is for ECG, xray, ABG interpretation. We all realise these diagnostic skills are imperfect and we all strive to improve them daily. its like emergency airway training and proficiency..we will never be perfect, we will fail to intubate eventually, but as long as we have a good strategy and preparation, the patient will be safe.
I decided to post a comment because I’m not biased at all…..ok, so maybe just a very slight bit. You made some great points and I’ll echo them -- no pun intended. I couldnt agree more with your point that the physician has to be able to “inspect, palpate, percuss, auscultate, ultrasound and cogitate….” -- and I wish they would do them all correctly. Just this week, I was at the ED with my elderly family member who was nauseated, feeling weak and had epigastric pain, with a heart rate in 110s. From the beginning: 5 IV attempts, unsuccessful until the miraculous 6th came through (no ultrasund to do a USG Periph IV), before fluids were given, they did orthostatics which showed an INCREASE in his BP when standing, but I demanded (yup, I was THAT “relative who was a doctor”) and they gave him fluids (no ultrasound to see the IVC), they did an abdominal exam with him sitting up -- and when I say “abdominal exam” I mean pressed on his abdomen kinda sorta while asking him questions. Finally, I asked if they had a bedside US to quickly check to make sure he didnt have a AAA or decline in contractility of his heart, and they said no “but we can wait for the H/H to come back in about an hour and see if his chest XR shows anything.”…..His H/H was stable, thankfully, and his Cr was a bit elevated. He got 2 Liters of fluids, felt better and was discharged. When we got back to his home, I took out the hand-held scanner I had in my bag and took a look at his heart myself (yup, still that “relative who is a doctor”) and saw a moderate sized pericardial effusion. I called his doctor and he got admitted to cardiology…. from home. He was in the ED for 5 hours and only an ultrasound could have quickened his stay, potentially decreased his medical cost, definitely increased his (and my) satisfaction, and made his diagnosis and ultimate disposition decision. The doctors did only what they knew how to do, and they were nice -- Ill give them that, but medicine is changing. That is only one case, but there are plenty of others that I could list where bedside ultrasound has expedited the management and diagnosis, not to mention save a life. It should be in the med schools, it should be in the residency training, and for those who are out of training, you should attend the workshops, practice it’s use, learn about it’s strengths and it’s limitations, and compare your bedside results to any confirmatory test until you are savvy to make that decision on your own. Some applications don’t require too many of those practice runs, but some require even more than what ACEP guidelines are currently.
As much as I cannot imagine my life without my smartphone, I cannot imagine my work without my ultrasound. I can know what a patient has, or (even better sometimes) what a patient does not have in 5 minutes. Physical exam has its limitations too, and there are few doctors I see actually do a physical exam completely and correctly anymore, let’s not forget that…..
The more we have at our hands that could give ore information, let’s use it.
my 2 cents….