RAMS Ultrasound Roadmap

Ultrasound Bedside Emergency Ultrasound is a core skill in Emergency Medicine. This skill is utilized at the bedside to provide point-of-care information for clinical decision-making and to guide procedures.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

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Senior RESIDENT

Resources

AUTHOR: Christine Luo, MD Contributors: Creagh Boulger, MD and Zachary Risler, MD Welcome to the Emergency Medicine Education Roadmap, your definitive step-by-step guide on how to succeed in Ultrasound at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, and publications can be found in “Resources.”

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

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insider Advice

1 - SENIOR MEDICAL STUDENT • P articipate in interest groups and seek out leadership positions in Emergency Medicine, Ultrasound, Critical Care, Radiology, Obstetrics/Gynecology, and Cardiology.

– Participate in ultrasound teaching sessions held by interest groups and in your medical school curriculum.

– If an interest group is not available, consider starting a group. For advice on how to start, visit AIUM Ultrasound, AIUM National Ultrasound Interest Group or Sonomojo webpages for suggestions.

• S eek Mentorship: Multiple Ultrasound-focused faculty are present in departments of Emergency Medicine, Critical Care, Obstetrics/Gynecology and Radiology.

• Shadow Mentors: Understand how Ultrasound is applied in diagnostics, resuscitation, procedures, and clinical decision making at the bedside in each specialty.

• P articipate in ultrasound symposiums: Often titled Ultrafest, these are free symposiums for medical students to have hands-on Ultrasound experience. Inquire if an ultrasound symposium is available near your medical school.

• Try to attend the national conferences and attend the ultrasound section meetings and events (SonoGames®, Sonoslam) .

• E xample Learning Objectives:

– Learn human anatomy and how various structures are represented on Ultrasound.

– Learn how to hold and move the Ultrasound probe for image optimization.

– Understand the physics of Ultrasound and the functions of each setting on the Ultrasound machine (aka Knobology).

– Learn to apply advanced functions including measurements, Doppler, and M-mode to identify pathology.

– Practice using Ultrasound in simulated procedures including IV placement and central venous catheter placement.

– Learn to identify pathology on Ultrasound imaging.

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Observe real time physiology. Examples include: ■ Lung sliding ■ Respiratory variation of the inferior vena cava ■ Ureteral jets ■ How vagal maneuvers affect the internal jugular vein

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• S elect clerkship rotations that provide opportunities for Ultrasound application including Emergency Medicine and Critical Care (Surgical ICU, Medical ICU, Cardiothoracic ICU).

• R ead about Ultrasound. There are several free, open-access resources for Ultrasound including, several high quality text books and iBooks.

• If available, take an elective/selective focused on Ultrasound. If not available, consider an away rotation.

• Consider a research elective or a research project focusing on Ultrasound.

• Demonstrate interest in Ultrasound during residency interviews. See Resources for elements to consider in a residency program.

• J oin SAEM and attend the SAEM Annual Meeting. Consider becoming an SAEM Medical Student Ambassador (MSA).

See Resources for SAEM Annual Meeting Ultrasound-oriented events.

Residency Application

• Elements to consider in an Emergency Medicine residency program: –

How is Ultrasound taught by the program?

■ Independent learning?

■ Faculty at bedside on rotation?

■ Faculty at bedside clinically?

– Are scans being used for MDM or are all required to have a follow up scan from radiology?

– Are other departments in the hospital doing bedside ultrasound?

– How many attendings are credentialed in Ultrasound?

– Do attending physicians bill for Ultrasound exams?

– What Ultrasound machines are available? What is the ratio of machines to patient rooms?

– How are performed scans reviewed? Immediate vs. delayed? Is there a quality review program?

– Is there direct observation or a standardized assessment program? How is feedback provided?

– Does the program have an active Ultrasound fellowship?

– How many Ultrasound fellowship-trained faculty are on staff?

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2 - JUNIOR RESIDENT • Participate in undergraduate medical Ultrasound education.

– Mentor interest groups

– Proctor ultrasound teaching sessions

– Assist in running ultrasound symposiums

– Mentor students in research

• Example learning objectives: – If no exposure to ultrasound curriculum as medical student, establish the following fundamentals: ■ Ultrasound physics ■ Ultrasound modalities ■ Basics of ultrasound probe motion ■ Anatomy on ultrasound ■ Pattern recognition

– Continue learning to identify pathology on Ultrasound imaging.

– Learn Ultrasound image optimization and image requirements necessary for clinical decision making.

– Utilize Ultrasound imaging in clinical decision making (ie. FAST exam in trauma activation, transthoracic echocardiography to evaluate cardiac function, evaluation for intrauterine pregnancy).

– Perform Ultrasound-guided procedures including central venous catheter placement, paracentesis, and IV placement.

– Learn to appropriately document findings and interpretations from Ultrasound imaging.

• Seek mentorship from Ultrasound-focused faculty at your program.

• Consider an Ultrasound-oriented subject to fulfill scholarly activity requirements.

• C onsider pursuing an Emergency Ultrasound (EUS) fellowship. Seek advice from senior residents, EUS fellows, and Ultrasound faculty.

• Join the SAEM Academy of Emergency Ultrasound (AEUS).

• J oin SAEM and attend the SAEM Annual Meeting. See Resources for SAEM Annual Meeting Ultrasound-oriented events, including SonoGames.

3 - SENIOR RESIDENT • Continue involvement in undergraduate medical Ultrasound education. Mentor and teach junior residents at bedside.

• Example learning objectives:

– Continue to utilize Ultrasound imaging in clinical decision making and performing Ultrasound-guided procedures.

– Learn to teach Ultrasound by directing the Ultrasound operator without handling the Ultrasound probe.

– Perform multiple Ultrasound exams for each core application. Per ACEP’s 2016 Ultrasound Policy statement, complete 25-50 quality-reviewed exams in each of the 12 core applications and 150-300 total EUS applications. Review your program’s requirements for specific graduation criteria for EUS credentialing.

– Refine documentation skills for Ultrasound imaging.

– Learn to review scanned images for quality improvement.

– Begin learning advanced ultrasound applications including Transesophageal Echocardiography (TEE), testicular ultrasound, and advanced ultrasound measurements.

– Begin exploring administrative elements (ie. quality, credentialing, billing).

• Begin to consider applying an EUS Fellowship.

• For residents planning to pursue a Fellowship, consider the following:

– For those considering an Ultrasound Fellowship, a full listing of resources can be found at the SAEM Academy of Emergency Ultrasound (AEUS) website

■ Also check out the AEUS Fellows Corner

– Complete a scholarly activity/research project involving Ultrasound. Consider a project that can extend into fellowship.

– Increase involvement in Ultrasound education.

■ Establish educational programs for undergraduate medical education, junior residents and other departments. Proctor scans and prepare lectures.

■ Begin to explore a niche. Examples include clinical Ultrasound, education, and administration.

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– I n your second-to-final residency year (PGY-2 if 3 year residency, PGY-3 if 4 year residency), consider registering at http://eusfellowships.com/index.php to explore different programs and their descriptions.

■ See Resources for elements to consider in a fellowship program and an example of the fellowship application timeline.

– Be on track to complete an Emergency Medicine residency training program and towards becoming EUS credentialed.

– Apply for an US Fellowship. See Resources for instructions on how to apply and to become familiar with the process for application and the match.

■ See SCUF page for detailed timeline

– Join the SAEM Academy of Emergency Ultrasound (AEUS).

– Join SAEM and attend the SAEM Annual Meeting. See Resources for SAEM Annual Meeting Ultrasound-oriented events.

– Example timeline* for applicants planning to enter an US Fellowship program upon finishing residency: ■ July-August of final residency year: Applications due. Register with NRMP ■ August-October of final residency year: Program interviews.

■ End of October Rank list due through NRMP ■ November of final residency year: Match with announcement of Fellowship positions. Previously, Eusfellowships.com set the time after which applicants can begin to receive offers.

– * The above are general guidelines and do not apply to all EUS fellowship programs. Review specific program due dates and application requirements (ie. CV, Letters of Recommendation, Cover Letter, Letter of Interest) at: http://eusfellowships.com/ programs.php

• H ow does an EUS fellowship change career options when EM residents should be able to have EUS credentialing after residency completion?

– An EUS fellowship will help prepare fellows for an EUS leadership position and provide further training in ultrasound techniques and advanced ultrasound topics. Fellowships will provide training in skills such as, quality improvement/quality assurance programs, credentialing, billing and coding, that will help prepare for leadership positions.

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4 - FELLOWSHIPS • L ength of training is 1-2 years. There may be opportunities to obtain additional advanced degrees.

• EUS fellowship is a designation of focused practice EM subspecialty. The accreditation guidelines for programs and the certifying exam are being created an will likely be live in the next 2-3 years • A goal is to prepare a skill set to lead an Emergency Ultrasound program. This includes thorough knowledge of advanced scanning techniques, administrative, research and teaching skills.

• Example program criteria: – Perform Ultrasound examinations – Learn Ultrasound billing and coding. (example: >1000 examinations).

– Understand the process of credentialing colleagues.

– Perform Ultrasound-related research for publication – Develop Ultrasound education curriculum. Become involved and/or presentation. in undergraduate and graduate medical education. Mentor – Understand how to run Quality Improvement/Quality interest groups, Ultrasound teaching sessions, and Ultrasound Assurance programs. symposiums.

– Know the elements necessary for machine purchases – Attend a national Emergency Ultrasound conference and maintenance. (ie. SAEM, ACEP, AIUM) • Consider community vs. academic career options.

– Community career options include becoming Emergency Ultrasound Director, – Those with more interest in research and education may consider academic career options over community career options.

Academic career options include becoming an Emergency Ultrasound Director, Emergency Ultrasound Fellowship Director, Emergency Ultrasound faculty, undergraduate or graduate medical education leadership.

• Central Resource for Fellowship Applicants: – Society of Clinical Ultrasound Fellowships: Emergency Ultrasound Fellowship.

• For a list of EUS Fellowships: – Visit: http://eusfellowships.com/programs.php – Details of individual programs are available at this site (ie. Graduation criteria, salary/funds, clinical duties, number of Ultrasound faculty).

• Elements to consider in a fellowship program: – Note that an EM US Fellow will be working as a faculty – What are your clinical responsibilities? What additional duties member, with clinical responsibilities at the attending level. do you have (teaching, administration, etc.)?

Consider programs with this in mind.

– What Ultrasound machines are available and when?

– How many faculty are in the division?

Who owns and maintains the machines?

– Who educates the fellow?

5 - BACKGROUND The history of Ultrasound has its inception surrounding the termination of WW2 when a boom in Global Science yielded increased experimentation in the field of Ultrasonics. Dr. Karl Theodore from Austria was the first to publish his work on the investigation of the brain through the use of transmission ultrasound. The 1960’s saw advances in grey scale imaging from still images to moving images. It wasn’t until the fusion of the recently invented Doppler imaging with the rapidly upgrading Ultrasound technology that Duplex scanning was created allowing for a more thorough understanding of the anatomy being viewed. Fast forward to the 2000’s and we now have advance digital display, power doppler and 3d-imaging.

Point-of-care use of ultrasound in the Emergency Department was introduced several decades ago and has rapidly grown to include many indications. Emergency Ultrasound is a desirable skill in the emergency department because it is portable, able to be brought to the bedside while patient care and monitoring continues, able to be repeated as patient’s status changes, causes no radiation exposure to the patient, can be executed rapidly, and is able to be packaged in such a manner where it utilized in many austere environments.

For a list of the current scope of emergency ultrasound, please refer to the ACEP Ultrasound Guidelines for the 16 core applications.

6 - RESOURCES Society for Academic Emergency Medicine, SAEM

FOAMed

– SAEM Academy of Emergency Ultrasound (AEUS)

– Collection of video lectures produced by the Academy of Emergency Ultrasound (AEUS), an academy of SAEM.

–U S Gel Podcast - recurring podcast discussing the latest innovations in EMUS

– Ultrasound FOAMed Suggestions by EM Physicians

– SAEM Annual Meeting

– SonoMojo - A Guide to Bedside Ultrasound Education

– 5minSono - short tutorial videos on ultrasound education

– Events at SAEM18 include the following:

■ SonoGames®: a point-of-care ultrasound competition amongst resident teams

■ Lightning Oral Abstracts and Oral Abstracts

■ Workshops: - Resuscitative Transesophageal Echocardiography (TEE) and Advanced Transthoracic Echocardiography (TTE): Applications in Emergency Critical Care ■ ePosters • Society of Clinical Ultrasound Fellowships

Textbooks – Introduction to Bedside Ultrasound iBook volume 1 and 2

–M a and Mateer’s Emergency Ultrasound by O. John Ma, James R. Mateer, Robert F. Reardon, Scott A. Joing

–M anual of Emergency and Critical Care Ultrasound by Vicki E. Noble and Bret P. Nelson

– (Fellow Level) Ultrasound Program Management by Vivek S. Tayal, Michael laivas, Troy R. Foster

• American College of Emergency Physicians, ACEP

Journals and Publications

– ACEP Emergency Ultrasound Section

– Academic Emergency Medicine

–A CEP Emergency Ultrasound Clinical & Practice Management Resources

– ACEP Sonoguide • American Institute of Ultrasound in Medicine, AIUM – AIUM Ultrasound in Medical Education Portal • World Congress on Ultrasound in Medical Education

– J ournal of Ultrasound in Medicine

7 - INSIDER ADVICE Dr. Barry Wagner, Ultrasound Fellow, Hennepin County Medical Center “I chose ultrasound due to interest and it being a growing field. I chose the program due to familiarity as a resident already at the same site, high quality of ultrasound machines and education within the department.”

Dr. Stephen Alerhand, Rutgers Department of Emergency Medicine “In this academically enriching year as an Ultrasound Fellow, I spent so much time ‘throwing myself ’ into diverse aspects of point-of-care ultrasound. I felt inspired by the creative and intellectually curious members of the ‘ultrasound community’ to learn advanced ultrasound skills, devour the latest knowledge via literature and FOAM, and attend engaging conferences around the world.

These experiences spurred my own creativity for writing and design, and have further pointed me toward this career path in ultrasound education that I truly enjoy and does not feel like ‘work.’ ”