Emergency Ultrasound Fellowship Research Articles

The effect of sonologist experience on the ability to determine endotracheal tube location using transtracheal ultrasound

Study objectiveTranstracheal ultrasound has been described as a method to evaluate endotracheal tube placement. Correlation between sonologist experience and the successful use of transtracheal ultrasound to identify endotracheal tube location has not been examined. Our objectives were to evaluate emergency physicians' ability to correctly identify endotracheal tube location using transtracheal ultrasound and to evaluate the role operator experience plays in successful identification of tube placement. MethodsThis was a cross-sectional, single-blinded study conducted in a cadaver laboratory. Two cadavers were used as models. One cadaver had an endotracheal tube placed in the esophagus, and the second had the tube placed in the trachea. Participants were asked to evaluate tube placement using transtracheal ultrasound and to record their interpretation. Examination clips were reviewed by the emergency ultrasound fellowship director. Descriptive statistics and χ2 test were used for analysis. ResultsTwenty-nine participants were included, 8 (27.6%) of whom were considered to be “most experienced” based on previous ultrasound experience (>150 scans). Eleven of 29 correctly identified esophageal intubation and 18 of 29 correctly identified tracheal intubation, resulting in a sensitivity of 62.0% (95% confidence interval [CI], 42.3-79.3) and a specificity of 37.9% (95% CI, 20.7-57.7). Transtracheal ultrasound performed by the most experienced sonologists showed better sensitivity and specificity, 75.0% (95% CI, 34.9-96.8) and 62.5% (95% CI, 24.5-91.5), respectively. ConclusionMost participants obtained adequate images, but correct interpretation of the images was poor. The most experienced sonologists correctly identified tube location more often. Additional education would be required before adopting this method.

Emergency Ultrasound Fellowship Training: A Novel Team-Based Approach

Over the past two decades, there has been growing interest in pursuing advanced training in emergency ultrasound (US) which is evidenced by a rapid proliferation of emergency US fellowship programs across the nation. However, considerable variation still exists in the structure and curriculum of emergency US fellowship programs. The objective of our study was to describe our experience with implementation of a novel team-based emergency US fellowship training program.

A Survey of the Emergency Ultrasound Administrative Systems Within North American Emergency Ultrasound Fellowship Programs

To determine the existing mechanisms being employed for quality assurance, documentation, image storage, credentialing, and reimbursement of emergency ultrasound (US) in North American emergency ultrasound fellowship programs. We prospectively surveyed North American emergency medicine (EM) ultrasound fellowship program directors, as identified on www.eusfellowships.com on March 11, 2011, via a previously piloted Web-based survey instrument containing 37 items spanning five topics including: 1) credentialing and training, 2) documentation and storage, 3) quality assurance (QA) and image review, 4) billing, and 5) overall satisfaction. The survey was developed initially by and later finalized by the investigation team including a master statistician, after incorporating feedback from pilot testing to EM ultrasound directors without fellowship programs, research experts, and survey experts. All surveys were distributed using the ACEP- SNAP survey software (Snap Surveys Ltd., Portsmouth, NH) via email to ultrasound fellowship directors, and once received, all survey responses were de-identified to ensure unbiased handling of the data. Descriptive statistical analyses are primarily used to display the data. Over a one-year period, 62% of the directors responded (n=47) and one program declined to participate out of 75 eligible fellowship programs. The programs reported a median number of 5000 (IQR: 3000- 8200) point-of-care US scans performed at their department annually. Respondents reported having an average of 4.3 (SD: 3.5) ultrasound faculty, 63% of whom completed an US fellowship. Sixteen out of 46 programs (34.8%) reported having using a commercial US workflow program with 9/16 (56%) of them choosing Q-Path (Telexy Health Care, Everett, WA). 57% of respondents reported having a formalized credentialing process with the majority of these programs (91%) incorporating ACEP credentialing criteria (www.acep.org). Regarding QA, 94% of the programs reported having a QA and image review process in place; these range in frequency from once a week (71%) to a daily-based process (4%). Only 45% of programs review 100% of the images during these QA sessions. In order to provide feedback to front-line providers, 63% of the directors reported using electronic email and only 10% are using Web-based system for this purpose. On average 45% of the programs reported billing for their scans and only a quarter of the programs reported submitting more than 51% of their performed scans for billing. Fourteen programs reported their estimated annual revenue, as a median of $375,000 (IQR: 46,250-1000,000), from the point-of-care ultrasound scans performed. This study describes the current state of administrative processes among North American EM ultrasound fellowship programs. This information provides useful demographics on the leading programs in emergency US for developing and expanding programs to potentially emulate. Furthermore, this data provides a foundation for further study of best practices and models in emergency ultrasound administration.

Donʼt Be Fooled: Take Serial FAST Scans in Blunt Flank Trauma

ImageA 38-year-old man presented to the emergency department after a horse kicked him in the left flank. He denied chest and abdominal pain. His heart rate was 85 bpm, blood pressure was 139/93 mm Hg, and oxygen saturation was 99%. He had tenderness over a 4 cm contusion on his left flank at the 10th posterior rib. His abdomen was not tender. The assessment was otherwise unremarkable. The initial focused assessment for sonography in trauma (FAST) scan was negative. (Image 1: Right upper quadrant.) A computed tomography (CT) scan illustrated a grade 3 splenic laceration without active extravasation, perisplenic hematoma, small hemoperitoneum, and left 9th and 10th rib fractures. (Image 2.) A repeat FAST scan 10 minutes later was positive in the right upper quadrant only. (Image 3: Right upper quadrant.) The patient was admitted to the intensive care unit where his hematocrit fell to a nadir of 36.4 % (normal 35.0-47.0%). He was discharged on hospital day three. Patients can present after blunt torso trauma with solid organ injury without abdominal tenderness or hypotension. The spleen is the most commonly injured organ, comprising one-third of such injuries. Splenic injury management includes observation, angiography and embolization, or laparotomy depending on the degree of injury and hemodynamic stability. The FAST scan is an accepted screening tool for trauma evaluation. (Curr Opin Crit Care 2007;13[4]:399.) The right upper quadrant view is the most sensitive in a supine patient no matter the location of injury due to the anatominal attachment of the posterior mesentery. In experienced hands, 250 ml of fluid can be detected with an overall sensitivity and specificity of 86% and 98%, respectively. (J Trauma 2001;50[1]: 108.) As this case illustrates, it is imperative to perform repeat FAST scans to increase sensitivity. (J Trauma 2004;57[5]:934; J Emerg Med 2000;18[1]:79.) In hemodynamically stable patients with a positive FAST, CT can diagnose the specific injury and evaluate the retroperitoneal space because FAST scans only evaluate the intraperitoneal space. When the physician has a high degree of suspicion for intra-abdominal injury but does not have access to CT or surgical services, the FAST scan should be repeated as to avoid missing life-threatening injury.Initial ultrasound of Morrison's pouch, right upper quadrantComputed tomography of abdomen. Arrow indicates a grade 3 splenic laceration without active extravasation. Asterisks indicate large perisplenic hematoma.Repeat ultrasound of Morrison's pouch demonstrating intraperitoneal fluid (arrow).Drs. Rossi and Gharahbaghian are emergency physicians in the department of surgery, division of emergency medicine, at Stanford University Medical Center. Dr. Gharahbaghian is also the associate director of Emergency Ultrasound and a director of the Emergency Ultrasound Fellowship at Stanford. Return to EM-News.com