are nurses really reading echos at some places?

[8ball]

Does anyone that posts here actually work at a shop now (or in the past) where this is happening? I was thinking about a cardiac fellowship because i really want to stay in the OR and I thought i could learn a skill that was untouchable (the ASE would never certify a nurse?) but i recently found a CRNA subforum on TEE??

Please tell me this isn't true.

---

Members don't see this ad.

 

[gasdoc77]

Does anyone that posts here actually work at a shop now (or in the past) where this is happening? I was thinking about a cardiac fellowship because i really want to stay in the OR and I thought i could learn a skill that was untouchable (the ASE would never certify a nurse?) but i recently found a CRNA subforum on TEE??

Please tell me this isn't true.

True. I know for a fact that at a state-of-the-art physician owned hospital nearby they are kept afloat entirely by their heart volume. It was started by a cardiologist and a ct surgeon. The state is NOT opt out, has traditionally been almost universally MD only, yet they have only crna's at this particular facility. Crna's usually just steer the probe for the surgeon, but they were talking about sending one to a coarse (a guy I personally happen to like). I had discussed providing services with the administration several times previously, but they seemed unmotivated to commit. Shame because its a truly beautiful place that would be very user friendly!

 

[ryanjmy]

Tee is not something you could learn at one coarse. I'm sure there are crnas dropping probes and getting views but surely they aren't making diagnosises. I can't imagine a ct surgeon that would change his planned surgery based on a crna's interpretation of an echo.

Getting good at tee is not easy. Do the fellowship if you enjoy cardiac.

 

[GasEmDee]

True. I know for a fact that at a state-of-the-art physician owned hospital nearby they are kept afloat entirely by their heart volume. It was started by a cardiologist and a ct surgeon. The state is NOT opt out, has traditionally been almost universally MD only, yet they have only crna's at this particular facility. Crna's usually just steer the probe for the surgeon, but they were talking about sending one to a coarse (a guy I personally happen to like). I had discussed providing services with the administration several times previously, but they seemed unmotivated to commit. Shame because its a truly beautiful place that would be very user friendly!

I am sure it is happening. Even a high school student can put down a probe and look at some images. Health care in the U.S. is breaking the bank, and its sad that the solution is to dumb down the requirements for healthcare providers. Now, a person who had mediocre performance in high school, went to a brief nursing program, and then spent a few years taking orders in the ICU can claim he is equivalent to another person who was a top academic performer throughout life and then put in 12+ years of post-HS education and 60-80hour work weeks during that entire time and was trained to make decisions on medical care.

That is an easier and quicker "solution" than to fix the REAL reason for high costs:
1) The spending of extreme amounts of money for futile care at the extremes of life
2) Excessive ordering of tests to CYA
3) The epidemics of obesity, HTN, diabetes, and numerous other preventable disease that lead to a subpopulation consuming the lions share of health resources.
4) A subset of the population (the insured) subsidizing the cost of non-paying patients, the later of which are fare more likely to have the above health issues.

To add insult to injury, if a physician wants to be paid for his work, he is called greedy by the public and the press. Meanwhile, other high performers in life go into tech or finance with only 4 years of school behind them and can make the same amount of money (and often more), without the liability and without giving up their entire 20s and early 30s. American health care is going down the tubes. You'd have to be nuts to go to medical school today.

 

[Noyac]

gasemdee, you missed one reason for the high cost of health care.

The ridiculous prices of medical supplies, instruments and hardware. Everyone seems to be tuning into he high cost of drugs but nobody seems to be discussing this.

 

[BuzzPhreed]

They can put the probe in and look all they want. They can't submit a written report of their findings or bill for it. So their interpretation is worth exactly what whomever is listening to it is paying for it: nothing.

 

[BLADEMDA]

Does anyone that posts here actually work at a shop now (or in the past) where this is happening? I was thinking about a cardiac fellowship because i really want to stay in the OR and I thought i could learn a skill that was untouchable (the ASE would never certify a nurse?) but i recently found a CRNA subforum on TEE??

Please tell me this isn't true.

It isn't true...yet. The question remains whether the DNAP CRNa can do a 6 month "fellowship" and become certified by the AANA. Then, the AANA will argue to CMS about "equivalency" for full reimbursement. Once CMS says yes (and they will) the private payers will be forced to pay the crna as well.

 

[deleted59964]

how do the crnas deal with liability - both related to miss diagnosis, missed diagnosed, and potential complications (oesophageal rupture).
can they get insurance to cover this ?

apologies if that's naive - we don't have crna's and our nurses won't do anything that increases their liability

 

[GasEmDee]

They can put the probe in and look all they want. They can't submit a written report of their findings or bill for it. So their interpretation is worth exactly what whomever is listening to it is paying for it: nothing.

They can bill for probe placement (but not interpretation), and then they can brag to the to the public how they can do TEE too. For what it is worth, I personally don't have the knowledge base and experience to do a formal TEE interpretation, but I acknowledge my limitations!

I have been to multiple TEE courses, but I don't think this is sufficient.

 

[GasEmDee]

gasemdee, you missed one reason for the high cost of health care.

The ridiculous prices of medical supplies, instruments and hardware. Everyone seems to be tuning into he high cost of drugs but nobody seems to be discussing this.

You are probably right. I don't know the impact of these on total health care costs so I didn't mention them. Regarding the cost of drugs, I do think there should be some regulation, but the cost of R&D is extremely high. There are many, many costly failed drug candidates for each one that makes it successfully to market. Drug companies need to be fairly incentivized to do this research. I say this as someone who has no involvement with pharmaceutical companies.

 

[deleted547339]

They can bill for probe placement (but not interpretation), and then they can brag to the to the public how they can do TEE too. For what it is worth, I personally don't have the knowledge base and experience to do a formal TEE interpretation, but I acknowledge my limitations!

I have been to multiple TEE courses, but I don't think this is sufficient.

Sorry for the novice question...but how long does it take one to become proficient with TEE? I'm an EM resident planning on going into CC. Some fellowships list TEE in their curriculum and I don't know how important of a factor this should be in selecting a fellowship. Is it realistic to think an intensivist could become proficient in TEE during a 2 year fellowship? I realize that there could be turf wars, but assuming I was employed somewhere that would let me do TEEs as an ICU attending, is it possible that I would be able to perform and interpret these?

As a somewhat related question, is this within the purview of general anesthesia? You say that you don't do them because of lack of knowledge/experience - is this just that this is one of your relative weaknesses or do only those that do a cardiac fellowship perform these? Thanks.

 

[Stank811]

Cardiac fellowship is essentially doing a years worth of echocardiography training in order to get advance certification. All anesthesia residency programs train their residents in TEE and if not they better start since it is going to be part of the future milestones for anesthesia.

In regards to CC and TEE….I would argue that TTE is much more useful training especially if you are doing primarily medical ICU training. I did a CC fellowship via anesthesia and spent a lot of time working on both TTE and TEE. The only time TEE comes in handy in an ICU situation is in post op cardiac patients. Post surgical cardiac patients have to much chest trauma and to many chest tubes which makes TTE for post op management useless.

 

[deleted547339]

Cardiac fellowship is essentially doing a years worth of echocardiography training in order to get advance certification. All anesthesia residency programs train their residents in TEE and if not they better start since it is going to be part of the future milestones for anesthesia.

In regards to CC and TEE….I would argue that TTE is much more useful training especially if you are doing primarily medical ICU training. I did a CC fellowship via anesthesia and spent a lot of time working on both TTE and TEE. The only time TEE comes in handy in an ICU situation is in post op cardiac patients. Post surgical cardiac patients have to much chest trauma and to many chest tubes which makes TTE for post op management useless.

Thanks! We use TTE fairly often in EM, but generally our use of US is to answer a binary question: is there free fluid on a FAST? is there tamponade? is cardiac output sufficient/is the patient in acute heart failure? is there significant hydronephrosis, etc. - NOT a comprehensive cardiac echo.

 

[Stank811]

Thanks! We use TTE fairly often in EM, but generally our use of US is to answer a binary question: is there free fluid on a FAST? is there tamponade? is cardiac output sufficient/is the patient in acute heart failure? is there significant hydronephrosis, etc. - NOT a comprehensive cardiac echo.

Then you will be one up on many of your CC colleagues in fellowship b.c that is all that is really necessary in CC practice. You have a sick patient and you don't feel like waiting for cardiology to give you a formal read and you don't want to send the pt to CT for PE protocol unless the patient absolutely requires it.

For example, here is a classic situation. Pt is transferred to unit secondary to respiratory distress, post op day #4 from ex lap for SBO. Pt is saturating at 90% on non-rebreather, tachycardic at 115, BP 95/56 (baseline 120/80). 5 lead EKG on monitor shows no specific evidence of ischemia. Option #1: send labs, get 12 lead, maybe consider bipap, order CT PE protocol, intubate and place on MV. Option #2: send labs, order 12 lead, obtain bedside TTE to look for tamponade, measure estimated PASP and look for RV strain, access LV for wall motion abnormality.

Bedside TTE shows you significant wall motion abnormality without significant RV strain and only mildly elevated PASP. 12 lead EKG shows no specific findings. Based on TTE you cancel CT scan, order 4 baby ASA, 5000u heparin and consult cardiology. Cardiology arrives and 5 lead on monitor is now showing new LBBB. Pt goes to cath lab and has 3v disease with significant left main disease and receives CABG and eventually goes home.

The above is an actual case from my fellowship in which TTE was huge in narrowing my differential allowing me to quickly treat the patient's underlying pathology.

 

[deleted547339]

Then you will be one up on many of your CC colleagues in fellowship b.c that is all that is really necessary in CC practice. You have a sick patient and you don't feel like waiting for cardiology to give you a formal read and you don't want to send the pt to CT for PE protocol unless the patient absolutely requires it.

For example, here is a classic situation. Pt is transferred to unit secondary to respiratory distress, post op day #4 from ex lap for SBO. Pt is saturating at 90% on non-rebreather, tachycardic at 115, BP 95/56 (baseline 120/80). 5 lead EKG on monitor shows no specific evidence of ischemia. Option #1: send labs, get 12 lead, maybe consider bipap, order CT PE protocol, intubate and place on MV. Option #2: send labs, order 12 lead, obtain bedside TTE to look for tamponade, measure estimated PASP and look for RV strain, access LV for wall motion abnormality.

Bedside TTE shows you significant wall motion abnormality without significant RV strain and only mildly elevated PASP. 12 lead EKG shows no specific findings. Based on TTE you cancel CT scan, order 4 baby ASA, 5000u heparin and consult cardiology. Cardiology arrives and 5 lead on monitor is now showing new LBBB. Pt goes to cath lab and has 3v disease with significant left main disease and receives CABG and eventually goes home.

The above is an actual case from my fellowship in which TTE was huge in narrowing my differential allowing me to quickly treat the patient's underlying pathology.

Impressive. My TTE skills are definitely not there yet. I can tell you if the RV/LV ratio is abnormal or if EF looks good, poor or somewhere in between....identifying regional wall motion abnormalities is quite a bit above my skill set. Hopefully that will change.

 

[fakin' the funk]

In regards to CC and TEE….I would argue that TTE is much more useful training especially if you are doing primarily medical ICU training. I did a CC fellowship via anesthesia and spent a lot of time working on both TTE and TEE. The only time TEE comes in handy in an ICU situation is in post op cardiac patients. Post surgical cardiac patients have to much chest trauma and to many chest tubes which makes TTE for post op management useless.

No, you're wrong. TTE in postop cardiac patients is actually quite useful...as long as you as are aware of its limitations.

Many IMMEDIATE postop cardiac patients have a midline sternotomy bandage, midline subxiphoid chest tubes, and often some intrapleural air. Nonetheless you can often get parasternal long and short, apical 4 and 2, and subcostal 4 and IVC. In my experience the subcostal is usually the most limited view due to mediastinal drains.

After extubation and mobilization you can typically get the same 3-5 views however usually with higher quality due to lower pleural pressures.

If you need echo to make a life-threatening diagnosis in an intubated, IMMEDIATE postop patient then certainly it's TEE time. Where I did fellowship, we had a badass ultrasound system (GE Sparq) that accomodated linear probe for procedures, TTE probe, and TEE probe. One-stop shopping for all your ultrasound needs. Can't recommend this unit highly enough.

Now that I'm done being contrary, the use of bedside "informal" TTE in the critically ill and perioperative medicine is exploding and needs to be part of every anesthesiologists training.

 

[Stank811]

Fakin my experience with it has been different…once your mediastinal tubes come out and a lot of the air has dissipated then it is a different story but by the time that happens you usually don't need the echo anymore. I placed a TTE probe on nearly every post op cardiac patient during my fellowship just for practice and I would say the majority (80-90%) of the time the views are limited and not at all helpful outside of maybe accessing volume or very gross anatomy of LV. If you are truly getting all those quality views on post op cardiac patients your surgeons are doing something different or every anesthesiologist and echo tech at the institution i trained needs to visit your shop for some lessons. Even when we ordered a formal bedside echo the final report from the cardiologist just stated it was a limited exam secondary to difficulty obtaining images and the report was usually worthless. We also have brand new US machines throughout our unit so I can not imagine that was the difference. We also had the htee machine which I have said in previous post is a waste of money as well. I always still tried TTE for educational purposes but rarely did it make a difference in my management in immediate post op cardiac patients b/c I didn't trust the images I was getting.

Someone actually tried to determine risk factors for poor TTE images post cardiac surgery…I like how they make excuses for the poor cardiology fellow who apparently can't get images either.

http://www.elearning.sachile.cl/upfiles/userfiles/file/eco_en_cx_cardiaca.pdf

 

[GA8314]

I feel they should reintroduce the practice experience pathway towards certification. That way docs can still get boarded in Advanced Echo.
There are lots of hearts being done in the community, far away from hot shot cardiac programs or tertiary care centers. Also, there are FAR too few fellowship slots available to meet the demand for Advanced Echo.

So, the fellowship requirement, while sounding great on paper, really isn't helping patients since MOST hearts are being done by non-fellowship trained docs ( not likely to change either given the small number of aforementioned slots) anyway. Why not reopen the practice experience pathway??

Meantime, nurses are starting to take weekend courses in TEE ( I have heard this from a CRNA in residency) and pain procedures......

 

[OB1🤙]

WRT nurses doing echo- it may not shock you to learn that there are arrogant cardiac surgeons out there. These folks think all they need is the echo shown to them, and they'll do the "reading." It turns out these are also the same surgeons who try and dictate every little bit of hemodynamic management too. So of course this subtype is happy with- and maybe even prefers- a CRNA.

Fortunately, I work with surgeons who realize what advanced echo training brings to the table, as well as fellowship training. They do the surgery, i do the cardiac anesthesia, and everyone is happy.

Oh, and they trust our reads more than the cardiologists'.

 

[OB1🤙]

The other thing I'll say about this- "amateur" intraop echocardiographers tend to focus only on the pathology in question. If you're doing an AVR, they'll get a few looks at the valve and that's about it.

They tend not to get a comprehensive look at the whole heart, looking for other abnormalities. There are subtle things that absolutely can impact surgery that a non-expert simply won't see. The coronary-PA fistula and persistent left SVC come to mind as recent examples of this for me.

Finally, I consider diastology pretty important. I've yet to see a non-certified exam that had any diastology. Also, the hemodynamics are in the Doppler studies. Stroke volume, CO, LVEDP, PASP, etc. Non-experts are not going to be getting these numbers, and they can matter.

 

[GA8314]

The biggest problem in anesthesiology is that we keep formalizing different skill sets such as Cardiac, Pain, and Peds. Fellowships, certifications etc etc. Its hard to argue that this isn't a good thing, but WE keep imposing increased barriers to entry for fellow anesthesiologists all the while nurses keep taking weekend courses and completely devaluing those same skills.

We require fellowship training now for Advanced TEE certification. Meantime nurses are saying f.ck you.

The danger of this is that our culture of exclusion is keeping a lot of docs from formalizing (because they are losing access to do so) their skillset. Again, all the while nurses are thumbing their noses at those same barriers.

So the biggest losers are generalists. The biggest winners are the nurses who have nothing to lose.