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deleted682700
What are the best and easily understandable TEE and ultrasound point of care for acute emergency in anesthesia courses on line. Which of these courses is ABA and ASA approved for certification and CME Purposes.
thanks
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If You Don't Look, You Don't Know! - Echocardiography and Perioperative Ultrasound
Echocardiography and Perioperative Ultrasound
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I’m perhaps biased, as a current CT fellow... But I think there are a couple of levels of complexity to TEE:
Level one: what chambers/valves am I looking at? Is everything moving? Is the patient dying because of PE with R heart strain, tamponade, dissection, etc?
Level one most anesthesiologists should graduate residency knowing how to do. Don’t think it’s something you need a course to learn.
Anything beyond that (grading severity of valve lesions, making hemodynamic calculations, more sophisticated assessment of ventricular function, etc) I think you need more than a weekend course. This is an area where it’s VERY tempting to think you know what you’re looking at, and you don’t realize until you learn more how much you don’t know. Acting on bad (or wrongly interpreted) data is worse than no data at all.
Possible exception for folks who are very facile with cardiac POCUS TTE and just need to learn how to read the images “backward” (guessing this mostly applies to the ICU crowd).
I don’t mean to be a grump, and of course I want to encourage lifelong learning and skill acquisition yada yada. Just cautioning that TEE isn’t something learned casually during a weekend course. If it were, the fellowship would be a lot shorter.
Level one: what chambers/valves am I looking at? Is everything moving? Is the patient dying because of PE with R heart strain, tamponade, dissection, etc?
Level one most anesthesiologists should graduate residency knowing how to do. Don’t think it’s something you need a course to learn.
Anything beyond that (grading severity of valve lesions, making hemodynamic calculations, more sophisticated assessment of ventricular function, etc) I think you need more than a weekend course. This is an area where it’s VERY tempting to think you know what you’re looking at, and you don’t realize until you learn more how much you don’t know. Acting on bad (or wrongly interpreted) data is worse than no data at all.
Possible exception for folks who are very facile with cardiac POCUS TTE and just need to learn how to read the images “backward” (guessing this mostly applies to the ICU crowd).
I don’t mean to be a grump, and of course I want to encourage lifelong learning and skill acquisition yada yada. Just cautioning that TEE isn’t something learned casually during a weekend course. If it were, the fellowship would be a lot shorter.
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I agree on some levels. But not all residency programs are created equally. My residency program is very TEE focused during cardiac months, with 3 divided weeks of dedicated TEE time. This includes performing 2-3 full exams ourselves each day, spending time with the simulator, reading interesting echoes for 1+hr per day with faculty. We are expected to be very comfortable getting all the views and fairly proficient in basic assessments like valve gradients and LVEF assessment with simpson biplane method, fractional shortening, etc .
Clearly I don't think this makes me an expert, nor does it mean I'm ready to go and do extremely complex cardiac cases, but I do feel that with my experience, a weekend refresher and some well done online videos would add value (but not make me an expert).
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Also, sorry I didn't catch the part about CME or certification. I just recommended this to improve your proficiency.University of utah. Free.
If You Don't Look, You Don't Know! - Echocardiography and Perioperative Ultrasound
Echocardiography and Perioperative Ultrasoundecho.anesthesia.med.utah.edu
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I am a non-CV fellowship trained anesthesiologist who does hearts. I had strong CV training in residency including a dedicated TEE month (in addition to 4 regular CV months). I was very motivated to obtain and maintain TEE skills when I started my job. I attended the SCA/ASE echo course (it used to be in San Diego, maybe in Atlanta now?) twice and did a tremendous amount of self study. I took the basic TEE exam the first year it was offered, and because there were no dedicated study materials (or even a real syllabus to go on), I just used study materials for the advanced exam. I spent tens to hundreds of hours preparing, and when I took the exam, it was a joke. I was focused on things like diastology, physics, M-Mode, and 3D stuff, and the basic exam questions were like "which AV leaflet is this?". I am fairly confident that I could have passed the advanced exam, and wish I had just taken it at that time. I still do my own TEE for heart cases eight years later, and feel good about my skills. All that said, my TEE skills pale in comparison to my CV trained partners and I am humbled when I watch them do an exam.
In the end, I think it's important to know what your goal is with a non-CV level of TEE proficiency. If it's really just for "**** hitting the fan, heart full vs heart empty" stuff where you shove a probe into a crashing pt in a last ditch effort to guide management, you probably don't need a fancy curriculum. In my experience, this situation actually comes up very very rarely. I've dealt with many hemodynamically unstable non-cardiac patients in my career, and I think I've placed a TEE probe in maybe two of them. Nobody throws a probe into a non-CV paitent who is "kind of" dwindling or "maybe needing a little more phenylephrine". It's a pretty invasive step to take for "run of the mill" hypotension, etc. By the time you think a TEE is necessary/might help you, your limited time and effort would be better spent trying therapies than finding a machine/probe (in a non-CV hospital or part of the OR) and doing an exam, and it's frequently too late for some new therapy (guided by your TEE) to make much of a difference.
If you happen to have some niche job where you would use TEE frequently for non-CV surgery (liver transplant or major vascular, I guess?), then maybe a god course makes sense. In that case, I'd do SCA/ASE echo week supplemented with lots of self study.
In the end, I think it's important to know what your goal is with a non-CV level of TEE proficiency. If it's really just for "**** hitting the fan, heart full vs heart empty" stuff where you shove a probe into a crashing pt in a last ditch effort to guide management, you probably don't need a fancy curriculum. In my experience, this situation actually comes up very very rarely. I've dealt with many hemodynamically unstable non-cardiac patients in my career, and I think I've placed a TEE probe in maybe two of them. Nobody throws a probe into a non-CV paitent who is "kind of" dwindling or "maybe needing a little more phenylephrine". It's a pretty invasive step to take for "run of the mill" hypotension, etc. By the time you think a TEE is necessary/might help you, your limited time and effort would be better spent trying therapies than finding a machine/probe (in a non-CV hospital or part of the OR) and doing an exam, and it's frequently too late for some new therapy (guided by your TEE) to make much of a difference.
If you happen to have some niche job where you would use TEE frequently for non-CV surgery (liver transplant or major vascular, I guess?), then maybe a god course makes sense. In that case, I'd do SCA/ASE echo week supplemented with lots of self study.
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Using TEE even "just" for rescue purposes sounds like it's straightforward, but I can assure you that it's not. No one can take a weekend course and then confidently be able to place the probe, acquire all the views, know artifacts from real findings, and be able to adequately diagnose tamponade, RV/LV failure w/wo RWMAs in a specific distribution, SAM/LVOTO, acute aortic syndromes, SVC/IVC/RA thrombi in transit/saddle PEs, acute moderate vs severe valvular lesions, low afterload vs hypovolemic states, etc with a high degree of accuracy. It really is one of those things where a little bit of knowledge can be more dangerous than none.
I think taking some TTE POCUS courses and learning about FATE exams for your own self-edification is great. Every anesthesiologist should be able to slap on a TTE probe and acquire a parasternal long, parasternal short, apical 4ch, and subcostal 4ch and be able to put color over the valves and give a qualitative assessment of wall motion. But I think a serious effort at learning even basic TEE or rescue TEE requires a physical mentor in your practice with expert TEE experience with whom you can read studies, do a bunch of exams, go over your exams etc.
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deleted697535
I cant fathom why one would want to make a potentially life saving or life ending decision based on an online course.
Will you stand up and tell the surgeon this is tamponade crack the chest, or this is a type A stickyourcannula there , or this is a pe with strain thrombolyse the arresting cesarean section. All things I've done this month while literally praying I wasn't wrong. Remeber your generalist anesthesia opinion isnt up for scrutiny, your echo loops are
But if you do then ptemasters and the sccm course for tte is by far the best. Next in line in Mathews excellent tee and perrinos book.
But in reality, don't just don't.
Will you stand up and tell the surgeon this is tamponade crack the chest, or this is a type A stickyourcannula there , or this is a pe with strain thrombolyse the arresting cesarean section. All things I've done this month while literally praying I wasn't wrong. Remeber your generalist anesthesia opinion isnt up for scrutiny, your echo loops are
But if you do then ptemasters and the sccm course for tte is by far the best. Next in line in Mathews excellent tee and perrinos book.
But in reality, don't just don't.
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That kinda **** seems to be part of our osce's now. Unfortunately we don't really have a choice on whether or not we should be able to use echo.
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bad things can happen in any case. A generalist wanting to increase their knowledge of echo shouldn't be frowned upon. Like most things life is lived in the middle. How did older general surgeons learn robotic surgery? How are current orthos learning robotic joint replacement? The entirety of medicine is filled with examples of practicing physicians learning CME to further their knowledge. I'm not sure why anyone would believe TEE is off limits.
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deleted682700
I do respect fellowship trained Cardiac fellows because of their commitment to learn above and beyond and do a course Formally. My intention to learn is driven By my desire to decrease my liability when dealing with sicker emergency when I am alone. Usually I Seek advise from the cardiac trained fellows ,if they are available, when unexpectEd events unfold.
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By all means, learn echo. It’s not “off limits”, and learning is great- I applaud the initiative. But I don’t think taking a weekend course and then making high stakes calls based on your TEE interpretations “decreases liability”. It’s much more likely that you will open yourself up to Monday morning quarterbacking
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First and foremost: we as anesthesiologists are doctors and we should be able to learn anything any other doctors know, which includes TEE.
However, this whole thread reminds me of when a ped friend asked me how to administer sedation safely so she could do it with lowered liability.... the answer is to be able to intubate the patient until the sedation wears off. But she wanted me to tell me something like "as long as you push less than 120mcg of fentanyl, the sedation is always safe and she will never have liability". But she was unwilling to take on the responsibility of intubating the child which actually meant her liability actually increased during the sedation. TEE is just like that, you can't just learn crash course over a weekend and lower your liability. The dunning-kruger effect will actually increase your liability.
If you want to lower you liability, the answer is to be as good as the next guy doing TEE every day which means go all out and learn everything the next guy knows. Otherwise when you have liability assessment, the question is always going to be "why didn't you get the more experienced guy to do it?" So truly the only to lower your liability is to be just as good as the next guy on paper, which means a minimum advanced PTEexam testamur, if not certification.
weekend/online courses are designed to take your money and give you a false sense of achievement. Really does nothing for you clinically.
If you want to start learning TEE, my advice is to start with perino and reeves book. Toronto has a free website with simulator that shows how the probe works, buy PTEmasters to see the extended range of things to learn, subscribe to Zimmerman's daily emails, drive the probe whenever you can. etc. I was able to become a testamur doing these things. But none of these is a quick fix that lowers your liability. And even as a testamur before CT fellowship, the experience of doing all the cases during fellowship is what really made my liability lower.
However, this whole thread reminds me of when a ped friend asked me how to administer sedation safely so she could do it with lowered liability.... the answer is to be able to intubate the patient until the sedation wears off. But she wanted me to tell me something like "as long as you push less than 120mcg of fentanyl, the sedation is always safe and she will never have liability". But she was unwilling to take on the responsibility of intubating the child which actually meant her liability actually increased during the sedation. TEE is just like that, you can't just learn crash course over a weekend and lower your liability. The dunning-kruger effect will actually increase your liability.
If you want to lower you liability, the answer is to be as good as the next guy doing TEE every day which means go all out and learn everything the next guy knows. Otherwise when you have liability assessment, the question is always going to be "why didn't you get the more experienced guy to do it?" So truly the only to lower your liability is to be just as good as the next guy on paper, which means a minimum advanced PTEexam testamur, if not certification.
weekend/online courses are designed to take your money and give you a false sense of achievement. Really does nothing for you clinically.
If you want to start learning TEE, my advice is to start with perino and reeves book. Toronto has a free website with simulator that shows how the probe works, buy PTEmasters to see the extended range of things to learn, subscribe to Zimmerman's daily emails, drive the probe whenever you can. etc. I was able to become a testamur doing these things. But none of these is a quick fix that lowers your liability. And even as a testamur before CT fellowship, the experience of doing all the cases during fellowship is what really made my liability lower.
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deleted697535
In the last 2 weeks alone ive seen a missed Type A and a missed PE due to falsely read POCUS. Both in their 40s with devastating results. I bloody hate POCUS and what echo has become. Every resident running around with a little probe declaring normal study etc bla bla bla
The Echo probe is a lethal weapon and should be treated with respect.
Im obviously bitter and biased due to the last 2 week run of call ive had so i apologise for my candour right now. But there is a reason why we did 80-100 hours a week for a year on cardiac fellowship, and lost probably 500k into it plus a few years off our lives.
Ill be more supportive after a reset ( a lot of booze)
The Echo probe is a lethal weapon and should be treated with respect.
Im obviously bitter and biased due to the last 2 week run of call ive had so i apologise for my candour right now. But there is a reason why we did 80-100 hours a week for a year on cardiac fellowship, and lost probably 500k into it plus a few years off our lives.
Ill be more supportive after a reset ( a lot of booze)
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Extensive reading, websites, lecture videos, courses etc to increase your echo knowledge are all great.
But I think we all agree though that bottom line is that it’s all for naught without 1. Significant hands-on probe time in real pts, I.e. ~75-150 comprehensive TEEs performed with an expert in TEE standing beside you. 2. Significant review time reading yours and others’ studies while sitting beside someone who’s an expert in TEE. This is both for increasing your knowledge and for quality control.
