Echo training

[EMbound1]

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There are a few ultrasound fellowships that allow the fellows to acquire a RDCS certification. Certainly this training could make someone a bit more marketable, but what could one do with this cert outside the ED setting? Could they work in an echo lab?

 

[Arcan57]

Why would you want to?

 

[Venko]

There are a few ultrasound fellowships that allow the fellows to acquire a RDCS certification. Certainly this training could make someone a bit more marketable, but what could one do with this cert outside the ED setting? Could they work in an echo lab?

George Washington University (my fellowship) has two RDCS and RDMS credentialed staff members. The degree only certifies that the individual can complete the study as a technician would complete the study. Ability to interpret a study is not shown by the title. So, if you get an RDCS, you would have the same qualifications as the technicians in the echo lab, but then have to push to be able to interpret the study based on your qualifications as a physician.

The utility of any of the RDCS, RDMS, RVT is mainly to show people in the boardroom that you are not simply messing around with ultrasound as a toy but rather take it seriously. The real learning in the fellowship will be different than that which the technicians go through and is the real valuable item here. The degree is just a bolus of studying...

 

[EctopicFetus]

Serious question. I am just a few years out of residency and got some pretty good US training. I have found it minimally useful outside of putting lines in people (Central or deep brachial). I use it in codes and trauma (one of the places is a level 1 trauma center).

Why would I want to do an Echo? why would I want to do a transvag or DVT or RUQ study? I know how to do a RUQ and DVT study and have done some transvag exams as a resident but never got comfortable enough with them?

So the question as someone out of residency what purpose other than academic does this serve?

 

[docB]

When I did residency one of the Kaiser docs we worked with was excellent at us. He could do an echo and it was clinically useful several times. One good example was looking for right atrial dilatation in a patient with suspected PE but kidney disease that precluded a CT.

The problem though for him and for me and for many of us is that no matter how useful US is it's very hard to do when you're seeing 3.5+ patients/hour. I just don't have time to do as many as I would if I weren't as busy.

 

[deuist]

I routinely perform focused echos on hypotensive patients to look for pericardial effusions, ejection fraction and murmurs. I wouldn't want to bolus someone with a liter of fluid if the heart is barely contracting. Also, the FAST is helpful in an undifferentiated hypotensive or anemic exam, although getting a positive result is extremely rare.

The rest of the studies mentioned: DVT, RUQ, transvag are nice techniques to know, and interpreting them are helpful, but the results are rarely needed RIGHT NOW! Doing them during a busy shift would waste large amounts of valuable time.

 

[Venko]

Serious question. I am just a few years out of residency and got some pretty good US training. I have found it minimally useful outside of putting lines in people (Central or deep brachial). I use it in codes and trauma (one of the places is a level 1 trauma center).

Why would I want to do an Echo? why would I want to do a transvag or DVT or RUQ study? I know how to do a RUQ and DVT study and have done some transvag exams as a resident but never got comfortable enough with them?

So the question as someone out of residency what purpose other than academic does this serve?

Well, you're right, for some people its not helpful. The easiest example is if you have someone with vaginal bleeding in the setting of a positive pregnancy test...in the different EDs I staff, the wait time for an ultrasound to confirm IUP can be > 2 hours sometimes and even > 4 off hours. If you can confidently obtain a FHR using transabdominal ultrasound and transvaginal early in pregnancy you can create a disposition for these individuals in less than 3-5 minutes.

As for the echo, I personally use it to help with the hypotensive patient to determine if the problem is a contractility one or if it is a preload issue or obstructive shock. I use it for some other things but I do not think it is reasonable for everyone to do so.

As for DVT, there is some controversy as to whether two point compression studies or sequential compression studies are sufficient, but if you have a good QA system for your studies and good support from the hospital system, you could do your own DVT study and send the patient home (again saving 2-4 hours of length of stay time)....

There are many other ways it helps in my practice, but it certainly varies from clinician to clinician.

 

[Socrates25]

I routinely perform focused echos on hypotensive patients to look for pericardial effusions, ejection fraction and murmurs. I wouldn't want to bolus someone with a liter of fluid if the heart is barely contracting. Also, the FAST is helpful in an undifferentiated hypotensive or anemic exam, although getting a positive result is extremely rare.

The rest of the studies mentioned: DVT, RUQ, transvag are nice techniques to know, and interpreting them are helpful, but the results are rarely needed RIGHT NOW! Doing them during a busy shift would waste large amounts of valuable time.

What happens to those images when you are done looking at them. Do they go to a cardiologist for an "official" review or do they get deleted like they never existed?

 

[Hamhock]

Although the OP questioned about the value of RDCS, it seems the thread has become more about the value of limited bedside ECHO.

To that discussion I will add:

I ECHO every critically ill patient and nearly all ill SOB/CP. I don't even listen to the heart.

In fact, I believe the stethoscope is an insensitive and inaccurate time-waste in the cardiopulmonary evaluation of ill patients. (except asthma)

HH

 

[EctopicFetus]

I will say I work in a pretty efficient place so maybe that makes all the difference. My personal record is a guy hits a bed, I order the CT head and have the radiologist call me with the results in 22 mins. Thats bed to CT read.

We do pretty well with US and any stat test I needed I could get done asap. Maybe that is the difference. In the time to get the US to the bedside and do the study it would only take a bit longer to get a result and in the meantime I could see and dispo another patient.

Curious.. but the people who ECHO all the sick patients, do you work in the community or academic. In academics its a much different world. Our triage to dispo time is 3-4 hours shorter than the number we had in residency. Makes a big difference.

 

[docB]

Maybe that is the difference. In the time to get the US to the bedside and do the study it would only take a bit longer to get a result and in the meantime I could see and dispo another patient.

That's what I'm talking about.

 

[Venko]

I will say I work in a pretty efficient place so maybe that makes all the difference. My personal record is a guy hits a bed, I order the CT head and have the radiologist call me with the results in 22 mins. Thats bed to CT read.

We do pretty well with US and any stat test I needed I could get done asap. Maybe that is the difference. In the time to get the US to the bedside and do the study it would only take a bit longer to get a result and in the meantime I could see and dispo another patient.

Curious.. but the people who ECHO all the sick patients, do you work in the community or academic. In academics its a much different world. Our triage to dispo time is 3-4 hours shorter than the number we had in residency. Makes a big difference.

I think if you can get ultrasounds that you need quickly, there are only a few studies that the ED doc would then want to be proficient in. Bedside Echo, AAA, Ocular, pneumothorax, FAST exams etc. Just the few that we need at the bedside quickly and cannot send away. The ocular study is something that very few technicians are going to know how to do and radiologists are not going to be able to interpret for you, so its one that is well within EM as a specialty. But you're, right in my opinion, to not spend your time if you can get it done just as fast by radiology.

 

[deuist]

What happens to those images when you are done looking at them. Do they go to a cardiologist for an "official" review or do they get deleted like they never existed?

They are stored on the ultrasound machine for QA evaluation later. No cardiologist ever sees the images as they are considered unofficial. The patient isn't billed for procedure as it only an adjunct to my physical exam.

 

[EctopicFetus]

I think if you can get ultrasounds that you need quickly, there are only a few studies that the ED doc would then want to be proficient in. Bedside Echo, AAA, Ocular, pneumothorax, FAST exams etc. Just the few that we need at the bedside quickly and cannot send away. The ocular study is something that very few technicians are going to know how to do and radiologists are not going to be able to interpret for you, so its one that is well within EM as a specialty. But you're, right in my opinion, to not spend your time if you can get it done just as fast by radiology.

I get the FAST and am certified to do them (the only study we are allowed to use to make clinical decisions) but IMO as discussed previously their utility is way overrated. It only helps in the undifferentiated unstable trauma. Thats a small number. CT is superior and if they have a decent BP they can get their CTs.

The Echo i dont get. I cant say I am fully comfortable with this but how will this change or alter my management?

I kind of get the AAA but again only if they are unstable. Used this successfully once to dx a huge AAA.

I also know how to do the ptx study but never fully realized why this would be helpful? CXR?

Lastly, I dont know how to do the ocular US though I have read about it.

Call me ignorant but I think the use of US as taught to me in residency and its utility in everyday (community EM) was extremely over exaggerated.

I ask again, Thymeless, hamhock and deuist, are you in academics?

 

[Venko]

I get the FAST and am certified to do them (the only study we are allowed to use to make clinical decisions) but IMO as discussed previously their utility is way overrated. It only helps in the undifferentiated unstable trauma. Thats a small number. CT is superior and if they have a decent BP they can get their CTs.

The Echo i dont get. I cant say I am fully comfortable with this but how will this change or alter my management?

I kind of get the AAA but again only if they are unstable. Used this successfully once to dx a huge AAA.

I also know how to do the ptx study but never fully realized why this would be helpful? CXR?

Lastly, I dont know how to do the ocular US though I have read about it.

Call me ignorant but I think the use of US as taught to me in residency and its utility in everyday (community EM) was extremely over exaggerated.

I ask again, Thymeless, hamhock and deuist, are you in academics?

Currently, I staff / scan at three EDs, one county, one veterans, and one teaching hospital. I use ultrasound in my practice at all three but less so at the veterans because their machine is quite inadequate.

Echo, PTX, and ocular scanning are staples in my practice and I certainly guide management based on my scans. They are stored and retrievable if question arises.

You should use it only as you feel comfortable because the big danger is when clinical decisions are made based on inadequate scans.

 

[EctopicFetus]

County hospital have residents? Is it quasi academic?

 

[Venko]

County hospital have residents? Is it quasi academic?

The EM residents rotate there...I like to think it is academic when I'm on🙂

 

[Venko]

I was thinking of examples of how US helps in generic EM practice (not an ultrasound fellow hands, not academic or community, even if you can get quick radiology scans etc)...

1. If you Diagnose PE on CT, do the echo because if there is RV strain they should go to ICU instead of general floor (floor vs. ICU)

2. If you have a dyspneic or hypotensive patient who has ESRD / dialysis, echo is necessary part of the evaluation to identify large pericardial effusions
(fluid vs. fluid and tap)

3. If you have a patient who is hypotensive without a known cause despite 1 or 2 liters of NS, the echo can help show if you are still preload deficient or if there is another problem such as a contractility one. (pressors vs more fluids)

4. Elderly patient with back pain that sounds MSK origin. Scan the abdomen to screen for AAA (home with meds vs. vasc surg evaluation)

5. Woman with positive pregnancy test and abdominal pain, vaginal bleeding, and or hypotension. Scan the abdomen for free fluid, and IUP (YES IUP and no FF go home vs. NO IUP and no FF OB consult vs. NO IUP and YES FF go OR)

6. Pt with floaters, scan the eye (+ Detachment call optho for immediate consult vs. no detachment and optho next day)

7. Trauma pt supine with dyspnea, scan the chest for PTX bc X-ray is an inferior test when the patient is supine (yes PTX consider pigtail or other catheter, no PTX continue evaluation)

there are more, but these I think are within most new grads' grasp.

TL

 

[EctopicFetus]

Thanks for your thoughts on this. I disagree with some of the points but nonetheless I appreciate your insight.

 

[jbar]

Good example of utility is I had a patient with bilateral leg swelling sent in for rule out DVT. Bilateral DVT didn't make a lot of sense, so I put the US probe on to do a quick echo, saw a huge pericardial effusion with RV wall collapse. This was a patient who I don't know if I could have justified an emergent formal echo given her stability and lack of shortness of breath or chest pain. But seeing the tamponade changed management and dispo real quick.

 

[Hamhock]

I get the FAST and am certified to do them (the only study we are allowed to use to make clinical decisions) but IMO as discussed previously their utility is way overrated. It only helps in the undifferentiated unstable trauma. Thats a small number. CT is superior and if they have a decent BP they can get their CTs.

The Echo i dont get. I cant say I am fully comfortable with this but how will this change or alter my management?

I kind of get the AAA but again only if they are unstable. Used this successfully once to dx a huge AAA.

I also know how to do the ptx study but never fully realized why this would be helpful? CXR?

Lastly, I dont know how to do the ocular US though I have read about it.

Call me ignorant but I think the use of US as taught to me in residency and its utility in everyday (community EM) was extremely over exaggerated.

I ask again, Thymeless, hamhock and deuist, are you in academics?

1. Yes, the original FAST is way over-rated and not very well understood. Since it is used on nearly every trauma activation at many academic centers, I think residents often forget the true indication for FASTs. However, now that more places are adding on a quick look for PTX and hemothorax, I think it's importance is increasing again.

[EDIT: FAST is also useful for triage of "stable" trauma patients awaiting CT..positive FAST jumps straight to the front of the line.]

2. ECHO: see above examples by other posters. If need be, I can try to explain how it changes my management every day, but that post may take a while. Of course, my management decisions are based on more than just pericardial effusion or no effusion. ECHO happens to be an interest of mine (although, one I haven't explored as much as I would like to) and so my ECHOs are a bit more involved than most folks who trained within the last 5-10 years. OTH, most senior residents in our department can make some fairly advanced interpretations without specific interest in ECHO.

3. AAA: one save is enough in my book to learn such an easy scan. [but probably not practical in the private world]

4. PTX: see above. Easy and very quick study for large PTX (admittedly, longer study and more difficult for small PTX or trying to identify the lead point). Indication? Trauma. I think any patient who you are going to take the time for traditional FAST should have a quick look for PTX. It's easy and picks up plenty of large PTX that are missed on supine CXR...plenty that I would not want to send to CT without a chest tube (especially if hemothorax is also present - another fairly quick and easy scan to add to the FAST).

5. Occular: I'll leave that to ThymeLess. I am very inexperienced and have read very little about it...It does seem useful in the sense it may get you emergent ophtho or clear cut indication for transfer...but again, I don't know enough about this.

6. Yes, I am in academics or quasi-academics, so I can't really speak about how I would use it in the private world...but I kinda tried to tailor my answers above to non-academic settings...when there's time in academic settings, I use it way more than above.

HH

 

[Socrates25]

They are stored on the ultrasound machine for QA evaluation later. No cardiologist ever sees the images as they are considered unofficial. The patient isn't billed for procedure as it only an adjunct to my physical exam.

QA evaluation by whom?

 

[jbar]

QA evaluation by whom?

Where I went to medical school there was a weekly QA done by the director of the ultrasound fellowship, which the fellows and students on the US rotation would participate. Took about 4 hours.

Also people seem to complain a lot about the time it takes to do an ultrasound. Eventually we might get to the point where there are ultrasound machines built in to most rooms in the ED, that are on and automatically have the patient's data when they are brought in (by scanning a bar code on the wrist band or something.) At that point using US will be like using the otoscope, just pull it off the wall and go. I think most of the time that it takes to ultrasound someone is walking around, finding the machine, finding it is in use, coming back, moving stuff out of the way to plug it in etc. I spend like 75% of my time getting set up for the exam compared to the 25% doing the study.

 

[Venko]

QA evaluation by whom?

Just as the OP explained, QA is performed by different people in each institution and unfortunately not performed at all in others. It is an essential process to make sure that any missed findings or inadequate studies are followed up on and the patients are protected. The QA process also ensures that individuals using ultrasound are providing high quality care and offers a chance to credential individuals to use this tool.