EM Ultrasound Rotation

[IH8ColdWeath3r]

Hey everyone,

So I am trying to set up a month of EM ultrasound. Genuinely interested in ultrasound and would like some additional practice before intern year as US training was not heavily utilized at my school. I had read a comment a few months ago on one of the previous threads regarding doing a traditional Sub-I vs US month for a SLOE (not the purpose of this thread), and I recall someone mentioning their experience at UCSF - Fresno and getting a great US rotation there, because it was extremely hands on. I went back through the threads and tried to find it but I can't seem to locate it now.

So, has anyone rotated at UCSF - Fresno and done the US elective, that would care to comment on their experience. Also, what are some other places where you guys have done or heard good things about doing US? Thank you!

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[IH8ColdWeath3r]

Really? Nobody has done the US rotation at UCSF Fresno? And nobody has any recommendations of some other good fourth year US rotations?

How about UC Davis? Or Maricopa's US elective? Or UT Southwestern?

 

[exsanguination]

Really? Nobody has done the US rotation at UCSF Fresno? And nobody has any recommendations of some other good fourth year US rotations?

How about UC Davis? Or Maricopa's US elective? Or UT Southwestern?

As you can see from the current ultrasound thread on our forums' front page, most community EM docs consider it a superfluous toy in all but a very few select situations outlined well in that thread. Ultrasound is mostly an academic masturbatory exercise in my opinion (again, I LOVE it for certain situations, pulse checks during codes, line placements, nerve blocks, unstable traumas, and maybe a few others I can't remember right now).

So it's not surprising at all that nobody has replied because the advice follows naturally from the thread's sentiment. Any ultrasound rotation will give you the experience (or at least exposure) you need to become proficient, dare I say "good," at ED ultrasound. The good part will come from how much effort you throw into the rotation. The hard part, which will come with experience, is interpreting some of the images, but that should also be in quotes. Even if you don't do any ultrasounding during MS, you'll easily get the training you need in any ACGME approved residency program.

Here's my experience: I went to a school that pushed ultrasound from day 1 of anatomy. We studied not only ultrasound imaging during our radiology modules (which coincided with anatomy lab), but we practiced ultrasound on the cadavers prior to dissecting. I had a ton of experience prior to starting residency (and of course I used it during my subIs, which rounded out the EM portion of ultrasound knowledge). Dare I say I was proficient at using the ultrasound at graduation, even on things like the orbits looking for RD/VH/VD.

So residency comes around, and I finally get to practice alongside residents that came from medical schools like yours, where they picked up an ultrasound for the first time during their subIs. It's interesting - because this is their first exposure to ultrasound they're so gung-ho about using it for everything. Me? I'm at the point where ultrasounding slows my efficiency, it's laborious, gel gets everywhere, and it's time I could be using to see (and learn from) another patient. If I need an ultrasound done, the US tech is doing it, and the radiologist is gonna read it. Of course I always take a look at my images as well, but you get the idea.

Just two days ago I told one of the medical students working with me to go ultrasound a patients gallbladder looking for a stone expecting that he had done a few already and wanted some practice. Nope - "Hey, could you teach me, I've never actually used the ultrasound before."

Still blows me away! But, I taught him, and he practiced a few more times on some random abdominal pain patients. And couldn't wait to do more. Good for him, but I suspect that he'll go through the same path my co-residents did. They'll quickly realize out in practice all it does is slow you down.

But yea the summary of my wall of text as it pertains to your question is that "it doesn't matter" where you go for your rotation as long as they let you use an ultrasound machine, and have a steady flow of patients.

 

[MSmentor018]

I haven't been to any of those places but I can't imagine any u/s rotation being bad. u/s is the safest thing for students, i did a whole research project as a ms4 using u/s. as long as you're just scanning and not poking people, its really safe. I would definitely do it under the "slor" angle or where you're interested in getting in at. prior to rotation I bought vicki noble's emergency and critical care u/s book (its small and cheap) and u/s myself till I got the hang of it. by the time I did the official rotation i had some very basic knowledge. I actually liked it so much, ended up doing a fellowship and now a director. have fun!

 

[tux4]

As you can see from the current ultrasound thread on our forums' front page, most community EM docs consider it a superfluous toy in all but a very few select situations outlined well in that thread. Ultrasound is mostly an academic masturbatory exercise in my opinion (again, I LOVE it for certain situations, pulse checks during codes, line placements, nerve blocks, unstable traumas, and maybe a few others I can't remember right now).

So it's not surprising at all that nobody has replied because the advice follows naturally from the thread's sentiment. Any ultrasound rotation will give you the experience (or at least exposure) you need to become proficient, dare I say "good," at ED ultrasound. The good part will come from how much effort you throw into the rotation. The hard part, which will come with experience, is interpreting some of the images, but that should also be in quotes. Even if you don't do any ultrasounding during MS, you'll easily get the training you need in any ACGME approved residency program.

Here's my experience: I went to a school that pushed ultrasound from day 1 of anatomy. We studied not only ultrasound imaging during our radiology modules (which coincided with anatomy lab), but we practiced ultrasound on the cadavers prior to dissecting. I had a ton of experience prior to starting residency (and of course I used it during my subIs, which rounded out the EM portion of ultrasound knowledge). Dare I say I was proficient at using the ultrasound at graduation, even on things like the orbits looking for RD/VH/VD.

So residency comes around, and I finally get to practice alongside residents that came from medical schools like yours, where they picked up an ultrasound for the first time during their subIs. It's interesting - because this is their first exposure to ultrasound they're so gung-ho about using it for everything. Me? I'm at the point where ultrasounding slows my efficiency, it's laborious, gel gets everywhere, and it's time I could be using to see (and learn from) another patient. If I need an ultrasound done, the US tech is doing it, and the radiologist is gonna read it. Of course I always take a look at my images as well, but you get the idea.

Just two days ago I told one of the medical students working with me to go ultrasound a patients gallbladder looking for a stone expecting that he had done a few already and wanted some practice. Nope - "Hey, could you teach me, I've never actually used the ultrasound before."

Still blows me away! But, I taught him, and he practiced a few more times on some random abdominal pain patients. And couldn't wait to do more. Good for him, but I suspect that he'll go through the same path my co-residents did. They'll quickly realize out in practice all it does is slow you down.

But yea the summary of my wall of text as it pertains to your question is that "it doesn't matter" where you go for your rotation as long as they let you use an ultrasound machine, and have a steady flow of patients.

Just curious, how often do you see it used to assess fluid responsiveness in sepsis patients, if at all?


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[MSmentor018]

i use it on every sepsis pt. it's to "ensure" we comply with the money, I meant guidelines

 

[hundreddaysoff]

Agree with the above that what you get out of an US rotation is mostly a function of how much effort you put into it, rather than due to any unique features of the rotation. If I were to do it over again and was really serious about learning US as a student (which as was said above you totally don't need to be because you get a ton as a resident), specific things I would look for in a rotation are (1) small number of students per block (like 1 or 2) so that I could maximize scan time, and (2) ability to practice lots and lots of US IVs on gomers (the most common procedure I do as an intern and one I'm still only average at). Maybe a big county hospital out in the boonies where no other students want to go is the place for you to start looking if you're serious about it? Kern perhaps?

I did my US rotation at UCI. It wasn't bad, but it's a rather small ED and there tend to be about 4 students scanning at any one time during the day, which was a few too many for me. And we didn't do procedures. I forgot most of what I learned there over the rest of MS4 and relearned it as an intern. But, my main goals at the time were to play on the beach and meet girls, and it's a great rotation for that.

 

[IH8ColdWeath3r]

Thanks to everyone who commented! I appreciate the insight. I checked out the the US thread on the first page and saw the instances where you guys had mentioned it's utility. I get that it is an academic thing, and most doc's don't really use it in the community unless it is for those specific instances that you mentioned. Still, I am interested in learning how to use it, since it is very operator dependent. I would like some exposure prior to intern year, which is why I signed up to do a US rotation.

I'll look into resources prior to my US rotation, especially since i'll have a family medicine rotation with some time too kill. It is nice to know that there is ample practice time during residency and that even though there are students (like myself) from schools where US is not widely used, that we get a chance to learn how to use it.

 

[exsanguination]

Just curious, how often do you see it used to assess fluid responsiveness in sepsis patients, if at all?


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All the time for this purpose and like MSmentor said above, it's purely because it's all but required for sepsis bundling/payment

Though I'm start to go more towards "clinical" re-evaluation notes which I've found work for guideline compliance. Saves me time, and the best part is for the 90% of my patient population who are overweight/obese, I don't have to spend time struggling to find an IVC for 10 minutes at the bedside.

 

[Druggernaut]

I did a month of ultrasound at MetroHealth in Cleveland and thought it was a good rotation. I think I did over 100 ultrasounds, though typically it was after the resident, fellow, or sometimes both had already done it. They also have over 40 hours of online modules for you to do during the downtime, which were created by their US director and used by a lot of residency programs across the country. Monday through Friday, and probably averaged about 40 hours a week.

Though if you really hate cold weather, it may not be for you...