Emergency physicians performing TEE

[StudentDoc327]

http://www.aemj.org/cgi/content/abstract/8/5/580-a


Do you guys do them at your residency programs? Are there ample opportunities in the ED where you think they would be useful? Do you think more EM residency programs should provide training for TEE?

Just curious.

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[Apollyon]

No. No. No. (In that order.)

 

[southerndoc]

There aren't enough TEE's done in the emergency department to maintain proficiency in them. I probably do at least two to three TTE's per shift in the ED. I've only done one TEE in 2 years in residency. Cardiology does our TEE's. We get teaching by them when one is performed, but when I finish residency, it is highly unlikely I will do them.

TTE's on the other hand are a different story, and I expect to be doing them bedside for many years to come.

 

[bulgethetwine]

No. No. No. (In that order.)

I think Apol is right. Mostly.

I think the only place where they would have utility insofar as ED physicians performing them would be in the high volume places where currently there are cards folks to do them anyway. Problem is, many cards folks are reticent to take the time to come down a grand total of 15 steps to do one.

An appropriate and timely TEE could potentially save resources and lives.

 

[Apollyon]

My rationale is for the reasons southerndoc gave - not enough to be proficient. Also, most patients are not kind enough to have been NPO for nearly enough time to even help not vomiting and aspirating.

If it needs to be done that urgently, the right person is the cardiologist.

 

[StudentDoc327]

An appropriate and timely TEE could potentially save resources and lives.

Thats what I was wondering. A lot of the Anesthesiology residents at my school were talking about how they were tapping into doing TEE's now and I was wondering if EM was headed in that route as well.

 

[bulgethetwine]

My rationale is for the reasons southerndoc gave - not enough to be proficient. Also, most patients are not kind enough to have been NPO for nearly enough time to even help not vomiting and aspirating.

If it needs to be done that urgently, the right person is the cardiologist.

We all agree on the above points. But I think the OPs questions was a "what if": If we could do them more often and ergo be skilled, then the issue distills to two things.

1) Is the cost/benefit (training, resources, etc. vs. lower cost and resources for working up someone who may very well have wall dysfunction +/- more timely life-saving interventions) favorable?

2) The above mentioned NPO status, but if truly concerned the protocol could routinely include NG tube. Sure, it sounds kinda extreme (can you imagine the new algorithm for CP including automatic NG tube!?!) but then again it must have been radical when MR told everyone in Detroit that everyone coming in with sepsis was gonna get the tube!

Hope SC treatin' you well Apol.

 

[southerndoc]

The NPO status really isn't relevant if it's an emergency. If I'm ruling out an aortic dissection and the patient can't get a CT for whatever reason (contrast allergy, creatinine of 2.5, etc.), then I call cards, we sedate the patient, and do a TTE. I ask them when they last ate, but in reality, I've never held up a conscious sedation because of this.

We sedate people all the time, not just for TEE's. Do you postpone your sedation for reduction of an ankle dislocation?

By the way, TEE's really aren't as hard as one thinks once you get used to the orientation. There really isn't anything special about them. However, I don't think there are enough of them to become proficient and certify someone to read them or to specifically advertise a particular residency as training residents on the procedure.

 

[GeneralVeers]

I don't think there's really a need for EPs to do TEEs. Usually a TTE is good enough to pick out the emergent things: Cardiac standstill, massive pericardial effusion, etc. I honestly don't care about determining wall motion abnormalities, atrial thrombi, or valve pathology.

 

[bartleby]

GeneralVeers is right about this one. There's no point to EP's doing an exam this specialized. TEE is too time consuming and invasive to fit the bill for the kind clinical decision-making conventional ultrasound is helpful for and is certainly of no assistance at all to the waiting room full of people sitting around while you do the cardiologist's job.

 

[southerndoc]

There is reason to do a TEE in the emergency department, as I've mentioned before. Patients with suspected aortic dissection with contraindications to CT scanning should have a TEE performed to rule out (or in) dissection.

 

[bulgethetwine]

I don't think there's really a need for EPs to do TEEs. Usually a TTE is good enough to pick out the emergent things: Cardiac standstill, massive pericardial effusion, etc. I honestly don't care about determining wall motion abnormalities, atrial thrombi, or valve pathology.

But the issue you mention -- cardiac standstill (or at least varying degrees).

I guess in my head I'm thinking wouldn't it be great if I was good enough at TTEs and comfortable enough with them that I could use them to detect not just cardiac standstill but wall abnormality before it becomes "stand still". Certainly a negative TTE would alter management in terms of intervention. Could you also not envision a scenario where those with suspected ACS but with a negative TTE could be moved to a lower risk category and appropriate resources utilized (or withheld) in terms of all the things in our armentatrium -- medications, dispo to observation unit vs. d/c home vs. admit to floor vs. admit to CCU vs. urgent cath.

And let me emphasize, I'm not saying I am right -- I want others to weigh in and either say yeah, that might be viable or no, it just wouldn't be worth it. But I don't think worth should be based on the number of TTEs we get, or how comfortable we would be with them, because any major paradigm shift towards TTEs in the ED would de facto result in more procedures and a heightened comfort level.

 

[southerndoc]

And let me emphasize, I'm not saying I am right -- I want others to weigh in and either say yeah, that might be viable or no, it just wouldn't be worth it. But I don't think worth should be based on the number of TTEs we get, or how comfortable we would be with them, because any major paradigm shift towards TTEs in the ED would de facto result in more procedures and a heightened comfort level.

OK, we need to get our debate back on track here.

The original poster mentioned TEE's, not TTE's.

Transthoracic echos (TTE's) should be performed by emergency physicians at the bedside, and most residencies now offer some form of training in emergency ultrasound. As I said before, I usually average two to three TTE's per shift looking at everything related to the heart, and not just cardiac standstill. Yes, I've detected wall motion abnormalities, but I don't feel comfortable enough to exclude wall motion abnormalities. If I see it, great, it adds more to my case for someone with minimal EKG changes and pending enzymes. If I don't see it, then I'm not comfortable saying everything is ok. I just don't have the experience that a cardiologist does. For the most part, I utilize TTE's to rule out effusion, LV dysfunction (e.g., marked dilation, estimating ejection fractions, etc.), and RV dysfunction (dilation, elevated RV pressures). I think this is a valuable trait that everyone in emergency medicine should know.

On the other hand, transesophageal echos (TEE's) can be performed by emergency physicians, but there isn't ample opportunities available to adequately train physicians in their interpretation. Although easy to interpret, there still must be a certain number done before one can be credentialled to interpret them.

 

[bulgethetwine]

OK, we need to get our debate back on track here.

The original poster mentioned TEE's, not TTE's.

Transthoracic echos (TTE's) should be performed by emergency physicians at the bedside, and most residencies now offer some form of training in emergency ultrasound. As I said before, I usually average two to three TTE's per shift looking at everything related to the heart, and not just cardiac standstill. Yes, I've detected wall motion abnormalities, but I don't feel comfortable enough to exclude wall motion abnormalities. If I see it, great, it adds more to my case for someone with minimal EKG changes and pending enzymes. If I don't see it, then I'm not comfortable saying everything is ok. I just don't have the experience that a cardiologist does. For the most part, I utilize TTE's to rule out effusion, LV dysfunction (e.g., marked dilation, estimating ejection fractions, etc.), and RV dysfunction (dilation, elevated RV pressures). I think this is a valuable trait that everyone in emergency medicine should know.

On the other hand, transesophageal echos (TEE's) can be performed by emergency physicians, but there isn't ample opportunities available to adequately train physicians in their interpretation. Although easy to interpret, there still must be a certain number done before one can be credentialled to interpret them.

Thanks Southern, I was addressing TEEs - and I guess my overarching point is that if the reason NOT to do them is because...

"there isn't ample opportunities available to adequately train physicians in their interpretation. Although easy to interpret, there still must be a certain number done before one can be credentialled to interpret them"

...

then it seems like this problem is self-correcting with a paradigm shift in their usage philosophy. If we don't do them because they are irrelevant or because they shouldn't change our mangagement, etc. then I buy that. But I keep circumlocuting to this point that lack of opportunity to get familiar shouldn't be a reason because that problem, in and of itself, is easily remedied (I feel like this thread is going in circles....

 

[USCDiver]

Once on my cardiology rotation at the end of rounds, the attending and fellow asked if there was anything they could teach us. I jokingly replied "Teach me to do a cath." They all kinda laughed, then I added "Because in 10 years, we'll probably be doing them in the ED anyway." They both kind of got this, "oh ****" look on their faces. Priceless.

Anyway, as far as the OP. I don't plan on ever ever ever doing a TEE in the ED. Not enough time or enough indications for it. And I don't think it'll ever be a part of my training anyway. Not to say that in 10 years we won't all be doing it, but I don't see it happening in the near future.

 

[GeneralVeers]

Once on my cardiology rotation at the end of rounds, the attending and fellow asked if there was anything they could teach us. I jokingly replied "Teach me to do a cath." They all kinda laughed, then I added "Because in 10 years, we'll probably be doing them in the ED anyway." They both kind of got this, "oh ****" look on their faces. Priceless.

Anyway, as far as the OP. I don't plan on ever ever ever doing a TEE in the ED. Not enough time or enough indications for it. And I don't think it'll ever be a part of my training anyway. Not to say that in 10 years we won't all be doing it, but I don't see it happening in the near future.

That would be appropriate, since the cardiologists stole the cath procedure from the interventional radiologists. Me might as well steal it from them!

 

[southerndoc]

then it seems like this problem is self-correcting with a paradigm shift in their usage philosophy. If we don't do them because they are irrelevant or because they shouldn't change our mangagement, etc. then I buy that. But I keep circumlocuting to this point that lack of opportunity to get familiar shouldn't be a reason because that problem, in and of itself, is easily remedied (I feel like this thread is going in circles....

The problem isn't easily remedied. There aren't many opportunities because there aren't many patients with indications for emergent TEE's.

As I said before, about the only indication for a TEE is ruling out an aortic dissection in a patient with a contraindication to CT scanning.

Ruling out mural thrombus is not an emergent thing.