U/S in the ER

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BLADEMDA

BLADEMDA

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As an Anesthesiologist who uses U/S 5-10 times per day what is the role of the U/S in the ER for the EP?

I see there are 1 year fellowships in U/S. Is this for nerve blocks, Central lines, IV placement, OB related, etc?

Any problems getting privileges at the hospital to do all these U/S guided procedures?
 
Why the fascination with EM all of a sudden? It cool to have you here on the forum, just curious...
 
Birdstrike said:
Why the fascination with EM all of a sudden? It cool to have you here on the forum, just curious...
Click to expand...

Probably due to the fact Med Students are Choosing EM more and more frequently in my state. I'm also seeing videos online of EM attendings doing U/S guided procedures and blocks; this includes nerve blocks and U/S assisted Cric.

Since a resident in EM can do his/her 4th year focusing on U/S or a fellowship I'm curious as to the real world application of such skills for an EP.
 
As a resident, I'm expected to graduate proficient in using U/S for procedures (central lines, para/thoracocentesis, PIVs), FAST exams, echo, RUQ, renal/bladder, AAA, OB, check wound for abscess/foreign body, checking IVC status, etc. They also teach ocular (retinal detachment), musculoskeletal, etc.

Mind you, we are doing focused exams. When I look at the heart, I'm looking for effusion, evaluating global contraction (i.e. ruling out cardiac shock), checking if there is gross regurg, comparing R and L ventricle size (for PE), and that's about it. I'm not calculating EF or anything like that. When I do pelvic scans, my goal is basically to find out whether or not their is an IUP, free fluid or a huge ovarian cyst/torsion. We're not doing crazy extensive studies, but very helpful a lot of the time.

My understanding is that the fellowship is geared towards people who want to either work in academics or be an ultrasound director for a community hospital (be in charge of QI, billing for U/S, U/S credentialing etc), but I may be wrong.

They started teaching us about U/S in the first week of residency. We also do a month of ultrasound training.
 
TimesNewRoman said:
As a resident, I'm expected to graduate proficient in using U/S for procedures (central lines, para/thoracocentesis, PIVs), FAST exams, echo, RUQ, renal/bladder, AAA, check wound for abscess/foreign body, checking IVC status, etc. They also teach ocular (retinal detachment), musculoskeletal, etc.

My understanding is that the fellowship is geared towards people who want to either work in academics or be an ultrasound director for a community hospital (be in charge of QI, billing for U/S, etc), but I may be wrong.

They started teaching us about U/S in the first week of residency. We also do a month of ultrasound training.
Click to expand...

Does the training including TTE of the heart? Do you learn U/S guided nerve blocks? U/S guided Peripheral IV placement?
AAA diagnosis with U/S?

So, after learning how to do these procedures with U/S there is no use for that skill outside academics? How can you stay sharp in a community hospital setting if you actually don't do the U/S exam or procedure yourself?
 
BLADEMDA said:
Will EP attendings be utilizing these U/S skills in the ER outside academics?
Click to expand...

I dont see why not. I got called for a micu pt for a resp failure that one of the old time ED docs (not ed trained and no US training) was thinking about lysing for presumed massive PE. Creat >5 so no scan. Story fit though. He tubed pt and called me for admit and asked if "id bring my fancy US machine down to look at the RV because its a pain getting the tech to come in at night". Gladly came down, sure enough wicked RV dilatation with global RV hypocontractility. He gave the lytics. Modern medicine at its finest. Presumably a newer ED doc out of an EM residency with US training would have just stuck the probe on, got his/her answer, lysed, and then called me for admit. I think it definitely has real time application in community EM/MICU. I use it daily on at least 4-5 pt's in a community 19 bed MICU. Lots of utility in the ED.

In addition, I came down and worked a VT arrest with one of the newer younger EM trained guys. we cooled the pt, did al lof his procedures right in the ED. Was great. He tubed the guy and put in an IJ, with the US, which was awesome to see finally. I threw in an art line and a chest tube( ptx was from compressions not his line 😛). Was like real teamwork. pt was fully setup and on the way to micu within 40 minutes all procedures completed and cooling.
Was great to finally not here "I don't need your stupid US im old school and do my S*** blind"....Ive had to put chest tubes in several of those...

US rocks. All CC people (EM, IM, SX, gas) should try and get as much training with it as possible.
 
BLADEMDA said:
Will EP attendings be utilizing these U/S skills in the ER outside academics?
Click to expand...

I do.

Well, I have.

I haven't worked in the ED for three months; but when I did work in the ED frequently, I used similar techniques both in academics and in "private practice" (moonlighting for money).

HH
 
BLADEMDA said:
Does the training including TTE of the heart? Do you learn U/S guided nerve blocks? U/S guided Peripheral IV placement?
AAA diagnosis with U/S?

So, after learning how to do these procedures with U/S there is no use for that skill outside academics? How can you stay sharp in a community hospital setting if you actually don't do the U/S exam or procedure yourself?
Click to expand...

TEE is beyond our scope. Some people do nerve blocks, some don't - they did more where I went to med school than where I'm training. I do a lot of PIVs. Did 2 in my last shift when the nurses couldn't get em.
 
Bostonredsox said:
CC people (EM, IM, SX, gas) should try and get as much training with it as possible.
Click to expand...

Did you forget OB/Gyn?

Surgical CCM has always considered them CCM-worthy -- don't you? :meanie:

HH
 
BLADEMDA said:
Will EP attendings be utilizing these U/S skills in the ER outside academics?
Click to expand...

Recent grad in a community shop. In order of frequency, I use U/S for:

CVL placement >> RUQ > abscess vs cellulitis > PIV > FB > AAA > IUP > FAST >> retinal detachment

I was not trained to do blocks or TTE, although I wouldn't mind learning to do blocks.
 
Much of it is dependent on practice location. My current job features a busted-ass sonosite. Given that I tend to see 2.5 patients per hour (and I'm solo coverage at night), I don't have time to look at the RUQ on patients with abdominal pain. Plus, I probably couldn't find the gallbladder anyway given the equipment. Our hospital's US techs are readily available and can do the RUQ and pelvic scans. I stick with echos and FAST exams with shocky patients. Looking for abscess vs cellulitis is also helpful as it greatly speeds up dispo when there's nothing to drain. I did an ocular U/S last month to look for retinal detachment. Never done a U/S-guided peripheral nerve block or lumbar puncture, although I would love to learn how to do both. I'm not sure where a U/S-guided cric would ever be needed. You just cut until you're through.
 
BLADEMDA said:
As an Anesthesiologist who uses U/S 5-10 times per day what is the role of the U/S in the ER for the EP?

I see there are 1 year fellowships in U/S. Is this for nerve blocks, Central lines, IV placement, OB related, etc?

Any problems getting privileges at the hospital to do all these U/S guided procedures?
Click to expand...

Most fellowships are aimed at ARDMS with abdominal and MSK being the most relevant to practicing EPs.

I was trained for abdominal/MSK exams, vascular access, rule out ectopics, torsions, retinal detachments, etc.. (usually followed by formal study), I also used it for blocks, most common being femoral, ulnar, ankle and wrist blocks mainly. I was uncomfortable with interscalene blocks in the ED. It is also very handy for deep brachial sticks for the difficult IV pt's who don't need CVL but nurses can't get access and EJs are failed.

You can bill for limited study exams but it usually involves a turf war with radiology. My training institution was able to bill for US studies during my last year there but I think it took awhile to get approval and overcome some political hurdles.

At my current job, I use it much less often.. Usually for eFAST, vascular access or blocks or soft tissue exams, , cardiac, OB stuff or the very occasional MSK. It's just faster to get a formal study where I'm at and it's a very busy place so I usually don't have time to play with the US. I see it being much more useful for academics. I logged about 1500 exams during residency.

I think we were exposed to a bit more regional blocks at my training institution due to having a faculty member who was an anesthesiologist with pain fellowship who went back to do EM residency and worked as an EM attending.
 
Last edited:
tkim said:
Recent grad in a community shop. In order of frequency, I use U/S for:

CVL placement >> RUQ > abscess vs cellulitis > PIV > FB > AAA > IUP > FAST >> retinal detachment

I was not trained to do blocks or TTE, although I wouldn't mind learning to do blocks.
Click to expand...

Thank you for all the responses
 
Do most ER Residents and EP attendings use U/S when placing Internal Jugular Central Lines? If so, do you use U/S live or static/quick look?

How many U/S guided central lines can a Resident expect to do in training? 30? 50?


http://www.ncbi.nlm.nih.gov/pubmed/16096454

Even though almost every Society recommends the use of U/S when placing a Jugular Central line this trial showed the quick look/static method was quite successful in experienced hands.
 
In my residency we pretty much all used a real time ultrasound approach to IJ's. I'm not sure about the attendings because in my experience it was mostly the senior residents teaching the junior residents. Now that I'm out in the community, most of the younger guys use real time, but I know at least one of my more experienced partners uses a quick look then stick. Seems to work well for him.
 
What CPT codes are you guys billing for each ultrasound and what reimbursement are you getting for them?
 
We use US for almost everything... (Level 1 Trauma Center with ~120k visits a year).
Off the top of my head from last night, we used US for:
MR for cardiac activity
6+ FAST exams
1 cardiac for effusion
3 IJ for central lines
3 AAA
1 perineal abscess I+D (soft tissue)
1 for US guided IV
1 for left kidney for stone (hydro)
1 for median nerve block
1 for volume status (sepsis)
1 for DVT
etc.

the other sections of the ED (we have 4) will have 20+ for IUP's, DVT's, etc. It's not uncommon for our resident on US month to get ~20-30 studies a shift.

Do most ER Residents and EP attendings use U/S when placing Internal Jugular Central Lines? Yes, at Carolinas it's considered standard of care.
If so, do you use U/S live or static/quick look? Live
How many U/S guided central lines can a Resident expect to do in training? 150-200
(this includes ones placed in the ER as well as ICU's)
 
TysonCook said:
We use US for almost everything... (Level 1 Trauma Center with ~120k visits a year).
Off the top of my head from last night, we used US for:
MR for cardiac activity
6+ FAST exams
1 cardiac for effusion
3 IJ for central lines
3 AAA
1 perineal abscess I+D (soft tissue)
1 for US guided IV
1 for left kidney for stone (hydro)
1 for median nerve block
1 for volume status (sepsis)
1 for DVT
etc.

the other sections of the ED (we have 4) will have 20+ for IUP's, DVT's, etc. It's not uncommon for our resident on US month to get ~20-30 studies a shift.

Do most ER Residents and EP attendings use U/S when placing Internal Jugular Central Lines? Yes, at Carolinas it's considered standard of care.
If so, do you use U/S live or static/quick look? Live
How many U/S guided central lines can a Resident expect to do in training? 150-200
(this includes ones placed in the ER as well as ICU's)
Click to expand...

That's the kind of training Med Students should seek out for an EM residency.

How many intubations with DL during Residency? 100? How about VL?
 
BLADEMDA said:
That's the kind of training Med Students should seek out for an EM residency.

How many intubations with DL during Residency? 100? How about VL?
Click to expand...

While the RRC only requires 30 intubations during an EM residency to graduate, I easily.... EASILY got over 100, even at my little tiny program in the midwest. By my senior year, I was giving them away to offservice residents because... meh, whatever. I quit logging them after 55 or so because it was too much of a pain in the ass to have the attending "sign-off" on them electronically.
 
BLADEMDA said:
Do most ER Residents and EP attendings use U/S when placing Internal Jugular Central Lines? If so, do you use U/S live or static/quick look?

How many U/S guided central lines can a Resident expect to do in training? 30? 50?


http://www.ncbi.nlm.nih.gov/pubmed/16096454

Even though almost every Society recommends the use of U/S when placing a Jugular Central line this trial showed the quick look/static method was quite successful in experienced hands.
Click to expand...

IM resident at a community unopposed program and US guided IJ is the norm for us. We also get quite a few procedures as besides 1or 2 EPs in the ED we are the only physicians in house 24/7 and run all floors codes/ rapids including ICU coverage.

For IJ we use live US and have a dedicated machine we keep in one of the units.

Have also used it to get several a-lines on pts with diffuse anasarca that RT or others were unable to get.

I'd say most of our EPs are using US for IJ as well. I'm sure there's a couple that do blind but I see the newer ones using US.
 
nlax30 said:
IM resident at a community unopposed program and US guided IJ is the norm for us. We also get quite a few procedures as besides 1or 2 EPs in the ED we are the only physicians in house 24/7 and run all floors codes/ rapids including ICU coverage.

For IJ we use live US and have a dedicated machine we keep in one of the units.

Have also used it to get several a-lines on pts with diffuse anasarca that RT or others were unable to get.

I'd say most of our EPs are using US for IJ as well. I'm sure there's a couple that do blind but I see the newer ones using US.
Click to expand...

U/S for arterial lines is fantastic after you master the art of the traditional, blind arterial line placement. I now get Arterial lines under U/s which are impossible with the blind technique; e.g., a trauma patient with a mean BP of 40 or a septic patient with no palpable pulses.
 
What % of EM residents do a CC Fellowship for 2 years? 5%? Also, can the fourth year of an EM residency be used towards the 2 year requirement for CC?

With all the talk of burnout being high as an EP maybe a joint FM/EM or IM/EM program isn't such a bad idea? IM/EM/CC= 7 years?
 
BLADEMDA said:
What % of EM residents do a CC Fellowship for 2 years? 5%? Also, can the fourth year of an EM residency be used towards the 2 year requirement for CC?

With all the talk of burnout being high as an EP maybe a joint FM/EM or IM/EM program isn't such a bad idea? IM/EM/CC= 7 years?
Click to expand...

Back when I was applying, I heavily considered the joint EM/FM, or EM/IM programs, largely because (I admit it) of a great degree of narcissism where I thought I would just be that guy that wanted to do it all.

The economics of the situation made my decision clear for me: Get in. Get out. Get going. Make money. Get the hell out of dodge. I had/have other life goals that couldn't wait around for another 2-3 years of 'training'.
 
I was trained to do IJs with or without. If it's available, I see no reason not to use it as it is becoming standard of care.

The CC fellowship is relatively new. What most people used to do...get accreditation under European Society of Intensive Care Medicine and then find a job in the ICU. The hurdle is finding an institution willing to give you a job. My impression after researching it thoroughly and talking with a few guys was that SICU jobs were more common and MICU jobs very rare. I have no idea if the new CC board fellows are going to change that trend or not. I'd be curious to see how it turns out. The gas attending who was dual boarded actually went on to do a CC fellowship to be able to work partially in the ICUs in another academic center but I think it was a gas CC fellowship.
 
I don't buy into the whole burn out thing to where I would actually consider a "prophylactic additional residency". The way I see it... even if I get burned out, I can always slow down. Hell, you could moonlight or find plenty of part time EM work and only work a handful of shifts a month for better work/pay ratio than by doing anything else.

If I ever get burned out, I'm going to open up a cosmetic boutique and do laser/botox on rich trophy wives.
 
BLADEMDA said:
Do most ER Residents and EP attendings use U/S when placing Internal Jugular Central Lines? If so, do you use U/S live or static/quick look?

How many U/S guided central lines can a Resident expect to do in training? 30? 50?


http://www.ncbi.nlm.nih.gov/pubmed/16096454

Even though almost every Society recommends the use of U/S when placing a Jugular Central line this trial showed the quick look/static method was quite successful in experienced hands.
Click to expand...

I do static/quick look if I am using US for a subclav, which is rare, as usually if I am doing a subclav there isn't time for the US or its not available. All IJs I do live. Takes about 6-8 minutes from prep to suture and that includes confirming wire with long/short axis views in real time. No reason not too.

As for the # in training, I am Internal Medicine and obviously my training is not the norm for an IM resident but including Cordis's for swans and pacers, and temp dialysis catheters, I have somewhere around 185-200 lines the last time I checked new innovations. I would venture without actually counting, 130-140 of those are Jugular lines. of those, all but 4-5 have been US guided and with real time wire guidance. One of my new EM docs just out of residency said he didn't do nearly as many lines as me, around 120-130 total in his residency. But he had far more airways than me, 250+ to my 85-90.

Several of my med school roomates are EM pgy3s now, I texted them your question. there lines numbers are 65, 81 and 124. Tubes are 95, 110, and the other said he stopped counting at 200. The latter guy on the list is at a very large volume ED that does not have anesthesia or surgery residents so he has had a plethora of procedural opportunities and taken advantage of it.
 
nlax30 said:
IM resident at a community unopposed program and US guided IJ is the norm for us. We also get quite a few procedures as besides 1or 2 EPs in the ED we are the only physicians in house 24/7 and run all floors codes/ rapids including ICU coverage.

For IJ we use live US and have a dedicated machine we keep in one of the units.

Have also used it to get several a-lines on pts with diffuse anasarca that RT or others were unable to get.

I'd say most of our EPs are using US for IJ as well. I'm sure there's a couple that do blind but I see the newer ones using US.
Click to expand...

I have started to do this routinely. Not because it makes the line "that" much easier, it does make it easier and as blade said, it makes the near dead pulse-less pts maxed on levo a bit easier to get, but more so because it allows me to access the radial artery further up the arm where it is deeper, further from the flexion/extension action of the wrist and less tortuous. I have found that these lines hold up and stay functional longer. And as most pts I put an a line in are those that I just placed an IJ in under US, the US is already out and draped.....
 
BLADEMDA said:
What % of EM residents do a CC Fellowship for 2 years? 5%? Also, can the fourth year of an EM residency be used towards the 2 year requirement for CC?

With all the talk of burnout being high as an EP maybe a joint FM/EM or IM/EM program isn't such a bad idea? IM/EM/CC= 7 years?
Click to expand...


The large majority of EM residencies are 3 years long (>75% at last count? haven't had to deal with the numbers on this in a few years). EM/IM/CC is 7 years long I believe. 4-year long EM programs used to traditionally just have lots of floor months and rotations, but nowadays a lot of those 4 year programs that still exist increasingly use the 4th year as a means of learning about some subspecialties in EM, be it wilderness, international, sports, u/s, etc. As for CC fellowships, only recently have those truly become available to us. My own program had 10% of its residents do CC fellowships for 4 years running, but that is quite high (your numbers are likely closer to truth) and my program also did not produce many other subspecialist.
 
BLADEMDA said:
Do most ER Residents and EP attendings use U/S when placing Internal Jugular Central Lines? If so, do you use U/S live or static/quick look?

How many U/S guided central lines can a Resident expect to do in training? 30? 50?

...

How many intubations with DL during Residency? 100? How about VL?
Click to expand...

Live looks. I did ~180 central lines and ~100 intubations in a 3-year residency: combinations of DL's and VL's
 
BLADEMDA said:
Does the training including TTE of the heart? Do you learn U/S guided nerve blocks? U/S guided Peripheral IV placement?
AAA diagnosis with U/S?

So, after learning how to do these procedures with U/S there is no use for that skill outside academics? How can you stay sharp in a community hospital setting if you actually don't do the U/S exam or procedure yourself?
Click to expand...
I use ultrasound for central lines all the time. Direct visualization of needle entry and also take another look at the guidewire once it's threaded. Occasionally use it for peripheral IV's as well.

We FAST a lot of our trauma patients, and I do TTE's occasionally (rarely) primarily to look for effusions. Although I was trained on looking for mall motion abnormalities, I usually leave that to cardiology since we have in-house cards 24/7.

I rarely use it for AAA since we have CT so readily available (4 CT machines in the department). If someone was unstable, then I would look for it when I did a FAST.
 
How about US for LP's? I have never done this but had heard from people doing it more frequently. I have had several fatty's I had significant trouble getting a good LP on, especially if they are already on the vent. If anyone does this routinely can you shed some light or a link on your technique?
 
figure out how to get the vented pt to be sitting upright. lp's are much easier upright in Fatty McPhees, lol
 
BLADEMDA said:
Does the training including TTE of the heart? Do you learn U/S guided nerve blocks? U/S guided Peripheral IV placement?
AAA diagnosis with U/S?

So, after learning how to do these procedures with U/S there is no use for that skill outside academics? How can you stay sharp in a community hospital setting if you actually don't do the U/S exam or procedure yourself?
Click to expand...

I'm in a community/academic center. We utilize the U/S very frequently. We do pretty much everything outside of TEEs. I do not do nerve blocks although some of our U/S Fellowship trained people do.

Commonly done (and billable) U/S procedures we do:

Lines - IJ/subclav
Renal
TTE
AAA
RUQ
peripheral lines
FAST
abscess/soft tissue
Lung
retinal
Appendicitis/intussuception (I do not do these as I don't work enough peds shifts to be comfortable with my read)
 
Bostonredsox said:
How about US for LP's? I have never done this but had heard from people doing it more frequently. I have had several fatty's I had significant trouble getting a good LP on, especially if they are already on the vent. If anyone does this routinely can you shed some light or a link on your technique?
Click to expand...

US is useful for one thing and one thing only when accessing the neuraxis: finding midline. Even the USRA gurus like Vince Chan out of Toronto (who loves to use US for everything from confirming NPO status by looking at fundal diameter to endotracheal intubation confirmation) can't find a good way to use the US live for spinal/epidural/LP. He does like to calculate distance to the ligamentum flavum, etc, but admits that in the cases where this might be helpful (i.e. fatties) the SQ fat is so compressible that distances are anything but fixed. Additonal factor against neuraxial US: the angles needed to visualize your needle AND visualize any neuraxial structures AND get your needle between bones into tiny spaces do not coincide. In general, US for LP is a non-starter.
 
B-Bone said:
US is useful for one thing and one thing only when accessing the neuraxis: finding midline. Even the USRA gurus like Vince Chan out of Toronto (who loves to use US for everything from confirming NPO status by looking at fundal diameter to endotracheal intubation confirmation) can't find a good way to use the US live for spinal/epidural/LP. He does like to calculate distance to the ligamentum flavum, etc, but admits that in the cases where this might be helpful (i.e. fatties) the SQ fat is so compressible that distances are anything but fixed. Additonal factor against neuraxial US: the angles needed to visualize your needle AND visualize any neuraxial structures AND get your needle between bones into tiny spaces do not coincide. In general, US for LP is a non-starter.
Click to expand...

I saw a tutorial for US-guided LPs...I'll see if I can find it.
 
TooMuchResearch said:
I saw a tutorial for US-guided LPs...I'll see if I can find it.
Click to expand...

Sure, turn a 5 minute procedure into a 1 hour one. Once you get good doing an L-P is easy. I can get CSF from anyone including a 90 year old hunch back with a lumbar fusion.
I also prefer to use a 22 gauge whitacre needle on all the patients under the age of 60 to minimize the incidence of headache.
 
1-s2.0-S0736467907002636-gr1.jpg


The Quincke needles have a very high incidence of causing post lumbar puncture headaches in younger patients. Please avoid using that needle.
 
BLADEMDA said:
What % of EM residents do a CC Fellowship for 2 years? 5%? Also, can the fourth year of an EM residency be used towards the 2 year requirement for CC?

With all the talk of burnout being high as an EP maybe a joint FM/EM or IM/EM program isn't such a bad idea? IM/EM/CC= 7 years?
Click to expand...

EM/IM/CC is 6 years at 3 of the EM/IM programs out there.
 
I generally don't have much of a problem with LPs but I live in one of the fattest states in the nation and occasionally I'll get a pt where it's just damn near impossible as you lose all landmarks and are engulfed in fat. I'll send those to IR. I did watch a video on US LPs and they made it look easy to find the ligamentum flavum and bony landmarks, etc.. In real practice, I could identify those structures on skinny pt's really well with a relatively new sonosite, or in other words on the exact pt population that I would never need to use it in the first place, but the fatties... noway. I didn't find that it helped with the fat pt's at all as, at most... I could visualize bone but def no flavum and skin marking didn't really help as the skin shifted everywhere at the slightest movement.
 
Thread seems to have gone in a number of directions but my thoughts are:

1) I also like BLADEMDA's perspective. I consider myself somewhat of a closet anesthesiologist because our two specialties are actually very much alike. I wish that we could have more dialogue with anesthesia because we can always learn more.

As mentioned above, I'm pretty hot on some of the peripheral nerve blocks with ultrasound. If we can do them safely, it's possible to avoid a sedation, which is one of the worst things to do in the ED in terms of time involved, loss of situational awareness, patient risk, etc.

2) As for procedures, I did probably 250+ intubations in residency with 40-50 via fiberoptic (did bronchoscopy as an elective), 50-60 central lines, and 800+ ultrasounds.

3) Ultrasound for LPs is largely worthless. Palpation is safe and effective. I exclusively use 22g whittacre needles since I started training, so I'm used to them.

4) As ultrasound becomes more portable and the workflow becomes more automated, it's going to become a bigger part of most EPs practices. Think about how many times you'd use your stethoscope if it were on a big cart in a corner of the ED and required you to input patient info in it every time.
 
For the young residents or attendings that are at facility without strong ultrasound didactic, emsono.com is a great place to start with online lectures and quizzes. Nothing beats real live practice, of course.
 
Anyone in community EM feel US slows you down enough to make it impractical?
 
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