Utility of learning TEE as a resident

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propadex said:
My residency program does zero TEE teaching and has zero TEE requirements. We do 2-4 months of hearts throughout residency but residents can get by and graduate without so much as knowing how to obtain a ME 4 chamber view, if they don't teach themselves. Is this common for other residents from other programs? Or is this a massive deficit in my residency program?

As a CA2 I have taken some time to teach and familiarize myself with the 11 views for basic PTE during my last rotation. But now that the majority of jobs in "desirable" locations require cardiac fellowship to even do hearts, is there any point in pushing myself to become facile with the probe if I don't plan on getting a job where I will be doing any hearts? My question is mostly for the private practice attendings out there. Ever find yourself dropping a probe in non-cardiac rooms?
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Is there a point in becoming facile? Probably not. But the main pathology and the 11 views from the Basic PTE curriculum are fair game on the ITE, advanced, and applied exams, so I wouldn't just totally skip it.

In addition, basic POCUS / TTE is becoming more and more emphasized by the ABA, and those skills are absolutely essentially imo for any general anesthesiologist.
 
There are rare situations where non cardiac trained folks need to acquire basic TEE proficiency: if you’re involved with frequent liver transplant, high risk open vascular, etc. However you’re unlikely to do much of that in PP, and to the degree that those cases happen they’ll likely be covered by the cardiac or ICU trained docs.

I think knowing echo makes you a better doctor and gives you a more fundamental understanding of all sorts of cardiac pathology. Keep in mind however that echo is the sort of thing where knowing a little bit can be more dangerous than knowing nothing- the Dunning-Krueger is real, and echo is prime territory (“I slapped a probe on the chest and took a quick look, wall motion looked fine...” have the potential to be famous last words when spoken by a generalist)
 
propadex said:
My residency program does zero TEE teaching and has zero TEE requirements. We do 2-4 months of hearts throughout residency but residents can get by and graduate without so much as knowing how to obtain a ME 4 chamber view, if they don't teach themselves. Is this common for other residents from other programs? Or is this a massive deficit in my residency program?

As a CA2 I have taken some time to teach and familiarize myself with the 11 views for basic PTE during my last rotation. But now that the majority of jobs in "desirable" locations require cardiac fellowship to even do hearts, is there any point in pushing myself to become facile with the probe if I don't plan on getting a job where I will be doing any hearts? My question is mostly for the private practice attendings out there. Ever find yourself dropping a probe in non-cardiac rooms?
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CA3 here.

My residency has no formal requirement to learn TEE. However, over half of my year (6 residents) took it upon ourselves to learn all of the standard views and be able to do a variety of the measurements associated with valve replacement, as well as diastolic measurements. Of those six, two are going into cardiac fellowship, three into private practice and one into pain fellowship.

To some extent, it was a matter of one or two people getting into it, and then others going “Hey! John’s getting pretty good at that. I should too!” Given that there is a tee component to the osce, I think it is nice to know, and several of the folks going into PP like to know that they could throw in a tee probe and see how if anything is extremely out of the ordinary in a complicated Trauma situation.

TEE dunning Kruger is very real, but it’s also fun as heck.
 
Hork Bajir said:
There are rare situations where non cardiac trained folks need to acquire basic TEE proficiency: if you’re involved with frequent liver transplant, high risk open vascular, etc. However you’re unlikely to do much of that in PP, and to the degree that those cases happen they’ll likely be covered by the cardiac or ICU trained docs.

I think knowing echo makes you a better doctor and gives you a more fundamental understanding of all sorts of cardiac pathology. Keep in mind however that echo is the sort of thing where knowing a little bit can be more dangerous than knowing nothing- the Dunning-Krueger is real, and echo is prime territory (“I slapped a probe on the chest and took a quick look, wall motion looked fine...” have the potential to be famous last words when spoken by a generalist)
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100%. As a CA-1 I was peripherally involved in a kidney transplant take back for an anastomotic leak. End of the case the patient’s Pa02 had plummeted and we were running through the differential. Generalist attending dropped a TEE probe and told the surgery team the right ventricle looked strained (implying a PE). Next thing you know the patient is being whisked off to the scanner. No PE. Formal TTE after showed normal cardiac function. Turns out it was pulmonary edema from excessive intraop fluids (pt was anuric).
 
Personally, I'd get good at performing FOCUS exams with a tte probe, especially as more portable systems become available. Like others have said the basic tee views are fair game for tests but real world application of a general anesthesiologist utilizing tee stuff is going to be extremely limited.
 
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Hrdrock said:
100%. As a CA-1 I was peripherally involved in a kidney transplant take back for an anastomotic leak. End of the case the patient’s Pa02 had plummeted and we were running through the differential. Generalist attending dropped a TEE probe and told the surgery team the right ventricle looked strained (implying a PE). Next thing you know the patient is being whisked off to the scanner. No PE. Formal TTE after showed normal cardiac function. Turns out it was pulmonary edema from excessive intraop fluids (pt was anuric).
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Curious, do you know if they had basic TEE certification?

I agree though. I've definitely seen people use echo poorly to justify bad decisions.
In my opinion, if you're going to use it to change management, you need to be able to do more than get the basic views.

For me, I knew I wanted to be facile at TEE with the hope that it would translate to better TTE skill. So on my 2nd cardiac month I was aggressive about getting my hands on the probe. The attendings were nice enough to worry about things like giving the ancef and all the other misc. things that needed to get done prior to incision.
 
Hork Bajir said:
There are rare situations where non cardiac trained folks need to acquire basic TEE proficiency: if you’re involved with frequent liver transplant, high risk open vascular, etc. However you’re unlikely to do much of that in PP, and to the degree that those cases happen they’ll likely be covered by the cardiac or ICU trained docs.

I think knowing echo makes you a better doctor and gives you a more fundamental understanding of all sorts of cardiac pathology. Keep in mind however that echo is the sort of thing where knowing a little bit can be more dangerous than knowing nothing- the Dunning-Krueger is real, and echo is prime territory (“I slapped a probe on the chest and took a quick look, wall motion looked fine...” have the potential to be famous last words when spoken by a generalist)
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100%. When I was a medical student the intensivist did a TTE on some patient, I think it was for hypotension but can’t quite remember, thought there was a WMA, called cardiology and made a big deal. After the cards consult they basically told the guy “stop doing ultrasounds on people’s hearts”
 
My thoughts wouldnt be popular on this so ill pipe down

Its commendable to learn the views but dont mistake your crash course with 3000+ hours cardiac anesthesia fellowship. If a generalist whips out an unsupervised TEE during a crisis and makes a bad call, it will be hard to support them
 
I think it is worth learning as part of being a good anesthesiologist. I did a lot of self teaching and when my attendings noticed that I wasn't totally useless at tee, they were a lot more willing to teach me than other residents. I've used it in livers, endovascular procedures and trauma as a resident but I don't touch it in pp. I think that the daily emails from the university of utah are great.
 
learning TEE rigorously and comprehensively elevates your understanding of the circulation from cartoon diagrams that most doctors work with to the level of true understanding. But there are just no shortcuts to this level of understanding. You probably have to do an ACTA fellowship if you want to actually know what you’re doing.

I gave a lecture once on TEE in peri-arrest and made it a point to illustrate pitfalls in diagnosis . Because I didn’t want to give people the idea that they can visualize a blown out RV and easily diagnose PE. It’s complicated and anyone that tells you otherwise is lazy and incompetent . Afterward a colleague approached me and said “you made it seem like a generalist can’t really do this”. Maybe I did..

Probably it’s best for an operating room to just have cardiac trained people be available if possible to consult when an emergent TEE is needed.
 
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GassYous said:
I think it is worth learning as part of being a good anesthesiologist. I did a lot of self teaching and when my attendings noticed that I wasn't totally useless at tee, they were a lot more willing to teach me than other residents. I've used it in livers, endovascular procedures and trauma as a resident but I don't touch it in pp. I think that the daily emails from the university of utah are great.
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T-burglar said:
learning TEE rigorously and comprehensively elevates your understanding of the circulation from cartoon diagrams that most doctors work with to the level of true understanding. But there are just no shortcuts to this level of understanding. You probably have to do an ACTA fellowship if you want to actually know what you’re doing.

I gave a lecture once on TEE in peri-arrest and made it a point to illustrate pitfalls in diagnosis . Because I didn’t want to give people the idea that they can visualize a blown out RV and easily diagnose PE. It’s complicated and anyone that tells you otherwise is lazy and incompetent . Afterward a colleague approached me and said “you made it seem like a generalist can’t really do this”. Maybe I did..

Probably it’s best for an operating room to just have cardiac trained people be available if possible to consult when an emergent TEE is needed.
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These four lectures are my gold standard on Rescue TEE, because beyond describing the pathology in a coherent way, Zimmerman hits home the point that even experienced echocardiographers can badly fck up calls in the heat of the moment with erroneous interpretations.

Echo to the Rescue, Now We’re Talkin’! – Part I, Volume and Afterload​


Even More Rescue Echo, Part II – Dynamic Obstruction and Pulmonary Embolism​


Rescue Echo, Gotta Love It! – Part III, Tamponade and Ventricular Failure​


Rescue Echo, Can’t Get Enough! – Part IV, Valve Disease, PTX, Arrhythmia​

 
My residency was very similar to OP. I'm the type of person to learn knowledge for knowledge's own sake. So I would highly recommend EVERYONE to learn TEE. But I realize this is not the standard and is not required by the ABA.

Will learning on your own allow you to become as good as the practiced seasoned CT anesthesiologist?? No. Will it give you a deeper understanding of the heart? Yes. And there will be cases where that understanding will help your patient. So I believe there is value to learning TEE. Ofc, you have to curb your ego and know what you don't know.

To answer OP's original question though, my first case on call in PP was a ruptured AAA and I dropped a TEE rescue. There was no one else around in the middle of the night. If I was not facile with TEE, I would not have obtained important information to treat the patient. But that was the only time that I recall I ever needed a TEE in a non heart case, and certainly no one would have blamed me if I didn't drop a TEE.

So in summary, it does matter. But it's not expected.
 
Learn tee and tte as much as you can. Spend your personal time and professional time getting views, interpret and have some one check your interpretation.
 
I did additional cardiac rotations and passed the Basic TEE exam as a resident. It came up during interviews for PP jobs...

I haven’t touched a probe since. It’s been almost 9 years.

I believe there is value to understanding and appreciating cardiac function by doing the work. Don’t necessarily expect it to be a reliable tool to utilize in your practice; you likely have fellowship trained colleagues to call if you really need to drop a probe.
 
My program has 3 dedicated weeks of TEE during our CT rotations. After a week we are expected to do a full exam with 20 views. Obviously under supervision with feedback on how to better improve views or do more complex assessments etc.

Those who are interested will learn more. We also have a TTE/TEE simulator that we get all access to.

I feel confident in a handful of things, but realize that I have many deficiencies which will be improved when I do CT fellowship. I think with this knowledge and experience at my current level, I can put a probe in with a reasonable level of comfort, see if the heart is working or not (55% looks very different from 25%), is it full or not, is there any obvious or significant valvular stenosis or regurgitation.

I realize that my current level of experience doesn't necessarily allow me to do more nuanced assessments of valves or precise measurements of EF. I don't know how to do tissue doppler or 3D. I don't know how to lots of things.

But ultimately I feel like I could put a probe in in an emergency and use it to guide some basic therapies like fluid vs no fluid. Inotropy vs not. And I also would not hesitate to call a more experienced colleague for extra help.
 
My place doesn't even give me privileges to place a probe despite us all having formalized TEE training in residency. Even in emergencies, I have to call somebody else to come do it.
 
dchz said:
You just press the "TDI" button or the "3D" button

You're welcome!
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Haha okay I have done that but my ability to make worthwhile pictures is.... Severely limited currently.
 
vector2 said:
These four lectures are my gold standard on Rescue TEE, because beyond describing the pathology in a coherent way, Zimmerman hits home the point that even experienced echocardiographers can badly fck up calls in the heat of the moment with erroneous interpretations.

Echo to the Rescue, Now We’re Talkin’! – Part I, Volume and Afterload​


Even More Rescue Echo, Part II – Dynamic Obstruction and Pulmonary Embolism​


Rescue Echo, Gotta Love It! – Part III, Tamponade and Ventricular Failure​


Rescue Echo, Can’t Get Enough! – Part IV, Valve Disease, PTX, Arrhythmia​

Click to expand...

these are great lectures .
If I was a generalist I would learn more TTE than TEE. And I would focus on knowing inside and out: RV dysfunction (of any etiology not just PE) , tamponade , PTX, Asthma. Also figure out how you're going to suspect these diseases when dyspnea makes it impossible to get TTE images, and no sedation for TEE isn't an option in that case.

There are a million cardiovascular pathologies but these are the ways that anesthesiologists assassinate patients because they arrest on induction and DONT EVER COME BACK no matter which pressor you’re giving. severe aortic stenosis will probably come back from post induction hypotension with some norepinephrine. Even if you didn’t know the patent had the disease. if you put someone to sleep with tenuous RV function or peri arrest tamponade (that you DIDNT know about or suspect) , and they lose their blood pressure, they’re probably about to develop refractory arrest and you can’t fix it once you tip them over the edge, there is no waking them up and there is no CPR, they are toast without Ecmo or in the case of tamponade or PTX extremely fast decompression.

I’m missing some stuff but those are some examples of the big ones . Learn to suspect the diseases that will cause refractory arrest on induction, then how to rule them in or out. You can save a life by putting off an intubation for further assessment if you suspect severe RV dysfunction. If you can do that you’ll be far ahead of a lot of anesthesiologists who tube people without question, do a little CPR and then just shrug their shoulders and say it must have been gods plan for that poor person
 
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This is going to be an unpopular opinion, but I think it's incredibly sad that anesthesiologists have just given up on TEE outside the realm of cardiac fellowship.

Yes, there's been an explosion in the knowledge base associated with TEE, but the idea that an anesthesia resident should graduate without having any ability to put a probe in case of emergency is ludicrous. The ED is doing rescue TEEs with 5-10 TEEs in most places because their leadership only cares about expanding their ability and here we are taking away a skill that was essentially advanced by anesthesiologists in the first place.
 
Ronin786 said:
This is going to be an unpopular opinion, but I think it's incredibly sad that anesthesiologists have just given up on TEE outside the realm of cardiac fellowship.

Yes, there's been an explosion in the knowledge base associated with TEE, but the idea that an anesthesia resident should graduate without having any ability to put a probe in case of emergency is ludicrous. The ED is doing rescue TEEs with 5-10 TEEs in most places because their leadership only cares about expanding their ability and here we are taking away a skill that was essentially advanced by anesthesiologists in the first place.
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I don't think that's unpopular at all. Well said.
 
J/k.... We were very regional heavy and during my CA-3 year I left all the morning blocks for the ca1/2 residents and did echo in the heart room. Was a great experience.
 
vector2 said:
Nope, I just think their lecture series is great. I'm also not cardiac trained, just CCM
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Ahh nice didn’t realize you are CC. That’s pretty awesome.

Utah has an amazing echo department- they actually run the echo lab there. We have a few of their fellows and they are top notch TEE/TEE rockstars.
 
I absolutely agree with the Utah TTE and TEE lecture series. I used them during residency as my basis for everything else. U Toronto website is also great.
 
I wish my residency had an echo rotation, there was talk of making one, but the pace is too busy, no attendings even available to teach echo during the day at the bedside, unless you did a heart case with an attending and did the TEE. Even in the heart room, yoj had to mind hemodynamics and vent before bypass, and before you know it yojr ready for bypass and yojr opportunity to do the echo was down the drain.
 
Ronin786 said:
This is going to be an unpopular opinion, but I think it's incredibly sad that anesthesiologists have just given up on TEE outside the realm of cardiac fellowship.

Yes, there's been an explosion in the knowledge base associated with TEE, but the idea that an anesthesia resident should graduate without having any ability to put a probe in case of emergency is ludicrous. The ED is doing rescue TEEs with 5-10 TEEs in most places because their leadership only cares about expanding their ability and here we are taking away a skill that was essentially advanced by anesthesiologists in the first place.
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I think it would be great if there was some core competency made up for TEE, and even create incentives to take the Basic exam, but residency being what it is, they want bodies in the ORs (doing whatever cases, giving breaks etc). They want you to check off that you did however many pump cases before graduating. It's going to be tough to learn the nuances of intra op TEE without a solid fellowship - understanding that a select few residency programs do cater to that, on a whole it's not enough.

Also as has been said before, mis-interpretation can be disastrous. We are the intra op consultants, so if you drop a TEE, which in itself isn't a benign thing to do, you'd better be damn sure you know what you're looking at, what to tell the team, and how to intervene.
 
drsamzie said:
I think it would be great if there was some core competency made up for TEE, and even create incentives to take the Basic exam, but residency being what it is, they want bodies in the ORs (doing whatever cases, giving breaks etc). They want you to check off that you did however many pump cases before graduating. It's going to be tough to learn the nuances of intra op TEE without a solid fellowship - understanding that a select few residency programs do cater to that, on a whole it's not enough.

Also as has been said before, mis-interpretation can be disastrous. We are the intra op consultants, so if you drop a TEE, which in itself isn't a benign thing to do, you'd better be damn sure you know what you're looking at, what to tell the team, and how to intervene.
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It would be lovely if our governing body could say come up with an anesthesiology-resident specific certification that would give knowledge and certification of TEE/TTE. Something that might bring us into the 21st century and maybe help increase value. But nope, lets just force everybody into doing a cardiac fellowship.

The ED gives their residents/members blanket approval that surpasses ACLS/BLS, but we're too busy jerking off the perioperative home.
 
drsamzie said:
I think it would be great if there was some core competency made up for TEE, and even create incentives to take the Basic exam, but residency being what it is, they want bodies in the ORs (doing whatever cases, giving breaks etc).
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Your post really highlights the difference between truly academic residencies and community (or academic-in-name-only) residences; between "residents are the workforce" and "residents are here to learn" residencies.

Beyond that fact that in places with good teaching on your cardiac rotation you'll be paired with a staff 1:1 and have plenty of time to go over echo in your 2nd and 3rd months once you've got a better grasp on case logistics and managing hemodynamics, good academic shops have enough schedule leeway that a resident can be on an "airway" rotation where they're hopping room to room doing the difficult ones instead of only sitting the stool. They have enough scheduling flexibility (like mine) where every resident can get 3 months of cardiac and at least 2 weeks of TEE where the resident can go room to room performing and reading TEE if so desired. They have designated echo reading time every week with fellows and residents, etc.

Now I'm not saying that you'll be anywhere close to having expert level TEE skills with that experience, but every good residency should put it within a motivated resident's grasp to pass the basic.
 
It actually makes a lot more sense for the ED to start to get better at using TEE, than for the general anesthesia community at large. I applaud the ED, so long as the training is rigorous enough that operators are making mostly correct calls on the images. Truth is an ED probably sees way more cases on average that could benefit from the imaging in a workday than your average private practice anesthesiologist. And so therefore they will get the necessary practice. Without lots of practice and lots of cases personally performed, you simply don't know what you're talking about. That's the hard truth. TEE is hardcore diagnostic imaging, just like radiology. How many of you would bet your license on your own read of a MDCT for some critical finding? What about if you were responsible for the technical details of the scan (similar to understanding all the knobology on a TEE machine)? And that's not even a time sensitive read

This thread has been repeated on this forum ad nauseum. It's always the same comments. The truth is TEE is indicated so rarely in a community private practice that it would be irresponsible for most generalists to even attempt it. Get an expert consultant to do it, its best for the patient. What would I say to a PP doc in the boonies with an unstable patient and nobody around to do a TEE or TTE expeditiously? I don't know man, thats a rock and a hard place. Doesn't make it any less true that without practice, that rural doc won't know what he or she is doing. I don't have a good answer for that. Not to mention that this kind of small practice, and even a lot of larger ones, won't even have a TEE machine. The ones in the hospital will be owned by the cardiology group or the hospital itself and won't look kindly on you using equipment unauthorized, or the fact that you don't have privileges for it either.

A question I always have is: why do you folks want to do TEE but not ACTA fellowships? If you can't examine the pre and post op cardiac patient confidently (the VAST MAJORITY OF SOLID INDICATIONS FOR TEE) then you can't really do TEE, can you?

Go ahead and dislike this post into oblivion. This is reality.

If you like this **** then just join us in the cardiac OR where you will actually learn it. Come on, it's fun.
 
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If you want to be ready for PP make sure to do plenty of bread and butter peds and blocks. The most likely time that you will need time sensitive TTE or TEE is if something goes sideways in cath lab. Guess what, the cardiologist is right there...
 
I dont get it, on a weekly basis i see hardcore cardiologists and cardiac Anesthesiologists make bad calls and people die. People who live echo for years.
And someone wants to come in with a few hours training and let rip
 
There is almost no scenario where someone who barely does tee use it in an emergent situation. Also now days the trend is that only fellowship people are doing hearts. So honestly maybe spend time with tte like the er docs do, and can gain valuable info for like pacu management.
 
It's the PA catheter problem all over again. PAC's are complicated enough and placed infrequently enough that most doctors weren't getting the practice or putting in the effort to understand how to use the data, so we just said stop putting them in cause you're just as likely to hurt someone.

TEE is lot more complicated than a pulmonary artery catheter.
 
I think it’s a disservice to just write off a resident’s education just because they likely won’t use it. It’s a cardiac rotation, you should’ve learning TEE just as much as learning the bypass machine, cardiac pathology, etc. Also, the basic exam is meant to be generally diagnostic but cannot guide therapy (that’s the advanced). With basic we should be able to do intraop monitoring such as gross valvular pathology, gross wall dysfunction. That isn’t that hard that you can’t learn in residency. Getting the basic views is not that hard to learn in residency as well. This is definitely within the wheelhouse of periopertaive medicine. Doing a POCUS or rescue TEE as someone showed in the University of Utah lectures. So most definitely, I wanted to learn some TEE in residency so I can get familiar with what a low EF looks like and such. The ER can do FAST exams. We should be able to do a POCUS TTE or basic TEE exam. I’m going into ICU so maybe my point of view is skewed. I’m sure general private practice never needs TEE. But I think it’s a basic part of our job to understand the heart and learn that in residency.
 
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