SonoCredentialing: ACGME ultrasound milestones summarized by @Takeokun

@Takeokun is not only one of the authors for the CORD article on this topic, but also has summarized the ACGME milestones’ ultrasound portion quite nicely on his site. It is well deserving of mention -

Go here for the full post.

Some Downloadables from his post:

  1. Core vs Advanced Emergency Ultrasound for Residents
  2. Assessment methods with skills tested, limitations, and associated milestones
  3. CORD US-SDOT Forms
  4. New Innovations version of the JMTF US milestone evaluation form

SonoGuidelines : AIUM guidelines for cleaning probes (external and internal) #FOAMus

In an official statement by the American Institute of Ultrasound in Medicine (AIUM), they updated their guidelines on cleaning probes: Read below:

“The purpose of this document is to provide guidance regarding the cleaning and preparation of external and internal ultrasound probes. Some manufacturers use the term “transducers” or “imaging arrays.”

Medical instruments fall into different categories with respect to their potential for pathogen transmission. The most critical instruments are those that are intended to penetrate skin or mucous membranes. These require sterilization. Less critical instruments (often called “semicritical” instruments) that simply come into contact with mucous membranes, such as fiber-optic endoscopes, require high-level disinfection rather than sterilization. “Noncritical” devices come into contact with intact skin but not mucous membranes.

External probes that only come into contact with clean, intact skin are considered noncritical devices and require cleaning after every use as described below.

All internal probes should be covered with a single-use barrier. If condoms are used as barriers, they should be nonlubricated and nonmedicated. Although internal ultrasound probes are routinely protected by single-use disposable probe covers, leakage rates of 0.9% to 2% for condoms and 8% to 81% for commercial probe covers have been observed in recent studies (Rutala and Weber, 2011). These probes are therefore classified as semicritical devices.

Note: Practitioners should be aware that condoms have been shown to be less prone to leakage than commercial probe covers and have a 6-fold enhanced acceptable quality level (AQL) when compared to standard examination gloves. They have an AQL equal to that of surgical gloves. Users should be aware of latex sensitivity issues and have non-latex-containing barriers available.

For maximum safety, one should therefore perform high-level disinfection of the probe between each use and use a probe cover or condom as an aid to keep the probe clean. For the purpose of this document, “internal probes” refer to all vaginal, rectal, and transesophageal probes, as well as intraoperative probes and all probes that are in contact with bodily fluids/blood or have a remote chance to be in contact with dry/cracked skin and body fluids, including blood.

Definitions

All cleaning, disinfection, and sterilization represent a statistical reduction in the number of microbes present on a surface rather than their complete elimination. Meticulous cleaning of the instrument is the key to an initial reduction of the microbial/organic load by at least 99%. This cleaning is followed by a disinfecting procedure to ensure a high degree of protection from infectious disease transmission, even if a disposable barrier covers the instrument during use.

According to the Centers for Disease Control and Prevention (CDC) “Guideline for Disinfection and Sterilization in Healthcare Facilities” (2008):

Cleaning is the removal of visible soil (eg, organic and inorganic material) from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products. Thorough cleaning is essential before high-level disinfection and sterilization because inorganic and organic material that remains on the surfaces of instruments interfere with the effectiveness of these processes.”

Disinfection describes a process that eliminates many or all pathogenic microorganisms, except bacterial spores.”

Low-Level Disinfection—Destruction of most bacteria, some viruses, and some fungi. Low-level disinfection will not necessarily inactivate Mycobacterium tuberculosis or bacterial spores.

Mid-Level Disinfection—Inactivation of M Tuberculosis, bacteria, most viruses, most fungi, and some bacterial spores.

High-Level Disinfection—Destruction/removal of all microorganisms except bacterial spores.

Sterilization describes a process that destroys or eliminates all forms of microbial life and is carried out in healthcare facilities by physical or chemical methods. Steam under pressure, dry heat, ethylene oxide (EtO) gas, hydrogen peroxide gas plasma, and liquid chemicals are the principal sterilizing agents used in health-care facilities. . . . When chemicals are used to destroy all forms of microbiologic life, they can be called chemical sterilants. These same germicides used for shorter exposure periods also can be part of the disinfection process (ie, high-level disinfection).”

The following specific recommendations are made for the cleaning and preparation of all ultrasound probes. Users should also review the CDC document on sterilization and disinfection of medical devices to be certain that their procedures conform to the CDC principles for disinfection of patient care equipment.

1. Cleaning—Transducers should be cleaned after each examination with soap and water or quaternary ammonium (a low-level disinfectant) sprays or wipes. The probes must be disconnected from the ultrasound scanner for anything more than wiping or spray cleaning. After removal of the probe cover (when applicable), use running water to remove any residual gel or debris from the probe. Use a damp gauze pad or other soft cloth and a small amount of mild nonabrasive liquid soap (household dish-washing liquid is ideal) to thoroughly cleanse the probe. Consider the use of a small brush, especially for crevices and areas of angulation, depending on the design of the particular probe. Rinse the probe thoroughly with running water, and then dry the probe with a soft cloth or paper towel.

2. Disinfection—As noted above, all internal probes (eg, vaginal, rectal, and transesophageal probes) as well as intraoperative probes require high-level disinfection before they can be used on another patient.

For the protection of the patient and the health care worker, all internal examinations should be performed with the operator properly gloved throughout the procedure. As the probe cover is removed, care should be taken not to contaminate the probe with secretions from the patient. At the completion of the procedure, hands should be thoroughly washed with soap and water. Gloves should be used to remove the probe cover and to clean the probe as described above.

Note: An obvious disruption in condom integrity does not require modification of this protocol. Because of the potential disruption of the barrier sheath, high-level disinfection with chemical agents is necessary. The following guidelines take into account possible probe contamination due to a disruption in the barrier sheath.

After removal of the probe cover, clean the transducer as described above. Cleaning with a detergent/water solution as described above is important as the first step in proper disinfection, since chemical disinfectants act more rapidly on clean and dry surfaces. Wet surfaces dilute the disinfectant.

High-level liquid disinfection is required to ensure further statistical reduction in the microbial load. Examples of such high-level disinfectants are listed in Table 1. A complete list of US Food and Drug Administration (FDA)-cleared liquid sterilants and high-level disinfectants is available at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm194429.htm, and other agents are under investigation.

To achieve high-level disinfection, the practice must meet or exceed the listed “High-Level Disinfectant Contact Conditions” specified for each product. Users should be aware that not all approved disinfectants on this list are safe for all ultrasound probes.

The CDC recommends environmental infection control in the case of Clostridium difficile, consisting of “meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate” (CDC, 2008). The current introduction and initial marketing of a hydrogen peroxide nanodroplet emulsion might provide an effective high-level disinfectant without toxicity.

Table 1. Sterilants and High-Level Disinfectants Listed by the FDA

Name Composition/Action
Glutaraldehyde Organic compound (CH2(CH2CHO)2)
Induces cell death by cross-linking cellular proteins; usually used alone or mixed with formaldehyde
Hydrogen peroxide Inorganic compound (H2O2)
Antiseptic and antibacterial; a very strong oxidizer with oxidation potential of 1.8 V
Peracetic acid Organic compound (CH3CO3H)
Antimicrobial agent (high oxidization potential)
Ortho-Phthalaldehyde Organic compound (C6H4(CHO)2)
strong binding to outer cell wall of contaminant organisms
Hypochlorite/hypochlorous acid inorganic compound (HClO)
Myeloperoxidase-mediated peroxidation of chloride ions
Phenol/phenolate Organic compound (C6H5OH)
Antiseptic
Hibidil Chlorhexidine gluconate (C22H30Cl2N10)
Chemical antiseptic

The Occupational Safety and Health Administration as well as the Joint Commission (Environment of Care Standard IC 02.02.01 EP 9) have issued guidelines for exposure to chemical agents, which might be used for ultrasound probe cleaning. Before selecting a high-level disinfectant, users should request the Material Safety Data Sheet for the product and make sure that their facility is able to meet the necessary conditions to minimize exposure (via inhalation, ingestion, or contact through skin/eyes) to potentially dangerous substances. Proper ventilation, a positive-pressure local environment, and the use of personal protective devices (eg, gloves and face/eye protection) may be required.

Immersion of probes in fluids requires attention to the individual device’s ability to be submerged. Although some scan heads as well as large portions of the cable may safely be immersed up to the connector to the ultrasound scanner, only the scan heads of others may be submerged. Some manufacturers also note that the crystals of the array may be damaged if, instead of suspending the probe in the disinfectant, it rests on the bottom of the container. Before selecting a method of disinfection, consult the instrument manufacturer regarding the compatibility of the to-be-used agent with the probes. Relevant information is available online and in device manuals. Additionally, not all probes can be cleaned with the same cleaning agents. Although some agents are compatible with all probes of a given manufacturer, others must be limited to a subset of probes.

After soaking the probe in an approved disinfectant for the specified time, the probe should be thoroughly rinsed (especially to remove traces of toxic disinfectants in the case of ortho-phthalaldehyde) and dried.

Summary

Adequate probe preparation is mandatory. The level of preparation depends on the type of examination performed. Routine high-level disinfection of internal probes between patients is mandatory, plus the use of a high-quality single-use probe cover during each examination is required to properly protect patients from infection. It would be reassuring for the user to be able to consult manufacturer’s instructions, particularly those that have been validated by the manufacturer for sterilizing devices. Preparation of external probes between patients is less critical and reduced to a low-level disinfection process. For all chemical disinfectants, precautions must be taken to protect workers and patients from the toxicity of the disinfectant.

The AIUM does not endorse or promote any specific commercial products. It is the responsibility of each entity to follow the manufacturer’s guidelines, law, and regulations.

Suggested Reading

  1. Amis S, Ruddy M, Kibbler CC, Economides DL, MacLean AB. Assessment of condoms as probe covers for transvaginal sonography. J Clin Ultrasound 2000; 28:295-298.
  2. Bloc S, Garnier T, Bounhiol C, et al. Ultrasound-Guided Regional Anaesthesia: An Effective Method for Cleaning the Probes. Quincy-Sous-Sénart, France: Service d’Anesthésie, Hôpital Privé Claude-Galien; 2010.
  3. Centers for Disease Control and Prevention, Hospital Infections Program. National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986-April 1996: a report from the NNIS system. Am J Infect Control 1996; 24:380-388.
  4. Frazee BW, Fahimi J, Lambert L, Nagdev A. Emergency department ultrasonographic probe contamination and experimental model of probe disinfection. Ann Emerg Med 2011; 58:56-63.
  5. Hignett M, Claman P. High rates of perforation are found in endovaginal ultrasound probe covers before and after oocyte retrieval for in vitro fertilization-embryo transfer. J Assist Reprod Genet 1995; 12:606-609.
  6. Kac G, Podglajen I, Si-Mohamed A, Rodi A, Grataloup C, Meyer G. Evaluation of Ultraviolet C for Disinfection of Endocavitary Ultrasound Transducers Persistently Contaminated Despite Probe Covers. Paris, France: Hygiène Hospitalière; 2010
  7. Koibuchi H, Fujii Y, Kotani K, et al. Degradation of ultrasound probes caused by disinfection with alcohol. J Med Ultrason 2011; 38:97-100.
  8. Milki AA, Fisch JD. Vaginal ultrasound probe cover leakage: implications for patient care. Fertil Steril 1998; 69:409-411.
  9. Mirza WA, Imam SH, Kharal MS, et al. Cleaning methods for ultrasound probes. J Coll Physicians Surg Pak 2008; 18:286-289.
  10. Muradali D, Gold WL, Phillips A, Wilson S. Can ultrasound probes and coupling gel be a source of nosocomial infection in patients undergoing sonography? An in vivo and in vitro study. AJR Am J Roentgenol 1995; 164:1521-1524.
  11. Rooks VJ, Yancey MK, Elg SA, Brueske L. Comparison of probe sheaths for endovaginal sonography. Obstet Gynecol 1996; 87:27-29.
  12. Rutala WA, Weber DJ. Sterilization, high-level disinfection, and environmental cleaning. Infect Dis Clin North Am 2011; 25:45-76.
  13. Whitehead EJ, Thompson JF, Lewis DR. Contamination and decontamination of Doppler probes. Ann R Coll Surg Engl 2006; 88:479-481.

Related Websites

  1. US Food and Drug Administration. Cleared liquid chemical sterilants/high-level disinfectants US FDA website; March 03, 2010. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm194429.htm.
  2. Centers for Disease Control and Prevention. Guideline for disinfection and sterilization in healthcare facilities, 2008. Centers for Disease Control and Prevention website; 2008. http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.
  3. Occupational Safety and Health Administration. Hospital eTool: clinical services. Occupational Safety and Health Administration website. http://www.osha.gov/SLTC/etools/hospital/clinical/pt/pt.html.

SonoNews: Robotic arm allows remote real-time ultrasound scans -made by French engineers

Now, this is pretty cool. Imagine doing an ultrasound on someone who is not right where you are, but could be in another hospital, or maybe even in another country? These french engineers has made something that is almost to that level. Read below for the EDMT medical imaging article:

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“In a breakthrough that might expand the frontiers of ultrasound examinations, a French company has developed the world’s first industrial-scale remote ultrasound system with a robot arm.

Introduced for radiography, remote imaging is now also used for ultrasound, which accounts for one third of medical imaging procedures, making it the most common such procedure in medicine. Today, ultrasound is the most efficacious of all diagnostic procedures, and on average costs half as much as CT scanning. However, medical exams during pregnancy and detailed investigations of organs, blood vessels, ligaments and the heart require the presence of a highly trained physician at the patient’s bedside as well as hands-on operation of the ultrasound device and interpretation of the resulting images.

Remote medical image scanning using a robot arm that functions as a genuine extension of the physician’s hand was invented by the head of the Department of Nuclear Medicine and Ultrasound at Tours University, Philippe Arbeille, as an outgrowth of manned space flight research that is supported by France’s CNES and by the ESA.

“The main challenge is to resolve the problem of synchronous video transmission. Also, the operator needs to be able to place his hand on the patient virtually,” notes AdEchoTech CEO Éric Lefebvre. The French company recently invested four years and one million Euros in the development of the world’s first industrial-scale remote ultrasound system. AdEchoTech has four patents pending for its Melody robot, two of them with Orleans University’s PRISME mechanical engineering research center.

AdEchoTech’s Melody workstation consists of two elements. For the medical practitioner, the workstation comprises a control box, a mini-console and a virtual probe that remotely controls the ultrasound probe arm. And on the patient side, the operator controls the probe arm remotely. The ultrasound probe, connected to the ultrasound device, is attached to the extremity of the robot arm, whose load is lightened by the arm’s carrier base while at the same time making the arm very easy to manipulate. Thanks to its modularity, the solution is readily adaptable to any given technical environment. Particularly, since operator and patient stations can be operated via satellite, as well as fiber optic 3G+ and 4G hookups. In this regard, the system is compatible with most commercially available ultrasound and video conferencing systems.

“Our R&D also focused on compression algorithms, so as to allow for the communication of information concerning the transmission of ultrasound images, as well as for control of the robot arm and for the realization of video conferences in real time – and all of this in a merely 2 Mbit/s symmetrical bandwidth,” says an AdEchoTech engineer.

The Melody robot, which obtained the CE mark in 2012, allows for 90% concordance with conventional ultrasound, and is useful for solving the growing problems entailed by the performance of ultrasound examinations on islands, in mountainous regions, and on ships or oil drilling platforms, in military zones, for repatriation medicine, and in prisons. Ten Melody stations are already in operation in French hospitals, where they are used for the following procedures: pelvic and abdominal emergencies (investigations of the hepatobiliary system, the urinary system, the abdominal aorta and the pancreas) and examinations during pregnancy. In such settings, the system helps to avoid lengthy trips for pregnant women to major hospitals.

“A second generation of patented Melody robots will benefit from two additional degrees of movement freedom, which will allow for the performance of remote cardiac ultrasound examinations,” says Lefebvre. A third generation of Melody robots, which is expected to be available in 2017, will carry out remote robot-assisted ultrasound for punctures and certain surgical procedures.

By: Bernard Banga, MD Report, France

SonoNews: New Guidelines- reduce risk of premature diagnosis of non-viable pregnancy #FOAMed

In a meeting of 15 members of the radiology, Ob/Gyn, and emergency medicine communities, new criteria were set that was published in NEJM Oct 2013 so that we dont prematurely state that a pregnancy is non-viable. This is pretty important, and a subject that I posted about earlier as well when discussing the usefulness (…or useless ness) of the beta hCG. Can you imagine what was done, and I remember this algorithm – you have a patient with 1st trimester pain or vaginal bleeding, no IUP seen on US, low beta Hcg, and OB was called and the patient was given methotrexate??? Well, there have been cases where those patients actually had a viable IUP that showed up a week later… and then the lawsuit happens….scary stuff. It’s different now where we dont care too much about the beta hCG, or whether there is not an IUP, but whether we see anything around the ovary….and even then, very close follow up and rechecks may be considered. Below is the Eurekalert and the AuntMinnie articles on it too:

Medical experts recommend steps to reduce risk of inadvertent harm to potentially normal pregnancies

New criteria aim to prevent misdiagnoses of nonviable pregnancies

A panel of 15 medical experts from the fields of radiology, obstetrics-gynecology and emergency medicine, convened by the Society of Radiologists in Ultrasound (SRU), has recommended new criteria for use of ultrasonography in determining when a first trimester pregnancy is nonviable (has no chance of progressing and resulting in a live-born baby). These new diagnostic thresholds, published Oct. 10 in the New England Journal of Medicine, would help to avoid the possibility of physicians causing inadvertent harm to a potentially normal pregnancy.

“When a doctor tells a woman that her pregnancy has no chance of proceeding, he or she should be absolutely certain of being correct. Our recommendations are based on the latest medical knowledge with input from a variety of medical specialties. We urge providers to familiarize themselves with these recommendations and factor them into their clinical decision-making,” said Peter M. Doubilet, MD, PhD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, the report’s lead author.

Among the key points made by the expert panel:

  • Until recently, a pregnancy was diagnosed as nonviable if ultrasound showed an embryo measuring at least five millimeters without a heartbeat. The new standards raise that size to seven millimeters
  • The standard for nonviability based on the size of a gestational sac without an embryo should be raised from 16 to 25 millimeters
  • The commonly used “discriminatory level” of the pregnancy blood test is not reliable for excluding a viable pregnancy

The panel also cautioned physicians against taking any action that could damage an intrauterine pregnancy based on a single blood test, if the ultrasound findings are inconclusive and the woman is in stable condition.

Kurt T. Barnhart, MD, MSCE, an obstetrician-gynecologist at the Perelman School of Medicine at the University of Pennsylvania and a member of the SRU Multispecialty Panel, added, “With improvement in ultrasound technology, we are able to detect and visualize pregnancies at a very early age. These guidelines represent a consensus that will balance the use of ultrasound and the time needed to ensure that an early pregnancy is not falsely diagnosed as nonviable. There should be no rush to diagnose a miscarriage; more time and more information will improve accuracy and hopefully eliminate misdiagnosis.”

Michael Blaivas, MD, an emergency medicine physician affiliated with the University of South Carolina and one of the panelists, emphasized that “These are critical guidelines and will help all physicians involved in the care of the emergency patient. They represent an up-to-date and accurate scientific compass for navigating the pathway between opposing forces felt by the emergency physician and his/her consultants who are concerned about the potential morbidity and mortality of an untreated ectopic pregnancy in a patient who may be lost to follow-up, but yet must ensure the safety of an unrecognized early normal pregnancy.”

Aunt Minnie article :

“In addition, the authors emphasized that the commonly used “discrimination level” of the pregnancy blood test is not reliable for excluding a viable pregnancy. They also cautioned physicians against taking any action that could damage an intrauterine pregnancy based on a single blood test, if the ultrasound findings are inconclusive and the woman is in stable condition.

“The guidelines presented here, if promulgated widely to practitioners in the various specialties involved in the diagnosis and management of problems in early pregnancy, would improve patient care and reduce the risk of inadvertent harm to potentially normal pregnancies,” the authors wrote.

Not stringent enough

Research over the past two to three years has shown that previously accepted criteria for ruling out a viable pregnancy are not stringent enough to avoid false-positive results, but it has been difficult both to disseminate this information to practitioners and to implement standardized protocols.

The challenge is that physicians from multiple specialties — including radiology, obstetrics and gynecology, emergency medicine, and family medicine — are involved in the diagnosis and management of early-pregnancy complications, according to the authors.

“As a result, there is a patchwork of conflicting, often outdated published recommendations and guidelines from professional societies,” they wrote.

To address the problem, SRU in October 2012 organized the Multispecialty Consensus Conference on Early First Trimester Diagnosis of Miscarriage and Exclusion of a Viable Intrauterine Pregnancy. At the conference, researchers reviewed the diagnosis of nonviability in early intrauterine pregnancy of uncertain viability and, separately, in early pregnancy of unknown location. They focused mainly on the initial or only ultrasound study performed during the pregnancy.

The conference participants developed the following guidelines for transvaginal ultrasound diagnosis of pregnancy failure in a woman with an intrauterine pregnancy of uncertain viability.

Findings diagnostic of pregnancy failure:

  • Crown-rump length of ≥ 7 mm and no heartbeat
  • Mean sac diameter of ≥ 25 mm and no embryo
  • Absence of embryo with heartbeat ≥ 2 weeks after a scan that showed a gestational sac without a yolk sac
  • Absence of embryo with heartbeat ≥ 11 days after a scan that showed a gestational sac with a yolk sac

Findings suspicious for but not diagnostic of pregnancy failure:

  • Crown-rump length of < 7 mm and no heartbeat
  • Mean sac diameter of 16-24 mm and no embryo
  • Absence of embryo with heartbeat 7-13 days after a scan that showed a gestational sac without a yolk sac
  • Absence of embryo with heartbeat 7-10 days after a scan that showed a gestational sac with a yolk sac
  • Absence of embryo ≥ 6 weeks after last menstrual period
  • Empty amnion (amnion seen adjacent to yolk sac, with no visible embryo)
  • Enlarged yolk sac (> 7 mm)
  • Small gestational sac in relation to the size of the embryo (< 5 mm difference between mean sac diameter and crown-rump length)

Pregnancy of unknown location

The panel also determined diagnostic and management guidelines related to the possibility of a viable intrauterine pregnancy in a woman with a pregnancy of unknown location.

For the finding of no intrauterine fluid collection and normal (or near-normal) adnexa on ultrasonography, the authors provided the following key points:

  • A single measurement of human chorionic gonadotropin (hCG), regardless of its value, does not reliably distinguish between ectopic and intrauterine pregnancy (viable or nonviable).
  • If a single hCG measurement is < 3,000 mIU/mL, presumptive treatment for ectopic pregnancy with the use of methotrexate or other pharmacologic or surgical means should not be undertaken, in order to avoid the risk of interrupting a viable intrauterine pregnancy.
  • If a single hCG measurement is ≥ 3,000 mIU/mL, a viable intrauterine pregnancy is possible but unlikely. The most likely diagnosis is a nonviable intrauterine pregnancy, so it is generally appropriate to obtain at least one follow-up hCG measurement and follow-up ultrasonogram before undertaking treatment for ectopic pregnancy.

If ultrasound had not yet been performed, the researchers offered the following key point: “The hCG levels in women with ectopic pregnancies are highly variable, often < 1,000 mIU/mL, and the hCG level does not predict the likelihood of ectopic pregnancy rupture,” they wrote. “Thus, when the clinical findings are suspicious for ectopic pregnancy, transvaginal ultrasonography is indicated even when the hCG level is low.”

Panel member Dr. Kurt Barnhart, an ob/gyn at Perelman School of Medicine at the University of Pennsylvania, said in a statement that the guidelines represent a consensus that will balance the use of ultrasound and the time needed to ensure that an early pregnancy is not falsely diagnosed as nonviable.

“There should be no rush to diagnose a miscarriage; more time and more information will improve accuracy and hopefully eliminate misdiagnosis,” he said in the statement.

SonoMedStudent: Integrating in Ultrasound into the First year of Med school by Dr Tarina Kang #FOAMed

Dr, Tarina Kang, the Ultrasound Director at USC, wrote to the Editor of Advances in Medical Education and Practice in the Aug 2013 journal . She poses quite a good argument for ultrasound in medical education ( with references ) and also discusses how she found it to be best done in the first year – a great read:

Dear editor,

For over 100 years, medical schools throughout the United States have typically followed a standardized curriculum that clearly delineates the preclinical (basic and clinical sciences) and clinical years (patient encounters and care).1 However, the transfer of learning that is derived from isolated data of basic science to clinically relevant information has been a topic of much debate and study throughout the years.

Recently, educators have attempted to unite the preclinical and bedside principles in an effort to make the basic sciences more relevant to medical practice. Basic, clinical, and social sciences are taught simultaneously to reaffirm “the importance of the relationship between the practitioner and patient. Further, the practitioner should focus [on the patient] as a whole, be informed by evidence, and make use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”2 Although implementation of an integrated learning curriculum in medical school poses political, logistical, and financial challenges, its rewards for the student may be profound.

The ideal approach to integrating basic science material with the practice of medicine is complex in that educators often have to incorporate innovative and pertinent student experiences, without compromising the existing curriculum requirements. The sheer amount of information that first year medical students are required to learn makes inclusion of additive curriculum difficult. However, it behooves course directors to constantly test, change, and expand course curriculums to maximize the educational benefit to students.

There are a number of ways to implement clinical practice into the first year courses of medical school, with the theoretically most successful ones being those that can be brought to the student during class, where other students and instructors are present for more in-depth and collaborative discussion. Point-of-care ultrasound was developed by emergency physicians in an effort to better evaluate the patient at the bedside. More recently, ultrasound has become an important educational and clinical tool across all specialties due to its ease of use, portability, and applicability at the bedside. Many institutions have integrated bedside ultrasound teaching into the clinical years of medical school. Several US institutions such as Wayne State, Ohio State, and the University of South Carolina have implemented ultrasound curriculums that span from the first year to the entire 4 years of medical school.35 In 2012 Fox et al6at the University of California (Irvine, CA, USA) implemented a novel medical curriculum which integrated web-based lectures and peer instruction for Year I students. They were successfully able to maximize teaching and practice time and integrate practical medicine into the basic science courses. Given the success of these programs and the potential educational benefit they afford students, a seamless introduction of ultrasound into the first year courses at our affiliated medical school seemed like a natural progression.

The goal of the project was to integrate ultrasound, a practical clinical modality, into the preclinical educational experience, specifically, during the anatomy and histology classes and laboratory sessions. The ultrasound instructors successfully completed a 10-week course which combined anatomy and histology laboratory sessions, small group sessions, and lectures. After a year of planning, we successfully integrated ultrasound into the course in a way which emphasized how teaching in a dynamic and safe manner with the ultrasound can illuminate the structural relativity of human anatomy.

The novelty of this curricular change in a course that has never had this type of teaching before was itself an impediment. I think that, in retrospect, the adage “There is strength in numbers” is a proverb one should follow when attempting to implement a new course at a medical school. The more people you know who represent different specialties and ranks in both the hospital and the medical school, the higher the likelihood for continued success of the course.

When I started this project, I was naive to the accepted conduct and decorum that one is expected to follow when trying to introduce unprecedented ideas into the medical school curriculum. I had an idea worthy of pursuing, I created a plan to implement it, and I spoke to the directors of the course, but I did not attempt to gain crucial allies in the medical school who could have accelerated its acceptance. The legacy of new projects and teaching initiatives at medical schools will constantly be endangered unless there is consistent support at the administrative level. As a result, although I had the full support from the course directors, I did not have the complete acceptance of the laboratory professors and instructors who taught the course. This disconnection manifested in frustration and bewilderment by some students attending our course during their teaching time. In addition, because there was no formal explanation of our pilot to the students, some were unable to fully grasp the concept of an integrated educational forum, and noted on course feedback their lack of understanding as to why, and how, point-of-care ultrasound correlates with anatomy and histology. This problem could have been curtailed, at least in some part, by a formal acknowledgment made by not only the course directors but also the administration. With this knowledge, we reached out to several medical school administrators, and we are in talks with them to gain valuable insight and input for further direction for next year’s course. In addition, we are recruiting physicians from different specialties to broaden the type of expertise in our curriculum.

Although I encountered barriers, the experience was invaluable. It helped me understand, with startling clarity, the political structure of medical education. I have since moved to another academic medical center, and we are scheduled to begin talks to create an integrated curriculum with first year medical students. The next time I introduce myself though, I think I’ll bring my friends.”

Go to this article’s link for a list of the references as well.

To read posts on US in Medical Education done at AIUM and other institutions, and see what others are doing and saying about it, go here.

SonoFellowship: Ultrasound Leadership Academy – apply now! @ultrasoundpod @bedsidesono

The Ultrasound Leadership Academy… the ULA….oh yeah! “What is it?” you ask?  It’s only the most awesome experience anyone who wants to learn ultrasound from all over the world could every have!!!

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It’s a virtual 12-month fellowship in ultrasound and Im excited to join Matt Dawson, Mike Stone, Mike Mallin (of ultrasound podcast), and the other awesome ULA professors to be part of enhancing future leaders’ ultrasound knowledge. The fellow not only gets mentorship, one-on-one sessions, and google hangouts to review their images they get from the Vscan obtained during the fellowship (yup, that’s right, you get a Vscan to use during the fellowship), but you also get to learn what it takes to create, direct, and enhance your ultrasound program as well as learn the ins and outs of bedside ultrasound applications…. from the best of the best! Awesome, right?

How can you apply? Go to the website and see how!

 

SonoSpot ! Now with SonoBilling info, SonoReferences list, SonoFellowship Curriculum & More! #FOAMed

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Remember when I stated that in August we will be revamping the SonoSpot site to include much more – well it took a little longer than one month, but Im very excited to show you what all that research and time has come to – A SonoSpot site that, well, looks the same, but with so much more exciting content!  – Information that will benefit not only those who want to learn bedside focused ultrasound and review cases and tutorials, but also those who want information on billing for ultrasound procedures, to review a list of references in each ultrasound application, as well as review a monthly fellowship curriculum that takes these references and adds the online sites and podcasts available to supplement that topic for each month!

Each of the headers will have drop down menus for even more content. Many topics on bedside ultrasound are found under SonoSpots when you go to sonospot.com. Oh, and those guest posts from others who have so patiently waited to have their awesome cases highlighted on SonoSpot will start this week too! Enjoy the new pages (…and they will keep getting enhanced with lecture videos throughout the year – it just gets better! )

Visit our SonoBilling and Privilege Form page – where you can see an estimate of the charges/wRVUs and LCD information that is all found publicly and incorporated into one excel sheet – scroll through it up/down/right/left to get it all in. Be warned: it is a ton of information that summarizes 1,000 pages of public pages into one sheet. Note the disclaimer. This page also has a sample Hospital Privilege form for those who want to get privileging in bedside ultrasound at their institution which is required at some places in order to bill, in addition to the list of items required for US billing as seen on the SonoBilling page.

Visit our SonoSmartphrases for EMRs – here is a sample of smartphrases that describe the documentation for each bedside limited ultrasound procedure that is being billed. The wording for each smartphrase is specifically stated due to the requirements for SonoBilling

Visit our SonoReferences pages – where we highlight the landmark and hot articles in each bedside focused ultrasound application, along with the link to the pubmed page for each. This is a page that is going to continually get updated as more studies get published. This is separate from our SonoStudies site, that go into further detail and discussion on specific studies that pick to highlight for various reasons.

Visit our SonoFellowship Curriculum pages. This is a sample of a curriculum should anyone want to do an ultrasound fellowship. It is a supplement to other educational opportunities that a fellow will get and describes the fellowship month-by-month on the reading assignments – including viewing online #FOAM resources for each topic (websites, blogs, podcasts, etc).

We will continue to optimize our Sonotutorials and SonoCases sites, which are our most popular sites for all bedside ultrasound believers in the world!

Hope you enjoy and, as always, I love any feedback or suggestions for additions to the site for our future upgrades.

SonoNews! AIUM President on Ultrasound in Medical Education & the US in MedEd portal #FOAMed

When I read this message, a light shined so bright inside my little head, that I had to share it. I got the usual emails from AIUM (American Institute of Ultrasound in Medicine), a multi-specialty organization with thousands of members, who educate/study/encourage/collaborate on issues related to ultrasound in medicine. But, the email that came out today, a message from the new AIUM President, discusses with such ease and obviousness about how ultrasound should be integrated into medical school education.

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I have been to a few of the national AIUM conventions and my most recent post about it discusses one of the best days of my life, the course in NY at AIUM2013 about ultrasound integration to medical school curriculums where the experts spoke of their experiences, their advice, their ideas ….followed by a panel of medical students who shared their point of view of how it affected their education. It was amazing! Even now, when i think about it, i am inspired, and continue to be excited about how we are starting to do the same at Stanford School of Medicine. I have posted about the reactions that Ultrafest (a free medical student workshop in California) brought to everyone, including what UC Irvine’s Dean Clayman stated about it all. It was quite honest and encouraging. All of this, brings me to this message that i keep reading over and over again. Is it because 2013 is the Year of Ultrasound? Well, likely so, but for that reason and so many more, I just cant stop reading it – please read it below, especially the end when the link to the Ultrasound in Med Ed portal is introduced.

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July 25, 2013

Dear Colleagues:

I believe there is no more important issue facing ultrasound than its incorporation into undergraduate medical schools’ curricula. Many of you saw the visionary presentation of Dean Richard Hoppmann, MD, at the 2012 AIUM Annual Convention in Phoenix, Arizona. Here at New York University School of Medicine, Uche Blackstock, MD, RDMS, an emergency department physician, is developing a multidisciplinary collaborative integrated preclerkship and clerkship curriculum. Consider the following:

It’s another typically busy day at the medical center. A critical care fellow supervises a senior resident placing ultrasound-guided central vascular access in a hypotensive septic elderly patient in the medical intensive care unit. In the outpatient surgery suite, an anesthesiologist prepares a patient for rotator cuff surgery by performing an ultrasound-guided interscalene brachial plexus block for regional anesthesia. In the echocardiography lab, a cardiologist assesses a patient admitted the night before with a non-ST segment elevation myocardial infarction for wall motion abnormalities and cardiac function. An obstetrics and gynecology attending performs a pelvic ultrasound examination on a young woman being ruled out for an ectopic pregnancy, appreciates an intrauterine pregnancy, and discharges the patient home safely.

Over the last 20 years, ultrasound performed at the bedside, by clinicians, has revolutionized the way medicine is practiced. In these diverse cases, the use of ultrasound was critical in providing patients with effective and quality clinical care. Although currently being used for diagnosis, management, and procedural guidance by physicians in numerous and diverse specialties, a significant gap currently exists between what medical students are being taught and how they are expected to practice on completion of their training. Future physicians will be expected to be familiar with the use of ultrasound in their clinical practice, regardless of specialty. At this time, medical educators have a unique and timely opportunity to use ultrasound at the bedside as an innovative teaching modality in the undergraduate medical curriculum.

Handheld ultrasound will transform how medical students are taught in the preclinical curriculum as well. Students will never experience learning medicine the same way. They will be able to scan a live model and appreciate the gallbladder as its lies within the main lobar fissure of the liver. They will have a deeper understanding of the cardiac cycle by viewing the diastolic and systolic phases of a live beating heart. During clerkships, students will learn how bedside ultrasound can be used to make important diagnoses and to allow them to safely perform critical procedures. Bedside ultrasound as a teaching tool will enhance what students have learned traditionally and help reinforce important concepts.

An integrated ultrasound curriculum will require a multidisciplinary collaborative effort by a medical school faculty. This approach will ensure that students receive comprehensive exposure to ultrasound from all perspectives. Medical educators are responsible for ensuring students are well equipped for future clinical practice. Ultrasound, as I see it, will have a dual role in undergraduate medical education. First, it can and should be incorporated into preclinical learning to teach anatomy, physiology, and pathology. Second, there is almost no clinical clerkship, as outlined by the scenarios above, that does not already or else will soon utilize bedside ultrasound. The future is now.

The AIUM’s Ultrasound in Medical Education Interest Group, chaired by David P. Bahner, MD, RDMS, has developed an outstanding online portal to assist those with an interest in integrating ultrasound into medical school curricula. This one-stop clearinghouse includes a mentor program; educational information from multiple organizations; and a tool kit that features curriculum examples, links to online lectures, sample proficiency assessments, tips on discussions with medical school leadership, instructor pools, equipment, and more. We encourage you to explore the Ultrasound in Medical Education Portal. If you know of additional resources that should be included, e-mail MedEd@aium.org.

In closing,

AIUM membership for students, residents, and fellows allows these individuals access to helpful ultrasound-related resources and the opportunity to network with experts in medical ultrasound–an excellent complement to the clinical training they receive. This membership category is $25 and offers students the full array of member benefits. The students of today are the future leaders of the AIUM. I hope you will share this opportunitywith those with whom you are in contact.

Sincerely,

Steven R. Goldstein, MD
AIUM President

SonoNews: Radiologists should guide point-of-care ultrasound training? …lets think about this…

In an insert of Diagnostic Imaging, Dr. Michael Blaivas (an emergency physician, past president of ACEP US Section, Section Chair of Emergency/Critical Care for AIUM, and basically about 3 or 4 more titles that would take a few more lines in this post to mention because he is that amazing) spoke about how radiologists have historically been threatened by and become obstructionists in its use by non-radiologists, then became less so as it was apparent that radiologists didnt have the time to do it  – possibly due to radiologist shortages and becoming focused on CT and MRI (according to Dr. John Cronan – chair of Radiology at Brown Univ), and now are not involved or part of the team with point-of-care ultrasound training – but they should be, according to Blaivas in this article by Sara Michael. However, this article concludes the wrong thing – in my opinion – and has misunderstood Blaivas’s point. Instead they reaffirm the angst felt by radiologists today and fail to explore why. Radiologists have submitted a “National Curriculum” for medical student education in ultrasound as well, that has come to add to further controversy as there are no other specialties involved in the discussion…. But, of all the medical student US curriculums out there, most, if not all, are coordinated by non-radiologists.

“Point-of-care ultrasound has become ubiquitous in medicine, from emergency departments to OB and trauma surgery. But that doesn’t mean it’s taking the modality away from radiologists.In fact, radiologists should be the ones guiding its training and promotion – not bemoaning and pushing back on the trend. “Radiologists are not involved in ultrasound education and promoting its use in point of care or elsewhere, but it would be nice to have more involvement,” Michael Blaivas, MD, an emergency medicine physician and past chair of the American College of Emergency Physicians ultrasound section, said during a presentation at RSNA 2012 this week. “It’s better to be seen as proponents of an application, guide it, and help with it, especially an application that is seen as critical at the bedside.” Radiologists are the ultrasound imaging experts, Blaivas said, and should be the first to share their expertise. The specialties shouldn’t be fighting each other, he said, but working to make sure the modality thrives for all clinicians. If radiologists were more involved in teaching, they could ensure quality in its use. “There really is a need for ultrasound education, and this is somewhere we can meet,” he said.”…”Today, [Dr Cronan] said, radiologists are “working feverishly to protect our income,” and the profession faces threats of commoditization with the rise of teleradiology and service-live imaging. Although ultrasound is likened to the stethoscope in its extension of the physical exam, Cronan noted, it’s used by many, understood by few.”

Ive been thinking a lot about it recently, and trying to understand radiologists’ continued angst about non-radiologists performing point-of-care ultrasound. I’ll start with these few points: radiologists do perform ultrasound studies – both limited and complete – and that hasn’t and shouldn’t change, they ARE imaging specialists. I do rely on them when my point-of-care ultrasound shows that a complete ultrasound study or a CT scan is needed. Many radiologists do not see the ultrasound studies that non-radiologists perform or how they are quality assured, and the fear of the unknown can drive quite a few political decisions. They have not been involved in point-of-care ultrasound training either, and this, in combination with the above, will give even more angst. I do agree, they SHOULD be a part of the education (and I know some will disagree with me) – this will have those who perform point-of-care ultrasound learn more techniques (with the applications that are also performed by radiology) and the radiologists will learn/see what we do, how we do it, and why it’s so important for us (and our patients) at the bedside. They will see that our images are actually quite good and that our QA and training direction is strict enough through our ACEP guidelines. Should they be in charge of it’s training? I dont think so. Is it an extension of the physical exam? No, it’s so much more than that. Here’s what keeps coming into my head:

1. The AMA passed a resolution that states ultrasound does not belong to any one specialty, but it can be incorporated into any specialty as defined by that particular specialty – later to also have a resolution that ultrasound is safe, effective, and efficient when used under the direction of an appropriately trained physician and should be supported in its educational efforts when integrating into medical education.

2. Many of the point-of-care ultrasound applications are not ordered/performed through radiology. Before emergency medicine and critical care docs started performing bedside ultrasound, they did not order an orbital ultrasound, an IVC ultrasound, a musculoskeletal ultrasound, a soft tissue ultrasound, an Aorta ultrasound, a cardiac ultrasound, a thoracic ultrasound, a procedural guided central or peripheral venous ultrasound…. through radiology. And, cardiologists did their echoes, OBGYN docs did their pelvic ultrasound over the last 15-20+ years, and, for the most part, trauma teams performed their own FAST scans.

3. Time matters. When there is a patient in shock, a crashing (or stable) trauma patient, and a patient who is acutely short of breath or with acute chest pain or acute abdominal pain or acute pelvic pain or with acute vision loss… and any procedure where ultrasound is needed…. we rule emergent conditions in and out and get that procedure done, quickly.

We need to have this conversation with our radiologists, let them know of our QA process, educate them on the way and the reasons we perform bedside ultrasound, and alleviate their (and all of our consultants’) angst about our ultrasound studies. The team approach to ultrasound training for medical students is very important, and they should be a part of that.

SonoNews: Chest ultrasound for acute dyspnea used by internal medicine…yes!

In a recent publication through Medscape, they site a research article and presentation at the American College of Chest Physicians – in Chest Oct 2012  – stating “With minimal training, internal medicine house staff can successfully use hand-held ultrasound devices in the diagnosis of acute dyspnea.” This is huge! Why? Well, where do I begin? First off, lung ultrasound is advancing like never before – not that it wasn’t already known it was awesome for pneumothorax, pleural effusion, and pulmonary edema, but now the evaluation for pneumonia has gotten a lot of press. Secondly, you have more studies coming out that with minimal training, lung ultrasound can be used by physicians to help diagnose the cause for shortness of breath, which is great and helps get the fear of looking out of the conversation. FInally, and more exciting to me than anything above, is that bedside ultrasound is spreading!!! – to internal medicine (in this posting), but also to involve surgical clinics, sports medicine, pediatrics, and ophthalmologists  – – using bedside ultrasound to aid in their evaluation of their patients.

The article describes: “Ravindra Rajmane, MD, from the New York University Langone Medical Center in New York City, and colleagues reported the study findings in a poster presentation here at CHEST 2012: American College of Chest Physicians Annual Meeting. “The technology of sonography has improved markedly over the past few years,” Dr. Rajmane told Medscape Medical News. “Our study underscores the ease of transporting and effectively applying this technology with minimal training,” she said. “Our residents were able to successfully learn the basics of lung ultrasonography with a 1-hour didactic lecture followed by 1 hour of hands-on training. Unstructured training was also provided during ICU [intensive care unit] rounds.” According to the researchers, acute dyspnea is normally assessed with a combination of history taking, physical examination, electrocardiography, chest x-ray, and lab work. Lung ultrasound is increasingly being used to assess acute respiratory conditions because it is faster, less invasive, and more sensitive.” – Hallelujiah!!!

Keep it spreadin….

Even the OBGYN doctors are learning to use lung ultrasound in evaluating shortness of breath in pregnant patients!

A prior case that evaluated a patient who came in with shock and shortness of breath illustrates a way lung ultrasound can be used to help evaluate, diagnose, and work up your patient and can be find here.