Rotation Administration Details
Rotation Directors: Laura Wallace, Erica Blustein, Allison Zanaboni Rotation Support Contact: Dora Miller, [email protected]
Site: Barnes-Jewish Hospital Emergency Department
Duration: 1 full block (26 days)
Emergency Absences
Please notify your admin chief and Rotation Director if you have an emergency. Otherwise, any absence during regular hours for non-ultrasound related activities (i.e. doctor’s appointments, meetings) must be pre-approved with the rotation director before the beginning of your rotation and will likely need to be made up in your off hours. Absences will only be approved for extenuating circumstances and emergencies.
Rotation Goals
The goal of this rotation is for residents to develop competence with the performance of core Emergency Medicine Point of Care Ultrasound Examinations and the communication skills and administrates tasks that go along with performing POCUS.
Rotation Objectives
  • Demonstrate professionalism in activities and presence in ED during scan shifts and interactions with peers, staff, and students.
  • Log at least 150 examinations during the rotation, including a variety of the 12 exam types needed for graduation.
  • Perform ultrasound examinations capturing the standard views and meeting the objectives for each scan type. See page 5. Use the flashcards on pocushub.com as a reference for each exam type.
  • Demonstrate professionalism with organization and documentation of examinations on a daily basis.
  • Prepare and participate in Image Review Days and integrate feedback into examinations.
    Description of Activities
• Arrive on time to scan shifts and be available for diagnostic and education scans during the scheduled clinical scan days.

   
  • Remain in the ER and available by phone during the scan days (other than lunch breaks). Place phone number on EPIC or on whiteboards and add yourself to the trauma pager each day.
  • When asked to perform an examination, ensure that the attending caring for the patient or an attending in the pod is aware beforehand so they can attest to your examination and help with image acquisition/interpretation.
  • Input patient information accurately for every exam and follow the exam standards as best as possible for each exam.
  • You must save an image and document for every scan you perform, including unsuccessful scans and procedures. All uploaded exams should be signed by the end of the day.
  • Complete the assigned independent curriculum (AEUS videos, page 10) by the end of each week (see below)
  • Review scans and follow up testing so you are prepared to discuss exam on Image Review Days. Keep your Review Day Worksheets handy so you can reassess personal goals and exam numbers each week.
    Schedule
    The QA/Scan Day schedules are subject to change-US Faculty will email beforehand to confirm times.
    Day/Time Activity Participants
    10 am, First Day of Rotation Rotation Orientation Intern, US Faculty (unless otherwise specified)

     
Monday-Friday 10am-7pm
(exceptions for Conference, Journal Club)
Scan shifts
Intern is expected to be in the ER available for scans.
Intern, Med student on rotation

Mondays 10am (unless otherwise scheduled)
Image Review/Scan Day
Review Scans from prior week and be prepared to discuss findings
Scan in ED w/ US Faculty
Intern, student, US Faculty

Thursdays 10am (unless otherwise scheduled)
Scan Day
Scan in ED w/ US Faculty
Intern, student, US Faculty
Third Thursday of month, 9am
US Journal Club Over Zoom
Intern, Student, US Faculty
Resident Assessment:
Formative: Image Review/Scan Day Worksheets (1-2 x weekly when working with US Faculty)
Summative: Will include your scans numbers logged in qPath, assessment of documentation Completion, Scan Day worksheet feedback and any other feedback we receive during the rotation.
Important Tips:
Prioritizing Tasks during Scan Shifts
Please prioritize US examinations and US guided procedures first. You can take advantage of opportunities for other non-ultrasound procedures (paracentesis, intubation, etc.) if you are not missing out on ultrasound opportunities.
Assume each exam takes at least 30 minutes so you can give a time estimate if you are asked to do multiple exams in a row. Please let the Rotation Faculty know if you have any difficulties.
IV placement
IV placement is one of the more common call you will receive. When you are called, it can be helpful to ask:
  • Where has the nurse attempted the IV placement?
  • Has the attending caring for the patient been notified the IV attempts have failed?
  • Has the nurse discussed with the attending what type of IV they will need? (22 in the hand, 18 above the elbow for CTA etc)
    OB Ultrasound
    An attending must be present for all transvaginal ultrasounds.
Emergency Medicine Resident Ultrasound Competencies (with goal exam numbers)
The extended version of the EM resident competencies can be found on POCUSHUB.com. A shortened version of competencies and exam expectations is below.
I. General Ultrasound Competencies
  1. Image Acquisition-see specific exam details below
  2. Patient Positioning-describes standard patient position and environment setup for
    optimization of image acquisition as well as draping for patient comfort
  3. QPath Documentation
1. QPath Documentation Requirements
  1. a)  Pull patient information from worklist if possible
  2. b)  Update information in QPath E immediately after finishing exam if
    worklist malfunctions
  3. c)  Add operators
  4. d)  Edit Exam Type
  5. e)  Write and Sign Note by the end of shift or workday
  1. Core Competency: Basic Physics, Important Artifacts
    1. Physics terms: Piezoelectric effect, Frequency, Resolution, Attenuation,
      Echogenicity, Doppler (color and spectral), Aliasing
    2. US System terms: Knobology, Image made, gain, Time gain compensation,
      Focus, Transducer types
    3. CommonArtifacts:Reverberation,Sidelobe,Mirror,Shadowing,Enhancement,
      Ring-Down
  2. Core Competency: Basic Echocardiography 25
    1. Describe the indications and limitations of cardiac POCUS.
    2. Perform standard POCUS windows (subcostal, parasternal, and apical) and
      planes (four chamber, long and short axis).
    3. IdentifyrelevantUSanatomyincludingpericardium,cardiacchambers,valves,
      descending aorta and IVC.
    4. Estimatequalitativeleftventricularfunctionandcentralvenouspressuretoguide
      hemodynamic assessment of patient (EPSS, IVC)
    5. Recognize cardiac arrest, pericardial effusion with or without tamponade, and
      dilation of the aortic root or the descending aorta.
    6. Advanced evaluation
      1. Acquire view of the aortic arch and recognize aortic arch dissection and/or aneurysm.
      2. Identification of right ventricular dysfunction.
      3. Assessment of cardiac output and fluid responsiveness.
    7. Procedural Guidance: pericardiocentesis, transvenous pacer, and cvc placement.
    8. IntegrateEmergencyechocardiographyfindingsintoindividualpatientand
      department management.
  3. Core Competency: Trauma- EFAST 25
    1. Describe the indications, clinical algorithm, and limitations of POCUS in blunt and penetrating thoracoabdominal trauma.
    2. Perform the POCUS protocol for Trauma in both primary and secondary surveys.
C. IdentifyrelevantUSanatomyincludingpleura,diaphragm,IVC,pericardium, liver, spleen, kidneys, bladder, prostate, and uterus.
  1. Recognizepathologicfindingsandpitfallsintheevaluationofpneumothorax, hemothorax, pulmonary contusion, hemopericardium, cardiac activity, volume status, and hemoperitoneum.
  2. Integrate Trauma POCUS findings into individual patient, departmental and disaster management.
  1. Core Competency: Renal/Bladder 25
    1. Describe the indications and limitations of POCUS of the kidneys and bladder.
    2. Perform POCUS protocols to evaluate the urinary tract.
    3. IdentifyrelevantUSanatomyincludingtherenalcortex,renalpelvis,ureter,
      bladder, liver, spleen and uterus or prostate.
    4. Recognizetherelevantfindingsandpitfallswhenevaluatingforhydronephrosis,
      renal calculi, renal masses, bladder volume, pregnancy and Foley catheter
      evaluation.
    5. Integrate POCUS of the urinary tract into individual patient and departmental
      management.
  2. Core Competency: First Trimester Pregnancy 25 (at least 10 TVUS)
    1. Describe the indications, clinical algorithm, and limitations of POCUS in first- trimester pregnancy pain and bleeding.
    2. Understand the utility of quantitative b-hcg in the evaluation of first-trimester pregnancy pain and bleeding.
    3. PerformPOCUSprotocolsfortransabdominalandtransvaginalviewsas appropriate, including fetal heart rate and gestation age measurement techniques.
    4. IdentifyrelevantUSanatomyincludingthecervix,uterus,adnexa,bladderand cul-de-sac.
    5. Recognize the relevant findings and pitfalls when evaluating for intrauterine and ectopic pregnancy:
      1. Early embryonic structures: gestational sac, yolk sac, fetal pole and heart.
      2. Location of embryonic structures in pelvis
      3. Embryonic demise (fetal pole without heartbeat)
      4. Molar pregnancy
      5. Findings of ectopic pregnancy including pseudogestational sac, free fluid and adnexal masses.
    6. Advanced Evalution: Basic gyn US, ovarian cysts, fibroids, tubo-ovarian abscesses, ovarian torsion, ectopic pregnancy, 2nd and 3rd trimester OB.
    7. Integrate pregnancy POCUS findings into individual patient and departmental management.
  3. Core Competency: Aorta 25
    1. Describe indications, clinical algorithms, and limitations or POCUS in the
      evaluation of abdominal and thoracic aortic pathology.
    2. Perform POCUS protocols to evaluate the abdominal and thoracic aorta including
      measurement techniques.
C. IdentifyrelevantUSanatomyincludingtheaortawithmajorbranches,inferior vena cava, and vertebral bodies.
  1. Recognizepathologicfindingsandpitfallswhenevaluatingforabdominaland thoracic aortic aneurysms and dissection.
  2. Integrate Aorta POCUS findings into individual patient and departmental management.
VIII. Core Competency: Thoracic 25
  1. Describe the indications and limitations of thoracic POCUS
  2. Perform POCUS protocols for the detection of:
1. Pneumothorax, pleural effusion and interstitial lung fluid (CHF, ARDS, pneumonia, pulmonary contusion).
C. IdentifyrelevantUSanatomyofthoracicstructures.
  1. Recognizetherelevantfindingsandpitfallswhenevaluatingforthoracic
    pathology.
  2. Recognize the sonographic findings of tracheal and esophageal anatomy,
    especially in regard to EM procedures.
  3. Integrate thoracic POCUS findings into individual patient and departmental
    management.
  1. Core Competency: DVT 25
    1. Describe the indications and limitations of POCUS for the detection of DVT.
    2. Understand the differences between lower extremity venous POCUS and
      radiology lab-or vascular lab-performed “Duplex evaluation”.
    3. PerformCUSprotocolsforthedetectionofdeepvenousthrombosisoftheupper
      and lower extremities including:
      1. Vessel identification
      2. Compression
      3. Doppler imaging of respiratory variation and augmentation.
    4. IdentifyrelevantUSanatomyoftheupperandlowerextremitiesincludingthe deep venous and arterial systems, major nerves and lymph nodes.
    5. Recognize the relevant findings and pitfalls when evaluating for DVT.
    6. Integrate EUS for DVT into individual patient and department management.
  2. Core Competency: Biliary 25
    1. Describe the indications and limitations of POCUS of the biliary tract.
    2. Perform POCUS protocols to evaluate the biliary tract.
    3. Identifyrelevantultrasoundanatomyincludingthegallbladder,portaltriad,
      inferior vena cava and liver.
    4. Recognizetherelevantfindingsandpitfallswhenevaluatingforcholelithiasisand
      cholecystitis.
    5. Advanced evaluation
      1. Common bile duct pathology (dilation and choledocholithiasis)
      2. Liver pathology (masses, pneumobilia, hepatomegaly)
      3. Portal vein abnormalities
      4. Pancreas pathology
    6. Integrate EUS of the biliary tract into individual patient and department management.
  1. Core Competency: Procedural Guidance 25 (5 for each individual procedure)
    1. Describe the indications and limitations when using US guidance for bedside
      procedures.
    2. Perform POCUS protocols for procedural guidance including both transverse and
      longitudinal approaches when appropriate. Procedures may include:
      1. Vascular Access: Central and Peripheral
      2. Confirmation of endotracheal intubation
      3. Pericardiocentesis
      4. Paracentesis
      5. Thoracentesis
      6. Foreign body detection and removal
      7. Evaluation and aspiration/drainage of body fluid
      8. Arthrocentesis
      9. Pacemaker Placement and capture
      10. Abscess identification and drainage
      11. Regional Anesthesia
    3. IdentifyrelevantUSanatomyforeachprocedure.
    4. RecognizetherelevantfindingsandpitfallswhenperformingPOCUSfor
      procedural guidance.
    5. Integrate POCUS for procedural guidance into individual patients and department
      management.
  2. Core Competency: Ocular 25
    1. Describe the indications, limitations, and relative contraindications of ocular US.
    2. Perform POCUS protocols for the detection of vitreous hemorrhage, posterior
      vitreous detachment, retinal detachment, optic nerve sheath diameter
      measurement, and optic disc evaluation
    3. Advancedevaluation:
      1. Lens pathology
      2. Foreign body
      3. Globe rupture
      4. Retrobulbar hematoma
      5. Central retinal artery/vein occlusion
      6. Subretinal hemorrhage
      7. Light reflex
    4. IdentifyrelevantUSanatomyoftheglobeandorbitalstructures.
    5. Recognize the relevant findings and pitfalls when evaluating for ocular pathology.
    6. Integrate ocular US into individual patient and department management.
  3. Core Competency: Skin/Soft Tissue 25
    1. Describe the indications and limitations of skin and soft tissue POCUS.
    2. Perform POCUS protocols for the evaluation of skin and soft tissue pathology.
    3. IdentifyrelevantUSanatomyincludingskin,adiposeandlymphnodes.
    4. Recognizetherelevantfindingsandpitfallswhenevaluatingthefollowing:
      1. Soft tissue infections: Abscess vs. Cellulitis
      2. Subcutaneous fluid collection identification.
      3. Foreign body location and removal.
E. Integrate skin and soft tissue US findings into individual patient and departmental management.
  1. Core Competency: MSK 25
    1. Describe the indications and limitations of musculoskeletal POCUS.
    2. Perform POCUS protocols for the evaluation of MSK pathology.
    3. IdentifyrelevantUSanatomyincludingtendonsandligaments,muscles,bones,
      and joints.
    4. Recognizetherelevantfindingsandpitfallswhenevaluatingthefollowing:
      1. Tendon injury (laceration, rupture)
      2. Fractures
      3. Joint identification
  2. Core Competency: Abdominal 25
    1. Describe the indications and limitations of bowel POCUS.
    2. Perform POCUS protocols for the detection of:
      1. Acute appendicitis
      2. Small and Large bowel obstruction
      3. Pneumoperitoneum
      4. Diverticulitis
      5. Hernia
      6. Intussusception and Pyloric Stenosis
      7. Evaluation/placement of orogastric/nasogastric or percutaneous
        gastrostomy tube.
    3. IdentifyrelevantUSanatomyofbowelstructures.
    4. Recognizetherelevantfindingsandpitfallswhenevaluatingforbowelpathology.
    5. Integrate bowel US findings into individual patient and departmental
      management.
  3. Advanced Competency: TEE
    1. Describe the indications, limitations and contraindications to resuscitative TEE.
    2. Perform standard TEE views to evaluate for cardiac pathology, guidance of chest
      compressions in cardiopulmonary resuscitation, and procedures, such as
      pericardiocentesis, pacemaker placement, and ECMO catheter placement.
    3. Advancedevaluation:
      1. Regional wall motion abnormalities
      2. Aortic dissection
      3. Aortic aneurysm
  4. Quality Assurance, Obtaining Credit for Residency Graduation
A. Current Process: Completion of intern rotation and 150 signed exams required
for graduation
  1. Goal Process ‘24-’25: 300 signed exams required for graduation, with 25
    in each type desired for credentialing. 10 TVUS and Abdominal exams
    required.
  2. Future Goal: Only exams of adequate quality are counted towards the
    graduation total. This requires re-tooling of QPath and standardization amongst faculty and is not ready for 2024-2025 AY
Asynchronous Curriculum
Week 1: Physics, FAST, Echo, Procedures
Introduction
ACEP POCUS Guidelines - https://tinyurl.com/y2pzdvau Physics and Instrumentation
AEUS Physics lecture- https://vimeo.com/channels/aeus/94786374 FAST
AEUS FAST lecture https://vimeo.com/channels/aeus/34118863
Cardiac
Echo part I - https://vimeo.com/channels/aeus/44570642 Echo part II - https://vimeo.com/channels/aeus/44575412
Inferior vena cava
5minsono.com IVC lecture - http://5minsono.com/ivc/
Procedures
5minsono.com US-Guided IV lecture - http://5minsono.com/ugiv/
5minosono.com CVC placement lecture - http://5minsono.com/cvc/
5minsono.com CVC confirmation lecture - http://5minsono.com/cvc_confirm/ 5minsono.com Pericardiocentesis lecture - http://5minsono.com/pericardiocentesis/ AEUS US-Guided procedures lecture (LP/para/thora) -https://vimeo.com/channels/aeus/59095992
ACEPNow Knee Arthrocentesis article - https://tinyurl.com/yxkyp559
Week 2: Early Pregnancy, Aorta, Renal
First trimester pregnancy
AEUS TAOB lecture - https://vimeo.com/channels/aeus/52830902 AEUS TVOB lecture - https://vimeo.com/channels/aeus/41808262
Abdominal aorta
AEUS Aorta lecture - https://vimeo.com/channels/aeus/41791516 Renal
AEUS Renal Lecture - https://vimeo.com/channels/aeus/69556457
Week 3: Lung, RUSH
RUSH
https://vimeo.com/channels/aeus/216695713
Thoracic
AEUS Thoracic lecture - https://vimeo.com/channels/aeus/46515236 Week 4: Biliary, Ocular, DVT, MSK, Bowel

              
Biliary tract

AEUS Biliary Tract lecture - https://vimeo.com/channels/aeus/87759897

Deep vein thrombosis

AEUS DVT lecture - https://vimeo.com/channels/aeus/52819569

 
Ocular

AEUS Ocular lecture - https://vimeo.com/channels/aeus/41575053

Bowel
AEUS Appendicitis lecture - https://vimeo.com/channels/aeus/93051990;
AEUS Small Bowel Obstruction lecture - https://vimeo.com/channels/aeus/69551555
MSK
MSK AEUS lecture - https://vimeo.com/channels/aeus/41682960
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