Welcome
Welcome to your Intern Ultrasound Rotation! Please read through this guide BEFORE you start your rotation. The goal of this rotation is to introduce you to the core applications of point-of-care ultrasound (POCUS). We have laid out specific objectives for your rotation that are based on the ACEP Policy Statement regarding POCUS educational guidelines in Emergency Medicine. We have made a concerted effort to be focused with our curriculum, but realize there are always ways to improve, and we invite your feedback at the end of the rotation.
Basics
Rotation Director: Laura Wallace, MD
Hours: Monday-Friday 10a-7p (2p-7p Tuesday)
Sites: Barnes-Jewish Hospital Emergency Department (and SLCH EU)
Duties: Perform POCUS examinations on ED patients as requested by the treating teams. All scans will be reviewed in real-time by a credentialed attending physician as well as during a weekly Image Review Session
Duration: 1 full block (26 days)
Orientation: First day of the rotation, usually 12:00, 8th floor offices
Image review and proctored scanning: Monday at 12:00, 8th floor offices
Educational Resources: POCUSHUB.com, texts listed at bottom of this document
Evaluation: By the Rotation Director, based on clinical demonstration of image acquisition and interpretation during scan shifts, meeting rotation objective
Rotation/course director evaluation: At the end of the rotation, you will be sent a questionnaire regarding your impression of the rotation, including strengths, weaknesses, and areas for improvement.
Schedule
Hours
Your hours are 10am-7pm Monday through Friday. You are excused for Tuesday conference and lunch, and journal club.
Unless at conference or previously approved absence, interns are expected to be in the ED available by phone and scanning during these hours (please break to eat lunch at some point).
Emergency Absences
Please notify your admin chief and Laura Wallace (lauraawallace@wustl.edu or 513-460-5950) by email 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 Dr. Wallace and will likely need to be made up in your off hours.
Important days
Orientation Day: Usually the first weekday of your rotation, meet on the 8th floor. Contact Dr. Wallace before your rotation starts to confirm your orientation.
QA: Weekly, usually Monday at noon. Meet in the 8th floor Barnard offices unless we plan otherwise. We will review your scans from the week (see US documentation).
Daily Routine (M-F, 10-7)
On arrival, add your work phone number to the EPIC “Message Log” and ask to be put on the trauma pager so you can go to level one traumas.
When you arrive or when you have time during the day, it is good to check that all the machines are there, working and have all their probes. If you discover a problem with any of the ultrasound machines, please ask the charge nurse to put in a work order for the machine. It will also make your day flow smoother if you restock the cart on the ultrasound machine at the beginning of each of your shifts.
The flashcards (available for download at pocushub.com) are a great reference for the ultrasound machines and scanning expectations. Refer to them first!
Rotation objectives
Core objectives:
1. Describe the differences between the 4 transducer types and their ideal applications.
2. Describe the differences between shadowing, reverberation, posterior enhancement, and mirror artifacts.
3. Demonstrate the location of transducer placement and orientation for the E-FAST exam.
4. Demonstrate the 4 basic windows for focused cardiac ultrasound.
5. Describe how to assess ejection fraction/cardiac contractility.
5a. Describe the appearance of a pericardial effusion on cardiac US
6. Demonstrate the technique for assessing the volume status of the IVC with ultrasound.
7. Describe the appearance of pleural effusion on lung US.
8. Identify B-lines and describe their clinical significance.
9. Identify and describe common renal ultrasound findings including hydronephrosis, simple cyst, and complex cyst.
10. Demonstrate the technique for evaluation of early pregnancy via transabdominal and transvaginal approaches.
11. Identify and describe the differences in appearance between soft tissue cellulitis and abscess.
12. Demonstrate the technique for evaluation of biliary pathology, including cholelithiasis, cholecystitis, and choledocholithiasis
13. Describe the technique for evaluation of abdominal aorta pathology.
14. Demonstrate the technique for evaluating for an abdominal fluid pocket for paracentesis.
15. Successfully place 5 ultrasound-guided peripheral IV catheters.
Reach objectives:
1. Describe common pathological findings on ocular US.
2. Demonstrate the complete lower extremity DVT evaluation (2-region/3-point or whole leg).
3. Describe the ultrasound findings of appendicitis.
4. Describe the technique for ultrasound-assisted lumbar puncture.
5. Demonstrate correct technique for US guided arthrocentesis.
Basic Workflow
Basic steps for each scan
- Turn on the ultrasound machine.
- Select your ultrasound probe.
- Select Exam Type (abdominal, cardiac, nerve etc presets)
- Press Patient Info and then Workflow, select the correct patient from the list. (If the patient is not in the list, enter their name and birth date so they can be merged in QPATH later)
- Enter resident WustlKey for READING DOCTOR and attending Wustlkey for REFERRING DOCTOR.
- Type in a label if needed.
- Scan some things! Remember to adjust depth and gain, add pressure or gel to maximize image quality.
- Save your image or clip and repeat, changing labels as needed.
- Press New/End to close your exam (which will automatically upload the exam to QPATH).
- 10. Document your scan in QPATH (QPATH workflow on pocushub.com
There is a log to download on POCUSHUB.com to keep track of your scans. Please make sure your log is filled out prior to QA each week.
Every time you do an ultrasound, you should save at least one image and write a note. This includes procedure (save a picture of the vessel you’re aiming for). Some exams will be inconclusive or incomplete, and some exams will be just for teaching purposes, but they should all at least one clip saved and have a note in the chart.
For incomplete/inconclusive scans (eg. pt taken to CT before FAST was completed or unable to get a complete RUQ view): document your findings and note which parts were incomplete and why.
Oversight
Every scan (even educational) must have images saved and an attending name attached. The attending in the pod must be aware and agree to attest BEFORE you begin an ultrasound. Every procedure, including ultrasounds and peripheral IVs, must be signed off by an attending, and they all have varying comfort levels of procedural oversight. NPs and PAs are not credentialed for ultrasound, so if you are asked to scan one of their patients, you must find an appropriate attending to attest to your scan BEFORE you do it. There are a few attendings that are not credentialed with ultrasound so they may refer you to someone else to attest to your images. If you are asked by a nurse to place an IV in the protocol room, find the swing attending, triage attending, or someone that is willing to attest to your procedure BEFORE you do it.
Furthermore, if you are not familiar with an exam, ask the attending to come perform the exam with you. If they are unable to perform the exam with you, then inform them it will need to be a teaching exam if you have not been formally trained in that particular application.
There are flash card guidelines in the pods and downloadable at POCUSHUB.com. You can use these to help when you are not sure where to start.
Educational/Teaching scans
Don’t wait for phone calls. If it is slow, drum up business for yourself by walking around to the different pods and offer up your skills. It is great to practice ultrasounds for educational purposes, if the patient and attending agrees. Please always ask the attending before you can do a teaching exam - they will have to attest to your exam and may be too busy.
You should still save images and write a note in the chart. If you select “educational” in the QPATH note, the images and note will not transfer over to EPIC and the patient will not be charged for the scan.
Prioritizing
You will sometimes get so many calls you can’t get to them all. You are not expected to perform every ultrasound in the ED. Make a good effort, but be honest when someone asks you to do a scan: if you already have 3 scans to do, let the team know you will be a long time before you can get there and they should consider doing it themselves.
If you are asked to do an “urgent" scan and you are busy, let the team know you cannot come just then and they will need to do it themselves. Keep in mind that often these ‘emergent’ scans have great learning potential. In the same vein, you should not stay late just for scanning. It is okay to stop taking calls early if you are behind on the scans you have already been asked to do.
You should always make time to eat lunch and do interesting educational scans. You are there to learn ultrasound, not be a workhorse.
If someone gives you a hard time or insists that you do their scan first because the patient is sick, remember you are the intern-they can ultrasound at least as well as you. The ultrasound section will always support you! If you have any problems, please email Laura Wallace quickly so that it can be addressed.
Procedures
Even if a senior resident is teaching you, you must let the attending know before you start. If you have any doubts or feel uncomfortable, please speak up!
IV
IV placement is likely the most common call you will receive. Although you do need to learn how to place peripheral IVs, you are not there to do other people’s work. If a nurse calls and asks you for an IV, you should ask the following questions:
- 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)
Obstetric Ultrasound
A few tips:
- Tell the patient before you begin that it is possible the pregnancy is too early, so if you are unable to find an IUP, they may need a vaginal ultrasound. This can help reassure the patient if you are unsure what you see.
- ALWAYS perform a transABDOMINAL ultrasound before a transVAGINAL ultrasound, even if another provide has attempted a transabdominal before you. This will help you understand the pathology / anatomy you are going to scan. Sometimes, you can prevent the transvaginal with your awesome ultrasound skills!
- You MUST be supervised for transVAGINAL scans by an attending. This is to prevent repeat scanning. You should never be asked to do a transvaginal ultrasound without an attending present.
- Do NOT tell the patient they have had a miscarriage if you are not certain or have not established a relationship with them. Discuss with the primary team how information should be disclosed with the patient before the scan.
- Unless you are 100% positive that you see a YOLK SAC or FETAL POLE IN THE UTERUS, every pregnancy should be considered ectopic until proven otherwise. Any patients with positive pregnancy tests but no confirmed intrauterine pregnancy should have OB consulted for evaluation and follow up planning.
Often you may be asked to participate in procedures, or even get an opportunity to participate in interesting cases just because you are nearby. That is okay as long as you are not missing ultrasounds to do so. If you are asked to do a procedure (like a paracentesis) but you have other ultrasounds to do, you should pass. It is nice to be helpful, but your main goal is to learn ultrasound not be the procedure resident.
Image Review
Mondays at noon with Dr. Wallace, unless otherwise directed
Meet in the 8th floor offices
During Image Review each week, we will be looking through all the images you saved form the week before to confirm your findings and improve your ultrasound skills. Keep close track of all the scans you performed, the indications for the scans and how you interpreted the images. Before Image Review each week, fill out the log sheet including. The more organized you are beforehand, the faster QA will go and the more time we will have to scan together!
Medical Students
There may be a 4th year medical student with you for an ultrasound elective for some or all of the month. These students are given your work phone number and should contact you to meet up in the mornings. It is not your job to keep track of the students, wait around for them, or police their attendance. It is helpful if you exchange information with them and keep them updated if you have an emergency absence or QA time gets changed.
As you become more proficient in scanning, you can walk the students through ultrasounds or have them get started without you on easier scans. They really appreciate your teaching.
In addition, there may be single days when medical students on an EM elective join you. It is still not your job to keep track of the students, wait around for them, or police their attendance. The students who are only present for one day are expected to shadow. Feel free to include them however is useful.
Sometimes, students move around their scanning days and this is not communicated to the US faculty. Just be flexible and teach the students when you can.
Problems:
If you ever have any questions or concerns, please bring them to Dr. Wallace, Dr. Theodoro, Kiesha (Ultrasound Division Admin) or the ultrasound fellows. Dr. Wallace is your primary contact. If it is an emergency, you can always page the Chief pager. We will do our best to address any concerns or problems you have.
Laura Wallace: (text or email 24/7, if I don’t respond I am probably sleeping but will respond when I wake up)
513-460-5950 (cell, prefer text)
lauraawallace@wustl.edu
Dan Theodoro (US Division Chair)
314 322 9250 (cell, prefer text)
theodorod@wustl.edu
Kiesha Cleark (US Division Admin)
kiesha.cleark@wustl.eduIntern Reading Curriculum
Week 1: Physics, FAST, Renal, Procedures
Week 2: Skin & Soft Tissue, Early Pregnancy, Aorta
Week 3: Cardiac, Lung, RUSH, Shock
Week 4: Biliary, Ocular, GU, DVT, MSK, Bowel
Please choose a reading reference. I recommend the free iBooks Introduction to Bedside Ultrasound Volume 1 & 2 (Matthew Dawson and Mike Mallin). If you do not have an Apple product, Manual of Emergency and Critical Care Ultrasound by Vicki Noble and Bret Nelson is available for free on the Becker Library website. www.jeffsono.org/curriculum also has recommendations.
The videos below are between 5-20ish minutes long, so should be fairly easily digestable, and for some you may be able to watch them while on rotation in between calls for scans.
Introduction
ACEP POCUS Guidelines - https://tinyurl.com/y2pzdvau
Physics and Instrumentation
AEUS Physics lecture- https://vimeo.com/channels/aeus/94786374
Trauma
AEUS FAST lecture https://vimeo.com/channels/aeus/34118863
First trimester pregnancy
AEUS TAP lecture - https://vimeo.com/channels/aeus/52830902
AEUS TVP lecture - https://vimeo.com/channels/aeus/41808262
Abdominal aorta
AEUS Aorta lecture - https://vimeo.com/channels/aeus/41791516
Cardiac
Introduction to Bedside Ultrasound, Volume 1, Chapter 2: Basic Cardiac
Inferior vena cava
5minsono.com IVC lecture - http://5minsono.com/ivc/
Biliary tract
AEUS Biliary Tract lecture - https://vimeo.com/channels/aeus/87759897
Urinary tract
AEUS Renal lecture - https://vimeo.com/channels/aeus/69556457
Deep vein thrombosis
AEUS DVT lecture - https://vimeo.com/channels/aeus/52819569
Soft tissue and MSK
Introduction to Bedside Ultrasound, Volume 2, Chapter 10: Soft tissue
AEUS MSK lecture - https://vimeo.com/channels/aeus/41682960
Thoracic
AEUS Thoracic lecture - https://vimeo.com/channels/aeus/46515236
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
Procedures
Introduction to Bedside Ultrasound, Volume 2, Chapter 9: 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 artcle - https://tinyurl.com/yxkyp559
FINAL THOUGHTS
We hope this rotation is a valuable experience for you. We have tried to develop a well-rounded curriculum covering all core aspects of POCUS. However, much of the rotation is self-directed--you will get out of it what out you put into it. Additionally, if there is any topic you want more exposure to (e.g. ultrasound-guided PIVs, advanced transthoracic echo) please let us know and we will make an effort to accommodate you. Now, go scan your face off!
We hope this rotation is a valuable experience for you. We have tried to develop a well-rounded curriculum covering all core aspects of POCUS. However, much of the rotation is self-directed--you will get out of it what out you put into it. Additionally, if there is any topic you want more exposure to (e.g. ultrasound-guided PIVs, advanced transthoracic echo) please let us know and we will make an effort to accommodate you. Now, go scan your face off!
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