NYP Emergency Ultrasonography Curriculum: Education, Patient Care & Research

Basic and Advanced Emergency Ultrasonography Applications

The emergency ultrasound curriculum will start with a full 2 day class given during the first year of residency training. The class will cover all of the primary and many of the advanced indications for emergency ultrasound as outlined by the American College of Emergency Physicians (ACEP ). Residents will become adept at each of these uses of ultrasound through the experience of performing multiple directly supervised exams over their four year training program.

1. Trauma Ultrasound:
   Residents will learn the standard four view focused abdominal sonography for trauma (FAST) exam in order to optimally facilitate trauma care. This exam includes the right hepatorenal, left perisplenic, suprapubic/pelvic and cardiac views. The primary goal of the FAST exam is to detect free fluid within the abdomen, pelvis and pericardial sac. Residents will also learn how to perform the newly developed expanded FAST (e-FAST) exam for evaluation of the thoracic cavity. The primary goals of the e-Fast exam are to detect pneumothoraces and pleural cavity free fluid.


2. OB/GYN:
   Residents will learn transabdominal and transvaginal sonographic approaches for OB/GYN sonography. The primary goal of first trimester OB/GYN sonography is the detection of intrauterine pregnancy defined as yolk sac or more. In addition, the Endo-Myometrial Mantle (EMM) must always be measured and documented (should be greater than 8mm) to evaluate for possible interstitial ectopic pregnancy. Advanced goals of first trimester OB/GYN sonography include evaluation of the adnexae and detection of ectopic pregnancy. The importance of checking for intra-abdominal and pelvic fluid with a FAST exam will also be stressed.


3. Emergency Echocardiography:
   The primary goals of bedside echocardiography include the detection of pericardial effusions, cardiac standstill in the presence of cardiac arrest / pulseless electrical activity (PEA) and gross determinations of left ventricular cardiac contractility. The use of emergency bedside cardiac ultrasound to better guide appropriate care during shock states and resuscitations will be emphasized. Advanced goals of bedside echocardiography include evaluation of the heart for signs of cardiac tamponade, with diastolic collapse of the right ventricle, if a pericardial effusion is diagnosed. Residents will also learn how to map out pericardial effusions using sonography to determine the optimal route for emergent pericardiocentesis. Additional advanced echo techniques will also be covered during the curriculum, including determination of right ventricle strain suggestive of pulmonary embolus. Finally, residents will learn to evaluate the inferior vena cava through the respiratory cycle to gain a rough gauge of patient volume status.


4. Abdominal Aortic Aneurysms:
   Training will be given in the examination of the entire abdominal aorta from diaphragm to the bifurcation of the iliac arteries. The primary goal of bedside aorta ultrasound is to recognize the presence of an abdominal aortic aneurysms defined as an aorta greater than 3 cm in diameter and iliac arteries greater than 1.5 cm in diameter.


5. Hepatobiliary:
   The primary goals of bedside gallbladder sonography are the evaluation for gallbladder stones, measure the anterior GB wall (normally less than 3mm) and assessment of the sonographic Murphy's sign. Advanced goals include detection of the secondary signs of cholecystitis and cholangitis such as common bile duct enlargement (greater than 6mm) and pericholecystic fluid.


6. Genitourinary:
   The primary goals of GU bedside ultrasound are the evaluation of obstructive uropathy and acute urinary retention. Both kidneys will be assess for hydronephrosis and the assessment of bladder size. Advanced goals include evaluation for kidney stones and other renal pathologies.


7. Vascular Ultrasound:
   The use of ultrasound to guide both peripheral and central venous vascular access will be emphasized. Residents will learn to use ultrasound to aid in placement of central lines in the internal jugular, subclavian and femoral veins in order to minimize the risk of these procedures to patients. Ultrasound guided peripheral venous access to the basilic and brachial veins of the arm will also be taught.


8. Thoracentesis, Paracentesis and Lumbar Puncture:
   Ultrasound will be used to first detect the presence of pleural effusions and ascites amenable to a drainage procedure. Residents will then learn ultrasound guided approaches to facilitate the procedures of thoracentesis and paracentesis in order to minimize risks to the patient. Ultrasound guided lumbar puncture will also be taught.


9. Foreign Body Detection:
   Ultrasound will be used to detect radiolucent foreign bodies that may be difficult to visualize with plain radiography. Ultrasound guided techniques to remove foreign bodies will also be covered in the curriculum.


10. Cellulitis and Abscess:
    Residents will learn to evaluate the soft tissues for fluid collections in order to allow for better diagnosis of abscess and differentiation from cellulitits. Residents will also learn to evaluate the tonsils for peritonsillar abscess requiring drainage.


11. Deep Venous Thrombosis:
    Residents will learn the limited DVT screening exam focusing on evaluation of the proximal common femoral vein, greater saphenous and superficial femoral veins down to the proximal popliteal vein down to trifurcation. Analysis of the compressibility of the vessel with direct pressure of the probe will be taught as a means to diagnose a deep venous thrombosis.


12. Musculoskeletal:
    Residents will learn how to use ultrasound to analyze joints for the presence of effusions. Ultrasound guided approaches to arthrocentesis will be taught. Residents will also learn how to use ultrasound to examine tendons and ligaments for disruption/rupture. Finally, residents will be taught how to use ultrasound to diagnose fractures.


13. Ocular Ultrasound:
    Residents will have the opportunity to learn ocular ultrasound with the primary goal of diagnosing posterior chamber and orbital pathology such as retinal detachment, vitreous hemorrhage, and disruptions of structures. Residents will also learn how to evaluate for increase in intracranial pressure by measuring the optic nerve sheath diameter.


14. Pediatric Applications:
    Residents will learn ultrasonography applied to children with a focus on abdominal pathology: appendicitis, pyloric stenosis, inguinal hernia and intussusception.


15. Other Advanced Applications:
    Residents will learn basic techniques of testicular ultrasound helpful in diagnosis of pathology in this organ. Ultrasound guided nerve blocks will also be taught. Finally, the RUSH (Rapid Ultrasound in Shock) examination will be taught as a synthesis of emergency focused echocardiography, evaluation of intravascular volume status and of arterial ruptures (aortic dissection and aortic aneurysms) and deep venous thrombosis, to help determine potential causes of undifferentiated shock states.

Continuing Emergency Ultrasound Education / EM Resident Credentialing Pathway:

Submission of Ultrasound Scans:

Residents will submit 150 ultrasound exams for analysis to the ultrasound directors. Optimally, the ultrasound exams should be divided 25 each among the primary indications for ultrasound as listed above. Ultrasound books with NYP Ultrasound Data Sheets and QA Forms are present in the Emergency Departments at both Columbia and Cornell for residents to post their ultrasound images for review. Completely fill out the data requested on the NYP Ultrasound Data Sheets and QA Forms and attach the ultrasound images to the back. Stapling the images to the back in a manner that will help the reviewers visually evaluate the scans will be helpful. If an EM Attending directly supervised your ultrasound scan, include their name on the submission sheet (many faculty are completing the same credentialing pathway). Submit Columbia scans in the books located in the wall racks in the individual clinical areas. Submit Cornell scans in the ultrasound book located in the ED Physician's room. NYP Ultrasound Data Sheets and QA Forms are available to download on Teamsite under documents.

Initial Resident QA of Submitted Ultrasound Scans:

Optimally, residents should hold on to their ultrasound submission sheets with attached images for a few days after performing the exam. They should then check the patient's electronic medical record to review if a confirmatory imaging study was ordered. The date and results of any confirmatory study should be written on the bottom of the ultrasound submission sheet. This allows for immediate feedback on the accuracy of the resident performed ultrasound and is a valuable teaching tool. Residents should also strive to submit their scans within 2 weeks after the time the scan was performed. This will avoid inappropriately late submissions of scans that can decrease the ability to perform QA in a timely manner. Resident performed QA and adherence to the above guidelines is MANDATORY, and ultrasound Directors will only review submitted scans that have formal official results written on the form. Reviewed scans will subsequently be logged into a database and then placed into each resident's personal ultrasound file.

Faculty / Resident Review of Submitted Ultrasound Scans:

All residents will have a yearly MANDATORY ultrasound feedback session to review their progress, establish goals and improve ultrasonography skills. Residents will find their personal ultrasound files in Dr. Carter's office at the Columbia Campus of NYP Medical Center. They will then have the opportunity to review comments made on their submitted ultrasound scans. Residents will be expected to review their ultrasound books periodically each year and meet with Ultrasound Directors to identify areas of improvement in their ultrasound techniques. It is crucial that residents make the effort to review their submitted scans for comments so that they can fully take advantage of the ultrasound curriculum offered at NY Presbyterian Hospital.

Completion of Ultrasound Training is a Prerequisite to Graduation

Residents who have not achieved the required submission of 150 ultrasound scans by the fourth year of training will be required to spend additional time in the Emergency Department performing ultrasonography. This time will be taken from the elective time available to each resident. Proficiency in ultrasound as defined by the above standards is a prerequisite for graduation from the NYP Emergency Medicine Residency.

Emergency Resident Ultrasound One Month Elective:

All residents are strongly advised to complete an elective in bedside emergency ultrasound during their senior years to further improve their ultrasound skills and knowledge. Residents will work directly in the clinical areas under the direct supervision of the ultrasound faculty at Columbia and Cornell.

This one-month rotation is for our fourth year residents who want to refine their skills in EM ultrasound and learn more advanced and in-depth materials in EM ultrasound. As an option, residents who are interested in obtaining the Registry of Diagnostic Medical Sonography (RDMS) certification in the future, will be given guidance in achieving this status.

EM Resident Ultrasound One Month Elective Curriculum:

Senior EM Residents Serve as Faculty for Yearly NYP Ultrasound Class:

Fourth Year EM Residents will serve as faculty for the workshop portions of the Annual NY Presbyterian Emergency Ultrasound Class. They will have the chance to solidify both their ultrasound knowledge base and their teaching skills through this experience. Incoming Chief Residents will be part of the key organizers of the event and are requested to attend all the planning meetings.

Emergency Ultrasound Credentialing:

In addition to the above requirements, residents are expected to attend the Wednesday Conference ultrasound lectures unless other EM Residency requirements conflict. Successful completion of the above requirements will allow for residents to receive a certificate of accomplishment as outlined by the ACEP ultrasound training criteria on graduation from the NYP Emergency Medicine Residency. Each resident will be able to use this certificate towards hospital credentialing in bedside emergency ultrasound at their future jobs.

Emergency Ultrasonography Conferences

Continuing ultrasound education will be emphasized during the Grand Rounds Wednesday lecture series with dedicated ultrasound conferences given each year. The conferences will reinforce the material covered in the Annual EM Ultrasound Class as well as covering advanced topics. Review of submitted resident ultrasound scans will be included as part of the conference curriculum.

Web Based Ultrasound Education:

Free ultrasound teaching videos are now available at www.cmedownload.com for ongoing resident education.

Additional sources of web-based ultrasonography education include:

ACEP Ultrasound Resources: www.acep.org/practres.aspx?id=32182

Neuraxium Ultrasound Guided Nerve Blocks: www.neuraxiom.com/
Ultrasound Guide for Emergency Physicians: www.sonoguide.com/introduction.html

Basic Ultrasound Echocardiography and Doppler for Clinicians: http://folk.ntnu.no/stoylen/strainrate/Ultrasound/

Emergency Ultrasound Exam: www.emsono.com/acep/exam.html

Sonographic Assessment of the Adnexa: www.gehealthcare.com/usen/education/proff_leadership/products/msucmeov.html

ICU Sonography: http://www.criticalecho.com/

Virtual TEE: http://pie.med.utoronto.ca/TEE/TEE_content/TEE_standardViews_intro.html#quickstart

Stanford Echo in ICU: https://www.stanford.edu/group/ccm_echocardio/cgi-bin/mediawiki/index.php/Main_Page

Heart Gross Anatomy: http://www.rjmatthewsmd.com/Definitions/anatomy_ofthe_heart.htm

Echo by Web: http://www.echobyweb.com/htm_level2_eng/formulas&calculations.htm

Critical Ultrasound Journal: http://springerlink.com/content/121538

Emergency Ultrasonography Research:

Residents will be encouraged to consider selecting a topic in ultrasound research as their required EM Residency research project. Opportunities for emergency ultrasound research in the Adult and Pediatric Emergency Departments at NY Presbyterian will be offered. Interested residents should speak directly to the ultrasound directors and Dr. Riley to discuss potential ED ultrasonography research projects.

Current ED Ultrasonography Research Projects include:

1. Emergency Department Real Time Cannulation of the Internal Jugular Vein on the First Attempt: Ultrasound-Guided Short-Axis vs. Long-Axis Method
2. Emergency Department Optimization of First Attempt Femoral Vein Catheterization: Ultrasound-Guided Short-Axis vs. Long-Axis Technique
3. Emergency Department Physician Evaluation of the Lower Extremity Greater Saphenous Vein and Deep Venous Thrombosis
4. Emergency Department Physicians and Nurses Optimizing Antecubital Vein Catheterization on the First Attempt: Ultrasound-Guided Short-Axis vs. Long-Axis Approach

Selected NYP Emergency Ultrasound Faculty Publications:

Aguilera, P, Durham, B, Riley, D: Emergency transvenous cardiac pacing placement using ultrasound guidance. Annals of Emerg. Med. 2000: 36(3); 224-27.

Perera, P, Mailhot, T, Riley, D, Mandavia, D: The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. EM Clinics North Am. 2010: 28; 29-56.

Riley DC, Cordi H: Emergency department diagnosis of mitral stenosis and left atrial thrombus using bedside ultrasonography. Academic EM: Internet video case and discussion. 2010: 17(5); e30-31.

Riley DC, Rezvankhoo, K, Yi, DH: Emergency department diagnosis of submassive pulmonary embolism using bedside ultrasonography. Academic EM: Internet video case and discussion. 2010: 17(7); e78-e80.

Riley DC, Gerson, S, Arbo, J: Emergency department right atrial pressure estimation using right ventricular tissue doppler bedside ultrasonography. Critical Ultrasound J: Internet video case and discussion. 2010: 2; 31-33.

Riley DC, Thayil C, Anthony DR: Emergency department diagnosis of massive pleural effusion causing right ventricular diastolic collapse using bedside ultrasonography. Critical Ultrasound J: Internet video case and discussion. 2010: 2; 35-37.

Riley DC, Glassman G, Hodges K: Emergency diagnosis of critical aortic stenosis using bedside ultrasonography. Critical Ultrasound J: Internet video case and discussion, accepted for publication-2010.

Kwon, A, Riley, D: Chapter: Bedside FAST Ultrasonography: Focused Assessment with Sonography for Trauma, Textbook: Essential Emergency Trauma, Shah, K, Egan, D, Quaas, J; Lippincott, 2010.

Riley, D: Section Editor on General Emergency Ultrasonography, Textbook: Handbook of Emergency Medicine Procedures, Shah, K , Mason, C; Lippincott, 2007.

Kwon, A, Riley, D: Chapter: Bedside FAST Ultrasonography: Focused Assessment with Sonography for Trauma, Textbook: Handbook of Emergency Medicine Procedures, Shah, K, Mason, C; Lippincott, 2007.

Riley, DC: Geriatric emergency ultrasonography: rule out the “four killers”. Topics in Emergency Medicine. 2001: 23(3); 30-38.

Senior Medical Student Elective in Emergency Ultrasound:

NYP EM Residency and the Columbia University College of Physicians and Surgeons offers a month long senior medical student elective in bedside emergency ultrasound. One to two medical students per month will rotate through the Emergency Department at Columbia University Medical Center with the aim of learning bedside emergency ultrasound and improving the care of patients presenting to the Emergency Department. Residents will be expected to help teach medical students during their shifts.

Further Ultrasound Resources:

Textbooks on ultrasound will be present in the Emergency Medicine Libraries at Cornell and Columbia. Residents can purchase their own copies at Barnes and Noble or at the ACEP Bookstore.All are welcome to read the ultrasonography textbooks in Dr. Riley's office at Columbia.

Core Textbook for NYP EM Ultrasound:M

Emergency Ultrasound. O. John Ma and James R. Mateer. McGraw Hill Publishing. 2007.
An excellent text that has been the foundation of many EM ultrasound curriculums around the country for years. Nice images with helpful commentary. Highly recommended. Includes an instructional DVD.