Tag Archives: education

ACEP National Faculty Teaching Award

The American College of Emergency Physicians awarded its annual National Faculty Teaching award in Seattle this year during the Academic Affairs committee meeting.

Bret Nelson, Director of the Emergency Ultrasound Division at Mount Sinai, was one of four faculty honored nationally.

NFTA group 500x332 ACEP National Faculty Teaching Award

Left to right: Federico E. Vaca, MD, MPH; Vicken Y. Totten, MD, MS, FACEP; Bret P. Nelson, MD, RDMS, FACEP; Yashwant Chathampally, MD, MS

According to ACEP,

The American College of Emergency Physicians sponsors a national faculty teaching and junior faculty teaching award to honor outstanding educators in emergency medicine. These awards are designed to support emergency medicine faculty in their efforts to achieve academic advancement, as well as support the continued academic development of the specialty. The awards recognize superior teaching activities including didactic lectures, clinical instruction, the development of innovative educational programs, as well as the endorsement by faculty, residents, and students.

Left to right: Kim Poh

2013 Ultrasound Fellow Graduation

We were proud to graduate three ultrasound fellows this year:

  • Kim Poh Chan, our international fellow who will return to Singapore and head up a new ultrasound program
  • Daniel Lakoff, who will co-direct the ultrasound program at Elmhurst Hospital, and
  • Ee Tay, our first pediatric emergency ultrasound fellow, who will remain at Sinai
ChanLakoffDuqueNelsonSanghviTayGraduationDiplomas 500x375 2013 Ultrasound Fellow Graduation

Left to right: Kim Poh Chan, Daniel Lakoff, Danny Duque, Bret Nelson, Amy Sanghvi, Ee Tay

AAMC article

logo aamc.gif data AAMC articleThe Association of American Medical Colleges (AAMC) has written an article about ultrasound education at the medical school level. In the current edition of their widely distributed publication The Reporter, they describe programs at the University of South Carolina School of Medicine, University of California (Irvine) School of Medicine, and the Mount Sinai School of Medicine.

The article notes,

With rapid advancements in ultrasound technology, such scenarios as this are becoming more commonplace, as a handful of the nation’s medical schools make ultrasound training a standard part of the curriculum. And there is a push to encourage more schools to use ultrasound.

The full article is available here.

Lung Ultrasound Pitfalls

US lung consolidation Tsung 500x514 Lung Ultrasound PitfallsThoracic sonography is one of the most rapidly growing areas of emergency and critical care ultrasound. One very important emerging indication is to assess for lung consolidation. The characteristic appearance of consolidated lung is very sensitive and specific for pneumonia, but novices should heed some important pitfalls in making the diagnosis.

Special thanks to Jim Tsung, MD, MPH and Brittany Jones, MD for their tips, videos, and ongoing research in this important field! For further reading on this topic, please see this article.

Pitfall #1 – confusing thymus for a consolidation

Normal thymus in sagittal view:

Thymus (top half of screen) and heart (bottom right). Don’t confuse thymus for lung consolidation. Note there are no air bronchograms, but thymus has a faint speckled appearance.

Normal thymus in transverse view:

Thymus (top half of screen) and heart (bottom right). Don’t confuse thymus for lung consolidation. Note there are no air bronchograms, but thymus has a faint speckled appearance
Pneumonia adjacent to Thymus in transverse view:

Lung consolidation with air bronchograms (top left) adjacent to normal thymus (speckled appearance on top right) with heart (bottom right)

Pitfall #2 – mistaking spleen for consolidation.

This is an important pitfall for everyone to know about. The same issue applies to the liver & stomach. The sensitivity of lung US for pneumonia rises >90% if this mistake is avoided.

Left lower chest- sagittal view:

Be careful scanning the left lower chest (left anterior and left axillary line) – air in stomach and spleen may look like pneumonia if you don’t realize that you have scanned inferior to the diaphragm and past the end of the pleural line. Most common error by novices.

Left lower chest- transverse view:

Be careful scanning the left lower chest (left anterior and left axillary line) – air in stomach and spleen may look like pneumonia if you don’t realize that you have scanned inferior to the diaphragm and past the end of the pleural line.

Pitfall #3- missing pleural effusion

Here are a few examples to refresh your memory.

Left pleural effusion:

Identify:

  • Pleural effusion (anechoic wedge just beneath ribs and pleura)
  • Lung
  • Diaphragm
  • Spleen
  • Air in stomach

Do not confuse spleen and air in stomach for pneumonia.

Right pleural effusion:

Identify:

  • Pleural effusion
  • Lung
  • Diaphragm
  • Liver

Core-Renal Ultrasound

kidney beans 300x300 Core Renal UltrasoundThis core didactic session recap is devoted to renal ultrasound. Point-of-care ultrasound uses focused clinical questions to guide management, and our didactic session use focused clinical questions to guide discussions of key literature.

Discussants Vincent Roddy and Phillip Andrus led our group through a series of questions which bring the relevance of renal sonography home.

1. Can the degree of hydronephrosis predict stone size?

In an word, yes. In a retrospective study of 177 patients with documented stones on CT scans, ultrasonographers blinded to the CT results were able to predict stone size (>5mm or <5mm) based on the degree of hydronephrosis observed (1).

Hydronephrosis was defined as mild, moderate, severe

  1. Mild: Enlargement of calices with preservation of renal papillae
  2. Moderate: Rounding of calices with obliteration of renal papillae
  3. Severe: Caliceal ballooning with cortical thinning

Results:

Increasing degree of hydro associated with increasing proportion of ureteral calculi > 5mm (p < 0.001)
Take-home points:

  • Stone size is an important predictor of stone passage and clinical outcome; < 5mm likely to pass regardless of location
  • Current guidelines recommend triage of “medical expulsion therapy” for calculi between 5 and 10 mm; > 10mm often require surgical removal
  • Ultrasound sensitivity for detection of stones greater than 5mm is poor. With severe hydro over one-third had stones over 5mm and one third of THAT group had caliculi larger than 10mm (2)

References:

  1. Goertz JK, Lotterman S. Can the degree od hydronephrosis on US predict kidney stone size? Am J Emerg Med 2010; 28:813-6.
  2. Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the mgmt of ureteral calcul. J Urol 2007; 178:2418-34.

2. Should the bladder be included in the renal scan?

Yes – rapid ED renal ultrasound including images of the bladder might exclude distal obstruction and allows clinicians to focus on other diagnoses (1).

Ultrasound of the bladder also allows for the evaluation of the presence of “ureteral jets.”  Although clinically utility is debatable, a unilaterally abnormal ureteral jet can be suggestive of high-grade obstruction on the ipsilateral body side.  Ultrasound is useful in making this determination, though it is limited in its ability to determine stone location.  It is important to note that  normal ureteral jets cannot be used to exclude a diagnosis of renal colic.  (2).

References:

  1. Wakins S, Bowra J. Validation of EP Ultrasound in Diagnosing hydronephrosis in ureteric colic. Emergency Medicine Australasia (2007) 19, 188-195.
  2. Sheafor D, Hertzberg B, et al. Nonenchanced Helical CT and US in the Emergency Evaluation of Patients with Renal Colic.

 

3. Can Emergency Physicians accurately diagnosis hydroneprhosis on bedside ultrasonography?

Yes, numerous studies have documented that ultrasound can accurately predict the degree of hydronephrosis as compared to that on CT scans (1-2) and that the degree of hydronephrosis is related to stone size (3).

References:

  1. Gaspari RJ, Horst K. Emergency Ultrasound and urinalysis in the evaluation of flank pain. Acad Emer Med 2005; 12:1180-4.
  2.  Watkins S, Bowra J, Sharma P, Holdgate A, et el. Validation of EP ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australas 2007; 19:188-95.
  3. Goertz JK, Lotterman S. Can the degree od hydronephrosis on US predict kidney stone size? Am J Emerg Med 2010; 28:813-6.

Angles for Doppler

A prior post discussed the optimal imaging angle for 2D scanning.

Quick quiz: what is that angle?
45 degrees
90 degrees
180 degrees
360 degrees

In this post we’ll illustrate the optimal imaging angle for Doppler evaluation. Let’s start with basic Doppler physics.
Where to police officers situate themselves to aim a radar gun at speeding cars?

radar 500x334 Angles for Doppler

The maximal Doppler shift will be seen at 180 degrees. In fact at the instant the car passes the officer, (90 degrees) there will be zero Doppler shift. At that instant there is no movement between the object and the listener. So they aim the gun directly at the oncoming traffic, so the direction of their beam is parallel to the direction of [traffic] flow.

The image below illustrates Doppler shift of ultrasound reflected off a red blood cell:

  1. Top: A normal ultrasound wave
  2. Middle: Doppler shift reflected off the RBC moving toward the transducer (thus increasing the frequency of the returning wave)
  3. Bottom: Doppler shift reflected off the RBC moving away from the transducer (thus decreasing the frequency of the returning wave).

to away composite 500x273 Angles for Doppler

Thanks to equipmentexplained.com for the image. Imaging at 180 degrees is impractical for diagnostic ultrasound, since the optimal B-mode imaging angle is 90 degrees. Therefore, most authorities recommend an imaging angle between 45-60 degrees for Doppler ultrasound imaging . If you are imaging a vascular structure at 90 degrees and getting no Doppler signal, try lowering your angle.

Physical exam

Is ultrasound the stethoscope of the future? Is it an extension of the physical examination? Will it replace the physical exam?

No.

Point-of-care ultrasound is a diagnostic test. It is a rapid, bedside, noninvasive, accurate, diagnostic test, but still a diagnostic test. It can certainly augment data obtained through physical examination and medical interviews, and adds to information obtained by blood assays and radiology studies.

It is performed using FDA-approved medical devices by clinicians with specialized training. Images used for medical decision-making may be archived and shared with colleagues from multiple specialties. Quality assurance programs improve clinician accuracy and accountability. These are not physical examination characteristics. These are qualities of good diagnostic tests.

There is and will continue to be debate about this issue. Whether we think about point-of-care ultrasound as a diagnostic test or part of the physical examination has ramifications for training, documentation, archiving, and billing.

We recommend checking the guidelines relevant to your specialty and making up your own mind on this issue. In either camp some things remain constant: train well and use ultrasound to enhance the care you provide your patients.