Faculty Bibliography

BACKGROUND: Although thoracic aortic dissections are uncommon in young patients, they must be considered in the differential diagnosis in the presence of chest pain and abnormal vital signs. Although computed tomography angiography is the test of choice for thoracic dissection in the emergency department, point of care (POC) transthoracic echocardiography has a high specificity in the diagnosis of this disease. It is especially helpful in patients with proximal ascending dissections in the presence of a pericardial effusion. CASE REPORT: This case report illustrates a young patient presenting with chest pain, persistent tachycardia, and fever with a presumed upper respiratory infection who had an ascending thoracic dissection with tamponade discovered on POC echocardiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POC echocardiography should be an important part of the algorithm in young patients presenting with chest pain and abnormal vital signs that do not improve with supportive measures. Definitive care in patients who present with a thoracic aortic dissection in the presence of cardiac tamponade diagnosed on POC echocardiography should not be delayed in order to wait for other imaging methods to be performed. POC echocardiography may expedite care and treatment in young patients presenting with this deadly disease.

Introduction/UNASSIGNED:As point-of-care ultrasound units become more compact and portable, clinicians in over 20 different medical and surgical specialties have begun using the technology in diverse clinical applications. However, a knowledge gap still exists between what medical students are learning in their undergraduate medical education curriculum and the clinical skills required for practice. Over the last 10 years, point-of-care ultrasound content has been slowly incorporated into undergraduate medical education, yet only a handful of medical schools have developed ultrasound curricula. This module was developed at our institution in response to survey feedback from medical students overwhelmingly requesting preclerkship ultrasound education. The target audience for this module is first-year medical students with no prior ultrasound exposure. Methods/UNASSIGNED:The module consists of a 1-hour introductory lecture and a 1-hour hands-on session during the abdominal anatomy course. Associated materials include the introductory lecture, presenter notes for the introductory lecture, instructor guidelines for the hands-on session, hands-on session setup instructions, a student handout for the hands-on session, and a module evaluation form. Results/UNASSIGNED:We have successfully implemented this module for the past 3-years and learner feedback has been overwhelmingly positive. Learner comments on a postmodule survey included, "Great job of explaining the science behind ultrasounds as well as how to interpret the images." Discussion/UNASSIGNED:As a result of our first-year students' evaluation responses, this module has been incorporated into our medical school's anatomy course.

Study Objective: Abdominal pain is a common complaint and comprises approximately 25% of all patients who present to the emergency department (ED). More than 25% of patients presenting to the ED with uncomplicated abdominal pain have computed tomography (CT) scans during their visit. The radiology literature has shown that despite the large number of CTs performed on patients in the ED presenting with abdominal pain, less than half (48%) are actually diagnostic. The objective of this study is to determine if performing a bedside screening ultrasound (US) on patients who present to the ED with undifferentiated abdominal pain can result in a reduction in CT scan usage. We hypothesize that performing a bedside US will decrease the use of CT imaging in the ED by 15% in patients with abdominal pain. Methods: This is a preliminary prospective observational study of ED patients at two urban academic medical centers beginning December 2014. Inclusion criteria include all patients between the ages of 18 and 65 who present with abdominal pain and have a CT of the abdomen and pelvis performed. Patients with an extensive abdominal surgical history or those who end up not having a CT are excluded. Emergency physician co-investigators trained in US, blinded to CT results, performed the following studies: a Focused Assessment with Sonography in Trauma (FAST) exam, right upper quadrant US, bilateral renal US, an abdominal aorta US, and a right lower quadrant US. All US results were discussed with the treating physician and any changes in management were documented. Medical records were reviewed for the final results of all CTs. Results: We calculated a sample size of 200 patients in order to reduce CT scan usage from 25% to 10%. Our preliminary data identified 31 eligible patients of which 28 were enrolled in the study. Three patients have been dropped due to the CT being canceled. Twenty-five patients received both the US and CT in the ED and were included in the analysis. Eleven patients (44%) had a normal US and no significant findings on a subsequent CT. Four patients (16%) had a normal US, but a positive CT. Two of these four had mild hydronephrosis on CT that was missed on US and two had more complicated diagnoses of fistulizing Crohn's and diverticulitis. Ten patients (40%) had a positive US, of which eight had the same diagnosis confirmed on CT and two patients (8%) had CT findings that differed from the US: one had acute appendicitis on US, but renal colic on CT and one had a possible SBO on US but a rectus muscle hematoma on CT. Ultrasound could have theoretically reduced CT utilization in 32% of patients. Although three patients were dropped, two of these had the CT scan canceled and a change in management based on US findings. The two diagnoses were appendicitis and cholelithiasis and both had subsequent radiology US confirming the findings. Therefore, our preliminary total theoretical and actual CT usage reduction is 40%. Conclusions: These preliminary findings suggest that ED performed bedside US in patients with uncomplicated abdominal pain may significantly reduce CT utilization. Bedside US will not replace CT in all patients and subsequent imaging may still be required. However, incorporating US into an abdominal pain algorithm may reduce radiation exposure, length of stay and costs associated with unnecessary CT usage in the ED

BACKGROUND: Medical students on clinical rotations rarely receive formal bedside ultrasound (BUS) training. We designed, implemented, and evaluated a standardized BUS curriculum for medical students on their Emergency Medicine (EM) rotation. Teaching was aimed toward influencing four cognitive and psychomotor learning domains: BUS instrumentation knowledge, image interpretation, image acquisition, and procedural guidance. METHODS: Participants viewed three instructional Web-based tutorials on BUS instrumentation, the Focused Assessment for Sonography in Trauma (FAST) examination and ultrasound-guided central venous catheter (CVC) placement. Subsequently, participants attended a 3-hour hands-on training session to discuss the same content area and practice with faculty coaches. A Web-based, multiple-choice questionnaire was administered before and after the session. During the final week of the rotation, students returned for skills assessments on FAST image acquisition and CVC placement. RESULTS: Forty-five medical students on an EM rotation were enrolled. Sonographic knowledge overall mean score improved significantly from 66.6% (SD +/-11.2) to 85.7% (SD +/-10.0), corresponding to a mean difference of 19.1% (95% CI 15.5-22.7; p < 0.001). There were high pass rates for FAST (89.0%, 40/45) and CVC (96.0%, 43/45) skills assessments. There was no significant difference between medical student posttest and EM resident test scores 85.7% (SD +/-10.0) and 88.1% (SD +/- 7.6) (p = 0.40), respectively. CONCLUSIONS: A formal BUS curriculum for medical students on EM rotation positively influenced performance in several key learning domains. As BUS competency is required for residency in EM and other specialties, medical schools could consider routinely incorporating BUS teaching into their clinical rotation curricula. (c) 2014 Wiley Periodicals, Inc. J Clin Ultrasound, 2014.

Background: Lower extremity compression ultrasound (US) for deep venous thrombosis (DVT) assessment by emergency physicians varies in technique and accuracy across published reports. This stems from differences in experience and training as well as paucity of data describing the minimal components needed to perform an accurate exam. Furthermore, no data exists describing emergency physician agreement during formal DVT ultrasound reviews. Emergency physician reviewer agreement is critical to developing a universal, standardized, and accurate approach to lower extremity compression US in the emergency department (ED). Study Objectives: This study evaluates agreement between expert sonographer reviewers in each component of the lower extremity compression US performed at our institution. We hypothesized emergency physician expert reviewers will strongly agree on all components of the review process. Methods: This is a prospective, observational study of ED patients at an urban, academic ED. Adult patients receiving an ED lower extremity compression ultrasound for DVT assessment prior to any other imaging study for DVT assessment were eligible. Enrollment was based on a convenience sample. Lower extremity compression US was performed by the treating physician per our departmental standard method: incremental compression and evaluation for complete coaptation of deep veins are performed from the common femoral vein and saphenous vein junction terminating ten centimeters distal over thigh, and again starting at the popliteal vein (PV) and terminating at the PV trifurcation. Data to calculate a Wells DVT score was also collected. ED lower extremity compression US studies were later evaluated by two of three expert ultrasound reviewers using a checklist of predetermined critical components (Table 1). These components were based on a literature review of exam elements thought to be valuable for DVT assessment and are included in our standard review process. Each category was judged as either present or !

Background: Although bedside ultrasound (BUS) competency is required for emergency medicine (EM) residents and BUS is an integral part of EM clinical practice, few opportunities exist for medical students to receive formal BUS instruction. Objectives: We developed a BUS simulation-based curriculum for rotating EM medical students consisting of web-based didactics and a hands-on skills session. We hypothesized that the curriculum would adequately prepare students to perform two common EM procedures: a Focused Assessment for Sonography in Trauma (FAST) exam and placement of ultrasound-guided internal jugular central venous access (IJ CVA). Methods: Forty-five medical students (16 2nd yr, 21 3rd yr, 8 4th yr) on an EM rotation were enrolled. Participants viewed three instructional web-based videos about BUS physics, the FAST exam, and BUS-guided IJ CVA. Subsequently, participants attended a 3-hour hands-on BUS simulation-based training session led by a BUS expert, an EM attending physician with > 7 years of BUS experience and > 3,000 completed BUS scans. After the initial training session, the BUS expert observed participants' FAST exams on a live volunteer, while a trained research assistant evaluated participants' IJ CVA skills on an instructional mannequin. Standardized checklists were used for both assessments. A passing score of 70% on each checklist was chosen prior to study initiation. Results: 89.0% (40/45) of participants passed the FAST and 96.0% (43/45) passed the IJ CVA skills assessments. Participants were successful in obtaining most required FAST views, yielding a right upper quadrant mean score of 90.6%, left upper quadrant score of 88.3%, bladder view score of 97.2%, and lung sliding score of 90.6%, but had the most difficulty with the cardiac view (72.2%). 84% (38/45) of participants placed successful IJ CVA within three attempts, with 64.4% (29/45) achieving success on the first attempt. 91% (41/45) avoided inadvertent puncture of the carotid artery. Conclusion: A standardized c!

Background: Bedside ultrasound (BUS) training is newly being integrated into medical school curricula as an innovative modality for teaching anatomy and pathophysiology. Few studies have evaluated BUS training in medical students. Objectives: To determine if integrating BUS training into the traditional liver physical examination improves accuracy of liver span measurements in fourth year medical students. Methods: A randomized, convenience sample of fourth year medical students was prospectively enrolled. Twenty-eight study participants were randomized into two groups. Group 1 received a 30-minute didactic session of the traditional examination for vertical liver span (VLS) using percussion/palpation. Group 2 received a 30-minute didactic session of the traditional examination for VLS plus BUS education on integrating BUS with the traditional liver examination. Next, VLS was measured along the mid-clavicular line by percussion/palpation by each medical student in groups 1 and 2 on one volunteer, and separately by two BUS experts. Three VLS measurements each by two BUS experts were averaged and considered the gold standard. We compared the VLS measurements between groups 1 and 2 as well as each group's VLS average to the BUS gold standard. Results: Group 1 (n=12) obtained a mean VLS of 7.3 cm (SD 1.0) and group 2 (n=16) obtained a mean VLS of 6.8 cm (SD 1.2). BUS experts' mean VLS measurement gold standard was 9.75 cm. The mean difference between Group 1 and the BUS experts' was -2.450 cm (95% CI, -3.085 to -1.815) and between group 2 and the BUS experts' was -2.950 cm (95% CI, -3.589 to -2.311), both p < 0.0001. The mean difference between the two groups was 0.49 cm (95% CI, -1.38 to 0.39). There was no statistical difference between the mean VLS of the two groups (p= 0.61). Conclusion: In our study, BUS training did not improve the accuracy of fourth year medical students' VLS measurements. Both groups' VLS measurements differed from the BUS gold standard, but did not differ between the two groups. This suggests that the VLS measurement by percussion/palpation and by BUS may not yield equivalent results. Further studies are needed to help clarify the role of BUS as compared to percussion/palpation in the examination of the liver span