An Innovative Curriculum For Teaching Transesophageal Echocardiography (TEE) to Emergency Medicine Residents.

BACKGROUND: Focused transesophageal echocardiogram (TEE) can be a valuable tool for emergency physicians (EP) during cardiac arrest. OBJECTIVES: We sought to demonstrate the ability of emergency medicine (EM) residents without prior TEE experience to perform a simulated four-view TEE following a short, flipped conference curriculum. METHODS: This was a prospective, simulation-based study where EM residents participated in the following four-view TEE curriculum: 1 h of online content reviewed prior to a 20-min in-person lecture and 30-min hands-on practice using a TEE trainer. Each resident attended four testing sessions over an 8-week period and performed a total of 25 TEE scans. Each TEE scan was graded in real time using a 10-point checklist by a TEE-credentialed EP. Interrater reliability of the checklist was calculated using the kappa coefficient (κ). A random sample of 10% of the TEE scans were reviewed by a TEE expert using a standard ultrasound 1-5 scale for image acquisition quality, with a "3" considered to be satisfactory. Residents completed an online pretest and posttest. RESULTS: Twenty-four residents participated. Mean pre- and posttest scores were 52% (SD 16) and 92% (SD 12), respectively. Mean TEE scores using the 10-point checklist after sessions one and four were 9.4 (SD 0.4) and 9.7 (SD 0.3), respectively. Mean time to complete each TEE scan after sessions one and four were 118.1 (SD 28.3) and 57.1 (SD 17.0) s, respectively. The κ for the checklist was 1. The median score for the image acquisition review was 3 (interquartile range 3-4). CONCLUSIONS: This simplified flipped conference curriculum can train EM residents to competently perform TEE in a simulated environment.

Can Medical Students Learn and Perform POCUS in the Pediatric Emergency Department? Implementation of a Short Curriculum.

Purpose: To determine medical student ability to accurately obtain and interpret POCUS exams of varying difficulty in the pediatric population after a short didactic and hands-on POCUS course. Methods: Five medical students were trained in four POCUS applications (bladder volume, long bone for fracture, limited cardiac for left ventricular function, & inferior vena cava collapsibility) and enrolled pediatric ED patients. Ultrasound-fellowship-trained emergency medicine physicians reviewed each scan for image quality and interpretation accuracy using the American College of Emergency Physicians' quality assessment scale. We report acceptable scan frequency and medical student vs. Ultrasound-fellowship-trained emergency medicine physician interpretation agreement with 95% confidence intervals (CI). Results: Ultrasound-fellowship-trained emergency medicine physicians graded 51/53 bladder volume scans as acceptable (96.2%; 95% CI 87.3-99.0%) and agreed with 50/53 bladder volume calculations (94.3%; 95% CI 88.1-100%). Ultrasound-fellowship-trained emergency medicine physicians graded 35/37 long bone scans as acceptable (94.6%; 95% CI 82.3-98.5%) and agreed with 32/37 medical student long bone scan interpretations (86.5%; 95% CI 72.0-94.1%). Ultrasound-fellowship-trained emergency medicine physicians graded 116/120 cardiac scans as acceptable (96.7%; 95% CI 91.7-98.7%) and agreed with 111/120 medical student left ventricular function interpretations (92.5%; 95% CI 86.4-96.0%). Ultrasound-fellowship-trained emergency medicine physicians graded 99/117 inferior vena cava scans as acceptable (84.6%; 95% CI 77.0-90.0%) and agreed with 101/117 medical student interpretations of inferior vena cava collapsibility (86.3%; 95% CI 78.9-91.4%). Conclusions: Medical students demonstrated satisfactory ability within a short period of time in a range of POCUS scans on pediatric patients after a novel curriculum. This supports the incorporation of a formal POCUS education into medical school curricula and suggests that novice POCUS learners can attain a measure of competency in multiple applications after a short training course.

Feasibility and safety of quantitative adenosine stress perfusion cardiac magnetic resonance imaging in pediatric heart transplant patients with and without coronary allograft vasculopathy.

BACKGROUND: Pediatric heart transplant patients require cardiac catheterization to monitor for coronary allograft vasculopathy. Cardiac catheterization has no safe and consistent method for measuring microvascular disease. Stress perfusion cardiac magnetic resonance imaging (MRI) assessing microvascular disease has been performed in adults. OBJECTIVE: To investigate the feasibility and safety of performing cardiac MRI with quantitative adenosine stress perfusion testing in pediatric heart transplant patients with and without coronary allograft vasculopathy. MATERIALS AND METHODS: All pediatric heart transplant patients with coronary vasculopathy at our institution were asked to participate. Age- and gender-matched pediatric heart transplant patients without vasculopathy were recruited for comparison. Patients underwent cardiac MRI with adenosine stress perfusion testing. RESULTS: Sixteen pediatric heart transplant patients, ages 6-22 years, underwent testing. Nine patients had vasculopathy by angiography. No heart block or other complications occurred during the study. The myocardial perfusion reserve for patients with vasculopathy showed no significant difference with comparison patients (median: 1.43 vs. 1.48; P=0.49). Values for both groups were lower than expected values based on previous adult studies. The patients were also analyzed for time after transplant and the number of rejection episodes. Patients within 6 years of transplantation had a nonsignificant trend toward a higher myocardial perfusion reserve (median: 1.57) versus patients with older transplants (median: 1.47; P=0.46). Intra- and interobserver reproducibility were 97% and 92%, respectively. CONCLUSION: Myocardial perfusion reserve is a safe and feasible method for estimating myocardial perfusion in pediatric heart transplant patients. There is no reliable way to monitor microvascular disease in pediatric patients. This method shows potential and deserves investigation in a larger cohort.