Point-of-Care Ultrasound in United States Pediatric Emergency Medicine Fellowship Programs: The Current State of Practice and Training.

OBJECTIVES: In 2015, the American Academy of Pediatrics (AAP) released a policy statement regarding point-of-care ultrasonography (POCUS) by pediatric emergency physicians, which included recommendations on education and training. In the 3 years since the AAP policy statement and its accompanying technical report were published, it is unclear which aspects of the recommendations set forth by this policy have been instituted by POCUS programs throughout the country. The objective of this study was to conduct a survey of pediatric emergency medicine (PEM) fellowship directors throughout the United States regarding the current state of education and training of POCUS in their department. METHODS: We conducted an online survey of all PEM fellowship program directors in the United States between April 1, 2018, and July 31, 2018. RESULTS: Of the 78 PEM fellowship program directors contacted, 62 (79.5%) responded. The majority reported having an ultrasound curriculum in place to educate their fellows (77%). Fellows are being taught using a variety of educational strategies. The most commonly reported barriers were lack of qualified faculty available for training (62.9%), lack of confidence or comfort in using the existing ultrasound machine(s) in their department (54.8%), and physician resistance to using new technology (50%). The majority of programs reported having processes in place for credentialing (56%) and quality assurance (72.6%). Whereas 77.4% have a system for archiving POCUS studies after they are performed, only half of the programs report utilization of middleware for their archival system. Compliance with documentation varied significantly between programs. CONCLUSIONS: Our survey results demonstrate that, although there is still room for improvement, POCUS programs have succeeded in many of the goals set forth by the 2015 AAP policy statement, such as establishing and growing an ultrasound curriculum and using various strategies to educate PEM fellows.

Comparison of Hands-On Versus Online Learning in Teaching Ultrasound Skills for Achilles Tendon Rupture: A Pilot Study.

Introduction In the emergency department, the diagnosis of an Achilles tendon rupture (ATR) is reportedly missed in greater than 20% of cases. A limited number of studies evaluate the use of cadaver models as a potential ultrasound teaching and training modality. We hypothesize that emergency medicine residents can effectively utilize point-of-care ultrasound (POCUS) on cadaver models and a focused teaching intervention to assess their ability to detect ATRs. Methods A prospective study of 23 EM residents was performed. All participants in the study were divided into two learner groups: (a) independent and (b) hands-on. The independent learner group received a 30-minute online didactic lecture demonstrating how to diagnose ATRs. The hands-on learner group received direct instruction on cadaver lower leg models with a ruptured and normal Achilles tendon (AT). Both groups then participated in identifying either normal or ruptured ATs on six cadaver lower leg models. Results The sensitivity and specificity were 89% and 82% in the independent learner group 96% and 100% in the hands-on learner group, respectively. The overall sensitivity and specificity were 91% and 88%, respectively. There was a trend toward successful identification with increased years of residency training. Conclusions In this study, lower leg and ankle cadaver models were found to be as effective as an independent learner model for potential POCUS teaching and training modality in both novice and more advanced trainees.

The use of cadaver models to diagnose rib fractures: A pilot study.

BACKGROUND: In the emergency department, rib fractures are a common finding in patients who sustain chest trauma. Rib fractures may be a sign of significant, underlying pathology, especially in the elderly patients where rib fractures are associated with significant morbidity and mortality. To date, no studies have evaluated the ability of ultrasound to detect rib fractures using cadaver models and subsequently use this model as a teaching tool. OBJECTIVES: The purpose of this study was to determine if it is possible to generate rib fractures on cadaver models which could be accurately identified using ultrasound. METHODS: This was a cross-sectional study performed during one session at a cadaver lab. A single hemithorax from four adult cadavers were used as models. Single rib fractures on each of rib five through eight were created. Four subjects, blinded to the normal versus fractured ribs, were asked to identify the presence of a fracture on each rib. RESULTS: A total of 8 of 16 potential ribs had fractured induced by study staff. Mean accuracy was 55% for all subjects. The overall sensitivity and specificity for detecting rib fractures was 50% (CI: 31.89-68.11) and 59.38% (CI: 35.69-73.55) respectively. The overall PPV and NPV was 55.17% and 54.29% respectively. CONCLUSIONS: In this pilot study, subjects were not able to detect induced rib fractures using ultrasound on cadaver models. The use of this model as a teaching tool in the detection of rib fractures requires further investigation.

Relevance of B-Lines on Lung Ultrasound in Volume Overload and Pulmonary Congestion: Clinical Correlations and Outcomes in Patients on Hemodialysis.

BACKGROUND: Volume overload in patients on hemodialysis (HD) is an independent risk factor for cardiovascular mortality. B-lines detected on lung ultrasound (BLUS) assess extravascular lung water. This raises interest in its utility for assessing volume status and cardiovascular outcomes. METHODS: End-stage renal disease patients on HD at the Island Rehab Center being older than 18 years were screened. Patients achieving their dry weight (DW) had a lung ultrasound in a supine position. Scores were classified as mild (0-14), moderate (15-30), and severe (>30) for pulmonary congestion. Patients with more than 60 were further classified as very severe. Patients were followed for cardiac events and death. RESULTS: 81 patients were recruited. 58 were males, with a mean age of 59.7 years. 44 had New York Heart Association (NYHA) class 1, 24 had class 2, and 13 had class 3. In univariate analysis, NYHA class was associated with B-line classes (<0.001) and diastolic dysfunction (0.002). In multivariate analysis, NYHA grade strongly correlated with B-line classification (0.01) but not with heart function (0.95). 71 subjects were followed for a mean duration of 1.19 years. 9 patients died and 20 had an incident cardiac event. A Kaplan-Meier survival analysis demonstrated an interval decrease in survival times in all-cause mortality and cardiac events with increased BLUS scores (p = 0.0049). Multivariate Cox regression analysis showed the independent predictive value of BLUS class for mortality and cardiac events with a heart rate of 2.98 and 7.98 in severe and very severe classes, respectively, compared to patients in the mild class (p = 0.025 and 0.013). CONCLUSION: At DW, BLUS is an independent risk factor for death and cardiovascular events in patients on HD.

Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States.

BACKGROUND: The use of emergency ultrasonography (EUS) has gained much popularity in the past few decades, and is now a mainstay of diagnostic decision-making. This expanded use is now highlighting the substantial issue of individual hospitals in credentialing its emergency medicine attending physicians in EUS in the United States. This issue is also of importance as more hospitals are now requesting reimbursements for emergency ultrasounds. The objective of this study is to gain an understanding of how many emergency departments are currently credentialing its attending staff in EUS, what the internal structure and staffing are of these emergency departments, and how they are currently performing quality assurance of the ultrasounds performed. METHODS: This was a cross-sectional, web-based survey sent to 160 ACGME-accredited EM residency programs from July 2013 to November 2013. The survey consisted of 23 questions regarding: (1) number of emergency medicine attendings on staff, (2) presence of an EUS fellowship, (3) quality assurance (QA) process, and (4) current US credentialing process. RESULTS: There was a 50 % response rate. Fifty percent of the total respondents (n = 40) had an EUS fellowship program. Of the sites with an EUS fellowship, 36 had EUS fellowship-trained attendings. Of the sites without an EUS fellowship, 19 had EUS fellowship-trained faculty, p ≤ 0.0001. Sites with an EUS fellowship had a greater percentage of staff credentialed to perform EUS as compared to sites with no EUS fellowship, p = 0.0161. All sites with an EUS fellowship had EUS-credentialed attendings. In sites with an EUS fellowship, 35 conducted a formal QA of ED performed EUS scans versus 22 at sites without an EUS fellowship, p = 0.003. CONCLUSIONS: The survey results support hiring emergency attendings that have completed postgraduate training in emergency ultrasonography to aid in credentialing staff. This also seems to be helpful in completing a timelier QA of all ED ultrasounds.

Bedside echocardiography for undifferentiated hypotension: diagnosis of a right heart thrombus.

A free-floating right heart thrombus is often a harbinger of a massive pulmonary embolism and must be diagnosed and treated rapidly in order to avoid significant adverse sequelae. We present the case of an 84-year-old female who presented with two days of dyspnea and was hypotensive on arrival. Bedside ultrasound was performed by the emergency physician and showed a large, mobile right heart thrombus leading to immediate administration of a thrombolytic. In this case, bedside ultrasound was utilized to help further delineate clinical care in a progressively worsening patient, leading to a potentially lifesaving treatment.

Subcapsular liver hematoma after colonoscopy diagnosed by emergency department bedside ultrasonography.

BACKGROUND: Hepatic subcapsular hematoma is an uncommon cause of right upper quadrant pain in the Emergency Department. It must be recognized early, as large volumes of acute blood loss and rupture into the peritoneum carry significant morbidity and mortality. In the absence of gallbladder disease, the differential diagnosis should include liver pathology. Bedside ultrasonography can be used to identify such lesions. OBJECTIVES: To discuss the presentation, evaluation, and management options of hepatic subcapsular hematoma. CASE REPORT: We report a case of a 30-year-old woman who presented with the chief complaint of right upper quadrant pain radiating to the right scapula 6 h after a screening colonoscopy for intestinal polyps. Emergency physician-performed bedside ultrasound revealed a large hyperechoic mass in the right lobe of the liver. Radiology-performed comprehensive ultrasound and subsequent computed tomography scan of her abdomen and pelvis revealed a subcapsular hematoma without intestinal perforation. CONCLUSION: In a patient with undifferentiated right upper quadrant abdominal pain, bedside ultrasonography is a rapid and effective modality in the diagnosis of liver masses, including subcapsular hematoma.

Two cases of post-coital vaginal cuff dehiscence with small bowel evisceration after robotic-assisted laparoscopic hysterectomy.

INTRODUCTION: Vaginal cuff dehiscence following robotic surgery is uncommon. Published reports of vaginal cuff dehiscence following robotic surgery are increasing, but the true incidence is unknown. PRESENTATION OF CASE: Case 1. A 45 year old female had sexual intercourse and presented with a vaginal cuff dehiscence complicated by small bowel evisceration 4 months after RA-TLH. Case 2. A 44 year old female had sexual intercourse and presented with a vaginal cuff dehiscence with small bowel evisceration 6 weeks after RA-TLH. DISCUSSION: We discuss the rate of vaginal cuff dehiscence by mode of hysterectomy, surgical and non-surgical risk factors that may contribute to vaginal cuff dehiscence, and proposed preventative methods at the time of RA-TLH to reduce this complication. CONCLUSION: Vaginal cuff dehiscence with associated evisceration of intraabdominal contents is a potentially severe complication of hysterectomy. We recommend counseling patients who undergo RA-TLH to abstain from vaginal intercourse for a minimum of 8-12 weeks.

Monozygotic twins in infertile patients with advanced maternal age: case reports and review of the literature.

OBJECTIVE: To report two cases of successful monozygotic twin pregnancies in women undergoing infertility treatment and to review possible etiologic factors. DESIGN: Case report and review of the literature. SETTING: University of Toronto-affiliated infertility clinic. PATIENT(S): A 43-year-old woman and a 44-year-old woman with history of secondary infertility. INTERVENTION(S): In vitro fertilization and ET. MAIN OUTCOME MEASURE(S): Monozygotic twin pregnancy. RESULT(S): Delivery of two sets of monozygotic twins. CONCLUSION(S): The only identified potential risk factors for monozygotic twins are maternal age and assisted reproductive technologies. Both patients reported here were aged >40 years and underwent assisted reproduction procedures, including high-dose gonadotropin stimulation, embryo culture, and, in case 2, intracytoplasmic sperm injection plus assisted hatching.

Epidemic of plurality and contributions of assisted reproductive technology therein.

A commentary on contributions of ART to the pandemic of multiple gestations is presented and mechanistic aspects therein are explored.

Community elder-care in Tasmania: examining whether caregivers believe they "make-a-difference" in an urban and rural island.

Adult caregivers (n = 184;Mage = 43.9 years old) working at a non-profit, eldercare program at five geographically diverse sites located in the self-contained, island state of Tasmania, Australia, completed a set of self-report measures. Results across the five sites indicated that respondents experienced a relatively strong sense of self-efficacy toward making a difference in their local community. However, there were significant differences (controlling for social desirability) when comparing caregivers from rural northern (n = 45) with urban southern (n = 139) communities, with rural caregivers claiming stronger sense of common mission with others, reciprocal responsibility to help others, and caregiver satisfaction, plus lower disharmony with other members and caregiver stress in helping the elderly than urban caregivers. Implications suggest that community self-efficacy may be high among eldercare staff, but their sense of community and caregiving perceptions may reflect geographic differences, especially in Tasmania.