Pilot study to determine the feasibility of training Army National Guard medics to perform focused cardiac ultrasonography.

OBJECTIVE: To assess the ability of Army National Guard combat medics to perform a limited bedside echocardiography (BE) to determine cardiac activity after a brief training module. METHODS: Twelve Army National Guard health care specialists trained to the level of emergency medical technician-basic (EMT-B) underwent an educational session consisting of a 5-minute lecture on BE followed by hands-on practical training. After the training session, each medic performed BEs, in either the subxiphoid (SX) or parasternal (PS) location at his or her discretion, on four healthy volunteers. The time required to complete the BE and the anatomic location of the examination (SX vs. PS) was documented. A 3-second video clip representing the best image was recorded for each BE. These clips were subsequently reviewed independently by two of the investigators with experience performing and interpreting BE; each BE was graded on a six-point scale designed for the study, the Cardiac Ultrasound Structural Assessment Scale (CUSAS). A score of 3 or greater was considered to be adequate to assess for the presence of cardiac activity. Where there was disagreement on the CUSAS score, the reviewers viewed the clip together and agreed on a consensus CUSAS score. We calculated the median time to completion and interquartile range (IQR) for each BE, the median CUSAS scores and IQR for examinations performed in the SX and PS locations, and kappa for agreement between the two reviewers on the CUSAS. RESULTS: A total of 48 BEs were recorded and reviewed. Thirty-seven of 48 (77%) were obtained in the SX location, and 11 of 48 (23%) were obtained in the PS location. Forty-four of 48 (92%) were scored as a 3 or higher on the CUSAS. Median time to completion of a BE was 5.5 seconds (IQR: 3.7-10.9 seconds). The median CUSAS score in the SX location was 4 (IQR: 4-5), and the median CUSAS score in the PS location was 4 (IQR: 4-4). Weighted kappa for the CUSAS was 0.6. CONCLUSION: With minimal training, the vast majority of the medics in our study were able to rapidly perform a focused BE on live models that was adequate to assess for the presence of cardiac activity.

Prospective validation of Wells Criteria in the evaluation of patients with suspected pulmonary embolism.

STUDY OBJECTIVE: The literature suggests that the d -dimer is useful in patients suspected of having pulmonary embolism and who have a low pretest probability of disease. A previously defined clinical decision rule, the Wells Criteria, may provide a reliable and reproducible means of determining this pretest probability. We evaluate the interrater agreement and external validity of Wells Criteria in determining pretest probability in patients suspected of having pulmonary embolism. METHODS: This was a prospective observational study. Trained research assistants enrolled patients during 120 random 8-hour shifts. Patients who underwent imaging for pulmonary embolism after a medical history, physical examination, and chest radiograph were enrolled. Treating providers and research assistants determined pretest probability according to Wells Criteria in a blinded fashion. Two d -dimer assays were run. Three-month follow-up for the diagnosis of pulmonary embolism was performed. Interrater agreement tables were created. kappa Values, sensitivities, and specificities were determined. RESULTS: Of the 153 eligible patients, 3 patients were missed, 16 patients declined, and 134 (88%) patients were enrolled. Sixteen (12%) patients were diagnosed with pulmonary embolism. The kappa values for Wells Criteria were 0.54 and 0.72 for the trichotomized and dichotomized scorings, respectively. When Wells Criteria were trichotomized into low pretest probability (n=59, 44%), moderate pretest probability (n=61, 46%), or high pretest probability (n=14, 10%), the pulmonary embolism prevalence was 2%, 15%, and 43%, respectively. When Wells Criteria were dichotomized into pulmonary embolism-unlikely (n=88, 66%) or pulmonary embolism-likely (n=46, 34%), the prevalence was 3% and 28%, respectively. The immunoturbidimetric and rapid enzyme-linked immunosorbent assay d -dimer assays had similar sensitivities (94%) and specificities (45% versus 46%). CONCLUSION: Wells Criteria have a moderate to substantial interrater agreement and reliably risk stratify pretest probability in patients with suspected pulmonary embolism.