Ultrasound Section

Emergency Ultrasound

LAC+USC Emergency Medicine Ultrasound Fellowship

The Mission of the LAC+USC Emergency Ultrasound Program:

To offer Emergency Medicine Residents, Attendings, Mid-Level Providers and Nurses in the LAC+USC Department of Emergency Medicine (DEM) the highest level of education and training in the use of emergency bedside ultrasonography in order to provide optimal care for their patients. Ultrasound imaging enhances the emergency provider’s ability to evaluate, diagnose and treat emergency department patients. Because ultrasound imaging is often time-dependent in the acutely ill or injured patient, the emergency physician is in an ideal position to use this technology to advance patient care and safety. Focused ultrasound examinations provide immediate information and can answer specific questions about the patient's physical condition. The American College of Physicians (ACEP) and the Society of Academic Emergency Medicine (SAEM) believe that ultrasound imaging is within the scope of practice of emergency physicians and endorses training in bedside emergency ultrasound within residency training
The Los Angeles County+USC Medical Center Emergency Medicine Residency puts a strong emphasis on ultrasound training throughout the four-year program. Residents receive ultrasound instruction through lectures and extensive hands-on training in bedside ultrasound. By the time of graduation, residents will have completed an extensive curriculum covering all basic and many advanced applications in emergency bedside ultrasound as outlined by published ACEP training guidelines. Completion of this curriculum will lead to a letter of successful emergency ultrasound training that can be used by graduates for credentialing at the hospitals of their future employment.

Annual LAC+USC Emergency Medicine Ultrasound Course:

The LAC+USC Emergency Medicine Residency Program hosts an Annual Emergency Ultrasound 2-day, 16-hour course each year in June. Morning lectures are complemented by extensive afternoon small group ultrasound workshops. The workshops utilize live models, as well as patients from the Medical Center with varying pathologies. Residents and staff are instructed in multiple approaches including trauma/extended FAST exam, hepatobiliary, OB/GYN, echocardiography, renal, abdominal aorta, vascular access, procedural and soft tissue/musculoskeletal ultrasound. The program is an annual event each June prior to the start of clinical practice for the incoming EM residency class.

Annual LAC+USC Advanced Emergency Medicine Ultrasound Course:

The LAC+USC Emergency Medicine Residency Program hosts an Annual Advanced Emergency Ultrasound Class each year in May. This is a 5-hour course that covers advanced application of bedside ultrasound. All four classes of the DEM residency participate in this seminar. The May 2011 course covered regional anesthesia using ultrasound guidance, central venous cannulation under ultrasound (including subclavian and axillary approaches) and detection/removal of foreign bodies with ultrasound.

PGY-2 Year Month Rotation in Emergency Ultrasound:

All PGY-2 Year Emergency Medicine Residents spend a month rotating on the emergency ultrasound service. During the month, residents work directly with the emergency ultrasound faculty on 14 proctored ultrasound shifts. This allows for intensive instruction and immediate feedback in multiple applications of emergency ultrasound. Residents complete over 150 scans over the month to work toward the ACEP credentialing guidelines. They also complete an online ultrasound training program, called SoundBytes (www.sound-bytes.tv), and then test their knowledge with an online test, developed by the ultrasound faculty with ACEP. Finally, they select an interesting ultrasound case and write this up for scholarly publication. This case write-up develops each resident’s skills in fully researching a topic and then writing scientifically for a peer reviewed journal. The PGY-2 ultrasound rotation guidelines are attached as a PDF file below.

Senior Year Electives in Emergency Ultrasound:

Senior Emergency Medicine Residents are offered 2-4 week elective blocks in emergency ultrasound. They can use this time to work on mastering advanced applications of bedside ultrasound or to concentrate on a research topic. Interested residents should contact the ultrasound program directors directly.

Emergency Ultrasound Curriculum:

The full emergency ultrasound curriculum is attached as a PDF file to this website. During the 4 years of the DEM residency, residents will become expert at the following emergency ultrasound applications through the experience of performing multiple directly supervised.
Trauma Ultrasound: Residents will learn the standard four view focused abdominal sonography for trauma (FAST) exam in order to optimally facilitate trauma care. This exam includes the right hepatorenal, left perisplenic, suprapubic/pelvic and cardiac views. The primary goal of the FAST exam is to detect free fluid within the abdomen, pelvis and pericardial sac. Residents will also learn how to perform the newly developed expanded FAST (e-FAST) exam for evaluation of the thoracic cavity. The primary goals of the e-Fast exam are to detect pneumothoraces and pleural cavity free fluid.
OB/GYN: Residents will learn transabdominal and transvaginal sonographic approaches for OB/GYN sonography. The primary goal of first trimester OB/GYN sonography is the detection of intrauterine pregnancy defined as yolk sac or more. Advanced goals of first trimester OB/GYN sonography include evaluation of the adnexae and detection of ectopic pregnancy.

Emergency Echocardiography: The primary goals of bedside echocardiography include the detection of pericardial effusions and gross determinations of left ventricular cardiac contractility. The use of emergency bedside cardiac ultrasound to better guide appropriate care during shock states and resuscitations will be emphasized. Advanced goals of bedside echocardiography include evaluation of the heart for signs of cardiac tamponade, with diastolic collapse of the right ventricle or atrium. Residents will also learn how to map out pericardial effusions using sonography to determine the optimal route for emergent pericardiocentesis. Additional advanced echo techniques will also be covered during the curriculum, including determination of right ventricle strain suggestive of pulmonary embolus. Finally, residents will learn to evaluate the inferior vena cava through the respiratory cycle to gain a rough gauge of patient volume status.

Abdominal Aortic Aneurysms:
Training will be given in the examination of the entire abdominal aorta from diaphragm to the bifurcation of the iliac arteries. The primary goal of bedside aorta ultrasound is to recognize the presence of an abdominal aortic aneurysms defined as an aorta greater than 3 cm in diameter and iliac arteries greater than 1.5 cm in diameter.

Hepatobiliary:
The primary goals of bedside gallbladder sonography are the evaluation for gallbladder stones and assessment of the sonographic Murphy's sign. Advanced goals include detection of the secondary signs of cholecystitis such as gallbladder wall thickening and peri-cholecystic fluid.

Genitourinary:
The primary goals of GU bedside ultrasound are the evaluation of obstruction and acute urinary retention. Both kidneys will be examined for hydronephrosis and the bladder assessed for size. Advanced goals include evaluation for kidney stones and other renal pathologies.

Vascular Ultrasound:
The use of ultrasound to guide both peripheral and central venous vascular access will be emphasized. Residents will learn to use ultrasound to aid in placement of central lines in the internal jugular, subclavian and femoral veins in order to minimize the risk of these procedures to patients. Ultrasound guided peripheral venous access to the basilic and brachial veins of the arm will also be taught.

Thoracentesis, Paracentesis and Lumbar Puncture:
Ultrasound will be used to first detect the presence of pleural effusions and ascites amenable to a drainage procedure. Residents will then learn ultrasound guided approaches to facilitate the procedures of thoracentesis and paracentesis in order to minimize risks to the patient. Ultrasound guided lumbar puncture will also be taught.

Foreign Body Detection:
Ultrasound will be used to detect radiolucent foreign bodies that may be difficult to visualize with plain radiography. Ultrasound guided techniques to remove foreign bodies will also be covered in the curriculum.

Cellulitis and Abscess:
Residents will learn to evaluate the soft tissues for fluid collections in order to allow for better diagnosis of abscess and differentiation from cellulitits. Residents will also learn to evaluate the tonsils for peritonsillar abscess requiring drainage.

Deep Venous Thrombosis:
Residents will learn the limited DVT screening exam focusing on evaluation of the proximal common femoral vein, greater saphenous and superficial femoral veins down to the proximal popliteal vein and the level of trifurcation. Analysis of the compressibility of the vessel with direct pressure of the probe will be taught as a means to diagnose a deep venous thrombosis.

Musculoskeletal:
Residents will learn how to use ultrasound to analyze joints for the presence of effusions. Ultrasound guided approaches to arthrocentesis will be taught. Residents will also learn how to use ultrasound to examine tendons and ligaments for disruption/rupture. Finally, residents will be taught how to use ultrasound to diagnose fractures.

Ocular Ultrasound:
Residents will have the opportunity to learn ocular ultrasound with the primary goal of diagnosing posterior chamber and orbital pathology such as retinal detachment, vitreous hemorrhage, and disruptions of structures. Residents will also learn how to evaluate for increase in intracranial pressure by measuring the optic nerve sheath diameter.

Rapid Ultrasound in Shock (RUSH Exam): Residents will learn the RUSH exam, a protocol developed to non-invasively evaluate the patient in shock using bedside ultrasound. The protocol is made up of 3 main areas; assessment of the pump, the tank and the pipes. Evaluation of the pump focuses on cardiac echo evaluation to look for left ventricular contractility, pericardial effusion and right ventricular strain. Evaluation of the tank focuses on assessment of the inferior vena cava and jugular veins to determine the central venous pressure. Evaluation of the pipes focuses on assessment of the aorta for abdominal aortic aneurysm, the thoracic aorta for aneurysm or dissection and the femoral and popliteal veins for deep venous thrombosis.

Pediatric Applications:
Residents will learn ultrasonography applied to children with a focus on abdominal pathology: appendicitis, pyloric stenosis, inguinal hernia and intussusception.

Other Advanced Applications:
Residents will learn basic techniques of testicular ultrasound helpful in diagnosis of pathology in this organ. Ultrasound guided nerve blocks will also be taught to better treat painful conditions in the Emergency Department.

Continuing Emergency Ultrasound Education / EM Resident Credentialing Pathway:

Submission of Ultrasound Scans:

Residents will submit at least 175-200 ultrasound exams for analysis to the ultrasound directors. Optimally, the ultrasound exams should be divided 25 each among the primary indications for ultrasound (cardiac, ob/gyn, hepatobiliary. genito-urinary, trauma/extended fast, aorta, vascular access).The QA scan sheets can be found online at wisdem.net (see link below).

Emergency Ultrasound Credentialing:

In addition to the above requirements, residents are expected to attend the Thursday Grand Rounds ultrasound lectures unless other EM Residency requirements conflict. Successful completion of the above requirements will allow for residents to receive a certificate of accomplishment as outlined by the ACEP ultrasound training criteria on graduation from the LAC+USC Emergency Medicine Residency. Each resident will be able to use this certificate towards hospital credentialing in bedside emergency ultrasound at their future jobs.
Resident Opportunity for Ultrasound Teaching at National Emergency Medicine Conferences:
Senior residents will have the opportunity to act as instructors at 2 yearly national Emergency Medicine conferences, USC Essentials in the fall and the Resuscitation Conference in the spring. They will gain the important experience of teaching bedside emergency ultrasound to practicing Emergency Physicians from academics and the community.

USC-Keck School of Medicine 4th Year Emergency Ultrasound Rotation:

1-2 students a month will have the opportunity to rotate on the emergency ultrasound senior medical student elective. Students will work directly with the ultrasound faculty on multiple proctored shifts to learn many applications of bedside ultrasound. Applications are taken through the USC-Keck School of Medicine. The full USC-Keck School of Medicine senior medical student ultrasound rotation guidelines are attached below as a PDF document.

LAC+USC Emergency Ultrasound Fellowship:

The fellowship in Emergency Ultrasound at LAC+USC Medical Center began in July 2011 with the first fellow, Dina Seif MD, a graduate of the LAC+USC Emergency Medicine Residency. Fellows receive intensive advanced instruction in emergency ultrasound over the one-year program. The fellow has specialized scan shifts each month in which they perform multiple ultrasound scans in a number of applications, together with the ultrasound faculty. The collected videos then provide the basis for weekly Thursday ultrasound review sessions. Fellows have multiple opportunities for advanced work in many areas of ultrasound; teaching, research, learning how to coordinate local and national conferences, mastering the many facets of running an ultrasound program and achievement of the RDMS (registered diagnostic medical sonographer) degree. Applications for the fellowship should be submitted from Sept-Nov. Selected applicants should send a CV and letter of intent to the Fellowship Directors at E-mails below. See attached LAC+USC EUS Fellowship Curriculum as attached PDF document.

LAC+USC Emergency Ultrasound Faculty:

Phillips Perera, MD RDMS FACEP
Associate Clinical Professor in Emergency Medicin
Emergency Ultrasound Program and Fellowship Co-Director
pperera1@mac.com

Thomas Mailhot, MD RDMS
Assistant Clinical Professor in Emergency Medicine
mergency Ultrasound Program and Fellowship Co-Director
Los Angeles County+USC Medical Center
mailhot@usc.edu

Dina Seif, MD
Clinical Instructor in Emergency Medicine
Emergency Ultrasound Fellow
Los Angeles County+USC Medical Center
seifdina@gmail.com

Jeannine Childs, RDMS
Emergency Ultrasound Faculty
Los Angeles County+USC Medical Center
jmchilds@yahoo.com

Diku Mandavia, MD RDMS FACEP
Associate Clinical Professor in Emergency Medicine
Emergency Ultrasound Program Senior Advisor
Los Angeles County+USC Medical Center
mandavia@usc.edu

Attachments:

1) LAC+USC EUS Curricular Doc
2) PGY-2 EM Ultrasound Rotation Guidelines
3) USC-KECK SOM EUS Rotation Guidelines
4) LAC+USC EUS Fellowship Guidelines

Links:

1)Wisdem.net- www.wisdem.net
Residency site for important forms and schedules.  Includes ultrasound QA for and yearly ultrasound OSCE forms.  Look under forms section.

2) SoundBytes-
Online ultrasound curriculum for LAC+USC EM Residency. Located at www.sound-bytes.tv or via www.cmedownload.com then courses at upper left, then SoundBytes as alphabetically arranged on page.

3) Sonoguide-
Online textbook of emergency ultrasound created by ACEP. Located at http://www.sonoguide.com/

4) ACEP Test-
Online test for assessment of knowledge base in emergency ultrasound. Sections created by LAC+USC EUS faculty.  Located at http://www.emsono.com/acep

5) ACEP Ultrasound Section Website-
Located at http://www.acep.org/ultrasound/
Current editors of this website include LAC+USC EUS Faculty

6) SAEM Ultrasound Academy Website-
Online resource of emergency ultrasound by SAEM. Located at http://www.saem.org/academy-emergency-ultrasound-library

7) Emergency Ultrasound Fellowship Guide:
Online guide for fellowships in emergency ultrasound. Located at http://www.eusfellowships.com/

University of Southern California University of Southern California