Point-of-Care Ultrasound (POCUS)

Educational Goals & Objectives

Family Medicine physicians manage a vast array of medical conditions where a timely and accurate diagnosis is paramount to patient outcomes. This pursuit of diagnostic excellence has been transformed by the advent of new imaging technologies, specifically Point-of-Care Ultrasound (POCUS). Often referred to as the "stethoscope of the future," POCUS is now an essential tool for the modern physician. Our longitudinal POCUS curriculum is designed to help residents become competent in the cost-effective use of ultrasound imaging for the evaluation and treatment of disease. Residents will gain hands-on experience in:

Operating point of care ultrasound modalities and interpreting real-time findings
Distinguishing between normal and abnormal anatomy
Recognizing ultrasonographic markers of common diseases
Utilizing ultrasound guidance to increase the safety and success of interventional procedures

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive, and appropriate care for patients in the course of evaluating and treating disease.

II. Residents will develop a fundamental knowledge of how POCUS can augment information derived from the history and physical exam.

III. Residents should become familiar with the indications, contraindications, complications, limitations, alternatives and interpretation of the following ultrasound studies:

Limited echocardiography
Lung
Abdomen
Retroperitoneum (kidneys, bladder, aorta)
Lower extremity proximal deep veins
Skin and soft tissue
Eye
OB/GYN

IV. All residents should be able to understand the role of imaging guidance to facilitate common radiological procedures, become familiar with, and develop competence in the following ultrasound guided procedures:

Paracentesis
Thoracentesis
Central line placement
Arterial line placement
Lumbar puncture

V. All residents will develop skill in use of point-of care ultrasound, when possible, in the following areas:

Cardiac – obtain standard echocardiography views, including parasternal long/short, apical four-chamber, and subxiphoid; identify pericardial effusion; assess for mitral regurgitation and aortic stenosis; estimate ejection fraction; examine IVC
Chest – identify pleural effusion, location of lung, and safest location for thoracentesis; identify pneumothorax
Abdomen – identify ascites, common locations for paracentesis, largest fluid pocket, and safest locations for paracentesis. Identify the liver and gallbladder; diagnose or exclude cholelithiasis; assess sonographic Murphy's sign
Vascular – identify jugular vein/carotid artery, common femoral vein/artery; differentiate vein from artery; check patency; identify proximal lower extremity DVTs
Renal/bladder – evaluate for presence/absence of hydronephrosis, urinary retention
Aorta – evaluate for AAA
Eye – evaluate for vitreous detachment, retinal detachment, vitreous hemorrhage, central retinal artery occlusion
Skin/Soft Tissue – evaluate for cellulitis, abscess, necrotizing soft tissue infection, joint effusions, ligamentous and tendinous injuries

Medical Knowledge

I. PGY1 and PGY2s will develop an understanding of the appropriate use of POCUS for imaging for patients with the following presenting conditions:

Abdominal aortic aneurysm
Acute abdomen
Acute hypoxic respiratory failure
Ascites
Bladder outlet obstruction
Cardiac tamponade
Congestive heart failure
Deep venous thrombosis
Gallstones
Hydronephrosis
Myocardial infarction
Pleural effusion
Pneumothorax
Pneumonia
Pulmonary embolism
Renal failure
Shock

PGY3s will be able to interpret results within the context of patient comorbidities, pretest probability of disease, and sensitivity and specificity of the study.

Practice-Based Learning and Improvement

I. All residents should

Be able to use the EMR to access radiology studies
Be able to access current national guidelines to apply evidence-based strategies to the appropriate use of echo and ultrasound studies and procedures
Develop progressive independence in understanding studies aimed at evaluating the utility of POCUS and interventional techniques in patient care, through Journal Club and independent study
Participate in case-based decision-making

II. All residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

I. All residents must demonstrate organized and articulate electronic and verbal communication skills that convey information to other health care professionals, and provide timely documentation in the chart as appropriate.

II. Residents should understand and comply with HIPPA with respect to use of health information.

III. PGY3s must be able to obtain consent for procedures in situations with complex social dynamics, for example, when identifying the power of attorney or surrogate decision maker is required.

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

II. PGY1 and PGY2s should be able to counsel patients and families on decisions involving ultrasound studies and procedures.

III. PGY3s should be able to provide constructive criticism and feedback to more junior members of the team.

Systems-Based Practice

I. PGY1 and PGY2s must be able to identify current quality issues in use of POCUS for diagnosis and treatment.

II. PGY3s must also demonstrate an awareness of alternatives in discussing interventional procedures and their costs, risks, and benefits and ensure appropriate EMR documentation of POCUS findings.

Teaching Methods

I. Supervised hands-on POCUS training sessions using live models, followed by review of normal and pathological images to reinforce learning.

II. Bedside didactics with faculty incorporating POCUS into routine clinical practice

III. Conferences

Specialty-specific didactics

IV. Independent study

Journal and Textbook reading TBD by POCUS attending
Online educational resources
- Performing a Basic US Examination
- Atlas of Radiological Images
- The following POCUS resource list was developed by Dr. Dversdal, the Director of the Oregon Health & Science University Point of Care Ultrasound and General Medicine Ultrasound Fellowship Director and provides an initial foundation for all learners:
  - POCUS Resource Handout
  - Cardiac Limited Ultrasound Examination (CLUE) webinar
  - Basic abdomen for internist by Irene Ma
  - PEARLS physical exam with pocket size US by Janice Boughton & Mike Wagner
  - IMpocus: a weekend on the wards
  - The Evidence Atlas (subset of POCUS atlas): fantastic compilation of evidence, including brief synopses of journal articles, tables with sensitivity/specificity, positive/negative likelihood ratios, and PMID with link to PubMed for article
  - Ultrasound of the week Tools page: Includes amazing stuff programmed by Dr. Ben Smith including sonogif (can deidentify, trim & convert to gif all in 1 program), clipdeidentifier, and several tutorials to make your US presentations better
  - Ultrasound Podcast
- Core Ultrasound
- ACP Online
- Butterfly Online Learning Modules
- Up to Date
- Clinical Key

Evaluation

I. Verbal ongoing individual feedback

II. Attending written evaluation of resident at the end of the year based on monthly observations and chart review

Rotation Structure

I. Monthly hands-on POCUS training sessions will occur at a predetermined time and location. Information will be provided ahead of time by the Program Administrator and POCUS faculty. During these sessions, residents may work with several attendings as well as with the ultrasonographers to develop POCUS and procedural skills

Residents are expected to complete assigned prework prior to hands-on POCUS training sessions.

II. Residents can check out hand-held ultrasound probes from the Program Administrator to use on service. The goal is to incorporate POCUS into routine clinical practice. **Note, residents are personally responsible for the probe until it is returned to GME.**

III. After residents have completed 25 scans of a particular organ system (e.g., cardiac, lung, abdomen, renal/bladder, DVT, eye, MSK), they can request an in-person skills and knowledge exam with POCUS faculty. If the resident achieves a passing score, they will be given a Certificate of Competence for POCUS in that particular organ system.

Practical Approach to Learning POCUS

Theory of Learning POCUS

Image Production: Learn probe placement, preset settings, and image adjustment through didactics and practice to obtain optimal images.
Pattern Recognition: Review online resources to distinguish normal anatomy from pathology.
Interpretation into Clinical Context: Taking the normal or abnormal images obtained and recognized and placing that into the context of the patient to improve management.
Feedback Loop: Upload images to storage software for preceptor review and feedback.

Modules and Basic Curriculum CMH Ventura

We will use the following free sources for the curriculum to guide independent learning of POCUS:

Butterfly Education - access Butterfly content online using your Butterfly login online or the Butterfly app on your phone or tablet.

ACP Online
Core Ultrasound
Sonosite courses and webinars - Go to Sonositeinstitute.com and obtain logon credentials using the serial number of one of our machines in MMG or the ER serial number 04X1FW.

Prior to attending hands-on POCUS scanning sessions, residents should watch relevant videos for that day’s instruction within a given curriculum. It is not necessary to watch all the Butterfly, Core Ultrasound, ACP, and Sonosite videos for each day, but residents should watch all of the videos provided by a particular instructional program.

Fundamentals
Butterfly:
US Physics
Introduction to POCUS Procedures

Cardiac/cardiovascular
Core Ultrasound:
How to Obtain Cardiac Windows
Basic Cardiac Function
Pericardial Effusion
Right Heart Strain

Butterfly:
Cardiac 1 – Basic Views
Cardiac 2 – Pericardial Effusion
Cardiac 3 – LV Systolic Function
Cardiac 4 – RV Assessment
Cardiac 5 – IVC

ACP:
Focused Cardiac Ultrasound

Abdomen
Core Ultrasound:
Gallbladder
E-FAST

Butterfly:
Gallbladder
E-FAST

ACP Members:
Gallbladder
Intraabdominal Free Fluid

Sonosite:
Gallbladder (3h, but you can skip the introduction and pretest)

Aorta
Butterfly:
Aorta

Core Ultrasound:
AAA

ACP Members:
AAA

Sonosite:
Course: Aorta (2hr 8min)