The Status of Bedside Ultrasonography Training in Emergency Medicine Residency Programs

Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published "Model of the Clinical Practice of Emergency Medicine," which includes BU as a necessary skill. OBJECTIVE: The authors sought to determine the current status of BU training in EM residency programs. METHODS: A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey. RESULTS: A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place. CONCLUSIONS: The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.     

经腹部彩色多普勒超声联合高频超声诊断良性胆囊息肉样病变的价值

目的探讨经腹部彩色多普勒超声(腹部超声)联合高频超声诊断良性胆囊息肉样病变的价值。方法回顾性分析2008年1月-2011年11月121例腹部超声联合高频超声检查提示为良性胆囊息肉样病变、且有手术病理检查结果的患者资料进行对照,以此评价经腹部超声联合高频超声对良性胆囊息肉样病变的诊断准确性。结果 121例术前经腹部超声联合高频超声诊断为良性胆囊息肉样病变的患者,手术后病理检查结果示胆固醇息肉62例(51.24%),炎性息肉27例(22.31%),腺瘤6例(4.96%),腺癌3例(2.48%),胆囊结石14例(11.57%),腺肌症3例(2.48%),囊壁腺体结构紊乱3例(2.48%),黏膜下层软结节3例(2.48%)。经腹部超声联合高频超声与手术后病理对比检查,其诊断符合率为78.51%(95/121),误诊率为21.49%(26/121)。结论经腹部超声联合高频超声检查对良性胆囊息肉样病变诊断准确性较高,可为临床预防胆囊癌前病变提供依据。     

Bedside Emergency Department Ultrasonography in the Evaluation of Ocular Pathology

The number of potential uses of emergency department (ED) ultrasound is growing. This brief report describes its use in two ED patients who presented with acute ocular pathology. The diagnoses were quickly made with ED ultrasound, and subsequently confirmed with more traditional methods of ocular evaluation.     

A Study of Bedside Ocular Ultrasonography in the Emergency Department

The use of ocular ultrasonography for the evaluation of emergency patients has recently been described in the emergency medicine (EM) literature. There are a number of potential uses that may greatly aid the emergency physician (EP) and avoid lengthy consultation or other diagnostic tests. OBJECTIVE: To examine the accuracy of bedside ultrasonography as performed by EPs for the evaluation of ocular pathology. METHODS: This prospective, observational study took place in a high-volume, suburban community hospital with an EM residency program. All patients arriving with a history of eye trauma or acute change in vision were eligible to participate in the study. A 10-MHz linear-array transducer was used for imaging. All imaging was performed through a closed eyelid, using water-soluble ultrasound gel. Investigators filled out standardized data sheets and all examinations were taped for review. All ultrasound examinations were followed by orbital computed tomography or complete ophthalmologic evaluation from the ophthalmology service. Statistical analysis included sensitivity, specificity, and positive and negative predictive values. RESULTS: Sixty-one patients were enrolled in the study; 26 were found to have intraocular pathology on ultrasound. Of these, three had penetrating globe injuries, nine had retinal detachments, one had central retinal artery occlusion, and two had lens dislocations. The remaining pathology included vitreous hemorrhage and vitreous detachment. Emergency sonologists were in agreement with the criterion standard examination in 60 out of 61 cases. CONCLUSIONS: Emergency bedside ultrasound is highly accurate for ruling out and diagnosing ocular pathology in patients presenting to the emergency department. Further, it accurately differentiates between pathology that needs immediate ophthalmologic consultation and that which can be followed up on an outpatient basis.     

Decreasing Length of Stay with Emergency Ultrasound Examination of the Gallbladder

OBJECTIVE: To determine whether patients who received emergency screening ultrasound examinations (ESUEs) of the gallbladder by emergency physicians (EPs) have a shorter ED length of stay (LOS) than do those receiving ultrasound studies from radiology. METHODS: A retrospective chart review from July 1995 to August 1998 identified 1,242 patients who received gallbladder ultrasound examinations. Seven hundred fifty-three patients received ESUEs by EPs of varying levels of ultrasound experience. Four hundred eighty-nine patients received gallbladder ultrasound examinations from radiology, and were not scanned by EPs. The LOSs of the two groups were compared. Significance was evaluated using a two-tailed t-test. RESULTS: When patients received an ESUE by an EP, the median LOS was 7% (22 min) less than that for those who received an ultrasound examination by radiology (p = 0.017; 95% CI = 4 min to 41 min). When evaluated by disposition, patients discharged home and scanned by EPs had their median LOSs shortened by 11% or 32 minutes (p = 0.02; 95% CI = 5 min to 55 min). When evaluated by time of day, patients who presented after hours (6 PM-6 AM) and were scanned by EPs spent 15% (52 min) less time in the ED (p = 0.0002; 95% CI = 26 min to 89 min). Those who were seen after hours and discharged home had their LOSs shortened by 20% (1 hr, 13 min, p = 0.001; 95% CI = 28 min to 1 hr, 56 min). CONCLUSIONS: In a teaching hospital with a residency program, ESUEs decrease ED LOS for these patients. The difference was most apparent for patients presenting after hours.     

超声造影在胆囊胆固醇性息肉诊断中的临床应用价值

目的:探讨超声造影对胆囊胆固醇性息肉的诊断及临床应用价值。材料与方法:对照手术病理结果,回顾性分析总结38例46枚胆囊胆固醇性息肉的超声影像资料。常规超声观察息肉的大小、形态、回声、彩色多普勒血流以及胆囊壁是否光滑完整,超声造影以同深度的肝脏增强方式作为参考,实时观察胆囊壁及息肉的增强时相及增强模式。结果:常规超声表现38例46枚胆囊胆固醇性息肉中,直径4~25 mm,平均9.5 mm,10 mm 33枚,≥10 mm 13枚;单发9例,多发29例,多发时选取最大一枚进行观察,或在同一切面上观察多枚病灶;菜花形21枚,长椭圆形10枚,乳头状15枚。彩色多普勒显示10枚胆囊息肉内测及血流信号(10/46),其中10 mm 4枚,≥10 mm 6枚。实时超声造影显示:增强方式上,46枚病灶均有增强,胆囊壁光滑整齐与病灶界限清晰,其中:高增强39枚(39/46),等增强7枚(7/46);病灶动脉期增强快于肝实质38枚(38/46),与肝实质同步8枚(8/46);蜂窝样增强31枚(31/46),整体增强15枚(15/46);在减退方式上,慢于肝实质减退36枚(36/46),与肝实质同步减退10枚(10/46);29枚病灶可见明显的蒂。结论:超声造影可提高胆囊胆固醇性息肉的血流显示率;蜂窝样增强,基底较窄,可见蒂,慢于或同步于肝实质减退是诊断胆囊胆固醇性息肉的主要超声表现;超声造影为临床选择治疗方式提供依据,具有重要的参考价值。     

Emergency Evaluation of Patients Presenting with Acute Scrotum Using Bedside Ultrasonography

Acute scrotal pain is not a rare emergency department (ED) complaint. Traditional reliance on medical history and physical examination can be precarious as signs and symptoms can overlap in various etiologies of acute scrotal pain. OBJECTIVE: To determine the accuracy with which emergency physicians (EPs) using bedside ultrasonography are able to evaluate patients presenting to the ED with acute scrotal pain. METHODS: The study was performed at an urban community hospital ED with a residency program and an annual census of 70,000. A retrospective chart review identified 36 patients who presented with complaints of acute scrotal pain and were evaluated by EPs using bedside ultrasound. A 5.0- or 7.5-MHz linear-array transducer with color and power Doppler capability was used to scan the scrotum. Patients were seen between July 1998 and September 1999. Diagnoses were verified by radiology or surgery. Sensitivity and specificity with 95% confidence intervals were calculated. RESULTS: The EP ultrasound examinations agreed with confirmatory studies for 35 of 36 patients, resulting in a sensitivity of 95% (95% CI = 0.78 to 0.99) and a specificity of 94% (95% CI = 0.72 to 0.99). Diagnoses included three testicular torsions, six cases of epididymitis, four cases of orchitis, one testicular fracture, three hernias, three hydroceles, and 15 normal examinations. One case of epididymitis was misdiagnosed as an epididymal mass. CONCLUSIONS: This study suggests that EPs using bedside ultrasonography are able to accurately diagnose patients presenting with acute scrotal pain. In addition, they appear able to differentiate between surgical emergencies, such as testicular torsion, and other etiologies.     

Emergency Medicine Resident Rotation in Pediatric Emergency Medicine: What Kind of Experience Are We Providing?

OBJECTIVES: To characterize emergency medicine (EM) residents' clinical experience during a pediatric emergency medicine (PEM) rotation. METHODS: Prospective observational study of EM resident-patient encounters in a children's hospital emergency department (ED). RESULTS: Fifty-six residents participated in the study. The mean (+/-SD) patient age was 6.3 (+/-5.6) years. Ambulatory infectious disease, respiratory illness, and wound management represented almost 50% of final diagnoses. Six and a half procedures/resident were performed per rotation, mainly nonemergent procedures, whereas resuscitations and child abuse evaluations were rare. A minority of patients required data interpretation: 34.4% had laboratory testing, 24.6% had radiographic studies, and 2.3% had electrocardiograms. CONCLUSIONS: Analysis of patient encounters during a PEM rotation showed deficiencies in critical care procedures, resuscitations, child abuse evaluations, and neonatal evaluations. Quantitative data of skills utilized during rotations can be used by residency programs to identify and correct deficiencies in their residents' PEM education.     

84例胆囊切除术后胆囊床的影像分析

本文分析８４例胆囊切除术后胆囊床部位Ｂ超影像特征，其中２９例为形态不规则的实体样光团，５５例为类似胆囊息肉、类似正常小胆囊、类似急性胆囊炎或合并胆囊结石及类似慢性胆囊炎等“伪胆囊”影像。认为，“伪胆囊”影像形态各异，其产生机制与病史、病理变化及手术方式等因素密切相关；患者手术后近期复查，或出现腹痛、发烧、黄疽等症状时，Ｂ超检查不仅需注意探查胆道及腹腔变化，还应注意观察胆囊床处“伪胆囊”影像的变化，这将有利于术后并发症的早期发现。因此，分析研究胆囊切除后胆囊床处“伪胆囊”影像，有一定临床诊断价值。     

B超对胆囊内隆起型病变的鉴别诊断

为探讨Ｂ型超声对胆囊内隆起型病变的鉴别诊断，将３２例经手术病理证实的患者Ｂ超检查结果作了分析。结果显示：（１）各类不同病理性质的胆囊隆起型病变，其病变的大小、数目和发生部位均有一定差异。本组中息肉病变、腺瘤和腺癌其病灶最大直径均值分别为９ｍｍ、１９．８ｍｍ和４２ｍｍ。（２）声像图的形态也各异，胆囊息肉多为乳头状或颗粒状，呈强回声或等回声，有蒂与胆囊壁相连，后方不伴声影，腺癌为不规则乳头状或分叶状，呈强回声、基底窄，腺癌多为半圆形或圆球形，基底宽、内部回声强弱不均等特征。     

The Use of Simulation for Emergency Medicine Resident Assessment

Simulations are exercises designed to mimic real-life situations in which learners are given the opportunity to reason through a clinical problem and make critical decisions without the potential of harming actual patients. Simulation, using a variety of formats, is useful for assessing the core competencies-particularly patient care (decision making, prioritizing, procedural skills), interpersonal skills (team leadership, communication), and systems-based practice (team structure and utilization, resource use). High-fidelity computerized human simulators are a relatively new tool for use in medical simulation. These realistic mannequins mimic physical findings including respiratory rate, breath sounds, central and peripheral pulses, murmurs, and pupil reactivity. They generate an electrocardiographic (ECG) waveform, cardiac indices, and oxygen saturation that can be viewed on standard cardiac monitoring equipment and can be programmed to respond physiologically to medications and invasive procedures. The use of human simulators to reproduce life-threatening situations will be especially useful in assessing the clinical competence of emergency medicine physicians. Operational definitions of competence and tools with which to evaluate performance must first be developed. Standardization of scenarios and evaluation tools will permit assessment of the reproducibility of scenarios and the reliability and validity of the tools used to measure competence.     

Gallbladder wall thickening in mononucleosis syndromes.

PURPOSE: We used sonography to measure gallbladder wall thickness in patients with mononucleosis syndromes and then evaluated laboratory data, spleen size, and clinical evolution to assess any relationship between gallbladder wall thickening (GBWT) and the severity of disease. METHODS: We retrospectively reviewed the medical records, sonograms, and sonographic reports of 39 patients who were diagnosed with mononucleosis syndromes on the basis of fever, tonsillopharyngitis, cervical adenopathy, hepatosplenomegaly, and lymphocytosis with atypical lymphocytes. All 39 were included in the study. The gallbladder wall thickness in each patient was sonographically determined. GBWT was defined as a wall thickness exceeding 3 mm. We assessed the laboratory data and clinical evolution in each patient, and the differences between patients with and without GBWT were statistically analyzed. RESULTS: Six patients (15%) had GBWT. The mean atypical lymphocyte count +/- standard deviation (SD) in the patients with GBWT (1,830/microl +/- 1,000/microl) was significantly higher than that in patients without GBWT (1,140/microl +/- 660/microl; p < 0.05). The mean total serum protein and serum albumin levels in the patients with GBWT (6.6 mg/dl +/- 0.7 mg/dl and 3.7 mg/dl +/- 0.5 mg/dl, respectively) were significantly lower than those in patients without GBWT (7.3 mg/dl +/- 0.4 mg/dl and 4.1 mg/dl +/- 0.3 mg/dl, respectively; p < 0.05). The duration of hospitalization in the patients with GBWT (14 +/- 8.5 days) was significantly higher than that in patients without GBWT (8 +/- 3.5 days; p < 0.05). CONCLUSIONS: GBWT in mononucleosis syndromes may be a sign of the severity of the illness and when present indicates the need to carefully monitor the clinical course.     

Elevated Intracranial Pressure Detected by Bedside Emergency Ultrasonography of the Optic Nerve Sheath

Patients with altered level of consciousness may be suffering from elevated intracranial pressure (EICP) from a variety of causes. A rapid, portable, and noninvasive means of detecting EICP is desirable when conventional imaging methods are unavailable. OBJECTIVES: The hypothesis of this study was that ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) could accurately predict the presence of EICP. METHODS: The authors performed a prospective, blinded observational study on emergency department (ED) patients with a suspicion of EICP due to possible focal intracranial pathology. The study was conducted at a large community ED with an emergency medicine residency program and took place over a six-month period. Patients suspected of having EICP by an ED attending were enrolled when study physicians were available. Unstable patients were excluded. ONSD was measured 3 mm behind the globe using a 10-MHz linear probe on the closed eyelids of supine patients, bilaterally. Based on prior literature, an ONSD above 5 mm on ultrasound was considered abnormal. Computed tomography (CT) findings defined as indicative of EICP were the presence of mass effect with a midline shift 3 mm or more, a collapsed third ventricle, hydrocephalus, the effacement of sulci with evidence of significant edema, and abnormal mesencephalic cisterns. For each patient, the average of the two ONSD measurements was calculated and his or her head CT scans were evaluated for signs of EICP. Student's t-test was used to compare ONSDs in the normal and EICP groups. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Thirty-five patients were enrolled; 14 had CT results consistent with EICP. All cases of CT-determined EICP were correctly predicted by ONSD over 5 mm on US. One patient with ONSD of 5.7 mm in one eye and 3.7 mm in the other on US had a mass abutting the ipsilateral optic nerve; no shift was seen on CT. He was placed in the EICP category on his data collection sheet. The mean ONSD for the 14 patients with CT evidence of EICP was 6.27 mm (95% CI = 5.6 to 6.89); the mean ONSD for the others was 4.42 mm (95% CI = 4.15 to 4.72). The difference of 1.85 mm (95% CI = 1.23 to 2.39 mm) yielded a p = 0.001. The sensitivity and specificity for ONSD, when compared with CT results, were 100% and 95%, respectively. The positive and negative predictive values were 93% and 100%, respectively. CONCLUSIONS: Despite small numbers and selection bias, this study suggests that bedside ED US may be useful in the diagnosis of EICP.     

The Impact of Environmental Factors on Emergency Medicine Resident Career Choice

OBJECTIVE: To evaluate the impact of environmental factors on emergency medicine (EM) resident career choice. METHODS: Program directors of all U.S. EM residencies were surveyed in November 1997. A 22-item questionnaire assessed resources allocated to research, fellowship availability, academic productivity of faculty and residents, and career choices of residency graduates. RESULTS: The response rate was 83%. The program director (mean+/-SD) estimates of resident career choice were as follows: 27.8+/-19.1% pursued academic positions with emphasis on teaching, 5.4+/-9.8% pursued academic positions with emphasis on research, and 66.8+/-23.1%, pursued private practice positions. In addition, 5.70+/-6.13% of the residency graduates were estimated to seek fellowship training. Univariate analyses demonstrated that increasing departmental funding for research, having substantial resource availability (defined as having at least two of the following: dedicated laboratory space; support for a laboratory research technician/assistant, a clinical research nurse or study coordinator, a statistician, or an assistant with a PhD degree), a greater number of peer-reviewed publications by residents (r = 0.22; p = 0.08), and a greater number of peer-reviewed publications by faculty (r = 0.26; p = 0.04) positively correlated with the percentage of graduates who pursue academic research careers. Using multiple regression, however, increasing intramural funding and the presence of substantial resource availability were the only variables predictive of resident pursuit of an academic research career. CONCLUSION: Modification of the EM training environment may influence the career choices of graduates. Specifically, greater commitment of departmental funds and support of resources for research may enhance the likelihood of a trainee's choosing an academic research career.     

胆囊息肉样病变B超与X线,手术,病理对照（附71例分析）

Ｂ超诊断为胆囊息肉样病变（简称胆囊息肉）１８５例，其中行手术切除者７１例。将Ｂ超与Ｘ线口服胆囊造影（简称胆囊造影）以及手术标本与病理进行比较，结果：Ｂ超检出率达１００％，胆囊造影仅１８．３％；手术中触及胆囊内有块物的仅２例，Ｂ超直径分别为１２及１６ｍｍ，病理检查皆呈腺瘤型改变，其余６９例较小或多发的息肉，手术中均未及肿块，病理检查均为胆固醇沉积，本组７１例皆未发现癌变征象，但直径＞１０ｍｍ的２例腺瘤型息肉则有不规则的腺上皮增生。作者认为：对息肉一般不须特殊处理，但Ｂ超定期随访很有必要     

超声和CT诊断胆囊息肉样病变的对照分析

目的　评价超声和CT对胆囊息肉样病变的诊断价值。方法　收集经手术和病理证实的胆囊息肉样病变 90例 ,对其超声和CT检查结果进行分析。结果　超声检查和CT诊断的符合率分别为 94.4%和 41.1%。结论　对胆囊息肉样病变的诊断价值 ,超声明显优于CT。     

超声胃镜在胆囊病变诊断中的意义

本文回顾分析103例非结石性胆囊病变超声内镜（EUS）检查结果，并与体表超声及手术后病理进行比较，以分析EUS在胆囊病变诊断中的意义。103例胆囊病变中，EUS诊断胆囊炎1例，胆囊息肉82例，胆囊腺肌瘤6例，胆囊癌10例，胆囊腺瘤4例；体表超声诊断胆囊息肉74例，其余2例误诊，6例漏诊，诊断胆囊癌6例，其余4例误诊，6例胆囊腺肌瘤体表超声均未做出诊断。12例胆囊疾病患者行手术治疗，与术后病理比较，EUS诊断正确率为75％，体表超声为41．6％。EUS对胆囊息肉、胆囊癌及胆囊腺肌瘤诊断符合率为100％，体表超声为55．6％。3例EUS误诊病例，2例为胆囊壁纤维化伴泥沙样结石，1例为化脓性胆囊炎，均误诊为胆囊占位性病变。结论。我们认为EUS对胆囊病变具有较高的诊断价值。