Welcome to your ED Ultrasound block!  The following is a syllabus to guide you in getting the most out of your ultrasound block, knowing our expectations, and your objectives during your ultrasound month.  

My rotation starts tomorrow… what’s the TL;DR??

  • Rotation starts on Monday at 9am. Meet in the trauma bay. A faculty member will be with you scanning most days, but occasionally due to scheduling conflicts, vacations, conferences, board examinations, and life, residents may have to scan alone some days.

  • This is a link to the US Division’s shared google calendar. Please take a look at it to figure out who you’re scanning with and what the dedicated topic is each day of the block. You do not NEED to only scan these types of scans, but the goal would be to review this material at bare minimum so you’re having a well-rounded education. You won't necessarily get a testicular scan or TVUS on your dedicated day. That's OK. At bare minimum try to watch a lecture on the suggested topic the night before or the morning before you come to shift (see attachments for some helpful resources). Keep the scan types you perform varied (do as many of these as possible when you have the opportunity: DVT, TV/TA pelvic, testicular, ocular, aorta, bowel/appy) and avoid just doing a bunch of heart/lung scans. Practice PIVs when you can, but again, your goal here is education. Attendings have been told to limit their requests for you to function as the ED US IV team… no more than two or three in a shift!

  • Everyone make an effort to physically scan. Even if that means switching off during a single patient encounter. A minimum goal of 20 scans per day would be ideal. DO NOT add any resident to the operator section unless they are present and scanning while you are scanning. We do not give credit to multiple people for scans just because they referred the team to scan their patient.

  • Tape review (TR) takes place on Fridays starting at 12pm. You guys are to scan from 9am to around 12p then grab food and join us for tape review at the EM house across the street.

  • Performance is assessed using three things:

    • OSCE where you perform bedside scans with an attending supervising you and prompting you with questions. Will take place on Thursday of the final week barring scheduling conflicts.

    • Written exam on the last Friday of the block. It is administered in the EM house. Show up at 10am to take the test at the EM house. You do not need to scan from 9am to 12pm on the final friday of the block.

    • Case Of the Week write up and presentation.

PLEASE READ THE SECTIONS BELOW FOR FURTHER RELEVANT DETAILS REGARDING YOUR ROTATION AND RESIDENT EXPECTATIONS FOR ULTRASOUND AT NYPQ.

 Scan Shifts and Tape Review

Your scan shifts are 9-5pm Monday, Tuesday, and Thursday. Tape review occurs every Friday. Because this means fewer days total scanning, Friday morning 9am-12pm will time for additional unsupervised scans in the ED prior to tape review. The faculty and fellows will be performing the administrative responsibilities of tape review during that time. Before leaving the ED for tape review on Friday, please clean the machines well (wipe all cords, screen, handles, even cart if needed, make sure no extra supplies are in the attached baskets). Then, grab food and come join us to eat in the EM house conference room for tape review. The goal of tape review is to assess your image acquisition skills, knowledge base, and to perform quality assurance. We often look up CTs and patient charts, do follow ups, etc. This gives you an opportunity to log patient follow ups with the Medhub app if you really want to! I highly urge you to do this so you don’t have to do all of them at the end of the year when Dr. Parikh ultimately requests it anyways.

The strategy of scan shifts: I think it’s most educational to not know the diagnosis so you can take a H&P and incorporate your findings into your assessment of what’s going on, then check back to see if you were right or wrong. Ask the teams if they have any interesting findings on CT or any patients that have a clinical question worth attempting to answer. Otherwise, just scroll through the track board (don’t forget teal and grey- there’s good MSK and eye complaints in EDS) too find potential candidates. Make sure you are BOTH scanning patients. Alternate even on the same patient encounter. EG PGY1 do Heart, PGY2 do lung, PG1 do GB, etc.

PGY1/PGY2 is excused for the critical care component of the rotation, whenever those conflict with scanning.

Lastly, I personally care more about quality over quantity and only want you guys to learn as much as possible. In general, but especially while you have faculty/fellows available for teaching, definitely focus on the scans most residents struggle to meet numbers with and historically feel uncomfortable performing on their own: DVT, transvaginal, pediatric (appy, intussusception, pyloric stenosis), and testicular scans. Despite caring most about your learning, the total number of scans performed does matter and will be tracked.

Feel free to seek out rare procedures, intubations, or other areas of interest while on US. That is totally part of the combined US/Critical Care rotation!

Expected Ultrasound Scan Numbers 

At bare minimum someone needs to be present for the scan to receive credit. Popping their head in, being present in the trauma bay during an alpha, asking you to scan their patient, etc., does not qualify someone to get credit for a scan. DO NOT ADD EVERY RESIDENT TO THIS LIST JUST BECAUSE THEY ASKED YOU TO SCAN IT. We will tally in tape review.

Minimum number of ultrasound scans required by:

End of PGY1 – 125 scans 

End of PGY2 – 325 scans 

End of residency – 400 scans 

**These numbers are very low and easily achievable if you keep your scan types diverse while on your US rotation and you do a minimum of 20 scans each day. Set this goal for yourselves so this isn’t an issue closer toward graduation!

CURRENT RESIDENT SCAN NUMBERS

To meet ACEP ultrasound requirements for graduation, we ask that you have 25 completed scans in each of the following: 

  • Aorta - AAA evaluation

  • eFAST

  • Biliary/RUQ

  • Cardiac

  • LE DVT

  • Lung

  • Transabdominal pelvic - how to evaluate for IUP and first trimester pregnancy (this is specifically what ACEP deems within the scope for ED practice)

  • Transvaginal pelvic - how to evaluate for IUP and first trimester pregnancy

  • Renal/Bladder 

  • MSK/Soft Tissue - hip US, pediatric fractures (supracondylar), shoulder US, cellulitis/abscess, rib fractures, flexor tenosynovitis, foreign body evaluation (this is why remembering to scan the Gray team is so important).

  • Ocular US

  • RUSH exam

  • Bowel - appendicitis, small bowel obstruction, intussusception, diverticulitis

  • Vascular Access

Other scans that should be studied and practiced during your block include:

  • Testicular

  • Peritonsillar Abscess

  • Cardiac Arrest

  • Procedures

    • Peripheral IV

    • Central Line

    • Paracentesis

    • Arthrocentesis

    • US-guided LP

    • Regional Anesthesia

      • Fascia Illiaca

      • PENG

      • Serratus Anterior

      • Supraclavicular Brachial Plexus

      • Interscalene

      • PECS1 and PECS2

      • Transgluteal Sciatic Nerve Block

      • Upper extremity / Forearm (median, ulnar, and radial) nerve blocks

      • Hematoma blocks

Logging and Documenting Scans:

Click end before starting an official scan (often prior images from another patient’s educational scan are present without knowing, so clicking END study first helps make sure this isn’t the case).

Scans will either be EDUCATIONAL or OFFICIAL/BILLING studies.  

An EDUCATIONAL study is not meant to influence a patient’s management/course and is not to be recorded in the patient chart; when documented it should be referred to as an educational scan and the need for formal testing required as followup (e.g. “bedside educational ultrasound shows reduced ejection fraction without apparent pericardial effusion. formal confirmation with TTE recommended.”)  When performing an EDUCATIONAL study, the patient must have a confirmatory study (ie. Radiology ultrasound, CT, xray, etc.).  When entering information for an EDUCATIONAL study on the Midray/Zonare machines it should be as follows (DO NOT ENTER THE MRN):

Patient ID: autogenerated ONCE AN IMAGE IS SAVED — there is a current technical hiccup with the machines where the autogenerated ID is not being generated initially if the machine has a barcode scanner installed. It waits for the scanner to populate the code. Saving a blank image with auto-generate a study ID.

MRN: ALWAYS BLANK

Last name: LASTNAME

First name: FIRSTNAME

Operator/Ref Physician: the first name first initial and the first three initials the last name of the people performing the exam. e.g. NZAR, JFRE, HPAR, etc. This is how we know who to give credit to.

OFFICIAL/BILLING studies are meant to influence the patient’s management/course, are uploaded to PACS and viewable by all physicians and are documented by the ED in the patient’s chart.Therefore IF YOU SCAN A PATIENT’S WRISTBAND, YOU ARE RESPONSIBLE FOR MAKING SURE THERE IS A NOTE IN THE PATIENT’S CHART.  OFFICIAL/BILLING Studies can only be done with credentialed clinicians.  Generally, these credentialed clinicians are only emergency ultrasound-trained faculty members. The exceptions to this are that ALL attending physicians are credentialed to perform US-guided peripheral IVs, eFAST studies, and bladder volume assessments.  All OFFICIAL/BILLING studies must be accompanied by an “Ultrasound Procedure Note.”

Patient ID: SCAN THE BLACK SIDE OF THE PATIENT WRIST BAND (scanning the red side will generate a different number starting with A####### - clearly not a MRN, please do not scan the red barcode).

MRN: ALWAYS BLANK

Last name: Last name

First name: First name

Operator/Ref Physician: the first name first initial and the first three initials the last name of the people performing the exam. e.g. NZAR, JFRE, HPAR, etc.This is how we know who to give credit to.


If you scan a black barcode, you are responsible for making sure the note is in EPIC. You may have to ask the team or the scribe of the team who requested you to do the scan to document PIV, eFAST, or Bladder Scan Ultrasound Procedure Note once you finish the scan. Otherwise, document it yourself since you are responsible for the images being uploaded into the patient’s chart.


How you are graded:

Resident Case of The Week (COW)

Each resident is responsible for 1 case of the week each rotation. This involves a written portion which can form the basis for your slides when you present at morning report. The goal is a short 5-10 minute presentation of something you learned while in tape review or on scan shift. You will present it at morning report on Monday at 9am of the third or fourth week of the block depending on your PGY level. It may be an awesome clip of something familiar or a rare clip of something you’ve never heard of. It may be something you knew nothing about so you read something on it and thought it was interesting. It can be anything. You’ll find a lot of cool ideas in TR.

You are to write up the case you choose in google doc form as if it were a case report: A very brief HPI or one liner, US findings, and an explanation or description of those findings and the implications for management are key. Avoid using patient names and keep identifying details out of your write up please! All images or information should be cited in AMA format when appropriate. Use this write up to make a slideshow for your COW presentation at Morning Report on the Monday scheduled below. This will ensure you know what you’re going to talk about and the findings to go over before you present.

Make sure the ultrasound faculty has approved your case/topic at least THREE DAYS BEFORE you are going to present it (i.e. after tape review the FRIDAY BEFORE the week of your presentation at the very latest). You may also request official CT/US if you feel it will be helpful but give ample heads up so it can be downloaded and deidentified as well. We will post these clips/GIFs in the residency dropbox under NYPQ Ultrasound Division > US images for COW with your name on the folder for you to download to incorporate into your write up. These images will be shared Instagram with links to your post on Kwaktalk.

Dr. Joann Hsu and our fellow are going to be responsible for reviewing these write ups for quality, accuracy and eventual sharing via Social Media. Please email her and the fellow, and cc Nate with the google document link once written.

COW Schedule:

First Monday of the block - Fellow/Faculty

Second Monday of the block - Fellow/Faculty

Third Monday of the block - PGY2 presentation

Fourth Monday of the block - PGY1 presentation 

End of Rotation OSCE and Written Exam

OSCE

During the last week of ultrasound, you will have a written exam, as well as an OSCE to judge technical skills. OSCE will be combined with basic questions we expect you to know for each of the below scans. Please know the required images that need to be collected for each scan type.

We expect to test you on the following on your OSCE:

  • EFAST

  • IJ/femoral for CV access

  • Transvaginal US on sim model

  • 4 views for POC echo

  • Renal/bladder US
    Abdominal aorta

  • GB 

  • Lung US

This is timed and the grades include pass, conditional pass (borderline, needs practice), and fail.

If you fail, you must repeat the OSCE.  This may need to be done on a day you’re not on ultrasound if rotation is already finished.  

This is the form we use.

End of Rotation Examination

We’ve made PGY1 and PGY2 exams. They are intentionally challenging and the average is around 70%. Remember, this is only a component of the total overall grade. Answers will be submitted online and automatically scored. Results will be given to you in your end of rotation evaluation.

Submit answers using this form.

Here are some prior years’ tape review notes for more depth of information. I recommend looking over this as a study guide that may be helpful for the test.

Ultrasound Journal Club

Ultrasound journal club may occur while you’re on your rotation.  If this happens to occur during your rotation your ultrasound faculty will help you choose the article most of the time.  Many landmark/core ultrasound papers (in PDF form) can be found at the link below:  

EUS Teaching - Articles


ONLINE RESOURCES

Narrated lectures can be found at these sites. Please review the relevant lectures prior to coming to your scan shift for that day.

In my opinion, the best formal lecture style resources are below. These are very easy to sit and watch while eating dinner or something:

Academy of Emergency Ultrasonography (FOAM)

Emergency Ultrasound Teaching (some overlap with the above lectures)


Great written guides with imbedded videos, how to perform scans (with citations and evidence), etc, can be found at ACEP’s Sonoguide site. 

Shorter 5 minute videos (great to review while on shift prior to performing) can be found at Core Ultrasound

Clip banks and example pathology (useful for your COW presentations):

Core Ultrasound

The POCUS Atlas



Suggested Reference Text/Reading: Emergency

A copy of one of the best US Textbooks can be found in the residency dropbox - Ma and Mateer. NYPQ Ultrasound Division > US Textbooks > US Books.

For those who have apple books: Practical Guide to Critical Ultrasound (ACEP resource) and Bedside Ultrasound 1 & 2 by Mallin & Dawson are free, phenomenal resources available to you through the app store.


For those who like structure, A suggested educational plan:

Week 1

Mon

Tues

  • Ma&Mateer Chap 6: Cardiology

Thurs

Fri

Week 2

Mon

Tues

Thurs

Fri

Week 3

Mon

Tues

Thurs

Fri


Week 4

  • Study up, prepare for Written Exam, OSCE’s 


Other:

How to use our mindray ME8 (laptop) machine: See this video, courtesy of Brian Smith.