Introduction to Bedside Ultrasound
The use of ultrasound (US) is expanding into bedside diagnosis, often referred to as point-of-care ultrasound (POCUS). It is well documented that POCUS can supplement the physical exam. Internal medicine residents were 6 times more sensitive at detecting CVP > 10 with US than with their physical exam.1 Furthermore, when residents use daily POCUS of the IVC to manage diuresis of CHF exacerbations, they decreased the 30 day CHF readmissions from 30% to 4% in a prospective RCT without increasing the length of stay or AKI.2 POCUS assessment for DVT has shown 99% agreement with formal radiology US while reducing time to diagnosis by 2 hours.3 POCUS is twice as sensitive for pneumothorax than a portable CXR while maintaining the same specificity.4 Doctors at the front lines can now make focused assessments and initiate appropriate therapy in real time. As a result of the rapidly growing body of literature, the American Society of Echocardiography has endorsed POCUS and believes it will become apart of the core curriculum for internal medicine resident training.5
Point-of-care US is not meant to replace formal diagnostic US. Instead training focuses on accurately assessing a small number of well-defined clinically significant pathologies. For instance the UCLA training in cardiac POCUS is restricted to recognizing moderately reduced EF, severely reduced EF, moderate-to-large pericardial effusions, and right heart strain. Diagnosis of conditions other than these can generally be safely delayed while waiting for a formal echo. Critical care and emergency medicine have embraced POCUS, and hospitalists across the country are quickly catching up.4 Up to 25% of internal medicine residencies have POCUS training, and an additional 35% were planning on starting curriculums soon.6 Under the direction of Dr. Igor Barjaktarevic, Director of Critical Care Bedside US, and the leadership of Dr. Jason Williams, the Internal Medicine Residency Program has produced this POCUS curriculum.
- Understand the indications for ultrasound application
- Recognize the limitations of operator skill and ultrasound utility
- Become competent in image acquisition and interpretation
- Appropriately integrate ultrasound into clinical management
- Encourage a life-long learning of POCUS with a commitment to continued ultrasound education and quality improvement.
This is a 1-week introduction to POCUS will include online learning, didactics, simulation, hands on instruction, and feedback on image acquisition and interpretation. Following the elective, participants will continue practicing their skills as they build a portfolio of US images for further review and feedback. Educational content is tailored to the inpatient medicine domains below:
- US physics
- Limitations of US and responsible use
- Global LV function
- Pericardial effusion
- Right heart strain
- Inferior vena cava
- Jugular venous height
- Deep vein thrombosis
- Bladder distention
1. Brennan JM, Blair JE, Goonewardena S, et al. A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure. The American journal of cardiology 2007;99:1614-6.
2. Laffin LJ, Patel A, Saha N, et al. Inferior Vena Cava Measurements by Focused Cardiac Ultrasound in Acute Decompensated Heart Failure Prevents Hospital Readmissions. Journal of the American College of Cardiology 2014;63.
3. Theodoro D, Blaivas M, Duggal S, Snyder G, Lucas M. Real-time B-mode ultrasound in the ED saves time in the diagnosis of deep vein thrombosis (DVT). The American Journal of Emergency Medicine 2004;22:197-200.
4. Soni NJ, Lucas BP. Diagnostic point-of-care ultrasound for hospitalists. Journal of hospital medicine : an official publication of the Society of Hospital Medicine 2015;10:120-4.
5. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography 2013;26:567-81.
6. Schnobrich DJ, Gladding S, Olson AP, Duran-Nelson A. Point-of-Care Ultrasound in Internal Medicine: A National Survey of Educational Leadership. Journal of graduate medical education 2013;5:498-502.
7. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. CHEST Journal 2009;135:1050-60.