Timothy Jang

Compression Ultrasonography of the Lower Extremity With Portable Vascular Ultrasonography Can Accurately Detect Deep Venous Thrombosis in the Emergency Department

STUDY OBJECTIVE Compression ultrasonography of the lower extremity is an established method of detecting proximal lower extremity deep venous thrombosis when performed by a certified operator in a vascular laboratory. Our objective is to determine the sensitivity and specificity of bedside 2-point compression ultrasonography performed in the emergency department (ED) with portable vascular ultrasonography for the detection of proximal lower extremity deep venous thrombosis. We did this by directly comparing emergency physician-performed ultrasonography to lower extremity duplex ultrasonography performed by the Department of Radiology. METHODS This was a prospective, cross-sectional study and diagnostic test assessment of a convenience sample of ED patients with a suspected lower extremity deep venous thrombosis, conducted at a single-center, urban, academic ED. All physicians had a 10-minute training session before enrolling patients. ED compression ultrasonography occurred before Department of Radiology ultrasonography and involved identification of 2 specific points: the common femoral and popliteal vessels, with subsequent compression of the common femoral and popliteal veins. The study result was considered positive for proximal lower extremity deep venous thrombosis if either vein was incompressible or a thrombus was visualized. Sensitivity and specificity were calculated with the final radiologist interpretation of the Department of Radiology ultrasonography as the criterion standard. RESULTS A total of 47 physicians performed 199 2-point compression ultrasonographic examinations in the ED. Median number of examinations per physician was 2 (range 1 to 29 examinations; interquartile range 1 to 5 examinations). There were 45 proximal lower extremity deep venous thromboses observed on Department of Radiology evaluation, all correctly identified by ED 2-point compression ultrasonography. The 153 patients without proximal lower extremity deep venous thrombosis all had a negative ED compression ultrasonographic result. One patient with a negative Department of Radiology ultrasonographic result was found to have decreased compression of the popliteal vein on ED compression ultrasonography, giving a single false-positive result, yet repeated ultrasonography by the Department of Radiology 1 week later showed a popliteal deep venous thrombosis. The sensitivity and specificity of ED 2-point compression ultrasonography for deep venous thrombosis were 100% (95% confidence interval 92% to 100%) and 99% (95% confidence interval 96% to 100%), respectively. CONCLUSION Emergency physician-performed 2-point compression ultrasonography of the lower extremity with a portable vascular ultrasonographic machine, conducted in the ED by this physician group and in this patient sample, accurately identified the presence and absence of proximal lower extremity deep venous thrombosis.

The Learning Curve of Resident Physicians Using Emergency Ultrasonography for Cholelithiasis and Cholecystitis

BACKGROUND Emergency department bedside ultrasonography (EUS) can expedite treatment for patients. However, it is unknown how much experience is required for competency in the sonographic diagnosis of cholelithiasis and cholecystitis. OBJECTIVES The objective was to assess the learning curve of physicians training in right upper quadrant (RUQ) EUS. METHODS This was a prospective study at an urban, academic emergency department from August 1999 to July 2006. Patients with suspected biliary tract disease underwent RUQ EUS followed by abdominal ultra sonography (AUS) by the Department of Radiology. Results of EUS were compared to AUS using a predesigned, standardized data sheet. RESULTS A total of 1,837 patients underwent EUS by 127 physicians. The overall sensitivity and specificity of EUS for cholelithiasis were 84% (95% confidence interval [CI] = 81% to 86%) and 86% (95% CI = 83% to 88%), respectively. The overall sensitivity of EUS for ductal dilation, gallbladder wall thickening, pericholecystic fluid, and sludge were each < 60%. When analyzing the EUS test characteristics, for every increase in 10 examinations up to 50 examinations, there was no significant improvement in the sensitivity or specificity for any of these sonographic findings. Moreover, on probit regression analysis, accounting for clustering or correlation among the examinations performed by each of the operators, there was no improvement for detecting any of the sonographic findings except for pericholecystic fluid for every 10 additional examinations performed. CONCLUSIONS When adjusting for operator dependence, performing up to 50 EUS examinations appears to have little effect on the accuracy of RUQ EUS. Rather than simply requiring an arbitrary number of examinations, another method of competency assessment may be necessary.

Bedside ocular ultrasound for the detection of retinal detachment in the emergency department.

OBJECTIVES Acute retinal detachments (RD) can be difficult to diagnose and may require emergent intervention. This study was designed to assess the performance of emergency department ocular ultrasound (EOUS) for the diagnosis of RD. METHODS This was a prospective, observational study using a convenience sample of emergency department (ED) patients. Physicians performed EOUS for the diagnosis of RD prior to evaluation by an ophthalmologist. The criterion standard was the diagnosis of a RD by the ophthalmologist who was blinded to the results of EOUS. RESULTS Fifteen physicians evaluated 48 patients with acute visual changes. Eighteen patients (38%) had RDs and all were correctly identified (true positives). Of the 30 patients (62%) without RD, 25 patients were correctly identified (true negatives), and five patients with vitreous hemorrhages were misidentified as having RDs (false positives). Therefore, the sensitivity and specificity of EOUS for RD were 100% (95% confidence interval [CI] = 78% to 100%) and 83% (95% CI = 65% to 94%), respectively. CONCLUSIONS Emergency department ocular ultrasound is sensitive for the diagnosis of RD and may have a role in excluding RD in patients presenting to the ED.

Residents Should Not Independently Perform Focused Abdominal Sonography for Trauma After 10 Training Examinations

Objectives. To assess whether 10 focused abdominal sonography for trauma (FAST) examinations could be used as a minimum standard for training, as suggested previously. Methods. This was a retrospective review of patients with abdominal trauma who underwent resident‐performed FAST examinations before surgical or Department of Radiology evaluation. Results. Six hundred ninety‐eight patients were examined by resident‐performed FAST followed by reference standard evaluations. Four hundred twelve patients were evaluated by residents who previously performed 10 FAST examinations; 154 were evaluated by 29 residents performing their 11th through 30th examinations; and 258 were evaluated by 10 residents performing their 31st and subsequent examinations. The results of resident‐performed FAST for intraperitoneal free fluid were as follows: 11 to 20 examinations—sensitivity, 73.9% (95% confidence interval, 51.3%–88.9%); specificity, 98.8% (92.5%–99.9%); true‐positive findings, 17; true‐negative, 81; false‐positive, 1; false‐negative, 6; total patients, 105; 21 to 30 examinations—sensitivity, 100% (73.2%–100%); specificity, 97.1% (83.3%–99.9%); true‐positive, 14; true‐negative, 34; false‐positive, 1; false‐negative, 0; total patients, 49; 31 and more examinations—sensitivity, 94.8% (88.6%–97.9%); specificity, 98.6% (94.5%–99.8%); true‐positive, 110; true‐negative, 140; false‐positive, 2; false‐negative, 6; total patients, 258. Conclusions. The suggestion that 10 examinations could be used as a minimum standard for training in FAST examinations was not validated.

Bedside ultrasonography for the detection of small bowel obstruction in the emergency department

Background Plain film radiography (x-ray) is often the initial study in patients with suspected small bowel obstruction (SBO) to expedite patient care. Objective To compare bedside ultrasonography (US) and x-ray for the detection of SBO. Methods This was a prospective study using a convenience sample of patients presenting to the emergency department (ED) with abdominal pain, vomiting, or other symptoms suggestive of a SBO. Patients were evaluated with US prior to x-ray and CT. US was performed by emergency physicians (EPs) who completed a 10 min training module and five prior US exams for SBO. The criterion standard for the diagnosis of SBO was the results of CT read by board-certified radiologists. Results In all, 76 patients were enrolled and evaluated with US for SBO. A total of 33 (43%) were diagnosed as having SBO. Dilated bowel on US had a sensitivity of 91% (95% CI 75 to 98%) and specificity of 84% (95% CI 69 to 93%) for SBO, compared to 27% (95% CI 14 to 46%) and 98% (95% CI 86 to 100%) for decreased bowel peristalsis on US. x-Ray had a sensitivity of 46.2% (95% CI 20.4 to 73.9%) and specificity of 66.7% (95% CI 48.9 to 80.9%) for SBO when diagnostic, but was non-diagnostic 36% of the time. Conclusion EP-performed US compares favourably to x-ray in the diagnosis of SBO.

The learning curve of resident physicians using emergency ultrasonography for obstructive uropathy.

BACKGROUND Given the time, expense, and radiation exposure associated with computed tomography (CT), ultrasonography (US) is considered an alternative imaging study that could expedite patient care in patients with suspected obstructive uropathy. However, there is a paucity of literature regarding bedside US for obstructive uropathy in the emergency department (ED), and it is unknown how much experience is required for competency in such exams. OBJECTIVES The objective was to assess the learning curve for the detection of obstructive uropathy of resident physicians training in ED bedside US (EUS) during a dedicated EUS elective. METHODS This was a prospective cohort study of residents participating in an EUS elective. Patients presenting with acute abdominal or flank pain suggestive of an obstructive uropathy were enrolled and underwent EUS prior to noncontrast CT. Physicians who had previously performed at least 10 EUS exams for obstructive uropathy recorded results on a standardized data sheet, which was subsequently compared to the results of noncontrast CT read by board-certified radiologists blinded to the results of the EUS. In addition to an unadjusted chi-square test for trend, a multivariable logistic regression analysis, adjusting for stone size and operator, was performed. Finally, generalized estimating equations were used to describe test characteristics while accounting for potential clustering between exams by operator. RESULTS Twenty-three resident physicians participated and enrolled a convenience sample of 393 patients. A total of 157 patients (40%) were diagnosed with an obstructing ureterolith, and three (1%) were diagnosed with nonobstructing ureterolithiasis. An unadjusted chi-square test for trend demonstrated a statistically significant increase in both sensitivity (χ(2) = 11.4, p = 0.02) and specificity (χ(2) = 6.4, p = 0.04) for each level of increase in number of exams. On multivariable regression analysis, when adjusting for size of stone and operator, for every five additional exams after the first 10 EUS exams, the odds ratio for a true positive for obstruction increased by 1.7 (95% confidence interval [CI] = 1.2 to 2.5, p = 0.003). After accounting for clustering of exams by operator, overall EUS sensitivity and specificity for obstructive uropathy were 82% (95% CI = 77% to 87%) and 88% (95% CI = 85% to 92%). Stratifying by number of exams, the sensitivity was 72% (95% CI = 62% to 80%) for the 11th through 20th exams, 90% (95% CI = 83% to 96%) for the 21st through 30th exams, and 95% (95% CI = 91% to 99%) for the 31st through 43rd exams. Likewise, specificity was 82% (95% CI = 75% to 89%) for the 11th through 20th exams, 90% (95% CI = 85% to 95%) for the 21st through 30th exams, and 92% (95% CI = 86% to 98%) for the 31st through 50th exams. CONCLUSIONS Physicians training in EUS may be able to accurately assess for obstructive uropathy after 30 exams.

Learning Curve of Emergency Physicians Using Emergency Bedside Sonography for Symptomatic First-Trimester Pregnancy

Objective. The purpose of this study was to prospectively assess the learning curve of emergency physician training in emergency bedside sonography (EBS) for first‐trimester pregnancy complications. Methods. This was a prospective study at an urban academic emergency department from August 1999 through July 2006. Patients with first‐trimester vaginal bleeding or pain underwent EBS followed by pelvic sonography (PS) by the Department of Radiology. Results of EBS were compared with those of PS using a predesigned standardized data sheet. Results. A total of 670 patients underwent EBS for first‐trimester pregnancy complications by 1 of 25 physicians who would go on to perform at least 25 examinations. The sensitivity and specificity of EBS for an intrauterine pregnancy increased from 80% (95% confidence interval [CI], 71%–87%) and 86% (95% CI, 76%–93%), respectively, for a physicians first 10 examinations to 100% (95% CI, 73%–100%) and 100% (95% CI, 63%–100%) for those performed after 40 examinations. Likewise, the sensitivity and specificity for an adnexal mass or ectopic pregnancy changed from 43% (95% CI, 28%–64%) and 94% (95% CI, 89%–97%) to 75% (95% CI, 22%–99%) and 89% (95% CI, 65%–98%), whereas the sensitivity and specificity for a molar pregnancy changed from 71% (95% CI, 30%–95%) and 98% (95% CI, 94%–99%) to 100% (95% CI, 20%–100%) and 100% (95% CI, 81%–100%). Although detection of an intrauterine or a molar pregnancy improved with training, even with experience including 40 examinations, the sensitivity of EBS for an adnexal mass or ectopic pregnancy was less than 90%. Conclusions. There is an appreciable learning curve among physicians learning to perform EBS for first‐trimester pregnancy complications that persists past 40 examinations.

The Technical Errors of Physicians Learning to Perform Focused Assessment With Sonography in Trauma

OBJECTIVES The objective was to assess the incidence of various technical errors committed by emergency physicians (EPs) learning to perform focused assessment with sonography in trauma (FAST). METHODS This was a retrospective review of the first 75 consecutive FAST exams for each EP from April 2000 to June 2005. Exams were assessed for noninterpretable views, misinterpretation of images, poor gain, suboptimal depth, an incomplete exam, or backward image orientation. RESULTS A total of 2,223 FAST exams done by 85 EPs were reviewed. Multiple noninterpretable views or misinterpreted images occurred in 24% of exams for those performing their first 10 exams, 3.6% for those performing their 41st to 50th exams, and 0% for those performing their 71st to 75th exams (Cochran-Armitage trend test = 10.5, p < 0.0001). A single noninterpretable view, poor gain, suboptimal depth, incomplete exam, or backward image orientation occurred in 48% of exams for those performing their first 10 exams, 17% for those performing their 41st to 50th exams, and 5% for those performing their 71st to 75th exams (Cochran-Armitage trend test = 11.6, p < 0.0001). CONCLUSIONS The incidence of specific technical errors of EPs learning to perform FAST at our institution improved with hands-on experience. Interpretive skills improved more rapidly than image acquisition skills.

The Competency-Based Mandate for Emergency Bedside Sonography Training and a Tale of Two Residency Programs

ord Smith, past president of the Royal College of Surgeons in England, once said, “It would take me one year to teach a trainee how to do an operation, five years to teach them when to do the operation, but a lifetime to teach them when not to do an operation.”1 A clinically competent physician possesses the ability to practice independently and is proficient across several domains, including knowledge, procedural skill, the ability to interpret and integrate the results of tests, and overall medical judgment. With regard to emergency bedside sonography, physician-sonographers must possess (1) an understanding of the disease processes and indications for this diagnostic modality, (2) technical skills to acquire appropriate and interpretable images, (3) the ability to reliably interpret sonograms, and (4) management skills to apply the findings in light of their patient’s clinical presentation. Recently, the Accreditation Council for Graduate Medical Education (ACGME) and the Emergency Medicine Residency Review Committee (RRC) adopted an outcomes-based approach to accreditation. Therefore, since the RRC designated emergency sonography as 1 of 3 core procedures assessed during accreditation visits,2 every emergency medicine (EM) training program must provide evidence of both training and competency assessment of residents to perform emergency sonography that “impact patient care.”2 However, the RRC only requires each program to assess competency and does not itself ensure the competency of individual graduates to perform emergency sonography. Although the RRC and American College of Emergency Physicians (ACEP) describe models for emergency sonography training and assessment in their guidelines,2,3 neither mandates specific training or assessment requirements. The ACEP recommends a minimum of 25 examinations per indication (eg, biliary, trauma, and renal) but acknowledges that proficiency may not always be defined by miniAddress correspondence to Timothy B. Jang, MD, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles Biomedical Institute at Harbor-UCLA, 1000 W Carson Ave, D-9A, Torrance, CA 90502 USA E-mail: tbj@ucla.edu

Prehospital Spirituality: How Well Do We Know Ambulance Patients?

OBJECTIVE To assess the religious spirituality of EMS personnel and their perception of the spiritual needs of ambulance patients. METHODS Emergency medical technicians (EMTs) and paramedics presenting to an urban, academic emergency department (ED) were asked to complete a three-part survey relating to demographics, personal practices, and perceived patient needs. Their responses were compared to those of ambulance patients presenting to an ED during a previous study period and administered a similar survey. RESULTS A total of 143 EMTs and 89 paramedics returned the surveys. There were 161 (69.4%) male and 71 (30.6%) female respondents with a median age range of 26-35 years old. Eighty-seven percent believed in God, 82% practiced prayer or meditation, 62% attended religious services occasionally, 55% belonged to a religious organization, 39% felt that their beliefs affected their job, and 18% regularly read religious material. This was similar to the characteristics of ambulance patients. However, only 43% felt that occasionally ambulance patients presented with spiritual concerns and 78% reported never or rarely discussing spiritual issues with patients. Contrastingly, > 40% of ambulance patients reported spiritual needs or concerns at the time of ED presentation, and > 50% wanted their providers to discuss their beliefs. Twenty-six percent of respondents reported praying or meditating with patients, while 50% reported praying or meditating for patients. Females were no more religious or spiritual than males, but were more likely to engage in prayer with (OR = 2.38, p = 0.0049) or for (OR = 6.45, p < 0.0001) patients than their male counterparts. CONCLUSION EMTs and paramedics did not perceive spiritual concerns as often as reported by ambulance patients, nor did they commonly inquire about the religious/spiritual needs of patients.