POCUS rotation

Introduction

Welcome to the UBC Internal Medicine Ultrasound and Procedures rotation!

This rotation has the potential to significantly increase your skill and knowledge in the area of point-of-care ultrasound (POCUS). Given that much of the rotation is self-directed, you will get out of this rotation what you put in.  

The importance of spending time at the bedside scanning cannot be overstated. Cardiac scanning in particularly takes significant time and repetition to begin to achieve competence – it may be frustrating at first, but the only way to improve is to keep scanning!

Our goal is that residents come out of this rotation with competence in the core scanning applications (see below), including image acquisition, image interpretation, a basic knowledge of the literature supporting POCUS, and an understanding of how to integrate POCUS findings clinically. This block is also designed to provide additional procedural experience, particularly with thoracentesis and paracentesis (+/- pigtail insertion).

Rotation Calendar

The UBC IM POCUS Rotation Google calendar serves as a monthly schedule of teaching activities, bedside scanning sessions, image review, etc.

Rotation Expectations and Activities

A. Hands-on scanning and image portfolio creation

This will make up the bulk of the rotation. On a daily basis, the POCUS service will receive consult requests from CTU, Hospitalists, and other specialties. In addition, you should be in contact with the CTU Sr Residents to identify patients who are appropriate to scan. This may include patients with:

• Undifferentiated pathology: patients presenting with dyspnea NYD (or “HF vs PNA vs COPD”), hypotension NYD, new cardiac murmurs, AKI (query pre-renal vs post-renal), etc

• Note that patients who are newly admitted/still in the ED often provide the most undifferentiated pathology and are excellent to scan

• Patients with known pathology to assess clinical change: reassessment of pulmonary edema in CHF patients, reassessment of cardiac function after introduction of medications, etc

• Patients with known pathology for educational purposes: known HFrEF, known valvular disease, known ILD, etc

• Patients with normal findings who are amenable to being scanned (particularly if they have good windows)

B.   Image Archiving

Formalized reporting is key for both quality assurance and education purposes; it serves to emphasize the interpretation and clinical integration aspects of POCUS.

We are using Qpath as our image archival system. You will be given an orientation on how to access the site on the first day. Images saved onto the POCUS machines will be automatically uploaded on to Qpath. Scans should be appropriately labelled. All scans (diagnostic and procedural) must be reported in Qpath. Choose the appropriate reporting form template on Qpath and complete the necessary information, including the indication, brief clinical Hx and summary of findings; but no identifiable patient information. After completion of the reporting form template, the form should be submitted to the fellow/staff for review. QA will be performed on each scan/report, and written and/or verbal (in-person) feedback will be given.

C.    Procedures

You are expected to provide procedural support when available. This will include both performing procedures yourself, as well as supervising CTU juniors who are performing procedures. Please see more information about the procedural aspect of the service in the Orientation document you should have received in your orientation email.

Note that we are NOT technicians; you should approach a request for a procedure as a limited consult, and your evaluation of the patient should include a brief chart review, POCUS evaluation, and discussion with the patient to see if the procedure is warranted.

If you go ahead with procedures, you are responsible for obtaining and documenting patient consent. If you end up performing the procedure, ensure you have written appropriate follow-up orders: CXR post-thoracentesis, orders to send fluid for analysis, clarification on when to clamp drains, albumin transfusion etc.

Please let the staff/fellow know as procedures come up. For the first week, we will be present for procedures to provide general supervision. After that, the need for staff/fellow presence will be determined on a case-by-case basis. If you are ever unsure about the safety of performing a procedure, always get in touch with the staff/fellow – they can come review images to determine if it is safe to proceed.

The CTU procedure cart is well-stocked for thoracentesis, paracentesis, pigtail insertion, LPs, etc. It is found in the back hallway between 10H and 10C. Door code is 4/2 – 3.

**Note for thoracic vs abdominal drains

• Abdominal drains/pigtails may be connected to Vaccutainers or Foley bags. Be sure to discuss with the bedside RN and the primary team re: amount to be drained, who is going to change the bag, when to clamp, etc.

• Thoracic drains/pigtails MUST be connected to a Pleurovac (unless only doing an in-and-out diagnostic thoracentesis). They required an airtight underwater seal (not present when the drain is connected to a Foley bag). Vaccutainers also provide this, but we generally prefer not to rapidly drain pleural effusions on suction (theoretical increased risk of symptoms and re-expansion pulmonary edema).

D.  Documentation and communication with the primary teams

You are expected to approach requests for diagnostic POCUS scans and procedures as “mini-consults.” Your evaluation should include a review of the chart - history, relevant labs, previous imaging – as well as your POCUS study. You will document your findings as a POCUS consult note. If a procedure (eg. thoracentesis, paracentesis) has been performed, an additional POCUS procedure note should document the procedural events, and any post-procedure instructions (see above). It is important to document a POCUS procedure note promptly, so that the healthcare teams are made aware of what was done for the patient. The POCUS consult note for the procedure can be written up at a later time.

Key information should be communicated directly (in person/via text) to the primary teams, and new nursing orders (eg. drain care) should be communicated directly to the nurse in-charge (see above).

E.   Image review sessions

Image reviews may be done at the end of the day, or as weekly scheduled image review sessions with the fellow/staff. We will review your images from the week and talk as a group about image optimization and interpretation, as well as review knowledge content.

F. Academic curriculum review and self-directed learning  

There will be didactic lectures throughout the block given by the staff/fellow.

You are also responsible for working your way through the expected curriculum material for each week. This includes scanning tutorials and other resources on the UBC IM POCUS website.

Rough outline of the expected curriculum to be covered is outlined in the Rotation Schedule below.    

G.    POCUS case-based presentation

During the block, you are asked to put together one clinical case where POCUS played a key role. This can be formatted as a powerpoint/keynote presentation and should include an initial clinical vignette (PMHx, Hx, Px, labs), POCUS findings (comprehensive studies of relevant areas), and a follow-up of their clinical course. It should also outline key POCUS learning points, and briefly touch on the supporting POCUS literature in that area.

These cases will be vetted by the fellow/staff and posted on the UBC IM POCUS website. You would have received instructions on how to retrieve the case template in your orientation email. Please ensure that all patient information is de-identified.

^ Top

Rotation Schedule      

 Outline for didactic/academic material (done both in-person with fellow/staff and self-directed). Self-directed learning videos can be found in “Learn POCUS” —> “Scanning tutorials” on the UBC IM POCUS website. It is recommended that self-directed learning videos are reviewed prior to the didactic sessions.

 Week 1

• Rotation Orientation

• Bedside focus: IVC/JVP, procedures (esp. paracentesis/thoracentesis), basic lung scanning

• Didactics: IVC, JVP, lung ultrasound basics

• Self-directed learning:
  - Scanning Basics: Machine Operation 101, Ultrasound Physics and Knobology, Probe manipulation
  - Vascular: JVP, IVC interpretation
  - Procedures: Paracentesis, Thoracentesis, Lumbar puncture
  - Lung: Lung US Image acquisition, Lung US Basics

Week 2

• Bedside focus: basic cardiac scanning, volume status assessment

• Didactics: Optimizing cardiac views, lung interstitial syndromes

• Self-directed learning:
  - Cardiac: Obtaining basic cardiac views
  - Lung: Lung US image acquisition and interpretation, Lung US interpretation, Pitfalls of lung US, Pulmonary edema, Consolidation, Pneumothorax
  - Fluid responsiveness and hemodynamics: Integrated IVC/Lung scan for fluid responsiveness

Week 3

• Bedside focus: LV systolic function, RV function, VExUS

• Didactics: LV systolic function, RV function, VExUS

• Self-directed learning:
  - Cardiac: LV function, RV assessment, Pericardial effusion
  - Clinical Integration: RUSH, EFAST exam
  - Venous congestion: Solid organ doppler for venous congestion

Week 4

• Bedside focus: Basic valve assessment, Exploring spectral doppler, hydronephrosis, DVT

• Didactics: Basic valve evaluation, Doppler physics and applications

• Self-directed learning:
  - Cardiac: Basic valve evaluation, Aortic sclerosis vs aortic stenosis
  - UBC IM POCUS tutorials: Principles of Doppler ultrasound, POCUS estimation of cardiac output
  - Abdomen: Hydronephrosis
  - Vascular: DVT

 ^ Top

Core Skills and Applications

A.  Ultrasound fundamentals

• Ultrasound physics

  • Understand how the ultrasound beam is produced

  • Understand basic ultrasound physics principles: frequency, reflection, attenuation, Doppler

  • Understand ultrasound artifacts and common pitfalls

  • Be able to apply basic physics principles to image acquisition

• Machine operation

  • Able to set up the machine: choosing the correct transducer and preset

  • Able to optimize the image using depth, gain, frequency, and focus

  • Able to use different modes appropriately: B-mode, M-mode, colour Doppler, spectral Doppler (advanced)

  • Able to save images and retrieve images from machines

By the end of your rotation, you should have an understanding of the following ultrasound domains and have accumulated scans in these areas (see section on specific quotas below):

B.  Vascular

• IJ

  • Estimate height of JVP

  • Recognize pitfalls and situations where US JVP may not be accurate, and proceed with caution when interpreting in these cases 

  • Recognize pathology that would make CVC placement difficult: narrow vessel, abnormal anatomy, thrombus

• IVC

  • Identify IVC and RA-caval junction, with hepatic vein in view

  • Measure IVC diameter and determine IVC collapsibility

  • Use IVC as part of volume status assessment and to determine fluid responsiveness/tolerance (in conjunction with cardiac/lung exam)

  • Recognize pitfalls and situations where IVC is not accurate, and proceed with caution when interpreting in these cases 

• Venous/arterial waveforms: carotid, hepatic, portal, renal interlobar, femoral

• DVT (optional)

  • Perform basic DVT study (femoral and popliteal) including compression at 5 key anatomic points: CFV, GSV takeoff, lateral perforator takeoff, DFV/SFV bifurcation, and popliteal vein 

C.  Thoracic (lung) ultrasound

• Basics

  • Perform systematic assessment of lung zones: 4-6 scans/side minimum

  • Understand the importance of beam orientation to produce lung artifacts

  • Able to recognize 4 basic lung artifact patterns: A-lines, B-lines, consolidation, and effusion

• Pneumothorax

  • Rule out/identify pneumothorax by the presence/absence of lung sliding

  • Differentiate pneumothorax from other causes of absent lung sliding

• Interstitial syndromes

  • Identify B-line pattern as diffuse vs patchy vs focal

  • Identify features (B-line distribution, pleural line characteristics) to help differentiate cardiogenic pulmonary edema from inflammatory interstitial syndromes

• Consolidation

  • Identify features that help differentiate atelectasis from pneumonia

• Pleural effusion

  • Identify pleural effusion and differentiate pleural effusion from contained fluid

  • Quantify pleural effusion

  • Identify features of complex pleural effusion/empyema

  • Recognize air-fluid levels in hydropneumothorax or empyema

  • Identify characteristics that differentiate complex effusion/empyema from lung abscess

  • Identify chest wall vessels to avoid during thoracentesis

• Integration

  • Interpret complete lung US and identify disease states based on patterns: pulmonary edema, pneumonia, dependent atelectasis 

D.  Abdominal ultrasound

• Basics

  • Identify basic abdominal anatomy (liver, spleen, kidneys, bladder, bowel and aorta)

  • Recognize ascites, complex ascites, and differentiate from pseudoascites

• Paracentesis

  • Recognize potential risks of paracentesis such as adhesions

  • Identify abdominal wall vessels to avoid during paracentesis

• Hydronephrosis

  • Be able to identify kidneys and bladder on ultrasound

  • Recognize moderate to severe hydronephrosis

• Bladder

  • Be able to identify bladder distention/retention

  • Recognize an in-dwelling urinary catheter in the bladder

• Bowel

  • Recognize features of bowel obstruction

E.  Basic cardiac ultrasound

• Basics

  • Acquire 4 basic cardiac views: parasternal long (PLAX), parasternal short (PSAX), apical 4-chamber (A4C), subxiphoid (subX)

  • Troubleshoot difficult cardiac windows and image optimization

  • Recognize the importance of using multiple views to reach conclusions

• LV systolic/diastolic function

  • Use Eyeball Method to categorize LV function: hyperdynamic, normal, moderately depressed, or severely depressed

    • Using 3 tools: myocardial excursion, myocardial thickening, and mitral valve EPSS (M-mode)

  • Estimate LA size using “rule of thirds” and recognize relationship of LA size to LVEDP, with LA enlargement a surrogate of possible HFpEF

• RV

  • Use 2/3 rule to identify RV enlargement (RV > 2/3 of LV)

  • Use TAPSE and RV free wall movement to assess RV function

  • Identify septal dyskinesia and flattening as a sign of RV pressure or volume overload

• Basic valvular assessment

  • Valve morphology

  • Use colour Doppler to identify severe valvular regurgitant lesions: MR, AR, TR

• Pericardial effusion

  • Identify pericardial effusion and estimate size (small/moderate/large)

  • Identify Echo features of cardiac tamponade including RA/RV collapse

    • Use in conjunction with IVC to rule out tamponade (if IVC normal)

• Advanced applications (optional)

  • Additional views including RV infow, apical 5/3/2 chamber, and subxiphoid short axis views

  • Learn the principles of spectral Doppler

  • Features of LV diastolic dysfunction (MV inflow, E/e’)

  • Cardiac output calculations (LVOT VTI)

  • RVSP estimation (TR jet) to detect elevated pulmonary pressures

  • Further assessment of valvular disease

F.  MSK

• Identify joint effusions: Knee, ankle, elbow, write, shoulder, hip

G.  Procedures with US guidance

• Thoracentesis

• Paracentesis

• LP (optional use of US guidance)

• CVC

• Arthrocentesis

• Peripheral IVs

• Principles of needle guidance

  • Machine operation

  • In plane and out of plane approach

  • Optimization of visualization

H.  Integration and application to clinical scenarios

• Clinical applications and limitations of estimating CVP

• Use of a systematic multi-system exam to determine the etiology of dyspnea and shock NYD

• Venous congestion and fluid tolerance vs fluid responsiveness

  • Use of serial, systematic, multi-system exams to guide resuscitative efforts including fluid delivery

 ^ Top

Exam quotas

These represent minimum numbers of recorded scans expected during a month-long rotation. You are encouraged to go above and beyond this to maximize your learning. Scans should meet the minimum criteria for that indication (see separate document/video).

• JVP: 5

• IVC: 10

• Lung: 20 comprehensive scans; including

  • 5 demonstrating an interstitial syndrome

  • 5 demonstrating pleural effusion

  • 5 demonstrating consolidation

  • Pneumothorax if encountered

• Cardiac: 20

  • At least10 of which are comprehensive scans with all 4 views (PSAX, PLAX, A4C, subxiphoid)

  • 5 with EF < 50% (seen in 2D and EPSS with M-mode)

• Abdomen: 10, including

  • 5 demonstrating ascites

• Comprehensive studies: 10

  • These must include full lung, cardiac, and IVC scans for a single patient. They should ideally be performed in the assessment of hypotension NYD, dyspnea NYD, or volume status determination

• Other: as encountered

  • Including DVT, hydronephrosis, joint effusions, abscess, lymphadenopathy, splenomegaly, etc

^ Top