Emory University
Atlanta, GA

Program Description
Our fellowship individualizes the second- and third-year experience to target the career goals of trainees by enrolling them in one of two pathways. Our Clinical Experts engage in a rigorous clinical experience with participation in clinical research and academic writing. Our Clinician-Scientists complete core clinical training prior to joining our NIH-funded Training Grant. These academic pathways provide the necessary protected time to develop a career in either clinical research or basic science.

Type of Program
Pulmonary and Critical Care

Number of Fellows in Program
14

Abstract Authors
Ahmed Khan₁, William Hunt₁, David Green₁, Timothy Udoji₁, Carter Co₁, David Quintero₁, Eliza Bacot₁, Rabih Bechara₁, Gautam Kumar₂, David Schulman₁

Submitter(s) of Abstract
David A. Schulman, MD

BACKGROUND
The portability and low cost of ultrasound make it an important point-of-care tool in modern critical care medicine. Critical care practitioners trained in the use of ultrasound can improve patient safety and obtain key bedside information about patients’ volume status, cardiac function, chest and abdominal pathology_1-3. The Accreditation Council for Graduate Medical Education (ACGME) currently requires fellows to demonstrate knowledge of “imaging techniques commonly employed in the evaluation of patients…including the use of ultrasound”₄. To our knowledge, few teaching institutions have employed structured curricula to develop pulmonary and critical care fellows’ ultrasound proficiency in accordance with ACGME recommendations. Therefore, we created a formal curriculum designed to foster the acquisition and maintenance of minimal competence in basic critical care ultrasound.

METHODS
A curriculum was structured to provide focused and high-yield learning objectives that met the minimum ultrasound competence outlined by previously-published consensus statements_5,6. The instructors constructed the course using a three-phase approach that involved initial core training, maintenance of skills, and immediate and longitudinal evaluation.

Initial training featured 16 hours of combined lecture series and supervised hands-on training sessions with consenting critical care patients. The lecture material reviewed basic ultrasound physics and key learning objectives required to achieve competence with acquisition and interpretation of vascular, abdominal, thoracic, and echocardiography images (Table 1). The value of the echocardiography portion of the course was enhanced by interdepartmental collaboration with the Division of Cardiology and exploration of cadaveric hearts provided by the medical school anatomy lab.

Multiple choice pre- and post-tests and direct instructor observation were used to evaluate the immediate impact of the course on fellows’ image interpretation and acquisition skills respectively. A Likert-scale survey was conducted to determine self-reported comfort interpreting ultrasound images. To reinforce initial training concepts, fellows were asked to log ultrasound images acquired during their clinical rotations and present them at monthly review sessions proctored by a course instructor. Long-term concept and skill retention will be assessed using a capstone objective structured clinical examination (OSCE), whereby fellows will be directly observed during a series of patient encounters and provided formal feedback. Finally, fellows will be required to demonstrate procedural competence using ultrasound while performing diagnostic thoracentesis, paracentesis, and central vein cannulation. Each fellow will be required to perform three successful ultrasound-guided procedures in each category, and one procedure must be supervised by a course instructor.

RESULTS
Following initial training, the mean score on the combined vascular, abdominal and thoracic image interpretation test improved from 72% to 89% (p<0.01) (Figure 1). Less pronounced, but significant increases in the group mean score were achieved on the echocardiogram image interpretation test after initial training (Figure 1).

Upon receiving the initial training, all fellows demonstrated competence acquiring and interpreting the vascular, thoracic, abdominal, and four-chamber echocardiogram images highlighted in Table 1. The Likert-scale survey revealed that fellows felt significantly more comfortable interpreting ultrasound images after course instruction (Figure 2).

CONCLUSIONS
We developed a novel curriculum to train and evaluate fellows in basic critical care ultrasonography. As assessed by both objective testing and subjective measures of self-reported comfort, the course increased our fellows’ critical care ultrasound competence. This experience should encourage other training programs to establish similar ultrasound competence initiatives for incoming members of the critical care profession.

REFERENCES
1. Jones AE, Tayal VS, Sullivan DM, et al. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med 2004; 32:1703-1708
2. Lichtenstein D, Goldstein I, Mourgeon E, et al. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 2004; 100:9-15
3. Randolph AG, Cook DJ, Gonzales CA, et al. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996; 24:2053-2058
4. American College of Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Pulmonary Disease (Internal Medicine) 2012. Online:http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PRFAQ PIF/156_pulmonary_critical_care_int_med_07132013_TCC.pdf. Accessed December 8, 2012
5. 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 2009; 135:1050-1060
6. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: A consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010; 23:1225-1230