POCUS

POCUS

Saint Joseph Hospital’s Internal Medicine program strives to keep its residents at the forefront of clinical medicine. The propagation of Point of Care Ultrasound (POCUS) in the field of internal medicine has increased exponentially. Residency programs across the country are trying to keep pace with this evolving technology, especially as evidence continues to accumulate in favor of its clinical utility. A successful POCUS program requires access to handheld ultrasound devices, qualified POCUS instructors and a robust quality assessment process. Saint Joe’s is one of a handful of programs that offers EACH RESIDENT THEIR OWN HANDHELD BUTTERFLY IQ+ system! These state-of-the-art ultrasound devices utilize microchip technology that creates a range of frequencies allowing for a wide array of imaging modalities including cardiovascular, pulmonary, abdominal, renal etc. These include advanced techniques like pulse wave and color flow Doppler, as well as M Mode. These devices also excel at procedural ultrasonography with the latest in biplane technology for vascular access. * For more information regarding the butterfly IQ+ system please visit: https://www.butterflynetwork.com/.

*Saint Joseph has no conflicts of interest to disclose regarding this product and has no direct financial ties with the Butterfly company.

Given the broad scope of POCUS applications, Saint Joe’s has implemented a multifaceted longitudinal curriculum, including ultrasound electives that combine traditional didactic teaching with extensive hands-on training. Residents have frequent opportunities for supervised scanning with POCUS faculty, while also having their own Butterfly handheld ultrasound device to assess patients and practice independently. To further encourage utilizing POCUS techniques, we have introduced game theory into POCUS education, creating an engaging team and individual learning environment. All residents have a dedicated video portfolio where their best images will be stored along with feedback for EACH image. The portfolio will mimic the requirements needed to complete the POCUS certification for the American College of Physicians, as well as the Society of Hospital Medicine. In addition, our POCUS program uses a novel tool called Probe Watch that records a trainee’s probe movement to give individualized recommendations regarding their probe motions.

Finally, Resident initiated POCUS research is strongly encouraged and supported. Current research projects include the identification of intercostal arteries for thoracentesis using POCUS and the ability of internal medicine residents to adequately categorize ejection fraction.

Meet the POCUS Faculty

Dr. Gerard Salame

Dr. Gerard Salame is a national expert in POCUS and is part of the national task force for ultrasound guided procedures sponsored by the Society of Hospital Medicine. He has been a POCUS educator for 12 years and guest speaker at multiple national venues including the Society of General Medicine, the Society of Hospital Medicine, the American Institute of Ultrasound in Medicine, among many others. He has dedicated his career to POCUS training and has infused game theory into various aspects of POCUS education. Since 2021 Dr. Salame has created a yearlong ultrasound competitions that helped boost ultrasound image submission significantly each year. For academic year 2023-24 the house staff have selected a Harry Potter themed competition. House staffs will be divided among the 4 houses and compete for the Triwizard Cup. Dr Salame is working alongside VR companies to help create a novel POCUS VR educational tool that he hopes to integrate into the POCUS curriculum In addition, Dr. Salame believes in a multifaceted approach to POCUS training ensuring frequent and recurrent interactions with all residents throughout the year.

Dr. Ken Lyn-Kew

Recognized as the one of the nation’s leading Pulmonary Critical Care experts, Dr. Lyn-Kew teaches critical care POCUS to residents during their ICU rotations with an emphasis on pulmonary ultrasound and ultrasound in shock. Dr. Lyn-Kew has taught POCUS nationally for the American College of Chest Physicians(ACCP), and has been honored as a Distinguished Chest Educator by the ACCP several years in a row. He has won the Residency “Teacher of the Year” award multiple times.

Education and Training

A. Curriculum

• The 3-year longitudinal POCUS curriculum parallels the requirements for POCUS certification from both the American College of Physicians and the Society of Hospital Medicine. Given the breadth of POCUS applications there is a strong emphasis on repetition and hands-on practice. Curricular goals for each PGY level are delineated in the table below. These goals are not exclusive to each PGY level and overlap frequently. First year house staff will solidify the basic applications of cardiopulmonary, abdominal, vascular, and renal POCUS. In their second year more advanced imaging techniques and POCUS protocols will be introduced. Third year residents will continue to hone their skills and be offered guidance on how to become better POCUS educators.
• All curricular content is maintained and accessible through a POCUS folder located in the residency website. The folder contains narrated lectures and power point presentations of all POCUS and POCUS ECG conferences.

PGY Level Curricular goals and Curricular Content/Expectations

Intern: Basic Applications and clinical integration of POCUS

• Cardiac: Basic Cardiac Views, Image optimization, Ejection Fraction Assessment, Chamber Quantification, Right Ventricle
• Pulmonary: Identification of lung Profiles, pneumothorax, pleural effusion
• Abdomen: Biliary tract, free fluid assessment
• Urinary tract: Renal ultrasound, identifying and staging hydronephrosis, bladder ultrasound and foley catheter assessment
• Vascular Ultrasound: DVT and IVC assessment, Peripheral artery disease identification

PGY2: Advanced Imaging Modalities and POCUS protocols

• Advanced Cardiac: Color Flow Doppler in valvulopathy, M Mode, HoCM, Regional ischemia
• Pulse Wave and continuous wave Doppler*
• Volume Assessment: Stroke volume and IVC
• Ultrasound in Shock: RUSH protocol Approach to the dyspneic patient: BLUE Protocol Ultrasound in Renal Failure
• Advanced Pulmonary Ultrasound: Lung Pulse, ARDS, and Atelectasis…

PGY 3: Becoming a POCUS educator/instructor

• Identifying/anticipating errors in novice POCUS users
• Presenting case conference ultrasound images
• Diastology

*If Residents complete advanced elective

B. Ultrasound Ward Rounds

• The aim of ultrasound Ward Rounds is to show the direct implementation of POCUS on patient care. Two to four times a month POCUS experts will touch base with non-ICU medicine teams to identify one of their respective patients to undergo a supervised POCUS evaluation. The POCUS assessment can occur either during or after rounds to answer a specific clinical question (e.g., EF evaluation), visualize a known pathology (e.g., pleural effusion) or simply practice their image acquisition skills. All images are obtained by residents and will count towards their monthly ultrasound quota. To minimize the interruption to the team’s workflow each assessment is limited to 7-10 minutes.

C. Yearlong Ultrasound Competition

• This exercise introduces game theory into POCUS education. At the beginning of the academic year residents are divided into 4 theme-based groups. Residents have the opportunity throughout the year to accumulate points for their respective groups (see table below for an example of the rules on point acquisition) and each month during POCUS conference the resident who contributed the most points to their team receives a small prize.

POCUS Competition

Awards

• Pathology of the Month: For the Most Fascinating Pathology (150 Points)
• Image of the Month: For the Most Perfect Image (150 Points)
• Dobby Awards: Nominate someone who helped you acquire the images (100 Points)
• Quota: Awarded for each person who reaches their ward ultrasound quota of 1 Full echo + 1 non-cardiac image (50 points)
• Horcruxes: Find the 7 rarest images if you dare!!
• Prolific Award: The Wizard with the most submitted images (100 Points)
• Seeker Award: Awarded to those who can identify pathologies as well as the Grand Master (150 Points)
• Special Events: Events throughout the year (Points Vary)

Horcrux: 250 Points

The 7 most sought-after Images!! These are the rarest of them ALL and each brave witch or wizard who captures them will be awarded the full 250 points.

1. Large Pericardial Effusion (>2cm) or Cardiac Tamponade Physiology
2. Pneumothorax with Lung Point
3. Infective Endocarditis with Vegetation (on any valve)
4. Pneumonia with Dynamic Air bronchograms
5. Stage III or IV Hydronephrosis
6. Intra-Vascular Clot either venous/arterial or cardiac
7. Loculated Pleural Effusion

D. Ultrasound Elective

• Basic level POCUS elective: Offered 6 times a year, this 5-day course offers intensive instruction of cardiopulmonary ultrasonography with two daily didactics and 4-5 hours of hands on supervised and unsupervised training. (See example curriculum below) This elective is a requirement for ultrasound credentialing by the residency program.
• Advanced POCUS Elective: Offered 1-2 times/year. This 5-day elective focuses on advanced imaging modalities such as pulse wave and continuous wave Doppler in vascular and cardiopulmonary ultrasonography.
• During the POCUS electives we utilize a novel device aptly named the Probe Watch. This quarter size device attaches to the ultrasound probe and records the trainee’s probe movement during image acquisition. This allows for personalized feedback of house staff’s probe “behavior” to assess their skill level in image acquisition.

Schedule

• Monday
• 8-9:00am (didactic): Welcome/Intro Pretest Cardiac Basics
• 9-11:30am: Un/Supervised Scanning
• 11:30-1:00pm: Lunch/Conf
• 1:30-2:00pm: Image Review
• 2:00-4:00pm: Unsupervised ScanningProbe Tracker
• Tuesday
  • 8-9:00am (didactic): EF Assessment
  • 9-11:30am: Un/Supervised Scanning
  • 11:30-1:00pm: Lunch/Conf
  • 1:30-2:00pm: Image Review RV/IVS Assessment
  • 2:00-4:00pm: Probe Tracker Unsupervised Scanning
• Wednesday
  • 8-9:00am (didactic): Lung Intro
  • 9-11:30am: Un/Supervised Scanning
  • 11:30-1:00pm: Lunch/Conf
  • 1:30-2:00pm: Image Review Cases
  • 2:00-4:00pm: Probe Tracker Unsupervised Scanning
• Thursday
  • 8-9:00am (didactic): Ultrasound in Shock
  • 9-11:30am: Un/Supervised Scanning
  • 11:30-1:00pm: Lunch/Conf
  • 1:30-2:00pm: Image Review
  • 2:00-4:00pm: Probe Tracker Unsupervised Scanning
• Friday
  • 8-9:00am (didactic): Volume Assessment Post-Test
  • 9-11:30am: Un/Supervised Scanning
  • 11:30-1:00pm: Lunch/Conf
  • 1:30-2:00pm: Image Review
  • 2:00-4:00pm: Probe Tracker Unsupervised Scanning

E. Monthly Conferences

• POCUS conference: Twice a month an afternoon conference is dedicated to a specific POCUS topic. During this conference POCUS images obtained by residents are reviewed and the monthly POCUS winner is announced.
• POCUS/ECG conference: Combining the expertise of our academic cardiologists, this case conference correlates ECG and Physical Exam findings with POCUS images obtained by house staff. Cases are selected from the general medicine teaching wards.

F. Mini-Workshops

• Once a month 2-3 residents on local elective rotations will receive an afternoon of directed POCUS training on pre-screened patients. Images obtained will count towards their monthly quotas.

G. Special Events

• Special events are a great way to accumulate massive points for your team! The last two academic years the department held a Jeopardy style POCUS competition and a zombie apocalypse POCUS escape room.

Video Portfolio and Quality Assessment

Quality Assessment

Saint Joseph wants to ensure that all aspects of POCUS proficiency are assessed including image acquisition, interpretation as well as clinical integration. When submitting a POCUS image house staff are asked to fill out a worksheet to evaluate their ability to interpret the image. Each resident will have their own video archive, portfolio, and personalized feedback for each image. In addition, residents are required to meet a monthly ultrasound quota in almost every rotation.

Video Portfolio

The portfolio consists of two parts: a) Quality assessment and b) Video Archive.

• a) The Quality Assessment: Each image is scored using a view specific scoring system. The house staff’s interpretation of the image is also compared to the reviewer’s assessment of the image.
• b) Video Archive: All images are stored in an individual folder.

Residents can use this portfolio for fellowship, job or academic applications as well as the POCUS certification process for both the American College of Physicians and the Society of Hospital Medicine.

See this example of a generic video portfolio.

Ultrasound Credentialing

Monthly Quotas

In almost every rotation residents will be required to meet a monthly POCUS quota that includes 2 full echocardiograms and 2 non-echo images, such as lung, renal, etc. All images obtained during educational activities such as ward ultrasound rounds, mini workshops, etc. count towards the quota tallies.

Credentialing

In addition to obtaining the required number of images for credentialing, in order to complete the credentialing process, residents must also complete the basic level POCUS elective and a final POCUS test. Once credentialed, residents will receive a certificate from the department of medicine and will no longer need to meet the monthly POCUS quotas.

Learn more details regarding credentialing.

Research and Publications

POCUS research is strongly encouraged and supported by POCUS faculty. The unique POCUS academic environment offered by Saint Joe’s is a fertile ground for innovative research that will help advance the careers of our trainees, especially those interested in fellowships or academic tracts.

Current projects include:

• Pre-procedural evaluation of intercostal arteries using POCUS prior to thoracentesis
• The ability of a novel Probe tracking device to monitor the progress of trainees during a POCUS elective
• The ability of resident house staff to assess Left Ventricular Ejection Fraction using common POCUS measurements

Publications

1. Holden MS, Portillo A, Salame G. Skills Classification in Cardiac Ultrasound with Temporal Convolution and Domain Knowledge Using a Low-Cost Probe Tracker. Ultrasound Med Biol. 2021.
2. Farasat M, Sanchez JM, West JJ, Burke JM, Prouse AF, Gore MO, Salame GA, et al. A Point-of-Care Algorithm to Guide Proper Device Selection for Ambulatory Electrocardiography. Crit Pathw Cardiol. 2021;20(3):140-142.
3. Trent SA, Stella S, Skinner A, Salame G, et al. Improving Atraumatic Chest Pain Evaluation in an Urban, Safety-net Hospital Through Incorporation of a Modified HEART Score. Crit Pathw Cardiol. 2020;19(4):173-177.
4. Salame G, Northcutt N, Soni NJ. Focused Cardiac Ultrasonography for Left Ventricular Systolic Function. N Engl J Med. 2020;382(10):976-977.
5. Soni NJ, Franco-Sadud R, Kobaidze K, Schnobrich D, Salame G, et al. Recommendations on the Use of Ultrasound Guidance for Adult Lumbar Puncture: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019;14(10):591-601.
6. Maw AM, Hassanin A, Ho PM, et al. Diagnostic Accuracy of Point-of-Care Lung Ultrasonography and Chest Radiography in Adults With Symptoms Suggestive of Acute Decompensated Heart Failure: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(3):e190703.
7. Salame G, Juselius WE, Burden M, et al. Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study. Crit Pathw Cardiol. 2018;17(2):98-104.
8. Soni NJ, Franco-Sadud R, Schnobrich D, Dancel R, Tierney DM, Salame G, Restrepo MI, McHardy P. Ultrasound guidance for lumbar puncture. Neurol Clin Pract. 2016;6(4):358-368.