I P 2  

A d v a n c e d   A p p l i c a t i o n s   C r e d e n t i a l i n g  Prepared  for:   Canadian  Emergency  Ultrasound  Society  Prepared  by:     Advanced  Applications  Committee  Date:  Oct,  2014    Proposal  #:  6.0    

   

Table  of  Contents  

Preamble  ...............................................................................................................  3  

Committee  Membership  ........................................................................................  4  

IP2  Credentialing  Process  .......................................................................................  8  Overview ...................................................................................................................... 8

1. Courses ................................................................................................................ 8 2. Apprenticeship ..................................................................................................... 8 3. Assessment of competence/Examination ............................................................ 9 4. Components of training ........................................................................................ 9 5. Supervising physician .......................................................................................... 9 6. Role of Sonographers ........................................................................................ 10

Advanced  Applications  Streams  ...........................................................................  11  IP2 Resuscitation Stream (Cardiac, Lung, IVC) ......................................................... 12 IP2 Diagnostic Stream (Gallbladder, Renal/Bladder, DVT) ........................................ 15 PoCUS Needle Guidance (POCUSNG) Stream ......................................................... 18 IP2 Musculoskeletal Stream (bones, joints) ............................................................... 19  

Table  1.  AdApps  Apprenticeship  Requirements………..……………………………….20    

Preamble    With the growing interest in advanced bedside ultrasound applications, a

number of members have asked CEUS to explore the development of an

advanced application certification process. The Advanced Applications

(AdApps) Committee, composed of members from coast to coast (and of

wide-ranging backgrounds in clinician-performed ultrasound) has begun

putting together a basic framework for such a process. This framework

includes a series of parallel streams representing various clinical aspects of

advanced bedside ultrasound. It is anticipated that trainees will be able to

pursue certification, or IP2 status, in such areas as resuscitative, needle

guidance, diagnostic, and musculoskeletal bedside ultrasound.

Sincerely,

Paul Olszynski, MD, MEd, CCFP (EM) (SK)

Chair, AdApps Committee/Président, Comité AdApp

Committee  Membership      Dr. Martin Betz, (FRCP EM) Practiced emergency medicine for 25 years without using ultrasound, and the

last 10 years, much more safely, using EDE. I teach EDE, EDE2 and EM

residents, now in Toronto, previously in Saskatoon, Sudbury and the Middle

East.

Dr. Greg Hall MD BSc CCFP (EM) FCFP Assistant clinical professor McMaster university and director of ED ultrasound

at Brantford General Hospital. CEUS Master instructor. Co-developer of the

EDE 2 Course and co-author of Point-of-care ultrasound for Emergency

Physicians. Director of EDE 3: Leading Edge Emergency Department

Echo. Speaker at multiple conferences including CAEP Scientific Assembly,

North York EM Update, UHN EM conference, Ottawa EM

Conference. Interests: POCUS education, ultrasound technology.

Dr. Ryan J. Henneberry MD, CCFP (EM), RDMS, Dip Sport Med

Emergency Physician with interest in Point of Care Ultrasound (Director of

Emergency Ultrasound, QEII HSC, Halifax) with a leadership role as Chair of

the CAEP POCUS Committee. Other interests include sports medicine. He is

an Assistant Professor of Medicine at Dalhousie University.

Dr. Ben Ho, MD, CCFP (EM)

Emergency Physician and CEUS Master Instructor. EDE 1 lecturer 2002-2009,

EDE 2 co-developer, lecturer 2008-present, EDE 3 lecturer 2012, 2013. The

EDE book chapter author - chapters thoracic, soft tissue. CEUS executive

board: portfolio: standards 2003-2009, portfolio: Western Canada

representative 2009-present. A few ongoing research projects so far - none

submitted for publication yet. Nanaimo regional general hospital ED U/S

director 2002-2013

Dr. David Kirschner, MD, (FRCP EM)

An avid user and advocate for the continued development and integration of

point of care ultrasound in the ED, he is pleased to be working with

CEUS. He plans on continuing this work in the coming years as he practices

in both pediatric and adult emergency departments. He is currently enrolled in

the Ultrasound Leadership Academy.

Dr. Jean-François Lanctôt MD, CCFP(EM) Dr Lanctôt is professor of medicine at McGill and Sherbrooke universities in

Montreal, Canada. He is the co-founder of the EGLS course and he is the co-

creator of the iOS Application Shock Echo. He participated in establishing

credentialing guidelines for advanced ultrasound in emergency medicine for

the Association of Emergency Physicians of Quebec(AMUQ/ASMUQ). His

main area of interest include resuscitation and critical care ultrasound.

Dr. David Lewis MB BS FRCS FCEM CFEU PGDipSEM,

Associate Professor Emergency Medicine - Dalhousie University, Ultrasound

Program Director - Saint John Regional Hospital New Brunswick. Co-Director

of the ECCU courses (www.emergencyultrasound.ca). The ECCU courses are

currently held in Saint John and Halifax, and have been running in the UK

since 2003. Other than teaching core and advanced PoCUS, I have an

interest in musculoskeletal ultrasound and sports medicine.

Dr. Paul Olszynski, MD, MEd, CCFP (EM)

Committee Chair

Assistant Clinical Professor at the University of Saskatchewan. Director of

Saskatoon Emergency Ultrasound Program. Interests include Clinician

Performed Ultrasound, Medical Education, Simulation-based Medical

Education. Currently undertaking study of CPU for SBO and Director of

Undergraduate Ultrasound Education at the U of S.

Dr. Laurie Robichaud, MD Resident/PGY4 at the Royal College EM program at McGill University. She is

currently enrolled as a fellow in the Ultrasound Leadership Academy for

Emergency Ultrasound. Her interests include PoCUS education, resuscitation,

and research.

Dr. Joel Turner, MD, MSc, FRCP

Former Program Director of the Royal College EM program at McGill, and is

the inaugural Fellowship Director of the EM ultrasound fellowship at McGill.

Working at the Jewish General Hospital, he is an instructor of the EDE2, and

EDE3 courses, and is a CEUS Master Instructor. He has authored chapters in

the EDE book (DVT, ocular) as well as in a recent volume of the EM Clinics of

North America (thoracic). He also helped initiate the development a CEUS

training site in Doha, Qatar.

Dr. Maxime Valois MD, CCFP(EM)

Assistant professor of medicine at Montreal, McGill and Sherbrooke

universities in Montreal, Canada. He was director of a CEUS training center in

Montreal until December 2013. He is the co-founder of the EGLS course and

he is the co-creator of the iOS Application Shock Echo. He is also a professor

of the Ultrasound Leadership Academy and participated in reviewing the

credentialing guidelines for advanced ultrasound in emergency medicine for

the Association of Emergency Physicians of Quebec(AMUQ/ASMUQ). His

main area of interest include resuscitation and critical care ultrasound.

Dr. Michael Woo MD Emergency Physician and Trauma Team Leader at the Ottawa Hospital and

an Associate Professor with the Departments of Emergency Medicine and

Family Medicine at the University of Ottawa. Received training in ultrasound at

the Ottawa Hospital and obtained his American Registry for Diagnostic

Medical Sonography certification in 2007. Director for both the Emergency

Medicine Ultrasonography program and Point-of-Care Ultrasonography

(Emergency Medicine) Fellowship. Continues to combine his passion for

education with clinical sonography with national and international speaking

engagements and maintaining an active research program.    

IP2  Credentialing  Process    

Overview     In keeping with the credentialing process established by CEUS for IP1,

the IP2 streams will require a combination of course attendance, supervised

apprenticeship and final examination.

1.  Courses  

Trainees pursuing CEUS credentials in IP2 streams must first complete

a CEUS recognized introductory course on the relevant application.

2. Apprenticeship

Having completed an introductory course in advanced applications,

trainees will be asked to formally register for apprenticeship in any of the four

IP2 streams (Resuscitation, Needle-Guidance, Diagnostic, and

Musculoskeletal). Each stream document sets out minimum standards for the

number of scans that must be completed prior to a competency

assessment/examination.

Apprenticeships must be supervised. Half of all apprenticeship scans

must be obtained under direct supervision of an IP2 instructor. In order to

ensure a solid understanding of clinical integration, the remaining required

scans must be submitted in the form of a training portfolio that consists of

recorded clips as well as accompanying documentation that explains patient

presentation, image interpretation and subsequent proposed integration of

findings into clinical care. This portfolio must then be submitted to the

supervising instructor for review and determination of adequacy of scans.

It is expected that trainees encounter both negative and positive

pathology during their apprenticeship. While this may be difficult to capture

under direct supervision, it is expected that upon completion of the required

number of scans, trainees will have documented at least 1 of each of the

relevant pathologies for that scan/indication.

Once a trainee has completed the required number of scans (50%

determinate under direct supervision, 50 % determinate and adequate scans

in portfolio), then a competence assessment can be initiated.

Apprenticeship should last no longer than 18 months.

3.  Assessment  of  Competence/Examination  

This final component of apprenticeship will include an online

examination, a visual exam completed with an IP2 instructor, and a bedside

practical assessment. Upon successful completion of each component, the

trainee will be granted IP2 status within the given IP2 stream.  

4.  Components  of  training  

Directly supervised dynamic scans on live human models

Reviews of recorded dynamic scans on live human models

Written examination in MCQ format can be done on-line or in person

Visual exam done with direct supervisor either in person or via internet

conferencing

5.  Instructor/  Master  Instructor  IP2  

An IP2 clinician can assist other trainees with the case portfolio

component of their apprenticeship (by helping ensure that trainees record

adequate clips of their cases), and thus taking on the role of instructor. Once

an IP2 clinician has assisted 5 other trainees with their portfolios, he/she is

eligible for Master Instructor apprenticeship on the recommendation of

another IP2 Master Instructor.

Master Instructor apprenticeship includes 2 components: a course

based bedside-instruction component (at a course recognized by CEUS) and

attendance at an IP2 teaching course.

6.  Role  of  Sonographers  

Sonographers and Echosonographers can offer trainees excellent

guidance in image generation (within their respective scopes). Such guidance

may prove to shorten the total number of attempts required to generate the

specified determinate views/scans for a given indication. As such, trainees

can seek out guidance/supervision from sonographers for the portfolio portion

of their apprenticeship. This should be arranged at a local level with

considerations for remuneration being addressed independently of CEUS.

       

Advanced  Applications  Streams  

Resuscitation

Diagnostic

Needle Guidance

Musculoskeletal

IP2  Resuscitation  Stream  (Cardiac,  Lung,  IVC)    I. CARDIAC a) Views: Parasternal Long Axis (PSL/PLAX) Parasternal Short Axis (PSS/PSAX) Apical 4 Chamber (A4C) Subxiphoid (SX) b) Image Generation Requirements: 50 supervised determinate scans of each of the three views with minimum 25 directly supervised, 25 recorded and reviewed in the applicants portfolio. c) Pathology: - PCE - LV dilation - RV dilation - LV failure Each pathology should be demonstrated at least once within the 50 scans. d) Determinate Scans: - PSL: Correctly identify midpoint of LV, MV and AV imaged, EPSS correctly identified (>1cm or <1cm), LV imaged in longest and widest orientation, Aortic root & Descending aorta visulaized - PSS: Assessment of LV contraction at level of papillary muscles, assessment of RV strain and septal bowing - A4C: All 4 chambers imaged in widest, longest view, Vertical orientation of septum, TV and MV imaged e) Clinical scenario management correctly incorporate findings of: - LV failure and LV dilation in shock and dyspneic patient - Hyperdynamic/empty LV in shock patient - RV dilation in shock and dyspneic patient II. Inferior Vena Cava (IVC) a) Views: Longitudinal and transverse intrahepatic IVC b) Image Generation Requirements: 10 supervised determinate scans, Minimum of 5 directly supervised, 5 recorded and reviewed The above applies to each of the patient states: spontaneously breathing patients (10 scans) and intubated (10 scans). c) Pathology: - Normovolemic nonintubated patient IVC respiratory variation

- Obstructive shock or failure, nonintubated patient - Hypovolemic shock, nonintubated patient - Hypovolemic shock, intubated patient d) Determinate Scans: - demonstrate IVC’s imaged in long axis and short axis in widest diameter - identify intrahepatic course of IVC and correct measurement technique - correctly position measurement markers for IVC diameter e) Clinical Scenario Management - correctly incorporate images for following scenarios: - flat/collapsing IVC in shock and dyspneic patient - distended IVC in shock and dyspneic patient - positive IVC in positive pressure ventilated shock patient III. Lung/Pleura a) Views: - Intercostal pleura in longitudinal, - Longitudinal view of diaphragm - supradiaphragmatic lung in sitting patient b) Image Generation Requirements - 20 intercostal pleural and supradiaphragmatic views with minimum of 10 directly supervised scans - Should include view of pleura and deeper lung tissue over anterior, lateral, and posterior aspects of lung in supine patient c) Pathology - Pneumothorax: - Interstitial fluid - Pleural Effusion d) Determinate Scans: - longitudinal image of lung pleura in three intercostal spaces - correctly identify on video recording or live patient: pleural line, pleural slide, ribs and rib shadow, true comet tails, A-lines - Cardiac lung point, liver lung point, spleen lung point - Demonstrate how to image least dependant region of lung in supine patient and follow pleura laterally to reach potential lung point - Images demonstrate definitive views of pleura, A-lines, ribs in longitudinal orientation - Images of lung bases demonstrate definitive views of diaphragm and supradiaphragmatic lung

- Identify A-lines, B-lines, lung consolidation, pleural effusion, air bronchograms, atelectasis e) Clinical Scenario Management- Demonstrate how to incorporate findings into clinical scenarios including: - Normal lung with high clinical suspicion of pneumothorax - Spontaneous pneumothorax - Patient with lack of lung slide due to other pathology such as pleurodesis - CHF with significant B-lines - Pneumonia with consolidation - Dyspneic patient with normal lung findings - Dyspneic patient with large pleural effusion and dyspnea - Shock patient with cardiac failure and lung edema

IP2  Diagnostic  Stream  (Gallbladder,  Renal/Bladder,  DVT)    I. Gallbladder a) Views: - Both long and short axis views of gallbladder using subcostal, lateral, and intercostal approach - use of supine and left lateral positioning b) Image Generation Requirements: total 40 determinate gallbladder scans with minimum 20 directly supervised c) Pathology - Cholelithiasis - Cholecystitis - Choledocolithiasis d) Determinate Scans: - Identification of “Exclamation Mark” sign: portal vein, MLF, gallbaldder - gallbladder visualized in long and short from fundus to gallbladder neck - identification of portal triad - identification of gallstones - identification of wall +/- thickening - identification of peri-cholecystic fluid - identification of enlarged gallbladder - Wall-Echo-Shadow sign (WES) e) Clinical Scenario management - gallbladder in setting of biliary colic - gallbladder in setting of cholecystitis - gallbladder in setting of pancreatitis - inflamed gallbladder in setting of critically ill patient (acalculus cholecystitis) - GB and CBD in setting of jaundice II. Renal a) Views: - Left and right Kidney in long and short axis (using lateral view) - Bladder in transverse and long b) Image generation: - Renal: 20 (10 directly supervised) - Bladder: 5 (3 directly supervised) c) Pathology

- Hydronephrosis: Mild, moderate, severe - Hydroureter: proximal (UPJ) and distal (UVJ) - Calyx rupture - Pyelonephritis - distended bladder d) Determinate Scans: - Visualization of kidneys in longest axis - clear view of renal pelvis and proximal ureter - correct localization of bladder trigone - evidence of proper visualization for possible ureteric jets e) Clinical Scenario Management - Assessment of kidneys in setting of renal colic - identification of nephrolithiasis - role of renal scan in patient presenting with new onset flank pain (r/o AAA and assess for hydronephrosis) - further imaging following identification of hydronephrosis (unilateral vs bilateral) - hydronephrosis in setting of sepsis - estimation of bladder volume in ?retention? - confirmation of catheter placement - Assessing hydro in the hypovolemic patient III. Deep Venous Thrombosis- 2 area/multipoint assessment a) Views (both left and right): - Transverse view of common femoral vein and its proximal branches - Transverse view of popliteal vein and their branches b) Image generation: 40 limbs (20 under direct supervision) c) Pathology - Femoral thrombus - Greater Saphenous thrombus - Popliteal thrombus - Identification of cellulitis or ruptured baker’s cyst d) Determinate Scans: - clear identification of common femoral vein and other structures/vascular bundle - appropriate use of multi-point compression in both areas - saphenous-femoral confluence - common-deep femoral branch and distally several cms - popliteal fossa from adductor canal to trifurcation - clear identification of popliteal artery and vein with appropriate depth of field

e) Clinical Scenario Management - identification of DVT in setting of patient in obstructive shock - identification of DVT in swollen leg - identification of negative study in difficult scan/patient

IP2  PoCUS  Needle  Guidance  (POCUSNG)  Stream    This document provides guidance on the process of acquiring recognized competency in PoCUSNG – the ability to safely manipulate a needle under ultrasound guidance to the target with precision. Attaining this competency does not imply competency in any particular procedure. Needle Guidance a) Views: There are a growing number of procedures in emergency medicine and other medical specialties that have been shown to be both safer and frequently more effective when performed under ultrasound guidance. Commonly performed procedures where there is strong evidence for the benefit of using ultrasound guidance include, but are not limited to: - Central venous line placement - Peripheral venous line placement - Thoracentesis - Pericardiocentesis - Paracentesis - Peripheral nerve blocks - Supra-pubic catheter placement - Fracture hematoma block - Foreign body localization - Joint aspiration / injection b) Image generation: The underlying principles that determine PoCUSNG competency in the above procedures are: - An ability to recognize the ultrasound appearance of the target and surrounding structures. - An ability to safely manipulate a needle under ultrasound guidance to the target with precision and utilizing appropriate aseptic technique. - Directly observed PoCUSNG using simulator/phantom At least 10 successful attempts c) Pathology - identification of needle tip - interpretation of artifacts related to needle guidance - set up of sterile technique for procedure d) Image adequacy/Competence: done under supervision of instructor* *The above components of competency achievement in PoCUSNG may all be acquired at the course, depending on its format. Alternatively the assessment of competency can be performed at a later date via local assessment.  

IP2  Musculoskeletal  Stream  (bones,  joints)    I Fractures a) Views: 2 views of long bones in 2 planes, perpendicular to each other. Single view of sternum, ribs, and clavicle. b) Image generation: - 30 scans, with a minimum 10 scans of the distal radius, and a minimum 10 scans of other sites. - 10 scans must be directly supervised, the remaining can be recorded and reviewed in portfolio. c) Pathology: i. Upper Extremity - Distal radius fracture (Smiths, Colles) - Humeral head - Boxer’s fracture ii. Lower Extremity - Femoral shaft - Lateral/medial malleolus - 5th metatarsal iii. Other Fractures of sternum, ribs, clavicle d) Determinate Scans - Clear identification of the displacement of the cortex, - Ability to identify the amount and direction of cortical displacement, angulation if present e) Clinical Scenario - Identification of fractures following traumatic injuries, - To be able to integrate findings on ultrasound with radiography (as needed), - to use POCUS to measure adequacy of closed reduction (if performed) II. Dislocations a) Views: Posterior view of the shoulder at the level of the scapula, assessing the position of the humeral head.

b) Image Generation Requirements: - 6 supervised scans, with a minimum 3 which must be directly supervised, the remaining can be recorded and reviewed in portfolio. c) Pathology: - Anterior Shoulder dislocation - Posterior Shoulder dislocation d) Determinate Scans: - Clear identification of the displacement (anterior or posterior) of the humeral head with respect to the glenoid/scapula. e) Clinical Scenario - Identification of dislocation following traumatic injuries, seizure, etc. , - To be able to integrate findings on ultrasound with radiography (as needed), - to use POCUS to measure adequacy of closed reduction (if performed). To provide US guidance for hematoma block. III. Joints Elbow, wrist, hip, knee, ankle a) Views: - Longitudinal and transverse views of the elbow, knee and ankle joints. Single, longitudinal views of the wrist and hip. b) Image Generation Requirements: - 20 determinate scans. A minimum of 10 scans must be directly supervised, the remaining can be recorded and reviewed in portfolio. c) Pathology: - Joint effusion d) Determinate Scans: Clear identification of articular area and ability to identify the presence or absence of a joint effusion. To differentiate a small effusion from the articular cartilage. e) Clinical Scenario - Identify presence or absence of a joint effusion in a patient presenting with swollen joint. - Identify the depth of the effusion (if present). - To provide surface landmarks to aid in the aspiration of the joint of effusion.

Table  1.  CEUS  AdApps  Image  Generation  Requirements  for  IP2  Apprenticeship      Advanced  EDUS  Applications  

Number  of  examinations*  

Positives**  One  of  each  of  the  following:  

Cardiac  PLAX,  PSAX,  A4C,  SX  

50  (25  directly  supervised)  

PCE,  RV  Dilation,  LV  Failure,  Hyperdynamic  LV  

IVC-­‐  (spont.  breathing  or  ventilated)    

10  (5  directly  supervised)  

N/A  

Lung/Pleura   20  (10  directly  supervised)  

Pneumothorax,  Interstitial  fluid,  Pleural  effusion  

Gallbladder  (Hepatobilliary)  

40  (20  directly  supervised)  

Cholelothiasis,  Cholecystitis,  

Renal   20  (10  directly  supervised)  

Mild,  moderate  and  severe  hydronephrosis  

Bladder   5  (3  directly  superivised)  

N/A  

DVT   40  limbs  (20  directly  supervised)  

Thrombus  in:  Femoral  vein,  Greater  Saph.  Vein,  popliteal  vein,  

Needle  Guidance   10  procedures  (all  supervised  on  simulators  or  in  practice)  

Venous  access,  fluid  aspiration,  nerve  block  

Fractures    

30  scans  (10  directly  supervised)      

Long  bone  fractures,  Boxer’s  fracture,  Smiths/Colles,  Sternum  

Dislocations   6  (3  directly  supervised)  

Anterior  and  Posterior  shoulder  dislocation  

Joints   20  scans  (10  directly  supervised)  

Joint  effusion  of  elbow,  knee,  ankle,  hip  

 *  Scans  should  be  performed  on  a  range  of  patient  types  (age,  body  habitus)  with  at  least  half  being  done  on  patients  >50  yoa.  **  If  a  specific  positive  scan  has  not  been  encountered  during  apprenticeship,  the  trainee  should  access  a  video  library  or  simulated  case  and  review  it  prior  to  challenging  the  exam.  All  positives  (pathologies)  must  have  been  either  encountered  or  at  least  reviewed  by  video  prior  to  challenging  the  credentialing  examination.