Dalhousie DEM SJRHEM/IWK PoCUS Fellowship/Elective

 

Dalhousie University

Emergency Point of Care Ultrasound

Clinical-Academic Fellowship

Department of Emergency Medicine,

Dalhousie University,

Saint John Regional Hospital.

Ultrasound and Research Programs

Dr. David Lewis FCEM, Ultrasound Program Director

Dr. Paul Atkinson FRCPC, Research Director

www.sjrhem.ca

 


 

Member of the Canadian Society of EM-PoCUS Fellowships – PoCUS.ca

 


 

Faculty

Fellowship Director, Dalhousie University, Saint John – Dr. David Lewis

Fellowship Director (Research), Dalhousie University, Saint John – Dr. Paul Atkinson

Fellowship Director, Dalhousie University, IWK – Dr. Kirstin Weerdenburg

 

 


 

  1. Overview and Objectives

Welcome to the Dalhousie University (DU) Emergency Point of Care Ultrasound (PoCUS) Elective and Fellowship Program at Saint John Regional Hospital (SJRH) with an optional up to 1-month placement in Pediatric PoCUS at the IWK Health Centre Pediatric Emergency Department.  We are very proud of our program and excited that you are considering joining us. This document outlines the nature and scope of the elective and fellowship options, with a breakdown of the individual components that comprise your educational experience. Particular attention is paid to how we plan on providing you with the tools you need to succeed in your career in each discipline, and on the expectations we have of you.

The Emergency PoCUS Program began in 2009 and has been a leading program in Canada. We offer a one-month elective, a three-month mini-fellowship, as well as 6 and 12 month fellowships to be completed either during the 4th year of the Royal College Residency Program in Emergency Medicine (or equivalent level international Emergency Medicine training program) or for graduates of emergency medicine residency programs who wish to improve their skills and knowledge to become ultrasound program directors or leaders in the field of emergency ultrasound.

The elective program is designed to provide additional scanning experience in the clinical setting as well as provide an introduction to ultrasound education.

There are four primary components to the mini-fellowship and fellowship programs:

 

  1. Clinical: optimizing image acquisition and interpretation skills for both core and advanced emergency and point of care ultrasound applications
  2. Education: developing lecturing and teaching skills by developing an emergency ultrasound lecture portfolio and contributing to the program’s educational mission. Acquiring expertise at bedside ultrasound teaching and assessment.
  3. Administration: understanding the critical components required to run an emergency ultrasound program, set up and deliver educational events/courses and how to best utilize information technologies for image archiving, database management, and quality assurance.
  4. Research: understanding the state of emergency ultrasound research by participating in ultrasound journal club activities and developing an independent research project from its inception to publication.

 

For physicians who have graduated residency and who wish to undertake a 12-month fellowship, the position may include an appointment (pending Nominations / Privileges agreement) as a locum part-time attending physician in the Department of Emergency Medicine in the Saint John region group of hospitals including Sussex, St Josephs UCC, Charlotte County and Saint John Regional Hospitals, and as such, it is available only to individuals meeting requirements for medical licensure in New Brunswick.

Residents will need to come with their own funding preferably via their own Residency Program. We may be able to direct residents towards other areas of funding such as educational grants, but all application requirements will be their responsibility.

International applications are welcome; however, these need to be fully funded and all the immigration requirements will need to be organized by the applicant. In addition a Fellowship fee may be required, depending on the circumstances of the application.

Expressions of interest are made in writing via email or letter to the Dr. David Lewis at the address below. An application form will be sent for completion. Appointment to a Fellowship will be decided by the Fellowship Nominations committee. Locum part-time attending physician appointments will be decided by the SJRHEM Nominations committee.

 

  1. Electives (one month)

 

Your weekly schedule requirements are approximately 36 hours per week and are very variable from week to week. In general, you should expect to spend approximately:

 

  • 32 hours/week clinical shifts (approximately)

 

During your one month elective in emergency ultrasound, you will work as a resident in the emergency department, following a regular schedule of 4 clinical shifts per week. These will be supervised by faculty with advanced ultrasound skills. The purpose of this elective is to enhance your sonographic skills in a clinical setting. You will be expected to provide clinical care for patients with a focus on the integration of point of care ultrasound in emergency medicine.

  • Scanning

You will save and log all scans performed and will aim to complete 50 scans in each of the following Core areas of Emergency Point of Care Ultrasonography (PoCUS)

 

  • Abdominal/FAST
  • Basic Cardiac
  • Lungs and Thorax
  • Abdominal Aorta
  • IVC / Shock
  • First Trimester Pregnancy
  • Vascular Access

 

 

  • For Residents with a documented prior Core level PoCUS competency, we will provide training and supervision in selected advanced applications. The nature of theses will be tailored to the individual’s requirements (e.g critical care, sports medicine, pediatrics etc).
  • You will be required to teach and assist with ultrasound courses run by the SJRH program.
  • You will present at journal club and rounds as required.
  • You will contribute at least one referenced pictorial case discussion per month to the Resident Pearls / PoCUS Rounds series on the sjrhem.ca website

 

 

  1. Mini-fellowship and fellowship (3-12 months)

The expectations outline below will be adjusted to the duration of your fellowship.

 

 II.Schedule

Your weekly schedule requirements are approximately 36 hours per week and are very variable from week to week. In general, you should expect to spend approximately:

  • 16 hours/week supervised clinical shifts in the Emergency Department (approximately)
  • 20 hours/week fellowship responsibilities; including scanning, education and research/administrative work. Vacation will be determined by your residency program guidelines.
  • Courses – you will be required to teach and assist with ultrasound courses run by the SJRH program.
  • You will present at journal club and rounds as required.

III. Education

You are expected to read provided materials to enhance your knowledge in the field. The topics to be covered are outlined below. You will be provided with material to cover all of these topics.

A. Ultrasound Physics and Instrumentation

 

  1. Units and Measurement
  2. Sound
  3. Pulsed Ultrasound
  4. Intensity
  5. Interaction of Sound and Media
  6. Range Equation
  7. Transducers
  8. Sound Beams
  9. Axial and Lateral Resolution
  10. Display modes
  11. Two-dimensional Imaging
  12. Temporal Resolution
  13. Pulsed Echo Instrumentation
  14. Displays
  15. Image Processing and Dynamic Range
  16. Hemodynamics
  17. Doppler
  18. Image Characteristics and Artifacts
  19. Quality Assurance
  20. Bioeffects

B. Emergency Point of Care Ultrasonography (PoCUS)

a. Core applications

  1. Abdominal/FAST
  2. Basic Cardiac
  3. Lungs and Thorax
  4. Abdominal Aorta
  5. IVC / Shock
  6. First Trimester Pregnancy
  7. Vascular Access

b. Advanced applications

  1. Advanced Cardiac
  2. Gallbladder
  3. DVT
  4. Renal
  5. Musculoskeletal
  6. Soft tissue
  7. Pediatric applications
  8. Regional anesthesia/nerve blocks
  9. Procedural guidance
  10. Ocular
  11. Bowel
  12. Doppler

 

c. Indications

d. Limitations

e. Literature-based evidence

f. Algorithms for incorporation of ultrasound into clinical practice

Expectations:

 

  • Become familiar with the operations of the Sonosim simulator or Vimedix simulator. Utilise the available learning packages on both simulators. Develop teaching methods that utilize these simulators in the education of others.
  • Complete all the online Emergency Ultrasound Exams at ACEP and other formative assessments as directed by the Fellowship directors.
  • Stay up-to-date with current literature, reading and reviewing ultrasound-related articles. Maintain the library of articles that we review.
  • You will be given support to prepare, acquire eligibility for and to take the Canadian Point of Care Society (CPoCUS) exam for the CPoCUS Core IP or Expanded Applications certification track (depending on level of competency at start of Fellowship).
  • Optionally – If you meet the eligibility requirements, you will be given support to adjust the components of this Fellowship to support an application for recognition of a Royal College of Physicians and Surgeons of Canada Area of Focused Competence Diploma in Acute are Point of Care Ultrasonography.

IV. Scanning

Paramount to all else in your fellowship, you must become an expert user of PoCUS. The skills you acquire in doing so will be invaluable to your career in emergency medicine and will make you a better clinician. Your skills need to reach a level where you feel confident in your own scans, both in identifying and ruling out pathology, and in knowing when the exams are inadequate to do so.

We will directly observe your scanning when possible and assess your images and interpretations for adequacy when not. You will have scanning shifts with an Emergency Physican PoCUS faculty, both when they are working clinically, and when they are not.

Expectations:

  • Perform a minimum of 250 scans per 3 month block.

These should consist of primary emergency ultrasound applications (FAST, echo, aorta, biliary, renal, 1st trimester ultrasound, DVT, procedural, soft tissue, thoracic), but may include some advanced applications. You should have an appropriate mix of both applications and findings (both positive and negative scans).

  • Log each of your scans and interpretations in a datasheet (We use Q-Path for this purpose).
  • Have a sample of your scans reviewed by the Fellowship Directors for both adequacy of image acquisition and interpretation.
  • Do your own external QA. Record when a patient that you scan has an “official” study performed (i.e. a formal echo, ultrasound, CT scan, operative report) and compare your findings to that study.
  • Spend approximately 4-8 hours a week scanning. If there are rotating residents during that week, your scanning time should be spent with them. If there are no residents or students, you should schedule your scanning time when an Emergency Physican PoCUS faculty is working clinically when possible.
  • Keep a log of the dates and times of your scanning shifts.
  • Assure that your scans are entered into Q-Path or equivalent database. Q-Path serves as our tool for tracking scanner numbers and accuracy.
  • Seek out pathology and novel applications of ultrasound when possible. Your scanning should not be limited to established applications.
  • Know how to acquire video clips as well as still images, and when each is appropriate.
  • Adhere to and enforce departmental policies regarding machine cleanliness and maintenance.

There is also an option to perform up to 1 month of scanning in pediatric applications at the IWK Health Centre Pediatric Emergency Department. The expectations would be the same as stated above.

 

V. Teaching

Learning to teach ultrasound is a fundamental portion of your fellowship. The most important component to superlative teaching is a strong grasp of the fundamentals of ultrasound. Your teaching experience will consist of both lecturing and hands-on teaching. We feel this is an essential component to your ultrasound fellowship experience.

We will provide you with background information, literature review, and access to image and video clip databases to help you prepare for your lectures, as well as review them for quality and presentation style pointers. You will have ample hands-on experience scanning with us, in preparation for your independent teaching.

Expectations:

  • Develop your own emergency ultrasound lecture portfolio consisting of at 2-4 lectures (depending on the duration of your fellowship). These need to be high-level case-based lectures covering at least scanning technique, normal and abnormal findings, treatment algorithms, and most importantly a critical review and appraisal of the current literature related to that application.
    • One of your lecture topics should be from the list of core applications: Abdominal/FAST, Basic Cardiac Echo, Lungs and Thorax, Abdominal aorta, IVC / Shock, First Trimester Pregnancy, or Vascular access
    • One of your lecture topics should cover an advanced application, such as Advanced cardiac echo, Gallbladder, DVT, Renal, Musculoskeletal/Soft tissue, Pediatric applications, Regional anesthesia/nerve blocks, Procedural guidance, Optic, Bowel or Doppler
    • Your other lecture topics can be of your choosing, from the lists above, or on another original subject (with prior approval from the fellowship directors)
  • Prior to presentation, you must review your lecture with an Emergency Physican PoCUS faculty. This should be done no less than a week before your talk is scheduled.
  • Present a minimum of 1 lecture at ED Rounds.
  • Spend individual time doing hands-on scanning with rotating residents.
  • Participate in teaching of EM staff when the opportunities arise.
  • Contribute at least one referenced pictorial case discussion per month to the Resident Pearls / PoCUS Rounds series on the sjrhem.ca website

VI.Research

Emergency ultrasound is at the cutting edge of clinical research in emergency departments across Canada and worldwide. New applications and uses are being frequently being studied and tested and can make immediate impact on clinical practice. We feel strongly that Dalhousie University Department of Emergency Medicine can and should be among the leaders in this field. Participation in research is an integral component of your fellowship.

We will provide you with all the mentorship, resources, and support that you need to pursue your research endeavors.

Expectations:

  • Actively seek and enroll patients in all ultrasound research projects. When you are on a scanning shift by yourself, research enrollment should be as important as educational scanning.
  • Support and advise other learners with their ultrasound related research projects.
  • Develop at least 1 research project. As the primary investigator, you should undertake all aspects of this research, including but not limited to idea conception, protocol authorship, IRB approval, consent and data forms, advertisement of the study, patient recruitment and enrollment, follow-up, data analysis, statistical analysis, and manuscript authorship.
  • Present at least one project at a regional, national or international conference.
  • Submit at least one project as lead author for publication in a peer-reviewed journal.
  • Meet deadlines for submission of research project abstracts. Be aware that the deadline for the annual CAEP conference (Usually in June) can be as early as December.

VII. Administration

A keen understanding of the administrative aspects of emergency ultrasound is a necessity for successful implementation of an emergency ultrasound program in any emergency department. Administrative issues are primarily but not exclusively financial, medico-legal, or political in nature. We will do our best to ensure exposure and familiarity with each of these topics.

 

Expectations:

  • Attend all ultrasound interest group meetings, department meetings, ultrasound research meetings.

 

  • Understand the various medico-legal aspects of performing and documenting emergency ultrasounds.
  • Understand the politics and business behind ultrasound machine companies.
  • Understand the nature of the politics of emergency ultrasound on a national level.
  • Aid in the organization and implementation of a recruitment and selection process for future fellows.
  • Attend a national Emergency Ultrasound Committee meeting—CAEP Emergency Ultrasound Committee.
  • Read the CAEP, CPoCUS and IFEM Emergency Ultrasound Guidelines
  • Participate in setting up ultrasound courses given within or outside of the hospital.
  • Understand the process of marketing, organizing and budgeting for an ultrasound course, dealing with those who have paid to attend and supporting the invited faculty.

 

VIII. Quality Assurance

Reviewing ultrasound images is an essential skill. To ensure that you are performing high-quality sonography, your images and videos will all be reviewed by the Fellowship Directors or deputy to assure that they support your interpretations. We refer to this as internal QA. In addition, there is external QA which compares your findings to “official” findings. To further hone your skills and prepare you for a directorship of your own, you will review other peoples’ ultrasounds and give them feedback on their scans.

Expectations:

  • Participate in QA of departmental exams. You will learn the QA process in a graduated manner. At first, you will observe how the Fellowship Directors or deputy assess image quality and adequacy and learn the scoring system for image feedback. Once you have become familiar with the process, you will perform the QA with oversight. When your assessment of images correlates well with Fellowship Directors or deputy assessments, you will be granted privileges to perform QA independently. The learning curve is variable, but we expect that within a few months you should be reading scans on your own.

 

IX. Image Management

As technology progresses, so does sophistication of ultrasound machines and systems. With increased usage of ultrasound in the emergency department, appropriate image storage and management becomes more and more imperative.

Expectations:

  • Aid in the maintenance of an organized image storage and retrieval system (Q-Path). Keep the Teaching Files up to date with appropriate keywords for easy searching.
  • Learn how to configure an ultrasound machine to record video and still images.
  • Understand the process of how to edit and convert digital images and clips from the ultrasound machine into ones that can be used in a presentation.
  • Make Keynote / Powerpoint presentations incorporating video clips.

X. Evaluation

Your scanning technique and images will be reviewed on a continual basis. You will receive verbal feedback on these. At the end of the Fellowship/Elective you will receive a summative assessment of Emergency PoCUS knowledge and competency. The details of this assessment will vary depending on the duration of your Fellowship/Elective and will be provided to you when you start.

You will meet with the Fellowship Directors every six weeks. At each meeting, we will review your performance and progress in line with the listed objectives. You will also have the opportunity to evaluate the Fellowship, the faculty, and your own performance. These evaluations are meant to be constructive, and to help shape the fellowship experience into one that meets your needs.

 

 

Address for expressions of interest

Dr. David Lewis – david.lewis@sjrhem.ca

 

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