Saskatchewan Emergency Ultrasound Guidelines – SEMAC XI

There has been A LOT of talk about POCUS governance lately – and at USASK we are right in there with a recent publication in The Ultrasound Journal on our efforts to develop a consensus-based multidisciplinary POCUS framework.

This Saturday @USASKEM and @usask_CME are hosting the 11th Saskatchewan Emergency Medicine Annual Conference (SEMAC XI) in Saskatoon, SK. We will be reviewing the recently adopted (province wide) Saskatchewan Emergency Ultrasound Guidelines: STANDARDS FOR EMERGENCY ULTRASOUND Final

These are in keeping (and in fact exceed) the above USASK POCUS Framework and are also well aligned with CAEP’s recent EM POCUS Position Statement.

Here’s the Executive Summary for the Sask EUS Guidelines:

Emergency ultrasound (EUS) comprises a set of focused applications utilized to diagnose life-threatening conditions, guide invasive procedures, and treat emergency medical conditions. [2] The proposed standards take into account that emergency care, and thus EUS, is within the scope of emergency physicians, family physicians and nurse practitioners. Given the significant contextual and resource differences between urban/tertiary centres and rural/regional sites, recommendations related to training, privileging and quality assurance are tailored accordingly.

  1. Scope includes use of ultrasound during emergency care to aid in diagnosis and procedures. Diagnostic applications include (but are not limited to) use of ultrasound in resuscitation (including focused cardiac and thoracic scans), in expediting diagnosis (including biliary, renal, venous applications), and in the assessment of musculoskeletal complaints (joints, fractures and soft tissue).
  2. Training (and proof thereof) should include a clear induction to the ultrasound application(s) in question, followed by a supervised apprenticeship, and an objective assessment of knowledge and skill. This standard, when applied to core/basic applications, is attainable throughout all sites in the province. However, with many of the extended applications where clinicians in rural/regional sites may have little local expertise to rely on, exceptions are warranted. In these cases, rural clinicians who already have credentials in basic EUS are advised to develop clear plans (in consultation with their site/area EUS lead) for ongoing practice and self-audit. Residents who have received robust emergency ultrasound training are encouraged to submit supporting documents that outline the details of their performance within their residency-based ultrasound training program.
  3. Privileges should be determined with the above training recommendations in mind, in recognition that not all credentials are created equally.
  4.  Documentation of emergency ultrasound should include a note in the patient’s chart that is trackable for review. Major teaching centers are encouraged to make use of image capture technologies.
  5. Quality assurance and improvement are now routine aspects of clinical practice. In urban/tertiary centres, this means continuous audits of group practice with feedback being provided to both individuals and the department from the site lead. In rural and regional centres where clinicians must balance a wide range of competing demands on time, emergency ultrasound should be included within broader quality improvement programs.
  6. Leadership will include emergency ultrasound leads (site and/or area) and the Director of Emergency Ultrasound, in collaboration with all members of the Department of Emergency Medicine. These leaders will work collaboratively to support excellence in emergency ultrasound training, clinical care and research.

These standards represent one of many initiatives developed to help ensure high quality training in, and use of, EUS in the province of Saskatchewan.

 

It’s like a Fitbit – but for POCUS!

The USASK experience with logging scans and the EchoLog App

In September 2019, Mac Russell (MS4 at Usask) had the privilege to attend the 7th annual World Congress of Ultrasound in Medical Education (WCUME) in Irvine, California. Alongside Dr. Wayne Choi (co-founder of the scan-tracking app called EchoLog ), the two had the opportunity to present on the University of Saskatchewan’s experience with clinical ultrasound in undergraduate medical education. They presented on the importance of tracking scans as a means of tracking growth and informing assessment.image1

In this first post, we focus on why tracking scans is important. In part 2 we’ll dive into the logistics of using the Echo Log app!

BACKGROUND

At USASK, we have had an integrated clinical ultrasonography (aka Point of Care Ultrasound) curriculum in our undergraduate medical program since the fall of 2014. We start in pre-clerkship with 4 distinct modules over 2 years, with ~10 hours of directly supervised scanning with qualified instructors. POCUS skills are assessed with exam questioned and through OSCEs. We also have other scanning and learning opportunities including near-peer tutoring through our student-led ultrasound interest group, as well as regularly hosted POCUS courses (EDE, EGLS, etc..) and our annual conference (SASKSONO). Once in clerkship, given the distributed nature of our program (several sites throughout our province) and range in terms of expertise amongst faculty in various disciplines,  there is variability in terms of supervision of scans. Furthermore, it should be note that at present, logging of clinical ultrasound scans is not a program requirement.

With that all said – one might ask: Why bother logging scans? Well, to borrow from the sport performance lingo – you can’t track what you don’t measure, and you can’t improve if you don’t know how you’re doing!

Measure Growth – a case study.

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Take for example an EM shift with a clerk and EM physician. EMS brings in a patient from a car accident, and the physician asks the student to perform a FAST scan. The trainee can generate a subxiphoid view of the heart, but in the RUQ is having a hard time getting around the rib shadows and clearing the caudal tip of the liver. Now, this is your first time this physician is working with this student, and other than the struggles with this particular scan, the physician doesn’t really know anything about the trainee’s experience with POCUS. Is it because the trainee is really new to scanning? Or is the trainee doing poorly despite a lot of practice opportunities?

Essentially, we want to know if this trainee is progressing appropriately given his/her stage of training (if this conjures images of a Rourke growth chart or a Fitbit – you’re on the right track). There is some evidence that clinical ultrasound skills follow learning curves as well. A study by Blehar et al.1 showed that learning curves can be reasonably predicted for some applications of clinical ultrasound, like FAST and RUQ.

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Now, it should be noted that the above graphs don’t look much like curves – but there’s a good reason why, with help from little red, we can make the case for what  Dr. Ray Wiss dubbed the “double learning curve” of POCUS.

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It would seem more appropriate for the graphs to look something like the one above – since generally speaking, a trainee must first be introduced to a scan before they can begin performing/practicing it! Recall, this study was based on recorded images – which trainee would only start doing AFTER a day long introduction to the scan. Such introductions can be quite intensive depending on the skills of the learner and nature of the scan(s) being taught (think of day-long workshops with several standardized patients to practice on) and so not surprisingly, trainees tend to come out with pretty solid technique (and certainly much better than when they started). As such, we see a two-part learning curving with the first curve being steep (intro session), followed by an apparent plateau in skills, and finally a 2nd flatter, final curve towards mastery. It is during the plateau (aka apprenticeship) that logging and spaced supervision is so critically important. There are many reasons why skills may seem to plateau or stop improving. This could be due to degradation of technique, or forgetting a key step, and these need to be corrected through ongoing supervision (which was the case in the above study). But their are also confounders (as mentioned by the authors) associated with gradually improving technique and confidence such as choosing to scan more challenging patients or environments resulting in an apparent lack of progress). All the more reason to ensure regular supervision with feedback – fostering deliberate practice (more on this below!).

This would seem to support the notion that most trainees improve with scan count, with approximately 50-100 encounters being a common threshold to achieve a reasonable level of performance for many applications. These learning curves show trajectory of skill acquisition, which can be applied to learners. By logging scans, it helps educators see whether a learner is developing their POCUS skills in an expected and appropriate level for their experience.

When we track scans, the benefits go beyond only measuring growth.

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Fostering Deliberate Practice

A second reason to track scans relates to Deliberate Practice².  You may recall that we mentioned that in clerkship supervision is variable, thus some trainee scans are supervised and others are unsupervised. When we log a supervised scan, it means a qualified instructor has signed off meaning there was  an opportunity for the instructor to give real time feedback and teaching, one of the key components of deliberate practice. However, given the large number of trainees (all medical students at USASK!) it is also necessary for trainees to engage in additional practice that incorporates the feedback they have received. This deliberate practice happens when you perform unsupervised scans on your own, practicing the skill and technique you’ve been coached in. And trainees should keep track of that too!image6

At USask, they have developed a Clinical Ultrasound Elective in Clerkship (CUSEC), that students can apply to in their 4thyear. It is an innovative 2 week elective that starts with one week of intensive hands-on scanning and small-group based learning, followed by a second week where trainees integrate POCUS into clinical rotations such as emergency medicine, pediatrics, internal medicine or surgery. Due to limited space in the elective (12 students), there is an application process. This involves a submission of a “POCUS CV” that outlines students’ past experience with clinical ultrasound. Part of the required POCUS CV is a copy of a log of all the scans you’ve completed. So, if you want to build a strong POCUS CV, you need to log scans showing your commitment to both supervised and non-supervised practice. While regular practice is doing something over and over, deliberate practice is different in that it involves regular feedback and has specific goals.

Assessment for Learning

We saw how the POCUS CV can be used to demonstrate a trainee’s commitment to deliberate practice. The side we have not yet discussed is how logging scans also benefits the educators in a few ways. Logging also informs the educator of the trainee’s baseline level of POCUS experience prior to the session in question (either on shift, in the skills lab or at a course). This helps the educators determine a learning plan for the day, or prepare materials for an upcoming session. In the presence of a strong cohort of trainees, educators can alter the introduction to a session and push forward to challenge trainees with new applications and learning opportunities.

Readiness for Assessment

Lastly, tracking scans helps guide Readiness for Assessment for trainees. Let’s take a look at another situation. This time, flying airplanes and helicopters.

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In order to get your pilot’s licence in Canada, there are many requirements: grounds school, supervised flight time of at least 45 hours, as well as a written exam. Additionally, there are milestones to achieve along the way: the first solo, a cross country solo, a pre-flight test, and the flight test, the equivalent of a final exam. So, how does the flight school figure out when a student is ready to attempt each of these milestones? Flight schools use logbooks as a general gauge to help them: the first solo happens around 10-20 hours of logged flight time, Cross country between 30 – 50, and the flight test usually after 55 (although the minimum is 45 hours). Along with feedback from their supervised training flights, these thresholds help guide the instructors on when their students may be ready to attempt a milestone.

In POCUS, in order to be proficient, you need both experience and formal assessment. The ACEP EUS policy statement in 2016 states that trainees should complete a benchmark of 25 – 50 reviewed exams for a particular application, and 150-300 EUS exams in total. The Canadian Point of Care Ultrasound Society (CPOCUS) also requires an apprenticeship of 50 supervised scans for each core indication, but to get the certification you need both the scan numbers as well as successfully challenging their exam. The Canadian Association of Emergency Physicians recently updated their EM POCUS Position Statement and they too emphasize the need for both a supervised apprenticeship as well as an summative examination of skills.

But, similar to getting the pilot licence, how do educators estimate when a learner may be ready for their formal assessments?

image8

There is evidence to confirm what is already ingrained in us, that practice is important in becoming proficient in POCUS. A study by Duanmu et al.3 looked at EM resident OSCE scores in comparison to the number of scans they’ve logged. They articulate that a plateau (we’ll call this the 2nd plateau..) begins at around 300 total scans (all core EM applications). From their results, we can extrapolate the number of scans above which most learners are likely to be ready to pass (which is important from a resource allocation perspective since we want to reserve a 3 hour examination for those instances where MOST trainees will be predicted to pass). Thus, more evidence that we can use a scan log as a guide to trigger summative assessment.

Screen Shot 2019-11-08 at 5.36.47 AM

We hope we’ve convinced you that logging your scans is important! But the question remains, what is the best way to do so? Image capture for a handful of EM residents is fairly straightforward – but what about 400 medical students!? How does USask do it? That’s part 2 – stay tuned!

MacKenzie Russell & Wayne Choi

Peer Reviewed by Paul Olszynski

References

1.     Blehar DJ, Barton B, Gaspari RJ. Learning curves in emergency ultrasound education. Academic Emergency Medicine. 2015 May;22(5):574-82.

2.     Anders Ericsson K. Deliberate practice and acquisition of expert performance: a general overview. Academic emergency medicine. 2008 Nov;15(11):988-94.

3.     Duanmu Y, Henwood PC, Takhar SS, Chan W, Rempell JS, Liteplo AS, Koskenoja V, Noble VE, Kimberly HH. Correlation of OSCE performance and point-of-care ultrasound scan numbers among a cohort of emergency medicine residents. The Ultrasound Journal. 2019 Dec;11(1):3.

 

 

 

SASKSONO19 – DEEP DIVE ON POCUS!

The SASKSONO19 program comes together!

Join us on Saturday, March 2nd, 2019!

REGISTRATION NOW OPEN: https://ccdeconference.usask.ca/index.aspx?cid=408

This year, our  “DEEP DIVE” means we will be going beyond test performance metrics,  exploring in-depth the role clinical ultrasonography can have in improving patient outcomes and system efficiencies. Our conference includes a range of learning experiences including short lectures, hands on workshops for beginners as well as those already familiar with the basics, a Sono-Round Table to develop a multidisciplinary clinical ultrasonography framework at USASK, supervised scanning with top level coaching, as well as rapid oral abstracts and the always entertaining Sonogames!

As organizers, we are committed to delivering a conference that supports the learning and wellness of all our attendees. We have included several optional opportunities for networking, exercise, relaxation and laughter! We will also have spaces for breastfeeding/pumping for those who may choose to use them, and as organizers, will do our best to help attendees secure quality childcare if needed.  We also hope to be a low/minimal waste conference so please consider bringing your own coffee mug and/or water bottle.

Detailed Program:

7:30: Wellness Opportunity (optional) “Run at the speed of sound” or  “Sound walk with talk”. We will provide a meeting location and encourage our attendee runners and walkers to join us for a great start to the day!

8:00 – 9:00 am: Registration and breakfast

9:00 am: Introductions and acknowledgement of our Treaty 6 commitment.

9: 15 am: Dan Kim – Deep Dive into EM POCUSSonoGrail.jpg

9:45 am: Dr. Peggy Lambos – Deep Dive into Pediatric POCUS

10:15 am: Nutrition break (Wellness oriented with healthy snacks offered)

10:30 am – 12:00 pm: Morning Concurrent Sessions

FUNdamentals: POCUS 101 will be an introductory session for those new to clinical ultrasonography/Point of Care Ultrasound (POCUS). It will include flipped content sent to you before the conference as well as a quiz. The workshop will include a brief review ovf key concepts and hands on scanning practice of three core applications: scanning for abdominal and pleural fluid as well as pericardial effusion. Completion will include an assessment which, if passed, makes you eligible for more supervised scanning in the afternoon!

PROfound: USask’s first ever multidisciplinary POCUS Round Table will give Saskatchewan clinicians a chance to further guide the adoption and integration of POCUS throughout the province of Saskatchewan. We hope to establish provincial recommendations on training, scope of practice, documentation and quality assurance. Key recommendations will then be shared with the entire conference audience at the last session of the day for feedback and ratification. There will be flipped content sent out for this session including a draft framework document.Screen Shot 2019-01-03 at 2.04.29 PM.png

SONO EXPO: For those interested in exploring the spectrum of POCUS applications at USASK, we are excited to offer you deep dives into Inflammatory Bowel ultrasound as well as Pediatric EM ultrasound. And as usual, expect at least 30 minutes of hands on scanning and anatomy learning as well! This is a great opportunity for students and residents to explore applications outside the core USASK POCUS curriculum.

12:00 pm – 1:00 pm: Break which includes a nutritious lunch, an optional stretching session, opportunities to connect with old friends and/or make new ones!

1:00 – 4:00 pm: Afternoon Concurrent Sessions

SONO Abstracts and SONOlympiad: Always inspiring, educational and a good time, the students square off with their abstracts and then go head to head in the sonogames.

1:00 pm: SonoAbstracts

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ABSTRACT DETAILS:
Clinical or educational research, QI Work, and case reports will be considered.
320 word limit
a) Clinical research abstracts should include: background, methods, results and conclusion.
b) Educational research abstracts should include background, description of intervention, outcomes and conclusion
c) Quality improvement should include background (with a clear QI methodology), aim statement, methods/intervention, results, and conclusion.
d) Case reports will be considered as well and should include introduction of case, summary of current evidence, highlight unique aspect of case, and conclusion.

2:00 pm to 3:45 pm : SONOlympiad

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SUPERVISED SCANNING: Struggling with an application or two? Need some POCUS coaching? Here’s your chance! Instructors qualified in basic, diagnostic and resuscitative POCUS will be on hand to help you take your scanning to the next level for 3 straight hours! And if that seems a bit daunting – don’t sweat it, we’ll offer a mid-point stretch and re-energizing session. This way you’ll be sure to finish strong as you head into the final hour which will include (for section 3 credits) a detailed assessment of your skills!

4 pm: Closing session

SONO ROUND UP: We will present the main recommendations for a USASK POCUS Framework as developed by the Round Table panels and participants. The audience will have the opportunity to provide feedback and vote using an audience response system.

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REGISTRATION NOW OPEN: https://ccdeconference.usask.ca/index.aspx?cid=408

Summary of the Academic Program (subject to minor changes)

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CHECK OUT THE TRAILER!

sono19-program

Download the poster (with an active registration link) for distribution to your colleagues!

SONO18-Poster 11.19.18

Wait, what did you just say?!

Image result for what did you just say? meme anchorman

As the role of clinical ultrasonography continues to grow throughout healthcare, the need for clear communication of bedside findings has never been greater. We know that communication plays a major role in high quality healthcare, and that miscommunication has been identified as a major contributor to medical error and patient complaints.

Last year at SASKSONO17 (Breaking the Sound Barrier), we discussed the need for clear communication amongst clinicians. Our panel of experts (Internist, Intensivist, Emergentologist and Hospitalist) offered great advice on how best to communicate clinical ultrasound (aka POCUS) findings with colleagues and consultants (you can check out the 8 minute video here: https://vimeo.com/215476593).

But clear communication with colleagues is only one piece of the puzzle. The other big piece is clear communication with the patient! And while this may seem self-evident, we suggest there’s more to it than simply applying basic clinician-patient communication skills. For example, I am sure you have heard a trainee or colleague say to their patient, after having completed a bedside scan, that everything looks OK. Seems harmless doesn’t it? But to the patient, there is now a very real potential for misinterpretation of both the purpose of the scan, and the findings! Here at Sasksonic we’ve heard it first hand. Patients have returned to their primary care providers with impressive stories of whole body scans where their liver, spleen and kidneys were evaluated by ultrasound and “Great news doc, everything was OK!”

Image result for houston we have a problem

By not clearly stating the indications for the scan, or not clearly explaining the findings, clinicians may give their patients the wrong impression that they have undergone a much more comprehensive evaluation than intended or necessary. This can lead to a lot of headache and frustration by downstream providers who now find themselves rummaging through the patient’s medical record looking for the “whole body scans” (assumed to be either consultative ultrasound or CT scans) when no such studies were performed. Furthermore, in the absence of a consultative report (or worse yet, no comments regarding to the point of care ultrasound in the visit note), it can also negatively impact the status of clinical ultrasonography in the eyes of our colleagues and patients. As an important and evidence-based part of the clinical assessment (now proposed to be the 5th pillar of the bedside assessment – inspection, palpation, percussion, auscultation and insonation), we need to ensure our colleagues and patients understand the role clinical ultrasonography plays in patient care.

The solution?

Whenever possible, clearly communicate with patients about the indications, findings and limitations of the clinical ultrasound scan in question. When performing a FAST scan this means letting the patient know you are looking for free fluid in the abdomen or chest, which if seen, would suggest internal bleeding. If no free fluid is seen, instead of saying “everything looks OK” we suggest you say “I don’t see any free fluid on my scan, but this clinical application of ultrasound has limitations and sometimes we miss injuries. Keeping the clinical picture in mind, I think we should proceed with…”

And there’s more! Whenever possible, be sure to give the patient a clear understanding of what the scan will include including where the transducer will be placed. Be sure to warn them about the room temperature gel that often feels ice cold. Then, while scanning, try to talk them through the findings as much as possible (this gets easier as your image generation skills improve). For example, when scanning the gallbladder for suspected cholelithiasis, take time to show them their gallbladder, what the wall looks like and whether there are any stones. Remember, one of the advantages of clinical ultrasonography is that you are learning about your patient’s (patho)physiology in real time at their bedside. So let the patient know what’s going on in the moment, tell them in a way they will understand, and quell their curiosity while also empowering them!

For an example of good communication with a patient (and other aspects of ultrasound etiquette) , check out this short clip we’ve prepared at Sasksonic for our trainees.

cheers,

Paul Olszynski and Qasim Hussain

Peer Review: Drs. Kish Lyster and Irene Ma

 

SASKSONO18 SONOGAMES HIGHLIGHTS

Congrats to “No Pain, No Gain”, our first place team at this year’s SASKSONO conference! Big thanks to all of our participants and to the crowd for cheering the teams on as they battled it out. Also big thanks to Dr. Quinten Paterson (PGY2 EM) and Ms. Alixe Dick (MS2 USASK) for their hard work in preparing the games this year and Drs. Kawchuk and Jelic for their sound judgment!

All in all, a very successful SASKSONO18 – We hope to see you next year at SASKSONO19!Screen Shot 2018-03-27 at 1.49.53 PM.png

Rural and Regional IP Core SKanapalouza

Great news! We’re hosting an IP Core SKanapalouza for Rural and Regional Clinicians on March 10th!

This ultrasound scanning day is to facilitate clinicians seeking to obtain their Canadian Point of Care Ultrasound Society (CPoCUS) CORE Independent Practitioner certification. The intent is to provide clinicians working in rural areas an opportunity to obtain scans towards their certification that are otherwise difficult to achieve in such locations. There will be an opportunity to obtain up to 28 scans towards your certification. All standardized patients will be female to allow for maximum scanning applications. There will be a high instructor to participant ratio to ensuring a quality scanning opportunity.

For more details and to register, click on this link

cheers,

The Sasksonic Team

 

 

Are we doing CPR wrong?

Did you ever wonder why we adjust for patient age and size for almost everything (meds, devices, intubations, casts) and yet we assume everyone should get compressions in the same place?!
When we first heard about u/s-guided compressions using transthoracic echo (TTE) many of us thought it was going to be near impossible. To our surprise – up to half of patients have decent A4C views that offer a glimpse at what is happening – and we have seen ETCO2 rise from 20 to 40  with correction of CPR position.
The limited evidence (mostly animal studies) is pretty compelling… then add the potential of improved views using TEE and suddenly intra-arrest care changes dramatically!
Check out this clip to learn more: https://vimeo.com/206051789
Better yet – want to discuss it? want to try it out on a simulator? Want to practice your scans?
Then register for SASKONO18 by going to www.sasksonic.com/sasksono
Deadline to register is Feb 15th, 2018!
Please forward this to anyone you think might be interested.
The Sasksonic team

Case of the Year – Just in time for the Holidays!

As we wrap up another great year at Sasksonic, we are thrilled to learn that one of our own recently took home POCUS-Toronto’s “Case of the Year” award!

USask EM’s Dr. Puneet Kapur (PGY5 EM, @Kapurp) was recognized for his stellar case submission involving identification and test performance of several transthoracic echo findings as they relate to identifying acute pulmonary embolism. Many of you have heard of the value of each of the following findings as they relate to distinguishing acute from chronic RV strain: Screen Shot 2017-12-20 at 9.39.03 AM

Here are clips from the actual case that show RV dilation in the PSL and McConell’s sign in the A4C. Despite these – it may remain challenging to reliably determine acute vs chronic strain (see details in the cited article below).

 

 

Well, don’t give up hope – introducing RVOT systolic excursion! This measurement is obtained using the parasternal short axis view at the level of the aortic valve.

 

Screen Shot 2017-12-20 at 9.34.22 AMIt appears that measuring RVOT systolic excursion (as a percentage of end-diastolic RVOT diameter minus end-systolic RVOT diameter divided by end-diastolic RVOT diameter) is both specific and highly sensitive for acute PE. Analysis of right ventricular outflow tract systolic excursion showed that a value <24.3% can be found in acute pulmonary embolism patients with 100% sensitivity and 95.56% specificity (AUC = 0.987, P < 0.0001).

Sounds promising – looking forward to hearing and learning more about this.

We’re proud of Puneet! And while we’re at it – big thanks to the team at POCUS-Toronto for giving trainees like Dr. Kapur an opportunity to learn and excel in emergency POCUS.

Want to learn more about RVOT systolic excursion and acute RV strain? Check out the article below:

  1. Lõpez-Candales A, Edelman K. Right ventricular outflow tract systolic excursion: A distinguishing echocardiographic finding in acute pulmonary embolism. Echocardiography. 2013;30(6):649-657. doi:10.1111/echo.12120.