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Training USGRA. Rafael Blanco,. AIMS. 10 TASKS Core competencies: can they do the block? Training practice pathway: which blocks? Residency-based training: how many blocks?. Examples of scopes of practice. American Medical Association (AMA) American College of Emergency Physicians(ACEP)
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Training USGRA Rafael Blanco,
AIMS • 10 TASKS • Core competencies: can they do the block? • Training practice pathway: which blocks? • Residency-based training: how many blocks?
Examples of scopes of practice • American Medical Association (AMA) • American College of Emergency Physicians(ACEP) • NICE • European Federation of Societies for Ultrasound in Medicine and Biology ( EFSUMB)
AMA • Resolution 802 • “The AMA affirms that ultrasound imaging is within the scope of practice of appropriately trained physicians.” • American Medical Association House of Delegates. Privileging for ultrasound • imaging. Resolution 802, Dec 1999; Reaffirmed; Sub. Res 108, Jun 2000. H-230.960. • Available at: http://www.ama-assn.org. Accessed July 9, 2007.
ACEP Emergency Ultrasound Guidelines. Approved by the ACEP Board of Directors, June 1, 2001. http://www.acep.org/NR/rdonlyres/8024079E-28E8-4875-93E6-6867EA705A2A/0/ultrasound_guidelines.pdf
EMFSUMB (minimum training requirements) • Theoretical knowledge • Ultrasound physics,safety,artifacts, anatomy,pathology Sonographic interpretation,scanning and guided techniques • Indication of minimum no - supervised and independent - (with designated reviewer and trainer) • Training program - involving training with recognised competent authority - accreditation and evaluation • Continuing professional education
EMFSUMB (minimum training requirements) Level 1 • Following abilities needed • to perform common examinations safely and accurately • to recognise and differentiate normal anatomy and pathology • to diagnose common abnormalities within certain organs systems • To recognise when referral for a second opinion is indicated • In most medical specialties , the training requisite to this level of practice would be gained during conventional post-graduate training
EMFSUMB (minimum training requirements) Level 2 • 1 year experience at level 1 with a minimum of one session per week • Further 300 examinations • Logbook listing all all examinations • Illustrated logbook of 25 cases • Supervision of experienced level 2 or Level 3 practitioner • Accept referrals from Level 1 practitioners
EMFSUMB (minimum training requirements) Level 3 • Advanced level of practice involving • To accept tertiary referrals from Level 1&2 practitioners • To perform specialised ultrasound examinations • To perform advanced ultrasound-guided invasive procedures • To conduct research and teach at all levels • To be aware o and pursue developments within ultrasound
Certificate and training in CC • Level 1 • 5-10 examinations per week(under supervision) • Minimum no of examination 25 per system (vascular, thorax , abdomen) • Logbook kept • Supervised training by Level 2 competent person or level 1 with 2 years experience • Appropriate theoretical knowledge - course on fundamentals of ultrasound • Competency based training and assessment
Certificate and training in CC • Level 3 • A level 3 practitioner will spend the majority of their time undertaking ultrasound - expert • Accept referrals from level 1&2 practitioners • Spend a continuous period of specialty training in critical care ultrasound • Able to mentor and supervise Level 1&2 practitioners • Aware and pursue developments including Doppler and intravascular contrast agents • Level 2 • 1years experience at level 1 with a minimum of one session per week • Further 300 examinations • Logbook listing all all examinations • Illustrated logbook of 25 cases • Supervision of experienced level 2 or Level 3 practitioner • Accept referrals from Level 1 practitioners
10 tasks • Visualize key landmarks • Identify nerves OP • Normal/Variable anatomy • Needle approach • Aseptic technique
10 Tasks • Follow needle in real time • Consider adjuvant • Test solution • Needle adjustments • Safety guidelines
Contraindications? NONE
Understanding Image generation • Basic principles of image generation • Selection appropriate transducer • Selection appropriate depth and focus • Time gain compensation (TGC) • Archiving images • Screen orientation
Image optimization • Transducer rotation • Transducer tilting • Transducer pressure • Transducer alignment
Image interpretation • Identify nerves • Identify muscle and fascia • Identify artery, vein,bone and pleura • Identify common acoustic artifacts • Identify anatomic artifacts,vascularity/trajectory
Needle insertion and injection To learn: • In plane • Out of plane • Intramuscular injection • Intraneural injection • Local spread ( correct/ incorrect) • Minimize transducer movement
Levels of difficulty • Deep blocks • Potential injuries • Small nerves • Nerves lacking ultrasonographic interfaces
Technique (PART) • PRESSURE • ALIGNMENT • ROTATION • TILTING
UGRA coordinator The Joint Committee recommends that the candidate obtain: • Letter of recommendation from department leadership. • A written description of clinical experience including case volume, length of experience, and safety. • Participation in at least one accredited ultrasound workshop.
Core competencies for residency training in UGRA Patient Care: • Perform gentle ultrasound exams, providing appropriate sedation • Demonstrate proper patient selection • Use appropriate monitoring during UGRA • Demonstrate proper nerve localization techniques • Perform effective and safe nerve blocks
Ultrasound Knowledge: • Understand the general principles of ultrasound physics • Understand benefits and limitations of UGRA techniques • Understand differences between in-plane vs. out-of-plane techniques and their indications • Understand key artifacts and pitfall errors associated with UGRA • Develop an intimate knowledge of 2D ultrasound anatomy of the major neurovascular structures of the upper and lower extremities
Appreciate common non-neural pathologic states that are diagnosed byultrasound: atherosclerotic disease and venous thrombosis • Establish familiarity with the major scientific literature related to UGRA • Learn techniques for UGRA • Understand the applications of color Doppler interrogation • Understand equipment specifications • Infection control and equipment cleaning
Local level • Breakfast meetings • Tutorials • Theatre supervision • Sono-club • Projects • Courses
What defines expertise in R.A. • Cognitive elements • Psychomotor elements • Affective elements
Flexibility • Confidence
Continuous assessment How do we assess trainees? • Beginners • Intermediate • Advance
CUSUM 1= success 0= failure Three successes,followed by a failure and 2 more successes
Anatomy Primal 3D Complete Human Anatomy McMinn’s Human Anatomy
Needling • Lamb thighs • Jelly phantoms • Chicken
ADDUCTOR LONGUS FEMORAL VEIN BICEPS FEMORIS GLUTEUS MAXIMUS SEMITENDINOUS SEMIMEMBRANOUS SCIATIC L.A. SCIATIC QUADRATUS FEMORIS ISCHIAL TUBEROSITY ADDUCTOR BREVIS ADDUCTOR MAGNUS GREATER TROCANTER PECTINEUS ADDUCTOR MAGNUS Pattern recognition
SUPRACLAVICULAR NERVES STERNOCLEIDOMASTOID MUSCLE C5 CEPHALIC VEIN PECTORALIS MAJOR MUSCLE LAT/MED PECTORAL NERVES SCALENUS MED. MUSCLE SCALENUS ANT. MUSCLE C6 PECTORALIS MINOR MUSCLE AV AA C7 SUBSCAPULARIS MUSCLE ? LUNG
