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PoCUS - Where do I begin?

FAQs prepared by Austin Terry, Justin Bowra and Lee Blair

1. Why should I get trained in Point of Care Ultrasound (PoCUS)?

Over the past decade ultrasound has become a core skill in emergency medicine training. Proper training will allow for accurate image acquisition, interpretation, and clinical correlation and will ensure patient care. Without appropriate training the advantages and limitations of ultrasound in the clinical setting may not be recognised.

2. How do I get trained in ultrasound?

Informal bedside training can begin at any stage in your career, including initial familiarization, informal bedside training and formal courses. There are many online and hardcopy resources that can further enhance your knowledge.

3. To what standard should I be trained?

In Australasia, the following standards apply to emergency doctors:

The International Federation for Emergency Medicine (IFEM)

IFEM has published international guidelines on point of care ultrasound (POCUS).

Australasian College for Emergency Medicine (ACEM)

ACEM recognises the importance of ultrasound in emergency medicine and sets guidelines for specific ultrasound examinations (but does not credential individual doctors).

The Australasian Society for Ultrasound in Medicine (ASUM)

ASUM publishes guidelines for doctors who wish to obtain either the Certificate in Clinician Performed Ultrasound (CCPU) and the Diploma of Diagnostic Ultrasound (DDU).

4. What's the difference between training and credentialing?

Credentialing quantifies training and ensures that minimum training and practice standards have been met.

5. Should I get credentialed in PoCUS?

This is a controversial area and in the end it is up to individuals and their employers to decide.

Argument against

There is an argument that formal credentialing should not be required in PoCUS. A commonly employed analogy is that ‘I didn’t get formally credentialed in using a stethoscope or intubating a patient, so why is it necessary for PoCUS?’

Argument in favour

In reality, all doctors are tested and credentialed in skills such as auscultation during their medical student training and formal exams. If PoCUS is ever formally integrated into medical student training programs, then it too will be assessed in this way. Until that time, it is probably wise to undergo PoCUS-specific credentialing.

This is because ultrasound is an extremely operator-dependent skill and can have a hugely detrimental impact on patient care. For example, I [Justin Bowra] have personally seen &/or been involved in the following cases:

  • Leaking AAA with diameter mistakenly measured as 5cm (true diameter was >9cm);
  • False-negative pericardial tamponade (clotted blood in pericardium was isoechoic with liver);
  • False-negative EFAST with delay to definitive care (free fluid in pelvis misidentified as bladder; also clotted blood misidentified as uterus);
  • False-positive EFAST resulting in inappropriate laparotomy;
  • False-positive diagnosis of pneumothorax (actually ETT placed in bronchus and contralateral lung unventilated);
  • False-positive diagnosis of testicular torsion (because of incorrect Doppler settings);
  • Caecum misidentified as bladder for SPC insertion.

Each one of these cases was due to an avoidable error of image acquisition or interpretation. Ultrasound is not nearly as ‘black and white’ as we may think.

Advantages of credentialing include:

  • Credentialing aims to maintain a minimum standard in point of care ultrasound, with the ultimate aim of ensuring the best possible patient care.
  • Formal recognition of a certain level of training.
  • Portability of recognition: healthcare employers throughout Australia and overseas are more likely to recognise your level of experience if you have a formal qualification such as CCPU / DDU.

6. Who can credential me?

Currently for ACEM members the best options arethrough ACEM or ASUM.

Australasian College for Emergency Medicine (ACEM)

ACEM recognizes the importance of ultrasound in emergency medicine and supports its use. ACEM sets out guidelines for appropriate credentialing, but does not credential individual health practitioners. Therefore, it is up to individual Emergency Departments or Local Health Districts to organise in-house training and credentialing.

Many Emergency Departments throughout Australasia organise ultrasound training programmes that are submitted to ACEM for approval. Once approved as having met the required ACEM standards (as set out below), these programmes are run locally for training and credentialing.

ACEM guidelines are available from the links below and outline a process similar to that required for certain ASUM CCPU units. ACEM has a formal link with ASUM and accepts successful completion of CCPU modules for the purpose of credentialing.

Australian Society for Ultrasound Medicine (ASUM)

ASUM was formed in 1970 with a mission to advance the clinical practice of medical ultrasound and to promote the highest possible standards of medical ultrasound practice in Australia and New Zealand. It is a non-profit organisation that provides ultrasound training and credentialing for sonographers, doctors and allied health professionals.

Credentialing available through ASUM

There are two main credentials suitable for emergency trainees through ASUM: the CCPU (Certificate in Clinician Performed Ultrasound) and DDU (Diploma of Diagnostic Ultrasound).

a. CCPU

The CCPU is a credential awarded by the ASUM Council to medical practitioners who are not imaging specialists but who may use ultrasound as a diagnostic tool at the point of care. The CCPU represents a level of proficiency in image acquisition, optimisation and ultrasound skills relevant to the specialty medical area.

In general, each unit consists of:

  • An online physics and image optimisation unit
  • A specialty course: usually 1-2 days of lectures and practical training taken with an accredited course provider
  • Logbook completion: A number of scans must be recorded
  • Two formative assessments 
  • Final summative assessment by an approved assessor

The CCPU is recognised by medical colleges such as ACEM, RACS, RANZCOG and FRACP.

The CCPU costs involve (as at July 2017):

  • ASUM annual membership $524 (3 and 5 year discounted memberships are available)
  • CCPU enrolment $621 (valid for three years)
  • DDU enrolment $856 (plus other costs, see website for details)
  • ASUM online physics unit is included in each of the CCPU and DDU enrolment fees. Stand-alone physics unit access is $371+membership (can be provided by an alternative accredited course).

Please note that ASUM membership does not include CCPU or DDU enrolment.

For the CCPU, a qualified supervisor is essential for the initial hands-on training and for the three directly supervised scans. Ideally a local supervisor should be present in your workplace and able to view and sign off your entire logbook; however, if a local supervisor is unavailable, then remote supervisors may be used for sign-off of your logbook. Logbook assessors for summative and formative scans need to have CCPU or DDU certification (or equivalent) in the module being assessed, or be a practicing and registered sonographer in that area.

There are currently 23 CCPU modules:

  • Which modules should I start with?

This can be determined by your area of practice and your supervisor.

Commonly, emergency doctors start with E-FAST, AAA, and vascular access. Other useful modules to consider when starting out include: BELS, lung and above knee DVT.

  • Process involved for each module of a CCPU

Please note you must be both a member of ASUM and enrolled in the CCPU to start. These enrolments are separate.

1) Complete an accredited physics module. This can either be online with ASUM or another accredited course

2) Complete an ASUM accredited training course or workshop for each module. This can be accredited didactic training with your supervisor.

3) A prescribed number of accredited scans need to be completed for each module and recorded in a logbook. There are a different number of scans required for each module. The scans should be reviewed or completed with an appropriate supervisor. E.g. the E-FAST logbook requires 25 accredited scans with 5 positive scans. This must be completed within 2 years of attending an accredited training course.

4) In addition to the accredited scans completed in your logbook, 2x formative and 1x summative assessments need to be completed with your supervisor. These are directly supervised scans that meet the requirements for each scan (the assessment pro forma is available on the ASUM website at the end of each CCPU syllabus). This must be completed within 2 years of attending an accredited training course.

5) Once your logbook has been completed with the appropriate number of scans, and these have been accredited by your supervisor, it then needs to be submitted to ASUM for certification.

6) After gaining a CCPU in a particular module you need to maintain an ongoing log book of scans to remain accredited with ASUM. There is a recertification process every five years, which requires submitting your logbook and achieving a certain number of CPD points (as stated in the CCPU regulations document).

b. DDU

The DDU is a more comprehensive ultrasound program than the CCPU and involves three modules:

1) Foundations in ultrasound practice: a study module followed by a 2-hour, 120 MCQ examination.

2) Clinical competence: be actively involved in clinical ultrasound for a period of over two year and approximately 500 hours. This needs to include a number of formative and summative assessments.

3) Advanced ultrasound practice: successful completion of a written and oral examination.

7. I have trained in PoCUS overseas. Can this training be recognised?

Yes, there is a process of recognition of prior learning through ASUM. This process is here.

8. Should I save my ultrasound images?

Like ‘Should I get credentialed in PoCUS’, this is a sometimes controversial area. Currently accepted practice is to save images and loops onto stand-alone external hard drives, but many clinicians choose not to save images.

Arguments against

Some argue that clinicians should not save their ultrasound images. Arguments employed include the following:

  • Too complex and time-consuming: it is true that the process of saving images and cineloops is difficult and demanding for PoCUS, because our machines are not connected to radiology PACS.
  • Medico-legally unwise to save: ‘if you don't save the images they can’t be subpoenaed’
  • Argument by analogy: ‘I don't save the sounds I hear through a stethoscope, so why is it necessary for PoCUS?’

Arguments in favour

  • Training requirement for achieving certification and maintaining credentials
  • Medico-legally unwise not to save: ‘they can sue you anyway, this is your chance to justify your decision’
  • Standard of care: other specialty groups save their ultrasound images (e.g. radiologists, cardiologists). The images generated by other modalities such as CT and x-ray are saved and filed, and one could argue that it is even more imperative that this is done for ultrasound, which unlike CT and x-ray is very operator- and interpreter-dependent (see also the examples described in ‘Should I get credentialed in PoCUS?’
  • With regard to the ‘stethoscope’ analogy, probably the only reason we don't save the sounds heard through stethoscopes is that it is not possible to do so.

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