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Original Study

Journal of Veterinary Emergency and Critical Care 23(3) 2013, pp 268–273
doi: 10.1111/vec.12056

Evaluation of a training course in focused
echocardiography for noncardiology house
officers
Yuki C. Tse, DVM; John E. Rush, MS, DVM, DACVECC, DACVIM; Suzanne M. Cunningham, DVM,
DACVIM; Barret J. Bulmer, MS, DVM, DACVIM; Lisa M. Freeman, PhD, DVM, DACVN and
Elizabeth A. Rozanski, DVM, DACVIM, DACVECC

Abstract

Objective – To determine whether a training course in focused echocardiography can improve the proficiency of
noncardiology house officers in accurately interpreting cardiovascular disease and echocardiography findings
in dogs entering the emergency room setting.
Design – Prospective, blinded, educational study.
Setting – University veterinary teaching hospital.
Study Subjects – House officers underwent training in focused echocardiography. Fifteen dogs, including
normal dogs and dogs with stable congenital or acquired cardiac disease, were used as study subjects during
the laboratory session.
Interventions – A 6-hour curriculum on focused echocardiography was developed that included didactic
lectures, clinical cases, and hands-on echocardiography.
Measurements and Main Results – Pre- and postcourse written examinations were administered to participants.
House officers attended didactic lectures that were subsequently followed by a hands-on laboratory session and
practical examination, which involved performing transthoracic echocardiography on dogs with and without
cardiovascular disease. Twenty-one house officers completed the focused echocardiography training course.
Written examination scores were 57 ± 12% before and 75 ± 10% after training (P < 0.001). Following the course,
97% of participants in the practical examination were able to obtain the correct right parasternal short- or longaxis view. Posttraining, most participants correctly identified pleural effusion (90%) and pericardial effusion
(95%) and discriminated normal atrial size from atrial enlargement (86%). However, successful identification of
a cardiac mass, volume status, and ability to recognize a poor quality study as nondiagnostic remained relatively
low. Most trainees responded that the length of hands-on laboratory training was too abbreviated and that the
course should be > 6 hours.
Conclusion – A focused echocardiography training course improved knowledge and yielded acceptable proficiency in some echocardiographic findings commonly identified in the emergency room. This training course
was not able to provide the skills needed for house officers to accurately assess fluid volume status, identify
cardiac masses, ventricular enlargement or hypertrophy, and certain cardiac diseases.
(J Vet Emerg Crit Care 2013; 23(3): 268–273) doi: 10.1111/vec.12056
Keywords: cardiac evaluation proficiency, imaging, emergency ultrasonography

Abbreviations

From the Department of Clinical Sciences, Cummings School of Veterinary
Medicine at Tufts University, North Grafton, MA 01536.

ECC
FAST
RPS

emergency and critical care
focused assessment sonographic technique
right parasternal

The authors declare no conflict of interest.
Presented in part at the 18th International Veterinary Emergency and Critical
Care Symposium, San Antonio, TX, September 2012.
Address correspondence and reprint requests to
Dr. John E. Rush, Department of Clinical Sciences, Tufts Cummings School
of Veterinary Medicine, 200 Westboro Rd, North Grafton, MA 01536, USA.
Email: john.rush@tufts.edu
Submitted September 14, 2012; Accepted April 1, 2013.

268

Introduction
Focused echocardiography has been performed and interpreted by emergency room veterinarians as a method 

C Veterinary Emergency and Critical Care Society 2013

and informed consent was obtained from the dog owners. (7) assessment of intravascular volume 269 . (5) identification of pericardial effusion. observational study was performed consisting of development of a model curriculum and implementation of a course in focused echocardiography.7 More recently. a consensus statement by the American Society of Echocardiography and the American College of Emergency Physicians was published supporting focused cardiac ultrasound as a fundamental tool to expedite diagnostic evaluation of the patient at the bedside and to initiate emergent treatment and triage decisions in the emergency room setting. The course consisted of 3 hours of didactic lectures. doi: 10.4 Subsequently. No dog was used for more than 60 minutes at a time. study participants completed a written examination to assess their baseline knowledge of ultrasound physics and machine use. or in a standing position for the echocardiographic examinations. Study protocol The initial phase of this study involved developing a curriculum designed to teach focused aspects of echocardiography. noncardiology residents. Its purpose is limited to answering straightforward. Prior studies have evaluated its reliability in assessing the presence of free fluid in the abdominal cavity following motor vehicle accidents. followed by a 3hour hands-on laboratory session on normal dogs. In people. sternal recumbency.2 and for determining the likelihood of congestive heart failure. but a qualitative. and emergency room physicians will have adequate clinical ability to preliminarily assess patients entering the emergency department in cardiac or respiratory failure. echocardiography has been used as a method for rapidly diagnosing cardiac tamponade in hemodynamically unstable patients.5 In human medicine. Before beginning the training course.12056 Materials and Methods Study design A prospective. (4) gross estimation of left ventricular function. The second written examination was completed 5–18 days after completion of the echocardiographic training course. echocardiography. The Clinical Studies Review Committee approved use of dogs employed in the laboratory training. The study was reviewed and approved by the University’s Institutional Review Board for conduct of human research.8 It has been suggested that with limited focused training in echocardiography. goal-oriented examination mainly reliant upon 2-dimensional (2D) imaging.Echocardiography for noncardiology house officers to establish a preliminary diagnosis and help guide the initial management of patients who present in acute circulatory or respiratory failure. All dogs were positioned in right lateral recumbency. guidelines for instruction in emergency ultrasonography have been published and endorsed by the American College of Emergency Physicians6 and the Society for Academic Emergency Medicine. The study was opened to all house officers (except for those enrolled in the cardiology training program) at the University’s teaching hospital including rotating interns from the small animal hospital. veterinarians with minimal prior ultrasonographic training could correctly identify the presence or absence of free abdominal fluid in dogs in a high percentage of cases. The dogs used for the training and testing components of this study included a combination of dogs with normal cardiovascular anatomy and dogs (n = 15) with stable congenital or acquired cardiac diseases (n = 5). The objectives of the goal-directed examination to be taught during the training course included (1) ultrasound machine use and physics. (6) identification of pleural effusion. and 3rd year residents in various specialty training programs. (2) correct identification of cardiac anatomy and image orientation. pleural effusion.1 for identifying hypovolemia. and echocardiographic identification of various diseases and clinical findings. Participants completed a practical examination immediately after the laboratory training. Study setting and population The echocardiography curriculum and training course was developed and administered by 3 board-certified veterinary cardiologists. The use of focused ultrasonography has emerged as a diagnostic tool in a variety of clinical situations in veterinary medicine. 1st.  C Veterinary Emergency and Critical Care Society 2013.4 Following 2 hours of didactic training in basic physics of ultrasonography and performance of training focused assessment sonographic technique (FAST) abdominal exams on 12 healthy dogs. and other thoracic injury in dogs. 2nd. clinical questions with the goal of dictating therapy in an accurate and rapid fashion.9–11 although the level of training required to define clinical competency was not determined. The purpose of this study is to determine if a focused echocardiography training course can improve the proficiency of noncardiology veterinary residents and interns in accurately interpreting cardiovascular disease and echocardiography findings in patients entering the emergency room setting. FAST protocols with a focus on thoracic assessment have been developed to rapidly diagnose pneumothorax. (3) evaluation of cardiac chamber size and/or hypertrophy.1111/vec.3 Echocardiography in this setting is not a comprehensive examination. Sedation was not administered.

but with some substantial change to each question or to the images for each question. status. The goals and curriculum were modified from previously published guidelines from human prospective studies in emergency ultrasound. RPS short-axis view of the aorta and left atrium. Categorical variables were analyzed using chi-square tests. Differences in scores between 3rd year residents and all other house officers were evaluated using single factor ANOVA. roundness of the left ventricle. with each station proctored by a board-certified veterinary cardiologist. at 2 sequential stations. or no image obtained. moderate. Normally distributed data were analyzed using paired t-tests (to compare pre. in a closed room with the attending cardiologist and one other person responsible for dog restraint.and postcourse written examinations scores) or independent t-tests (to compare scores between emergency-critical care [ECC] and nonECC house officers). the 9 additional questions asked each participant about both 270 aspects of their comfort level and specific questions to evaluate the structure and content of the echocardiography course. the acquired image was assessed for the presence and symmetry of the papillary muscles. Tse et al. Nine additional questions (in addition to the 30 examination questions above) were given at the end of each exam. A 6-hour curriculum was developed and designed to teach these concepts. Values of approximately 35% for fractional shortening (±10%) or values of approximately 60% for ejection fraction (±10%) were considered acceptable estimates.a. Each participant had 5–10 minutes to correctly obtain a series of predetermined echocardiographic views at each station (eg. The trainee was allowed to select the appropriate transducer for the dog and adjust the machine setting as was needed to get the requested images. participants were asked in these 9 questions to rate their comfort level with various echocardiographic findings on a 4-point scale (none. (8) identification of cardiac mass or thrombus (9) cardiac disease identification and. This score was obtained from a predetermined assessment of specific criteria for each view–eg.c All house officers participating in the study were instructed to attend all of the didactic and practical training sessions. Statistical analysis Data were analyzed using a commercial software program. for participants who wished to view them again. The curriculum included static images. all participants were randomly assigned a number that was used as the participant’s only identification on the examinations so that the identity of the participant was not available to the persons grading the written examinations or to faculty evaluating the house officers in their respective residency programs. In addition to the pre. Before the course. echocardiographic loops.b. Statistical significance was set at P < 0.1111/vec. and RPS long axis 5-chamber view of the left ventricular outflow tract and left atrium in normal dogs using 3 different echocardiographic machines. C. “please obtain a right parasternal short-axis view of the aorta and left atrium”). and to estimate global left ventricular function. Each trainee was examined individually.and postcourse written examination.d Data were examined graphically for normality. and included 3 hours of lecture and 3 hours of hands-on echocardiography laboratory training. For the postcourse examination. or high level of comfort). RPS long axis 4-chamber view. a fair quality image. A 30-question written. multiple-choice examination was administered before and after training. the ability to see the right ventricle in the image. Results Twenty-seven house officers took the precourse written examination. to obtain an M-mode image of the LV. and practice cases relevant to conditions that are commonly encountered in the emergency room. The echocardiographic images and loops were projected to the entire group for 1 minute each and again at the end of the examination. and correct orientation of the probe. Dogs with clinically stable cardiac disease were used for the postcourse practical examination. and to complete both precourse and postcourse examinations. during or after the course. The participants were not given their scores to the written or practical examinations before. The posttraining examination used a similar format and topics to the pretraining examination. Three to 4 house officers rotated per group between 3 different stations. The quality of each view was classified subjectively by the examiner as a good quality image. House officers were taught to obtain 2D images of the right parasternal (RPS) short-axis view of the left ventricle. The practical examination tested each individual on their ability to obtain adequate views with proper probe orientation in the RPS short.and long-axis views. the participants completed a postcourse practical echocardiography examination immediately after the hands-on laboratory session. (10) the ability to identify an echocardiographic study as nondiagnostic so as to not interpret findings from a nondiagnostic study. the 5 other questions related to ultrasound physics or other aspects of echocardiography). to accommodate all trainees in the laboratory section of training. The examination was devised with the goals listed above in mind and included both static 2D and M-mode echocardiographic images and 2D echocardiographic loops (25 questions. doi: 10. 24 house officers completed the precourse  C Veterinary Emergency and Critical Care Society 2013. low.05.Y.7. 10 The course was administered over 3 weekends. For the precourse examination.12056 . on the RPS short-axis view of the left ventricle.

77% of participants gave an acceptable estimate of LV contractile function. many participants had low or no comfort in identifying common echocardiographic findings. Eighteen house officers (86%) improved their score on the written examination. left atrial enlargement. However. doi: 10. LV contractile function. 13% of participants obtained a good quality image and 87% obtained a fair quality image.and long-axis views. when house officers were asked to obtain specific echocardiographic views. percentage of items answered correctly. the mean pre. LAE.56 for the precourse written examination and P = 0. However. 59% obtained a fair quality image.99 for postcourse written examination). respectively (P < 0.29 for precourse written examination and P = 0. most participants had low or no comfort in identification of hypovolemia even after the course (13/21). For the 2D RPS 5-chamber long-axis view of the left ventricular outflow tract and left atrium.and postcourse written examination scores were 57 ± 12% and 75 ± 10%. At the beginning and end of the training course. Twenty-one house officers completed all phases of the study (pre. nutrition: n = 1. left atrial enlargement. and 4% obtained a poor quality image. and 3rd year residents (n = 7). When participants were asked to evaluate the focused echocardiography curriculum. radiology: n = 3. % correct. hands-on echocardiographic laboratory session. 28% of participants obtained a good quality image.1111/vec. all 21 participants had moderate to high comfort levels in identifying pericardial and pleural effusion and left atrial enlargement. the percentage of items that participants were able to correctly identify the presence or absence of pleural effusion. Most participants had moderate or high comfort levels in identification of LV contractile function (14/21) and right heart enlargement (15/21). volume status. and 64% precourse to 95% postcourse. Most participants (13/21) responded that the number of lecture hours was 271 .and postcourse written examination. 1 specialty intern). 70% obtained a fair quality image. Twentythree percent of participants were able to obtain a good quality M-mode image of the LV. and pericardial effusion increased from 80% precourse to 90% postcourse. For the 2D RPS long axis 4-chamber view. Twenty-four house officers completed the hands-on echocardiography laboratory session and practical examination. and hypovolemia (Table 2). For the 21 house officers who completed all components of the study.Echocardiography for noncardiology house officers written examination and hands-on echocardiographic laboratory session and practical examination. 1st year residents (n = 7). respectively (Table 1). right heart enlargement.and postcourse written examination from house officers who participated in a 6-hour focused echocardiography course Precourse examination Postcourse examination Number % Number % of items Correct of items Correct Pleural effusion Pericardial effusion LAE/RAE Contractile function Volume status Cardiac mass Machine/physics/normal Doppler/color flow doppler Nondiagnostic examination Disease identification Ventricular enlargement or hypertrophy 6 3 5 5 2 2 11 4 1 10 5 80 64 55 53 22 63 52 56 63 51 57 5 2 6 4 2 1 11 6 1 9 5 90 95 86 81 31 14 78 58 62 69 69 Number of items. The remaining 11 house officers were from other specialty services within the hospital (anesthesia: n = 1. Mean scores of the ECC house officers were not significantly different from house officers of the other subspecialties (P = 0. When asked to obtain a 2D RPS short-axis view of the LV. rotating intern: n = 2). internal medicine: n = 4. and ability to recognize a poor quality study as nondiagnostic remained relatively low.001). All house officers were not able to complete all phases of the study due to scheduling issues. After the course. including pericardial or pleural effusion. right atrial enlargement. tained a fair quality image. Before the course. Two house officers had no change in examination scores. there were 10 ECC house officers (9 residents. The percentage of participants who were able to discriminate normal left and right atrial size from atrial enlargement increased from 55 to 86%. 27% obtained a good quality image. When asked to obtain a 2D RPS short-axis view of the aorta and left atrium. while 73% obtained a fair image and 4% obtained a poor quality image. On the written examination. successful identification of a cardiac mass. When asked to calculate or estimate either the fractional shortening or the ejection fraction. The 21 house officers consisted of interns (n = 3). the participants were asked to rate their comfort levels regarding certain echocardiographic findings. most of the participants were able to obtain standard RPS short. Among these trainees. the majority of participants (14/21) felt that the time devoted to hands-on laboratory training was too short (Table 3). 21% of participants obtained a good quality image.12056 Table 1: Results of replies to specific items asked during the pre. 2nd year residents (n = 4). and 2% obtained a poor quality image. Median scores of the 3rd year house officers were not significantly different compared to those of the other house officers (P = 0.97 for postcourse written examination). For the practical examination. and 14% obtained a poor quality image. RAE. number of items on the examination in each subject category. and practical examination). and 1 house officer had a decrease in the written examination score. 75% ob C Veterinary Emergency and Critical Care Society 2013.

Vignon et al11 revealed that a 12-hour training course in focused echocardiography for noncardiology house officers with no previous ultrasound experience allowed for adequate assessment of left ventricular systolic function. It was not designed to take the place of. and the ability to correctly identify a nondiagnostic study as nondiagnostic remained low. the subjects were all emergency medicine residents with varied levels of noncardiac ultrasound experience. To the authors’ knowledge. 5 but there has not been any literature documenting the utility of focused echocardiography. or make an attempt to train house officers in performing a comprehensive echocardiographic examination. 3 participants did not provide answers to these questions on the precourse examination.Y. Tse et al. although 6/21 participants responded that the number of lecture hours was too few. and 4/21 participants each responded that the training course should be 12 hours or more. the absence or presence of a cardiac mass. Table 2: Participants’ self-reported comfort level with interpretation of certain echocardiographic findings before (pre-) and after (post-) the echocardiographic training course. In a similar study in human medicine. Number out of 21 total participants. When participants were asked to design an echocardiography training course for residents. The purpose was to determine whether a training course in focused echocardiography could offer a role in optimizing patient care by initiating emergent treatment and triage decisions by the emergency clinician. this is the 272 first study evaluating the utility of a focused echocardiography training course for noncardiology house officers in veterinary medicine. Table 3: Results of the overall course evaluation following completion of the 6-hour focused echocardiography training curriculum Way too few Too few Just right Too many Way too many Number of lecture hours associated with the training course Number of hands-on echo lab hours associated with the training course 1/21 6/21 13/21 1/21 0/21 4/21 10/21 7/21 0/21 0/21 adequate to achieve the training needed before the laboratory.001) Hypovolemia (P = 0. and pericardial effusion. In that particular study. 8/21 participants responded that the course should be approximately 8–10 hours. doi: 10.1111/vec. yet no standardization has been achieved. 9–11 These studies used various training strategies to determine an acceptable level of proficiency in focused echocardiography. This study showed that following a training course of this duration.12056 . The number of correct responses to questions pertaining to pericardial and pleural effusion.or long-axis view. In addition. 97% of the participants were able to correctly obtain a fair to good right parasternal 2D short.001) Right heart enlargement (P = 0.3. the participants’ ability to correctly answer questions pertaining to volume status. such that they would acquire the minimum echocardiographic skills necessary for use in an emergency room setting. P value is for the comparison of pre.4. In addition.to postcourse responses Level of comfort No comfort Low Moderate High ∗ † Pericardial and pleural effusion (P < 0. Additionally. The results of this study demonstrate that a 6-hour training course in focused echocardiography improved the proficiency in some echocardiographic findings as determined by a significant improvement in the written examination score. C.04) Pre∗ Post Pre∗ Post Pre∗ Post Pre∗ Post Pre† Post 1 7 9 2 0 0 5 16 1 7 9 2 0 0 13 8 5 11 2 1 0 7 14 0 6 11 2 0 0 6 14 1 5 9 4 0 1 12 7 1 2 participants did not provide answers to these questions on the precourse examination. during the practical examination. Discussion Focused ultrasonography has been shown to be a useful diagnostic tool in assessing veterinary patients after motor vehicle trauma. Jones et al10 showed that a 6-hour training course in focused echocardiography significantly improved both written and practical examination scores. and atrial size had >85% accuracy rate following completion of the training course. ventricular hypertrophy. Numerous studies in human medicine have shown the emerging importance of focused echocardiography as a diagnostic tool for evaluating patients in respiratory distress.007) Left ventricular contractile function (P < 0.001) Left atrial enlargement (P = 0. most of the house officers felt that more hands-on echocardiography training would  C Veterinary Emergency and Critical Care Society 2013.

5. 4. J Vet Emerg Crit Care 2008. Moore CL. Unluer EE. Acad Emerg Med 2003. Bayata S. WI. volume status) could not be compared statistically between the pre. Hewlett Packard. The original intent of this section was for descriptive purposes only and. Lisciandro GR. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. Sonos 4500 system. Available at: http://www. Heller M. Another limitation is that there was no baseline assessment of the participants’ practical skills in echocardiography so while there was a significant improvement in knowledge.0. Nagdev A. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. 9:186–193. Philips. There were many limitations to this study. J Trauma 2011. Postaci N. et al. et al. the performance on the practical examination may have reflected prior skills in addition to or instead of skills gained in the training course. 10:1054–1058. Tidwell AS. et al. ACEP on the Internet.12056 acquired cardiovascular disease. et al. 10. Kline JA. J Am Vet Med Assoc 2004. DE. Murthi S. but it may also help alter how patients in respiratory distress are triaged and ultimately treated. the number of questions relating to each specific subject category was not equal on the precourse or postcourse written examination. 23:1225–1230. only 21 house officers completed all aspects of the training and examination. Model curriculum for physician training in emergency ultrasonography. this study did not test the ability of candidates to find specific lesions in dogs during the practical examination. 70:56–62. 3. pericardial effusion) was tested in the written examination. 29:280–283. Nonetheless. 8. Further investigation in performing focused echocardiography on this subset of patients and how it reflects patient management and outcome is needed.and posttest. 9. suggesting that a 6-hour training course is not sufficient enough to teach these specific pathologic findings. Crit Care Med 2011. Evaluation of a focused assessment with sonography for trauma protocol to detect free abdominal fluid in dogs involved in motor vehicle accidents. Acad Emerg Med 2002. 2008. Another limitation is that individual categories of questions shown in Table 1 (eg. Next. Point-of-care ultrasound evaluation of pericardial effusions: does this patient have cardiac tamponade? Resuscitation 2011. Bothwell. while the ability to recognize cardiac lesions on prerecorded images/loops (eg. Ann Emerg Med 1994. discussion 62–54. et al. GE-Medical. as demonstrated by an improvement in the written examination scores. but not all categories provides some information on the changes in performance after a training course in focused echocardiography. as a result. participants performed their practical examinations on dogs with stable congenital or  C Veterinary Emergency and Critical Care Society 2013. 82:671–673. some categories had only 1–2 questions or had different numbers of questions on the pre. Rose GA. et al. Bellec F. Systat 12. First. Labovitz AJ. having a larger population of participants in the training program may have changed this finding.org/clinical-practice-management/ emergency-ultrasound-guidelines-2008. Tayal VS. IL. 2. Mucke F. Jones AE.1111/vec. American College of Emergency Physicians Board of Directors. Tayal VS. 11. Chicago. References 1. SPSS. Milwaukee. 23:95–102. Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients. Anand RJ. 7. Vignon P. et al. Further investigation is warranted to determine the appropriate number of hours needed in order to attain proficiency in identifying these echocardiographic abnormalities. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. 18:258–269. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. the numerical increase in some. J Am Soc Echocardiogr 2010. Plummer D. Footnotes a b c d GE Vivid 7 echocardiograph. Although statistical significance was seen. Evaluation of a thoracic focused assessment with sonography for trauma (TFAST) protocol to detect pneumothorax and concurrent thoracic injury in 145 traumatized dogs. doi: 10. Lagutchik MS. 6. et al. 39:636–642. Noble VE. 225:1198–1204. Rozanski EA.and posttest due to the design of the study. Emerg Med J 2012. HDI 5000 system. Mann KA. Ferrada P. Many patients entering the emergency room with hemodynamic instability may present with concurrent problems making interpretation of the echocardiography examination more difficult. 273 . which precluded statistical comparison. Not only could their participation contribute to findings in a future study similar to ours. Boysen SR. Also. Stone MB.Echocardiography for noncardiology house officers be helpful.acep. Bierig M. pleural effusion. One possible way to increase the number of participating veterinarians is to determine whether a training course could be applied to the general population of emergency room veterinarians in private practice. Mateer J. Finally. WA. Emergency Ultrasound Guidelines. Wilmington. Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart failure.