University of Florida- Jacksonville
Department of Emergency Medicine
Emergency Ultrasound
Third Year Rotation
Rotation:
Emergency Ultrasound Elective
Timing:
 One month rotation during the third year.
Residents will participate in Emergency
Ultrasound Monday – Friday, 8am – 5pm for 3
weeks. During this time, residents will attend
regular Thursday morning conferences and
then return to duties related to the ultrasound
course.
 The first two days of the rotation will be at
CSESaR (Simulation Center).
 On Tuesday mornings the resident will report
to Candiss DeJesus, Ultrasound Supervisor, in
the ultrasound department in Radiology at
9am to scan with an ultrasonographer.
 The resident is required to attend Ultrasound
Rounds with an attending physician on
Wednesday mornings at 9am.
 The resident will have 1 week of vacation and
take back up call for clinical shifts in the
Emergency Department as well.
Goals:
Residents will further their knowledge of core
emergency ultrasound applications (see core
applications) and further their ultrasound education by
learning more advanced techniques. Residents will
experience intensive exposure to hands-on ultrasound
and begin assisting educate medical students and
Participant:
Third year EM residents
Evaluation:
 Participants will obtain ultrasound images in
all of the core emergency ultrasound
application areas and submit them to the
Emergency Department Ultrasound QA
process for evaluation. Participants are
expected to produce enough images of
acceptable quality to meet the total number of
scans required by ACEP guidelines (25 scans
in each of the 10 core areas, 250 total
required).
 The Ultrasim program provides over 140
cases that may qualify towards credentialing
in each specific core ultrasound application.
Participants are expected to print and submit
pictures and reports from at least 10 of the 20
FAST exams available, 20 of the 100+ OB-
Gyn exams and 15 of the 28 Biliary exams.
 Residents will be required to write up one
ultrasound case for the Ultrasound Education
blog. The submitted case may demostrate an
innovative use for ultrasound or illustrate an
important teaching point on one of the core
ultrasound topics.
 Residents are required to assist in the
departmental QA process by reviewing 25
scans that have been submitted previously for
QA. The participant will be responsible for
ensuring that the resident who submitted the
scan has reviewed the critique.
 Participants will be required to complete and
pass all 12 sections of the online Emergency
Ultrasound Exam
(http://www.emsono.com/acep/exam.html)
created by the American College of
Emergency Physicians (ACEP) and print the
passing certificate to turn in at the end of the
rotation
 The course director will meet with each
participant at least twice during the rotation to
review their images and their progress toward
credentialing.
Preparation:
 Reading/Lecture material:
o Internet based text: Sonoguide
(www.sonoguide.com),
o Ultrasound lectures on CD
o UF EM Ultrasound Education Blog
(www.UFEMUltrasound.blogspot.com)
interns in core EM ultrasound. Residents will produce
scans of qualifying ultrasound images to complete their
ACEP credentialing (>250 scans).
Participation:
Residents will work in the simulation center, at the
bedside in the emergency department, Radiology
department with a licensed Sonographer and the OB-
Gyn department with core faculty who are credentialed
in ultrasound.
 Ultrasim curriculum
 Preceptor meeting – each resident will meet
with the ultrasound course director before
beginning the rotation for orientation.
 Weekly US Rounds
 Ultrasound Blog Case Presentation
 Medical Student/Intern Lecture
Location:
UF/Shands Emergency Department, UF/Shands
Ultrasound Department, Radioloy and UF/Shands
Center for Simulation Education and Research
(CSESaR).

Deliverables/Outcome measures: Professional expectations of resident:

 Ultrasound scan log documenting ultrasounds Pre-meeting contact with ultrasound course director
performed to be evaluated by the for orientation. Attendance of assigned ultrasound
departmental QA process simulation, rounds and didactic sessions.
 Log of ultrasound guided procedures End-of-rotation evaluation
performed. Professional behavior as defined in UFCOM-J
 Printed copies of scans done on the Ultrasim Professionalism Expectations
program.
 Ultrasounds performed outside the ED will
require the witnessing sonographer to sign the
resident’s scan log.
 Ultrasound lecture and scan demonstration for
Medical Students and Interns
 Ultrasound Educational blog case presentation
 Completed QA reports for 25 scans

Goals and Objectives:

1. Each resident should already have a working knowledge of core emergency ultrasound
applications, indications, techniques and procedures prior to the start of this rotation. During
this rotation residents are to further their ultrasound education and work toward completion of
the American College of Emergency Physicians’ (ACEP) guidelines for credentialing.
Residents will accomplish this by studying the text, reviewing the lectures for each ultrasound
protocol on the lecture CD, using the listed internet websites, using the Ultrasim program in
the simulation center and on patients in the emergency department, ultrasound department
and OB department. Residents will also attend ultrasound rounds and didactics with certified
attending physicians during which they will observe and perform ultrasound imaging at the
bedside on patients in the Emergency Department.
2. Each resident will obtain images of high enough quality to qualify for credentialing in
ultrasound as defined by ACEP. Residents will accomplish this by performing and printing their
scans done on the Ultrasim system in the simulation center, saving their studies with reports
on the M-Turbo ultrasound machines in the emergency department or by having the OB-Gyn
credentialed preceptor or Radiology Ultrasonographer sign-off on ultrasounds done in their
department. The resident will keep a patient scan log sheet with the signature of the OB-Gyn
preceptor or Ultrasonographer for verification with a description of pertinent findings from that
ultrasound. For ultrasounds done with the Titan ultrasound machine, the hard images must be
printed and the appropriate QA form filled out and placed in Dr. Duran’s box in the attending
office.
 3. Each resident will submit images to the emergency department QA committee for review. This
will be done automatically for all scans saved on the M-Turbo ultrasound machine in the
emergency department and for all images placed in Dr. Duran’s box.
4. At the completion of the QA process, each ultrasound will be critiqued for quality of images
and correct diagnosis and whether the scan is of acceptable quality to count toward the
required number for ACEP credentialing. Residents will be required to view all their ultrasound
QA reports in Dr. Duran’s office after the completion of the rotation.
5. Furthermore, since the QA process is so important, residents will be required to assist in this
process by critiquing 25 ultrasounds submitted by their peers. The goal is to tech the resident
the finer points of image acquisistion and what entails a quality image from one reviewing a
scan not performed by themselves. Dr. Duran will give the resident a group of printed
Ultrasound to review for image quality, correct diagnosis and scan protocol accuracy. The
resident must fill out the attached QA form for each scan and return the complete QA form to
either Dr. Duran or her assistant, Debbie Eurom.
6. Residents are required to take the 12 part ultrasound test sponsored by ACEP. The resident
must pass each area with a 70% or higher. If a section is failed, it must be re-taken until a
passing score is obtained. The resident must print out the passing score report and turn it in
to Dr. Duran or her assistant by the end of the rotation.
7. The Ultrasound Education blog posts new cases weekly that illustrate important ultrasound
educational points or share an interesting case that illustrate how ultrasound can be used in a
new or interesting way. Residents are required to submit one case write up based on their
ultrasounds for the month. The images must clearly illustrate the point of discussion. The
resident will receive credit on the blog for their authorship.
8. Residents are required to attend weekly bedside teaching Ultrasound Rounds. Although
lectures and texts are important to ultrasound education, bedside ultrasound scanning is
essential to learning this important skill. Ultrasound Rounds are comprised of a mini-lecture
on a topic of interest chosen by the resident, review of some of the resident’s previous
ultrasounds, question and answer session and then bedside scanning in the department.
During this time the faculty will review the resident’s hand position and image acquisition and
make corrections in real time as needed. The faculty will also give the resident real time
feedback on how to improve their image acquisition.
9. Residents are expected to complete the UltrasSim cirriculum in the Simulation Center. This
simulation program teaches residents about probe orientation and ultrasound scanning planes
and how this can alter an image.

For the specific requirements of which images need to be submitted to count towards credentialing,
see the goals for each core ultrasound application and the “Required Views” form on new innovations
or attached to the ultrasound machines.

Introduction:

This course is set up with the goal of certifying and credentialing all UF- Jacksonville Emergency
Medicine residents in the use of ultrasound as defined by the American College of Emergency
Physicians (ACEP). The list of goals in this course is taken directly from ACEP’s statement on
emergency ultrasound and the scope of practice expected by physicians trained in emergency
medicine. The “primary goals” are the minimum requirements to become certified in ultrasound. This
list is what residents are required to demonstrate that they are in fact competent in obtaining and
interpreting ultrasound images. “Secondary goals” are suggested goals that emergency physicians
should be able to accomplish but at this time are not required to demonstrate competency. “Specific
websites” are free websites that provide images and techniques for obtaining images. They are very
helpful in recognizing what normal and abnormal images look like. It has been shown in studies that
the more images residents obtain and see are directly related to competency in emergency
ultrasound. The websites are meant as an adjunct to actually performing the ultrasounds. Like all
procedures in medicine, you need to do them in order to know how to do them.

Core Ultrasound Applications

Aorta

Primary Goal Secondary Goal Methods To Submit

Identify infrarenal Identify Suprarenal Obtain US images Images from 15-25
AAA, if AAA is AAA, Infrarenal from diaphragm to patients in 2 planes
present, then dissection, thoracic bifurcation. Obtain with measurement
identify free fluid in dissection, Iliac transverse and of aortic diameter
abdomen (see artery aneurysms longitudinal and identification of
FAST exam) measurements of abnormalities
the aorta.

Specific websites:
 http://www.sonoguide.com/aa.html
 http://www.hqmeded.com
o click on “images”, there are images of normals and abnormals
 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on “abdominal aorta” parts 1 and 2 in the right hand column
 http://www.med-ed.virginia.edu/courses/rad/edus/index.html
o click on “epigastric pain” then “AAA”

RUQ/ Gallbladder

Primary Goal Secondary Goal Methods To Submit

Identify Identify Obtain images of Images from 15-25
Cholelithiasis Cholecystitis, Bile RUQ organs in 2 or patients with a
duct abnormalities more planes (sagital transverse and a
(dilatation and and transverse). sagital view with
choledocholithiasis), Identify gallbladder measurement of
Liver abnormalities and the presence or gallbadder wall
(tumors, abscesses, absence of thickness and
intrahepatic gallstones. identification of
cholestasis, Measure Gall gallstones, sludge
pneumobilia, bladder wall and pericholecystic
hepatomegaly), thickness. Identify fluid. There are over
Portal vein common bileduct 28 cases available
abnormalities, Identify on Ultrasim, 10 of
Abnormalities of the pericholecystic fluid these can count
pancreas, gall towards the total
bladder tumors,
 unexplained
jaundice, ascites

Specific websites for RUQ US

 www.sonoguide.com/biliary.html
 www.hqmeded.com
o click on “images” for normals and abnormals
o click on “instructional videos” then click “Ultrasound in gallbladder evaluation”
o Also, this site has some videos that we can download and put on our website that go
through the technique

 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on gallbladder parts 1 and 2
 http://www.med-ed.virginia.edu/courses/rad/edus/index.html
o click on RUQ pain then Gallstones, acute cholecystitis

Echocardiography
Primary Goal Secondary Goal Methods To Submit
Identify cardiac Estimate left Obtain images of Images for 10-25
activity and ventricular EF. the heart in 3 planes patients with at least
pericardial effusion. Evaluate patient (four chamber, long two of the four
Identify cardiac volume status axis and short axis) views. Identify
tamponade based on ultrasound using the standard cardiac motion,
images of inferior ultrasound windows abnormal structures
vena cava and (subcostal, and the presence or
internal jugular vein parasternal and absence of a
apical). pericardial effusion.
If an effusion is
present, submit
image identifying
the presence or
absence of right
ventricular collapse

Specific websites for Cardiac US

 http://www.sonoguide.com/cardiac.html
 www.hqmeded.com
o click on Ultrasound in right column for some cases
o Also, this site has some videos that we can download and put on our website that go
through the technique
 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on echocardiography in the hypotensive patient, parasternal echo

Urinary Tract
 Primary Goal Secondary Goal Methods To Submit
Identify the Identify Obtain images of Images from 15-25
presence or hydronephrosis. both kidneys in 2 patients showing
absence of the Identify renal calculi. planes. Obtain both kidneys in two
kidneys. Identify Identify renal images of the planes and images
the bladder and the masses bladder in 2 planes. of the bladder in two
volume of urine in planes. Identify
the bladder abnormalities such
as hydronephrosis,
renal calculi, renal
masses and bladder
distension

Specific websites for Renal US

 http://www.sonoguide.com/renal.html
 www.hqmeded.com
o click on Ultrasound in right column for some cases
o Also, this site has some videos that we can download and put on our website that go
through the technique
 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on renal
 http://www.med-ed.virginia.edu/courses/rad/edus/index.html
o click on flank pain then nephrolithiasis, hydronephrosis

First Trimester Pregnancy

Primary Goal Secondary Goal Methods To Submit
Indentify the Identify fetal pole. Obtain images of Images from 15-25
presence or Identify presence of the uterus in at least patients showing
absence of an intra- free fluid. Identify 2 planes using the uterus in at least
uterine pregnancy cardiac activity. either 2 different planes.
Identify adnexal transabdominal or Identify the
structures. transvaginal presence or
approaches. Identify absence of
the presence of embryonic
embryonic structures. If no
structures fetus is seen and
the patient has an
hCG compatible
with seeing an
intrauterine
pregnancy- turn in
images
demonstrating the
presence or
 absence of free fluid
in the abdomen.
There are over 59
scans available on
Ultrasim. 15 of the
Ultrasim scans may
be submitted
towards
credentialing.

Specific websites for Pelvic US

 http://www.sonoguide.com/obgyn.html
 www.hqmeded.com
o click on Ultrasound in right column for some cases
o Also, this site has some videos that we can download and put on our website that go
through the technique
 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on pelvic ultrasound, a tale of two pregnancies part 1 and 2
 http://www.med-ed.virginia.edu/courses/rad/edus/index.html
o click on pelvic pain then ectopic pregnancy

Trauma
Primary Goal Secondary Goal Methods To Submit
Identify Evaluate volume Obtain at least 4 Images from 20-25
hemoperitoneum. status by using IVC images including: patients showing
Identify and IJ RUQ/ hepato-renal hepato-renal
hemopericardium. recess, LUQ/ recess, spleno-renal
Identify hemothorax. spleno-renal recess, recess, pericardium,
Identify Cardiac/pericardium and bladder.
pneumothorax , and bladder. Identify the
Obtain video clip of presence of
the chest hemothorax,
demonstrating hemopericardium
pleural slide to and
evaluate for hemoperitoneum.
pneumothorax There are 20 cases
available on the
Ultrasim. 10 of
theses scans can
count towards
credentialing.
Chest scans to
evaluate for
 pneumothorax may
be included in
trauma scan.

Specific websites for Trauma US

 http://www.sonoguide.com/FAST.html
 www.hqmeded.com
o click on Ultrasound in right column for some cases
o Also, this site has some videos that we can download and put on our website that go
through the technique
 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on FAST RUQ, Morrison’s pouch pitfalls, FAST LUQ, FAST suprapubic,
Echocardiography in the hypotensive patient
 http://www.emergencyultrasound.org.uk/
o scroll down and click on FAST, an overview

Deep Venous Thrombosis

Primary Goal Secondary Goal Methods To Submit
Identify the Identify the Obtain images Images from 10-25
presence or presence or and/or video clips of patients from at
absence of thrombi absence of blood common femoral least 2 different
in the deep venous flow in the deep artery and vein with sites identifying
system venous system compression compressability of
images. Obtain the veins
images and/or video
clips of the popliteal
artery and vein with
compression
images. Obtain
images of deep
femoral artery and
vein with
compression
images. Obtain
images of
superficial femoral
artery and vein with
compression
images. Obtain
images and/or video
clips of deep
brachial artery and
vein with
compression
images
Specific websites for Venous thrombosis US
 http://www.sonoguide.com/dvt.html
 http://cmedownload.com/store/soundbytes.php?sid=6bc133a9cf9eef2967630e1ae3f6c8f4 
o click on thromboembolic disease and ultrasound
 http://www.med-ed.virginia.edu/courses/rad/edus/index.html
o click on swollen extremity

Thoracic:
Primary Goal Secondary Goal Methods To Submit
Identify None Obtain intercostal Images from 10-25
pneumothorax. images and/or video patients from 2 or
Identify pleural clips demonstrating more intercostal
effusion the presence or spaces. Identify the
absence of pleural presence of or
sliding. Obtain absence of
RUQ and LUQ pneumothorax.
views the abdomen May submit UQ
to visualize pleural views from FAST
fluid. exam to
demonstrate pleural
effusion.

Ocular:
Primary Goal Secondary Goal Methods To Submit
Identify posterior Identify signs of Obtain images of Images from 10-25
chamber increased the orbit identifying patients identifying
hemorrhage. intracranial pressure important anterior chamber,
Identify retinal by ocular ultrasound structures. posterior chamber
detachment. Measure optic nerve and optic nerve.
Identify diameter. Identify optic nerve
pappilledema. and measure
diameter to rule out
ICP.
Soft Tissue and Musculoskeletal:
Primary Goal Secondary Goal Methods To Submit
Identify abscesses. Identify fractures. Obtain images of Images from 5-25
Identify foreign Identify tendon the soft tissue in at patients in at least
bodies in soft tissue injuries. Identify least two planes two planes
joint effusions demonstrating the
presence or
absence of abscess
or foreign body

US guided procedures
Primary Goal Secondary Goal Methods To Submit
Use ultrasound Use ultrasound Successfully Log of specified
guidance for the guidance for the perform the above procedure and
placement of central drainage of procedures with the acknowledgment of
venous catheters. pericardial fluid. Use guidance of success or failure of
Use ultrasound of ultrasound ultrasound the procedure as
guidance for the guidance for well as list of
placement of abscess drainage. complications if any
peripheral venous Use ultrasound
catheters. Use guidance for lumbar
ultrasound guidance puncture
for drainage of
pleural effusion.
Use ultrasound
guidance for
drainage of
peritoneal fluid

Specific websites for US guided procedures

 http://www.sonoguide.com/line_placement.html
 http://www.sonoguide.com/pericardiocentesis.html
 http://www.sonoguide.com/thoracentesis.html
 http://www.sonoguide.com/paracentesis.html
 http://www.sonoguide.com/foreign_bodies.html
 Objectives versus Competencies Taught and Evaluated
Medical Patient Professionalism Interpersonal Systems Practice
Knowledge Care skills and Based Based
communication Practice Learning and
Improvement
Identify core X X X X
emergency
ultrasound
applications
Review and be X X X X
able to explain
pathophysiology
of core
emergency
ultrasound
applications
Identify common X X X X X X
emergency
management
principles of
conditions
diagnosed by
core emergency
ultrasound
applications
Identify how to X X X X X X
use emergency
ultrasound as a
risk management
tool.
Identify business X X X X
principles related
to emergency
ultrasound and
credentialing