ORIGINAL CLINICAL REPORT

Is 1 Day of Focused Training in

Echocardiographic Assessment Using
Subxiphoid-Only (EASy) Examination Enough?
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A Tertiary Hospital Response to the COVID-19

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Crisis and the Use of the EASy Examination to

Support Unit-Wide Image Acquisition
Nibras F. Bughrara, MD, FCCM,
OBJECTIVES: We assessed the efficacy of 1-day training in echocardiography FASA1,2,3
assessment using subxiphoid-only (EASy) followed by supervised image interpre- Maegan R. Neilson, MD4
tation and decision-making during patient rounds as a novel approach to scaling
Stephanie Jones, MD1,2,3
up the use of point-of-care ultrasound (POCUS) in critically ill patients.
Lorna Workman, MBBS5
DESIGN: Retrospective analysis of medical records and EASy examination
Amit Chopra, MD1,2,6
images.
Aliaksei Pustavoitau, MD, MHS,
SETTING: Tertiary care academic hospital. FCCM7
PATIENTS: A total of 14 adults (> 18 yr old) with COVID-19-associated respira-
tory failure under the care of Albany Medical Center’s surge response team from
April 6–17, 2020 who received at least one EASy examination.
INTERVENTIONS: Residents (previously novice sonographers) were trained in EASy
examination using 1 day of didactic and hands-on training, followed by independent
image acquisition and supervised image interpretation, identification of hemodynamic
patterns, and clinical decision-making facilitated by an echocardiography-certified
physician during daily rounds.
MEASUREMENTS AND MAIN RESULTS: We recorded the quality of
resident-obtained EASy images, scanning time, and frequency with which the
supervising physician had to repeat the examination or obtain additional images.
A total of 63 EASy examinations were performed; average scanning time was 4.3
minutes. Resident-obtained images were sufficient for clinical decision-making on
55 occasions (87%), in the remaining 8 (13%) the supervising physician obtained
further images.
Copyright © 2024 The Authors.
CONCLUSIONS: EASy examination is an efficient, valuable tool under conditions Published by Wolters Kluwer Health,
of scarce resources. The educational model of 1-day training followed by Inc. on behalf of the Society of
supervised image interpretation and decision-making allows rapid expansion of Critical Care Medicine. This is an
the pool of sonographers and implementation of bedside echocardiography into open-access article distributed under
routine ICU patient management. the terms of the Creative Commons
Attribution-Non Commercial-No
Derivatives License 4.0 (CCBY-

C
NC-ND), where it is permissible to
OVID-19 due to severe acute respiratory syndrome coronavirus download and share the work pro-
2 (SARS-CoV-2) was declared a pandemic by the World Health vided it is properly cited. The work
Organization on March 11, 2020 (1). Approximately 5% of patients cannot be changed in any way or
with COVID-19 were progressing to acute respiratory distress syndrome used commercially without permis-
(ARDS), septic shock, and multiple organ dysfunction (2). On March 7, 2020, sion from the journal.
New York State, where our hospital is located, declared a state of emergency, DOI: 10.1097/CCE.0000000000001038

Critical Care Explorations www.ccejournal.org     1

 Bughrara et al
KEY POINTS
Question: Is 1-day training in echocardiography
assessment using subxiphoid-only (EASy) exami-
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nation followed by supervised image interpretation
adequate for novice sonographers to incorporate
bedside echocardiography into daily practice?
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Findings: Trained residents efficiently imple-
mented EASy examinations into daily assessments
of critically ill patients. Scanning time averaged
under 5 minutes, with 87% of examinations pro-
viding diagnostic information.
Meanings: Our training paradigm in a single-
window EASy examination may serve as an ed-
ucational model for rapidly expanding the pool of
sonographers and incorporating EASy examina-
tion into routine management of critically ill patients
when resources are scarce.
with hospitalizations reaching a peak of 18,825 on
April 12 (3).
Like many institutions, our hospital initially
encountered shortages of qualified staff and personal
protective equipment in the setting of a massive influx
of patients with respiratory failure. Point-of-care ultra-
sound (POCUS) can become an invaluable tool under
these circumstances to assess patient-specific physi-
ology, assist in investigation of pathology, and guide
clinical decision-making (4–8). Our institution used
the echocardiographic assessment using subxiphoid-
only (EASy) examination to standardize how POCUS
is used to manage workflow and direct patient care.
The EASy examination is an abbreviated cardiac,
vascular, and lung ultrasound that consists of visualiz-
ing the heart and inferior vena cava (IVC) via the sub-
costal window and is supplemented by evaluation of
the upper lung fields and pleural space. The EASy ex-
amination leads to faster acquisition of clinically use-
ful images than more extensive focused transthoracic
echocardiography (FTTE) (9). Qualitative diagnostic
information to assess patients with hemodynamic in-
stability or respiratory distress or to define volume
status in the perioperative setting is also comparable
between EASy examination and FTTE (9). In our hos-
pital, we successfully incorporated EASY examina-
tion in management of patients with undifferentiated
2     www.ccejournal.org
shock (10, 11) and hospital-based advanced life sup-
port (12). Given the unprecedented demand imposed
by the pandemic to train large numbers of clinicians
and implement POCUS into clinical practice within
a limited time, we condensed training in EASy exam-
ination into a 1-day course followed by independent
image acquisition, supervised image interpretation and
decision-making during patient rounds and assessed
the efficacy of this approach.
MATERIALS AND METHODS
We conducted a retrospective analysis of critically ill
adult patients diagnosed with COVID-19 and admit-
ted to Albany Medical Center (AMC), a 766-bed re-
gional tertiary care center in Albany, NY. The study was
approved by the AMC institutional review board (reg-
istration number 6091). Procedures followed the insti-
tution’s ethical standards on human experimentation
and the Helsinki Declaration of 1975. Requirements
for informed written consent were waived by the
committee.
Clinical Setting
During spring 2020, AMC’s surge plan created dedi-
cated response teams, each managing 8–12 patients
with COVID-19-associated respiratory failure requir-
ing mechanical ventilation. Each team included a crit-
ical care physician and three residents (two surgical
and one anesthesia). EASy examinations were per-
formed by the response team led by an anesthesia crit-
ical care physician.
EASy Examination
The EASy examination uses only the subcostal window
to obtain views of the heart and IVC and is supple-
mented by anterior lung field views. As needed, the
posterolateral diaphragmatic pleural recess can also
be evaluated for effusion. A phased array transducer is
used for the entire examination, depth is set at 21 cm,
far gain set differentially higher, and frequency lowered
for penetrating mode. The examination starts with
the subcostal four-chamber view of the heart (trans-
ducer indicator oriented to the 2 or 3 o’clock position).
Tilting the probe slightly down can bring the left ven-
tricular outflow tract (LVOT) into visualization. Next,
the IVC is visualized by rotating the probe 90 degrees
March 2024 • Volume 6 • Number 3
 Original Clinical Report

counterclockwise (transducer indicator to 12 o’clock).
The descending aorta is seen by tilting the probe to the
patient’s left. Rocking the probe toward the heart and
rotating the probe toward the patient’s left shoulder
provides the midpapillary short-axis view of the heart
(obtained in approximately 50% of the EASy exami-
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to assess the component of the examination; one point
was assigned if there was incomplete view and additional
views would be required for evaluation, and two points
were assigned if there was complete view of the structure.
Based on the total score the examination was graded as
good (scores 10–12), adequate (scores 7–9), or poor (score

nations in our study). Finally, images of the anterior 6 and below). Studies where subcostal views were of poor
lungs are obtained below the middle third of the clav- quality or documented as “‘unobtainable’” were excluded
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icle with the transducer indicator oriented toward the from the analyses; nevertheless, the rest of the examina-
patient’s head (Fig. 1; and Video 1). tion was completed and saved for further review.

Evaluation of the Subcostal Image Quality Hemodynamic Phenotyping

To evaluate the quality of studies, we used a scoring system
by assigning 0–2 points for each one of the six compo-
nents of examination (pericardium, right ventricular [RV]
size and thickness, RV function, interventricular septum,
left ventricular [LV] size and thickness, and LV func-
tion) based on confidence of evaluator in observed find-
ings. Zero points were assigned if evaluator was unable
Following the Surviving Sepsis COVID-19 guidelines
(13, 14), we characterized POCUS findings according to
hemodynamic phenotypes (patterns) (10, 11). The phe-
notypes are based on information following EASy exami-
nation on cardiac performance, fluid responsiveness, and
fluid tolerance. All patients are classified into three com-
mon clusters and subdivided into seven phenotypes, with

Figure 1. Probe locations and steps for obtaining echocardiographic assessment using subxiphoid-only (EASy) examination views.
A visual depiction of obtaining EASy examination views. These images show proper probe placement on the body and corresponding
examples of echocardiographic images produced from these views. Placements and images are numbered 1–4 to be obtained in this
order. 1A, Subxiphoid 4 chamber cardiac view. 1B, Midpapillary axis view with probe rotated toward patient’s left shoulder. 2, Same probe
placement rotated with probe marker to patient’s head for visualization of the inferior vena cava (IVC). 3 and 4, Anterior lung images with
corresponding examples of A-line lung patterns. ARDS = acute respiratory distress syndrome, HTN = hypertension, LV = left ventricle,
RV = right ventricle, RVH = right ventricular hypertrophy.

Critical Care Explorations www.ccejournal.org     3

 Bughrara et al

a differential approach to clinical management (Fig. 2). septic shock, and tension pneumothorax are less com-
Cluster 1 includes phenotypes representing patients with mon phenotypes (cluster 4 in Supplemental material 1,
normal to hyperdynamic LV systolic function. Cluster 2 http://links.lww.com/CCX/B312).
includes phenotypes associated with LV systolic dysfunc-
tion with or without RV dysfunction. Cluster 3 represents
EASy Examination Training
the phenotypes of acute or acute on chronic isolated RV
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dysfunction. Cardiac tamponade, catastrophic valvular To educate COVID-19 response team residents in the
pathologies such as acute valve rupture in the setting of EASy examination, we designed a 1-day course with
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Figure 2. Patient phenotypes by echocardiographic assessment using subxiphoid-only (EASy) examination image findings. Previously
published in Anesthesiology Clinics, with permission from Bughrara et al (10). EASy images to categorize phenotypes for COVID-
19 patients. Adapted from previous phenotyping model in septic shock patients which also included lung profiles per phenotype.
Phenotypes are based on three images obtained from subxiphoid probe positioning plus rapid analysis of anterior lungs to visualize
the four-chamber heart and inferior vena cava (IVC) and upper lung fields, respectively. These images provide cardiac evaluation to
assess cardiac performance, IVC evaluation to assess volume responsiveness, and brief lung examination to differentiate fluid tolerance
(A profile) from fluid intolerance (B profile). Together these comprise the components that are organized by findings into different
phenotypes. Phenotypes are dispersed between cluster 1 category of increased heart function, cluster 2 category of left ventricular
(LV) or biventricular (Bi V) dysfunction, and cluster 3 category of isolated right ventricular (RV) dysfunction. Although lung examinations
were performed in each COVID-19 patient on EASy examination, despite cardiac and IVC findings, all patients in this study displayed
A-lines/B-lines pattern or bilateral B-lines pattern lung profiles secondary to acute respiratory distress syndrome (ARDS) picture due to
COVID-19. Phenotype profiles otherwise remain identical to prior studies. Phenotype 1 is generally characteristic of hypovolemic shock
with small ventricular chambers and flat IVC with respiratory variation. Phenotype 2 is consistent with distributive shock in an adequately
resuscitated patient with good cardiac filling and normal IVC size. Phenotype 3 describes a patient with LV hypertrophy (LVH), dilated left
atrium (LA), and small and collapsible IVC. Phenotypes 4 and 5 highlight isolated LV and Bi V dysfunction, respectively, which are usually
affiliated with a plethoric IVC with B profile lung examination when no longer fluid responsive. Phenotype 6 could represent an ARDS
patient with RV dysfunction as evidenced by enlarged RV, plethoric IVC, and B profile lung examination reflecting nonhydrostatic edema.
Phenotype 7 considers patients with pulmonary hypertension (HTN) and RV hypertrophy who develop acute on chronic RV failure as
represented by enlarged and hypertrophic RV, plethoric IVC, and variable lung profile. Bi A = biatrial, RA = right atrium, RVH = right
ventricular hypertrophy.

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didactic and hands-on experiences. This was followed
by ongoing real-time feedback on image acquisition, in-
terpretation, and patient management based on EASy
examinations performed for clinical indications (mod-
eled after the I-AIM framework [15]) (Fig. 3). The
course was modeled according to the five-step method
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for teaching psychomotor clinical skills originally used
in the Advanced Trauma Life Support course (16):
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1) describing EASy examination and its indications,
2) demonstrating EASy examinations and its tech-
nical aspects via moderated web-based videos, 3) pro-
viding detailed live narration of the EASy assessment of
COVID-19 patients in the ICU with focus on pattern
recognition, 4) verbalization of the EASy examination
process by the residents facilitated by providing EASy
Examination Report Sheets (Supplemental material 2,
http://links.lww.com/CCX/B313), and 5) learners per-
forming the EASy examination on ICU patients and re-
ceiving real-time feedback from a supervising clinician.
The 1-day course consisted of two segments: the
morning didactic and the afternoon hands-on train-
ing. The didactic 4-hour segment consisted of: 1) a
2-hour web-based curriculum moderated by POCUS
expert, and covered ultrasound physics, the acquisi-
tion of subcostal cardiac and IVC views and anterior
Figure 3. Translating the Skills Teaching Protocol to image acquisition, interpretation, and patient management (I-AIM) protocol to
echocardiographic assessment using subxiphoid-only (EASy) examination education. Illustrates from left to right the University of
Nottingham’s Skill Teaching Protocol, the I-AIM protocol, and finally our institution’s steps in EASy examination education for residents
previously untrained in echocardiography.
Critical Care Explorations
Original Clinical Report
chest lung views, and qualitative ventricular assess-
ments, 2) a 1-hour question-answer session to ensure
that the trainees had a solid grasp of the material, and
3) a 1-hour interactive presentation which revisited
the EASy phenotypes as previously outlined. The af-
ternoon hands-on training was conducted on non-
COVID-19 patients in the surgical ICU (SICU). This
training involved completing 10 supervised EASy
examinations on patients as part of the routine clinical
care within the SICU (Video 1), allowing the trainees
to practice image acquisition. During the 1-day course,
we focused on image acquisition only, rather than de-
veloping additional expertise in image interpretation
or management; both of those aspects of imaging were
provided only as introductory concepts All trainees
were signed off to independently acquire images as
part of patient evaluation.
After the course, residents independently acquired
EASy images during patient assessments. Ongoing
learning in image interpretation and patient man-
agement were enforced during daily rounds, led by
a critical care anesthesiologist (N.B.) who has passed
the National Board of Echocardiography (NBE)
special competencies in critical care echocardiog-
raphy (CCE) and uses CCE on a regular basis. In this
www.ccejournal.org     5
 Bughrara et al
manner, large numbers of patients with COVID-19
could be assessed with the EASy examination while
residents received ongoing feedback in image acqui-
sition and supervised training in image interpreta-
tion and decision-making.
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EASy Examination Workflow
Residents obtained EASy examinations (Video 2) ei-
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ther during routine daily assessments and/or for emer-
gent indications (e.g., worsening arterial hypotension
or hypoxia). All images were obtained using the same
ultrasound machine (X-Porte, FUJIFILM Sonosite,
Bothell, WA), saved, and later reviewed outside of
the patient’s room during rounds (Video 3) with N.B.
Here, feedback was provided on residents’ image ac-
quisition while image interpretation and clinical
decision-making were approached together. The inten-
sivist would perform echocardiography independently
when either: 1) the images were inadequate for clin-
ical decision-making or additional views were neces-
sary or 2) chronic cardiac disease was suspected based
on original EASy findings of atrial enlargement and/
or ventricular thickening (phenotypes 3, 4, 5, and 7),
necessitating complete quantitative FTTE. An EASy
Examination Report Sheet (Supplemental material 2,
http://links.lww.com/CCX/B313) was completed for
each examination (Video 2), the hemodynamic phe-
notype was assigned and a care plan was established.
All images and reports were saved as part of the med-
ical record.
Each examination followed standardized infectious
disease precautions (Video 4).
Data Collection and Outcomes of Interest
We included all adults (> 18 yr old) with COVID-19-
associated respiratory failure requiring mechanical
ventilation under the care of the anesthesiology-led re-
sponse team from April 6 to 17, 2020. In all patients,
COVID-19 was diagnosed by reverse transcription-
polymerase chain reaction from a nasopharyngeal
swab.
Demographic information, comorbidities, ICU
length of stay, days of ventilation, ventilator settings,
patient mortality, laboratory values, diagnoses dur-
ing hospitalization, pertinent medications given, and
interventions performed were extracted from med-
ical records. Laboratory values included ferritin,
6     www.ccejournal.org
C-reactive protein, d-dimer, procalcitonin, troponin,
lactate, and fibrinogen. We collected data on acute
kidney injury (AKI), continuous renal replacement
therapy, requirement for vasoactive agents, thrombo-
embolic events, prone positioning, diuresis, anticoagu-
lation, and initiation of antibiotics. We calculated the
Sequential Organ Failure Assessment (SOFA) score
(17), Acute Physiology and Chronic Health Evaluation
II score (18), Simplified Acute Physiology Score (19),
and Brescia score (20) for each patient to estimate the
severity of illness.
The EASy Examination Report Sheet (Supplemental
material 2, http://links.lww.com/CCX/B313) described
examination indication, graded image quality, assigned
hemodynamic phenotype, and noted subsequent deci-
sions in clinical management and outcomes. The time
to complete each EASy examination (scanning time)
was measured by the duration between two time-
stamped images per examination, the first one blank to
indicate when the probe first touched the patient and
the second one being the final captured image. Amid
the crisis, minimizing trainees’ exposure to COVID-
19 while examining patients in the ICU was impera-
tive. Hence, we only included the time spent within the
patient’s room during the examination and omitted all
activities conducted outside the room, where the res-
ident was not exposed to COVID-19 risk. We did not
specifically document time to prepare the patient and
machine and cleaning afterward (similar across all
patients) and the time to subsequently review image
quality and findings with the attending intensivist
(variable across patients).
Donning and doffing were also excluded as these
procedures would take place for all patients regardless
of the use of POCUS.
Our primary outcomes of interest were the quality
of EASy images obtained by the novice sonographer,
the scanning time to obtain them, and the frequency
with which N.B. entered the room for additional im-
aging. We also assessed whether there were changes in
clinical management secondary to the EASy examina-
tion (evaluated by interventions performed as a direct
response to information obtained from the EASy ex-
amination images) and patient responses to these clin-
ical decisions (measured by changes in phenotypes and
findings on follow-up EASy examinations). All data
obtained from EASy Examination Report Sheets, ultra-
sound images, and medical records were deidentified
March 2024 • Volume 6 • Number 3

and stored in the Health Insurance Portability and
Accountability Act-compliant institutional network
drive that was password protected and only accessible
to those with an institution-associated account and
permission given by the principal investigator.
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Data Analysis
Data were presented as medians with interquartile
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ranges for continuous variables, and numbers and
percentages for categorical variables. Analysis was
performed using Minitab (v.19.2020.1; Minitab, State
College, PA) and R (v.3.6.1; R Foundation for Statistical
Computing, Vienna, Austria) statistical software.
RESULTS
A total of 14 patients were identified. All patients were
endotracheally intubated and received mechanical
ventilation, with median (interquartile range [IQR])
Pao2/Fio2 131 (83–155). Median (IQR) age was 65
[50–74] years, and median [IQR] SOFA score was 8
(7–10). Most patients had elevated serum troponin,
received vasoactive medications, and developed AKI.
Three patients (21%) died during the time of the study
(Table 1).
Three residents were trained in the EASy exam-
ination during the study and performed 63 EASy
examinations, varying from 1 to 10 examinations
per patient (Table 2). There were 84 indications for
performing EASy examinations. The most common
indications included first encounter with patients
(n = 14; 16%), volume assessment (n = 35; 42%), sys-
temic arterial hypotension (n = 21; 25%), and acute
worsening hypoxia (n = 14; 17%). Average scanning
time was 4.3 minutes, with a range of 1–10 minutes.
Only in 1 patient (7%) we could not obtain views
from a subcostal window on two separate occasions,
leading to the decision to cease further attempts at
EASy examination after the second failure. For this
patient, the expert instead obtained views from other
windows (apical and parasternal). Given the low like-
lihood of obtaining images, on subsequent examina-
tions, we deemed it unnecessary to expose trainees to
COVID-19 risks. Consequently, the attending physi-
cian independently performed the daily CCE for this
patient. In two patients (14%) EASy examination
images were rated as poor only once during their stay
(in one patient during one of five encounters, and in
Critical Care Explorations
Original Clinical Report
the other patient during one of six encounters). In 11
patients (79%), images were consistently rated as ac-
ceptable or good. Thus, subcostal images were suc-
cessfully obtained from 13 of the 14 patients.
N.B. used information for clinical decision-making
from 55 EASy examinations (87%), and independently
collected additional images on eight occasions (13%).
In six of these latter encounters, additional views out-
side the scope of the EASy examination were needed to
rule out deep venous thrombosis (DVT) (n = 2) and to
confirm the diagnosis or assess signs of chronic disease
(n = 4). In the remaining two encounters, an additional
examination was performed due to poor quality of the
EASy images. Chronic cardiac disease was identified
in six patients (43%), including RV hypertrophy with
right atrial enlargement (n = 4; 29%), LV hypertrophy
(n = 3; 21%), interventricular septal hypertrophy with
signs of LVOT dynamic obstruction inducing systolic
anterior motion (n = 1; 7%), and severe aortic valve
stenosis (n = 1; 7%). All patients in the study shared a
similar lung pattern consistent with underlying ARDS.
Of the eight encounters that required independent
image collection from the attending intensivist, five of
the encounters necessitated quantitative FTTE for full
diagnostic information and clinical management deci-
sions. The images obtained from FTTE agreed with the
phenotyping found in the original EASy examination
performed by the novice sonographer in five encoun-
ters (100%) and the additional information provided
by FTTE supported or confirmed clinical diagnoses.
All interventions received by patients follow-
ing EASy examination findings are summarized in
Supplemental material 3 (http://links.lww.com/CCX/
B314). Common interventions following the EASy
examination included stopping or initiating volume
resuscitation or diuresis according to volume status,
titrating vasoactive medications when volume status
was optimized, initiating neuromuscular blocking
agents, placing the patient into prone position, and
starting anticoagulation for newly diagnosed DVT. In
one patient, the onset of new vasodilatory shock trig-
gered obtaining of blood cultures to evaluate for a new
secondary bacterial infection.
All EASy examination encounters led to infor-
mation used in clinical decision-making, ranging
from specific interventions selected to no indica-
tion of change in current management. The two
cases below (Table 2; and Supplemental material
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 Bughrara et al

TABLE 1.
Patient Cohort Demographics and Outcomes
Variables COVID-19 Patients, n = 14

Sex, n (%)
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 Male 7 (50)
 Female 7 (50)
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Age, yr
 Mean, median (IQR) 63.5, 65 (50–74)
Ethnicities, n (%)
 White 6 (43)
 Black 1 (7)
 Hispanic 5 (36)
 Asian 0 (0)
 Other 2 (14)
Body mass index, mean, median (IQR) 31.3, 30.5 (27–36)
Severity indexes, mean, median (IQR)
 Acute Physiologic Assessment and Chronic Health Evaluation II 22.9, 23 (18–25)
 Simplified Acute Physiology Score II 59.9, 57.5 (51–64)
 Sequential Organ Failure Assessment 8.6, 8.0 (7–10)
Inflammatory markers, mean, median (IQR)
 Ferritin (ng/mL) 939, 806 (356–1166)
 C-reactive protein (mg/L) 168, 166 (61–256)
 
d-dimer (mg/L fibrinogen equivalent units) 43.8, 21.5 (11.2–81.5)
 Procalcitonin (ng/mL) 4.07, 1.1 (0.6–3.1)
 Lactate (mmol/L) 1.4, 1.3 (1.0–1.7)
 Fibrinogen (mg/dL) 486.4, 459 (406–659)
Respiratory variables, mean, median (IQR)
 Pao2/Fio2 ratio 127.3, 131 (83–155)
 Static compliance (mL/cm H2O) 45.1, 43.8 (26.3–53.1)
 Plateau pressure (cm H2O) 23.9, 23 (21–28)
Positive troponin (> 0.04 ng/mL), n (%) 10 (71)
Vasoactive agents, n (%) 11 (79)
Acute kidney injury, n (%) 14 (100)
Continuous renal replacement therapy, n (%) 3 (21)
Thromboembolic events, n (%) 5 (36)
Prone, n (%) 7 (50)
14-d Status, n (%)
 Discharged 0 (0)
 Extubated and transferred to floor 2 (14)
 Remained intubated in ICU 9 (64)
 Death 3 (21)
Mortality, n (%) 8 (57)
IQR = interquartile range.
Data on patient demographics and outcomes obtained by retrospective chart review. All categorical and descriptive statistics are provided as listed.

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 Original Clinical Report

TABLE 2.
Echocardiographic Assessment Using Subxiphoid-Only Examination Results
Case Image Status on Last
Number Encounters Qualitya Phenotypes Type of Schock Day of Service

1 10 Good (10) 1→2 Hypovolemic → Distributive Intubated

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2 5 Good (2) 2 Distributive Extubated and

Adequate (2) transferred to floor
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Poor (1)
3 5 Good (5) 1→2→7 Hypovolemic → Distributive→ Deceased
Acute on chronic cor pulmonale
4 1 Adequate (1) 2 None Extubated and
transferred to floor
5 10 Good (6) 2→6→2 Distributive →Acute cor Intubated
Adequate (4) pulmonale→
Distributive
6 9 Good (7) 2→6→2 Distributive→ Intubated
Adequate (2) Acute cor pulmonale→
Distributive
7 6 Good (3) 3 Distributive with later development Deceased
Adequate (2) of left ventricular outflow tract
Poor (1) obstructive shock
8 1 Adequate (1) 2 None Deceased
9 4 Good (1) 4 Left ventricular systolic dysfunction Intubated
Adequate (3) Cardiogenic shock
10 3 Good (1) 3 None Intubated
Adequate (2)
11 3 Good (3) 3 Distributive shock with diastolic Intubated
dysfunction
12 1 Good (1) 2 Distributive Intubated
13 3 Good (3) 7 Obstructive Intubated
14 2 Unable (2) 2 based on apical Distributive Intubated
4 chamber
a
Image quality refers to subjective analysis by critical care physician (N.B.). Analysis was systematically performed after each
echocardiographic assessment using subxiphoid-only (EASy) examination performed by novice sonographers by filling out an EASy
examination report (Supplemental material 2, http://links.lww.com/CCX/B313)) with N.B. during rounds. N.B. assessed overall image
quality (1—Good, 2—Adequate, 3—Poor, 4—Unable to assess) by ability to interpret, diagnose, and manage patient care based on analysis
of subgroup quality of items including pericardial assessment, right ventricular (RV) cavity, RV contractility, septum, left ventricular (LV)
cavity, LV contractility.

3, http://links.lww.com/CCX/B314) highlight the embolism evaluation. Left-femoral DVT was diag-

value of routine EASy examination.
In case 5, initial EASy examination findings were
consistent with phenotype 2. EASy examination was
later repeated for acute hypoxemia without significant
change in lung compliance and showed development
of acute on chronic RV dilation (phenotype 7). This
prompted performance of lower extremity duplex ul-
trasound as a surrogate examination for pulmonary
nosed, and systematic anticoagulation was initiated.
In case 11, EASy examination served as a screen-
ing tool that demonstrated signs of chronic cardiac
disease (LV thickness and left atrium dilation),
prompting N.B. to obtain a full critical care echo-
cardiogram. Severe aortic valve stenosis was diag-
nosed, affecting further management of fluids and
vasopressor titration.

Critical Care Explorations www.ccejournal.org     9

 Bughrara et al
DISCUSSION
We demonstrated that short high-quality training of
novice sonographers in the EASy examination fol-
lowed by systematic use of inpatient care augments
the capacity of critical care clinicians to provide care,
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especially during a surge in critically ill patients,
such as those with COVID-19-associated respiratory
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 02/28/2024
failure. One-day training focused on image acquisi-
tion resulted in rapid implementation of the EASy ex-
amination in daily practice with efficient examination
times (just under 5 min) and a successful assessment of
absolute majority of critically ill patients with COVID-
19 (13/14 patients, or 93% during most encounters).
We followed the I-AIM framework to define com-
petence and guide clinical practice (16) and modeled
EASy training after the previously developed five-step
method for teaching psychomotor clinical skills (17),
an approach that promotes daily practice and feed-
back to achieve mastery. In this model (Fig. 3), inter-
pretation and management are the most difficult to
translate into individual practice given the time and
repetition necessary for learning. To facilitate learn-
ing we developed EASy examination reports to assist
with pattern recognition for novice providers. Our
EASy Examination Report Sheets serve as a visual
tool to identify phenotypes, prompt a differential di-
agnosis within each phenotype, and suggest interven-
tions (Supplemental material 2, http://links.lww.com/
CCX/B313), and have the potential to be used in other
environments providing care to critically ill patients
outside of the ICU.
Simultaneously, our educational program allowed
for rapid upscaling of the pool of proficient sonogra-
phers in acquiring images. Like in previous studies (9–
12), we demonstrated that EASy examination can be a
possible entry point to bedside echocardiography with
novice sonographers becoming proficient in image ac-
quisition after only 1 day of training. Trainees can then
independently acquire images within the program,
which incorporates timely review and interpretation
of images and adjustment of patient management
with the supervising POCUS credentialed physician.
POCUS was identified as one of the top 10 health tech-
nology hazards in 2020 (21), mainly due to insufficient
oversight leading to misdiagnosis and uncertainty
about seeking assistance. Our methodology ensures
that all video loop studies are saved for subsequent
10     www.ccejournal.org
expert review, with feedback being provided in 100%
of studies obtained by trainees, a critical measure for
quality assurance.
Our study has several limitations. First, our study
included a small sample size with only one attending
physician as an image reviewer for our objective data
points. This was representative of the urgent, surge en-
vironment in which this study was held with only one
clinical team managing patients for the short time in
which echocardiography credentialed physician N.B.
was in service. Despite this limitation, our descriptive
study supports further investigation, preferably using
prospective study design. Second, despite clinical use-
fulness of the EASy examination, we do not have data
to assess whether outcomes of patients were affected by
use of ultrasound as part of the clinical management
strategy. Third, we only trained three residents in the
EASy examination and followed patients only during
the 2 weeks of the study when the NBE-certified crit-
ical care physician was on service in the ICU. Although
trained residents showed efficacy in image acquisi-
tion and benefited from supervised image interpreta-
tion and discussion of patient management, we had no
formal objective measure for novice sonographers’ in-
terpretation and management skills after EASy training.
Because these skills require development over time, we
caution against relying on the EASy phenotypes without
the appropriate supervision by experts as this was not
specifically studied. Although expert himself may have
been biased in interpreting serial images from patients
based on previous interpretations, we described several
cases where image interpretations differed when com-
pared with previous images and were correlated to clin-
ical presentation. Finally, patients with signs of chronic
cardiac disease on EASy examination automatically re-
quire acquisition of additional views by expertly trained
sonographers. Adequate management directed by image
interpretation was particularly important in COVID-19
patients with chronic cardiovascular disease who have
a mortality rate of 69.5% (22) when they develop acute
myocardial injury. Despite these limitations, our study
suggests value for 1-day education in EASy examina-
tion with its routine implementation in a supervised en-
vironment, particularly when demand for critical care
services rapidly escalates.
A prospective multicenter trial is warranted to further
investigate the potential benefits of routine EASy exami-
nations in the ICU setting. All POCUS interpretation
March 2024 • Volume 6 • Number 3

relies on the collective ICU-wide experience (know-
ledge, skills, and attitudes) of those who are acquiring
and interpreting those images. It is crucial to ensure that
poor images and inexperienced interpretations do not
pose harm to patients, echoing the principle, “First, do
no harm.” As of now, we do not advocate for the adop-
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tion of this approach, our objective is to share our expe-
riences during times of exigency and highlight the need
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for expert’s presence to oversee the unit-based POCUS
practice. However, there are potential technical advance-
ments rooted in artificial intelligence that can enhance
image acquisition (23), laying the groundwork for more
refined interpretation and mitigating the risks posed by
poor image quality and inexperienced interpretations.
CONCLUSIONS
Short high-intensity training in EASy examination
coupled with ongoing supervised image interpretation
and clinical decision-making based on comprehen-
sive patient data can be considered as entry point to
POCUS practice to rapidly expand the pool of sonog-
raphers during the time of rapidly increasing patient
volumes. Further evaluation of this training method-
ology and unit-based POCUS practice is required to
establish their role in routine ICU care.
1 Department of Anesthesiology and Critical Care Medicine,
Albany Medical Center, Albany, NY.
2 Department of Surgery, Albany Medical Center, Albany, NY.
3 Department of Anesthesiology and Critical Care Medicine,
Albany Medical Center, Albany, NY.
4 Department of Anesthesiology and Critical Care Medicine,
Brigham and Women’s Hospital, Boston, MA.
5 Department of Anesthesiology and Critical Care Medicine,
Wagga Wagga Base Hospital, Wagga, NSW, Australia.
6 Department of Internal Medicine, Albany Medical College,
Albany Medical Center, Albany, NY.
7 Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins Hospital, Baltimore, MD.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s website
(http://journals.lww.com/ccejournal).
Dr. Pustavoitau has the broad disclosure of individual stock
ownership in publicly traded companies Butterfly, GE Health,
SANA Biotechnology, Moderna, Pfizer, AstraZeneca, and
Atea Pharmaceuticals. He also discloses equity ownership in
CoapTech. The remaining authors have disclosed that they do
not have any potential conflicts of interest.
For information regarding this article, E-mail: BughraN@amc.edu
Critical Care Explorations
Original Clinical Report
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March 2024 • Volume 6 • Number 3