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President's message Who should perform echocardiography?
AMERICAN SOCIETY OF ECHOCARDIOGRAPHY NEWS President's Message WHO SHOULD PERFORM ECHOCARDIOGRAPHY?
Most physician members of the American Society of Echocardiography are cardiologists, and all Cardiology Fellowship programs include training in the performance and interpretation of echocardiograms. Thus, it is not surprising that most echocardiograms are performed under the supervision of cardiologists and interpreted by cardiologists. But it is also not surprising that the quantity and quality of diagnostic information available from the echocardiogram, as well as its safety, portability, and real-time nature, should make the technique appealing to other medical disciplines. Physicians w h o practice in emergency departments have discovered echocardiography and are beginning to use it to evaluate patients with suspected cardiovascular emergencies. In June 1997 the American College of Emergency Physicians stated. "ACEP specifically supports the use of ultrasound imaging by emergency physicians for at least the following clinical indications: traumatic hemiperitoneumic, abdominal aortic aneurysm, pericardial .fluid, etopic pregnancy, and evaluation of renal and biliary tract disease" (italics mine).The presidents of ACEP and the Society of Academic Emergency Medicine have written to us that they primarily envision the use of ultrasound to help in making the diagnosis of pericardial tamponade and to confirm or refute the presence of pulseless electrical activity (electromechanical dissociation) during cardiac arrest. A number of issues arise. The American Society of Echocardiography has always been inclusive: our motto,"excellence in echocardiography" emphasizes our concern with the quality of the examination rather than with w h o performs and interprets it. But some disciplines as a matter of course include extensive training in echocardiography (e.g., cardiology), whereas others do not. Thus, the backgrotmd of the echocardiographer becomes a concern since this has usually determined the echo training the person has received. Similarly, maintenance of performance and interpretation skills can be an issue: can an emergency physician, w h o may only have the opportunity or need to perform echocardiography occasionally,
22A
perform and interpret the examination accurately? What about reporting, storage, and retrieval of the ultrasound data, which echocardiography laboratories do routinely but which many emergency departments may not? Is this a trivial matter? Are pericardial effusions, for example, so hard to diagnose by echo? Is a noncontractile heart so difficult to demonstrate? For a fully trained and experienced echocardiographer, these diagnoses should not be difficult, but for the inexperienced echocardiographer or the physician w h o uses echo infrequently, many pitfalls exist. ASE members w h o train cardiology fellows and/or sonographers have surely seen, as I have, pleural effusions confiased with pericardial effusions. And the difference between a severely depressed but still viable myocardium--for example, a dilated cardiomyopat h y - - a n d an almost asystolic, nonviable ventricle may be subtle. To c o m p o u n d these concerns, remember that emergency department patients may be among the most critically ill, and the echo examination often must be done hastily, frequently while
Journal o f the American Society o f Echocardiography
Volume 10 N u m b e r 9
other personnel are attending the patient and inserting arterial and venous catheters, etc. The high light and noise levels in most emergency departments are vastly different from the low-light, quiet environments that are optimal for performance of echocardiography. Quality echo performance and interpretation under such conditions is a challenge for even the welltrained and highly experienced echocardiographer. We share c o m m o n ground with our emergency medicine colleagues on some points. ACEP states, "ultrasound examination, interpretation and clinical correlation should be available in a timely manner 24 hours a day for emergency department patients."ASE agrees, and of course we would apply this philosophy to any patient. In a large and well-organized medical center with qualified echocardiographers, this should not be a problem. But what about small emergency departments in small, rural hospitals, where cardiologists or other persons with Level 2 (independent performance and interpretation) training may not be available immediately--or perhaps not be available at all? Telemedicine--the immediate transmission of the ultrasound images to a center where appropriate expertise is available to review and advise--could offer a solution here. ACEP also states,"emergency physicians providing emergency ultrasound services should possess appro-
Volume 10 N u m b e r 9
priate training and hands-on experience to perform and interpret limited bedside ultrasound imaging:'To me, this is the most important issue. What training? How much training? By whom? On whom? Is it realistic to expect noncardiologists to achieve Level 2 status? Is there such a thing as a "limited" echocardiographer? What is the appropriate syllabus for such a person? Who should prepare it? These are not easy issues, and in fact they are not limited to emergency department physicians; intensive care unit/critical care medicine physicians, for example, also find echo to be extremely useful and could advance the same claim to perform and interpret echo. I have appointed a Task Force, under the chairmanship of Dr. William Stewart of the Cleveland Clinic, to consider these issues. We will work with the appropriate emergency medicine professional organizations and with the American College of Cardiology to develop appropriate policies and recommendations, always keeping in mind that there is tremendous potential benefit for patients when specialized techniques for echocardiography are properly used in emergency departments--or, indeed, anywhere. Richard E. Kerber, MD President
American Society of Echocardiography
Journal o f the American Society o f Echocardiography
23A
Most physician members of the American Society of Echocardiography are cardiologists, and all Cardiology Fellowship programs include training in the performance and interpretation of echocardiograms. Thus, it is not surprising that most echocardiograms are performed under the supervision of cardiologists and interpreted by cardiologists. But it is also not surprising that the quantity and quality of diagnostic information available from the echocardiogram, as well as its safety, portability, and real-time nature, should make the technique appealing to other medical disciplines. Physicians w h o practice in emergency departments have discovered echocardiography and are beginning to use it to evaluate patients with suspected cardiovascular emergencies. In June 1997 the American College of Emergency Physicians stated. "ACEP specifically supports the use of ultrasound imaging by emergency physicians for at least the following clinical indications: traumatic hemiperitoneumic, abdominal aortic aneurysm, pericardial .fluid, etopic pregnancy, and evaluation of renal and biliary tract disease" (italics mine).The presidents of ACEP and the Society of Academic Emergency Medicine have written to us that they primarily envision the use of ultrasound to help in making the diagnosis of pericardial tamponade and to confirm or refute the presence of pulseless electrical activity (electromechanical dissociation) during cardiac arrest. A number of issues arise. The American Society of Echocardiography has always been inclusive: our motto,"excellence in echocardiography" emphasizes our concern with the quality of the examination rather than with w h o performs and interprets it. But some disciplines as a matter of course include extensive training in echocardiography (e.g., cardiology), whereas others do not. Thus, the backgrotmd of the echocardiographer becomes a concern since this has usually determined the echo training the person has received. Similarly, maintenance of performance and interpretation skills can be an issue: can an emergency physician, w h o may only have the opportunity or need to perform echocardiography occasionally,
22A
perform and interpret the examination accurately? What about reporting, storage, and retrieval of the ultrasound data, which echocardiography laboratories do routinely but which many emergency departments may not? Is this a trivial matter? Are pericardial effusions, for example, so hard to diagnose by echo? Is a noncontractile heart so difficult to demonstrate? For a fully trained and experienced echocardiographer, these diagnoses should not be difficult, but for the inexperienced echocardiographer or the physician w h o uses echo infrequently, many pitfalls exist. ASE members w h o train cardiology fellows and/or sonographers have surely seen, as I have, pleural effusions confiased with pericardial effusions. And the difference between a severely depressed but still viable myocardium--for example, a dilated cardiomyopat h y - - a n d an almost asystolic, nonviable ventricle may be subtle. To c o m p o u n d these concerns, remember that emergency department patients may be among the most critically ill, and the echo examination often must be done hastily, frequently while
Journal o f the American Society o f Echocardiography
Volume 10 N u m b e r 9
other personnel are attending the patient and inserting arterial and venous catheters, etc. The high light and noise levels in most emergency departments are vastly different from the low-light, quiet environments that are optimal for performance of echocardiography. Quality echo performance and interpretation under such conditions is a challenge for even the welltrained and highly experienced echocardiographer. We share c o m m o n ground with our emergency medicine colleagues on some points. ACEP states, "ultrasound examination, interpretation and clinical correlation should be available in a timely manner 24 hours a day for emergency department patients."ASE agrees, and of course we would apply this philosophy to any patient. In a large and well-organized medical center with qualified echocardiographers, this should not be a problem. But what about small emergency departments in small, rural hospitals, where cardiologists or other persons with Level 2 (independent performance and interpretation) training may not be available immediately--or perhaps not be available at all? Telemedicine--the immediate transmission of the ultrasound images to a center where appropriate expertise is available to review and advise--could offer a solution here. ACEP also states,"emergency physicians providing emergency ultrasound services should possess appro-
Volume 10 N u m b e r 9
priate training and hands-on experience to perform and interpret limited bedside ultrasound imaging:'To me, this is the most important issue. What training? How much training? By whom? On whom? Is it realistic to expect noncardiologists to achieve Level 2 status? Is there such a thing as a "limited" echocardiographer? What is the appropriate syllabus for such a person? Who should prepare it? These are not easy issues, and in fact they are not limited to emergency department physicians; intensive care unit/critical care medicine physicians, for example, also find echo to be extremely useful and could advance the same claim to perform and interpret echo. I have appointed a Task Force, under the chairmanship of Dr. William Stewart of the Cleveland Clinic, to consider these issues. We will work with the appropriate emergency medicine professional organizations and with the American College of Cardiology to develop appropriate policies and recommendations, always keeping in mind that there is tremendous potential benefit for patients when specialized techniques for echocardiography are properly used in emergency departments--or, indeed, anywhere. Richard E. Kerber, MD President
American Society of Echocardiography
Journal o f the American Society o f Echocardiography
23A