Are you looking for a bridge after taking an ultrasound course at a conference? Do you feel like you need a bit more oversight until you get comfortable with probe in hand? Are you having trouble conceptualizing what it means to have ultrasound guide your practice in the critically ill?… Read on.
I recently had the pleasure of attending a CCUS POCUS mini-fellowship – it was everything I was hoping for & more- and has pushed me to be a better clinician.
First, a blurb about ultrasound fellowships. As a PA, there isn’t really any hands on US training during our programs. There likely is some POCUS for PA EM residents – but most practicing EM PA’s are not residency trained. Therefore, we’re at the mercy of our co-workers who may (or may not) have any US training. It’s hard to learn POCUS when you don’t have someone over your shoulder to guide you!
I had done a few ultrasound courses, but was struggling to really implement it into my practice regularly. Ultimately, this was my own fault. I was repeatedly told to pick up the probe and practice. Literally, every sono-savvy person has told me this. A large part of my problem was that I did not pick up the probe immediately after courses to drill down on fundamentals – and scan every person regardless of their complaint. This is not meant to disrespect those that I took courses with before – they were *extremely* helpful and I’m incredibly thankful for their expertise! – the fact that I continued to seek out ultrasound training is a testament to prior courses showing me the importance of developing this tool set. Now, onto Canada.
I ended up taking a 2 day course with Philippe Rola in Montreal. Philippe is extremely responsive via email, we had spoken on the phone a few times prior to my arrival as well. He’s friendly, approachable, and has been doing mini-fellowships since 2009 (!).
I was looking to optimizing views, particularly on patients with challenging anatomy (I mean, have you seen the average American BMI recently?), and what started with, “where the hell is the IVC” turned into, “This is a plethoric IVC.” While it might be that the 3rd (or is it 4th?) time is the charm for courses for me, and that I would get it eventually via spaced repetition, but there is something about practicing on patients with acute illness and watching Rola make decisions based on POCUS in real time that helps put the pieces together a bit faster.
I believe the main advantage of this US course is the real time feedback on real patients… and if you are there for more than one day, you get to watch the ICU story unfold. You see about 10-12 patients in their ICU, and a handful of ICU consults on the floors or in the ED. You may or may not go to a rapid response, and see how it really makes a difference in the heat of the moment. Fortunately, this is not reminiscent of your student days when the mentor says, “You’ll have to sit this out, this one’s mine, sorry.” Philippe was extremely patient with me in the hypotensive altered patient while I scanned. He’s excellent at questioning at just the right time to help tie it together- “ok, what are you seeing? A plump IVC and some pleural effusions in this hypotensive patient? So whats your next step?”
To maximize your experience, I would strongly encourage you to have 1-2 specific goals in mind like, “I want be able to consistently visualize the IVC and have a few back up views just in case.” Expecting more than 1-2 things is probably spreading yourself thin. You’re not going to become a pro overnight. Be upfront & honest with Rola – he can tailor to your skill level- whether it be an assessment of valvular function or just wanting to visualize the heart. Philippe had recommended 2-3 days at a time, which I agree with – I think after 2-3 days you reach the point of diminishing returns and “get full.” You need some time to process what you’ve learned, and to practice on your own (before going back!).
Upon my return home, I made it a point to utilize the probe on my next shift. If at all possible, I would recommend arranging shifts to be “main ED” shifts when you get back home such that you see the belly pain, shortness of breath, and chest pain patients so that you can apply what you learned immediately. I did this on my first shift back with the hope of scanning 5 patients or more – I literally brought the machine with me when I walked into the room. Surprisingly, I thought it would slow me down. This was not the case at all. I also realized a major benefit that I was not expecting. The cognitive offloading of using the probe and eliminating some of the guess work kept me fresher longer. I saw more patients than average, with sicker than average patients, and it did not feel like taxing shift at all. I didnt have to task switch to check on that xray or CT nearly as much as I usually do (though I was still ordering what I usually would to confirm suspicions since I’m still early in POCUS training)…. I would be interested to see the throughput of docs using POCUS vs those not, and I’d also like to see the level of “decision fatigue” at the end of a shift – I’m convinced that POCUS provides a significant cognitive offload to the EM provider, and the POCUS’ers are less fatigued at the end of their shift.
Bottom line, I think I needed other courses to whet my appetite and open the door, and I needed Montreal to push me through the door and get me to start practicing more. If you work in an environment where you don’t have much POCUS backup and want to learn with one of the best and don’t want to break the bank, come to Montreal!