PGY2 Ultrasound HSC

Supervisor:               Dr. Eric Sala, Health Sciences Centre

The following is an outline of both the curriculum as well as the goals and objectives of the ultrasound rotation during PGY2, incorporated into CANMEDS format.  The medical expert expectations have been organized by year.  The remaining CANMEDS roles will be assessed throughout all rotations and will remain consistent throughout all of residency. 

The assessment tools utilized during the rotation include global faculty ratings such as the ITER rotation evaluation sheet.  An examination assessing knowledge obtained as per the listed curricula at each stage of training will be given on the last day.  The examination will assess the acquisition of knowledge throughout the rotation.  A pass mark is 70%.  The inability to pass the exam will render the rotation incomplete, and the rotation will be completed at a later date.  360 degree evaluations by the ultrasound technologists will also be included in the ITER evaluation sheet.  This will also include nursing staff.

The submission of Daily Encounter Cards (Daily ITERs) are required for this rotation.

Duties and Responsibilities

All emergency patients and inpatients are to be checked with the resident by the technologist, and should be scanned by the resident in achieving the hands on scanning criteria listed below.

 

It is also the responsibility of the resident to obtain informed consent, as well as assisting staff, for all patients that are scheduled to undergo ultrasound guided procedures during the rotation period.

 

As the volume of both emergency and inpatients, as well ultrasound guided procedures, can widely vary during the course of the rotation, the resident should participate in the evaluation of other cases during the work day as is reasonably achievable.

 

As a rough guideline, at least half of the cases preformed in the ultrasound department each day should be evaluated by the resident, with review by the attending staff.

 

A contribution each week to interesting case rounds should also be made by the resident, using a case during the rotation that emphasizes the role of ultrasound in imaging the patient and managing care period.

 

At least one case during the rotation should be submitted to the department teaching file. This is to be reviewed with attending staff.

 

Required Reading List

Please read the corrresponding RSNA physics module, as outlined in the physics curriculum

• Ultrasound: The Requisites, by Middleton
• Learning How to Scan, the Text: Ultrasound Scanning Principles and Protocols by Tempkin

 

1. Medical Expert
2. “Hands On” Scanning:

In addition to the acquisition of knowledge specific to ultrasound, there is an expectation that the resident will learn to scan during all rotations.  In addition, knowledge of physics specific to ultrasound is expected.  In addition to hands on scanning, the acquisition of interventional skills using ultrasound guidance will also be assessed.

Know the anatomy and pathology related to the body parts being scanned including the musculoskeletal system, neck, pleural space, abdomen and pelvis.

Be able to scan and interpret an ultrasound study of the pleural space, abdomen, pelvis, neck, and musculoskeletal system.

Know the role of ultrasound in situations of trauma.

Recognize and give the differential diagnosis of a lesion based on its anatomical location and echogenicity.

Perform an ultrasound guided biopsy and ultrasound guided drainage.

By the end of the first level of training, the resident should be able to scan most clinical scenarios listed below in each training category.

• Gallbladder:(gallstones/acute cholecystitis)
• Liver:(masses)
• Kidney:(hydronephrosis and stones)
• Transabdominal/Endovaginal Pelvis:(mass/cyst/free fluid)
• Testes: torsion/epididyimitis
• Lower Extremity:(DVT Study)
• Abdominal Aorta:(aneurysm)
• Pleural Effusion and Ascites
• Normal and Abnormal Intrauterine Early Pregnancy
• Thyroid Gland, specifically overall size and echogenicity
• Ultrasound guided procedures: basic techniques

 

                        Ultrasound Physics

• Define ultrasound, including the relationship of sound waves using imaging.
• Transducer choice: curvi-linear, linear, sector, vector
• Generation and detection of ultrasound waves.
• Frequency, sound speed, wave length, intensity, decibels, beam width, Frezno zone, Frown Hopper Zone.
• Interaction of sound waves with tissues:reflection, attenuation, scattering, refraction, absorption, acoustic impudence pulse echo principles
• Straight and narrow sound beams, suprareflection constant sound speed
• Beam shape:linear, sector, curved ray.
• Probes:transabdominal and endocavitary
• Display:Gray-scale, m-mode, pulse wave Doppler, color and power Doppler.
• Image orientation
• Image optimization:power output, gain, time gain compensation
• Acoustic properties of fluid, cysts, calcification, complex fluid and solid structures
• Tissue characteristics:acoustic shadowing and enhancement
• Focal zone

 

 

 

                        Clinical Applications

• Liver: normal echotecture, size and shape (including anatomic variants), diffuse disease:(for example fatty infiltration, acute and chronic hepatitis, cirrhosis, edema), focal masses, metastasis, granuloma
• Gallbladder:normal appearance, wall thickening, gallstones, sludge, acute cholecystitis (calculus vs acalculus), sonographic Murphy sign, other etiologies of wall thickening, polyp
• Bile ducts:normal, intra and extra hepatic bile duct diameters and dilatation
• Pancreas:normal anatomy, pancreatic duct, mass
• Spleen:normal echotexture, size and shape (including anatomic variants), focal masses, cystic versus solid, lymphoma, abscess, infarction, granuloma
• Peritoneal cavity:ascites, fluid localization/quantification(free versus loculated)
• Pleural effusion

 

Genitourinary System

• Normal kidney cortical echotexture, size and shape, medical renal disease, simple renal cyst
• Ureters: hydronephrosis and pylenephrosis
• Urinary bladder:caliculi, wall thickening, urethral jets, bladder volume

 

Gynecology

• Uterus:normal size, shape, position, echogenicity, fibroid identification
• Endometrium:normal appearance during phases of menstrual cycle and thickness measurement (premenopausal, postmenopausal, effects of hormone replacement), IUD, fluid
• Ovary:normal size, shape, echogenicity, physiologic variation during phases of the menstrual cycle (follicles, corpus luteum, hemorrhagic ovarian cyst)
• Free pelvic fluid
• First trimester ultrasound:normal gestational sac appearance, size, gestational sac growth, yolk sac, embryo, cardiac activity including normal embryonic heart rate, normal early fetal anatomy/growth, crown rump link measurement, correlation with beta HCG levels and menstrual dates

 

Thyroid/Neck

• Normal thyroid echotexture, size and shape
• Thyroid disease:diffuse and focal disease
• Multinodular thyroid, evaluation of neck lymph nodes

 

                        Vascular/Doppler

• Abdominal Aorta:normal appearance and measurement, aneurysm
• Inferior vena cava:normal appearance, thrombosis
• Lower extremity DVT
• Hematoma
• Pseudoaneurysm

                        Scrotum

• Testes:normal echotexture and shape and size
• Epididymis
• Testicular mass
• Hydrocele

                       

Musculoskeletal

• Mass
• Hematoma, Baker’s cyst, incomplete rupture
• Abscess

 

                        Interventional         

• Informed consent
• Sterile technique
• Localization of fluid for paracentesis or thoracentesis, with ultrasound guided aspiration of same
• Techniques for ultrasound guided invasive procedures:understanding important landmarks and pit falls of percutaneous procedures including recognition of critical structures
• Random core solid visceral biopsies

 

Throughout all ultrasound rotations, the following CANMEDS competencies should be demonstrated:

 

1. Communicator
2. Collaborator

            Dictate prompt, accurate and concise reports for ultrasound studies

Development effective communication skills with patients, patient families, physicians and other members of the health care team.

Promptly communicate urgent, critical or unexpected ultrasound findings to residents, referring physicians or clinicians while documenting the communication in the report.

Dictate accurate and concise radiological reports for more complex studies with concise impression and diagnosis and/or differential diagnosis, as well as recommendations for further imaging and/or management.

Communicate effectively and demonstrate caring, respectful behaviour when interacting with patients and their families, answering their questions and helping them to understand the ultrasound procedure as well as its clinical significance and as well understand the importance of the physician/patient interaction during an ultrasound exam

 

Interact with residents and attending physicians in consultation when clinical and radiologic correlation is necessary.

If there are medical students rotating through the department during electives, time spent by the medical student in ultrasound should be with the resident in reviewing cases and performing procedures.

 

1. Manager
2. Health Advocate

Use information technology to manage information, to access online medical information and for self learning.

Understand how medical decisions affect patient care within a larger system.

Know how types of ultrasound practice and delivery systems differ from one another.

Effectively prioritize patients requiring ultrasound studies.

Use information technology to support patient care decisions.

Participate in quality assurance programs for sonographers and physicians.

Be aware of equipment quality assurance programs.

Practice cost effective evaluation of patients requiring ultrasound studies that does not compromise the quality of care.

 

Understand the bio effect and safety issues in diagnostic ultrasound.

 

1. Scholar
2. Professional

Demonstrate knowledge of principles of research methods, statistical methods, study design and their implementation.

Demonstrate critical assessment of the scientific literature.

Demonstrate knowledge and application of the principles of evidence based medicine in practice.

Facilitate teaching of medical students, stenographers, other residents and other health care professionals.

Apply basic knowledge of study design and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.

 

Demonstrate honor, integrity, respect and compassion to patients, other physicians and other health care professionals.

Demonstrate positive work habits, including punctuality and professional appearance.

Demonstrate a commitment to the ethical principles pertaining to confidentiality of patient information.

Demonstrate responsiveness to the needs of patients that super cedes self interest (altruism).

Demonstrate accountability to the patients, society and the profession.

            The work day begins at 8:00 and the resident is expected to be present on time.

In cases where the resident is unable to attend to patients in the department for any reason (including having to attend rounds/teaching sessions, or other duties), the resident is expected to communicate this with both the attending staff as well as the ultrasound technologist, in order to ensure no interruption in delivery of patient care.

 

Ultrasound SCM
 

PGY2 Ultrasound SCM

Supervisor:               Dr. Cheryl Jefford, St. Clare’s

The following is an outline of the goals and objectives of the ultrasound rotation during PGY2, incorporated into CANMEDS format.  The medical expert expectations have been organized by year.  The remaining CANMEDS roles will be assessed throughout all rotations & will remain consistent throughout residency. 

The assessment tools utilized during the rotation include global faculty ratings such as the ITER rotation evaluation sheet.  An examination assessing knowledge obtained as per the listed curricula at each stage of training will be given on the last day.  The examination will assess the acquisition of knowledge throughout the rotation.  A pass mark is 70%.  The inability to pass the exam will render the rotation incomplete, and the rotation will be completed at a later date.  360 degree evaluations by the ultrasound technologists will also be included in the ITER evaluation sheet.  This will also include nursing staff.

 

Duties and Responsibilities

All emergency patients and inpatients are to be checked with the resident by the technologist, and should be scanned by the resident in achieving the hands on scanning criteria listed below.

 

It is also the responsibility of the resident to obtain informed consent, as well as assisting staff, for all patients that are scheduled to undergo ultrasound guided procedures during the rotation period.

 

As the volume of both emergency and inpatients, as well ultrasound guided procedures, can widely vary during the course of the rotation, the resident should participate in the evaluation of other cases during the work day as is reasonably achievable.

 

As a rough guideline, at least half of the cases preformed in the ultrasound department each day should be evaluated by the resident, with review by the attending staff.

 

A contribution each week to interesting case rounds should also be made by the resident, using a case during the rotation that emphasizes the role of ultrasound in imaging the patient and managing care period.

 

At least one case during the rotation should be submitted to the department teaching file. This is to be reviewed with attending staff.

 

Required Reading List

• Ultrasound: The Requisites, by Middleton
• Learning How to Scan, the Text: Ultrasound Scanning Principles and Protocols by Tempkin

 

1. Medical Expert
2. “Hands On” Scanning:

In addition to the acquisition of knowledge specific to ultrasound , there is an expectation that the resident will learn to scan during all rotations.  In addition, a knowledge of physics specific to ultrasound is expected.  In addition to hands on scanning, the acquisition of interventional skills using ultrasound guidance will also be assessed.

Know the anatomy and pathology related to the body parts being scanned including the musculoskeletal system, neck, pleural space, abdomen and pelvis.

Be able to scan and interpret an ultrasound study of the pleural space, abdomen, pelvis, neck, and musculoskeletal system.

Know the role of ultrasound in situations of trauma.

          Recognize & give the differential diagnosis of a lesion based on its anatomical location & echogenicity

Perform an ultrasound guided biopsy and ultrasound guided drainage.

By the end of the first level of training, the resident should be able to scan most clinical scenarios listed below in each training category.

• Gallbladder:(gallstones/acute cholecystitis)
• Liver:(masses)
• Kidney:(hydronephrosis and stones)
• Transabdominal/Endovaginal Pelvis:(mass/cyst/free fluid)
• Testes: torsion/epididyimitis
• Lower Extremity:(DVT Study)
• Abdominal Aorta:(aneurysm)
• Pleural Effusion and Ascites
• Normal and Abnormal Intrauterine Early Pregnancy
• Thyroid Gland, specifically overall size and echogenicity
• Ultrasound guided procedures: basic techniques

 

                        Ultrasound Physics

• Define ultrasound, including the relationship of sound waves using imaging.
• Transducer choice: curvi-linear, linear, sector, vector
• Generation and detection of ultrasound waves.
• Frequency, sound speed, wave length, intensity, decibels, beam width, Frezno zone, Frown Hopper Zone.
• Interaction of sound waves with tissues:reflection, attenuation, scattering, refraction, absorption, acoustic impudence pulse echo principles
• Straight and narrow sound beams, suprareflection constant sound speed
• Beam shape:linear, sector, curved ray.
• Probes:transabdominal and endocavitary
• Display:Gray-scale, m-mode, pulse wave Doppler, color and power Doppler.
• Image orientation
• Image optimization:power output, gain, time gain compensation
• Acoustic properties of fluid, cysts, calcification, complex fluid and solid structures
• Tissue characteristics:acoustic shadowing and enhancement
• Focal zone

                       

                        Clinical Applications

• Liver: normal echotecture, size and shape (including anatomic variants), diffuse disease:(for example fatty infiltration, acute and chronic hepatitis, cirrhosis, edema), focal masses, metastasis, granuloma
• Gallbladder: normal appearance, wall thickening, gallstones, sludge, acute cholecystitis (calculus vs acalculus), sonographic Murphy sign, other etiologies of wall thickening, polyp
• Bile ducts:normal, intra and extra hepatic bile duct diameters and dilatation
• Pancreas:normal anatomy, pancreatic duct, mass
• Spleen:normal echotexture, size and shape (including anatomic variants), focal masses, cystic versus solid, lymphoma, abscess, infarction, granuloma
• Peritoneal cavity:ascites, fluid localization/quantification(free versus loculated)
• Pleural effusion

 

Genitourinary System

• Normal kidney cortical echotexture, size and shape, medical renal disease, simple renal cyst
• Ureters: hydronephrosis and pylenephrosis
• Urinary bladder:caliculi, wall thickening, urethral jets, bladder volume

 

Gynecology

• Uterus:normal size, shape, position, echogenicity, fibroid identification
• Endometrium:normal appearance during phases of menstrual cycle and thickness measurement (premenopausal, postmenopausal, effects of hormone replacement), IUD, fluid
• Ovary:normal size, shape, echogenicity, physiologic variation during phases of the menstrual cycle (follicles, corpus luteum, hemorrhagic ovarian cyst)
• Free pelvic fluid

 

Thyroid/Neck

• Normal thyroid echotexture, size and shape
• Thyroid disease:diffuse and focal disease
• Multinodular thyroid, evaluation of neck lymph nodes

 

                        Vascular/Doppler

• Abdominal Aorta:normal appearance and measurement, aneurysm
• Inferior vena cava:normal appearance, thrombosis
• Lower extremity DVT
• Hematoma
• Pseudoaneurysm

 

                        Scrotum

• Testes:normal echotexture and shape and size
• Epididymis
• Testicular mass
• Hydrocele

 

 

                        Musculoskeletal

• Mass
• Hematoma, Baker’s cyst, incomplete rupture
• Abscess

 

                        Interventional         

• Informed consent
• Sterile technique
• Localization of fluid for paracentesis or thoracentesis, with ultrasound guided aspiration of same
• Techniques for ultrasound guided invasive procedures:understanding important landmarks and pit falls of percutaneous procedures including recognition of critical structures
• Random core solid visceral biopsies

 

Throughout all ultrasound rotations, the following CANMEDS competencies should be demonstrated:

 

1. Communicator
2. Collaborator

            Dictate prompt, accurate and concise reports for ultrasound studies.

Develop effective communication skills with patients, patient families, physicians and other members of the health care team.

Promptly communicate urgent, critical or unexpected ultrasound findings to residents, referring physicians or clinicians while documenting the communication in the report.

Dictate accurate and concise radiological reports for more complex studies with concise impression and diagnosis and/or differential diagnosis, as well as recommendations for further imaging and/or management.

Communicate effectively and demonstrate caring, respectful behavior when interacting with patients

and their families, answering their questions and helping them to understand the ultrasound procedure as well as its clinical significance and as well understand the importance of the physician/patient interaction during an ultrasound exam.

 

Interact with residents and attending physicians in consultation when clinical and radiologic correlation is necessary.

If there are medical students rotating through the department during electives, time spent by the medical student in ultrasound should be with the resident reviewing cases & performing procedures.

 

1. Manager
2. Health Advocate

Use information technology to manage information, to access online medical information and for self learning.

Understand how medical decisions affect patient care within a larger system.

Know how types of ultrasound practice and delivery systems differ from one another.

Effectively prioritize patients requiring ultrasound studies.

Use information technology to support patient care decisions.

Participate in quality assurance programs for sonographers and physicians.

Be aware of equipment quality assurance programs.

Practice cost effective evaluation of patients requiring ultrasound studies that does not compromise the quality of care.

 

Understand the bio effect and safety issues in diagnostic ultrasound.

 

1. Scholar
2. Professional

Demonstrate knowledge of principles of research methods, statistical methods, study design and their implementation.

Demonstrate critical assessment of the scientific literature.

Demonstrate knowledge and application of the principles of evidence based medicine in practice.

Facilitate teaching of medical students, stenographers, other residents and other health care professionals.

Apply basic knowledge of study design and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.

 

Demonstrate honor, integrity, respect and compassion to patients, other physicians and other health care professionals.

Demonstrate positive work habits, including punctuality and professional appearance.

Demonstrate a commitment to the ethical principles pertaining to confidentiality of patient information.

Demonstrate responsiveness to the needs of patients that super cedes self interest (altruism).

Demonstrate accountability to the patients, society and the profession.

            The work day begins at 8:00 and the resident is expected to be present on time.

In cases where the resident is unable to attend to patients in the department for any reason (including having to attend rounds/teaching sessions, or other duties), the resident is expected to communicate this with both the attending staff as well as the ultrasound technologist, in order to ensure no interruption in delivery of patient care.