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The National Board of Echocardiography Certificati ...
The National Board of Echocardiography Certification in Advanced Critical Care Echocardiography
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Everybody, thank you for joining us this morning to discuss board certification in advanced echocardiography. Before we get started, I just want to take a moment of silence to reflect on the massacre of more than 1,200 Israelis, including women, children, and babies that have been raped and murdered and kidnapped. Very happy to have Dr. Paul Mayo here with us who we have to blame and he's going to go into the history of this Examination and board certification process for all of you He is an ultrasound guru and most of us call him the father of Ultrasound in the United States because he really brought it over here and has pushed all of us to take better care of our patients Dr. Hasan over here trained under Paul Mayo, a co-fellow of mine And every time I talk to him and he sends me his update and all the things that he's doing I wonder how on earth do you have time for all of that? You're still at the at the mothership at Northwell training and following in the footsteps. I trained under Paul Mayo. I worked in Newark, New Jersey at a tertiary academic medical center So our objectives today are to discuss the differences between basic and advanced critical care echocardiography We're going to review the importance of achieving competence in advanced critical care echocardiography And then we're going to spend the bulk of the time really focusing on the National Board of Echocardiography special examination in critical care echo. We'll talk about how to prepare for the exam and Dr. Mayo is going to walk everybody through what a complete image set looks like for a critical care echo And the hope here is really to have a vibrant interactive discussion And we want all of you to come out with all of your questions answered So, please don't hesitate to throw your hands in the air and speak So Basic echo is Something that you're all probably familiar with if you're already talking about taking advanced echo. It's essential like Said for anyone that's in the ICU or even on the floors pulmonologist that are in the office. It's really helpful all around It Uses the five basic views we all we're all familiar with that personal long axis short axis, etc, and it's helped you Categorize your patient with shock and hemodynamic failure whether it's respiratory cardiac helps you figure that out here We dr. Mayo has some slides later. We'll show you some pictures you can see here What we'd like to say on rounds with dr. Mayo is a big Goomba sitting in their right side there This is why we do this right you you're not sure why your patient's so sick You can't figure it out And then you see something an image like this and it helps guide your management in that acute setting Obviously and the actual image interpretation would be a little bit more professional, but I think you've used that word a few times Dr. Mayo Hassan. I noticed the date April 24th 2020 I wonder what the patient what their underlying disease. Yeah Wonder if I'm the one that did this one probably I'm curious on just before we move forward to show of hands who here is just doing basic echocardiography Not really using Doppler, but it's here because they're interested in delving into some more complex echo Okay, who here is? Slated to take the echo exam in the next 12 months Has committed in their head and now it's trying to figure out how to be successful Excellent Important but At the end of this talk Hopefully we convince a lot of you that are already doing basic echo to move on and start doing advanced echo and how that can help So that's what this purpose is, right? The ACE advanced critical care echocardiography. It's for the ICU doc, pulmonologist, the medicine doc, whomever Who can do an echo similar to what cardiologist does so rather than waiting for the echo tech to come down and that image to Get uploaded and then, you know cardiologist to read it You can perform it at the bedside with the focus of what exactly is going on with my patient I don't need to know about all these other things I just want to focus on what I think is happening right now to help answer a question Makes it more efficient And you're the one that's able to integrate all that information in real time at that moment Rather than waiting eight hours for the read to come back It incorporates a full range of 2d views which is basic echo and then some advanced views like Doppler here We're showing you a picture of an LDO TBTI You're trying to calculate the stroke volume for your patient trying to figure out are they in a low flow state? Do I have some data that can convince someone? You know, maybe to start a ninotrope or go even further some mechanical support for your patient without getting too invasive This is a very basic skill for someone that's working in a high-intensity ICU and I noticed by casual exam that there's reciprofasic variation of the velocity profile That would leave the discerning piece of heart person Think why is there reciprofasic variation of stroke volume? Is there preload sensitivity? Is it RV failure? Do they have pericardial tamponade, etc, etc So a cardiologist would not ordinarily notice that or even be interested in it in the echo lab Only enough the ICU person really thinks about that or they're writing it in their report that comes back to you a couple hours later Or the next day even when you're on rounds and and you're saying well that was yesterday What did we do about it in the last 12 hours? It's sort of delaying care and that's where Advanced critical care echo really helps because you're integrating all that information You're learning new information at the real time that you didn't expect to find in the first place maybe you didn't think the patient was going to be volume responsive or or Have respiratory reciprofasic variation and now you integrate that into whatever you were thinking Maybe I do need to give them fluid and not diuresis So, you know the advanced critical care echo requires a little bit more thinking a little bit cognitive Load and technical training with image acquisition than the basic echo does but it's totally doable a very achievable Zubair says a little more But I think he would agree that the cognitive load is very significant compared to basic echo and you learn Many assumptions that we teach to new learners new scanners with basic that get thrown out the window as you start learning the more advanced I don't want to undersell The the commitment in the cognitive load it is completely achievable by all of you. We'll talk about the board exam It's more condensed in terms of the amount of material the breath than our pulmonary boards or critical care boards But it's still a lot of material to get through So when when we have cardiologists why should intensivists ICU doctors pulmonologists are working in ICU Why should they bother with? It's largely the same stuff that we've talked about, right? You're able to perform a complete examination at point of care at that moment, you know what the vitals are for the patient You know the context, you know the history they're presenting with something that the cardiologist can look through You know with with their EMR on the HMP But not quite the same as being at the bedside and not to give them or not to knock the cardiologist But they're not there. They're looking at it after the fact and that's just their workflow. And that's why Allows you to better take care of your patients at that moment It answers questions in real time and then you can intervene and come back to the patient and just do a focused exam let's say you Gave a patient diuretic and you're concerned Or rather you gave them a fluid bolus and you want to look at that IVC You want to measure their stroke volume see if that respirophasic variation still exists You can come back in an hour and just quickly do that part of the exam and say, okay Well, they still seem like maybe they're volume responsive. I should give them more fluid And the pressures have come down a little bit. Let's see we can improve it a little bit, or say, no, you know, there's no more respirophasic variation, and their IVC appears dilated, and now their RV's starting to get a little bit big, and I noticed some, you know, TAPC's worsening, or whatever have you, you can integrate that information and say, whatever I was just doing is no longer set it and forget it, I need to make a change in my plan so I can continue taking care of the patient. It eliminates the clinical time dissociation associated with consultative cardiology, so basically that different time that you're waiting for someone to read the report, upload it, and then read it back to you a few hours later, now it's four hours have passed since you've actually taken that image, and something's happened to the patient. It allows you to visualize physiology in real time, and most important, it improves quality of care. I mean, this is what we do all the time in all of our patients, and if you're in our ICU, our fellows are trained to do an echo on every patient, whether they're the simple DKA, you know, 20-year-old with DKA that comes in, or the 50, 60-year-old with complex heart failure, complex sepsis, ARDS, on events, you're thinking about ECMO. All those patients get basic echoes, and then dive into advanced echoes as well once you start finding something that you weren't expecting to find, and maybe that explains why the patient's so sick. It improves the quality of care, and it's something that everyone should be doing now to make sure it's gonna become standard of care at some point. So I'll just say, because Zubair had mentioned every patient getting an echo, that's not the practice everywhere. So my institution, you know, my fellows are instructed, anybody who's hemodynamically unstable is in shock, and so I tell them that you may have a pretty good idea of why you're in shock, but we have to be humble that our physical exam and clinical acumen misses things sometimes. So all of those patients are getting an echo, and it's not uncommon to find things that are surprising and practice-changing, but our practice is not on a standard DKA patient that comes in 15 times a year because of non-adherence to do an echo. Dr. Mayo might argue that maybe it shouldn't. What do you think, Dr. Mayo? Yeah, well, there are some patients where you probably would not do one. I can't think of too many of those patients, but remember, diabetes causes cardiovascular disease. Fair enough, fair enough. And even in a younger patient, they have a rotting toe. Well, you notice it in your physical exam. How do you know their heart is in good condition? And an echo is a simple matter, so we don't disagree with you violently, but we disagree with you somewhat. Yeah, right, yeah. And once you achieve advanced critical care echo, then the simple echoes get that much faster, so this is a skill that's very achievable. It requires some work, but it's something that makes the rest of your job a lot more easier, where it's no longer a hassle to grab the machine and just do a quick four-chamber on your patient with DKA and see if there's anything surprising. You're able to integrate that information and interpret it a lot faster once you've gotten the advanced echo stuff down. So some of you are sitting here saying, ACE sounds great, I definitely wanna start doing it, I'm gonna add on certain components of it, but I already have my IM boards and my pulmonary boards and my crit care boards and my sleep boards, and then maybe we have some neurocrit care people here, I need a buddy palliative boarded, and then now I'm gonna add on special competence in critical care echo, why on earth do I need to do that? And that becomes, I think, a very personal decision, and we'll try to highlight some of the reasons why this may be of interest. So when I started at my current institution after graduating from Dr. Mayo's fellowship program, I came to a place where they were doing some echo, but we really wanted to take it up a few notches, and having that board certification really lent credibility to be able to sit down with my chair of medicine who's a cardiologist and to explain why we're gonna be doing X, Y, and Z. That was something, I think, that they found to be very valuable. That's not to say that I think that you need to have board certification in order to be able to do advanced echo, but many will feel much more comfortable with you if you have that. There are quality of care standards, and down the road there may be a push to say that there should be a certain level of competence, which, what is competence, but an examination and board certification can be used to demonstrate that somebody may have competence. This can help you to become more confident. So when I learned ACE very piecemeal. I wasn't like some of you in the audience who kind of decided, registered, and then now are spending three to six months acquiring the knowledge. I learned these things over the course of a couple of years. I added on how to calculate RVSP. I added on how to do LVOT VTI, and then down the road other things. But as you acquire this, you become much more confident when you're managing your patient because you know how to think, you know the pitfalls and the nuances of what you're seeing. Most of us that went into home and crit did so because we love physiology. There's nothing cooler than being at the bedside and playing with the ventilator and invasive catheters, and performing the advanced echoes and Doppler is the same thing. It's like being a kid in a candy shop. You just get to see what's happening. It's cool. You understand your patient better. And then for those of you that are early career or are looking for a change in career, it's one of those new techniques, and so there's a desire for it. It makes you a more valuable commodity on the stock exchange, and I think soon we have some inside knowledge that the ACGME is gonna be changing requirements in terms of fellowship training. To raise the bar from the current, you have to understand ultrasonography, to fellows are gonna need to be able to graduate with competence and skill, not just knowledge, and so there's gonna be a huge need in academic medical centers, and you can imagine that they're gonna really want people that have the highest level of credentials to lead those programs. I'm just curious, are there any fellows here that are thinking about taking ACE, or just thought, you know those guys? The fellows, most of them are recovering from last night's Jeopardy party. We regret their absence, but fellows are particularly interested in the certification process for all the reasons you've talked about. Yeah, and some of the fellows on our program that have graduated have actually used that to parlay that into jobs at other academic centers. It's one of their selling points, saying that I'm ACE certified or ACE awarded, and that's let them become directors and whatnot at their respective institutions, and allow them to parlay it into advocating for TEs in their ICU, for example. They already do advanced echo, and now they can take it to the next step. So obviously a little bit beyond the scope of this talk, but you can imagine how having this board certification is just something nice to have on your resume, and makes you, like Yoni said, more marketable in your future. So where on earth do we start here? This is what the exam is like. It's very similar to the other proctored exams that you've all done. It's 200 items. The exam's held every January, and registration opens in November. Pearson View's the company that administers the exam, so you can take it nearby your home location. There are two different pathways. After you have taken the exam and passed it, you become what's called a testamere of the exam. But in order to become board certified, you have to complete an image portfolio. And there's two different pathways that clinicians can take. One of them is the supervised training pathway, which is really the long-term pathway that's going to exist for this. So this is for those that are in fellowship training. It has to be in critical care fellowship training that can then do everything during their fellowship and have things signed off by their fellowship program. The other pathway is a pathway that's gonna be phased out, as you can see here, the end of 2026. And this is the practice experience pathway. So this pathway is designed for those clinicians that are post-fellowship that are doing this and want to achieve board certification. And so for those of you that fit into this category, be aware that this option will go away. And this actually, I think, was extended. It was supposed to sunset earlier because of the pandemic. They extended it. It's now been extended to 2030 after a discussion with NVE. So that's new news. So there's no time pressure, particularly. The portfolio is 150 full critical care ECHO exams that get logged and get mentored. Many of you will be looking online trying to figure out what on earth a full ECHO exam is. And we'll direct you to our opinion of that. But the NVE has purposely left that open and vague. So that's really a discussion between you and your mentor for what they define as a complete exam. The NVE, at a recent meeting, it became clear that there has to be a little better definition. Everyone knows what it is, but nobody is willing to write it down. So the NVE, I think, is gonna mount a project where they are gonna write a sort of position statement of what constitutes, in their view, the minimum standard for a full exam, both for transthoracic and TE. It's gonna take about a year to do, just so you know. Right now, there's ambiguity, but it's pretty clear what it is. You have a website on this, don't you? Yeah, I think we have a slide here. We'll talk about that. So board certification means passing the exam, completing the image portfolio, and like our other boards, you get a 10-year certification. It's not clear what's gonna happen in terms of, I hate the three-letter MOC word. I can bring you news from a Denver meeting last week where, like many professional societies on the internal medicine side, the 10-year certification exam will no longer exist, starting now. And instead, the NBE, like many of the other societies, will have a pretty well-designed MOC program, details of which we released, I think, in January, starts on July 1st. And for those of you concerned that you're gonna be abused financially, I was astonished when the NBE decision was that the charge for the MOC per year will be $80 a year, I believe with CME. So they've really worked hard not to rip people off. That's a concern with some of these MOC programs. So in fact, to maintain, there'll be a nicely-designed computer-based, phone-based system, okay? You guys are gonna be asked to write some MOC questions, just so you know. Yeah. Just to getting into the weeds a little bit, some people had asked us in the courses here, how much time do you have to do those 150 exams for your portfolio? If you look at the website for NBE, it's buried in there. You have about three years before you apply for board certification for those exams. So let's say I wanted to apply for board certification today. All my 150 exams have to be within the last three years. Anything I did four or five years ago, when I log it in my portfolio, it wouldn't count. So hopefully that helps answer that question, if anyone has that. You have three years before you apply for board certification for those exams to count. So what to study? The NBE's website is echoboards.org. It's a nice website. They have PDF handbooks for both the examination and for the certification process. Two separate handbooks. And then the website below is a website that I run, advancedcriticalcareecho.org. And the goal of the site is basically to provide information so that you weren't in the position that I was in when I took the first offered exam, which was really wondering what to expect. So luckily I had some mentors and people that had some familiarity with the European process, but we were really kind of flying in the dark. The NBE gives an exam content outline. And so you can see a screenshot of it below. This is just a little bit. It's about four pages of this. It is, I get sometimes people email me questions. Is this gonna be on it? Is that gonna be on it? And the outline, while it's boring to read, really goes through every part of the ECHO exam. And if that's there, then it is fair game. If it's not there, then it's not something you need to worry about. So for example, most of us agree that an intensivist is not performing 3D echocardiography and an intensivist is not doing strain and an intensivist is not doing left-sided diffinity contrast. And an intensivist is not delving into congenital malformations of the heart, congenital ECHO. And so you'll see when you go through that outline that those things are not there. I think a general rule that we tell people is that if you think it's something that you're not gonna encounter in your ICU practice as a medical intensivist or whatever, then it's likely not gonna be tested on the exam. It's just not the scope of the exam. I think that's generally a good rule. That means- There is some trauma, though, so they go broader than medical intensivists. Yeah, and I think that's gonna be listed on the outline as well. But if you don't think you're gonna necessarily see it in an ICU setting, that's Ione's point, 3D ECHO or strain, for example, then you're not gonna have to worry about it on the exam. But knowing everyone here, if you're already thinking about doing advanced ECHO, you're gonna wanna really dive into the weeds and probably will learn it anyway to some extent. But don't stress that there's stuff on there that you have to be a full cardiologist-level ECHO. It's not the same type of exam. To your surprise, when you face it off on the exam, about probably 10% of it is general body ultrasonography, correct? So some lungs, some abdomen, some DVT, stuff like that. And then I think about 10% relates to TE images. So that's a required component. Keep in mind that trans-sophial ECHO, the image interpretation is actually very simple because it's simply trans-thoracic upside down, okay? And that brings up a good point. So you need to have knowledge of how to look at TE images. And they're going to be adding on the announcements coming in January. Yeah, the American side of ECHO and the NVE came to an agreement that once a person is certified in critical care ECHO by NVE, that person, they've done the logbook, they pass the exam, they have all the paperwork done, that person can add 50 TE examinations under supervision and they'll be then qualified for TE in addition to general critical care ECHO, trans-thoracic. So that's now a new option. It's an add-on option, it's not a required option. The Europeans require it. Their approach, I think, is wrong because they're shutting out all the people in Europe who don't have probes. The United States method is more democratic. If you have a probe, you can add it on as a qualification later. So how to go about studying for this? I would say it's similar but different to what we're all used to. I would recommend that you really first focus on developing the cognitive base of the advanced ECHO image set. And so you're gonna need an ECHO textbook. We'll talk about some of those options in a moment. But really paying special attention to topics specific to critical care. Now, while you're developing that cognitive image set, please go to the bedside and acquire some of those things as you're reading about them because it will really help you to understand and lock it in. I'm not advocating for reading the entire cardiology textbook and then starting to acquire the images. Learn about how to measure a TR jet and how to calculate the pressure gradient and then go and do it. And then read about cardiac output and go and do it and so on and so forth. And that will make your life a lot easier. As you're reading, you wanna start doing image interpretation. And so doing this with colleagues, group-based is very helpful. In my program, I'm modeled after what Dr. Mayo does at his. We every two weeks have an ultrasound conference where we show advanced ECHO and also general ultrasound and the fellows interpret it and we kinda add on and build in complexity. And you have to review hundreds of images. This may be with your friendly cardiologist in their ECHO reading room, seeing what they're seeing and how they're interpreting it. And then, like we do for our other exams, we need a question bank so you can really start to understand what these exam questions are like. Because that was one of the scariest things for me is I had no idea what an ECHO board question was like. And luckily now, there's a crit care ECHO-specific question bank, but there are also some excellent cardiology banks that serve me well. It was easy to see a question that was totally irrelevant but then to focus on the ones that were relevant. And even in the questions that seem irrelevant, the way those cardiology question banks are, they give you good explanations on each point. And there's still something to take home from that just for our purposes as well. So even if you look through them and go through those questions and they seem like I'm never gonna need to know this, just the answers themselves are a good study resource, similar to any other board that you've taken. As an oddball idea in the New York City area, for the last three years, we've had a free access image interpretation session at seven o'clock every Tuesday. It goes on for about an hour and a half. And it's sort of freewheeling, voluntary faculty. It's designed for fellows. And we show a couple of cases. We put one program on the hot seat so they do the primary interpretation. And when this started, we had about 12 people who joined. This time we're up around 65. And slowly the word has spread. So we have some people beaming in from Texas and Connecticut and also more recently I think Philly. So there are all sorts of ways to do this. I'm on the writing committee so I don't train people to pass the exam. I'm prohibited from doing that. But it's very useful to get a community effort either locally or even more, just look at a lot of images. That's how you get good at image interpretation. So here and on the website I referenced, this information's there as well, are some books to help you with the cognitive base, some suggestions. We don't get any kickback, although Dr. Mayo did author one of them. But on the ECHO side, I wound up using Catherine Otto's ECHO textbook, the smaller one which is called Baby Otto, colloquially. It's not that small, but it's not one of those reference textbooks that can be used as a weapon. And I really opened it up and went through each chapter that covered the material that was needed. And as I was studying, different from other board exams, I was really writing things down, typing up some references. Because what I found with the exam was, you know, you read all this stuff, and then you forget some of the calculations and nuances, and opening the whole book each time is kind of a pain in the neck. And so I would just kind of pull out the important stuff that I just knew had to be completely memorized when it came time for exam time. A newer book that's out is this Oxford textbook of Advanced Critical Care Echo. So this did not exist when I was studying for the exam. It's a nice book. I've looked through some of the chapters, and it's really geared towards critical care doctors. And then you have the cardiology books, which you don't need. But sometimes, you know, we like to look at what the masters say about something. And, you know, J.O. is a giant in the field. But as Dr. Mayo said, general critical care ultrasound is part of this exam. So this audience here is probably doing DVT studies and lung and abdomen and all that. But for somebody who isn't, you're gonna wanna spend time learning that. And here are some of the textbooks that can help you with that content. There's a reading list that's listed on my website from EDEC, the European Diploma of Echocardiography. It's a long reading list. Some of the articles are helpful, and then some of them are not helpful. So I'd recommend looking at the reading list, pulling the article, and you should be able to skim it and say to yourself, okay, this is not gonna be something really testable versus this is gonna be something testable. But you really wanna pay attention to heart-lung interactions, volume responsiveness, hemodynamic monitoring, and then cardiac function and sepsis. Those are things that are gonna be on the exam. I would say those are probably the hardest concepts to grasp for this exam, just because we don't really tend to think about it in echo terms. You know, you understand heart-lung interactions physiologically at the bedside, you know, what's gonna happen to my blood pressure when I go up on the peep and whatnot. But understanding it on an echo basis is a little bit different. So to Yoni's point, you know, if you're gonna focus a lot of your time and energy on something, these are the highlights here, because these are the hardest concepts to grasp, I think. Yeah, so image interpretation, to Dr. Romeo's point, is best done in a group setting, whether that's at your local institution or friends and colleagues, people that you meet here, even if you wanna exchange numbers here and just get on a call and, you know, set up a Zoom meeting and just share pictures. What do we see? You know, you meet every few weeks, months, whatever it may be, months probably a little too long for the purpose of this exam, and just go over pictures. And even if it looks normal, you know, talk about what things you could look at and what calculations you would do. What would it look like if it wasn't this presentation with the patient came in with shock or this or that? And what I find helpful is when I'm doing these image acquisitions at the bedside, I look back at the official echo that was done maybe in the past, or if there's one already being done there, and use that as sort of a reference and say, okay, well, this is what they saw. This is what's happening with the patient. Let me see if I can get it, and why are they seeing it this way? Why does the picture look the way that it does? Because I think that's the other part of echo that we tend to underestimate, that we know what the physiology is, and we know that TR jets help us figure out if the patient has pulmonary hypertension, but why does it look the way that it does, and how do I get this image? Follow that sonotech that's coming to the bedside and doing the images and saying, what are you doing? How are you doing it? What settings are you applying? And then talk to your cardiologist and say, this is what I saw in this patient. What do you guys think? How does this work? How does this, what does this mean physiologically? They're the ones at our institution are more than happy to help out, and sometimes they like it because that's one less thing that they have to read when they're doing, that's one less echo that's being ordered, and they're not inundated. If they can just help answer the specific question that you have, that'll help you for your patient, but also help you for this exam, because they are sort of your gold standard, so to speak. I would also add that doing questions as a group that's not listed here, this is image interpretation, but just going back to the question bank, doing questions as a group with friends and colleagues that are interested in the exam is also helpful, because each of you can bring something to the table and explain a concept that someone else may not understand. So that's another thing that you should be doing as a group, as well. Practice questions should include image interpretation and clinical applications of advanced echo. There's some books here that have Q-banks, like Yoni, I took the exam when it first came out, so we really didn't know what to expect, so we were doing cardiology echo Q-banks, which were really, really intense, and it covered a lot of material that's just not applicable to the exam. So it's these other textbooks that have come out that kind of simplify it a little bit. But if you wanted to have more questions, because you just want more access, so the cardiology Q-banks that are listed here, and then on Yoni's website are also great resources. And again, the same concept applies. If it's something that seems like an intensivist wouldn't need to know, strain, 3D echo, that sort of thing, then it's probably not a question that you need to worry about for the purpose of the exam. When I took the exam, this Chang echo question book was not available, but I've heard very good things about that one, and I actually used the bottom two, the Klein and Ramdas one. The Klein one I really loved, it was really well done, I weeded out the questions that weren't relevant. I wasn't the biggest fan of the Ramdas question book. So I would say, depending on how many you want to do, I think more is better, so I'd probably go Chang, and Klein if you have time. I found the Pi one to be a little disheartening, because their questions are really intense, but there is something to be learned from each of those questions. So definitely start with the Chang, and then the Klein one is a great one, like Yoni said. So the echo portfolio itself, we sort of touched on this before. It's 150 exams that you have to log, the date that they were done, why you did it, and this is on the NBE website, this table over here, this example. Indication for why the echo was done, and then your findings. And I think this is the hardest part for people that are doing the portfolios, what to put in the findings section. You really want to make clear in your portfolio and in your log that you know how to do advanced echo. They're not looking for you to say, okay, the normal LV, normal cardiac exam. They're looking for you to justify that, right? So there's an example here. If the patient has a normal cardiac output, they want you to say, I calculated a VTI. So you write down LVOT VTI of 23 centimeters, the valve looks normal. They want some elements of advanced echo to be listed in the findings section, so that when they're looking through your portfolio after a mentor has signed off on it, they can say, okay, there's evidence here that you did some advanced maneuver on this exam. It doesn't have to be every advanced maneuver for every exam, but there has to be some example of something that is not the basic critical care echo. So maybe I'll comment, because what has been happening, because I sit on the certification committee as well, that the logbooks that we were getting fell sort of into three categories. One category were these maniacally detailed full reports. Great. Then there was another group who sort of understood that to follow the instruction, you don't need all the report. You need to demonstrate that there was Doppler activity. The NBE does not want to see the full reports. Rather, the supervisor is the person that is trusted to make sure that it was a full exam, but they want verification that there were Doppler measurements made, et cetera. And then there was another whole group where the results were normal LV function. And that was all. And the supervisor was signing off on this. So it's very awkward because you trust the supervisor, but the supervisor maybe doesn't know what needs to go in the report, or maybe it wasn't done. So in January, with the new iteration, there are gonna be very, very specific a statement of requirements, and it's gonna be more detailed than what this is. So when I prepared my damnable logbook, I had to do a logbook. NBE, no, if you're certified, you have to do it. Fine, 150 studies. And I fell into a pattern where I'd make a statement about something like normal RVLV size and function, LVOT, VTIs, whatever, E wave, A wave, E prime. I threw in a TAPSE, and I've got a PASAP, because I knew that that's what the committee, they needed that level of evidence, but I was not required to put in the full report. And they're gonna tighten the requirements considerably. And unless there's evidence of Doppler activity, that will be rejected once the new requirements are put out. Okay, aside from requirements, we should talk for a minute about some of the heartache that I experienced when I was trying to get certified. So they are really sticklers for every little detail. And you'll go to committee, and if something isn't right, they will send you back from committee and tell you what was wrong, and you have to resubmit and wait three months. So my initial issue was, if you look at the indication section, it wasn't clear when they released the requirements of the exam what a critical care ECHO was. And so I was doing the full image set for about 20 of the patients on just people that didn't need an ECHO. 18, yeah. These weren't critically ill patients. These were just patients that I did the full care ECHO exam on. And so I wrote under indication educational, and they rejected those. And they said these must be done on patients who are critically ill at the time of the examination and need the ECHO. I was part of that decision-making. I stood up for you. I fought hard for you. And then Yoni was really mad about this. But what'd you do? You went back and you did 18 on critically ill patients. So be careful about indication. Make sure they're sick. The other thing that might be swirling through your head is are they looking at the images? Are we submitting that? And the answer's no. It's really, I found it to be kind of interesting. It's an honor system. So they're trusting. The supervisor. Make sure that the supervisor is supervising and is making sure that you're doing what is supposed to be done. Logbook should be de-identified as the other bit. And then the three-year thing is important. Make sure that you get all the studies done in the timeframe required. What about that diagnosis category? You sort of indicate the type of shock or paratonic. You wanna indicate that you thought through it. It doesn't have to be a full analysis. But it should not simply be a repetition of the findings. A lot of mine were, it's a septic patient who was in shock and I would write for diagnosis, septic shock or distributive shock. No evidence of X, Y, and Z as a cause. And for TEE, the committee decided that you do not have to put in any Doppler information. Nothing like that. They decided that they had tortured you so much with 150 transthoracic that if the supervisor said you did a TEE exam, that's all you have to document. The supervisor signs off on it. So the TEE logbook will be a lot easier than the transthoracic. Okay, keep that in mind. We're gonna speed up a little bit so that we can get the image set up. So why don't we skip. This is the image set. So we're gonna show you the image set. They haven't released the next time that they're doing this, but there's an annual CritCare Echo board review exam done through CHESS. That's quite excellent. A lot of people who train me have designed that. So for those of you who like to do a review course, would recommend that. Yeah. Yoni and Zubair, I thought you did a very good job because it was a cooperative effort. The way, I thought it was gonna be separate, separate presentations. We did train together, so we know how. Yeah, yeah, right. And not that I'm worried, but I recognize that I'm the third wheel here at this table, that this is the younger generation, and they're not pushing aside this PGY44, but they're moving into leadership position. And I'm a little worried. I have to be very careful what I say because Dr. Hassan, respectfully, also known as the Z-man in the division, he's going to be my boss on January 1st, the MICU director. I sent you my schedule requests. They're a little complex, but please. It's clear. All I do is just the schedule. Right, yeah, all right. But anyway, I'm a little nervous. I'm just taking that to another extreme. And when I listen to them, I'm saying, it's the change of the guard. And all in the room can be part of that process, okay? It's now a fellows game, junior attending game, largely, but I've met a fair number of people who are in the PGY30 to even 40 class who are actually doing this. It's really, really interesting to talk to them. You say, they have practice need. They're already doing it. They want to get credibility. Or they say, it's another mountain to climb. Just going to do it. Going to take better care of my patients. So it can be done at all levels of training, but now the fellows are piling in and their junior attendings are piling in because they're scared. You know, they want to know as much as the fellows. And it's spreading like wildfire in the New York area, other metro groups. So anyway, what we thought then, I was advised to cancel my slide group. Politely but firmly, Yoni said, no, we're covering all that. I showed it to him, the reading room, the prep room. So he suggested instead to, I think it's called scaring you straight, which is to show what actually the logbook requires in terms, and your supervisor, if they're a good supervisor, will require of you. It's not just five views. Let's show a quick image set. No discussion beyond casual comment to show you what you face and what you can do once you're trained. Dr. Mayo, we'd just like to point out there's about 15 minutes left for you to go through all this. We'll go fast. Yeah, he's always, uh-oh, now this is it, how it happens, right, yeah? The image set, when you first start doing it, it's gonna take you 30, 40 minutes to do one. But once you do about 10 or 15, you'll be able to complete a full image set in about eight to 11 minutes. Yeah, and some of my fellows, on rounds, I'm leading the group, and they're there, and they complete a full image set once they're really good at it, right during the discussion, I've seen that, yeah. So starting January 1st, he'll be more vigorous in his order, in his command voice. He's recommending that I start? Okay, all right. Yes, sir, okay, yeah. So now I'm clicking something, yeah, all right. So this is simple. You acquire the images, et cetera, et cetera. Let's emphasize, or I'll ask a question. Has anyone here in this room seen a cardiology fellow do a complete echo personally, themselves, in your ICU? No, and the reason for that is cardiologists have no interest in image acquisition, period. They read, they're expert readers, but they're not gonna come out and into the trenches with you guys, and therefore, what separates you from them is you know stuff they know about echo, but you know other stuff that they don't know about echo in the cognitive base. On the other hand, they know congenital, stuff like that, okay? So there's a lot of shared cognitive base, but what really separates you is you're really good at image interpretation, but you acquire the images, and that's why there's this rigorous 150 image requirement. It's not required of cardiologists, but it's required of you. Once you complete the 150 in the certification, then you use what aspect of your toolbox is required for the patient, obviously, but the 150, it's hard, but it needs to be done. Let's start. Barisona-Long, we all know what that is, and then you make a number of requisite measurements, which you ordinarily don't consider for goal-directed echo. These are not required for every image set, but you need to know how to do them. Here they are, the usuals, and then, of course, you jump to color. Both valves are obviously colored here and here, and here, and you make the suitable calculations of severity, et cetera, et cetera, and then, oh, they pick up a enlarged ascending aorta. Just so you can notice that, you make some measurements. Here, for the goal-directed people, this is a new but required image. It's the RV inflow, shows some TR. The TR results in a inadequate jet envelope. We would reject this as a underestimate of PSAP derivative, but it has to be made, it has to be documented for the logbook, and you have to know when it's good quality. Then, of course, for the goal-directed people, you stay on short axis at the midventricular level. Here, you have to start learning the anatomy of the base of the heart. We have the aortic valve in mid-position. Oh, what are the cusps? You gotta know the cusps, just like the cardiologist. Yes, uh-oh. You just had one comment. You said that sometimes you get an inadequate envelope. Is it okay to say on your logbook that it's an inadequate envelope, and it still counts as an advanced window? Yeah, we'd love to hear that. That person knows what they're doing, okay? So don't be discouraged if you can't get a good window, and you know it's not gonna be accurate. You can still say attempted, but inadequate envelope, and it'll still count. And the tricuspid valve requires color. There's an intra-atrial septum, which is bowed over to the right side, so left atrial pressure is at least 20. So right away, more advanced level, you're noticing these things. Then you're required to do color of any valve that you see, and comment here. And here, we make another attempt off of a truncated, probably off-axis jet, which is also inadequate. You have the need to know, obviously. You still save the image, and you say inadequate, in this view, okay? We measure the pulmonary artery. This is a requirement for full image set, the diameter. And we find pulmonary insufficiency. Pulmonary insufficiency, all regurg jets, all stenotic jets require careful Doppler analysis. It starts with acceleration time. If you don't know what that is, it's a useful measurement, easy to make, part of your logbook-level full exam. And then we do a Doppler envelope of the pulmonary insufficiency jet. The cardiology tech will be doing this. The cardiologist will not be doing it. They'll be interpreting it. That's the big difference between us and them. And you can estimate the mean pulmonary artery pressure, and the PAD off of this jet. You can remove the pulmonary artery catheter from the patient, please do. And here we go at three levels, not just mid-ventricular level. We start at the basal segments. Of course, by the time you step up to the exam, I think it's, what, January 30th this year, everyone will recognize there's significant segmental wall motion abnormality, and obviously the board wants you to know the segments by name, just as a cardiologist does, or graduating cardiology fellow. They know them reflexively. This is a deeper knowledge requirement. You go to mid-ventricular level, and you finish at the apex, okay? And then, of course, all here present who go Gold Direct Echo, you're interested in LV size ratio, but that's where you really go to work. You're gonna color the mitral valve. You're gonna color the aortic valve to detect the insufficiency of the aortic valve. You're then going to do a two-chamber. Yes, there are other ways of looking at the ventricle, which the Gold Directed person doesn't need to know, but you will need to know. The three-chamber, and subcostal. Here, then, we're looking at the right side, the TAPSE, the S-prime, the velocity of the tricuspid valve annulus. These are all just standard measurements for full logbook. Once you're certified, would you do this in every patient? No. You used to like the carpenters. Sometimes you bring out the table saw. Sometimes a screwdriver works, but the good carpenter knows how to use everything. The good echocardiographer has a full toolbox, okay? Then, we're looking on the mitral valve annular velocity here, E-prime, and E, the mitral valve inflow. You're gonna do ratios to confirm the LAP is elevated. Of course, as soon as you see that, you're doing lung ultrasonography because you're WUBU specialists, whole-body ultrasound specialists, not just ace-of-heart people. Then, we are looking for the VTI, which, curiously, with this terrible ventricle, is rather near normal, but, of course, you're thinking the effect of the aortic insufficiency. Is it severe or not? These two guys notice the interesting artifact during diastole, which is the AI aliasing. Yeah, you gotta know what that is. We then do a series of estimates of severity of AI, and we conclude, fortunately, based on these measurements, which are straightforward, part of your toolbox, that the patient has mild AI, so their VTI of 16. Most of it is being distributed to the periphery, and not much of it is returning to the ventricle during diastole. Then, we have the somewhat useful, mostly useless IVC measurement. The hepatic inflow pattern, hepatic venous inflow pattern, you need knowledge of that, unfortunately, or fortunately. We show this to you to not exactly frighten you, but to show that this is very, very different than gall direct echo. It's a major investment of time and effort, but I hope my younger colleagues have convinced you that when you go through this process, you'll be a very different type of intensivist than beforehand, okay? The image set that we just went through on the website, Dr. Mayo and I did a video about five years ago going through the entire image set, and I just looked at the video on YouTube, and it always shocks me. It's at 209,000 views right now, but it's quite boring. I think it's about 30 minutes. We make fun of each other a little bit. So I'll kind of walk you through all of those exams with a live model on kind of how to acquire things. You say I have six more slides in there? That's what it looks like, yes. I'm a little worried what they are. Oh, oh, this is, yeah, this image set comes from Dr. Zarama in Cali, Colombia. I was her supervisor, and she insisted, I told her, you don't have to do Simpsons. In Cali, Colombia, we do that on every patient. You don't have to in your logbook. Oh, no, no, she's gonna do it. There she goes, and she does it in two axes, and then she's definitely gonna do a LA volumetric assessment, and she's just a great scanner, but over the top, okay? So she's, I think, the first Latin American candidate who supervised, who was qualified for certification. So we have about four minutes. If there are any questions, please come up to the microphone so we can try to answer them. We're hoping for a lot of questions, so please don't hold back. So here is our colleague from the Grady in Atlanta, a real frontline critical care person who you're starting a fellowship, and I am sure in the first year, your first group, don't let them think about ACE. They have so much other stuff to learn. For example, PFTs, bronchoscopy, basic echo. Once they're in their second year, in my program, all of my second year fellows are taking the exam because we found if they wait till third year, they're focused on the pulmonary boards, and then they have a nervous breakdown trying to study for the January. So strongly advised, nothing in the first year, and then you start moving in. Send me an email, and I'll give the connection for the image interpretation group, which will be next year as well, okay? What's your question? Thank you, yeah, that timeline is very helpful. Well, my question deals with the certification process. Should we start doing the program? Yeah, so the way it works is fellows, the certification process is much easier in terms of paperwork because all that the NB requires, and this is tradition with all fellowship issues, you write a letter saying they can do bronchoscopy, airway management, central line stuff. Nobody ever challenges that if it's coming out from a fellowship program director traditionally. So along those lines all that has to be done at graduation is they sign a document, notarized, that says that this fellow is competent to perform this and this, they did 150 exams, and that's all that's needed, that golden letter. Once if a person isn't attending, it's a little more complicated, but it's easy, the paperwork does. So tell your program director, wait, haven't passed the exam, do the logbook, and the last month make out the, yeah, there's no pressure. Thank you so much, this was so informative. Where are you from? Watertown, New York. Watertown, okay. Yeah, great, okay. My question is about what are your thoughts on handheld ultrasounds? With respect to image acquisition and logbooks, because getting that heavy ultrasound whenever I see a patient. So there's been a big breakthrough. We were sort of laughing at the certification committee because early on people were submitting logbooks with Butterfly. Now Butterfly doesn't have Doppler, it cannot be a full exam. But I'm now told that the new GE, we call them UPUMS, ultra portable ultrasound machines, the new wireless UPUM now has pulsed wave Doppler in it. They hadn't figured out how to put CW in it. And the other UPUM companies are racing to do this, but GE is first out of the block. So if you have the GE machine and keep on, I think there's another machine that's almost FDA approved that might even have CW. If you get one of those, then you can do it. Yeah, absolutely. You just need Doppler. You need Doppler in your machine. The GE machine is very attractively priced, and it's now top rated by the hospitalist community as most convenient, easy to use, and they just brought Doppler onto it. Wonderful. Thank you so much. Yeah. Hi guys. Hello, where are you from? Oh, Peter Kuhn. I'm from Washington State. Great. Okay. Where in Washington State? Bellevue. Right. We met. That's right. But you have a hat on now. That's right. I have a hat on. Yeah. Yeah. What question? Yeah. You were at a day session. Well, first of all, thank you guys for all the wonderful sessions. It's really great getting all of this information. So my question is, I currently, after fellowship, I went to practice at a community hospital. And in terms of finding a supervisor and a mentor, what kind of qualifications does a supervisor need? So the NBE requires that person be certified by NBE in some form of echo. There are many thousands of cardiologists, cardiac anesthesiologists who qualify, but also they have an odd subcategory, which is people who are not certified by NBE in echo, but have recognized capabilities. So it's all negotiable. The best is if you're married to a cardiologist, your brother or sister, or you have a really good friend who's like a little out of the box, right, yeah, I'll supervise you. So if you're aware of this in community hospitals, often there's political connotation, you know, with cardiology, unfriendly colleagues, things like that. So what the college is thinking about is to offer a remote mentorship supervisor program to meet your needs. So for example, I supervised Cali, Colombia, and also a lady in Brazil a couple of years ago. They were fantastic. I knew them. I had met them at courses. So we're trying to figure that out. Yoni, you have some interest in that, do you? So I just want to say, we're over time, so we have to end. But Pete, you and I go way back, so you're taken care of. Let's chat on this. Oh, thank you. The other option would be, you know, if you know a cardiologist from training, like your residency or whatever, you can share the screen and go over your echoes with them over Zoom or whatever, and if they're willing to certify you, they can just supervise your exams that way as well. Yeah. Okay. And the best for TE access, cardiologists generally won't be helpful for actually practical reasons sometimes. But if you're friendly with cardiac anesthesiologists, they're putting probes down all the time, and they're getting bored reading the Wall Street Journal. You know what I'm saying? They're just looking. They're bored. And if you go down pre-trained ones with a simulator, you go down, hey, yeah, I'll train you, but you want to go down pre-trained, otherwise they get a little frustrated. So that's a lot of programs are qualifying their people that way. Okay? Yeah. Okay. All right. So we're over time. Thank you. Thank you, everybody.
Video Summary
In this video, Dr. Zubair Hassan and Dr. Paul Mayo discuss the process of board certification in advanced echocardiography. They highlight the importance of achieving competence in advanced critical care echocardiography and how it can improve patient care. They also provide information on the National Board of Echocardiography special examination in critical care echo and how to prepare for the exam. They emphasize the need for a complete image set in the logbook and provide examples of image acquisition and interpretation. Dr. Mayo also mentions the availability of handheld ultrasounds for image acquisition. He explains that a supervisor for the logbook needs to be certified by the National Board of Echocardiography or have recognized capabilities in echo. They conclude the video by answering questions from the audience.
Meta Tag
Category
Imaging
Session ID
1166
Speaker
Yonatan Greenstein
Speaker
Paul Mayo
Speaker
Gulrukh Zaidi
Track
Imaging
Keywords
board certification
advanced echocardiography
competence
critical care echocardiography
patient care
National Board of Echocardiography
special examination
image acquisition
interpretation
handheld ultrasounds
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