OBJECTIVES:The growth in ultrasound usage necessitates concurrent growth in the number of sonographers. Despite the increasing importance of ultrasound, there is a shortage of sonographers in the United States that has never been specifically quantified. This study examines recent trends in the number of ultrasound exams, sonography graduates, open sonographer positions, and wages.METHODS:This retrospective study uses public databases and surveys including the Medical Expenditure Panel Survey (MEPS), Bureau of Labor Statistics (BLS), Integrated Postsecondary Education Data System (IPEDS), and Zippia, a human resources platform to determine metrics. These metrics include the number of ultrasound exams conducted in the United States (excluding inpatient setting), number of sonographers and sonographer wages, sonography graduates, and open sonographer positions.RESULTS:Ultrasound exams in the United States from 2011 to 2021 increased from 38.6 million to 59.8 million (+55.1%,) while the number of sonographers (2011-2021) increased from 54,760 to 78,640 (+43.6%). There was a significant difference between supply and demand of sonographers with the number of sonography graduates (2011-2021) increasing from 4,386 to 5,393 (+23.0%) while the number of open sonographer positions (2012-2021) increased from 18,462 to 25,162 (+36.3%).CONCLUSIONS:From 2011 to 2021, the increase in the number of ultrasound exams has significantly outpaced the increase in the number of sonographers. Furthermore, the increase in demand for sonographers has grown significantly faster than the supply, leading to a shortage and consequent strain on the healthcare system. To address the shortage, the number of sonography school openings should be increased, and the attendant challenges addressed.

Objective: Re-hospitalization after sepsis can lead to impaired quality of life. Predictors of re-hospitalization could help identify sepsis survivors who may benefit from targeted interventions. Our goal was to determine whether low heart rate variability (HRV), a measure of autonomic nervous system dysfunction, is associated with re-hospitalization in pediatric septic shock survivors.Materials and Methods: This was a retrospective, observational cohort study of patients admitted between 6/2012 and 10/2020 at a single institution. Patients admitted to the pediatric intensive care unit with septic shock who had continuous heart rate data available from the bedside monitors and survived their hospitalization were included. HRV was measured using age-normalized z-scores of the integer HRV (HRVi), which is the standard deviation of the heart rate sampled every 1 s over 5 consecutive minutes. The 24-h median HRVi was assessed on two different days: the last 24 h of PICU admission (“last...

Healthcare regulatory bodies have escalated concerns regarding the use of point-of-care ultrasound by nonradiology and noncardiology physicians. A recently published PCCM Perspective identified that data do not support many of these concerns and addressed common misconceptions associated with point-of-care ultrasound use in the critical care setting. Indeed, the global point-of-care ultrasound community and specifically the pediatric critical care community have the opportunity to be leaders in demonstrating how to translate new skills and technologies to the bedside in a safe and effective manner. We seek to extend the conversation and propose next steps in supporting integration of point-of-care ultrasound in pediatric critical care practice.

BACKGROUND AND OBJECTIVES:Measuring pediatric emergency medicine (PEM) fellow competency in point-of-care ultrasound (POCUS) is important for ensuring adequate training and performance. Assessment may include direct observation, image review, quality assessment, and written examination. The purpose of this study was to develop a pediatric POCUS question bank that could subsequently be used as a POCUS assessment for graduating PEM fellows.METHODS:We organized a 10-person question writing group (QWG). Eight hold expertise in POCUS and two hold expertise in medical education. Members of the QWG created questions within four domains: interpretation/diagnosis (50% of questions), anatomy (30%), physics (10%), and pitfalls (10%). POCUS faculty ascertained content validity and the medical education faculty revised questions for syntax and readability. In 2016, we recruited 31 pediatric POCUS experts. The majority were members of the P2 Network, an international group of experts and leaders in PEM POCUS, to participate in three iterative rounds of a modified Delphi process to review, revise, and establish consensus on the question bank.RESULTS:Thirty-one pediatric POCUS experts participated in the three rounds of the modified Delphi process and evaluated 437 questions developed by the expert panel. Forty-nine percent (n = 216) of the questions were accepted in round 1, 30% (n = 130) in round 2, and 11% (n = 47) in the final round. The final question bank included 393 questions covering 17 pediatric POCUS applications.CONCLUSION:We developed a 393-question bank to aid in the assessment of PEM POCUS competency. Future work includes piloting the questions with PEM fellows to evaluate the response process and implementing the assessment tool to establish a minimum passing score.

Background: We have recently tested an automated machine-learning algorithm that quantifies left ventricular (LV) ejection fraction (EF) from guidelines-recommended apical views. However, in the point-of-care (POC) setting, apical 2-chamber views are often difficult to obtain, limiting the usefulness of this approach. Since most POC physicians often rely on visual assessment of apical 4-chamber and parasternal long-axis views, our algorithm was adapted to use either one of these 3 views or any combination. This study aimed to (1) test the accuracy of these automated estimates; (2) determine whether they could be used to accurately classify LV function. Methods: Reference EF was obtained using conventional biplane measurements by experienced echocardiographers. In protocol 1, we used echocardiographic images from 166 clinical examinations. Both automated and reference EF values were used to categorize LV function as hyperdynamic (EF>73%), normal (53%-73%), mildly-to-moderately (30%-52%), or severely reduced (<30%). Additionally, LV function was visually estimated for each view by 10 experienced physicians. Accuracy of the detection of reduced LV function (EF<53%) by the automated classification and physicians' interpretation was assessed against the reference classification. In protocol 2, we tested the new machine-learning algorithm in the POC setting on images acquired by nurses using a portable imaging system. Results: Protocol 1: the agreement with the reference EF values was good (intraclass correlation, 0.86-0.95), with biases <2%. Machine-learning classification of LV function showed similar accuracy to that by physicians in most views, with only 10% to 15% cases where it was less accurate. Protocol 2: the agreement with the reference values was excellent (intraclass correlation=0.84) with a minimal bias of 2.5 +/- 6.4%. Conclusions: The new machine-learning algorithm allows accurate automated evaluation of LV function from echocardiographic views commonly used in the POC setting. This approach will enable more POC personnel to accurately assess LV function.

The COVID-19 pandemic requires a substantial change to the traditional approach to conference didactics. Switching to a virtual medium for conference sessions presents several challenges, particularly with regard to aspects that rely heavily on in-person components (e.g., simulation, ultrasound). This paper will discuss the challenges and strategies to address them for conference planning in the era of COVID-19.

By providing for individualized learning with standardized outcomes, Mastery Learning (ML) provides a sophisticated and feasible educational method within today’s competency based residency training. ML has already been demonstrated to reduce complications and improve skill retention for multiple procedures. Yet, ML has not been adopted widely in Emergency Ultrasound (US). The objective of this multicenter educational research study, is to develop a robust mastery learning (ML) checklist for the requisite knowledge and skill of image acquisition, and then determine the needed minimal passing standard for independent performance of the Extended Focused Assessment with Sonography in Trauma (EFAST) by Emergency Medicine residents. The authors created an initial EFAST ML checklist based on the published American College of Emergency Physicians (ACEP) Imaging Compendium. Next, the checklist underwent methodical revisions via two rounds of a modified delphi technique with ten fellowship trained ultrasound faculty experts at seven institutions. The final wording of the preliminary checklist was then tested during actual EFAST training. Lastly, a second panel of ten new experts at the same seven institutions established a minimal passing standard for an adequately trained EMR using the Mastery Angoff Standard Setting method. The first group of ten experts created an EFAST ML checklist that included twenty four distinct actions with completion marked as Yes/No utilizing a modified delphi technique. Each EFAST view requires that the trainee select the appropriate probe, properly adjust depth and gain to adequately visualize relevant anatomy, then verbally and physically identify relevant anatomy and potential spaces. The second group of ten new experts then set a minimal passing standard requiring that 94% of checklist items be completed in order for an Emergency Medicine Resident to be considered proficient in the EFAST image acquisition. Utilizing best practices in ML, we created a rigorous expert consensus EFAST Checklist and minimal passing standard. Although local practice may vary, starting with the published ACEP US imaging compendium, then refining with ten experts at seven institutions, we believe that our EFAST checklist adequately reflects current performance standards. The next steps for our educational research network are to determine interobserver reliability, utilize the EFAST checklist as both a pre and post-assessment within a ML curriculum, and compare performance on the EFAST checklist versus completion of traditional set number benchmarks. When rigorously developed and validated, ML may supplement and ultimately even replace traditional set number procedure benchmarks for each application within Emergency Ultrasound.

Physicians with training in point-of-care ultrasound (POCUS) can reliably estimate left ventricular ejection fracture (LVEF). However, those without experience or at novice level may misestimate LVEF. The reference standard for calculation of LVEF involves obtaining both apical four-chamber (AP4) and apical two-chamber (AP2) views, and tracing the endocardial border. In POCUS, these views are difficult to obtain due to a number of patient, machine and environmental factors. Physicians may therefore use other views such as the parasternal long axis (PLAX) when determining LVEF, and do not assign specific quantitative values to LVEF.

BACKGROUND:Pediatric emergency medicine (PEM) physicians have variably incorporated point-of-care ultrasound (POCUS) into their practice. Prior guidelines describe the scope of POCUS practice for PEM physicians; however, consensus does not yet exist about which applications should be prioritized and taught as fundamental skills for PEM trainees. Members of the PEM POCUS Network (P2Network) conducted a consensus-building process to determine which applications to incorporate into PEM fellowship training.METHODS:A multinational group of experts in PEM POCUS was recruited from the P2Network and greater PEM POCUS community if they met the following criteria: performed over 1,000 POCUS scans and had at least 3 years of experience teaching POCUS to PEM fellows, were a local academic POCUS leader, or completed a formal PEM POCUS fellowship. Experts rated 60 possible PEM POCUS applications for their importance to include as part of a PEM fellowship curriculum using a modified Delphi consensus-building technique.RESULTS:In round 1, 66 of 92 (72%) participants responded to an e-mail survey of which 48 met expert criteria and completed the survey. Consensus was reached to include 18 items in a PEM fellowship curriculum and to exclude two items. The 40 remaining items and seven additional items were considered in round 2. Thirty-seven of 48 (77%) experts completed round 2 reaching consensus to include three more items and exclude five. The remaining 39 items did not reach consensus for inclusion or exclusion.CONCLUSION:Experts reached consensus on 21 core POCUS applications to include in PEM fellowship curricula.

Point-of-care ultrasound is increasingly being used throughout clinical medicine, especially in the emergency department and intensive care units. A more focused area within point-of-care ultrasound is in echocardiography. In this review, the use of point-of-care cardiac ultrasound, specifically for rapid cardiac evaluation in the pediatric emergency department, is examined to highlights its benefits and utility.

Introduction: Emergency Medicine Physicians have been incorporating Point-of-Care Ultrasound (POCUS) into their practice for over twenty years. Only recently has its use become more widespread in the practice of Pediatric Emergency Medicine (PEM). Recent guidelines have described the scope of applications for PEM physicians. However, no consensus exists as to which applications should be prioritized and routinely taught to PEM fellowship trainees and therefore expected of PEM graduates as they enter practice. The PEM POCUS Network, a multinational group of Physicians with POCUS expertise formed in 2014, set out to reach expert consensus as to which applications should be incorporated into PEM fellowship training curricula. Methods: A multinational group of PEM POCUS experts was recruited from the PEM POCUS Network via a screening process that identified PEM physicians who have performed over 1000 pediatric POCUS scans and met any of one of the following criteria: having 3 years or more experience teaching POCUS to PEM fellows, being local academic POCUS leaders or had completed a dedicated PEM POCUS fellowship. These experts rated each of the 60 possible PEM POCUS applications using a modified Delphi consensus building technique for their importance in inclusion into a PEM Fellowship curriculum. Consensus was reached when >80% of respondents agreed to include or exclude each item. Results: In the first round, 66 out of 92 (72%) PEM POCUS Network members responded to the survey email, of whom 45 met expert criteria and completed the first round. During round 1, consensus was reached to include 18 of the 60 applications in a PEM fellowship curriculum and to exclude 2 applications from a PEM fellowship curriculum. Eighty-two percent (37 /45) of the experts completed Round 2 where 40 items were rated; consensus was reached to include 3 additional applications and exclude 5 applications. The decision was made not to carry on with future rounds after this stage, since no significant changes were observed between the two rounds, with regard to items that had not reached consensus. Conclusion: This project of the PEM POCUS Network reached consensus on 21 applications that should be included in a PEM Fellowship curriculum. This project will have significant impact on how PEM fellowships teach POCUS to their trainees.

Point of care sonography is a useful tool in the evaluation of both medical and traumatic ocular conditions. Traditional ocular evaluation including fundoscopy, computed tomography and magnetic resonance imaging involves significant patient cooperation, radiation exposure, and/or transfer of sometimes critically ill patients. Sonography is safe, does not utilize radiation and is done at the patient's bedside. Imaging is done through the closed eyelids which permit sonographic ocular examination even with significant eyelid edema and limited patient cooperation. The nature of the fluid filled eye allows for assessment of the anterior and posterior chambers, and even behind the eye itself to assess for increased intracranial pressure.

Background: Point-of-care ultrasound (POCUS) has been used to identify ingested gastric foreign bodies. Our aim was to describe the sonographic findings of radiopaque and radiolucent gastric foreign bodies (FBs) in children. Case Report: Three children ingested different FBs. Two were confirmed with standard radiographs, one was not identified radiographically but was passed in the stool. All three objects were initially found in the stomach using POCUS. Why Should An Emergency Physician Be Aware of This?: With increased training and comfort, emergency physicians may begin to use POCUS for identification and monitoring of ingested FBs in the pediatric population. (C) 2016 Elsevier Inc.

Introduction: Pre-hospital focused assessment with sonography in trauma (FAST) has been effectively used to improve patient care in multiple mass casualty events throughout the world. Although requisite FAST knowledge may now be learned remotely by disaster response team members, traditional live instructor and model hands-on FAST skills training remains logistically challenging. The objective of this pilot study was to compare the effectiveness of a novel portable ultrasound (US) simulator with traditional FAST skills training for a deployed mixed provider disaster response team.Methods: We randomized participants into one of three training groups stratified by provider role: Group A. Traditional Skills Training, Group B. US Simulator Skills Training, and Group C. Traditional Skills Training Plus US Simulator Skills Training. After skills training, we measured participants' FAST image acquisition and interpretation skills using a standardized direct observation tool (SDOT) with healthy models and review of FAST patient images. Pre-and post-course US and FAST knowledge were also assessed using a previously validated multiple-choice evaluation. We used the ANOVA procedure to determine the statistical significance of differences between the means of each group's skills scores. Paired sample t-tests were used to determine the statistical significance of pre-and post-course mean knowledge scores within groups.Results: We enrolled 36 participants, 12 randomized to each training group. Randomization resulted in similar distribution of participants between training groups with respect to provider role, age, sex, and prior US training. For the FAST SDOT image acquisition and interpretation mean skills scores, there was no statistically significant difference between training groups. For US and FAST mean knowledge scores, there was a statistically significant improvement between pre-and post-course scores within each group, but again there was not a statistically significant difference between training groups.Conclusion: This pilot study of a deployed mixed-provider disaster response team suggests that a novel portable US simulator may provide equivalent skills training in comparison to traditional live instructor and model training. Further studies with a larger sample size and other measures of short-and long-term clinical performance are warranted.

Occult fractures due to child abuse can be difficult to identify because there is usually no history of trauma, and chief complaints are vague. In addition, the osseous injuries are often subtle, becoming obvious only after healing begins. Missed injuries can lead to inappropriate disposition of a patient and can cause children to be placed at high risk for further injury and death. It is therefore imperative that these children be diagnosed as soon as possible. Ultrasound has some properties that are desirable for detecting fractures, especially in children. Ultrasound waves are almost completely reflected by cortical bone. Thus, fractures easily appear on an ultrasound screen. The cartilaginous nature of pediatric bones makes some fractures difficult to identify on x-ray. The nature of ultrasound waves, however, allows the cartilaginous areas of pediatric bones to be identified. This brief report presents 2 cases of children younger than 1 year presenting with vague complaints (limp, irritability) without a history of trauma. Both children underwent bedside ultrasound by a pediatric emergency medicine physician with training in emergency ultrasound. The bedside ultrasound led to the identification of occult or unsuspected fractures in both children, and state social services were notified. In both cases, the cause of the fracture was determined to be from abuse, and necessary measures were taken to ensure the child's future safety. This report demonstrates that ultrasound may be useful for early identification of some types of occult or unsuspected fractures commonly seen in cases of child abuse.

Study objective: Inadvertent arterial placement of a femoral venous catheter may result in serious morbidity, including limb necrosis. The Flush the Line and Ultrasound the Heart (FLUSH) test is visualization of the heart by a subxiphoid ultrasonic view while the central catheter is flushed with agitated saline solution. We wish to determine whether the FLUSH test can verify proper femoral venous line placement.Methods: We prospectively studied a convenience sample of children undergoing cardiac catheterization, for whom both femoral venous and arterial access were part of their standard care. The cardiologist flushed manually agitated saline solution through each catheter in randomized sequence while the blinded physician sonographer recorded the presence or absence of right atrial opacification. We calculated the sensitivity and specificity of the FLUSH test relative to our reference standard, the cardiologist's fluoroscopic visualization of catheter wire placement.Results: Of the 51 subjects enrolled, the FLUSH test was 100% sensitive (95% confidence interval 95% to 100%) and 90.3% specific (95% confidence interval 81% to 96%) in confirming femoral catheter placement. In no case was an arterial flush misidentified as a femoral flush. The interrater reliability of the test was strong: K 0.82 for all images and 0.9 for those of good quality.Conclusion: The FLUSH test is simple and reliable, and appears to accurately confirm femoral venous line placement.

Wilms tumor arises from the renal parenchyma and in most cases is asymptomatic. Neuroblastoma develops from the adrenal gland or along the sympathetic chain and may thus be manifested as either a midline or flank mass. It is an aggressive malignancy and has often metastasized at diagnosis. Ultrasonography and computed tomography (CT) are useful for investigation of abdominal lesions. A pediatric surgeon and oncologist should be consulted early for management of abdominal tumors.

In contrast to adult emergency medicine, bedside ultrasound has not been widely used in pediatric emergency medicine. Recent literature suggests that bedside ultrasound may have multiple uses for pediatric emergency care. This review will provide an overview on how to implement this tool into a pediatric emergency department and the integration of ultrasonography into a fellowship curriculum. In addition, this article will highlight evidence derived from the technology and business literature regarding the development of this technology for pediatric emergency medicine. Special emphasis will be placed on practical evidence to identify barriers to adoption as well as strategies to overcome these barriers.

This is the case of a 13-year-old adolescent girl who presented to the emergency department and was diagnosed with severe pulmonary hypertension. In the intensive care unit, she underwent a comprehensive evaluation for the underlying etiology of her pulmonary hypertension and was determined to have pulmonary venoocclusive disease, a rare disorder of pulmonary venous fibrosis and thrombosis.