Chapter 1. Training and Program Development

Establishing a training program in point-of-care ultrasound is an exciting and rewarding experience. The impact of ultrasound on the clinical practice of medicine becomes so clear that many clinicians, after acquiring basic ultrasound skills, wonder how they got along without this technology. This chapter outlines the process for developing a point-of-care ultrasound training program and addresses the common questions encountered when starting a new program.

Point-of-care ultrasound examinations are performed in real time at the bedside by clinicians to answer specific questions in order to expedite care and improve patient care. These studies are not intended to provide comprehensive surveys of anatomical areas nor are they mere extensions of the physical examination.1 Point-of-care ultrasound provides imaging to rule in or rule out specific disease entities for which timely treatment is crucial (e.g., ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy, and cardiac tamponade) or for whom invasive intervention could be especially unsafe (e.g., paracentesis, abscess drainages, and foreign body removal). As such, these studies require the highest levels of competence, accuracy, and clinical acumen.

In order to establish a high-quality point-of-care ultrasound program, ultrasound directors must:

1. Determine type of examinations to be performed.

2. Develop a program implementation plan.

3. Obtain leadership approval of the implementation plan.

4. Acquire an ultrasound machine.

5. Train the group.

6. Incentivize group members to complete training and credentialing.

7. Perform problem solving, quality assurance, and ongoing training.

A critical factor in the timely implementation and success of an ultrasound program is to have the full support and active assistance of the department leadership. Also, appointing a dedicated ultrasound director with protected time is the best approach because each step in program implementation is very time intensive.

Ultrasound use continues to expand along with technological advances and improvement in individual operator expertise. It makes sense to start with applications that will get the most use in a particular practice setting. For example, in a small community hospital, evaluation of cardiac arrest may be more pertinent than trauma evaluations. Likewise, in centers without 24-hour ultrasound services, it may be important to learn ultrasound for the evaluation of ectopic pregnancy and cholecystitis. We recommend starting with applications unique to the ED for which timely diagnosis and intervention are critical. This includes the focused assessment with sonography for trauma (FAST) examination, evaluation of cardiac arrest states, and evaluation of hypotension. In addition, procedural applications, such as intravenous line placement, paracentesis, thoracentesis, and abscess localization and drainage, are becoming standard of care.2 Training in emergency medicine residency programs, however, should cover all of the primary applications and include exposure to emerging applications (Tables 1-1 and 1-2).