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Emergency Ultrasound

Author

Kristin Schmid, MD
Department of Surgery, Division of Emergency Medicine, Class of 2020
Saint Louis University

Faculty Editor

Joseph Walline, MD, FAAEM, FACEP
Assistant Program Director, Emergency Medicine Residency
Emergency Ultrasound Program Director
Department of Surgery, Division of Emergency Medicine
Saint Louis University

Special thanks to our 1st edition writing team

Sharmin Kalam, MD
Bob Stuntz, MD, RDMS, FAAEM, FACEP

INTRODUCTION

Description of the specialty 
Ultrasound is a rapidly progressing field and has become a widely accepted medical imaging modality that has revolutionized the field of acute care medicine. This fellowship specifically targets those who are interested in becoming experts and future leaders in utilizing ultrasound in emergency medicine.

History of the specialty/fellowship pathway 
Emergency medicine now includes bedside ultrasonography as a standard part of EM practice. The history of ultrasound in EM can be traced back to the publication of the first emergency ultrasound curriculum by Mateer et al. in 1994. The initial curriculum was composed of core applications such as trauma/focused assessment with sonography in trauma (FAST), renal, cardiac, biliary, aorta, and early pregnancy ultrasonography. Due to the portability, relative ease of use, and lack of harmful radiation, bedside ultrasound rapidly increased in popularity through the 1990s as a means to improve and expedite patient care. The first formal policy statement for the use of ultrasound in EM was published by the American College of Emergency Physicians in 2001. Emergency ultrasound (EUS) became a required part of the core curriculum of EM residency programs upon the recommendation of the ACGME Review Committee for Emergency Medicine. The rapid growth of EUS has led to the development and validation of new point-of-care ultrasound (POCUS) applications and the dissemination of basic training in developing standard systems of care in the United States and abroad. As the use of POCUS has grown, so too have its applications. The emergency physician can learn to use ultrasound to diagnose vascular, musculoskeletal, soft tissue, ocular, gastrointestinal, genitourinary, thoracic, gynecological, and cardiac pathology and can also use it to guide fluid resuscitation. Ultrasound has become an important tool to facilitate bedside procedures including vascular access, thoracentesis, paracentesis, pericardiocentesis, incision and drainage, arthrocentesis, peripheral nerve blocks, foreign body removals, and lumbar punctures.

Why do residents choose to follow this career path?
Some may feel they did not receive adequate training during residency, simply want to improve their ultrasound skills, or want to obtain an advanced ultrasound skill set. Many will also hope to become an ultrasound director, whether in a community or academic setting, and require a fellowship to learn the requisite administrative skills required of the position. Ultrasound fellowships also afford graduating residents an opportunity to work at an academic center in a specific geography, with the hopes of being offered a faculty position after fellowship completion.  Ultrasound fellowships provide specific ultrasound-oriented research opportunities for interested fellows. Some may be interested in global health and the applications of ultrasound to resource-limited settings in low- to middle-income countries.

How do I know if this path is right for me?
Residents who have a strong interest in bolstering their ultrasound skills, have an interest in pursuing a career as an ultrasound director, or working in an academic setting teaching ultrasound to students and residents should consider an ultrasound fellowship. The ideal applicant should be passionate about ultrasound in clinical, educational, and research settings. The path is right for you if you enjoy being involved in ultrasound practice and teaching and training others in ultrasound. 

Career options after fellowship 
An ultrasound fellowship affords many different career pathways, including education, research, and administration. Opportunities are available to become an EUS division director or residency program director, whether in an academic or a community setting. Those who are more educationally inclined can pursue a career as an EUS fellowship director or assistant/associate director. Some may find their passion within ultrasound research, while others may want to be primarily an academic faculty member with ultrasound as their clinical and educational niche. Getting a strong background in educational administration also lends to the possibility of becoming a member of a residency leadership team. As ultrasound is also being taught and used in the setting of global health, many physicians are using their skills to be an educator and leader in ultrasound while travelling abroad.

Academic vs. community positions 
Ultrasound training prepares physicians for both clinical and academic positions. Those interested in teaching and/or research tend to gravitate towards academic positions. When choosing a position, it is important to consider the department’s support of ultrasound, current ultrasound equipment, and willingness to purchase future equipment. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs 
In July 2018, there were 121 fellowships available, according to the Emergency Ultrasound Fellowships website. Some programs offer “global/international” tracks, geared toward those interested in both global health and ultrasound. These programs provide additional training on establishing ultrasound programs and ultrasound education internationally.

Differences between programs 
Ultrasound fellowship programs are varied, just like residency programs. Emphasis can be placed on clinical ultrasound, research, international work, or education. Speaking directly with the ultrasound fellowship director, as well as current and former fellows, will allow prospective applicants to better understand the education offered. To a much greater degree than in residency, WHOM you work with in the fellowship has a massive effect on your learning and your focus. For example, the EUS Fellowship Program Director may have an area of specialization in international activities that may or may not align with your personal goals – a key consideration when choosing a program! 

Length of time required to complete the fellowship
1-2 years. Some programs incorporate either a master’s degree in clinical epidemiology or combined training in another specialty, such as global health. 

Skills acquired during fellowship
Fellows can expect to learn how to perform and interpret both basic and advanced ultrasound applications and apply them to their clinical practice. You will also learn how an EUS program functions within the larger hospital or health care system. Many administrative aspects of running and maintaining an ultrasound program are emphasized: machine purchases and maintenance, integration with your electronic medical record (billing, coding and documentation), working with other medical specialties that utilize ultrasound such as radiology and cardiology, and physician credentialing and education. Specific skills in ultrasound research will likely be a part of your fellowship education as well. 

Typical rotations/curriculum 
ACEP has provided an EUS fellowship curriculum that most programs follow. Overall, you are required to obtain at least 1,000 scans during the year, participate in image review and Q-and-A sessions, submit a scholarly project, prepare ultrasound-related lectures, attend a national ultrasound meeting, and perform hands-on teaching to medical students, residents, and physicians in other specialties. In addition, you will likely work as a part-time attending in the emergency department to help fund your residency position. 

Board certification afterwards? 
While the possibility of accreditation for EUS is being explored, this fellowship is not currently recognized by the ACGME as a certified subspecialty in EM. There is debate in the specialty of EM about the utility of outside certification (eg, ARDMS) in EUS. ACEP "strongly opposes the use of any non-emergency medicine external certification process to validate competency in the use of emergency ultrasound."

Average salary during fellowship 
The average salary during fellowship varies. Some programs pay fellows commensurate to their PGY level and also allow you to moonlight. Others fund the fellowship by paying you as a part-time faculty member. You should discuss salary with each specific site you are considering.

PREPARING TO APPLY

How competitive is the fellowship application process? 
Some geographical locations can becompetitive. The number of positions and applicants vary from year to year. In the past few years, there have been more spots than applicants, but this may not predict future years. 

Requirements to apply 
Many programs require that you are EM-trained and either board-eligible or board-certified. Additionally, applicants should have some basic exposure to ultrasound and meet the RRC requirements for POCUS in residency. 

Suggested elective rotations to take during residency 
If available, residents should take a dedicated ultrasound rotation or participate in an ultrasound elective. 

Suggestions on how to excel during these elective rotations
Be engaged and learn any novel approaches to ultrasound in different settings. You should be familiar with the ACEP Emergency Ultrasound Compendium. Overall, being enthusiastic, asking questions, and getting your hands on as many scans as possible will be beneficial.

Should I complete an away rotation? 
There is no need for an outside rotation during residency, unless your residency program does not offer strong ultrasound training, or you are looking at a specific program and want to do an audition rotation. 

What can I do to stand out from the crowd?
Getting involved in ultrasound education and/or research during your residency will allow you to stand out from other applicants. Clinical excellence, the desire to work hard, and your accomplishments during residency are all important. Different fellowship directors use different criteria for selecting a fellow. One common theme is personality; they want fellows who are likable and who fit in with the rest of the crew. Energetic and proactive applicants with a history of getting things accomplished will be the most sought-after candidates. 

Should I join a hospital committee? 
This is not required. However, hospital committees can be a valuable learning experience and can help to develop your leadership skills. 

Publications other than research 
Being engaged academically certainly helps, and having non-research publications, such as in EMRA’s EM Resident magazine or in ACEP Now magazine, will certainly make you stand out. 

How many recommendations should I get? Who should write these recommendations?
Three recommendations are fine. At least one should be from a faculty member active in ultrasound. The others should be from leaders at your EM residency or department. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship? 
You can still be competitive in many programs if you are applying after working clinically. Be prepared to explain why you did not do a fellowship right out of residency. 

What if I’m a DO applicant? 
You can apply for a fellowship position if you completed a DO residency in emergency medicine. 

What if I am an international applicant?
International applicants with a license to practice medicine in the United States can be competitive applicants for EUS fellowships. International applicants without a license to practice medicine in the United States will have difficulty participating fully without the ability to work clinically, especially considering ultrasound fellows generally work part-time as EM attendings. Applicants who need a visa should apply to sites with experience in accepting such applicants.

APPLICATION PROCESS

How many applications should I submit? 
There is no right answer to this question. It is good to see multiple fellowships so you can more accurately compare them. The average applicant applies to 7-8 programs. 

How do I pick the right program for me? 
There is no “right” program for most applicants, as many programs will provide good training. If you have a strong interest in an area of ultrasound, you may want to find a program that focuses on that area. Applicants should be specific in identifying which clinical ultrasound applications they will master during their fellowship training. Look at the structure of the fellowship to see if they can fulfill your needs. Ask where their prior fellows have gone and see if they have found good jobs. Geographical location is paramount to some fellows. 

Common mistakes during the application process
The most common mistake made during the application process is to have letters submitted to a site that refers the application to another site. Another common mistake is not having a good answer about why you want to attend that particular program. Prospective applicants may assume that an ultrasound fellowship is akin to a simple extension of residency, and some applicants come into the process without having a good explanation as to why they are interested in the fellowship. Using the years as a resident to solidify basic ultrasound skills, engage in research, and attend national meetings is now the norm for competitive fellowship programs. 

Application deadlines 
Follow the NRMP Fellowships Match calendar. In general, the match opens in August, and results are announced in November. 

Tips for writing your personal statement 
Don’t overthink the personal statement. Try to make a compelling narrative about why you want to do ultrasound. Please be simple, brief, and concise. A long letter describing various skills is unlikely to be helpful, because fellowship directors already have your CV. 

Is this a match process? 
Yes. EUS joined the NRMP Fellowships Match in spring 2018. 

What happens if I don’t obtain a fellowship position? 
If you do not obtain a position the first day that offers go out, you can scramble and contact other fellowship programs that have open slots. This is coordinated through eusfellowships.com. You can also wait a year and reapply. If you plan to reapply, try to do something ultrasound-related during that gap to improve your application. Do not hesitate to contact the fellowships you applied to and ask how to make your application stronger. If you simply desire to improve your skill set in POCUS, many great courses are available online and in-person. 

INTERVIEW PROCESS

How do I stand out from the crowd? 
Be yourself! Be energetic and enthusiastic about the subspecialty. Research the program where you are interviewing so you can ask individualized questions. Be professional – remember, this is a job interview. Be prepared to discuss your reason for pursuing the subspecialty, as well as all aspects of your application. 

What types of questions are typically asked?

  • Why do you want to come to this fellowship?
  • Why do you want to do an ultrasound fellowship?
  • What do you want to do with your career in ultrasound? 

How many interviews should I go on? 
You should go on as many interviews as you want and can afford. There is no right number. Most applicants go to around 7 interviews. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Dawson M, Mallin M. Introduction to Ultrasound: Volume 1. Emergency Ultrasound Solutions; 2013.
  • Ma OJ, Mateer JR, Reardon RF, Joing S. Ma and Mateer's Emergency Ultrasound. 3rd ed. Philadelphia, PA: McGraw-Hill Education; 2013.
  • Carmody KA, Moore CL, Feller-Kopman D, Carmody KA, Moore CL, Feller-Kopman D. Eds. Handbook of Critical Care and Emergency Ultrasound.New York, NY: McGraw-Hill; 2011. 

Important skills to practice while in residency to prepare for fellowships 
In addition to working on your ultrasound skills, practice interviewing, team-building, demonstrating reliability in accomplishing tasks, and taking initiative. 

Tips on how to succeed as a fellow 
During fellowship, take advantage of all opportunities offered. Fellowship is a unique time to develop your skills in image acquisition and interpretation, the education of other healthcare providers in ultrasound, leadership and administrative skills in developing ultrasound infrastructure and curriculum, and, finally, research skills. Also, strive to maintain a balance with your life outside of fellowship to help prevent burnout. 

CONCLUSION

Additional resources

Blogs/Podcasts

National organizations

Conferences
Some of the conferences with EUS activities include ACEP, SAEM, AAEM, AIUM, and P2SK. They are very different, but each is attended by ultrasound enthusiasts and offers opportunities to learn about and get involved in ultrasound on a national level. 

How to find a mentor 
Local mentors are best, so ask around your residency first, or check the Former Fellows Map listed on EUS. You can also network at national meetings to identify individuals who will help you with your interest in ultrasound. Email individuals directly. The community is friendly, open, and willing to help.