1. Clinical Ultrasound Course Thomas Cook, MD, Program Director, Emergency Medicine Patrick Hunt, MD, Emergency Ultrasound Fellowship Director Palmetto Health Richland Columbia, South Carolina

2. The indications & techniques presented in this cousre have been recommended in the medical literature and/or conform to the clincial practice of OUR faculty.The equipment has not necessarily been approved by the Food and Drug Administration (FDA) for use in the techniques for which they are recommended. The package insert for the equipment should be consulted for use as recommended by the FDA. Because standards, practices and recommendations change, it is advisable to keep abreast of revised recommendations, particularly those concerning new drugs and techniques. While the techniques described are successfully used in our practice, they should be followed with discretion since their complications may be dependent on the operator, patient and/or other accompanying clinical circumstances. The equipment discussed in this course is shown solely for teaching purposes. Similar equipment from other manufacturers may produce similar clinical results to ours. Slide 2

3. 3rd Rock Ultrasound would like to give a special thanks to Dr. Joseph Woo for his permission to use the historical pictures of ultrasound systems in this presentation.For more information about Dr. Woo’s work on the history of obstetrical ultrasound, please see the URL below. http://www.ob-ultrasound.net/history1.html Slide 3

4. MODULE 1Introduction to Clinical Ultrasound

6. Why are we doing this?

7. Program Goals

8. Course Curriculum

9. Post-Course Learning OpportunitiesSlide 5 LECTURE OBJECTIVES

10. A Brief History of Ultrasound

12. Industrial Use

13. Military Use (SONAR)

15. Slide 9 A BRIEF HISTORY OF ULTRASOUNDEarly Ultrasound Images

17. 1960’s – Cardiology

18. 1970’s – Obstetrics & GynecologySlide 10

19. A BRIEF HISTORY OF ULTRASOUNDEVERYTHING CHANGES Slide 11

20. Slide 12 A BRIEF HISTORY OF ULTRASOUNDComputer Technology Explosion

21. Slide 13 A BRIEF HISTORY OF ULTRASOUNDCircuit Boards to ASICs

22. Slide 14 A BRIEF HISTORY OF ULTRASOUNDSmaller and Smaller

23. Slide 15 A BRIEF HISTORY OF ULTRASOUNDNerd to Chic

26. Slide 18 1970 1985 1990 1995 2000 2002 2005 A BRIEF HISTORY OF ULTRASOUNDEffects on Imaging

27. Slide 19 A BRIEF HISTORY OF ULTRASOUNDEVERYTHING CHANGES (AGAIN)

29. Necessitates Separate Departments (Radiology)

30. Equipment

31. Space

33. Slide 22 CT-scan Nuclear X-Ray MRI A BRIEF HISTORY OF ULTRASOUNDComparison to Other Imaging “PACS”

35. Ubiquitous Presence at the Bedside

36. Limited Equipment Needs

37. Small Space Requirement

38. Small Data Loop

39. Reduced Work Flow Needs“PACS” Slide 23 A BRIEF HISTORY OF ULTRASOUNDComparison to Other Imaging

40. Slide 24 A BRIEF HISTORY OF ULTRASOUNDEffects on Ultrasound Labs

42. 1980’s and beyond

43. General Surgery & Trauma

44. Emergency Medicine

45. Anesthesia

46. Critical Care

47. Orthopedics

48. EMS, USAR, Military, NASASlide 25 A BRIEF HISTORY OF ULTRASOUNDUltrasound Uses in Medicine

49. Slide 26 A BRIEF HISTORY OF ULTRASOUNDTheoretical Considerations CLINICAL Medicine Versus RADIOLOGY Specific Indications & Goals

50. Why are we doing this?

51. COMPARISON OF EFFECTIVENESS OF HAND-CARRIED ULTRASOUND TO BEDSIDE CARDIOVASCULAR PHYSICAL EXAMINATION Kobal, S.L., et al, Am J Card 96(7):1002, October 1, 2005 METHODS: The authors, from Cedars-Sinai Medical Center and UCLA, compared the diagnostic accuracy of physical examination performed by one of five board-certified cardiologists, and use of a hand-carried ultrasound (HCU) device (OptiGo, Philips) by one of two first-year medical students in 61 patients with clinically significant cardiac disease. The students received 18 hours of training in use of the HCU device, which provides two-dimensional and conventional color- flow Doppler imaging, including four hours of lectures and 14 hours of practical experience. Expert echocardiography was the diagnostic gold standard. RESULTS: Standard echocardiography identified 239 abnormalities in these patients (average, 3.9 per patient). Using the HCU, the students recognized 75% of these abnormalities compared with 49% identified by the cardiologists on physical examination (p<0.001). Corresponding specificities were 87% vs. 76% (p<0.001). The students were significantly more accurate than the cardiologists in the recognition of the most severe cases of left ventricular (LV) dysfunction and severe valvular disease (96% vs. 68%, p<0.001), and HCU exams by the students were also more accurate than physical exams by the cardiologists in the recognition of lesions that cause systolic or diastolic murmurs. CONCLUSIONS: These findings reflect the inherent difficulties in evaluation of organ systems through percussion, palpation and auscultation, and the utility of technology developed to facilitate patient assessment at the bedside. Slide 28 WHY ARE WE DOING THIS?Can we do better? . . . . (Hand-Carried Ultrasound) exams by the (medical) students were also more accurate than physical exams by the cardiologists (without ultrasound) . . . .

52. Making Health Care Safer: A Critical Analysis of Patient Safety PracticesAgency for Healthcare Research & QualityU.S. Department of Health & Human ServicesShojania KG, et al. University of California at San Francisco / Stanford University Slide 29 WHY ARE WE DOING THIS?Why Do We Need Ultrasound for Vascular Access?

53. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin™) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. Slide 30 WHY ARE WE DOING THIS?Why Do We Need Ultrasound for Vascular Access?

54. Slide 31 WHY ARE WE DOING THIS?Standard Imaging Paradigm

55. Slide 32 WHY ARE WE DOING THIS?Standard Imaging Paradigm What happens when they are not available?

56. Slide 33 WHY ARE WE DOING THIS?New Paradigm

57. Program Goals

58. PROGRAM GOALSVision & Mission Statements VISION STATEMENT Diagnostic ultrasound will become an integral component of the training and practice of clinical medicine. MISSION STATEMENT We will empower clinicians with a comprehensive curriculum to learn and integrate ultrasound technology into their patient management. Slide 35

59. Slide 36 PROGRAM GOALSThree Components of Skill Acquisition Introductory Leaning Practice-Based Learning Use in Clinical Decision Making

60. Slide 37 PROGRAM GOALSThree Components of Skill Acquisition Introductory Leaning Practice-Based Learning Use in Clinical Decision Making

61. Slide 38 PROGRAM GOALSEUC Offerings Introduction to Emergency Ultrasound Introduction to Vascular Access Introduction to Trauma Ultrasound Introduction to Critical Care Ultrasound Advanced Emergency Ultrasound

62. Slide 39 PROGRAM GOALSThree Components of Skill Acquisition Introductory Leaning Practice-Based Learning Use in Clinical Decision Making

63. Slide 40 PROGRAM GOALSThree Components of Skill Acquisition Introductory Leaning Practice-Based Learning Use in Clinical Decision Making

64. Course Curriculum

65. Slide 42 COURSE CURRICULUMCourse Modules

66. Slide 43 Live Lectures Training Labs Cardiac Ultrasound Web-Based Educational Tools Web-Based Testing COURSE CURRICULUMModular Learning

67. POST-COURSE ACTIVITIES & LEARNINGOn-Line Access to Course Lectures Requires Subscription Fee emergencyultrasound.com Slide 44

68. Slide 45 POST-COURSE ACTIVITIES & LEARNINGOn-Line Scan Review Requires Separate Subscription Fee

71. Slide 48 COURSE INTRODUCTIONFinal Thoughts A Historic Opportunity A pivotal movement in the future of clinical medicine

72. ULTRASOUND-GUIDED PROCEDURESFor More Information Slide 49