6/25/10 v25
BIDMC Non-invasive/Echocardiography Fellowship Rotation
1st and 2nd Year Cardiology Fellows:
Summary of ASE/ACC Echocardiography Training Guidelines
Dur
Level 1 (all fellows) 3 mo
Minimum additional
150 perform and interpret
Level 2 (indep inter) 3 mo
300 perform and interpret
Level 3 (lab direct)
450 interpret
Maintenance
6 mo
Stress
TEE
100 interp
50 perform
25 eso
50 sup
15/mo
25-50/y
Goals:
1. Understand the basic and fundamental principles of cardiac imaging
i.
cardiac ultrasound [2D, Doppler, color Doppler]
ii.
Nuclear cardiology
iii.
Cardiac MR
iv.
Cardiac CT
2. To understand the indications and comparative value of cardiac imaging
i.
Transthoracic, TEE, stress echo, contrast (saline/Definity)
ii.
Nuclear cardiology
iii.
Cardiac MR
iv.
Cardiac CT
3. To become proficient at performing TTE for urgent/emergent indications
i.
When indicated
ii.
How to perform
[performing ~25 studies/mo x 2 mo/year x 2 years & nightcall = ~150 studies]
5. To become proficient at interpretation of TTE for common (1st year) and more
complex (2nd year) findings.
- [independent performance of 150 studies, with exposure to 500+ studies]
- independent interpretation of 25 studies/wk during 2nd month of 1st year
- independent interpretation of 25 studies/wk during 2 months of 2nd year
6. To achieve Level II training in echocardiography (TTE)
7. To achieve Level I training in Nuclear Cardiology, Cardiac MR and Cardiac CT
6/25/10 v25
Expectations - Practical:
1. Mornings are focused on scanning technique - how to perform TTE examinations
- sonographer mentoring [Marilyn]
- laminated “scan” cards
- 1-2 cases/day [target of >7 cases/WEEK]
- Review your clips and download study to Image Vault
- ENCOR (database) listing as “scanning fellow.”
- Create prelim ENCOR report for studies you scan. Save as “scanned
done” so that preliminary results available (will be listed as
preliminary). Be sure to indicate “FELLOW Interpretation” on the
General Tab – Administration Question.
- Scanning Target is >7 scanning cases during the week (1.4/day)
<5
Low
5-6
Low average
7-9
Average
10-12 Very good
13-15 Excellent
>15 Outstanding
2. If morning cases are not available – print/video/CD resources in Black cabinet in
WEST CAMPUS sonographer room. There is an EchoPAC workstation and
VCR/monitor for fellows in the room behind the WC receptionist
- review Mayo Clinic series of echo instruction tape
in general, tapesCDs should NOT be removed from the Echo Lab
- Texts:
o 2009 “Baby” Otto text will be provided to each 1st year fellow during
their 1st monthly rotation: Suggested reading:
1st year/1st two rotations:: chapters 1, 2, 5-14
1st year/3rd and 4th rotations: chapters 4, 5-14 (again), 15-17
o J Oh Mayo Clinic text
o Feigenbaum Echo text (advanced, but excellent reference/ DVD)
o Texts may be removed (list what you have on white board)
- ACC Echo-CD
- Congenital Heart Disease CD
- Fellow Wednesday morning PowerPoint Presentations on Echo web site
3. Suggested Focus:
First Year – First and second two-week blocks
Comprehension of basic cardiac anatomy pertaining to echo (Mayo
Tapes, Otto chapters listed above, teaching CDs for orientation/views)
Capability to recognize and obtain cardiac echo views (scanning 1-2 pts daily,
target of >7 studies/wk)
parasternal long axis, RV inflow, RV outflow/PValve
parasternal short axis (aortic valve, mid-ventricular levels)
apical four chamber, five chamber
6/25/10 v25
apical two chamber, long axis
subcostal
suprasternal
Ability to identify structures on M-Mode and make appropriate measurements
Basic knowledge of conventional and color flow Doppler
Attend daily reading sessions and acquire basic interpretative skills
Working knowledge of ultrasound machine
Ability to triage requests for portables
Assist with all portable studies
Perform saline contrast PFO/shunt studies
Perform Definity endocardial border definition contrast studies
Familiarity with stress echo procedures (treadmill and dobutamine)
First Year – second and third two-week blocks and Second Year
Review of basic cardiac anatomy pertaining to echo (Mayo Tapes, Otto suggested
chapters above, teaching CDs)
Refine scanning skills in lab and units (target of >7 studies/wk)
Ability to perform full echo/Doppler studies
Attend daily reading sessions and refine interpretative skills
Improve knowledge of ultrasound machine including quantification
of gradients and valve areas
Ability to triage, perform and troubleshoot all stress echo procedures
Triage and perform portables and emergent echo studies
Complete preliminary report in ENCOR
2nd Month of First Year Fellows:
Week 1:
Scanning with sonographer
Week 2-4:
More independent scanning
Week 3-4
Focus on Portable studies
Second Year Fellows: Focus on more complex lab studies
Independent interpretation of studies
4. For each study in which you are involved as a scanning fellow (weekday/weekend):
- Complete preliminary report in ENCOR (2nd mo 1st yr fellows, all 2nd yr fellows)
- Confirm your name is listed as “imaging” and interpreting fellow in ENCOR
6/25/10 v25
5. Attend afternoon WEST Campus reading sessions (target of >30 cases/wk
- case reviews with Echo Staff
- be sure the attending lists you as an “interpreting” fellow
- assist with contact for urgent/emergent interpretations
- I will provide you with your reading #s at the end of the block.
- Participate in >30 interpretations (7.5/day with 1 clinic session/wk)
- <20
Low
- 20-27
Low average
- 28-32
Average
- 32-40
High average
- 40-49
Very Good
- >50
Excellent
6. Perform saline contrast injections (inpatient and outpatient labs); including placing
IVs for outpatients (if needed)
7. Prepare and perform Definity endocardial border definition contrast studies; including
placing IVs for outpatients (if needed).
8. Monitor patients for dobutamine/adenosine/persantine stress echoes
9. To attend and to present at Wednesday morning conference during your echo month.
 (Topic is“flexible,” – related to non-invasive imaging, research, journal
club, etc.).
 Fellows present during the 2nd month of their first year and both months
during
their 2nd year.
10. Echo examination – each block will be assigned 2 studies to interpret (see web)
11. Rotation review – I will meet with you on the 2nd and 4th Wednesday of the month
7:30-8:00am
East Campus Library
Rotation review
12. Cardiac MR case review – Required exposure to Cardiovascular MR
Cardiac MR-EAST – SH-462 (CMR fellows room)
11am-noon: Tuesday
11am-noon Friday
13. Cardiac CT case review – Required exposure to CCT (Tom Hauser)
Tue/Thur
2:309-3:30pm [East Campus-Ansin 3]
14. Nuclear Cardiology case review – Required exposure to Nuclear [Tom Hauser]
Wednesday
9:30-10:30am (lecture – EAST Campus, Finard 1)
Wednesday
2-3pm (case review – EAST Campus, Finard 1)
6/25/10 v25
15. REQUIRED Conferences:
- Monday
12-1pm CMR/CCT/Nuclear conference (WC, Baker 4 library)*
- Tuesday
7-7:45am Core Curriculum Lecture (WC, Farr 60
8-9am Division clinical conference (WC, Baker 4 library)
12-1pm ECG conference (WC, Baker 4 conference room)*
- Wednesday 7:30-8am (2nd & 4th Wed of month) – East Card Library – WJM*
8-9am Echo conference (EAST Cardiology Library)
9-9:30am: Meeting with advanced non-invasive fellows*
9:30-10:30am Nuclear conference (EC, Gryzmich 1)
- Thursday 7-8am Fellows Chief Conference (WC, Baker 4 library)
- Friday
8-9am Cardiology Grand Rounds (WC, CC250 auditorium)*
12:30-1:30pm (2nd & 4th Friday of month) Case Based Noninvasive Imaging Seminar (Baker 4 library)
* September-June
Optional Conferences
- attend Friday Firm and Tuesday M&M conferences and present echo studies
- cardiac MR research conference (Tuesday noon-1pm; East CV Library)
EAST/WEST
Mon
7-8am
8-9am
Tue
Wed
Fellow
Conf
7:30a,
Thur
WJM 2/4th
Echo Conf
Clin Conf
Fri
Card GR
9-9:30
9:3010:30am
11-12pm
12-1pm
Nuclear
Teaching
CMR/CCT/Nucl
Teaching
CMR
ECG
Teaching
Nuclear
2pm
2:30pm
CMR
12:30-1:30pm
Nuclear
Cases/Journal
Club
Cardiology
CCT
CCT
4-5pm
13. “2nd” week of rotation
- Test cases provided on Wednesday (to be reviewed with WJM the
following week on a day he/she is in the lab).
6/25/10 v25
- complete ENCOR report as “ORDERED” so will NOT be part of the patient’s
record.
- Meet with WJM 9-9:30am to review the rotation
- Complete “New Innovation” NON-INVASIVE attending evaluation
15. Vacation
- notify WJM (and Marilyn Riley) in advance
- need to arrange coverage for saline/Definity contrast/dobutamine echo
16. On-call
- off-hours (evenings after 5pm, weekends, holiday) echoes are performed by the
on-call clinical cardiology fellow with back-up by the on-call TEE fellow (who
performs all TEEs) and by the on-call Echo Attending.
- If the echo fellow is uncertain of the interpretation, the TEE fellow followed
by the echo attending should be contacted for review.
- off-hours studies should be logged into the ENCOR system with the fellow
listed as the performing and interpreting fellow and the attending of the following
“work day” listed as the staff attending. The fellow should
i. complete an ENCOR preliminary interpretation. Be sure to label as
PRELIMINARY using the “emergent study by fellow” and “fellow
interpretation” answers in the GENERAL TAB of ENCOR.
ii. download the studies to the ImageVault.
iii. Leave the sonographer prelim form in the WEST Campus reading
room (including East campus studies).
iv. send an e-mail to the echo attending (weekend and next business day
WEST reader) and to Marilyn Riley (mriley1@bidmc.harvard.edu) that a study
was done, pt name/MRN, location (e.g., floor/ICU), indication for echo, findings.
- a sonographer is present from 8am-4:30pm on Saturday. They will do 7
studies. Priority is given to ICU followed by pre-discharge. Page the
sonographer (Beeper #31578] for all urgent requests.
- Fellows on cardiology service call for the division are excused from morning
obligations in the echo lab on the day following call, and should participate in the
afternoon activities.