Learning Basic Critical Care Echocardiography: Is It as Simple as This*? Feroze Mahmood, MD Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA Mario Montealegre-Gallegos, MD Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA; and Departamento de Anestesiología Hospital México, C.C.S.S. Universidad de Costa Rica San José, Costa Rica
I
n his book Wind Sand and Stars, de Saint Exupéry said that perfection is attained not when there is nothing more to add, but when there is nothing more to remove (1). Educators of today are being asked to train better and more in less time. Conflicting demands of simultaneous qualitative and quantitative improvements within the same time frame mandate innovative approaches to medical education. The current graduate training model is being transformed from a time based to a competencydriven approach with performance metrics (2). It is hoped that this will result in tangible improvements in clinical performance of trainees and patient outcome. Specialized medical training has certain costs associated with it. The most important of these is the fiscal element of graduate medical education. Others can be computed in terms of the spent time and human-related factors. The challenge is to improve quality without prolonging the duration and the cost of training. Introduction of new technologies has led to re-evaluation of the traditional roles associated with certain specialties. In this context, the scope of echocardiography has extended from the realm of outpatient cardiology clinics to the operating rooms and the ICUs. The use of echocardiography has evolved from a monitoring modality to a procedural adjunct in the operating room environment. In the critical care arena, ultrasound in general and echocardiography in particular has established *See also p. 2169. Key Words: echocardiography; echocardiography skills; fellowship education The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000449
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itself as a vital monitoring and diagnostic tool. Basic critical care echocardiography (BCCE) skills are now considered a valuable asset for all critical care medicine physicians. Despite having clearly established its value as a safe, noninvasive technique with significant diagnostic and monitoring yield, there are still no structured training guidelines for BCCE. Various critical care training programs have introduced some form of echocardiography training, but there is no uniformity of the content or evaluation. Although there may be multiple reasons, some of the most often cited are the lack of simple, easy-toimplement, and low-cost approaches to BCCE training for critical care fellows. In this issue of Critical Care Medicine, See et al (3) address this problem by using a simplified training model for BCCE that relies on online resources and a time efficient clinical supervision program. Their results show that this economical approach to BCCE training results in a high diagnostic accuracy by the trainees. However, there is an element of required experience in that this was observed when the trainees completed more than 30 transthoracic examinations. They suggest that the level of competency attained by these trainees may be adequate to diagnose prevalent cardiac abnormalities that generate worse patient outcomes. This is an important finding since it identifies the minimum number of required procedures to be qualified as a proficient examiner. The introduction of web-based didactics is an innovative approach to address the training time constraints faced by the graduate medical education programs. Faculty narrated lectures can be recorded in high resolution for viewing by the trainees in their own time. The current state of technology also allows for an element of interactivity and objectifying the knowledge gain with pre- and postlecture tests. The study by See et al (3) has demonstrated that trainees can be effectively supervised in a time efficient manner. These innovative strategies can be employed by various programs to improve cognitive understanding as well as the basic psychomotor skills required to obtain an adequate BCCE image and correctly interpret the results. The study by See et al (3) has set the standard for such endeavors. Despite the evidence presented by See et al (3), we must be cognizant of the possible consequences of oversimplification of BCCE teaching. First, the trainees who diligently and voluntarily get involved in nonmandated educational program are a self-motivated group. Therefore, these results may not be applicable universally. Second, acquisition of manual dexterity requires repetitive performance for retention of skills. Whereas acquisition of basic skills was demonstrated, their retention may require further training and experience. Also, a self-learning strategy does not allow for an interactive teaching experience based on immediate instructor feedback and remediation. Finally, although the operator may have basic training, the patient presentation may require advanced skills and the October 2014 • Volume 42 • Number 10
Editorials
training to appropriately ask for help is also a component of basic education. Although a reasonable level of competence could be possibly achieved with an abbreviated training program with reduced supervision, it may still be insufficient to make a proficient examiner. In this study, the trainees were able to diagnose common pathologic states. A proficient examiner should also be able to provide exclusionary information and rule out potential diagnoses as well. Since the consequences of “missing” a diagnosis can be catastrophic in critical care settings, more supervised exposure may be required to achieve this level. Furthermore, the training model suggested by See et al (3) may allow for the detection of the more prevalent pathologies affecting intensive care patients, but it may not be adequate for the trainees to detect infrequent pathologies that may also affect outcome. In conclusion, the study described by See et al (3) is an innovative approach to introduce basic echocardiography skills in a rigorous training program. They have set the standard to be
tested with future studies. It is a commendable effort to motivate trainees to get involved in a voluntary educational initiative without significant attrition. As significant as these results are, we should be careful not to overstate them. Acquisition of proficiency in echocardiography is a complex process. It is a composite of cognitive understanding and manual dexterity. Furthermore, the boundaries of a “basic level” echocardiographer are difficult to define and enforce, as the patient presentations do not abide by these definitions.
REFERENCES
1. de Saint Exupéry A: Wind Sand and Stars (Translated by Lewis Galantièr). New York, NY, Harcourt Brace, 1967 2. Matyal R, Mitchell JD, Hess PE, et al: Simulator-based transesophageal echocardiographic training with motion analysis: A curriculumbased approach. Anesthesiology 2014; In Press 3. See KC, Ong V, Ng J, et al: Basic Critical Care Echocardiography by Pulmonary Fellows: Learning Trajectory and Prognostic Impact Using a Minimally Resourced Training Model. Crit Care Med 2014; 42:2169–2177
Ventilator-Associated Pneumonia: We Cannot Wish It Away* Andrew F. Shorr, MD, MPH Section of Pulmonary and Critical Care Medicine Medstar Washington Hospital Center Washington, DC Marya D. Zilberberg, MD, MPH EviMed Research Group, LLC Goshen, MA School of Public Health and Health Sciences University of Massachusetts Amherst, MA
V
entilator-associated pneumonia (VAP) remains a challenging conundrum for the clinician. No consensus exists regarding the diagnostic criteria for this
*See also p. 2178. Key Words: diagnosis; epidemiology; Pseudomonas aeruginosa; ventilator-associated pneumonia Dr. Shorr has served as a consultant to, received research support from, or been a speaker for AstraZeneca, Bayer, BMS, Cubist, Endoclear, Forrest, Pfizer, Tetraphase, and Theravance. He lectured for and received support for travel from Astellas, Cubist, Pfizer, and AstraZeneca. Dr. Zilberberg has received research or consulting funding from Cubist, Astellas, Pfizer, Theravance, and ViroPharma. Dr. Zilberberg consulted for Cubist, Astellas, and CareFusion. Her institution received grant support from Cubist. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000565
Critical Care Medicine
syndrome. Despite this, multiple studies using differing diagnostic criteria document that VAP leads to excess morbidity (1, 2). VAP increases the duration of mechanical ventilation (MV) and the length of stay in the ICU (1, 2). More recent analyses reveal that VAP results in excess attributable mortality (3, 4). For these reasons, VAP remains a focus of quality initiatives in the ICU. Although not classified as “never events” the way catheter-associated bloodstream infection are, intensivists face substantial pressure to drive down rates of VAP. In this issue of Critical Care Medicine, Kollef et al (5) report the results of an international prospective observational study focusing on the incidence of VAP and the microbiology of this syndrome. Using a rigorous definition of VAP that required a combination of clinical signs and symptoms along with specific radiographic changes and microbiology findings, these authors report that approximately 15% of patients requiring MV develop VAP. Strikingly, the crude rate of VAP varied little across international boundaries (5). This important observation suggests that VAP represents a global challenge in the ICU. These investigators, more significantly, only defined VAP as occurring if the chest imaging revealed a new or evolving infiltrate on multiple days. Given the day-to-day variability in chest radiographs in ventilated patients, this nuance in their diagnostic criteria helps ensure that the data they report truly reflects the incidence of VAP. In other words, since the definition used was relatively specific, the estimates of Kollef et al (5) likely represent a lower bound with respect to the incidence of VAP. Furthermore, most of their patients underwent lower www.ccmjournal.org
2297
I
n his book Wind Sand and Stars, de Saint Exupéry said that perfection is attained not when there is nothing more to add, but when there is nothing more to remove (1). Educators of today are being asked to train better and more in less time. Conflicting demands of simultaneous qualitative and quantitative improvements within the same time frame mandate innovative approaches to medical education. The current graduate training model is being transformed from a time based to a competencydriven approach with performance metrics (2). It is hoped that this will result in tangible improvements in clinical performance of trainees and patient outcome. Specialized medical training has certain costs associated with it. The most important of these is the fiscal element of graduate medical education. Others can be computed in terms of the spent time and human-related factors. The challenge is to improve quality without prolonging the duration and the cost of training. Introduction of new technologies has led to re-evaluation of the traditional roles associated with certain specialties. In this context, the scope of echocardiography has extended from the realm of outpatient cardiology clinics to the operating rooms and the ICUs. The use of echocardiography has evolved from a monitoring modality to a procedural adjunct in the operating room environment. In the critical care arena, ultrasound in general and echocardiography in particular has established *See also p. 2169. Key Words: echocardiography; echocardiography skills; fellowship education The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000449
2296
www.ccmjournal.org
itself as a vital monitoring and diagnostic tool. Basic critical care echocardiography (BCCE) skills are now considered a valuable asset for all critical care medicine physicians. Despite having clearly established its value as a safe, noninvasive technique with significant diagnostic and monitoring yield, there are still no structured training guidelines for BCCE. Various critical care training programs have introduced some form of echocardiography training, but there is no uniformity of the content or evaluation. Although there may be multiple reasons, some of the most often cited are the lack of simple, easy-toimplement, and low-cost approaches to BCCE training for critical care fellows. In this issue of Critical Care Medicine, See et al (3) address this problem by using a simplified training model for BCCE that relies on online resources and a time efficient clinical supervision program. Their results show that this economical approach to BCCE training results in a high diagnostic accuracy by the trainees. However, there is an element of required experience in that this was observed when the trainees completed more than 30 transthoracic examinations. They suggest that the level of competency attained by these trainees may be adequate to diagnose prevalent cardiac abnormalities that generate worse patient outcomes. This is an important finding since it identifies the minimum number of required procedures to be qualified as a proficient examiner. The introduction of web-based didactics is an innovative approach to address the training time constraints faced by the graduate medical education programs. Faculty narrated lectures can be recorded in high resolution for viewing by the trainees in their own time. The current state of technology also allows for an element of interactivity and objectifying the knowledge gain with pre- and postlecture tests. The study by See et al (3) has demonstrated that trainees can be effectively supervised in a time efficient manner. These innovative strategies can be employed by various programs to improve cognitive understanding as well as the basic psychomotor skills required to obtain an adequate BCCE image and correctly interpret the results. The study by See et al (3) has set the standard for such endeavors. Despite the evidence presented by See et al (3), we must be cognizant of the possible consequences of oversimplification of BCCE teaching. First, the trainees who diligently and voluntarily get involved in nonmandated educational program are a self-motivated group. Therefore, these results may not be applicable universally. Second, acquisition of manual dexterity requires repetitive performance for retention of skills. Whereas acquisition of basic skills was demonstrated, their retention may require further training and experience. Also, a self-learning strategy does not allow for an interactive teaching experience based on immediate instructor feedback and remediation. Finally, although the operator may have basic training, the patient presentation may require advanced skills and the October 2014 • Volume 42 • Number 10
Editorials
training to appropriately ask for help is also a component of basic education. Although a reasonable level of competence could be possibly achieved with an abbreviated training program with reduced supervision, it may still be insufficient to make a proficient examiner. In this study, the trainees were able to diagnose common pathologic states. A proficient examiner should also be able to provide exclusionary information and rule out potential diagnoses as well. Since the consequences of “missing” a diagnosis can be catastrophic in critical care settings, more supervised exposure may be required to achieve this level. Furthermore, the training model suggested by See et al (3) may allow for the detection of the more prevalent pathologies affecting intensive care patients, but it may not be adequate for the trainees to detect infrequent pathologies that may also affect outcome. In conclusion, the study described by See et al (3) is an innovative approach to introduce basic echocardiography skills in a rigorous training program. They have set the standard to be
tested with future studies. It is a commendable effort to motivate trainees to get involved in a voluntary educational initiative without significant attrition. As significant as these results are, we should be careful not to overstate them. Acquisition of proficiency in echocardiography is a complex process. It is a composite of cognitive understanding and manual dexterity. Furthermore, the boundaries of a “basic level” echocardiographer are difficult to define and enforce, as the patient presentations do not abide by these definitions.
REFERENCES
1. de Saint Exupéry A: Wind Sand and Stars (Translated by Lewis Galantièr). New York, NY, Harcourt Brace, 1967 2. Matyal R, Mitchell JD, Hess PE, et al: Simulator-based transesophageal echocardiographic training with motion analysis: A curriculumbased approach. Anesthesiology 2014; In Press 3. See KC, Ong V, Ng J, et al: Basic Critical Care Echocardiography by Pulmonary Fellows: Learning Trajectory and Prognostic Impact Using a Minimally Resourced Training Model. Crit Care Med 2014; 42:2169–2177
Ventilator-Associated Pneumonia: We Cannot Wish It Away* Andrew F. Shorr, MD, MPH Section of Pulmonary and Critical Care Medicine Medstar Washington Hospital Center Washington, DC Marya D. Zilberberg, MD, MPH EviMed Research Group, LLC Goshen, MA School of Public Health and Health Sciences University of Massachusetts Amherst, MA
V
entilator-associated pneumonia (VAP) remains a challenging conundrum for the clinician. No consensus exists regarding the diagnostic criteria for this
*See also p. 2178. Key Words: diagnosis; epidemiology; Pseudomonas aeruginosa; ventilator-associated pneumonia Dr. Shorr has served as a consultant to, received research support from, or been a speaker for AstraZeneca, Bayer, BMS, Cubist, Endoclear, Forrest, Pfizer, Tetraphase, and Theravance. He lectured for and received support for travel from Astellas, Cubist, Pfizer, and AstraZeneca. Dr. Zilberberg has received research or consulting funding from Cubist, Astellas, Pfizer, Theravance, and ViroPharma. Dr. Zilberberg consulted for Cubist, Astellas, and CareFusion. Her institution received grant support from Cubist. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000565
Critical Care Medicine
syndrome. Despite this, multiple studies using differing diagnostic criteria document that VAP leads to excess morbidity (1, 2). VAP increases the duration of mechanical ventilation (MV) and the length of stay in the ICU (1, 2). More recent analyses reveal that VAP results in excess attributable mortality (3, 4). For these reasons, VAP remains a focus of quality initiatives in the ICU. Although not classified as “never events” the way catheter-associated bloodstream infection are, intensivists face substantial pressure to drive down rates of VAP. In this issue of Critical Care Medicine, Kollef et al (5) report the results of an international prospective observational study focusing on the incidence of VAP and the microbiology of this syndrome. Using a rigorous definition of VAP that required a combination of clinical signs and symptoms along with specific radiographic changes and microbiology findings, these authors report that approximately 15% of patients requiring MV develop VAP. Strikingly, the crude rate of VAP varied little across international boundaries (5). This important observation suggests that VAP represents a global challenge in the ICU. These investigators, more significantly, only defined VAP as occurring if the chest imaging revealed a new or evolving infiltrate on multiple days. Given the day-to-day variability in chest radiographs in ventilated patients, this nuance in their diagnostic criteria helps ensure that the data they report truly reflects the incidence of VAP. In other words, since the definition used was relatively specific, the estimates of Kollef et al (5) likely represent a lower bound with respect to the incidence of VAP. Furthermore, most of their patients underwent lower www.ccmjournal.org
2297
