CARDIAC ANATOMY AND PHYSIOLOGY FOR TECHNOLOGISTS (one day)
One of the key problems facing those who are interested in cardiac ultrasound is a familiarity with detailed three dimensional cardiac anatomy. Even those individuals who are very comfortable with basic cardiac circulation have seldom been forced into a position of actually conceptualizing the three dimensional geometry of the heart because relatively few job specialties require day to day use of such information. Add to this the fourth dimension of time and the problem becomes magnified. The situation would pose a difficult enough problem if all that were needed was an understanding of the normal heart. The necessity for those doing cardiac ultrasound to also have a working knowledge of abnormal cardiac anatomy and the effects that various disease states have on other parts of the heart makes it easy to understand the initial confusion as people attempt to integrate the various ultrasound modalities (M mode, 2D and Doppler). Our Cardiac Anatomy and Physiology course is approximately six hours of intense review which is designed to give those attending the tools necessary to quickly develop the anatomical orientation to more successfully image the heart and to understand the extent of the lesions found. This session is offered immediately prior to the Level One and Level Two Cardiac Ultrasound Programs. Any prospective student (regardless of their experience in cardiac ultrasound) would find this program beneficial if they have not had formal training in three dimensional cardiac anatomy and/or the physiological effects of various valvular diseases on the chambers, walls and great vessels of the heart.
LEVEL ONE CARDIAC ULTRASOUND FOR TECHNOLOGISTS (11 days)
The Level One Cardiac Ultrasound Program for Technologists is generally designed for technologists with 0 — 1 year of “on the job” experience (>70 cardiac cases per month), but may be appropriate for those with up to three years of “on the job” experience if they have little or no formal training in cardiac ultrasound and/or if their monthly cardiac case load is substantially below 70. Those who have completed a long term, general ultrasound course will also find the course appropriate if they had no cardiac rotation, if their monthly cardiac case load was substantially below 70 or if their cardiac rotation was in a general ultrasound lab (rather than in a dedicated cardiac ultrasound lab under the supervision of Cardiologists). Comprehensive instruction in pertinent anatomy, physiology, pathology, basic echographic interpretative parameters and techniques necessary for data acquisition is provided. Instruction in acquiring data is accomplished as both instructor and student attempt studies on hired subjects. Students will analyze approximately 300 echoes during the course — of widely varied data quality — to develop skills in quality control and a basic understanding of interpretative parameters with data similar in quality to that found in most labs on a day to day basis.
The purpose of this program is to provide the student with the basic foundation necessary for technical competence in the field of echocardiography. It is not reasonable to discuss data acquisition without also discussing the difference between adequate and inadequate data quality. Likewise, it is not reasonable to discuss data quality without first understanding the data, its origin and the various subjective and quantitative parameters which lead to interpretative conclusions. The academic content of the course is strongly guided by the philosophy that a technologist is unlikely to demonstrate an abnormality unless he or she recognizes the abnormality and also knows the physiological effects that influence clinical management by Cardiologists and Internists. Instruction in these areas combined with actual probe experience provides a strong basis from which “on the job” training can grow. It is essential that participants in the program have access to an operational cardiac ultrasound lab soon after (no more than two weeks) their completion of the Level One program. This additional lab experience is necessary to continue development of “hands on” skills (this process will take between 3 and 12 months, depending upon the manual dexterity of the student, the number of patients studied and the amount of information the student retains from the Level One program). The principals of ultrasound physics which directly effect image quality (and thereby directly influence diagnostic information) will be reviewed. The Level One Cardiac Ultrasound Program for Technologists is objectively evaluated by a series of three quizzes and one final exam. For details of the objection exams, contact our Office as noted below.
In terms of modalities of ultrasound covered in the Level One Program for Technologists, those attending will receive instruction in both M mode and 2D (Doppler can be added to the Level One Program — see the "Standard Cardiac Doppler" description below). The underlying philosophy is that these two modalities are not competitive: rather, they are complimentary. From published population surverys as of this date, cardiac ultrasound labs in both the US and CANADA should quantitate wall thickness and chamber size by M mode. As a result, quantitation of these parameters are reviewed by both M mode and 2D. Further, the very high sampling rate of M mode affords an opportunity to empasize the time versus motion relationships so essential to both 2D and Cardiac Dopppler. Sufficient 2D instruction is provided to familiarize students with plnal orientation, specific anatomy visualitzed in each view and an appreciation of basic valvular heart disease as well as an instrocutions to observation of wall function. During the last 35 years this integrations of 2D and M mode techniques has proven to provide the best foundation possible for hose technologists who wish to develop a basic understanding of the heart and how both imagin and Doppler should be used to their maximum potential. Without such an in depth background, technologists are left with the impossible task of attempting to generate adequate diagnostic information simply mimicking illustrative pages in ultrasound textbooks.
In terms of daily schedule, one half of the day is spent in a formal Lecture environment, one fourth of the day is spent in a “hands on” session operating equipment under Staff supervision and one fourth of the day is spent reviewing edited case studies with Staff to develop skills in recognizing disease and in doing preliminary interpretations as preferred by most cardiologists.
Optional Extended “Hands On” Session for Level One Cardiac Ultrasound for Technologists
As the name of this class implies, it is designed to offer additional supervised time for the technician to further develop skills in operation of the equipment. While the Level One Cardiac Ultrasound Program for Technologists outlined above offers such instruction, many students with limited backgrounds often desire additional “hands on” time due to ever increasing levels of material they must learn during regular class hours. This increase in the volume of material covered has been necessitated by expansion of the ultrasound field and, hence, of technician educational requirements. The session is conducted during the weekend that separates the two weeks of the Level One Program which allows the student to focus their efforts entirely on operating the equipment while having the benefit of the anatomy and the view orientation acquired during the first week of the Level One Program. The class is offered as two, one half day sessions.
LEVEL TWO CARDIAC ULTRASOUND FOR TECHNOLOGISTS (4 days)
In terms of prerequisites, this program is designed for individuals with at least one year of “on the job” experience (greater than 70 cardiac studies per month); however, most technologists who attend the session have been performing cardiac ultrasound studies for at least 3 years. Technologists who have completed our Level One Program for Technicians (described above) will find the program an excellent extension of their education if they have anywhere from 6 months to 15 years of “on the job” experience after completing our Level One course. Technologists who have completed a long term general ultrasound program with a high quality cardiac ultrasound rotation therein will also find the class appropriate if they have at least 1 year of “on the job” experience with a busy cardiac workload and input from cardiologists who read the studies they generate (2 years recommended if cardiac workload is under 50 studies per month, 3 years recommended if input from cardiologists is minimal or non existent).
In terms of daily schedule, one half of the day is spent in a formal Lecture environment, one fourth of the day is spent in a “hands on” session operating equipment under Staff supervision and one fourth of the day is spent reviewing edited case studies with Staff to develop skills in recognizing disease and in doing preliminary interpretations as preferred by most cardiologists (technologists may elect to review additional case studies rather than participate in the “hands on” session if they already have good “hands on” skills).
In terms of academic content, measurement parameters are reviewed utilizing both M mode and 2D techniques. While M mode criteria for primary valvular diseases are reviewed and compared with 2D parameters, the Level Two Cardiac Ultrasound Program emphasizes 2D parameters. Substantial review of 2D assessment of both segmental disease and general output status is provided. Emphasis is placed on data quality, structural and planal orientation, anatomical orientation and interpretative pitfalls (both operator and conceptual). Assessment and use of physiological effects to detect and quantitate valvular disease is reviewed in detail and heavily emphasized. Those completing the program will find that it greatly enhances their ability to understand the data they generate (in contrast to simply generating data that they only partly understand). Many technologists with extensive “on the job” training utilize this program in preparation for completing a certification exam in cardiac ultrasound, while others take the course predominantly to improve the patient care they deliver by better understanding the ultrasound data that cardiologists and internists utilize to read the echo and clinically manage the patient. The Level Two Program for technologists is objectively evaluated by two quizzes. For details on the objective exams, contact our Office as noted below.
NOTE: Technologists new to cardiac ultrasound (i.e., those who do not meet the experience guidelines above) should first complete Level One prior to attending the Level Two Program. Participation in the Level Two Program with less than the recommended background proves to be very difficult for most students; however, it is possible that some individuals without specific cardiac ultrasound background, but with rather extensive cardiac nursing and/or cardiac cath lab background may find the course appropriate. Should any questions arise in this regard, please contact this Office prior to enrollment.
STANDARD CARDIAC DOPPLER FOR TECHNOLOGISTS (2.5 days)
Substantial confusion and misunderstanding about the practical clinical utility of cardiac Doppler exists in cardiac ultrasound labs throughout most of the western world. While it is clear that Doppler can usually detect most forms of valvular regurgitation, its ability to quantitate any form of valvular heart disease is very dependent upon not only technical problems (such as gain, beam vs. jet angle, number, size and shape of holes, etc.), but also upon contamination produced by coexisting valvular lesions, cardiac output status and other variables. Those individuals with extensive Doppler background know that for every diagnostic criteria in Doppler, there are several different disease states that will mimic the criteria. This session is designed to provide those attending with a practical working knowledge of both spectral and color Doppler. Emphasis is placed on integration of the Doppler with the 2D and M mode studies so as to place into perspective Doppler’s role in correlating to the physiological effects that various types of valvular disease have on the walls, chambers and great vessels of the heart (i.e., matching the amount of ventricular hypertrophy to the Doppler estimate of AS severity so as not to underestimate severity of AS due to technical problems associated with the angle of jet versus the Doppler beam angle, etc.). Those attending usually find the audiovisual lab to also be an excellent 2D and M mode interpretative review.
In terms of prerequisites, the need to correlate information produced by 2D and M mode with the Doppler coupled with the relatively short duration of the Doppler program dictates that those who attend have significant 2D and M mode background. Those who have previously completed (or who are currently taking) our Level One and/or Level Two Cardiac Ultrasound program will do well with the Doppler data reviewed. Those without experience in our cardiac ultrasound programs should have at least one year of “on the job” experience to benefit properly from the course material. Should any question exist regarding background of a prospective student, we recommend that you contact this Office prior to enrollment.
In terms of daily schedule, three hours a day are spent in a lecture format which reviews Doppler interpretative parameters and their pitfalls (both conceptual and practical), 2 hours a day are spent in a “hands on” session to provide practical technical experience in obtaining Doppler data from hired subjects and two hours a day are spent in an audiovisual lab with our Staff to review edited case studies (Doppler, 2D and M mode) so as to apply the criteria reviewed in the lecture session (technologists may elect to review additional case studies rather than participate in the “hands on” session if they already have good “hands on” skills).
Dynamics of Blood Flow Session for Standard Cardiac Doppler for Technologists
While conduction and/or interpretation of echocardiograms certainly improves familiarity with how walls and valves of the heart move, it fails to provide adequate background in the conceptualization of how blood actually moves as “seen” by a Doppler machine. This session is designed to familiarize participants with the relationship between pressure and velocity, Doppler turbulence at various points in normal hearts and the characteristics of blood flow (both in terms of speed and turbulence) which can be anticipated in various types of valve disease, shunt flow and prosthetic devices. Detailed reviews of flow timing in multiple pathologies is provided (i.e., timing to differentiate left-to-right shunt flow in an ASD versus venae cava flow or timing the onset of diastolic turbulence in the LVOT to differentiate between AR and opening of the mitral valve, etc.). Emphasis is also placed on those pathologies which result in Doppler flow patterns that could be mistaken for several different disease states at the same time. The program is required for all participants of the Level One Cardiac Ultrasound for Technologists program who complete the Standard Cardiac Doppler program at the same time they complete the Level One program. The program is strongly recommended for anyone who completes the Standard Cardiac Doppler program unless they have current, active cardiac cath lab background.
In terms of daily schedule, the program begins at 10:45 am and ends at approximately 1:00 p.m. The class is conducted in a lecture format.
While some individuals attending the Standard Cardiac Doppler program have substantial background in actually producing cardiac ultrasound studies, others may be relatively new to the ultrasound field. In order to provide an opportunity for more extensive review of probe technique as specifically related to Doppler, an extended Doppler probe session of approximately three hours in duration is available immediately after the regular Standard Cardiac Doppler Course.
CARDIAC DOPPLER UPDATE FOR TECHNOLOGISTS (1 day)
New Course Beginning May 1, 2011
In terms of academic content, the main thrust of the course is to review the most current interpretative and quality control aspects of cardiac Doppler. The program includes a “hands on” session only to emphasize key technical challenges. The Lecture titles currently scheduled during 2013 are:
Quantitation of Mitral Regurgitation — Multiple Criteria Must Agree — No One Criteria is Reliable Enough to Stand Alone. Specific topics covered include physiological effects, vena contracta size, color Doppler “mapping”, PISA, signal intensity and calculation of percentage regurgitant volume. Changes in flow related to cardiac output status, conceptual pitfalls and technical challenges of the various quantitative parameters reviewed are emphasized.
Diastolic Dysfunction of the Left Ventricle — Points of Agreement and Disagreement within the Echocardiography Community. Specific topics covered include LA volume (and other physiological effects), Doppler of mitral inflow, pulmonary vein flow, tissue Doppler (TDI) and IVRT. Changes in flow related to cardiac output status, conceptual pitfalls and specific technical challenges of the various quantitative parameters reviewed are emphasized.
Quantitation of Aortic Stenosis — the Importance of LVOT Size, Cardiac Output Status and Physiological Effects (“it’s not just aortic valve velocity”). Specific topics covered include physiological effects, aortic orifice area, peak gradient, mean gradient and other pathologies associated with significant aortic stenosis. Changes in flow related to cardiac output status, conceptual pitfalls and specific technical challenges of the various quantitative parameters are reviewed. Great emphasis is placed on the multiple views needed to find the highest aortic valve velocity, accurate LVOT VTI, the critical importance of accurate LVOT size and the relationship of small changes in combinations of these measurements in moderate or severe Aortic Stenosis with aortic valve velocities at or below 3.0 meters/second.
Doppler Quantitation of Right Heart Hypertension — the Role of Tricuspid Regurgitation, Pulmonic Regurgitation, Pulmonic Valve Acceleration Time and Criteria for IVC “Sniff”, Right Atrial and Right Ventricular size. Specific topics covered include physiological effects of pulmonary hypertension, estimation of RV systolic pressure utilizing TR velocity, estimate of diastolic pulmonary artery pressure utilizing end diastolic velocity of pulmonic regurgitation and estimation of systolic pulmonary artery pressure utilizing pulmonic valve acceleration time. Changes in flow related to cardiac output status, conceptual pitfalls and specific technical challenges of the various quantitative parameters reviewed are emphasized.
In terms of the daily schedule, approximately six hours of the day are spent in lecture format with the remaining four hours (maximum available) of the day spent reviewing edited case studies with our Staff so as to make practical use of the information covered during lecture. The program includes a “hands on” session only to emphasize key technical challenges. CMEs awarded will be dependent on the Sessions actually attended.
In terms of prerequisites, this program is designed for individuals with good cardiac ultrasound skills. Those who have previously completed our Level One, Level Two and/or Level Three Cardiac Ultrasound Programs will find the Course to be a very useful update which is actually related to their clinical work. The class is also appropriate for Sonographers with at least one year of “full time” employment in cardiac ultrasound. Students in an “approved” Cardiac Ultrasound School can attend with proof of enrollment at the time of registration. Should any questions regarding prerequisites arise, please contact our Office prior to enrollment.
CERTIFICATION REVIEW FOR TECHNOLOGISTS
Technologists preparing to take some form of competency exam in cardiac ultrasound will find either the Level Two Cardiac Ultrasound program (usually taken in conjunction with the Standard Cardiac Doppler or Cardiac Doppler Update) or the Level Three Cardiac Ultrasound program to be very useful.
INTRODUCTION TO CAROTID DUPLEX FOR TECHNOLOGISTS (2.5 days)
This course is designed to serve as an introduction to both the technical and interpretative aspects of carotid duplex. The session reviews the utility of imaging, spectral Doppler and color Doppler to detect and quantitate carotid stenosis and plaque. The program rejects those parameters which have historically resulted in a huge false positive rate and inaccurate estimates of percentage stenosis. The relationship between cardiac status and carotid flow is heavily emphasized (i.e., the effect of AS, AR and high vs. low cardiac output on carotid flow). A review of high velocity Doppler flow principals (in contrast to low velocity flow) and the quality control parameters necessary to insure accurate Doppler estimates of speed and turbulence is provided.
In terms of daily schedule, approximately three hours a day are spent in lecture format reviewing pertinent anatomy, interpretative parameters and their pitfalls, two hours a day are spent reviewing edited case studies with Staff applying the parameters reviewed in Lecture and two hours a day are spent in a “hands on” environment conducting carotid studies on hired subjects.
In terms of prerequisites, those with background in cardiac ultrasound will find the program extremely useful. Those individuals who have been involved with carotid studies previously but have little or no formal training in cardiac ultrasound and/or evaluation of high velocity Doppler flow will also find the program extremely useful. Those individuals with background in general ultrasound imaging other than the heart and/ or carotids usually find the course appropriate; however, they need to pay particularly close attention to the principals of Doppler flow and its quality control which are presented in the first lecture session. The program is generally not recommended for those individuals who have no background in any form of ultrasound imaging. Should any questions arise in this regard, please contact this Office prior to enrollment.
ABDOMINAL AORTA, PERIPHERAL ARTERIES, RENAL ARTERIES + KIDNEYS and UPPER EXTREMITY IMAGING and DOPPLER FOR TECHNOLOGISTS (2days)
This course is designed to serve as an introduction to both the technical and interpretative aspects of vascular ultrasound in the upper extremities other than the Carotids (see above). The session reviews the utility of imaging, spectral Doppler and color Doppler to detect and quantitate vascular disease in the areas noted above. The daily schedule and prerequisites for this portion of our general vascular program are the same as for the carotid program outlined above; however, participants in this portion of the vascular program must have background in performing and/or interpreting Carotid Duplex studies in order to make maximum use of the information covered. In this regard completion of our Carotid Duplex program outlined above is ideal preparation for our general vascular course; however, past experience in carotid studies should be sufficient assuming a good background in Doppler (reviewed in the Carotid course outlined above).
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