Can Hand-Carried Ultrasound Devices be

Extended for Use by the Noncardiology

Medical Community?
W. Lane Duvall, M.D., Lori B. Croft, M.D., and Martin E. Goldman, M.D.
The Zena and Michael Weiner Cardiovascular Institute, Mount Sinai Medical Center, New York,
New York
Echocardiography (echo) is a powerful, noninvasive, inexpensive diagnostic imaging technique that
provides important information in a variety of cardiovascular diseases. Echo provides rapid information regarding ventricular and valvular function in the clinical management of patients. Smaller,
relatively inexpensive hand-carried cardiac ultrasound (HCU) devices have become commercially
available, which can be used for diagnostic cardiac imaging. Because of their relative ease of use,
portability, and affordable cost, these new hand-held systems have made point-of-care (bedside)
echocardiography available to all medical personnel. The rate-limiting step to the widespread use
of this technology is the lack of personnel with echo training at the immediate contact point with
patients. Although extensive training and experience are needed to acquire and interpret a complete
echo, training medical personnel to perform and interpret a limited echo (defined as a brief, diagnosis
focused exam) may fully exploit the potential of echo as a point-of-care diagnostic tool and may be
accomplished in a short period of time. Presently there are guidelines for independent competency in
echocardiography and HCU echo established by several professional organizations and as a result
of these rigorous guidelines, other noncardiology medical professionals who could practically derive
the greatest benefit are discouraged and virtually precluded from utilizing echo during the initial
encounter with the patient. However, there is now a growing body of literature in a diverse group
of noncardiology medical personnel that demonstrates that it is possible to quickly and effectively
train them to perform and interpret limited echocardiograms. Medical students, medical residents,
cardiology fellows with limited experience, emergency department physicians, and surgical intensive
care unit staff have all been evaluated after only brief, focused training periods, and investigators
found that HCU echo provided important new information, changed therapeutic management, and
was vastly superior to the physical exam alone with an acceptable overall level of accuracy. The
contribution of echocardiography to the field of cardiovascular disease since its invention has been
significant and the newer compact, portable, ultrasound systems have the potential to revolutionize
the utilization and availability of echocardiography. To maximize integration of echo into medical
practice, physicians and physician extenders could be trained to perform and interpret limited echo
to complement their clinical examination and improve their diagnostic skills. The challenge is to provide practical training programs to assure competency in performing point of care echocardiograms.
(ECHOCARDIOGRAPHY, Volume 20, July 2003)
hand-carried ultrasound, echocardiography, accuracy, training
Echocardiography (echo) is a powerful, noninvasive, inexpensive diagnostic imaging technique that provides important information in
a variety of cardiovascular diseases. Echo pro-

Address for correspondence and reprint requests: Martin

E. Goldman, M.D., The Zena and Michael Weiner Cardiovascular Institute, Box 1030, Mount Sinai Medical Center,
One Gustave L Levy Place, New York, NY 10029; Fax: (212)
426-6376; E-mail: martin.goldman@mssm.edu

Vol. 20, No. 5, 2003

vides rapid information regarding ventricular

and valvular function in the clinical management of patients. Smaller, relatively inexpensive hand-carried cardiac ultrasound (HCU)
devices have become commercially available,
which can be used for diagnostic cardiac
imaging. Because of their relative ease of use,
portability, and affordable cost, these new handheld systems have made point-of-care (bedside) echocardiography available to all medical
personnel.

ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech.

471

DUVALL, ET AL.

Cardiovascular physical examination, along

with the patient interview, are the foundations of the evaluation of a patient with cardiovascular disease. Unfortunately, physical exam
and cardiac auscultatory proficiency skills have
deteriorated as medical technology has advanced.1,2 Often the most important clinical information needed from the history and physical
exam involves the determination of left ventricular (LV) function and the identification of
cardiac murmurs, both of which are easily provided by echocardiography. A recent study reported that in a test of cardiac auscultation of
American, Canadian, and British physiciansin-training, participants were only able to correctly identify the prerecorded cardiac events in
22%, 26%, and 20% of patients, respectively.3 In
another study by Mangione and Nieman,4 453
internal medicine or family practice residents
and 88 advanced medical students listened to
prerecorded cardiac findings and could only correctly identify 20% of auscultutory events with
little improvement with advanced training. In
a review by Etchells et al.,5 cardiologists were
found to be only fair at detecting systolic murmurs, while noncardiolgists were less accurate.
Previous work has indicated that echocardiography is superior and adds to the cardiologists
physical exam in determining whether precordial murmurs are functional or pathologic.6,7
Newer generation HCU systems are compact and portable and may be utilized as an
echo-stethoscope to supplement the history and
physical exam. The HCU could differentiate
functional versus pathologic murmurs at the
time of the physical exam. Integration of echo
into the physical exam may be cost-effective
considering that standard echocardiograms
are frequently ordered to identify murmurs
because physicians can no longer confidently
identify them based on physical exam skills
alone. Perhaps even more important than the
identification of murmurs is the ability of HCU
to quickly and accurately determine LV size
and function, which has important prognostic
information for patients with coronary artery
disease, congestive heart failure, and valvular disease.810 The rate-limiting step to the
widespread use of this technology is the lack
of personnel with echo training at the immediate contact point with patients. Although extensive training and experience are needed to
acquire and interpret a complete echocardiogram, training medical personnel to perform and interpret a limited echocardiogram
(defined as a brief, diagnosis focused exam) may
472

fully exploit the potential of echo as a point-ofcare diagnostic tool. To maximize integration
of echo into medical practice, physicians and
physician extenders could be trained to perform
and interpret limited echo to complement their
clinical examination and improve their diagnostic skills.
The spectrum of HCU units varies from 5-lb
clipboard-sized systems to laptop-configured
systems with costs ranging from $15,000 to
$50,000. Currently there are two main handheld ultrasound imagers commercially available, which are the SonoHeart (Sonosite, Bothell, WA, USA) and OptiGo (Philips Medical
Systems, Andover, MA, USA). The Terason device (Teratech, Burlington, MA, USA) has the
miniaturized ultrasound system incorporated
into the transducer and connects to a notebook
personal computer. The Cypress laptop system
(Siemens, Mountain View, CA, USA) is significantly larger, less portable, and more fully
equipped than the other units and is not categorized as a HCU.
Guidelines and Requirements
Presently there are guidelines for independent competency in echocardiography and
HCU established by several professional organizations including the American Society of
Echocardiography (ASE), the American College
of Cardiology (ACC), the American Heart Association (AHA), and the American College of
Emergency Physicians (ACEP).1113 For specific HCU training the ASE recommends that
persons who use HCU for cardiovascular education or self-instruction have at least Level 1
training (performing 75 examinations and personally interpreting 150 exams).14 However, to
independently perform and interpret a comprehensive clinical echocardiographic examination
such as a clinically applied HCU exam, the ASE
and ACC/AHA strongly recommend Level 2
training (a total of 150 personally performed exams and 300 interpreted studies). These guidelines warn that persons with less than Level 2
training who use HCU must fully acknowledge
the increased potential of inadequate information and misinterpretation.
The ACEP has taken a very pragmatic approach to training for use of the HCU devices.
Emergency room physicians recognize that echo
can provide immediate diagnostic and triage information but that extended training may not
be feasible. Thus they have provided guidelines for emergency room physicians to perform

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HCUD BY NONCARDIOLOGISTS

and interpret basic ultrasound studies in emergency situations.15 Their cardiac defined needs
are specifically for diagnosing cardiac tamponade and ventricular function during CPR. Mateer et al.16 recommended a training period
for emergency physicians for general ultrasound, which included 40 hours of instruction,
and 25 to 50 cardiac ultrasound examinations.
However, there is concern in the cardiology community regarding the level of diagnostic competency achievable with these less stringent recommendations. The ASE and the ACC have
recommended guidelines for echocardiographic
extenders.17 These guidelines recommend a
minimal of 6 months didactic training and
6 months of hand-on experience, for sonographers, and 3 months of didactics and 150
echocardiographic examinations for physicians.
Additionally, the guidelines recommend that
only in situations of dire emergency should
the echocardiographic extender function alone
to provide diagnostic information for clinical
decisions.
As a result of these rigorous guidelines, other
noncardiology medical professionals who could
practically derive the greatest benefit are discouraged and virtually precluded from utilizing echo during the initial encounter with the
patient.
Studies on HCU
Medical Students
The use of HCU by medical students completing abbreviated training programs has been
evaluated in several studies and has been found
to be additive to the history and physical exam.
An initial study of the feasibility of teaching
medical students to use HCU as an extension to
their physical exam involved four first-year students at Mount Sinai School of Medicine trained
to use the SonoHeart (Sonosite) to perform a
limited echocardiogram in the emergency department and the intensive care unit.18 The students training consisted of 30 hours of didactics
and observation of echo exams and performance
of 40 supervised echocardiograms prior to initiation of the study. The limited echocardiogram consisted of five standard views (parasternal long, parasternal short, apical four, apical
two, and subcostal views) to define left and
right ventricular function, valvular abnormalities, and pericardial effusions. No color, pulsed
or continuous-wave Doppler, or M-modes were
used. Each student performed approximately
50 echocardiograms as part of routine clinical
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use on patients that presented to the emergency department with the chief complaint
of chest pain or dyspnea (nonasthmatic), and
patients in the surgical intensive care unit.
The students limited echocardiograms were reviewed by an experienced echocardiologist. The
students echocardiograms were diagnostic in
>90% of the patients and were interpreted correctly in >80% of the patients. This preliminary
study confirmed that it is feasible to train medical students to perform and interpret limited
echocardiograms on a portable echo machine.
Medical Residents
The largest single study of a training program and the resultant accuracy of noncardiologists using HCU comes from the Duke Limited
Echo Assessment Project (LEAP).19,20 Twenty
medical house officers (16 internal medicine
residents and 4 beginning cardiology fellows
without significant prior echocardiography experience) participated in a standardized 3-hour
HCU training program. The program for two to
six students at a time consisted of 30 minutes of
introduction to ultrasound and the HCU device,
75 minutes of case reviews, and 75 minutes of
hands-on practice. A total of 537 patients underwent a HCU echo by the medical house officers
within 24 hours of a standard echocardiogram.
The investigator recorded their assessment of
LV ejection fraction and whether there was significant mitral regurgitation, aortic stenosis, or
pericardial effusion after a brief history and
physical exam, and again after performing a
HCU with the OptiGo (Philips Medical Systems). The average time to complete a HCU
echo was 8.5 minutes and the study demonstrated the HCU substantially improved the assessment of LV function and pericardial effusion over history and physical exam, but was
less effective for mitral regurgitation and aortic
valve disease. This study suggested that despite
having only a 3-hour training period, medical
residents can use HCU echo to substantially
improve their assessment of LV function and
pericardial effusion with an acceptable level of
accuracy compared with standard echo.
A study by Kimura et al21 provides additional insight into the training and use of
HCU with internal medicine residents. Thirteen second- and third-year residents underwent a curriculum consisting of a 1-hour lecture
on cardiac physical exam and a 1-hour session
of echocardiogram instruction, including review
of videotaped examples and performance of five

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DUVALL, ET AL.

practice echocardiograms using the OptiGo

(Philips Medical Systems) HCU. Residents were
then evaluated in their examination of 12 model
patients (5 abnormals and 7 normals) to determine LV function based on physical exam
and a 5-minute HCU echo using the parasternal long-axis view. The study found that 10 residents exhibited a net improvement in their
accuracy, 2 residents demonstrated no net
improvement, and 1 resident revealed a worsening of diagnostic accuracy with the use of
HCU. This study concluded that it was feasible
to quickly train residents to incorporate HCU
into their physical exam, and that HCU improved their ability to accurately determine LV
function.
A Stanford pilot study involved a 10-hour
training curriculum for third-year internal
medicine residents in the echocardiographic
assessment of valvular abnormalities.22 Residents then performed HCU echos lasting less
than 10 minutes on 26 model patients selected
for a wide variety of valvular pathology. Using a
standard echo performed and interpreted by an
experienced cardiologist as the gold standard,
the HCU echo reduced the number of major discrepancies from the physical examination from
44.2% to 27.8%. Despite still having a significant number of disparities after the HCU echo,
HCU plus the physical exam was vastly superior to the physical exam alone.
In another study, Croft et al.23 trained medical residents to perform, interpret, and integrate into their clinical practice a rapid HCU
echo after a short training period. Medical residents (first or second year) underwent a 2.5-day
hands-on tutorial on HCU echo using the
OptiGo system (Phillips Medical Systems). The
HCU echo consisted of four standard views
(parasternal long, parasternal short, apical
four, and apical two chamber) and color Doppler,
but no pulsed or continuous-wave Doppler or
M-mode was used. The residents performed
HCU echos on their own patients in the outpatient medical clinic as an integral component
of their office visit. The echo performed by the
residents were overread and repeated by an experienced echocardiologist who graded the residents technical and interpretive skills. A total of the 73 HCU echos were performed. The
residents HCU echo was technically diagnostic
in >90% and interpreted correctly in >90% of
patients. The HCU echo reinforced or changed
the residents pre-echo diagnosis in >75% of the
cases and induced a change in management in
>30% of the patients.
474

Cardiology Fellows With Limited Experience

A study by Lemola et al.24 utilized cardiology fellows with only 6 weeks of echo training to evaluate the ability of the SonoHeart
(Sonosite) HCU system to accurately determine LV function in cardiology patients. Fortyfive patients underwent both a HCU echo performed by the fellow (average length 6
2 minutes) and a standard echo performed by
a sonographer, and the study found there was
100% agreement with systolic function (39 normal, 5 abnormal). The HCU device did not perform as well with regards to measuring septal thickness or end-diastolic dimensions, but
was felt to be a valuable tool for bedside cardiac
screening.
Emergency Department
Croft et al.25 evaluated the impact of limited
rapid HCU echo on the diagnosis and management of 100 consecutive patients presenting to
the emergency department with chest pain and
or dyspnea (nonasthmatic). The HCU echo was
performed by a medical student and an echocardiologist, and consisted of a 5- to 8-minute
study with five standard views (parasternal
long, parasternal short, apical four, apical two,
and subcostal views) to define left and right ventricular function, valvular abnormalities, and
pericardial effusions. Based on the results of the
HCU, the emergency room physician changed
the diagnosis in >25% of patients and management in >15% of patients. This study suggested that a focused, expedited HCU echo
could impact the management of patients with
possible cardiac diagnosis in the emergency
department.
Surgical Intensive Care Unit
HCU has been evaluated in the intensive care
setting, examining the impact of limited HCU
echo on patient management in 75 patients
admitted to the surgical intensive care unit.18
After clinical assessment, patients underwent
a HCU exam with SonoHeart (Sonosite) consisting of two to four views without Doppler
or M-mode assessment by a medical student
or surgical intensivist. The study found that
a diagnostic echo was possible in >95% of the
patients in the surgical intensive care unit
and, additionally, the HCU echo affected the
cardiac diagnosis in >25% of the cases and
changed management >20% of the time. These
findings suggest that the HCU echo provided

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HCUD BY NONCARDIOLOGISTS

important new information and change therapeutic management in a significant number of

critical ill patients.
Discussion
The contribution of echocardiography to the
diagnosis, management, and understanding of
cardiovascular disease in the 30 years since its
invention has been significant. The technologic
advances in the field have allowed for refinement of imaging and miniaturization of equipment. These compact, portable, and relatively
inexpensive ultrasound systems have the potential to revolutionize the utilization, availability, and reimbursement of echocardiography and forever alter physician practices. The
role of the HCU in noncardiologists hands is not
to replace or detract from a complete echocardiogram performed on a standard high-end
platform, but to elevate and augment the physical exam to standards established during the
golden age of cardiology. The HCU systems do
not need to replicate studies performed by standard machines, but only provide information
not available from the physical exam, notably
LV function, gross valvular pathology, and identification of pericardial effusions. It is generally
assumed that to perform any echo an examiner
must be completely trained and certified, but for
answering basic questions it may not be necessary to go to these extremes. The challenge is
to provide practical training programs to assure competency in performing point of care
echocardiograms.

8.
9.

10.

11.

12.

13.

14.

15.
16.
17.

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