Original Study

Journal of Veterinary Emergency and Critical Care 23(3) 2013, pp 268273

doi: 10.1111/vec.12056

Evaluation of a training course in focused

echocardiography for noncardiology house
officers
Yuki C. Tse, DVM; John E. Rush, MS, DVM, DACVECC, DACVIM; Suzanne M. Cunningham, DVM,
DACVIM; Barret J. Bulmer, MS, DVM, DACVIM; Lisa M. Freeman, PhD, DVM, DACVN and
Elizabeth A. Rozanski, DVM, DACVIM, DACVECC

Abstract

Objective To determine whether a training course in focused echocardiography can improve the proficiency of
noncardiology house officers in accurately interpreting cardiovascular disease and echocardiography findings
in dogs entering the emergency room setting.
Design Prospective, blinded, educational study.
Setting University veterinary teaching hospital.
Study Subjects House officers underwent training in focused echocardiography. Fifteen dogs, including
normal dogs and dogs with stable congenital or acquired cardiac disease, were used as study subjects during
the laboratory session.
Interventions A 6-hour curriculum on focused echocardiography was developed that included didactic
lectures, clinical cases, and hands-on echocardiography.
Measurements and Main Results Pre- and postcourse written examinations were administered to participants.
House officers attended didactic lectures that were subsequently followed by a hands-on laboratory session and
practical examination, which involved performing transthoracic echocardiography on dogs with and without
cardiovascular disease. Twenty-one house officers completed the focused echocardiography training course.
Written examination scores were 57 12% before and 75 10% after training (P < 0.001). Following the course,
97% of participants in the practical examination were able to obtain the correct right parasternal short- or longaxis view. Posttraining, most participants correctly identified pleural effusion (90%) and pericardial effusion
(95%) and discriminated normal atrial size from atrial enlargement (86%). However, successful identification of
a cardiac mass, volume status, and ability to recognize a poor quality study as nondiagnostic remained relatively
low. Most trainees responded that the length of hands-on laboratory training was too abbreviated and that the
course should be > 6 hours.
Conclusion A focused echocardiography training course improved knowledge and yielded acceptable proficiency in some echocardiographic findings commonly identified in the emergency room. This training course
was not able to provide the skills needed for house officers to accurately assess fluid volume status, identify
cardiac masses, ventricular enlargement or hypertrophy, and certain cardiac diseases.
(J Vet Emerg Crit Care 2013; 23(3): 268273) doi: 10.1111/vec.12056
Keywords: cardiac evaluation proficiency, imaging, emergency ultrasonography

Abbreviations

From the Department of Clinical Sciences, Cummings School of Veterinary

Medicine at Tufts University, North Grafton, MA 01536.

ECC
FAST
RPS

emergency and critical care

focused assessment sonographic technique
right parasternal

The authors declare no conflict of interest.

Presented in part at the 18th International Veterinary Emergency and Critical
Care Symposium, San Antonio, TX, September 2012.
Address correspondence and reprint requests to
Dr. John E. Rush, Department of Clinical Sciences, Tufts Cummings School
of Veterinary Medicine, 200 Westboro Rd, North Grafton, MA 01536, USA.
Email: john.rush@tufts.edu
Submitted September 14, 2012; Accepted April 1, 2013.

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Introduction
Focused echocardiography has been performed and interpreted by emergency room veterinarians as a method

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Echocardiography for noncardiology house officers

to establish a preliminary diagnosis and help guide the

initial management of patients who present in acute
circulatory or respiratory failure. In people, echocardiography has been used as a method for rapidly diagnosing cardiac tamponade in hemodynamically unstable patients,1 for identifying hypovolemia,2 and for
determining the likelihood of congestive heart failure.3
Echocardiography in this setting is not a comprehensive
examination, but a qualitative, goal-oriented examination mainly reliant upon 2-dimensional (2D) imaging. Its
purpose is limited to answering straightforward, clinical
questions with the goal of dictating therapy in an accurate and rapid fashion.
The use of focused ultrasonography has emerged as
a diagnostic tool in a variety of clinical situations in
veterinary medicine. Prior studies have evaluated its
reliability in assessing the presence of free fluid in the
abdominal cavity following motor vehicle accidents.4
Following 2 hours of didactic training in basic physics of
ultrasonography and performance of training focused
assessment sonographic technique (FAST) abdominal
exams on 12 healthy dogs, veterinarians with minimal
prior ultrasonographic training could correctly identify
the presence or absence of free abdominal fluid in
dogs in a high percentage of cases.4 Subsequently,
FAST protocols with a focus on thoracic assessment
have been developed to rapidly diagnose pneumothorax, pleural effusion, and other thoracic injury in
dogs.5
In human medicine, guidelines for instruction in
emergency ultrasonography have been published and
endorsed by the American College of Emergency
Physicians6 and the Society for Academic Emergency
Medicine.7 More recently, a consensus statement by the
American Society of Echocardiography and the American College of Emergency Physicians was published
supporting focused cardiac ultrasound as a fundamental tool to expedite diagnostic evaluation of the patient
at the bedside and to initiate emergent treatment and
triage decisions in the emergency room setting.8 It has
been suggested that with limited focused training in
echocardiography, noncardiology residents, and emergency room physicians will have adequate clinical ability to preliminarily assess patients entering the emergency department in cardiac or respiratory failure,911
although the level of training required to define clinical competency was not determined. The purpose of
this study is to determine if a focused echocardiography
training course can improve the proficiency of noncardiology veterinary residents and interns in accurately
interpreting cardiovascular disease and echocardiography findings in patients entering the emergency room
setting.


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Materials and Methods

Study design
A prospective, observational study was performed consisting of development of a model curriculum and implementation of a course in focused echocardiography.
Before beginning the training course, study participants
completed a written examination to assess their baseline knowledge of ultrasound physics and machine use,
echocardiography, and echocardiographic identification
of various diseases and clinical findings. The course consisted of 3 hours of didactic lectures, followed by a 3hour hands-on laboratory session on normal dogs. Participants completed a practical examination immediately
after the laboratory training. The second written examination was completed 518 days after completion of the
echocardiographic training course. The study was reviewed and approved by the Universitys Institutional
Review Board for conduct of human research. The Clinical Studies Review Committee approved use of dogs
employed in the laboratory training, and informed consent was obtained from the dog owners.

Study setting and population

The echocardiography curriculum and training course
was developed and administered by 3 board-certified
veterinary cardiologists. The study was opened to all
house officers (except for those enrolled in the cardiology
training program) at the Universitys teaching hospital
including rotating interns from the small animal hospital, 1st, 2nd, and 3rd year residents in various specialty
training programs. The dogs used for the training and
testing components of this study included a combination of dogs with normal cardiovascular anatomy and
dogs (n = 15) with stable congenital or acquired cardiac
diseases (n = 5). All dogs were positioned in right lateral
recumbency, sternal recumbency, or in a standing position for the echocardiographic examinations. No dog
was used for more than 60 minutes at a time. Sedation
was not administered.

Study protocol
The initial phase of this study involved developing a
curriculum designed to teach focused aspects of echocardiography. The objectives of the goal-directed examination to be taught during the training course included
(1) ultrasound machine use and physics, (2) correct
identification of cardiac anatomy and image orientation,
(3) evaluation of cardiac chamber size and/or hypertrophy, (4) gross estimation of left ventricular function, (5)
identification of pericardial effusion, (6) identification of
pleural effusion, (7) assessment of intravascular volume

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Y. C. Tse et al.

status, (8) identification of cardiac mass or thrombus

(9) cardiac disease identification and, (10) the ability to
identify an echocardiographic study as nondiagnostic so
as to not interpret findings from a nondiagnostic study.
A 6-hour curriculum was developed and designed to
teach these concepts. The curriculum included static
images, echocardiographic loops, and practice cases
relevant to conditions that are commonly encountered
in the emergency room. The goals and curriculum were
modified from previously published guidelines from
human prospective studies in emergency ultrasound.7, 10
The course was administered over 3 weekends, to
accommodate all trainees in the laboratory section of
training, and included 3 hours of lecture and 3 hours of
hands-on echocardiography laboratory training. Three
to 4 house officers rotated per group between 3 different
stations, with each station proctored by a board-certified
veterinary cardiologist. House officers were taught to obtain 2D images of the right parasternal (RPS) short-axis
view of the left ventricle, RPS short-axis view of the aorta
and left atrium, RPS long axis 4-chamber view, and RPS
long axis 5-chamber view of the left ventricular outflow
tract and left atrium in normal dogs using 3 different
echocardiographic machines.a,b,c
All house officers participating in the study were instructed to attend all of the didactic and practical training sessions, and to complete both precourse and postcourse examinations. Before the course, all participants
were randomly assigned a number that was used as the
participants only identification on the examinations so
that the identity of the participant was not available to
the persons grading the written examinations or to faculty evaluating the house officers in their respective residency programs. A 30-question written, multiple-choice
examination was administered before and after training.
The posttraining examination used a similar format and
topics to the pretraining examination, but with some substantial change to each question or to the images for each
question. The examination was devised with the goals
listed above in mind and included both static 2D and
M-mode echocardiographic images and 2D echocardiographic loops (25 questions; the 5 other questions related
to ultrasound physics or other aspects of echocardiography). The echocardiographic images and loops were projected to the entire group for 1 minute each and again at
the end of the examination, for participants who wished
to view them again. Nine additional questions (in addition to the 30 examination questions above) were given
at the end of each exam. For the precourse examination, participants were asked in these 9 questions to rate
their comfort level with various echocardiographic findings on a 4-point scale (none, low, moderate, or high
level of comfort). For the postcourse examination, the 9
additional questions asked each participant about both
270

aspects of their comfort level and specific questions to

evaluate the structure and content of the echocardiography course.
In addition to the pre- and postcourse written examination, the participants completed a postcourse practical echocardiography examination immediately after the
hands-on laboratory session. Dogs with clinically stable
cardiac disease were used for the postcourse practical
examination. Each trainee was examined individually,
at 2 sequential stations, in a closed room with the attending cardiologist and one other person responsible
for dog restraint. The trainee was allowed to select the
appropriate transducer for the dog and adjust the machine setting as was needed to get the requested images.
Each participant had 510 minutes to correctly obtain a
series of predetermined echocardiographic views at each
station (eg, please obtain a right parasternal short-axis
view of the aorta and left atrium). The practical examination tested each individual on their ability to obtain
adequate views with proper probe orientation in the RPS
short- and long-axis views, to obtain an M-mode image
of the LV, and to estimate global left ventricular function. The quality of each view was classified subjectively
by the examiner as a good quality image, a fair quality
image, or no image obtained. This score was obtained
from a predetermined assessment of specific criteria for
each vieweg, on the RPS short-axis view of the left ventricle, the acquired image was assessed for the presence
and symmetry of the papillary muscles, the ability to
see the right ventricle in the image, roundness of the left
ventricle, and correct orientation of the probe. Values of
approximately 35% for fractional shortening (10%) or
values of approximately 60% for ejection fraction (10%)
were considered acceptable estimates. The participants
were not given their scores to the written or practical
examinations before, during or after the course.
Statistical analysis
Data were analyzed using a commercial software
program.d Data were examined graphically for normality. Normally distributed data were analyzed using
paired t-tests (to compare pre- and postcourse written
examinations scores) or independent t-tests (to compare
scores between emergency-critical care [ECC] and nonECC house officers). Differences in scores between 3rd
year residents and all other house officers were evaluated
using single factor ANOVA. Categorical variables were
analyzed using chi-square tests. Statistical significance
was set at P < 0.05.

Results
Twenty-seven house officers took the precourse written
examination; 24 house officers completed the precourse

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Echocardiography for noncardiology house officers

written examination and hands-on echocardiographic

laboratory session and practical examination. All house
officers were not able to complete all phases of the study
due to scheduling issues. Twenty-one house officers
completed all phases of the study (pre- and postcourse
written examination, hands-on echocardiographic laboratory session, and practical examination). The 21 house
officers consisted of interns (n = 3), 1st year residents
(n = 7), 2nd year residents (n = 4), and 3rd year residents
(n = 7). Among these trainees, there were 10 ECC house
officers (9 residents, 1 specialty intern). The remaining 11
house officers were from other specialty services within
the hospital (anesthesia: n = 1; internal medicine: n = 4;
nutrition: n = 1; radiology: n = 3; rotating intern: n = 2).
For the 21 house officers who completed all components of the study, the mean pre- and postcourse written
examination scores were 57 12% and 75 10%, respectively (P < 0.001). Mean scores of the ECC house
officers were not significantly different from house officers of the other subspecialties (P = 0.29 for precourse
written examination and P = 0.97 for postcourse written
examination). Median scores of the 3rd year house officers were not significantly different compared to those
of the other house officers (P = 0.56 for the precourse
written examination and P = 0.99 for postcourse written
examination). Eighteen house officers (86%) improved
their score on the written examination. Two house officers had no change in examination scores, and 1 house
officer had a decrease in the written examination score.
On the written examination, the percentage of items
that participants were able to correctly identify the
presence or absence of pleural effusion, and pericardial effusion increased from 80% precourse to 90%
postcourse, and 64% precourse to 95% postcourse,
respectively (Table 1). The percentage of participants
who were able to discriminate normal left and right
atrial size from atrial enlargement increased from 55
to 86%. However, successful identification of a cardiac
mass, volume status, and ability to recognize a poor
quality study as nondiagnostic remained relatively low.
Twenty-four house officers completed the hands-on
echocardiography laboratory session and practical examination. For the practical examination, when house
officers were asked to obtain specific echocardiographic
views, most of the participants were able to obtain standard RPS short- and long-axis views. When asked to
obtain a 2D RPS short-axis view of the LV, 28% of participants obtained a good quality image, 70% obtained a
fair quality image, and 2% obtained a poor quality image. When asked to obtain a 2D RPS short-axis view of
the aorta and left atrium, 13% of participants obtained
a good quality image and 87% obtained a fair quality
image. For the 2D RPS long axis 4-chamber view, 21%
of participants obtained a good quality image, 75% ob
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Table 1: Results of replies to specific items asked during the

pre- and postcourse written examination from house officers who
participated in a 6-hour focused echocardiography course

Precourse
examination

Postcourse
examination

Number %
Number %
of items Correct of items Correct
Pleural effusion
Pericardial effusion
LAE/RAE
Contractile function
Volume status
Cardiac mass
Machine/physics/normal
Doppler/color flow doppler
Nondiagnostic examination
Disease identification
Ventricular enlargement or
hypertrophy

6
3
5
5
2
2
11
4
1
10
5

80
64
55
53
22
63
52
56
63
51
57

5
2
6
4
2
1
11
6
1
9
5

90
95
86
81
31
14
78
58
62
69
69

Number of items, number of items on the examination in each subject

category; % correct, percentage of items answered correctly; LAE, left
atrial enlargement; RAE, right atrial enlargement.

tained a fair quality image, and 4% obtained a poor quality image. For the 2D RPS 5-chamber long-axis view of
the left ventricular outflow tract and left atrium, 27% obtained a good quality image, 59% obtained a fair quality
image, and 14% obtained a poor quality image. Twentythree percent of participants were able to obtain a good
quality M-mode image of the LV, while 73% obtained a
fair image and 4% obtained a poor quality image. When
asked to calculate or estimate either the fractional shortening or the ejection fraction, 77% of participants gave
an acceptable estimate of LV contractile function.
At the beginning and end of the training course, the
participants were asked to rate their comfort levels regarding certain echocardiographic findings. Before the
course, many participants had low or no comfort in identifying common echocardiographic findings, including
pericardial or pleural effusion, left atrial enlargement,
LV contractile function, right heart enlargement, and hypovolemia (Table 2). After the course, all 21 participants
had moderate to high comfort levels in identifying pericardial and pleural effusion and left atrial enlargement.
Most participants had moderate or high comfort levels in
identification of LV contractile function (14/21) and right
heart enlargement (15/21). However, most participants
had low or no comfort in identification of hypovolemia
even after the course (13/21).
When participants were asked to evaluate the focused
echocardiography curriculum, the majority of participants (14/21) felt that the time devoted to hands-on laboratory training was too short (Table 3). Most participants
(13/21) responded that the number of lecture hours was
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Y. C. Tse et al.

Table 2: Participants self-reported comfort level with interpretation of certain echocardiographic findings before (pre-) and after
(post-) the echocardiographic training course. Number out of 21 total participants. P value is for the comparison of pre- to postcourse
responses

Level of
comfort

No comfort
Low
Moderate
High

Pericardial and
pleural effusion
(P < 0.001)

Left atrial
enlargement
(P = 0.007)

Left ventricular
contractile
function
(P < 0.001)

Right heart
enlargement
(P = 0.001)

Hypovolemia
(P = 0.04)

Pre

Post

Pre

Post

Pre

Post

Pre

Post

Pre

Post

1
7
9
2

0
0
5
16

1
7
9
2

0
0
13
8

5
11
2
1

0
7
14
0

6
11
2
0

0
6
14
1

5
9
4
0

1
12
7
1

2 participants did not provide answers to these questions on the precourse examination.
3 participants did not provide answers to these questions on the precourse examination.

Table 3: Results of the overall course evaluation following completion of the 6-hour focused echocardiography training curriculum

Way too few

Too few
Just right
Too many
Way too many

Number of lecture
hours associated
with the
training course

Number of hands-on
echo lab hours
associated with
the training course

1/21
6/21
13/21
1/21
0/21

4/21
10/21
7/21
0/21
0/21

adequate to achieve the training needed before the laboratory, although 6/21 participants responded that the
number of lecture hours was too few. When participants were asked to design an echocardiography training course for residents, such that they would acquire the
minimum echocardiographic skills necessary for use in
an emergency room setting, 8/21 participants responded
that the course should be approximately 810 hours,
and 4/21 participants each responded that the training
course should be 12 hours or more.

Discussion
Focused ultrasonography has been shown to be a useful diagnostic tool in assessing veterinary patients after
motor vehicle trauma,4, 5 but there has not been any literature documenting the utility of focused echocardiography. Numerous studies in human medicine have shown
the emerging importance of focused echocardiography
as a diagnostic tool for evaluating patients in respiratory
distress.3, 911 These studies used various training strategies to determine an acceptable level of proficiency in
focused echocardiography, yet no standardization has
been achieved. To the authors knowledge, this is the
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first study evaluating the utility of a focused echocardiography training course for noncardiology house officers
in veterinary medicine. It was not designed to take the
place of, or make an attempt to train house officers in
performing a comprehensive echocardiographic examination. The purpose was to determine whether a training
course in focused echocardiography could offer a role in
optimizing patient care by initiating emergent treatment
and triage decisions by the emergency clinician.
The results of this study demonstrate that a 6-hour
training course in focused echocardiography improved
the proficiency in some echocardiographic findings as
determined by a significant improvement in the written examination score. The number of correct responses
to questions pertaining to pericardial and pleural effusion, and atrial size had >85% accuracy rate following
completion of the training course. In addition, during
the practical examination, 97% of the participants were
able to correctly obtain a fair to good right parasternal
2D short- or long-axis view. In a similar study in human medicine, Jones et al10 showed that a 6-hour training course in focused echocardiography significantly improved both written and practical examination scores.
In that particular study, the subjects were all emergency medicine residents with varied levels of noncardiac ultrasound experience. Additionally, Vignon et al11
revealed that a 12-hour training course in focused
echocardiography for noncardiology house officers with
no previous ultrasound experience allowed for adequate
assessment of left ventricular systolic function, ventricular hypertrophy, and pericardial effusion.
This study showed that following a training course
of this duration, the participants ability to correctly answer questions pertaining to volume status, the absence
or presence of a cardiac mass, and the ability to correctly identify a nondiagnostic study as nondiagnostic
remained low. In addition, most of the house officers felt
that more hands-on echocardiography training would

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Echocardiography for noncardiology house officers

be helpful, suggesting that a 6-hour training course is

not sufficient enough to teach these specific pathologic
findings. Further investigation is warranted to determine
the appropriate number of hours needed in order to attain proficiency in identifying these echocardiographic
abnormalities.
There were many limitations to this study. First, only
21 house officers completed all aspects of the training
and examination. Although statistical significance was
seen, as demonstrated by an improvement in the written examination scores, having a larger population of
participants in the training program may have changed
this finding. One possible way to increase the number
of participating veterinarians is to determine whether a
training course could be applied to the general population of emergency room veterinarians in private practice.
Not only could their participation contribute to findings
in a future study similar to ours, but it may also help alter
how patients in respiratory distress are triaged and ultimately treated. Next, the number of questions relating to
each specific subject category was not equal on the precourse or postcourse written examination. Another limitation is that there was no baseline assessment of the participants practical skills in echocardiography so while
there was a significant improvement in knowledge, the
performance on the practical examination may have reflected prior skills in addition to or instead of skills
gained in the training course. Also, while the ability to
recognize cardiac lesions on prerecorded images/loops
(eg, pericardial effusion) was tested in the written examination, this study did not test the ability of candidates
to find specific lesions in dogs during the practical examination. Another limitation is that individual categories
of questions shown in Table 1 (eg, pleural effusion, volume status) could not be compared statistically between
the pre- and posttest due to the design of the study. The
original intent of this section was for descriptive purposes only and, as a result, some categories had only
12 questions or had different numbers of questions on
the pre- and posttest, which precluded statistical comparison. Nonetheless, the numerical increase in some,
but not all categories provides some information on the
changes in performance after a training course in focused
echocardiography. Finally, participants performed their
practical examinations on dogs with stable congenital or


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acquired cardiovascular disease. Many patients entering

the emergency room with hemodynamic instability may
present with concurrent problems making interpretation
of the echocardiography examination more difficult. Further investigation in performing focused echocardiography on this subset of patients and how it reflects patient
management and outcome is needed.

Footnotes
a
b
c
d

GE Vivid 7 echocardiograph, GE-Medical, Milwaukee, WI.

Sonos 4500 system, Hewlett Packard, Wilmington, DE.
HDI 5000 system, Philips, Bothwell, WA.
Systat 12.0, SPSS, Chicago, IL.

References
1. Nagdev A, Stone MB. Point-of-care ultrasound evaluation of pericardial effusions: does this patient have cardiac tamponade? Resuscitation 2011; 82:671673.
2. Ferrada P, Murthi S, Anand RJ, et al. Transthoracic focused rapid
echocardiographic examination: real-time evaluation of fluid status
in critically ill trauma patients. J Trauma 2011; 70:5662; discussion
6254.
3. Unluer EE, Bayata S, Postaci N, et al. Limited bedside echocardiography by emergency physicians for diagnosis of diastolic heart
failure. Emerg Med J 2012; 29:280283.
4. Boysen SR, Rozanski EA, Tidwell AS, et al. Evaluation of a focused
assessment with sonography for trauma protocol to detect free abdominal fluid in dogs involved in motor vehicle accidents. J Am Vet
Med Assoc 2004; 225:11981204.
5. Lisciandro GR, Lagutchik MS, Mann KA, et al. Evaluation of a thoracic focused assessment with sonography for trauma (TFAST) protocol to detect pneumothorax and concurrent thoracic injury in 145
traumatized dogs. J Vet Emerg Crit Care 2008; 18:258269.
6. American College of Emergency Physicians Board of Directors.
Emergency Ultrasound Guidelines. ACEP on the Internet, 2008.
Available at: http://www.acep.org/clinical-practice-management/
emergency-ultrasound-guidelines-2008.
7. Mateer J, Plummer D, Heller M, et al. Model curriculum for physician training in emergency ultrasonography. Ann Emerg Med 1994;
23:95102.
8. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound
in the emergent setting: a consensus statement of the American
Society of Echocardiography and American College of Emergency
Physicians. J Am Soc Echocardiogr 2010; 23:12251230.
9. Moore CL, Rose GA, Tayal VS, et al. Determination of left ventricular
function by emergency physician echocardiography of hypotensive
patients. Acad Emerg Med 2002; 9:186193.
10. Jones AE, Tayal VS, Kline JA. Focused training of emergency
medicine residents in goal-directed echocardiography: a prospective study. Acad Emerg Med 2003; 10:10541058.
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