Critical Care Echocardiography
It is a myth that transthoracic (TTE) scans are very difficult to perform on ventilated patients. They are more challenging than in the outpatient department as positioning is more difficult and positive pressure ventilation tends to make the lungs get in the way. With modern machines however the images are usually adequate to answer the clinical question and images can be excellent. For this reason I personally believe TTE is more useful to master than TOE for critical care but both have unique advantages.
There are currently 2 levels of echocardiography competence that you can achieve in the UK:
1. Focussed scanning (TTE).
There are 2 courses I would recommend in the UK. For those of you who are, or want to be, Intensivists there is the Intensive Care Society’s focused new echo accreditation module called FICE. The other alternative is FEEL. Both are recognised by the BSE and FEEL also by the Resuscitation Council. Doing the courses and than performing 50 scans under mentorship will get you certified. This is as far as many intensivists will want to take echo. You will be able to diagnose major abnormalities like hypovolaemia, severe left or right ventricular failure, effusions and tamponade and RV pressure or volume overload. You should note that all FEEL courses count towards FICE accreditation (at present). I suggest you look carefully at the course programmes and choose the one with the most hands on training (HOT).
2. BSE accreditation (TTE or TOE).
This is full echocardiography and is the level that echo technicians and cardiologists are encouraged to achieve. Consequently much more demanding than focussed scanning. Requires passing a tricky exam and compiling a logbook of 250 scans (5 of which are video cases). You will need this for your cardiology department to take you seriously. You can accredit in standard TTE, Critical Care TTE or TOE (150 scans needed for TOE logbook). The TTE pages on this site are in enough detail for you to pass the exam either the standard or critical care exam (I know because they are the notes I compiled and learnt to pass it). The additional critical care echo information will make you much more effective at using echo in your intensive care unit.
You may notice that there is a very large gap in-between these 2 levels of competence which is not currently catered for. This is a controversial subject with some arguing that the pitfalls of echo mean you should have to learn it to a very high standard if going beyond focussed studies. The other school of thought (which I agree with) is that the advantages of an intermediate level of echo competence outweigh the potential for errors. Your patients will be better off if you can assess fluid responsiveness more accurately, assess LV filling pressures and pick up significant valvular disease or aortic dissection. As long as people are aware of their own limitations and the limitations of echo and have a help from more expert echocardiographers, the patients will benefit.
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