From the Hofstra North Shore Long Island Jewish School of Medicine.
CORRESPONDENCE TO: Margarita Oks, MD, Department of Medicine, North Shore Long Island Jewish Health System, 300 Community Dr, Manhasset, NY 11030; e-mail:firstname.lastname@example.org
FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
We thank Dr Adrish for his interest in our study.1 He has pointed out that it is important to recognize some challenges of critical care ultrasonography (CCUS), specifically the following.
1. The requirement for adequate training in CCUS: There is no question that competence in CCUS requires training, just as with other ICU procedures such as vascular access, endotracheal intubation, or interpretation of chest radiographs. Fellowship training is the best time to obtain skills in CCUS. For the attending intensivist, training in CCUS may be challenging given numerous constraints. The American College of Chest Physicians (CHEST) and many other organizations offer well-designed national-level courses on CCUS that meet the needs of the intensivist who is postfellowship.
2. The recognition of the limitations of CCUS: We agree that CCUS cannot answer every clinical question, as is the case with traditional radiology imaging. The clinician skilled in CCUS formulates specific questions and then deploys bedside ultrasonography to find an answer. This requires training in the recognition of abnormal imaging and of the limitations of ultrasonography, which are both part of CCUS training.
Dr Adrish mentions two additional limitations of CCUS with which we disagree.
1. Excessive time requirement of CCUS: Volpicelli et al2 reported that full-body ultrasonography requires 4.9 min to complete. In capable hands, CCUS can be performed within a reasonable time frame with results that have major clinical implications. The duration of a full echocardiography study3 that Dr Adrish mentions will necessarily take up a substantial amount of time, but this type of examination is not typical of CCUS.
2. The challenge of documentation and billing: When CCUS is used multiple times a day, as is described in our article, a large number of studies is generated. Ideally, every ultrasound study should be fully documented, but in a busy ICU, this may not be feasible. A rigid policy requiring documentation of every image set blocks full, immediate, and repeated use of this very valuable imaging modality. CCUS is used as an extension of the physical examination, so the argument may be made that rules of documentation should be the same for CCUS and physical examination. Modern wireless archiving systems have greatly improved our ability to document, store, and formally interpret acquired images and are highly recommended. Documentation and billing are closely linked because the latter requires the former. A heavy focus on billing may block the appropriate use of CCUS in an urgent situation. A simple solution to the challenge of billing is to bundle CCUS into the critical care hour code.
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