Emergency ultrasound: A prospective study on sufficient adequate training for military doctors

Diagnostic Accuracy of Bedside Lung Ultrasound in Detecting Traumatic Pneumothorax by Novice Physicians in the Emergency Department of a Tertiary Care Hospital of Nepal

Introduction

Traumatic pneumothorax is a life-threatening condition requiring vigilant clinical assessment and urgent management. Lung ultrasound (LUS) is considered to be a safer, rapid, and accurate modality for the early diagnosis of traumatic pneumothorax. The principle objective of this study was to evaluate the diagnostic accuracy of bedside LUS performed by trained novice physicians in the diagnosis of traumatic pneumothorax as compared to supine chest X-rays (CXRs) and/or computed tomography (CT) scans and/or air leak during needle/tube thoracostomy as composite standard.

Methods

It is a prospective, cross-sectional, single-blinded study using a nonprobability quota sampling technique. A total of 96 patients presenting to the emergency department (ED) with polytrauma and chest injuries within a period of twelve months were included. The diagnostic accuracy of bedside LUS performed by trained novice physicians was calculated in terms of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and compared with the composite standard.

Results

The sensitivity of LUS in diagnosing traumatic pneumothorax as compared to the composite standard was 100% (95% confidence interval (CI): 59.05%-100.00%), whereas its specificity was 97.75% (95% CI: 92.12%-99.73%). Similarly, the PPV and NPV of LUS were 77.7% (95% CI: 39.99%-97.19%) and 100% (95% CI: 95.85%-100.00%), respectively.

Conclusion

The results of the study showed that the application of LUS in detecting traumatic pneumothorax had similar diagnostic accuracy as supine CXR. Bedside LUS is widely available, portable, and inexpensive. It also has the capability of real-time imaging and can be repeated as necessary with less risk of radiation exposure. Therefore, physicians working in tertiary and rural health institutions must be trained adequately in order to uplift the clinical utility of LUS for the timely and cost-effective detection of traumatic pneumothorax.

Point of Care Ultrasounds Obtained by Novice Physician Assistant Residents (POCUS ON PAR)

INTRODUCTION

The integration of Point of Care Ultrasound (POCUS) into the care of trauma patients, specifically the E-FAST, has improved the accuracy of initial diagnoses and improved time to surgical intervention in critically ill patients. Physician assistants (PAs) are critically important members of any military trauma resuscitation team and are often team leaders in a pre-hospital setting. They may receive training in ultrasound but there are little data to support their use or evaluate their effectiveness in using POCUS. We designed a study to evaluate the image quality of an E-FAST Exam performed by Emergency Medicine Physician Assistant (EMPA) Fellows and Emergency Medicine (EM) Interns following identical training. Our hypothesis is that image quality obtained by EMPAs will be non-inferior to those images obtained by EM Interns.

MATERIALS AND METHODS

This is a prospective single-blinded study comparing the image quality of E-FAST exams performed by first year EM interns and first year EMPA fellows. All participants completed standard POCUS training prior to enrollment in the study. A total of 8 EMPAs and 8 EM first year residents completed 10 recorded E-FAST exams to be used as study images. Participants also viewed a 15-question slide show containing images of positive (6) and negative (9) E-FAST exams and recorded their interpretations. Images were reviewed by expert reviewers who were blinded to which images were collected by which group. An image quality score was recorded for each view as well as an overall image quality score. Image quality was rated on a 1 to 5 image quality scale.

RESULTS

For overall image quality, the mean score for EMPAs was 3.6 ± 0.5 and for EM residents was 3.2 ± 0.5 with statistical significance favoring better image quality from the EMPAs. The time to completion for the EFAST exam for EMPAs was 4.8 ± 1.3 minutes and for interns it was 3.4 ± 1.4 minutes (P value = 0.02). There was no difference in image interpretation quiz scores between the groups (mean score 92% among interns and 95% among PAs).

CONCLUSIONS

POCUS is an imaging modality which is very portable and relatively inexpensive which makes it ideal for military medicine. PAs are essential members of military trauma teams, and often run an initial trauma resuscitation. Being able to correctly identify patients who have free fluid early in the course of treatment allows for more correct evacuation criteria to ensure the sickest patients get to care the fastest. Although there are limited data to support POCUS use by non-physicians, our data support a growing body of evidence that it is not the profession or baseline medical education that determines an individual's ability to use and incorporate ultrasound into bedside and clinical practice. Our study shows that with training and experience PAs or other members of the military health care team can use the EFAST to better care for trauma patients.

Point-of-Care Ultrasound Psychomotor Learning Curves: A Systematic Review of the Literature

OBJECTIVES

Use of point-of-care ultrasound (POCUS) in clinical medicine and inclusion in medical training is increasing. Some professional societies recommend that 25-50 POCUS examinations be completed for each application learned; however, the amount of practice required is not well studied. As such, a better understanding of the learning curves of POCUS psychomotor skills is needed. This systematic review characterizes the learning curves for POCUS psychomotor skill acquisition.

METHODS

With the assistance of a research librarian, the available literature through August 28, 2023, was identified. The titles and abstracts, and then the full text were reviewed by two reviewers to screen for inclusion. All studies included after full-text review then underwent data extraction and analysis.

RESULTS

The search identified 893 unique studies. Forty-five studies underwent full-text review, with 17 meeting full inclusion criteria. Substantial heterogeneity was noted in study design, duration of education, number and type of learners, and methods for statistical analysis. Clear and validated definitions for learning endpoints, such as plateau points or competency, are lacking. Learning curves and endpoints differ for different applications of POCUS.

CONCLUSION

The results are overall supportive of the recommendations to complete 25-50 examinations per application of POCUS learned. However, specific applications require more practice than others. Certain applications, such as cardiac and the Focused Assessment with Sonography in Trauma (FAST) exams, are closer to 50; while others, such as soft tissue, airway, and eye require no more than 25.

Point-of-care ultrasound to diagnose acute cholecystitis in the emergency department: A scoping review

Introduction/Purpose

Ultrasound is the first-line imaging modality for suspected acute cholecystitis. This can be radiology-performed ultrasound or point-of-care ultrasound (POCUS). POCUS can potentially streamline patient assessment in the emergency department (ED). The primary objective was to evaluate the literature for the diagnostic accuracy of POCUS performed for acute cholecystitis in the ED. Secondary objectives were to assess the effect of POCUS operator training on diagnostic accuracy for acute cholecystitis, utility of POCUS measurement of the common bile duct and POCUS impact on resource utilisation.

Methods

A systematic scoping review of articles was conducted using Medline, Embase, CENTRAL and CINAHL. Original studies of adults with POCUS performed for the diagnosis of acute cholecystitis in the ED were included. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist (PRISMA-ScR).

Results

A total of 1090 publications were identified. Forty-six met the eligibility criteria. Studies were thematically grouped into categories according to specified objectives. Point-of-care ultrasound was of acceptable but variable accuracy, contributed to by the absence of a consistent reference standard and uniform training requirements. It may positively impact ED resource utilisation through reduced ED length of stay and radiology-performed imaging, whilst improving patient experience.

Conclusion

This review highlights the heterogeneity of existing research, emphasising the need for standardisation of training and reference standards in order to precisely define the utility of POCUS for acute cholecystitis in the ED and its benefits on ED resource utilisation.

Learning curves for point-of-care ultrasound image acquisition for novice learners in a longitudinal curriculum

BACKGROUND

A learning curve is graphical representation of the relationship between effort, such as repetitive practice or time spent, and the resultant learning based on specific outcomes. Group learning curves provide information for designing educational interventions or assessments. Little is known regarding the learning curves for Point-of-Care Ultrasound (POCUS) psychomotor skill acquisition of novice learners. As POCUS inclusion in education increases, a more thorough understanding of this topic is needed to allow educators to make informed decisions regarding curriculum design. The purpose of this research study is to: (A) define the psychomotor skill acquisition learning curves of novice Physician Assistant students, and (B) analyze the learning curves for the individual image quality components of depth, gain and tomographic axis.

RESULTS

A total of 2695 examinations were completed and reviewed. On group-level learning curves, plateau points were noted to be similar for abdominal, lung, and renal systems around 17 examinations. Bladder scores were consistently good across all exam components from the start of the curriculum. For cardiac exams, students improved even after 25 exams. Learning curves for tomographic axis (angle of intersection of the ultrasound with the structure of interest) were longer than those for depth and gain. Learning curves for axis were longer than those for depth and gain.

CONCLUSION

Bladder POCUS skills can be rapidly acquired and have the shortest learning curve. Abdominal aorta, kidney, and lung POCUS have similar learning curves, while cardiac POCUS has the longest learning curve. Analysis of learning curves for depth, axis, and gain demonstrates that axis has the longest learner curve of the three components of image quality. This finding has previously not been reported and provides a more nuanced understanding of psychomotor skill learning for novices. Learners might benefit from educators paying particular attention to optimizing the unique tomographic axis for each organ system.

Objective structured assessment ultrasound skill scale for hyomental distance competence - psychometric study

BACKGROUND

Ultrasound assessment of the airway recently integrates the point-of-care approach to patient evaluation since ultrasound measurements can predict a difficult laryngoscopy and tracheal intubation. Because ultrasonography is performer-dependent, a proper training and assessment tool is needed to increase diagnostic accuracy. An objective, structured assessment ultrasound skill (OSAUS) scale was recently developed to guide training and assess competence. This work aims to study the psychometric properties of OSAUS Scale when used to evaluate competence in ultrasound hyomental distance (HMD) measurement.

METHODS

Prospective and experimental study. Volunteers were recruited and enrolled in groups with different expertise. Each participant performed three ultrasonographic HMD evaluation. The performance was videorecorded and anonymized. Five assessors blindly rated participants' performance using OSAUS scale and a Global Rating Scale (GRS). A psychometric study of OSAUS scale as assessment tool for ultrasound HMD competence was done.

RESULTS

Fifteen voluntaries participated on the study. Psychometric analysis of OSAUS showed strong internal consistency (Cronbach's alpha 0.916) and inter-rater reliability (ICC 0.720; p < 0.001). The novice group scored 15.4±0.18 (mean±SD), the intermediate 14.3±0.75 and expert 13.6±0.1.25, with a significant difference between novice and expert groups (p = 0.036). The time in seconds to complete the task was evaluated: novice (90±34) (mean±SD), intermediate (84±23) and experts (83±15), with no significant differences between groups. A strong correlation was observed between OSAUS and global rating scale (r = 0.970, p < 0.001).

CONCLUSION

The study demonstrated evidence of validity and reliability. Further studies are needed to implement OSAUS scale in the clinical setting for training and assessment of airway ultrasound competence.

Hands-On Time in Simulation-Based Ultrasound Training - A Dose-Related Response Study

Purpose Point of care ultrasound (POCUS) is widely used, but the sensitivity and specificity of the findings are highly user-dependent. There are many different approaches to ultrasound training. The aim of this study was to explore the effects of hands-on practice when learning POCUS. Methods Junior doctors with no or limited ultrasound experience were included in the study and divided into three groups. They all completed a Focused Assessment with Sonography for Trauma (FAST) course with different amounts of hands-on practice: 40 minutes (n=67), 60 minutes (n=12), and 90 minutes of hands-on time (n=27). By the end of the course, they all completed a previously validated test. Results More hands-on time improved the mean test scores and decreased the test time. The scores of the 40-, 60-, and 90-minute groups were 11.6 (SD 2.1), 12.8 (SD 2.5), and 13.7 (SD 2.5), respectively (p<0.001). The 90-minute group completed the test significantly faster than the other two groups (20 versus 26 minutes, p=0.003). A large inter-individual variation was seen. Conclusion The necessary amount of hands-on training is unknown. This study demonstrates that performance increases with prolonged hands-on time but the inter-individual variation among trainees is very large, thereby making it impossible to define the "optimal" time. This supports the use of the concept of mastery learning where each individual trainee can continue training until proficiency is reached.

Point-of-care ultrasound assessment of the abdominal aorta by physician assistant students: a pilot study

OBJECTIVE

Point-of-care ultrasound (POCUS) decreases time to diagnosis and improves mortality of those diagnosed with abdominal aortic aneurysms and dissections. While medical students have demonstrated an ability to obtain adequate POCUS images of the abdominal aorta (AA), physician assistant (PA) student studies are lacking. This pilot study aims to evaluate the ability of PA students to acquire AA POCUS images.

METHODS

PA students, instructors, and models voluntarily participated. Student participants received online material to review several weeks before the study. During the study, students performed 4 precepted practice scans of the AA, and their fifth scan was recorded for review by three ultrasound fellowship trained Emergency Medicine physicians. Images were graded on proper identification and measurement of the AA, as well as interpretability of images.

RESULTS

A total of 20 PA students participated. Ninety-five percent were able to obtain interpretable transverse images of the distal aorta and longitudinal views of the aorta, and 65% were able to obtain interpretable transverse images of the proximal and mid aorta.

CONCLUSIONS

In the most rigorous evaluation of student-obtained AA POCUS images to date, we found that PA students were able to obtain adequate AA images. PA students were able to image the distal and longitudinal aorta in the transverse plane where the majority of AAAs are found to a very high degree. Results demonstrate PA students' ability to learn POCUS and encourage PA education to take steps to incorporate POCUS education and development of competency standards for PA graduates.

Surgeon-performed point-of-care ultrasound for acute cholecystitis: indications and limitations: a European Society for Trauma and Emergency Surgery (ESTES) consensus statement

BACKGROUND

Acute cholecystitis (AC), frequently responsible for presentation to the emergency department, requires expedient diagnosis and definitive treatment by a general surgeon. Ultrasonography, usually performed by radiology technicians and reported by radiologists, is the first-line imaging study for the assessment of AC. Targeted point-of-care ultrasound (POCUS), particularly in the hands of the treating surgeon, may represent an evolution in surgical decision-making and may expedite care, reducing morbidity and cost.

METHODS

This consensus guideline was written under the auspices of the European Society of Trauma and Emergency Surgery (ESTES) by the POCUS working group. A systematic literature search identified relevant papers on the diagnosis and treatment of AC. Literature was critically-appraised according to the GRADE evidence-based guideline development method. Following a consensus conference at the European Congress of Trauma & Emergency Surgery (Valencia, Spain, May 2018), final recommendations were approved by the working group, using a modified e-Delphi process, and taking into account the level of evidence of the conclusion.

RECOMMENDATIONS

We strongly recommend the use of ultrasound as the first-line imaging investigation for the diagnosis of AC; specifically, we recommend that POCUS may be adopted as the primary imaging adjunct to surgeon-performed assessment of the patient with suspected AC. In line with the Tokyo guidelines, we strongly recommend Murphy's sign, in conjunction with the presence of gallstones and/or wall thickening as diagnostic of AC in the correct clinical context. We conditionally recommend US as a preoperative predictor of difficulty of cholecystectomy. There is insufficient evidence to recommend contrast-enhanced ultrasound or Doppler ultrasonography in the diagnosis of AC. We conditionally recommend the use of ultrasound to guide percutaneous cholecystostomy placement by appropriately-trained practitioners.

CONCLUSIONS

Surgeons have recently embraced POCUS to expedite diagnosis of AC and provide rapid decision-making and early treatment, streamlining the patient pathway and thereby reducing costs and morbidity.

Is E-FAST possible and useful on the battlefield? A feasibility study during medical courses in hostile environment (MEDICHOS): preliminary results

Introduction

The extent of the French forces’ territory in the Sahel band generates long medical evacuations. In case of many victims, to respect the golden hour rule, first-line sorting is essential. Through simulation situations, the aim of our study was to assess whether the use of ultrasound was useful to military doctors.

Methods

In combat-like exercise conditions, we provided trainees with a pocket-size ultrasound. Every patient for whom the trainees chose to perform ultrasound in role 1 was included. An extended focused assessment with sonography for trauma (E-FAST) was performed with six basic sonographic views. We evaluated whether these reference views were obtained or not. Once obtained by the trainees, pathological views corresponding to the scenario were shown to assess whether the trainees modified their therapeutic management strategy and their priorities.

Results

168 patients were treated by 15 different trainee doctors. Of these 168 patients, ultrasound (E-FAST or point-of-care ultrasound) was performed on 44 (26%) of them. In 51% (n=20/39) of the situations, the practitioners considered that the realisation of ultrasound had a significant impact in terms of therapeutic and evacuation priorities. More specifically, it changed therapeutic decisions in 67% of time (n=26/39) and evacuation priorities in 72% of time (n=28/39).

Conclusion

This original work showed that ultrasound on the battlefield was possible and useful. To confirm these results, ultrasound needs to be democratised and assessed in a real operational environment.

Usefulness of point-of-care ultrasound in military medical emergencies performed by young military medicine residents

INTRODUCTION

To evaluate the usefulness of point-of-care ultrasound (POCUS) performed by young military medicine residents after short training in the diagnosis of medical emergencies.

METHODS

A prospective study was performed in the emergency department of a French army teaching hospital. Two young military medicine residents received ultrasound training focused on gall bladder, kidneys and lower limb veins. After clinical examination, they assigned a 'clinical diagnostic probability' (CP) on a visual analogue scale from 0 (definitely not diagnosis) to 10 (definitive diagnosis). The same student performed ultrasound examination and assigned an 'ultrasound diagnostic probability' (UP) in the same way. The absolute difference between CP and UP was calculated. This result corresponded to the Ultrasound Diagnostic Index (UDI), which was positive if UP was closer to the final diagnosis than CP (POCUS improved the diagnostic accuracy), and negative conversely (POCUS decreased the diagnostic accuracy).

RESULTS

Forty-eight patients were included and 48 ultrasound examinations were performed. The present pathologies were found in 14 patients (29%). The mean UDI value was +3 (0-5). UDI was positive in 35 exams (73%), zero in 12 exams (25%) and negative in only one exam (2%).

CONCLUSION

POCUS performed after clinical examination increases the diagnostic accuracy of young military medicine residents.

Procedure rates performed by emergency medicine residents: a retrospective review

BACKGROUND

The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency.

METHODS

The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated.

RESULTS

In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing "resuscitations," the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year.

CONCLUSIONS

Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

Credentialing of Hospitalists in Ultrasound-Guided Bedside Procedures: A Position Statement of the Society of Hospital Medicine

Ultrasound guidance is used increasingly to perform the following 6 bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis. Yet most hospitalists have not been certified to perform these procedures, whether using ultrasound guidance or not, by specialty boards or other institutions extramural to their own hospitals. Instead, hospital privileging committees often ask hospitalist group leaders to make ad hoc intramural certification assessments as part of credentialing. Given variation in training and experience, such assessments are not straightforward "sign offs." We thus convened a panel of experts to conduct a systematic review to provide recommendations for credentialing hospitalist physicians in ultrasound guidance of these 6 bedside procedures. Pathways for initial and ongoing credentialing are proposed. A guiding principle of both is that certification assessments for basic competence are best made through direct observation of performance on actual patients.

Diagnostic accuracy of emergency-performed focused assessment with sonography for trauma (FAST) in blunt abdominal trauma

Introduction

Intra-abdominal hemorrhage due to blunt abdominal trauma is a major cause of trauma-related mortality. Therefore, any action taken for facilitating the diagnosis of intra-abdominal hemorrhage could save the lives of patients more effectively. The aim of this study was to determine the accuracy of focused assessment with sonography for trauma (FAST) performed by emergency physicians.

Methods

In this cross-sectional study from February 2011 to January 2012 at 7^th Tir Hospital in Tehran (Iran), 120 patients with abdominal blunt trauma were chosen and evaluated for abdominal fluid. FAST sonography was performed for all the subjects by emergency residents and radiologists while they were blind to the other tests. Abdominal CTs, which is the gold standard, were done for all of the cases. SPSS 20.0 was used to analyze the results.

Results

During the study, 120 patients with abdominal blunt trauma were evaluated; the mean age of the patients was 33.0 ± 16.6 and the gender ratio was 3/1 (M/F). The results of FAST sonography by emergency physicians showed free fluid in the abdomen or pelvic spaces in 33 patients (27.5%), but this was not observed by the results of CT scans of six patients; sensitivity and specificity were 93.1 and 93.4%, respectively. As for tests performed by radiology residents, sensitivity was a bit higher (96.5%) with lower specificity (92.3%).

Conclusion

The results suggested that emergency physicians can use ultrasonography as a safe and reliable method in evaluating blunt abdominal trauma.

Prehospital ultrasound of the abdomen and thorax changes trauma patient management: A systematic review

BACKGROUND

Ultrasound examination of trauma patients is increasingly performed in prehospital services. It is unclear if prehospital sonographic assessments change patient management: providing prehospital diagnosis and treatment, determining choice of destination hospital, or treatment at the receiving hospital.

OBJECTIVE

This review aims to assess and grade the evidence that specifically examines whether prehospital ultrasound (PHUS) of the thorax and/or abdomen changes management of the trauma patient.

METHODS

A systematic review was conducted of trauma patients who had an ultrasound of the thorax or abdomen performed in the prehospital setting. PubMed, MEDLINE, Web of Science (CINAHL, EMBASE, Cochrane Central Register of Controlled Trials) and the reference lists of included studies were searched. Methodological quality was checked and risk of bias analysis performed, a level of evidence grade was assigned, and descriptive data analysis performed.

RESULTS

992 unique citations were identified, which included eight studies that met inclusion criteria with a total of 925 patients. There are no reports of randomised controlled trials. Heterogeneity exists between the included studies which ranged from a case series to retrospective and prospective non-randomised observational studies. Three studies achieved a 2+ Scottish Intercollegiate Guidelines Networks grade for quality of evidence and the remainder demonstrated a high risk of bias. The three best studies each provided examples of prehospital ultrasound positively changing patient management.

CONCLUSION

There is moderate evidence that supports prehospital physician use of ultrasound for trauma patients. For some patients, management was changed based on the results of the PHUS. The benefit of ultrasound use in non-physician services is unclear.

Addressing requests for emergency ultrasonographic examinations when implementing teleradiology services

PURPOSE

To prospectively assess how to address requests for ultrasonographic examinations when setting up an on-call teleradiology service.

MATERIALS AND METHODS

An analytical prospective study was performed from January 2012 to December 2012 inclusively. All requests received for after-hours ultrasonographic examinations during this period were analyzed. Ultrasound requests were classified as being postponable until working hours, replaceable by an alternate cross-sectional imaging modality, or urgent and needing to be performed after hours.

RESULTS

A total of 176 requests for ultrasonographic examinations were analyzed. They predominantly included requests for abdominal and pelvic ultrasonographic examinations (63%). Thirty-nine requests (22.2%) were considered as postponable, 49 (27.8%) as replaceable and 64 (36.4%) as both postponable and replaceable. Twenty-four requests (13.6%) were considered as urgent; they consisted of 10 requests for venous duplex Doppler ultrasonographic examinations of the lower limbs, eight requests for testicular ultrasonographic examinations, five for pelvic ultrasonographic examinations and one for soft-tissue ultrasonographic examination. In these urgent cases, realistic options were either to transfer the patient to another institution or to train emergency department physicians in ultrasonography for local handling.

CONCLUSION

Although the need for addressing requests for ultrasonographic examinations should be taken into account when setting up an on-call teleradiology service, it should not impede such plans.