Fellowship training in critical care ultrasound

  • Brian BuchananEmail author
  • Hailey Hobbs
  • Robert Arntfield
To the Editor,

Key professional competencies and related training objectives3,5

Key professional competency




6 months

12 months

Technical proficiency

Minimum performance criteria for acquisition and interpretation. All studies overseen by CCUS program director

Optional: Identification of specific examinations that may be challenged (i.e., ARDMS, NBE)

Minimum 250 performed and interpreted/ 6 months

Core CCUS applications including CCE, thoracic, abdominal, vascular, and procedural guidance

Minimum 500 performed and interpreted/ 12 months

Core + additional modalities (i.e., advanced TEE, transcranial Doppler)

Quality assurance

Administrative duties including quality assurance of CCUS resident rotator scans.

Provide real-time assistance to residents learning CCUS

Set minimum QA 250/ 6 months

Weekly QA rounds

Set minimum QA 500/ 6 months

Weekly QA rounds


Participation in postgraduate CCUS education

Additionally, identify optimal educational materials including courses, modules, textbooks

Facilitate or participate in:

 Bedside rounds with students/ residents

 National CCUS training courses

 Resident academic half day

 Ultrasound conferences

 Ultrasound journal club

 Curriculum and resource design and development

 Dedicated self-study


Training on program administration, delivery and development of academic deliverables


 Competency-based assessments of trainee performance.

 Participate in CCUS program design and evaluation activities


Research requirement in the area of CCUS flexible depending on time and long-term goals

Case report publication

Design of an original project or systematic review

ARDMS = American Registry for Diagnostic Medical Sonographers; CCE = critical care echocardiography; CCUS = critical care ultrasound; NBE = National Board of Echocardiography; QA = quality assurance; TEE = transesophageal echocardiography

Critical care ultrasound (CCUS) comprises techniques commonly used by the intensive care physician including critical care echocardiography and general critical care ultrasonography (lungs, abdomen, deep vein thrombosis assessment, and procedural guidance). Mounting evidence validates the ability of CCUS to improve patient-centred outcomes including reductions in procedural complications and mortality.1 Furthermore, CCUS improves diagnostic accuracy and has comparable, if not superior, performance to traditional diagnostic modalities.2 Critical care ultrasound is non-invasive, repeatable, reduces costs, and has strong inter-user reliability. For these reasons, it has been endorsed as a core skill by 12 critical care societies worldwide, including Canada.3

Despite the framework offered by training guidelines from Canada, the United States, and on an international level,3 organized CCUS education in North America is lacking.4 The greatest barrier to training in CCUS today is the scarcity of experienced faculty to take on the non-trivial training and administrative requirements associated with program-level CCUS training.4

A specialty-wide shortage of skilled leaders in ultrasound is not a novel problem. As the earliest adopters of point-of-care ultrasound, emergency medicine (EM) long ago reached the crossroads we in critical care currently face. The EM community embraced post-graduate fellowship training and, since the mid-1990s, EM point-of-care ultrasound fellowships have produced leaders in ultrasound who, in addition to being competent at wielding a transducer, are steeped in the other non-clinical skills needed to implement ultrasound training and curricula. As CCUS is now firmly established within the milieu of critical care medicine, we submit that CCUS fellowship programs will be required to meet the demand for training from fellows in critical care medicine (CCM) and to satisfy society-level encouragement of its uptake. A CCUS fellowship also offers a sound platform for advancement of research into CCUS.

On this basis, Western University has developed the first CCUS fellowship. The impetus of our fellowship program arose organically from the recognized need to groom future faculty and national leadership in the expanding sub-specialty of CCUS. We designed broad professional competencies by amalgamating the suggestions from EM literature and CCUS consensus recommendations, shown in the Table. Technical proficiency, educational leadership, quality assurance, administration, and research form the cornerstones of the program.

Educational, academic, and administrative leadership is vital to the instantiation of a CCUS program. Indeed, a single expertly trained individual carried the Western University program from conception through to curriculum design, resource development, workshop implementation, integration of quality assurance, and initiation of a formal CCUS rotation. With 40 senior residents per year completing dedicated rotations in CCUS, and nearly 4000 CCUS studies archived and over-read each year, Western University’s intensive care unit offers a unique environment in North America for CCUS training and dissemination.5

Our proposed fellowship model could accommodate either six or 12 months’ duration of training, with 12 months permitting a larger variety and volume of ultrasound studies. Our CCUS fellowship will equip its graduates to perform CCUS expertly themselves, lead scholarly work, and, eventually, complete the pedagogical lifecycle and establish CCUS training and fellowship programs at other sites. Although CCM is most prepared to take advantage of this fellowship and was the original intent, consideration is made for other specialties, where interest and need for ultrasound champions are greatest, including internal medicine and anesthesia.

As other specialties such as internal medicine, anesthesiology, general surgery, and hospital medicine begin seeking similar ultrasound training, how we in critical care address our training needs will be followed closely. A dialogue between CCUS experts and educational stakeholders may promote consensus and the subsequent formation of CCUS fellowship standards. Through such fellowships, we may finally meet the standard of CCUS training that worldwide critical care societies established nearly ten years ago.


Conflicts of interest

None declared.


Dr. Arntfield is an educational consultant for Fujifilm Sonosite, Inc.

Editorial responsibility

This submission was handled by Dr. Gregory L. Bryson, Deputy Editor-in-Chief, Canadian Journal of Anesthesia.


  1. 1.
    Kanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH. Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. J Crit Care 2014; 29: 700-5.CrossRefPubMedGoogle Scholar
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    Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ. Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome. Anesthesiology 2004; 100: 9-15.CrossRefPubMedGoogle Scholar
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    Arntfield R, Millington S, Ainsworth C, et al. Canadian recommendations for critical care ultrasound training and competency. Can Respir J 2014; 21: 341-5.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Mosier JM, Malo J, Stolz LA, et al. Critical care ultrasound training: a survey of US fellowship directors. J Crit Care 2014; 29: 645-9.CrossRefPubMedGoogle Scholar
  5. 5.
    Arntfield RT. The Utility of remote supervision with feedback as a method to deliver high-volume critical care ultrasound training. J Crit Care 2015; 30: 441.e1-6.Google Scholar

Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  • Brian Buchanan
    • 1
    Email author
  • Hailey Hobbs
    • 2
  • Robert Arntfield
    • 2
  1. 1.Department of Critical Care MedicineUniversity of AlbertaEdmontonCanada
  2. 2.Department of Adult Critical Care Medicine, London Health Sciences Centre – Victoria HospitalWestern UniversityLondonCanada

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