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Objectives: Gallstone disease is a common reason for emergency department (ED) presentation. Surgeons often prefer radiology department ultrasound (RUS) over point of care ultrasound (POCUS) because of perceived of unreliability. Our study was designed to test the hypothesis that POCUS is sufficient to guide the management of surgeons treating select cases of biliary disease as compared to RUS. Methods: This was a prospective cohort study. Patients who presented to the ED with abdominal pain and findings of biliary disease on POCUS were included. The surgeon was then presented the case with POCUS only and recorded their management decision. Patients then proceeded to RUS, were followed through their stay, and analysis was performed to analyze the proportion of patients where the introduction of the RUS changed the management plan. Results: 100 patients were included in this study, and all received both POCUS and RUS. Depending on the surgeons' POCUS based management decisions, the patients were divided into three groups: (1) surgery, (2) duct clearance, (3) no surgery. Total bilirubin was 34±22 mmol/L in the duct clearance group vs 8.4±6.5 mmol/L and 16±12 mmol/L in the surgery and no surgery groups, respectively (p<0.05). POCUS results showed 68 patients would have been offered surgery, 21 offered duct clearance, and 11 no surgery. In 90% of cases, the introduction of RUS did not change management. The acute care surgeons elected to operate on patients more frequently than other surgical subspecialties (p<0.05). Conclusions: This study showed that fewer than 10% of patients with biliary disease seen on POCUS had a change in surgical decision-making based on the addition of RUS imaging. In uncomplicated cases of biliary disease, relying on POCUS imaging for surgical decision-making has the potential to improve patient flow. Level of evidence: II Prospective Cohort Study.

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Summary: Multiple studies confirm that point of care ultrasound (PoCUS) has a high sensitivity and specificity for cholelithiasis and cholecystitis. However, there is poor perceived reliability of biliary PoCUS by surgeons. This survey was performed to assess surgeons' opinions on using PoCUS in gallstone disease and barriers that exist for its institution. The majority (60.3%) of respondents reported a total lack of confidence in PoCUS for the diagnosis of biliary disease. Most felt the sensitivity of PoCUS was poor and had concerns about the user-dependent nature of the test and the lack of imaging details provided. If offered ideal clinical/laboratory findings with PoCUS results, only 4.7% of surgeons would definitely operate for unremitting biliary colic and 5.4% for cholecystitis. The ability to replicate findings independently increased confidence in clinical decision-making. Our findings suggest there is substantial distrust in biliary PoCUS but that specific ultrasound training for the surgical workforce may prove tremendously beneficial for its utilization.

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BACKGROUND: Competency-based medical education has renewed focus on the attainment and evaluation of resident skill. Proper evaluation is crucial to inform educational interventions and identify residents in need of increased training and supervision. Currently, there is a paucity of studies rigorously evaluating resident chest tube insertion skill. MATERIALS AND METHODS: Residents of all training levels before their intensive care unit rotation or currently rotating through the intensive care unit were invited to participate. Trainees inserted a thoracostomy tube on a high-fidelity simulator. Their performances were recorded and scored by blinded raters using the validated TUBE-iCOMPT rubric. Surgical and nonsurgical residents were compared. RESULTS: Forty-nine residents participated; 30 from nonsurgical and 19 from surgical training programs. Overall, trainees were most deficient in the "preprocedural checks" and "patient positioning and local anesthetic" domains. Surgical trainees demonstrated higher chest tube insertion skill than their nonsurgical peers (median total score 88 [interquartile range, 74-90] versus 75 [interquartile range, 66-85], respectively, P = 0.01), particularly in the "patient positioning" and "blunt dissection" domains (P = 0.01 and P = 0.03, respectively). These differences were no longer significant when controlled for experience and Advanced Trauma Life Support certification. CONCLUSIONS: Overall, surgical residents were more skilled than nonsurgical residents in tube thoracostomy placement. Relative skill deficits within the domains of chest tube insertion have also been identified among residents of different specialties. These areas can be targeted with educational interventions to improve resident performance, and ultimately, patient safety.

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BACKGROUND: Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as a diagnostic tool. The purpose of this study is to analyze the usefulness of POCUS in predicting the need for surgical intervention in biliary disease. METHODS: A retrospective study of patients visiting the emergency department who received a biliary POCUS from December 1, 2016 to July 15, 2017 was performed. The physician interpretations of the biliary POCUS scans were collected, as well as data from the electronic health records including lab values, the subsequent use of diagnostic imaging, surgical consultation or intervention, and 28 days follow-up for representation or complication. RESULTS: Two hundred and eighty-three patients were identified as having received biliary POCUS. Of the patients referred to general surgery who received biliary POCUS 43% received a cholecystectomy. For the outcome of cholecystectomy, the finding of gallstones on POCUS was 55% sensitive (95% CI 40% to 70%) and 92% specific (95% CI 87% to 95%). A sonographic Murphy's sign was 16% sensitive (95% CI 7% to 30%) but 95% specific (95% CI 92% to 97%) and, gallbladder wall thickness was 18% sensitive (95% CI 9% to 33%) and 98% specific (95% CI 95% to 99%). Patients who received POCUS but did not proceed to confirmatory radiology department imaging had a shorter length of stay (433 min ± 50 min vs. 309 min ± 30 min, P<0.001). DISCUSSION: Point-of-care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gallstones and increased gallbladder wall thickness are highly predictive of the need for surgical intervention, and use of POCUS is associated with shorter ER visits. LEVEL OF EVIDENCE: Retrospective cohort study, level III.