(1)
Hôpital Ambroise Paré Service de Réanimation Médicale, Boulogne (Paris-West University), France
Adding LUCI in the armamentarium of critical ultrasound should result in a change of priorities, by training the intensivist (emergency physician, anesthesiologist, etc.) to the essential of the BLUE-protocol first. This physician should then be free to take as long time as needed for learning the complex expert echocardiography, during as many years as necessary, but will be ready to face night emergencies, using the best of the BLUE- or FALLS-protocol.
It seems wise to limit this initial training to the most basic alphabet: lung sliding and lung rockets. With just these two “letters,” they will be able to compose countless “words,” but we can limit this to one application: ruling out pneumothorax. The user must know that, each time this question is raised (i.e., several times a day), the simple unit can be used, with an immediate answer each time. Once these two “letters” are mastered, one can add another one (exponentially multiplying the number of possible applications) and so on for an indeterminate period.
Using this way, the intensivists will little by little change their way of working, with always the possibility to go backward in case of difficulty. Sudden changes are never good. Ultrasound mastery has a beginning but no end, and this author learns everyday.
How to train? Let us make a travel to the past. Since 1989, we had to choose between defining critical ultrasound (a full-time work) and training colleagues. We devoted 90 % of our time in defining the field, i.e., submitting manuscripts, hoping that this work would be easy. This was a mistake, but it is true that we found nobody during all our studies and after who told us how long it is, once a discovery made, to make it accepted. A training center was created, in order to modestly widespread our vision of simplicity (10 % of our time). The CEURF (Cercle des Echographistes d’Urgence et de Réanimation Francophones) was born from the absence of adapted structure at these remote periods, in 1989 [1]. Some courageous colleagues in the mid 1990s had to register to traditional diplomas, know about thyroid, obstetrics, liver segmentation, etc., but quite nothing about acutely ill patients and of course not a word on the lung. The CEURF (pronounce surf) describes new rules and does not sound confusing by itself; it was therefore accepted by the SLAM [2].
Making subsequently international courses, CEURF kept its initial label (just, the final F was first for France, then French-speaking countries, and now accounts for Foreign). It is a nonprofit association, which wants to be “99 % scientific and 1 % administrative.”
CEURF is independent from the power of manufacturers or academicians’ goodwill. CEURF focuses on personalized training, a slow but solid way to do. Our experiences have shown promising results. A 30 min session every week during 18 months covering the whole-body control has given an 18.5/20 accuracy [3]. Obviously, obtaining the value of 17.5/20 is shorter. A training for the limited BLUE-protocol, focusing only on an anterior analysis of lung sliding (yes/no) and lung rockets (yes/no), gives, after short sessions making a total of 90 min (90 min), an average accuracy of 19/20 (nineteen on twenty). A training focused on the lung part of the BLUE-protocol has given, after roughly seven sessions of 1 h, the accuracy of 19.5/20 (nineteen point five on twenty).
A Suggestion for the Training
There are now countless training centers, some world known, and we are glad to see this dynamism, so many years after our princeps publication [4]. CEURF remains different through seven peculiarities.
1.
A focused training. Registrants benefit from a training focusing exclusively on points yielding therapeutic management of critical situations (that is, the definition of critical ultrasound). No energy is lost on noncritical points (physics of ultrasound, diaphragmatic visualization, no space for describing a steatosic liver, and many others), and it is carefully explained why. No time is lost for spectacular propaganda: we assume nowadays that physicians know “why” to use ultrasound and just want to know “how” to practice it.
2.
On–site training. A unique access at the bedside of critically ill patients, in the ICU, i.e., not in healthy, vigorous but little informative models (but see below).
3.
Personalized training. This bedside training is limited to two attendees – warranting a personalized training. One interest of the bedside step is to show optimal ways to hold the probe, have the best image, etc.
4.
Adapted training. CEURF does not just copy traditional models of radiologic or cardiologic cultures (gallstones, use of Doppler, multiple probes, etc.). It provides a different approach, using an adapted unit, one universal probe, and adapted fields: the lung is the core of this approach, with respiratory and hemodynamic use. A traditional, expert approach to echocardiography with Doppler is not provided by CEURF. Adding simple emergency cardiac sonography, it shows an alternative approach for answering clinical questions, offering a direct parameter of volemia (FALLS-protocol) and a direct approach to respiratory failure (BLUE-protocol). Also is featuring the lung of the neonate, mesenteric infarction, pneumoperitoneum, optic nerve, the one-probe philosophy, the use of simplicity, mainly.
5.
Simplicity. This is the keyword of CEURF, used at its extreme without compromise to the patient’s safety. The consideration of the lung, with suitable machine and suitable approach, allows to simplify other fields (the heart). FALLS-protocol is a basic example.
6.
Homogeneous training. It is warranted by the didactic potential coming from one lecturer. A one-author presentation is a drawback, since it expresses only one opinion. This drawback is balanced since this opinion (which is the one of simplicity anyway) is the one of a medical intensivist, with 26 years of ultrasound research at the bedside of critically ill patients seen between the ER and the ICU. Visiting professor, author of six textbooks, some dozens of publications, regularly invited in international congresses, he uses his didactic abilities for making critical ultrasound a holistic tool, centered by the lung.
7.
Long-term training. The after-CEURF. Each CEURFer can use the line (infos@ceurf.net) without limitation of time for questions, comments, or advice. A remote didactic refresher day (included in the registration) allowed near CEURFers to see again, after several months of use, the didactic program. The personalized training favors contacts and makes way for future collaborations.
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