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Dieiev V, Dubrov S, Díaz-Gómez JL, Stevens RA, Salinas P, Gudzenko V, Matolinets N, Kravets O, Krishtafor D, Pavlysh O, Cherniaiev S, Pustavoitau A. Point-of-care ultrasonography in Ukraine: a survey of anesthesiologists-intensivists participating in ultrasonography courses. Can J Anaesth 2024:10.1007/s12630-024-02789-z. [PMID: 38918272 DOI: 10.1007/s12630-024-02789-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 06/27/2024] Open
Abstract
PURPOSE Despite the potential value of point-of-care ultrasonography (POCUS) in resource-limited environments, it is not widely used in low- and middle-income countries compared with high-income countries. We sought to evaluate the current POCUS practice of Ukrainian anesthesiologists who attended POCUS courses to guide future POCUS training in Ukraine. METHODS We conducted a 25-question web-based survey. It was distributed to 255 participants of POCUS courses held in Ukraine in 2023. The survey sections described current POCUS practice, perception of POCUS value, POCUS skills self-assessment, and perceived barriers to implementing POCUS in clinical practice. RESULTS Two hundred and forty-four out of 255 course participants completed the survey, representing 214 unique respondents. Those who self-rated their skills identified themselves as either novices or beginners in areas of POCUS knowledge (118/157, 75%), image acquisition (110/158, 70%), image interpretation (117/158, 74%), and integration into clinical decision-making (105/155, 68%). Among all survey responders, 55% (118/214) reported using POCUS for vascular access procedures, 45% (97/214) for trauma assessment, and 44% (93/214) for regional anesthesia. Reported barriers to POCUS implementation included lack of ultrasound devices (101/214, 47%) and lack of trained faculty (112/214, 52%). CONCLUSION Among anesthesiologists who participated in POCUS courses in Ukraine, the majority were in early stages of ultrasound practice. Respondents identified POCUS applications not currently practiced and evaluated barriers to POCUS use. Based upon these survey findings, we propose the following measures in Ukraine: 1) developing a standardized national POCUS curriculum; 2) increasing the number of experienced instructors of POCUS; and 3) acquiring ultrasound devices to support clinical applications of POCUS, especially in the Central, Southern, and Eastern regions.
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Affiliation(s)
- Vladyslav Dieiev
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.
- Aurora St. Luke's Medical Center, Suite 315, 2901 W. Kinnikinick River Parkway, Milwaukee, WI, 53215, USA.
| | - Sergii Dubrov
- Bogomolets National Medical University, Kiev, Ukraine
| | | | - Rom A Stevens
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Pedro Salinas
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Vadim Gudzenko
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Olga Kravets
- Dnipro State Medical University, Dnipro, Ukraine
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Mulye A, Bhasin A, Borger B, Fant C. Virtual immediate feedback with POCUS in Belize. Front Digit Health 2023; 5:1268905. [PMID: 38026838 PMCID: PMC10649964 DOI: 10.3389/fdgth.2023.1268905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Point of care ultrasound (POCUS) is a portable and accessible tool that has immense potential in low- and middle-income countries (LMIC) for diagnostic accuracy and medical education. We implemented a hybrid in-person and virtual training curriculum to teach providers in Belize the basic techniques of lung ultrasound in the diagnosis of pneumonia. Between August 2021 and June 2022, a total of eleven lung scans were performed at Hillside Clinic for patients presenting with respiratory complaints. Deidentified images were shared via the ButterflyIQ web platform to POCUS experts in the United States. We found that training was solidified through virtual, immediate feedback using the common interfaces Butterfly iQ + and WhatsApp to share images and guide diagnostic reasoning. The aim of this review study is to share our experience and challenges in the implementation of a POCUS training curriculum in an LMIC, provide an example of training methodology that can be effective, and discuss how this can be implemented and modified for clinicians in similar settings.
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Affiliation(s)
- Anita Mulye
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Bonita Borger
- Department of Family Medicine, Hillside Healthcare International Clinic, Punta Gorda, Belize
| | - Colleen Fant
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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Moher JM, Morales-Pérez L, Chiume M, Crouse HL, Mgusha Y, Betchani F, D'Amico BM. Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi. Trop Med Int Health 2023; 28:17-24. [PMID: 36416491 DOI: 10.1111/tmi.13832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings. METHODS Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded. RESULTS In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%). CONCLUSIONS POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.
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Affiliation(s)
- Justin M Moher
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Heather L Crouse
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Yamikani Mgusha
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Fanuel Betchani
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Beth M D'Amico
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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4
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Lobo MJCD, Tavares SCCNM, Pereira de Almeida RP. Point of care prehospital ultrasound in Basic Emergency Services in Portugal. Health Sci Rep 2022; 5:e847. [PMID: 36189415 PMCID: PMC9489087 DOI: 10.1002/hsr2.847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aims The Point of Care Ultrasound and Point-of-Care Ultrasound in Resource-Limited Settings are differentiated diagnostic methods using ultrasound, essential in urgent patients screening, allowing better guidance in the diagnostic process and therapeutic approach. This study intends to observe the impact of these techniques in two Basic Emergency Services (SUB) in Portugal. Methods A longitudinal study was carried out in two remote locations in Portugal (SUB N and SUB S). Data were collected by trained radiographers in each location, and a total of 972 exams were considered. Imaging findings were documented by exam type, the exam normality and the resolution after exam. χ 2 and Cramer's V tests were performed to check significant correlations between the variables. Results Regarding the type of echographic findings, 289 (29.7%) were considered normal, 628 (64.6%) were classified as abnormal and 55 (5.7%) were considered inconclusive. As for the type of resolution, 58% had local resolution, 24% were referred to a hospital emergency service and 18% referred to ambulatory care. Regarding the Location versus Resolution after exam versus Findings variables, it was verified a stronger statistically significant association for the exams considered "Abnormal" (Cramer's V = 0.414; p < 0.001). In the variables Location versus Findings versus Resolution after exam, it was verified a stronger statistical significance for "Referral to Ambulatory" (Cramer V = 0.443; p < 0.001) although Referral for Hospital (Cramer V = 0.252; p = 0.003) or Local Resolution (Cramer V = 0.252; p < 0.001) also had a moderate association strength. Conclusion Ultrasonography is a useful diagnostic tool for patients screening, having an influence on patient management in remote settings. Given the limited literature in Portugal about this matter, further research and literature will be needed to support and complement the results of this study.
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Affiliation(s)
- Manuel José Cruz Duarte Lobo
- Local Health Unit of the Northeast (ULSNE), International Society of Clinical Ultrasound (SIEC), Medical Imaging and Radiotherapy Portuguese Association (APIMR), International Society of Radiographers and Radiological Technologists (ISRRT)BragançaPortugal
| | | | - Rui Pedro Pereira de Almeida
- Medical Imaging and Radiotherapy Department, Center for Studies and Development in Health (CES)University of Algarve, Portugal, CHCR ‐ Compreensive Health Research Center, Évora ‐ Portugal. APIMR (Medical Imaging and Radiotherapy Portuguese Assciation)FaroPortugal
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Young K, Moon N, Wilkinson T. Building point-of-care ultrasound capacity in rural emergency departments: An educational innovation. CANADIAN JOURNAL OF RURAL MEDICINE 2021; 26:169-175. [PMID: 34643556 DOI: 10.4103/cjrm.cjrm_65_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Point-of-care ultrasound (POCUS) use is the standard of care in emergency medicine (EM), but rural physicians face barriers to obtaining and retaining this skill and cite low confidence in their use of POCUS. Without access to high-quality educational opportunities, this important clinical tool may not be used to its full potential in rural hospitals. The Hands-On Ultrasound Education (HOUSE) programme, launched in 2015 by the University of British Columbia's (BC) Division of Rural Continuing Professional Development, is a rurally focused POCUS training and education programme that travels to rural and remote communities and aims to build a rural POCUS community of practice within BC. In this study, we present and evaluate the HOUSE programme. Methods The HOUSE programme is described. A comprehensive qualitative evaluation of semi-structured interviews pertaining to HOUSE was conducted in the 4th year of the programme to assess participant experience and programme outcomes. Results Results from 52 semi-structured interviews indicate that there is a significant increase in self-reported confidence on specific POCUS applications and increased POCUS use after completion of the course, and we report positive experiences with the HOUSE programme. Conclusion By providing a customizable, accessible, hands-on training opportunity, the HOUSE programme removes barriers to POCUS training and education for physicians in rural and remote BC. The rurally focused elements have contributed to education for rural participants that demonstrates increased confidence and the use of POCUS as a clinical tool.
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Affiliation(s)
- Kathryn Young
- Division of Continuing Professional Development, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Nicole Moon
- Division of Continuing Professional Development, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Tandi Wilkinson
- Division of Continuing Professional Development, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Peterson WJ, Munzer BW, Tucker RV, Losman ED, Harvey C, Hatton C, Sefa N, Bassin BS, Hsu CH. Rapid Dissemination of a COVID-19 Airway Management Simulation Using a Train-the-Trainers Curriculum. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1414-1418. [PMID: 33856362 PMCID: PMC8475643 DOI: 10.1097/acm.0000000000004120] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PROBLEM The most effective way to train clinicians to safely don and doff personal protective equipment (PPE) and perform aerosol-generating procedures (AGPs), such as intubations, is unknown when clinician educators are unavailable, as they have been during the COVID-19 pandemic. Proper PPE and airway management techniques are critical to prevent the transmission of respiratory illnesses such as COVID-19. APPROACH In March 2020, the authors implemented a structured train-the-trainers curriculum to teach PPE techniques and a modified airway management algorithm for suspected COVID-19 patients. A single emergency medicine physician trainer taught 17 subsequent emergency medicine and critical care physician trainers the proper PPE and airway management techniques. The initial trainer and 7 of the subsequent trainers then instructed 99 other emergency medicine resident and attending physicians using in situ simulation. Trainers and learners completed retrospective pre-post surveys to assess their comfort teaching the material and performing the techniques, respectively. OUTCOMES The surveys demonstrated a significant increase in the trainers' comfort in teaching simulation-based education, from 4.00 to 4.53 on a 5-point Likert scale (P < .005), and in teaching the airway management techniques through simulation, from 2.47 to 4.47 (P < .001). There was no difference in the change in comfort level between those learners who were taught by the initial trainer and those who were taught by the subsequent trainers. These results suggest that the subsequent trainers were as effective in teaching the simulation material as the initial trainer. NEXT STEPS Work is ongoing to investigate clinician- and patient-specific outcomes, including PPE adherence, appropriate AGP performance, complication rate, and learners' skill retention. Future work will focus on implementing similar train-the-trainers strategies for other health professions, specialties, and high-risk or rare procedures.
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Affiliation(s)
- William J. Peterson
- W.J. Peterson is assistant professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0003-3950-3054
| | - Brendan W. Munzer
- B.W. Munzer is assistant professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ryan V. Tucker
- R.V. Tucker is clinical lecturer, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Eve D. Losman
- E.D. Losman is assistant professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Carrie Harvey
- C. Harvey is assistant professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Colman Hatton
- C. Hatton is a resident, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nana Sefa
- N. Sefa is assistant professor, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0001-8693-8080
| | - Ben S. Bassin
- B.S. Bassin is assistant professor, Department of Emergency Medicine and Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, Michigan
| | - Cindy H. Hsu
- C.H. Hsu is assistant professor, Departments of Emergency Medicine and Surgery and Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-8192-6969
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8
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Gunther KH, Smith J, Boura J, Sherman A, Siegel D. The Use of Bedside Ultrasound for Gallstone Disease Care within a Community-based Emergency Department: A Confirmation Bias. Spartan Med Res J 2021; 6:18182. [PMID: 33869999 PMCID: PMC8043902 DOI: 10.51894/001c.18182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Traditional evaluation for suspicion of gallstone or gallbladder-related disease includes evaluation with a formal technician-performed ultrasound. However, the use of point-of-care bedside ultrasounds (Bedside US) has been shown to be a viable alternative for the diagnosis of gallstones and gallbladder-related diseases. Purpose Statement: The purpose of this study was to evaluate the impact of Bedside US use in gallbladder evaluation on key patient care outcomes within our community-based emergency department setting. METHODS This retrospective study compared the use of no ultrasound (No US), a formal technician performed ultrasound (Tech US) and Bedside US for gallstone and gallbladder related diseases within a community hospital emergency department between January 1, 2015 and January 1, 2018. Initial vitals, lab work, patient socio-demographics, medical history, emergency department length of stay in hours and disposition were reviewed. RESULTS Of a total N = 449 patients included, patients who received a Bedside US had the fewest computerized tomography scans (No US 62% vs. Tech US 29% vs. Bedside US 16%; p < 0.0001), the shortest median emergency department length of stay (No US 4.5 days vs. Tech US 5.0 days vs. Bedside US 3.0 days; p < 0.0001), and were more likely to be discharged home (No US 41% vs. Tech US 55% vs. Bedside US 81%; p = 0.0006) compared to those that received no ultrasound or a formal ultrasound. Patients who received a Bedside US also had the statistically significant highest incidence of prior cholelithiasis (No US 29.4% vs Tech US 14.3% vs. Bedside US 31.3%; p = 0.001) and lowest total median bilirubin levels (No US 0.5 vs. Tech US 0.5 vs. Bedside US 0.3; p = 0.016) when compared to the other two groups. CONCLUSIONS Although there was a confirmation bias, these study results indicate that point-of-care bedside ultrasound could be a viable alternative for gallstones and gallbladder-related diseases with benefits of use in a community hospital setting.
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Hall EA, Matilsky D, Zang R, Hase N, Habibu Ali A, Henwood PC, Dean AJ. Analysis of an obstetrics point-of-care ultrasound training program for healthcare practitioners in Zanzibar, Tanzania. Ultrasound J 2021; 13:18. [PMID: 33829362 PMCID: PMC8026796 DOI: 10.1186/s13089-021-00220-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background A point-of-care ultrasound education program in obstetrics was developed to train antenatal healthcare practitioners in rural Zanzibar. The study group consisted of 13 practitioners with different training backgrounds: physicians, clinical officers, and nurse/midwives. Trainees received an intensive 2-week antenatal ultrasound course consisting of lectures and hands-on practice followed by 6 months of direct supervision of hands-on scanning and bedside education in their clinical practice environments. Trainees were given a pre-course written exam, a final exam at course completion, and practical exams at 19 and 27 weeks. Trainees were expected to complete written documentation and record ultrasound images of at least 75 proctored ultrasounds. The objective of this study was prospectively to analyze the success of a longitudinal point-of-care ultrasound training program for antepartum obstetrical care providers in Zanzibar. Results During the 6-month course, trainees completed 1338 ultrasound exams (average 99 exams per trainee with a range of 42–128 and median of 109). Written exam scores improved from a mean of 33.7% (95% CI 28.6–38.8%) at pre-course assessment to 77.5% (95% CI 71–84%) at course completion (P < 0.0001). Practical exam mean scores improved from 71.2% at course midpoint (95% CI 62.3–80.1%) to 84.7% at course completion (95% Cl 78.5–90.8%) (P < 0.0005). Eight of the 13 trainees completed all training requirements including 75 proctored ultrasound exams. Conclusion Trainees improved significantly on all measures after the training program. 62% of the participants completed all requirements. This relatively low completion rate reflects the challenges of establishing ultrasound capacity in this type of setting. Further study is needed to determine trainees’ long-term retention of ultrasound skills and the impact of the program on clinical practice and health outcomes.
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Affiliation(s)
- Elizabeth A Hall
- Department of Emergency Medicine, Providence St. John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA. .,Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.
| | - Danielle Matilsky
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Department of Emergency Medicine, Howard County General Hospital, John Hopkins University, Baltimore, MD, USA
| | - Rachel Zang
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Naomasa Hase
- Obstetrics & Gynecology, Wayne State University, Detroit, MI, USA
| | | | - Patricia C Henwood
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Anthony J Dean
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Emergency Medicine and Emergency Medicine in Radiology, University of Pennsylvania, Philadelphia, PA, USA.,World Interactive Network for Focused Ultrasound (WINFOCUS), Philadelphia, PA, USA
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10
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Eke OF, Henwood PC, Wanjiku GW, Fasina A, Kharasch SJ, Shokoohi H. Global point-of-care ultrasound education and training in the age of COVID-19. Int J Emerg Med 2021; 14:12. [PMID: 33602112 PMCID: PMC7890382 DOI: 10.1186/s12245-021-00338-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/02/2021] [Indexed: 11/25/2022] Open
Abstract
The COVID-19 pandemic has disrupted traditional global point-of-care ultrasound (POCUS) education and training, as a result of travel restrictions. It has also provided an opportunity for innovation using a virtual platform. Tele-ultrasound and video-conferencing are alternative and supportive tools to augment global POCUS education and training. There is a need to support learners and experts to ensure that maximum benefit is gained from the use of these innovative modalities.
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Affiliation(s)
- Onyinyechi F Eke
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Patricia C Henwood
- Department of Emergency Medicine, Sidney Kimmel Medical College - Thomas Jefferson University, Philadelphia, PA, USA
| | - Grace W Wanjiku
- Department of Emergency Medicine, Brown University, Providence, RI, USA
| | | | - Sigmund J Kharasch
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Barros LM, Pigoga JL, Chea S, Hansoti B, Hirner S, Papali A, Rudd KE, Schultz MJ, Calvello Hynes EJ, For The Covid-Lmic Task Force And The Mahidol-Oxford Research Unit Moru Bangkok Thailand. Pragmatic Recommendations for Identification and Triage of Patients with COVID-19 Disease in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:3-11. [PMID: 33410394 PMCID: PMC7957239 DOI: 10.4269/ajtmh.20-1064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/20/2020] [Indexed: 01/08/2023] Open
Abstract
Effective identification and prognostication of severe COVID-19 patients presenting to healthcare facilities are essential to reducing morbidity and mortality. Low- and middle-income country (LMIC) facilities often suffer from restrictions in availability of human resources, laboratory testing, medications, and imaging during routine functioning, and such shortages may worsen during times of surge. Low- and middle-income country healthcare providers will need contextually appropriate tools to identify and triage potential COVID-19 patients. We report on a series of LMIC-appropriate recommendations and suggestions for screening and triage of COVID-19 patients in LMICs, based on a pragmatic, experience-based appraisal of existing literature. We recommend that all patients be screened upon first contact with the healthcare system using a locally approved questionnaire to identify individuals who have suspected or confirmed COVID-19. We suggest that primary screening tools used to identify individuals who have suspected or confirmed COVID-19 include a broad range of signs and symptoms based on standard case definitions of COVID-19 disease. We recommend that screening include endemic febrile illness per routine protocols upon presentation to a healthcare facility. We recommend that, following screening and implementation of appropriate universal source control measures, suspected COVID-19 patients be triaged with a triage tool appropriate for the setting. We recommend a standardized severity score based on the WHO COVID-19 disease definitions be assigned to all suspected and confirmed COVID-19 patients before their disposition from the emergency unit. We suggest against using diagnostic imaging to improve triage of reverse transcriptase (RT)-PCR–confirmed COVID-19 patients, unless a patient has worsening respiratory status. We suggest against the use of point-of-care lung ultrasound to improve triage of RT-PCR–confirmed COVID-19 patients. We suggest the use of diagnostic imaging to improve sensitivity of appropriate triage in suspected COVID-19 patients who are RT-PCR negative but have moderate to severe symptoms and are suspected of a false-negative RT-PCR with high risk of disease progression. We suggest the use of diagnostic imaging to improve sensitivity of appropriate triage in suspected COVID-19 patients with moderate or severe clinical features who are without access to RT-PCR testing for SARS-CoV-2.
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Affiliation(s)
- Lia M Barros
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Jennifer L Pigoga
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins, Baltimore, Maryland
| | - Sarah Hirner
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marcus J Schultz
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom.,Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
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Point-of-Care Ultrasound: Applications in Low- and Middle-Income Countries. CURRENT ANESTHESIOLOGY REPORTS 2021; 11:69-75. [PMID: 33424456 PMCID: PMC7785781 DOI: 10.1007/s40140-020-00429-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 01/31/2023]
Abstract
Purpose of Review This review highlights the applications of point-of-care ultrasound in low- and middle-income countries and shows the diversity of ultrasound in the diagnosis and management of patients. Recent Findings There is a paucity of data on point-of-care ultrasound in anesthesiology in low- and middle-income countries. However, research has shown that point-of-care ultrasound can effectively help manage infectious diseases, as well as abdominal and pulmonary pathologies. Summary Point-of-care ultrasound is a low-cost imaging modality that can be used for the diagnosis and management of diseases that affect low- and middle-income countries. There is limited data on the use of ultrasound in anesthesiology, which provides clinicians and researchers opportunity to study its use during the perioperative period.
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Wood CB, Yancey KH, Okerosi SN, Wiggleton J, Seim NB, Mannion K, Netterville JL. Ultrasound Training for Head and Neck Surgeons in Rural Kenya: A Feasibility Study. JOURNAL OF SURGICAL EDUCATION 2020; 77:866-872. [PMID: 32146136 DOI: 10.1016/j.jsurg.2020.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/10/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine the feasibility of training otolaryngologists to perform head and neck ultrasound in low- and middle-income countries over a short timeframe. DESIGN Prospective cohort evaluating an ultrasound training course for otolaryngologists in low- and middle-income countries. SETTING Surgical training camp for otolaryngologists in semirural Kenya. METHODS Participants were prospectively recruited to participate in an ultrasound training course during a 2-week surgical training camp. They performed baseline ultrasound exams (9-item test, 5-point scale) with no assistance, followed by didactic sessions teaching ultrasound techniques. Participating surgeons then performed head and neck ultrasound exams on patients in clinic or in the operating room with direct supervision. Postcourse ultrasounds were performed, and the results of these tests were compared to baseline exams. RESULTS Eight surgeons were enrolled out of a total of 13 (62%). Three were attending surgeons (37.5%), 1 enrollee was a head and neck surgery fellow, and 4 were senior residents (50%). Six of 8 surgeons were from Kenya. The mean precourse test score was 25 (range 21-30) compared to a mean postcourse test score of 40 (range 37-45, p < 0.005). All participants significantly improved their scores, with a mean improvement of 16 points (range 10-23). DISCUSSION Otolaryngologists are uniquely equipped to learn head and neck ultrasound given their familiarity with the anatomy and pathology in this region. Training physicians without prior experience can be done even over short timeframes. Early training should focus on ultrasound, with later stages of training focusing on pathology.
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Affiliation(s)
- Carey Burton Wood
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Kristen H Yancey
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel N Okerosi
- Department of Otolaryngology, University of Nairobi, Nairobi, Kenya
| | - Jaime Wiggleton
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nolan B Seim
- Department of Otolaryngology - Head and Neck Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Kyle Mannion
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James L Netterville
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Shrestha R, Blank W, Shrestha AP, Pradhan A. Evaluation of Interdisciplinary Emergency Ultrasound Workshop for Primary Care Physicians in Nepal. Open Access Emerg Med 2020; 12:99-109. [PMID: 32431554 PMCID: PMC7200392 DOI: 10.2147/oaem.s246656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/18/2020] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Point-of-care ultrasound (POCUS) is a quick bedside tool that has the potential to improve emergency care in resource-limited settings due to its relatively low cost and accessibility. Effort to disseminate the knowledge and skills about POCUS is inadequate in low and middle income countries like Nepal. We conducted a two-day interdisciplinary advanced emergency ultrasound workshop that targeted physicians working in emergency department and primary care, especially in rural Nepal. We explored the effectiveness of this training based on validated Kirkpatrick's 4 steps of evaluating training outcomes. MATERIALS AND METHODS We conducted a prospective quasi-experimental study with mixed research design. Multidisciplinary physicians working in emergency departments participated in the two-day workshop. We assessed and compared the pre- and post-workshop knowledge. We collected on-site and a follow-up feedback to explore pre- and post-workshop confidence level, perceived usefulness and clinical use of ultrasound using a 5-point Likert scale. The barriers to use POCUS were explored. RESULTS A total of 50 physicians from different parts of Nepal participated in the workshop. The academic level of the participants, duration of their clinical experience and the previous use of POCUS did not have a significant difference in their pre- and posttest knowledge scores. The difference between the median (IQR) pre- and posttest scores [14 (12.75-17.75) and 24.5 (22.25-25.5), respectively] was statistically significant (p<0.001). Perceived confidence level and usefulness of the POCUS increased significantly in all of its domains (p<0.001). Self-reported increase in its clinical use was significant (p<0.001) for all fields. CONCLUSION The participation in this emergency ultrasound workshop increased the knowledge of participants in POCUS. Their confidence, perceived usefulness and clinical use of POCUS improved significantly. Objective longitudinal follow-up of participants' skill and demonstration of increased clinical use of POCUS in emergency department influencing the clinical outcome would be the focus of future research.
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Affiliation(s)
- Roshana Shrestha
- Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal
| | - Wolfgang Blank
- Medical Clinic I, Klinikum am Steinenberg Reutlingen Teaching Hospital, University Tübingen, Tübingen, Germany
| | - Anmol Purna Shrestha
- Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal
| | - Alok Pradhan
- Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal
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Burleson SL, Pigott DC, Gullett JP, Greene C, Gibson CB, Irvine S, Kaminstein D. Point-of-care ultrasound in resource-limited settings: the PURLS fellowship. Ultrasound J 2020; 12:14. [PMID: 32193724 PMCID: PMC7082434 DOI: 10.1186/s13089-020-00159-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/06/2020] [Indexed: 01/21/2023] Open
Abstract
Background The role of point-of-care ultrasonography (POCUS) is rapidly expanding in both resource-rich and resource-limited settings (RLS). One limitation to this rapid expansion has been the lack of educators adequately trained to teach this user-dependent skill. This is particularly true in RLS, where disease presentations, infrastructure limitations, and approach to medical education present unique challenges to the direct application of resource-rich emergency department POCUS curricula. Objectives We describe the point-of-care ultrasound in resource-limited settings (PURLS) fellowship, a novel curriculum designed to provide advanced training and expertise in clinical care and POCUS application and education in RLS. Conclusion Our curriculum design is one approach to create context-specific POCUS education for use in RLS, thereby improving patient care.
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Affiliation(s)
- Samuel L Burleson
- Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Old Hillman Building Suite 251, 619 19th St S, Birmingham, AL, 35249, USA.
| | - David C Pigott
- Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Old Hillman Building Suite 251, 619 19th St S, Birmingham, AL, 35249, USA
| | - John P Gullett
- Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Old Hillman Building Suite 251, 619 19th St S, Birmingham, AL, 35249, USA
| | - Christopher Greene
- Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Old Hillman Building Suite 251, 619 19th St S, Birmingham, AL, 35249, USA
| | - Courtney B Gibson
- Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Old Hillman Building Suite 251, 619 19th St S, Birmingham, AL, 35249, USA
| | - Scott Irvine
- Department of Emergency Medicine, University of Alabama at Birmingham Hospital, Old Hillman Building Suite 251, 619 19th St S, Birmingham, AL, 35249, USA
| | - Daniel Kaminstein
- Department of Emergency Medicine, Augusta University, Augusta, GA, USA
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Lewandowski LB, Schiffenbauer A, Mican JM, Moses SJ, Fallah MP, Plotz P, Katz JD. Rheumatology capacity building: implementing a rheumatology curriculum for Liberian health-care providers in 2016. Clin Rheumatol 2020; 39:689-696. [PMID: 31960207 PMCID: PMC10461609 DOI: 10.1007/s10067-019-04817-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Liberia has no rheumatology providers for the nation's 4.7 million people. We proposed a short course format rheumatology curriculum to educate Liberian providers as an initial step in providing graduate medical education in musculoskeletal health. METHOD A 1-week training curriculum in rheumatology encompassing introduction to musculoskeletal exam and approach to rheumatology diagnosis and management was designed. The curriculum used multiple education methods including interactive lectures, bedside training, and hands-on learning. RESULTS A 1-week rheumatology training curriculum for 24 local physicians was feasible. The execution of the designed rheumatology curriculum in Liberia relied upon a mixed method format that was both didactic and case-based. A survey of the Liberian trainees revealed that the curriculum was salient to care of patients and barriers to optimal learning such as time and space limitations were identified. CONCLUSIONS A 1-week rheumatology training education program is possible and relevant to local providers, but training length and setting may need to be optimized. Future training will aim to minimize barriers to education and expand the cohort of providers with rheumatologic knowledge in Liberia.Key Points• Liberia, like many nations in sub-Saharan Africa, has no trained rheumatologists to serve the nation's population.• Education and capacity building for rheumatologic care in short course format are relevant and feasible to local health-care providers.• Further efforts are needed to develop and evaluate continuing rheumatology education in Liberia.
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Affiliation(s)
| | - Adam Schiffenbauer
- Environmental Autoimmunity Group, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD, USA
| | - JoAnn M Mican
- NIAID, National Institutes of Health, Bethesda, MD, USA
| | - Soka J Moses
- John F. Kennedy Medical Center, Monrovia, Liberia
| | | | - Paul Plotz
- NIAMS, National Institutes of Health, Bethesda, MD, USA
| | - James D Katz
- NIAMS, National Institutes of Health, Bethesda, MD, USA
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Straube S, Chang-Bullick J, Nicholaus P, Mfinanga J, Rose C, Nichols T, Hackner D, Murphy S, Sawe H, Tenner A. Novel educational adjuncts for the World Health Organization Basic Emergency Care Course: A prospective cohort study. Afr J Emerg Med 2020; 10:30-34. [PMID: 32161709 PMCID: PMC7058880 DOI: 10.1016/j.afjem.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/22/2019] [Accepted: 11/24/2019] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The World Health Organization's (WHO) Basic Emergency Care Course (BEC) is a five day, in-person course covering basic assessment and life-saving interventions. We developed two novel adjuncts for the WHO BEC: a suite of clinical cases (BEC-Cases) to simulate patient care and a mobile phone application (BEC-App) for reference. The purpose was to determine whether the use of these educational adjuncts in a flipped classroom approach improves knowledge acquisition and retention among healthcare workers in a low-resource setting. METHODS We conducted a prospective, cohort study from October 2017 through February 2018 at two district hospitals in the Pwani Region of Tanzania. Descriptive statistics, Fisher's exact t-tests, and Wilcoxon ranked-sum tests were used to examine whether the use of these adjuncts resulted in improved learner knowledge. Participants were enrolled based on location into two arms; Arm 1 received the BEC course and Arm 2 received the BEC-Cases and BEC-App in addition to the BEC course. Both Arms were tested before and after the BEC course, as well as a 7-month follow-up exam. All participants were invited to focus groups on the course and adjuncts. RESULTS A total of 24 participants were included, 12 (50%) of whom were followed to completion. Mean pre-test scores in Arm 1 (50%) were similar to Arm 2 (53%) (p=0.52). Both arms had improved test scores after the BEC Course Arm 1 (74%) and Arm 2 (87%), (p=0.03). At 7-month follow-up, though with significant participant loss to follow up, Arm 1 had a mean follow-up exam score of 66%, and Arm 2, 74%. DISCUSSION Implementation of flipped classroom educational adjuncts for the WHO BEC course is feasible and may improve healthcare worker learning in low resource settings. Our focus- group feedback suggest that the course and adjuncts are user friendly and culturally appropriate.
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Affiliation(s)
- Steven Straube
- Department of Emergency Medicine, 533, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA, USA
| | - Julia Chang-Bullick
- Department of Emergency Medicine, 533, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA, USA
| | - Paulina Nicholaus
- Department of Emergency Medicine, Muhimbili National Hospital, Malik Road, Dar es Salaam, Tanzania
| | - Juma Mfinanga
- Department of Emergency Medicine, Muhimbili National Hospital, Malik Road, Dar es Salaam, Tanzania
| | - Christian Rose
- Department of Emergency Medicine, 533, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA, USA
| | - Taylor Nichols
- Department of Emergency Medicine, 533, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA, USA
| | | | - Shelby Murphy
- Department of Emergency Medicine, 533, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA, USA
| | - Hendry Sawe
- Department of Emergency Medicine, Muhimbili National Hospital, Malik Road, Dar es Salaam, Tanzania
| | - Andrea Tenner
- Department of Emergency Medicine, 533, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA, USA
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Trovato G. SEPSIS. Educational and Best Practice Frontiers. Beyond the Boundaries of Fatality, Enhancing Clinical Skills and Precision Medicine. Ther Clin Risk Manag 2020; 16:87-93. [PMID: 32103969 PMCID: PMC7024868 DOI: 10.2147/tcrm.s232530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/28/2020] [Indexed: 12/19/2022] Open
Abstract
Dissemination and exploitation of knowledge regarding affordable clinical skills and innovative precision medicine, two current topics in active development in medicine, may contribute to improve also sepsis management. Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is strongly related to all body organs or to systemic diseases and to the quality of the best-practice in use, which is particularly critical in surgical or intervention techniques. Trauma, surgical and mini-invasive procedures, vascular or endoscopic interventions, otolaryngology, obstetrics-gynecological and urological procedures, malnutrition, dental, skin, chronic liver, kidney and respiratory disease are frequently involved. Accordingly, apart from the clinical risk analysis and management of the process of care, the actual factors that may be easily neglected are the techniques used, the personal skills of the health professionals and the quality of the equipment. The quest for biomarkers consistent with the unmet needs of medical doctors and of their patient and the efforts for overcoming bacterial antibiotic resistances are currently the main foci of medical research. In addition, in this regard, research and innovation would benefit from greater knowledge, skills and use of bioinformatics and omics. The caveats related to in-silico approaches must be flagged: algorithms may equally warrant scientific innovations or hide the lack of them; a patient is more than a set of covariates. Epidemiology and prevention includes all the actions suitable for achieving an adequate hygiene and immunization of populations and for safer hospital policies and procedures during Patients’ stays. In any subset, the most unresolved critical point in sepsis is a timely diagnosis. This is impaired by low degrees of suspicion for the possibility of emerging sepsis, by the shortage of use of the simplest microbiological testing but, equally or more, by the insufficient diffusion of non-invasive imaging skills suitable to detect and monitor the emerging sites and sources of infection. In primary care, in emergency facilities, in hospital wards and in intensive care units, inclusion of appropriate knowledge, skills, expertise and imaging equipment must be extended as much as possible. The low cost of UltraSound machines and of increasing bioinformatics literacy by e-learning, makes such investments affordable even in limited-resources contexts. Frontier educational and best practice intervention enhancing affordable clinical skills and innovative precision medicine may lead beyond the boundaries of fatal outcomes in sepsis. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/S7CuEYUwa1s
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Affiliation(s)
- Guglielmo Trovato
- The European Medical Association (EMA) and the School of Medicine, State University of Catania, Catania, Italy
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19
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Henry J. Paediatric point‐of‐care ultrasound in a resource‐limited Melanesian setting: A case series. Australas J Ultrasound Med 2020; 23:66-73. [DOI: 10.1002/ajum.12199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/25/2019] [Accepted: 01/04/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jonathan Henry
- Emergency Physician (FACEM) Northern Provincial Hospital Luganville Santo Espiritu, Vanuatu
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20
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Terry B, Polan DL, Nambaziira R, Mugisha J, Bisanzo M, Gaspari R. Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting. Afr J Emerg Med 2019; 9:140-144. [PMID: 31528532 PMCID: PMC6742845 DOI: 10.1016/j.afjem.2019.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/31/2019] [Accepted: 05/17/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as "task-shifting" where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs. METHODS POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated. RESULTS Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32-4.32) to 4.68 (95% CI, 4.35-5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2-83.0) and 98.5 (95% CI, 93.3-99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged. CONCLUSIONS Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs.
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Affiliation(s)
- Benjamin Terry
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | - David L. Polan
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | | | - Julius Mugisha
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark Bisanzo
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Romolo Gaspari
- University of Massachusetts Medical School, Worcester, MA, United States of America
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Duanmu Y, Henwood PC, Takhar SS, Chan W, Rempell JS, Liteplo AS, Koskenoja V, Noble VE, Kimberly HH. Correlation of OSCE performance and point-of-care ultrasound scan numbers among a cohort of emergency medicine residents. Ultrasound J 2019; 11:3. [PMID: 31359167 PMCID: PMC6638613 DOI: 10.1186/s13089-019-0118-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background Point-of-care ultrasound (POCUS) is an important clinical tool for a growing number of medical specialties. The current American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend that trainees perform 150–300 ultrasound scans as part of POCUS training. We sought to assess the relationship between ultrasound scan numbers and performance on an ultrasound-focused observed structured clinical examination (OSCE). Methods This was a cross-sectional cohort study in which the number of ultrasound scans residents had previously performed were obtained from a prospective database and compared with their total score on an ultrasound OSCE. Ultrasound fellowship trained emergency physicians administered a previously published OSCE that consisted of standardized questions testing image acquisition and interpretation, ultrasound machine mechanics, patient positioning, and troubleshooting. Residents were observed while performing core applications including aorta, biliary, cardiac, deep vein thrombosis, Focused Assessment with Sonography in Trauma (FAST), pelvic, and thoracic ultrasound imaging. Results Twenty-nine postgraduate year (PGY)-3 and PGY-4 emergency medicine (EM) residents participated in the OSCE. The median OSCE score was 354 [interquartile range (IQR) 343–361] out of a total possible score of 370. Trainees had previously performed a median of 341 [IQR 289–409] total scans. Residents with more than 300 ultrasound scans had a median OSCE score of 355 [IQR 351–360], which was slightly higher than the median OSCE score of 342 [IQR 326–361] in the group with less than 300 total scans (p = 0.04). Overall, a LOWESS curve demonstrated a positive association between scan numbers and OSCE scores with graphical review of the data suggesting a plateau effect. Conclusion The results of this small single residency program study suggest a pattern of improvement in OSCE performance as scan numbers increased, with the appearance of a plateau effect around 300 scans. Further investigation of this correlation in diverse practice environments and within individual ultrasound modalities will be necessary to create generalizable recommendations for scan requirements as part of overall POCUS proficiency assessment.
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Affiliation(s)
- Youyou Duanmu
- Department of Emergency Medicine, Stanford University School of Medicine, 900 Welch Road Suite 350, Palo Alto, CA, 94304, USA.
| | - Patricia C Henwood
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sukhjit S Takhar
- Department of Emergency Medicine, Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - Wilma Chan
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua S Rempell
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA
| | - Andrew S Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Viktoria Koskenoja
- Department of Emergency Medicine, UP Health System-Marquette, Marquette, MI, USA
| | - Vicki E Noble
- Department of Emergency Medicine, University Hospitals-Cleveland Medical Center, Cleveland, OH, USA
| | - Heidi H Kimberly
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
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22
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Vinograd AM, Fasina A, Dean AJ, Shofer F, Panebianco NL, Lewiss RE, Gupta S, Rao AKR, Henwood PC. Evaluation of Noncommercial Ultrasound Gels for Use in Resource-Limited Settings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:371-377. [PMID: 30043460 DOI: 10.1002/jum.14697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/27/2018] [Accepted: 04/22/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Ultrasound (US) is increasingly used in settings where commercial US gel is unavailable. This study evaluated noncommercial gel recipes compared to commercial gel. METHODS A search for US gel formulations revealed 6 recipes. Half-strength commercial gel and a modified glucomannan recipe were also tested. Nine gels, including commercial gel, were tested in Liberia and the United States. In each session, 2 physician sonologists evaluated 9 gels on 2 models, obtaining videos from the hepatorenal space with a curvilinear transducer, the cardiac parasternal long view with a phased array transducer, and the left basilic vein with a linear transducer. The sonologists and models, who were blinded to gel identity, made independent quantitative and qualitative gel evaluations comparing the test gel to commercial gel. Two physician sonologists who were blinded to the gel identities and a US operator reviewed the images and rated their quality. An analysis of variance in repeated measures was performed to test for differences in the overall score, real-time quality, and other characteristics. Post hoc pairwise comparisons to commercial gel were performed with a Tukey-Kramer adjustment. Inter- and intra-rater reliability was calculated for the image review. RESULTS Commercial gel earned a perfect score. Compared to commercial gel, xanthine gum gel scored highest, followed by half-strength commercial gel. Hot concentrated glucomannan and cold glucomannan gel were found to be significantly worse than commercial gel. No significant difference was found between images based on the gel used on the image review. CONCLUSIONS No significant difference in image quality was found between commercial and noncommercial gels on US image review.
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Affiliation(s)
- Alexandra M Vinograd
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Abiola Fasina
- US Military HIV Research Program, Bethesda, Maryland USA
| | - Anthony J Dean
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Frances Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Nova L Panebianco
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania USA
| | - Resa E Lewiss
- Department of Emergency Medicine, University of Colorado, Denver, Colorado USA
| | - Saurabh Gupta
- State University of New York Upstate Medical University, Syracuse, New York USA
| | | | - Patricia C Henwood
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts USA
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Abstract
BACKGROUND Point-of-care ultrasound has gained widespread use in developing countries due to decreased cost and improved telemedicine capabilities. Ultrasound training, specifically image acquisition skills, is occurring with more frequency in non-medical personnel with varying educational levels in these underdeveloped areas. This study evaluates if students without a high school education can be trained to acquire useful FAST images, and to determine if an 8th grade student can teach peers these skills. METHODS The 8th grade students at a small middle school were divided into two groups. One group received training by a certified medical sonographer, while the other group received training by a peer 8th grade student trainer who had previously received training by the sonographer. After training, each student was independently tested by scanning the four FAST locations. A blinded ultrasound expert evaluated these images and deemed each image adequate or inadequate for clinical use. RESULTS Eighty video image clips were obtained. The overall image adequacy rate was 74%. The splenorenal window had the highest rate at 95%, followed by retrovesical at 90%, hepatorenal at 75%, and subxiphoid cardiac at 35%. The adequacy rate of the sonographer-trained group was 78%, while the adequacy rate of the student-trained group was 70%. The difference in image adequacy rate between the two groups was not significant (P-value 0.459). CONCLUSION The majority of 8th graders obtained clinically adequate FAST images after minimal training. Additionally, the student-trained group performed as well as the sonographer-trained group.
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Affiliation(s)
- Alexander S Kwon
- Sage Hill School, 20402 Newport Coast Drive, Newport Coast, California 92657, USA
| | - Shadi Lahham
- Department of Emergency Medicine, UC Irvine Medical Center, UC Irvine School of Medicine, Irvine, Orange, California 92868, USA
| | - John C Fox
- Department of Emergency Medicine, UC Irvine Medical Center, UC Irvine School of Medicine, Irvine, Orange, California 92868, USA
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Wanjiku GW, Bell G, Wachira B. Assessing a novel point-of-care ultrasound training program for rural healthcare providers in Kenya. BMC Health Serv Res 2018; 18:607. [PMID: 30081880 PMCID: PMC6091199 DOI: 10.1186/s12913-018-3196-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 05/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A novel point-of-care ultrasound (PoCUS) training program was developed to train rural healthcare providers in Kenya on the Focused Assessment with Sonography for Trauma (FAST), thoracic ultrasound, basic echocardiography, and focused obstetric ultrasonography. The program includes a multimedia manual, pre-course testing, 1-day hands-on training, post-testing, 3-month post-course evaluation, and scheduled refresher training. This study evaluates the impact of the course on PoCUS knowledge and skills. Competency results were compared based on number of previous training/refresher sessions and time elapsed since prior training. METHODS Trainees were evaluated using a computer-based, 30 question, multiple-choice test, a standardized observed structured clinical exam (OSCE), and a survey on their ultrasound use over the previous 3 months. RESULTS Thirty-three trainees were evaluated at 21 different facilities. All trainees completed the written exam, and 32 completed the OSCE. Nine trainees out of 33 (27.3%) passed the written test. Trainees with two or more prior training sessions had statistically significant increases in their written test scores, while those with only one prior training session maintained their test scores. Time elapsed since last training was not associated with statistically significant differences in mean written test scores. Mean image quality scores (95% confidence interval) were 2.65 (2.37-2.93) for FAST, 2.41 (2.03-2.78) for thoracic, 2.22 (1.89-2.55) for cardiac, and 2.95 (2.67-3.24) for obstetric exams. There was a trend towards increased mean image quality scores with increases in the number of prior training sessions, and a trend towards decreased image quality with increased time elapsed since previous training. Forty percent of trainees reported performing more than 20 scans in the previous 3 months, while 22% reported less than 10 scans in the previous 3 months. Second and third trimester focused obstetric ultrasound was the most frequently performed scan type. Frequency of scanning was positively correlated with written test scores and image quality scores. CONCLUSION This novel training program has the potential to improve PoCUS knowledge and skills amongst rural healthcare providers in Kenya. There is an ongoing need to increase refresher/re-training opportunities and to enhance frequency of scanning in order to improve PoCUS competency.
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Affiliation(s)
- Grace W. Wanjiku
- Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, Suite 100, Providence, RI 02903 USA
| | - Gregory Bell
- Emergency Medicine, Emergency Ultrasound University of Iowa Carver College of Medicine, Iowa City, Iowa USA
| | - Benjamin Wachira
- Emergency Medicine, Section Head & Interim Clinical Director, Accident & Emergency Department, The Aga Khan University, Nairobi, Kenya
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Kim ET, Singh K, Moran A, Armbruster D, Kozuki N. Obstetric ultrasound use in low and middle income countries: a narrative review. Reprod Health 2018; 15:129. [PMID: 30029609 PMCID: PMC6053827 DOI: 10.1186/s12978-018-0571-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited. Hence, questions around the purpose and the intended benefit as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric ultrasound technology in low-and middle-income countries (LMICs). MAIN BODY This narrative review discusses these issues for those trying to implement or scale-up ultrasound technology in LMICs. Issues addressed in this review include health personnel capacity, maintenance, cost, overuse and misuse of ultrasound, miscommunication between the providers and patients, patient diagnosis and care management, health outcomes, patient perceptions and concerns about fetal sex determination. CONCLUSION As cost of obstetric ultrasound becomes more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation. Additionally, there is a need to more clearly identify the capabilities and the limitations of ultrasound, particularly within the context of limited training of providers, to ensure that the purpose for which an ultrasound is intended is actually feasible. We found evidence of obstetric uses of ultrasound improving patient management. However, there was evidence that ultrasound use is not associated with reducing maternal, perinatal or neonatal mortality. Patients in various studies reported to have both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex was raised as a concern.
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Affiliation(s)
- Eunsoo Timothy Kim
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27516 USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Carolina Square, Suite 210, 123 West Franklin St, Chapel Hill, NC 27516 USA
| | - Kavita Singh
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27516 USA
- MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, Carolina Square, Suite 330, 123 West Franklin St, Chapel Hill, NC 27516 USA
| | - Allisyn Moran
- US Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC 20523 USA
| | - Deborah Armbruster
- US Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC 20523 USA
| | - Naoko Kozuki
- International Rescue Committee, 1730 M St. NW Suite 505, Washington, DC 20036 USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205 USA
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Fentress M, Heyne TF, Barron KR, Jayasekera N. Point-of-Care Ultrasound in Resource-Limited Settings: Common Applications. South Med J 2018; 111:424-433. [DOI: 10.14423/smj.0000000000000827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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International Scope of Emergency Ultrasound: Barriers in Applying Ultrasound to Guide Central Line Placement by Providers in Nairobi, Kenya. Emerg Med Int 2018; 2018:7328465. [PMID: 29854463 PMCID: PMC5964574 DOI: 10.1155/2018/7328465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/28/2018] [Accepted: 04/01/2018] [Indexed: 11/18/2022] Open
Abstract
Background While ultrasound (US) use for internal jugular central venous catheter (CVC) placement is standard of care in North America, most developing countries have not adopted this practice. Previous surveys of North American physicians have identified lack of training and equipment availability as the most important barriers to the use of US. Objective We sought to identify perceived barriers to the use of US to guide CVC insertion in a resource-constrained environment. Methods Prior to an US-guided CVC placement training course conducted at the Aga Khan University Hospital in Nairobi, Kenya, physicians were asked to complete a survey to determine previous experience and perceived barriers. Survey responses were analyzed using summary statistics and the Rank-Sum test based on different specialty, gender, and previous US experience. Results There were 23 physicians who completed the course and the survey. 52% (95% CI: 0.30–0.73) had put in >20 CVCs. 21.7% (95% CI: 0.08–0.44) of participants had previous US training, but none in the use of US for CVC insertion. The respondents expressed agreement with statements describing the ease of the use and improved success rate with US guidance. There was less agreement to statements describing the relative convenience and cost effectiveness of US CVC placement compared to the landmark technique. The main perceived barriers to utilization of US guidance included lack of training and limited availability of US equipment and sterile sheaths. Conclusion Perceived barriers to US-guided CVC placement in our population closely mirrored those found among North American physicians, including lack of training and limited availability of US machines and equipment. These barriers have the potential to be addressed by targeted educational and administrative interventions.
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Mackenzie DC, Nasrin S, Atika B, Modi P, Alam NH, Levine AC. Carotid Flow Time Test Performance for the Detection of Dehydration in Children With Diarrhea. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:1397-1402. [PMID: 29119578 DOI: 10.1002/jum.14478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 08/25/2017] [Accepted: 08/26/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Unstructured clinical assessments of dehydration in children are inaccurate. Point-of-care ultrasound is a noninvasive diagnostic tool that can help evaluate the volume status; the corrected carotid artery flow time has been shown to predict volume depletion in adults. We sought to determine the ability of the corrected carotid artery flow time to identify dehydration in a population of children presenting with acute diarrhea in Dhaka, Bangladesh. METHODS Children presenting with acute diarrhea were recruited and rehydrated according to hospital protocols. The corrected carotid artery flow time was measured at the time of presentation. The percentage of weight change with rehydration was used to categorize each child's dehydration as severe (>9%), some (3%-9%), or none (<3%). A receiver operating characteristic curve was constructed to test the performance of the corrected carotid artery flow time for detecting severe dehydration. Linear regression was used to model the relationship between the corrected carotid artery flow time and percentage of dehydration. RESULTS A total of 350 children (0-60 months) were enrolled. The mean corrected carotid artery flow time was 326 milliseconds (interquartile range, 295-351 milliseconds). The area under the receiver operating characteristic curve for the detection of severe dehydration was 0.51 (95% confidence interval, 0.42, 0.61). Linear regression modeling showed a weak association between the flow time and dehydration. CONCLUSIONS The corrected carotid artery flow time was a poor predictor of severe dehydration in this population of children with diarrhea.
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Affiliation(s)
- David C Mackenzie
- Maine Medical Center, Portland, Maine, USA
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Sabiha Nasrin
- International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Bita Atika
- International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Payal Modi
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Nur H Alam
- International Center for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Adam C Levine
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Reynolds TA, Amato S, Kulola I, Chen CJJ, Mfinanga J, Sawe HR. Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania. PLoS One 2018; 13:e0194774. [PMID: 29694406 PMCID: PMC5918616 DOI: 10.1371/journal.pone.0194774] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 03/11/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Point of care ultrasound (PoCUS) is an efficient, inexpensive, safe, and portable imaging modality that can be particularly useful in resource-limited settings. However, its impact on clinical decision making in such settings has not been well studied. The objective of this study is to describe the utilization and impact of PoCUS on clinical decision making at an urban emergency department in Dar es Salaam, Tanzania. METHODS This was a prospective descriptive cross-sectional study of patients receiving PoCUS at Muhimbili National Hospital's Emergency Medical Department (MNH EMD). Data on PoCUS studies during a period of 10 months at MNH EMD was collected on consecutive patients during periods when research assistants were available. Data collected included patient age and sex, indications for ultrasound, findings, interpretations, and provider-reported diagnostic impression and disposition plan before and after PoCUS. Descriptive statistics, including medians and interquartile ranges, and counts and percentages, are reported. Pearson chi squared tests and p-values were used to evaluate categorical data for significant differences. RESULTS PoCUS data was collected for 986 studies performed on 784 patients. Median patient age was 32 years; 56% of patients were male. Top indications for PoCUS included trauma, respiratory presentations, and abdomino-pelvic pain. The most frequent study types performed were eFAST, cardiac, and obstetric or gynaecologic studies. Overall, clinicians reported that the use of PoCUS changed either diagnostic impression or disposition plan in 29% of all cases. Rates of change in diagnostic impression or disposition plan increased to 45% in patients for whom more than one PoCUS study type was performed. CONCLUSIONS In resource-limited emergency care settings, PoCUS can be utilized for a wide range of indications and has substantial impact on clinical decision making, especially when more than one study type is performed.
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Affiliation(s)
- Teri Ann Reynolds
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Emergency Medicine and Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Stas Amato
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, United States of America
| | - Irene Kulola
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Chuan-Jay Jeffrey Chen
- School of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Juma Mfinanga
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Hendry Robert Sawe
- Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Abstract
The use of point-of-care ultrasound in trauma is widespread. Focused Assessment with Sonography for Trauma examination is a prototypical bedside examination used by the treating provider to quickly determine need for intervention and appropriate patient disposition. The role of bedside ultrasound in trauma, however, has expanded beyond the Focused Assessment with Sonography for Trauma examination. Advancements in diagnostics include contrast-enhanced ultrasound, thoracic, and musculoskeletal applications. Ultrasound is also an important tool for trauma providers for procedural guidance including vascular access and regional anesthesia. Its portability, affordability, and versatility have made ultrasound an invaluable tool in trauma management in resource-limited settings. In this review, we discuss these applications and the supporting evidence for point-of-care ultrasound in trauma.
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Affiliation(s)
- Timothy Gleeson
- Department of Emergency Medicine, University of Massachusetts, University of Massachusetts Medical School, Worcester, MA.
| | - David Blehar
- Department of Emergency Medicine, University of Massachusetts, University of Massachusetts Medical School, Worcester, MA
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Denny SP, Minteer WB, Fenning RT, Aggarwal S, Lee DH, Raja SK, Raman KR, Farfel AO, Patel PA, MarkLieber, Bernstein ME, Lahham S, Fox JC. Ultrasound curriculum taught by first-year medical students: A four-year experience in Tanzania. World J Emerg Med 2018; 9:33-40. [PMID: 29290893 PMCID: PMC5717373 DOI: 10.5847/wjem.j.1920-8642.2018.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/06/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diagnostic imaging is an integral aspect of care that is often insufficient, if not altogether absent, in rural and remote regions of low to middle income countries (LMICs) such as Tanzania. The introduction of ultrasound can significantly impact treatment in these countries due to its portability, low cost, safety, and usefulness in various medical assessments. This study reviews the implementation of a four-week ultrasound course administered annually from 2013-2016 in a healthcare professional school in Mwanza, Tanzania by first-year allopathic US medical students. METHODS Participants (n=582, over 4 years) were recruited from the Tandabui Institute of Health Sciences and Technology to take the ultrasound course. Subjects were predominantly clinical officer students, but other participants included other healthcare professional students, practicing healthcare professionals, and school employees. Data collected includes pre-course examination scores, post-course examination scores, course quiz scores, demographic surveys, and post-course feedback surveys. Data was analyzed using two-tailed t-tests and the single factor analysis of variance (ANOVA). RESULTS For all participants who completed both the pre- and post-course examinations (n=229, 39.1% of the total recruited), there was a significant mean improvement in their ultrasound knowledge of 42.5%, P<0.01. CONCLUSION Our data suggests that trained first-year medical students can effectively teach a point of care ultrasound course to healthcare professional students within four weeks in Tanzania. Future investigation into the level of long-term knowledge retention, impact of ultrasound training on knowledge of human anatomy and diagnostic capabilities, and how expansion of an ultrasound curriculum has impacted access to care in rural Tanzania is warranted.
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Affiliation(s)
- Sean P. Denny
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - William B. Minteer
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Reece T.H. Fenning
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Sahil Aggarwal
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Debora H. Lee
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Shella K. Raja
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Kaavya R. Raman
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Allison O. Farfel
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Priya A. Patel
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - MarkLieber
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Megan E. Bernstein
- School of Medicine, University of California Irvine, Orange, California 92868, USA
| | - Shadi Lahham
- Department of Emergency Medicine, University of California Irvine, Orange, California 92868, USA
| | - John C. Fox
- Department of Emergency Medicine, University of California Irvine, Orange, California 92868, USA
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Henwood PC, Mackenzie DC, Liteplo AS, Rempell JS, Murray AF, Leo MM, Dukundane D, Dean AJ, Rulisa S, Noble VE. Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1189-1194. [PMID: 28258591 DOI: 10.7863/ultra.16.05073] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/29/2016] [Indexed: 05/24/2023]
Abstract
OBJECTIVES Few studies of point-of-care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer-term quality of trainee-performed studies. We characterized the long-term effect of a point-of-care ultrasound program on clinical decision making, and evaluated the quality of clinician-performed ultrasound studies. METHODS We conducted point-of-care ultrasound training for physicians from Rwandan hospitals. Physicians then used point-of-care ultrasound and recorded their findings, interpretation, and effects on patient management. Data were collected for 6 months. Trainee studies were reviewed for image quality and accuracy. RESULTS Fifteen participants documented 1158 ultrasounds; 590 studies (50.9%) had matched images and interpretations for review. Abdominal ultrasound for free fluid was the most frequently performed application. The mean image quality score was 2.36 (95% confidence interval, 2.28-2.44). Overall sensitivity and specificity for trainee-performed examinations was 94 and 98%. Point-of-care ultrasound use most commonly changed medications administered (42.4%) and disposition (30%). CONCLUSIONS A point-of-care ultrasound training intervention in a low-resource setting resulted in high numbers of diagnostic-quality studies over long-term follow-up. Ultrasound use routinely changed clinical decision making.
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Affiliation(s)
- Patricia C Henwood
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David C Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland, Maine, USA
| | - Andrew S Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua S Rempell
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alice F Murray
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Megan M Leo
- Department of Emergency Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Damas Dukundane
- University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda
| | - Anthony J Dean
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Rulisa
- University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda
| | - Vicki E Noble
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Shaffer M, Brown HA, McCoy C, Bashaka P. Evaluation of a Short-term Training Program in Bedside Emergency Ultrasound in Southwestern Tanzania. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:515-521. [PMID: 28088840 DOI: 10.7863/ultra.16.04006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 06/13/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To evaluate the effect of a short-term training program in emergency ultrasound on physician skills and attitudes in southwestern Tanzania. METHODS Eight registrar physicians at Mbeya Zonal Referral Hospital (Mbeya, Tanzania) underwent a 5-day course in bedside emergency ultrasound, focusing primarily on the focused assessment with sonography for trauma examination, including didactic sessions, practical sessions, and on-job training. The impact on ultrasound knowledge was assessed by pretest and posttest evaluations. Provider skill was evaluated by a standardized observed simulated patient encounter. Attitudes toward ultrasound training, utility, and self-confidence were assessed by a post-training questionnaire. RESULTS All 8 physicians who began the training completed the course and successfully passed their objective structured clinical examination. There was a statistically significant improvement in written ultrasound test scores from 31% to 66% (P < .01) after the course. Most trainees felt confident performing and interpreting a basic focused assessment with sonography for trauma examination at the end of the course, and 7 of 8 stated that they would consider paying tuition for similar courses in the future. Main concerns with the course revolved around insufficient time dedicated to practicing under supervision. CONCLUSIONS Registrar physicians in Tanzania can effectively learn basic emergency ultrasound skills in a short-term training program. Similar future programs may consider heavier emphasis on practical hands-on training with experts. Ongoing data collection is required to understand the true impact of such training on long-term ultrasound use and patient outcomes.
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Affiliation(s)
- Mark Shaffer
- Departments of Family and Preventive Medicine, University of South Carolina/Palmetto Health Richland, Columbia, South Carolina, USA
| | - Heather A Brown
- Department of Emergency Medicine, Palmetto Health Richland, Columbia, South Carolina, USA
- Department of Surgery, University of South Carolina, Columbia, South Carolina, USA
| | - Chloé McCoy
- Emergency Medicine, University of South Carolina/Palmetto Health Richland, Columbia, South Carolina, USA
| | - Prosper Bashaka
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Henwood PC, Mackenzie DC, Rempell JS, Douglass E, Dukundane D, Liteplo AS, Leo MM, Murray AF, Vaillancourt S, Dean AJ, Lewiss RE, Rulisa S, Krebs E, Raja Rao AK, Rudakemwa E, Rusanganwa V, Kyanmanywa P, Noble VE. Intensive point-of-care ultrasound training with long-term follow-up in a cohort of Rwandan physicians. Trop Med Int Health 2016; 21:1531-1538. [DOI: 10.1111/tmi.12780] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Patricia C. Henwood
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA USA
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
| | - David C. Mackenzie
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; Maine Medical Center; Portland OR USA
| | - Joshua S. Rempell
- Department of Emergency Medicine; Brigham and Women's Hospital; Boston MA USA
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
| | - Emily Douglass
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
| | - Damas Dukundane
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- University Teaching Hospital of Kigali; Kigali Rwanda
| | - Andrew S. Liteplo
- Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
| | - Megan M. Leo
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; Boston Medical Center; Boston MA USA
| | - Alice F. Murray
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; Boston Medical Center; Boston MA USA
| | - Samuel Vaillancourt
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; St. Michael's Hospital; Toronto Canada
| | - Anthony J. Dean
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Resa E. Lewiss
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; University of Colorado; Denver CO USA
| | | | - Elizabeth Krebs
- Department of Emergency Medicine; Duke University Medical Center; Durham NC USA
| | - A. K. Raja Rao
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
| | | | | | | | - Vicki E. Noble
- Point-of-Care Ultrasound in Resource Limited Environments; Boston MA USA
- Department of Emergency Medicine; Massachusetts General Hospital; Boston MA USA
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A pilot training program for point-of-care ultrasound in Kenya. Afr J Emerg Med 2016; 6:132-137. [PMID: 30456079 PMCID: PMC6234186 DOI: 10.1016/j.afjem.2016.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/12/2016] [Accepted: 03/03/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction Ultrasound is an effective and affordable clinical diagnostic tool highly attractive for use in low and middle income countries (LMICs), but access to training programs in these countries is limited. The objective of our study was to develop and pilot a program for healthcare providers in Kenya in the use of point-of-care ultrasound. Methods Trainees were recruited in district hospitals for participation in three all-day workshops held every 3–5 months from September 2013 through November 2014. Prior to the initial workshop, trainees were asked to study a training manual, and a knowledge test was administered. Ultrasound-credentialed emergency physicians provided brief didactic lessons then hands-on training for eFAST and obstetric training. This was followed by an observed assessment of scanning image quality (IM) and diagnostic interpretation (IN). Results Eighty-one trainees enrolled in four initial training sessions and 30 attended at least one refresher session. Among those trainees who attended refresher sessions, there was an increase in the proportion passing both the knowledge and practical tests at the follow-up, as compared to the initial session. Overall, mean practical skill scores also trended toward an increase over time, with a significantly higher mean score in November 2014 (2.64 + 0.38, p = 0.02) as compared to March 2014 (2.26 + 0.54), p < 0.05. Pre-workshop preparation evolved over time with the goal of maximizing trainee readiness for the hands-on course. A strong correlation was observed between knowledge and practical skill scores illustrating the importance of pre-workshop training. Conclusions Our pilot workshop showed promise in promoting knowledge and practical skills among participants, as well as increasing use in patient care. Results also suggest that refresher training may provide additional benefits for some participants. These findings provide a strong rationale for expanding the training program and for measuring its clinical impact.
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Reynolds TA, Noble J, Paschal G, Sawe HR, Sohoni A, Shah S, Nicks B, Mwafongo V, Stein J. Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico. Afr J Emerg Med 2016; 6:125-131. [PMID: 30456078 PMCID: PMC6234160 DOI: 10.1016/j.afjem.2016.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 02/06/2016] [Accepted: 03/08/2016] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION In resource-rich settings, bedside ultrasound has rapidly evolved to be a crucial part of emergency centre practice and a growing part of critical care practice. This portable and affordable technology may be even more valuable in resource-limited environments where other imaging modalities are inaccessible, but the optimal amount of training required to achieve competency in bedside ultrasound is largely unknown. We sought to evaluate the feasibility of implementation of a mixed-modality bedside ultrasound training course for emergency and generalist acute care physicians in limited resource settings, and to provide a description of our core course components, including specific performance goals, to facilitate implementation of similar initiatives. METHODS We conducted a standardised training course at two distinct sites-one large, urban tertiary hospital in Tanzania with a dedicated Emergency Centre, and one small, rural, hospital in southern Mexico with a general, acute intake area. We report on pre-training ultrasound use at both sites, as well as pre- and post-training views on most useful indications. RESULTS Overall, participants were very satisfied with the course, although approximately one-third of the providers at both sites would have preferred more hands-on training. All participants passed a standardised exam requiring image acquisition and interpretation. DISCUSSION Introducing bedside ultrasound training in two distinct resource-limited settings was feasible and well-received. After a brief intensive period of training, participants successfully passed a comprehensive examination, including demonstration of standardised image acquisition and accurate interpretation of normal and abnormal studies.
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Blanco P. A Traditional Paradigm vs. an Ultrasound-Supported Paradigm in Emergency and Critical Care Medicine: A Crisis of the Mind Is Needed. J Emerg Med 2015; 49:e63-4. [PMID: 26014762 DOI: 10.1016/j.jemermed.2015.02.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 02/27/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Pablo Blanco
- Intensive Care Unit, Hospital Dr. Emilio Ferreyra, 4801, 59 Street, Necochea 7630, Argentina
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Out of hospital point of care ultrasound: current use models and future directions. Eur J Trauma Emerg Surg 2015; 42:139-50. [PMID: 26038015 DOI: 10.1007/s00068-015-0494-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 01/16/2015] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Ultrasound has evolved from a modality that was once exclusively reserved to certain specialities of its current state, in which its portability and durability lend to its broadly increasing applications. OBJECTIVES This review describes portable ultrasound in the hospital setting and its comparison to gold standard imaging modalities. Also, this review summarizes current literature describing portable ultrasound use in prehospital, austere and remote environments, highlighting successes and barriers to use in these environments. DISCUSSION Prehospital ultrasound has the ability to increase diagnostic ability and allow for therapeutic intervention in the field. In austere environments, ultrasound may be the only available imaging modality and thus can guide diagnosis, therapeutics and determine which patients may need emergent transfer to a healthcare facility. The most cutting edge applications of portable ultrasound employ telemedicine to obtain and transmit ultrasound images. This technology and ability to transmit images via satellite and cellular transmission can allow for even novice users to obtain interpretable images in austere environments. Portable ultrasound uses have steadily grown and will continue to do so with the introduction of more portable and durable technologies. As applications continue to grow, certain technologic considerations and future directions are explored.
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