Point-of-care ultrasound education: the increasing role of simulation and multimedia resources

Improving the diagnostic performance of inexperienced readers for thyroid nodules through digital self-learning and artificial intelligence assistance

Background

Data-driven digital learning could improve the diagnostic performance of novice students for thyroid nodules.

Objective

To evaluate the efficacy of digital self-learning and artificial intelligence-based computer-assisted diagnosis (AI-CAD) for inexperienced readers to diagnose thyroid nodules.

Methods

Between February and August 2023, a total of 26 readers (less than 1 year of experience in thyroid US from various departments) from 6 hospitals participated in this study. Readers completed an online learning session comprising 3,000 thyroid nodules annotated as benign or malignant independently. They were asked to assess a test set consisting of 120 thyroid nodules with known surgical pathology before and after a learning session. Then, they referred to AI-CAD and made their final decisions on the thyroid nodules. Diagnostic performances before and after self-training and with AI-CAD assistance were evaluated and compared between radiology residents and readers from different specialties.

Results

AUC (area under the receiver operating characteristic curve) improved after the self-learning session, and it improved further after radiologists referred to AI-CAD (0.679 vs 0.713 vs 0.758, p<0.05). Although the 18 radiology residents showed improved AUC (0.7 to 0.743, p=0.016) and accuracy (69.9% to 74.2%, p=0.013) after self-learning, the readers from other departments did not. With AI-CAD assistance, sensitivity (radiology 70.3% to 74.9%, others 67.9% to 82.3%, all p<0.05) and accuracy (radiology 74.2% to 77.1%, others 64.4% to 72.8%, all p <0.05) improved in all readers.

Conclusion

While AI-CAD assistance helps improve the diagnostic performance of all inexperienced readers for thyroid nodules, self-learning was only effective for radiology residents with more background knowledge of ultrasonography.

Clinical Impact

Online self-learning, along with AI-CAD assistance, can effectively enhance the diagnostic performance of radiology residents in thyroid cancer.

Teaching Medical Students Rapid Ultrasound for shock and hypotension (RUSH): learning outcomes and clinical performance in a proof-of-concept study

BACKGROUND

Point-of-care ultrasound (POCUS) is a critical diagnostic tool in various medical settings, yet its instruction in medical education is inconsistent. The Rapid Ultrasound for Shock and Hypotension (RUSH) protocol is a comprehensive diagnostic tool, but its complexity poses challenges for teaching and learning. This study evaluates the effectiveness of a single-day training in RUSH for medical students by assessing their performance in clinical scenarios.

METHODS

In this prospective single-center observational proof-of-concept study, 16 medical students from Saarland University Medical Center underwent a single-day training in RUSH, followed by evaluations in clinical settings and on a high-fidelity simulator. Performance was assessed using a standardized scoring tool and time to complete the RUSH exam. Knowledge gain was measured with pre- and post-training written exams, and diagnostic performance was evaluated with an objective structured clinical examination (OSCE).

RESULTS

Students demonstrated high performance in RUSH exam views across patients (median performance: 85-87%) and improved scanning times, although not statistically significant. They performed better on simulators than on live patients. Written exam scores significantly improved post-training, suggesting a gain in theoretical knowledge. However, more than a third of students could not complete the RUSH exam within five minutes on live patients.

CONCLUSIONS

Single-day RUSH training improved medical students' theoretical knowledge and simulator performance but translating these skills to clinical settings proved challenging. The findings suggest that while short-term training can be beneficial, it may not suffice for clinical proficiency. This study underscores the need for structured and possibly longitudinal training programs to ensure skill retention and clinical applicability.

Benefits of simulation for ultrasound-guided midline placement training: MC-in-Sim pilot study

INTRODUCTION

Ultrasound-guided placement of Midlines catheters (MCs) is a standard procedure with many benefits for patients. Even if there are some guidelines worldwide, this invasive technique is still taught at the patient's bed and relies on mentoring in many care centers. The performance of this care by novice practitioners raises ethical and quality of care issues mainly because of its risk of complications. This study aimed to propose and assess a simulation-based learning method for the placement of MCs in novice practitioners.

METHODS

A single-center prospective observational study was conducted with anesthesia residents who had no prior experience of Midline placement. Two workshops were planned. The first one consisted of a theoretical training and a simulated practical phase. The second workshop included an assessment of theoretical memorization, a practical exercise and adherence to the training program.

RESULTS

The median score of the theoretical memorization was 14.6 (interquartile range [IQR]: 13.5-15.8). The MCs placement time was significantly higher (Med: 12.23 min; IQR: 12.21-12.80) for novice practitioners who did not successfully complete solo MCs placement in simulation versus novice practitioners who successfully completed solo MCs placement in simulation 6.66 min (IQR: 5.92-8.93) (p = 0.002). The number of attempts was significantly higher (p = 0.034) for the novice practitioners who did not successfully complete solo MCs placement in simulation with 67% having performed three punctures, against 0% for the novice practitioners who successfully completed solo MCs placement in simulation. All novice practitioners found this training model efficient for learning how to place MCs and considered it allows for reproducibility in care situations.

CONCLUSION

This ultrasound-guided MCs training on simulation is an agile and fast alternative to traditional bedside training for anesthesia novice practitioners.

Anatomically realistic aortic dissection simulator as a potential training tool for point-of-care ultrasound

Aim

Simulators for aortic dissection diagnosis are limited by complex anatomy influencing the accuracy of point-of-care ultrasound for diagnosing aortic dissection. Therefore, this study aimed to create a healthy ascending aorta and class DeBakey, type II aortic dissection simulator as a potential point-of-care ultrasound training model.

Material and methods

3D mould simulators were created based on computed tomography images of one healthy and one DeBakey type II aortic dissection patient. In the next step, two polyvinyl alcohol-based and two silicone-based simulators were synthesised.

Results

The results of the scanning electron microscope assessment showed an aortic dissection simulator's surface with disorganised surface texture and higher root mean square (RMS or Rq) value than the healthy model of polyvinyl alcohol (RqAD = 20.28 > RqAAo = 10.26) and silicone (RqAD = 33.8 > RqAAo = 23.07). The ultrasound assessment of diameter aortic dissection showed higher than the healthy ascending aorta in polyvinyl alcohol (dAD = 28.2 mm > dAAo = 20.2 mm) and Si (dAD = 31.0 mm > dAAo = 22.4 mm), while the wall thickness of aortic dissection showed thinner than the healthy aorta in polyvinyl alcohol, which is comparable with the actual aorta measurement. The intimal flap of aortic dissection was able to replicate and showed a false lumen in the ultrasound images. The flap was measured quantitatively, indicating that the intimal flap was hyperechoic.

Conclusions

The simulators were able to replicate the surface morphology and echogenicity of the intimal flap, which is a linear hyperechoic area representing the separation of the aorta wall.

Efficiency of Simulation-Based Learning Using an ABC POCUS Protocol on a High-Fidelity Simulator

Critically ill patients with rapidly deteriorating clinical status secondary to respiratory and cardio-vascular compromise are at risk for immediate collapse if the underlying pathology is not recognized and treated. Rapid diagnosis is of utmost importance regardless of the setting. Although there are data to support the use of point-of-care ultrasound in critical patients, there is no consensus about the best educational strategy to implement. We designed a curriculum based on the ABC (Airway, Breathing, Circulation) protocol that covers essential airway, lung, and cardiac ultrasound skills needed for fast diagnosis in critical patients and applied it in high-fidelity simulation-based medical education sessions for anesthesia and intensive care residents year one and two. After theoretical and practical assessments, our results show statistical differences in the theoretical knowledge and above-average results in practical assessment. Our proposed curriculum based on a simple ABC POCUS protocol, with an Airway, Breathing, and Circulation approach, is useful in teaching ultrasound basics regarding airway, lung, and cardiac examination using high-fidelity simulation training to anesthesia and intensive care residents, but further research is needed to establish the utility of Simulation-Based Medical Education in Point of Care Ultrasound in the critical patient.

Normology: Is it Time to Rethink Point-of-Care Ultrasound Training?

Point-of-care ultrasound (PoCUS) is increasingly being adopted by clinicians to augment their clinical examination and aid procedures. Evidence-based clinical practice guidelines now support many aspects of PoCUS practice. As a result, more and more medical schools are integrating PoCUS into their curricula, creating a significant demand for training resources. All training must ensure that trainees have the appropriate knowledge, skills and behaviour to enable the clinical integration of PoCUS. The transition from supervised to unsupervised practice is an important step in PoCUS, but should not be confused with expertise. At the start of clinical practice, confirming that something is not normal is probably enough, and trainees can subsequently improve their PoCUS diagnostic accuracy at the bedside during clinical rotations. Our hypothesis is that competency can be achieved without the need to scan patients suspected or suffering from the target pathology. This would enable most of the training to be carried out outside the clinical environment, using volunteers in planned sessions. These planned sessions will be able to accommodate a larger number of trainees and may facilitate collaboration between specialties. When patients are scanned in the clinical environment, trainees should have acquired a good level of competence beforehand. In summary, normology principles could help PoCUS trainees, at the start of their training, to acquire the knowledge, skills and behaviour necessary to achieve a level of competency allowing them to proceed to unsupervised practice. Initially confirming whether something is normal or not is enough. Nevertheless, further research should be conducted to support this concept, and its impact on PoCUS teaching in clinical practice.

The effect of e-learning on point-of-care ultrasound education in novices

BACKGROUND

Current studies assessed the learning efficacy of e-learning in ultrasound (US) training using questionnaires, or simulation in well-controlled conditions. This study investigates the effect of e-learning on the clinical US performance of the first postgraduate year (PGY-1) residents.

METHODS

In this prospective observational study, we enrolled PGY-1 and second postgraduate year (PGY-2) residents. The e-learning was introduced on the first day and each PGY-1 was authorized to access the e-learning platform. The point-of-care ultrasound (PoCUS) curriculum for the focused assessment of sonography for trauma (FAST) was conducted on the 7^th day for PGY-1 and the objective structured clinical examination (OSCE) followed. The PGY-2 received bedside one-to-one random learning before the study and did not have the authorization to access the e-learning. The FAST examinations performed by the PGY-1 and PGY-2 were collected on the 30th day. The clinical FAST performance was assessed by the instructor not involved in the curriculum and blinded to the use of e-learning, including numbers, image quality, and diagnostic accuracy between PGY-1 e-learning users, non-users, and the PGY-2.

RESULTS

One hundred and seventy PGY-1 with 736 FAST examinations and 53 PGY-2 residents with 134 examinations were included. Seventy PGY-1 used e-learning with a median time spent of 13.2 mins (IQR, 6.5-21.1 mins) at the first access. The PGY-2 had more PoCUS experience than the PGY-1, however, the 70 e-learning users performed more FAST examinations than the PGY-2 (median [IQR], 4 [2-6] vs. 2 [1-3], p = 0.0004) and had better image quality than the PGY-2 (3 [3-3.2] vs. 3 [2.7-3], p = 0.044). There were no significant differences in the diagnostic accuracy between the PGY-1 and PGY-2.

CONCLUSIONS

E-learning has a positive effect on US learning. The PGY-1 users had comparable performance with the PGY-2 and even better image acquisition although the PGY-2 had more PoCUS experience.

TRIAL REGISTRATION

NCT03738033 at ClinicalTrials.gov.

Educational programs for implementing ultrasound guided peripheral intravenous catheter insertion in emergency departments: A systematic integrative literature review

BACKGROUND

Ultrasound-guided peripheral intravenous catheter insertion has been identified as an effective method to improve the success rate of cannulation, thereby improving patient experience. However, learning this new skill is complex, and involves training clinicians from a variety of backgrounds. The aim of this study was to appraise and compare literature on educational methods in the emergency setting used to support ultrasound guided peripheral intravenous catheter insertion by different clinicians, and how effective these current methods are.

REVIEW METHODS

A systematic integrative review was undertaken using Whittemore and Knafl's five stage approach. The Mixed Methods Appraisal Tool was used to assess the quality of the studies.

RESULTS

Forty-five studies met the inclusion criteria, with five themes identified. These were: the variety of educational methods and approaches; the effectiveness of the different educational methods; barriers and facilitators of education; clinician competency assessments and pathways; clinician confidence assessment and pathways.

CONCLUSIONS

This review demonstrates that a variety of educational methods are being used in successfully training emergency department clinicians in using ultrasound guidance for peripheral intravenous catheter insertion. Furthermore, this training has resulted in safer and more effective vascular access. However, it is evident that there is a lack of consistency of formalised education programs available. A standardised formal education program and increased availability of ultrasound machines in the emergency department will ensure consistent practices are maintained, retained, therefore leading to safer practice as well as more satisfied patients.

Nephrologist-Led Simulation-Based Focused Cardiac Ultrasound Workshop for Medical Students: Insights and Implications

Background

Point-of-care ultrasonography (POCUS) is being increasingly recognized as an adjunct to physical examination. However, limited availability of trained faculty in specialties other than emergency medicine and lack of universal training standards remain key barriers to its widespread integration into undergraduate and graduate medical curricula. In this study, we sought to explore the effectiveness of a short simulation-based workshop for medical students teaching basic cardiac ultrasound led by a nephrologist.

Methods

Workshops were conducted for 2 different groups of 4th-year medical students with a total of 25 attendees. The workshop consisted of a 1-hour lecture followed by 15 minutes of cardiac anatomy simulation and a 2- to 2.5-hour hands-on session in the simulation laboratory. An anonymous precourse questionnaire comprising 10 questions assessing the interpretation of common grayscale ultrasound findings encountered in patients with undifferentiated hypotension was performed. After the workshop, a postcourse exam and survey were conducted, retesting the same concepts and seeking the students' feedback on the course.

Results

In total, 23 and 20 students answered the pre- and postcourse surveys, respectively. The mean total score on the pretest was 63.8% ± 13.6%, which significantly increased to 91.5% ± 10.5% on the posttest (P < .001). About 90% of the respondents strongly agreed that the cardiac anatomy simulation improved their understanding of the cardiac sonographic anatomy; 75% strongly agreed that the hands-on simulation enhanced their confidence in image acquisition and interpretation; and 70% said they would choose nephrology elective if POCUS training was integrated with it.

Conclusions

A nephrologist-led diagnostic POCUS workshop using simulation techniques is effective in improving the learners' knowledge, understanding of the sonographic cardiac anatomy, and confidence in image acquisition. Integration of POCUS training may increase medical student interest in nephrology elective rotations.

Development of a novel observed structured clinical exam to assess clinical ultrasound proficiency in undergraduate medical education

OBJECTIVES

A pilot study was performed to develop and test an observed structured clinical exam (OSCE) for clinical ultrasound in second-year medical students. The goal was to assess a longitudinal clinical ultrasound curriculum for medical students and to help determine readiness to perform ultrasound during clinical clerkships.

METHODS

The OSCE contained 40 tasks over 30 min in a one-to-one examiner to examinee environment using standardized patients covering cardiac, pulmonary, and inferior vena cava (IVC) ultrasound exams along with 6 critical diagnoses. Examinees were assessed using a binary checklist approach. A two-way ANOVA analysis was performed to determine if there were differences between the day and session the OSCE was administered. Results are presented as mean ± standard deviation.

RESULTS

One hundred fifty-two students were tested with an overall mean score of 64.9 ± 17.6%. Scores between the cardiac, IVC, and lung sections varied-67.8% ± 18.8%, 62.4% ± 26.2%, and 57.1% ± 20.6%, respectively. One hundred twenty-six (82.9%) answered at least one critical diagnosis incorrectly. Students in the late session performed better than the early session (1: 60% vs 2: 69%, p = .001).

CONCLUSIONS

Students performed better in later sessions. Additionally, the number of questions left blank at the end of the exam suggests that the length of the OSCE should be evaluated. Incorporating critical diagnoses was challenging for examinees. The proposed OSCE is a valuable assessment tool that could be adapted to assess student's readiness to use clinical ultrasound prior to clerkships.

Emergency Point-of-Care Ultrasound Stewardship - A Joint Position Paper by EuSEM and EFSUMB and Endorsed by IFEM and WFUMB

Emergency Medicine Point-of-Care Ultrasound (EMPoCUS) is a convincing concept. It has spread rapidly because of its intuitive, simple applicability and low equipment costs. The speed of its emerging growth frequently outpaces the development of quality assurance and education. Indeed, education standards vary worldwide, and in some cases seem to neglect the principles of modern competence-based education. Additional challenges are encountered such as remote or low resource medical practice. Here, EMPoCUS might be the only ad-hoc imaging modality available. Once mastery of EMPoCUS is achieved, emergency physicians should be able to independently and efficiently care for their patients using a variety of PoCUS skills. However, most curricula only define these tasks as non-binding and in general terms or use outdated measures, such as length of training and self-reporting of achieved examinations with variable oversight, or administrative measures to create educational milestones. This threatens to take quality assurance down the wrong path. It created a scenario in which concrete EMPoCUS skill outcome measures that would realistically reflect the training objectives and simultaneously would be easily observable and verifiable are lacking. In view of the dangers of poorly controlled EMPoCUS dissemination and the current lack of European guidelines, we would like to set central standards for European EMPoCUS stewardship based on a critical review of the current situation. This position paper, which was jointly developed by EuSEM and EFSUMB and endorsed by IFEM and WFUMB, is also intended to accompany the EFSUMB/EuSEM guidelines on PoCUS currently being prepared for publication.

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.

Detecting Hydronephrosis Through Ultrasound Images Using State-of-the-Art Deep Learning Models

The goal of this study was to assess the feasibility of three models for detecting hydronephrosis through ultrasound images using state-of-the-art deep learning algorithms. The diagnosis of hydronephrosis is challenging because of varying and non-specific presentations. With the characteristics of ready accessibility, no radiation exposure and repeated assessments, point-of-care ultrasound becomes a complementary diagnostic tool for hydronephrosis; however, inter-observer variability still exists after time-consuming training. Artificial intelligence has the potential to overcome the human limitations. A total of 3462 ultrasound frames for 97 patients with hydronephrosis confirmed by the expert nephrologists were included. One thousand six hundred twenty-eight ultrasound frames were also extracted from the 265 controls who had normal renal ultrasonography. We built three deep learning models based on U-Net, Res-UNet and UNet++ and compared their performance. We applied pre-processing techniques including wiping the background to lessen interference by YOLOv4 and standardizing image sizes. Also, post-processing techniques such as adding filter for filtering the small effusion areas were used. The Res-UNet algorithm had the best performance with an accuracy of 94.6% for moderate/severe hydronephrosis with substantial recall rate, specificity, precision, F1 measure and intersection over union. The Res-UNet algorithm has the best performance in detection of moderate/severe hydronephrosis. It would decrease variability among sonographers and improve efficiency under clinical conditions.

Open-Source Ultrasound Trainer for Healthcare Professionals: A Pilot Randomized Control Trial

INTRODUCTION

This technical report describes the development of a high-fidelity, open-source ultrasound trainer and showcases its abilities through a proof-of-concept, pilot randomized control trial. The open-source ultrasound trainer (OSUT) aims to enhance anatomical visualization during ultrasound education. The OSUT can attach to any ultrasound transducer, uses minimal hardware, and is able to be used during live patient ultrasound examinations.

METHODS

After viewing a standardized training video lecture, 24 incoming first-year medical students with no prior ultrasound experience were randomized into a control group given an ultrasound system or an intervention group given the OSUT in addition to an ultrasound system. Both groups were tasked with localizing the thyroid, abdominal aorta, and right kidney on a patient. Performance outcomes were structure localization time, ultrasound image accuracy, and preactivity and postactivity participant confidence.

RESULTS

The OSUT decreased right kidney localization time (Kruskal-Wallis, P < 0.001), increased sonographer right kidney accuracy ratings (Mann-Whitney U , U = 10.5, P < 0.05), and increased confidence in structure identification (Mann-Whitney U , U = 37, P = 0.045) and overall ultrasound ability (Wilcoxon signed-rank test, P = 0.007). There was no significant change in localization time, accuracy ratings, or participant confidence for locating the thyroid and abdominal aorta.

CONCLUSIONS

A high-fidelity, open-source ultrasound trainer was developed to aid healthcare professionals in learning diagnostic ultrasound. The study demonstrated the potential beneficial effects of the OSUT in localizing the right kidney, showcasing its adaptability and accessibility for ultrasound education for certain anatomical structures.

The ultrasound use of simulators, current view, and perspectives: Requirements and technical aspects (WFUMB state of the art paper)

Simulation has been shown to improve clinical learning outcomes, speed up the learning process and improve learner confidence, whilst initially taking pressure off busy clinical lists. The World Federation for Ultrasound in Medicine and Biology (WFUMB) state of the art paper on the use of simulators in ultrasound education introduces ultrasound simulation, its advantages and challenges. It describes different simulator types, including low and high-fidelity simulators, the requirements and technical aspects of simulators, followed by the clinical applications of ultrasound simulation. The paper discusses the role of ultrasound simulation in ultrasound clinical training, referencing established literature. Requirements for successful ultrasound simulation acceptance into educational structures are explored. Despite being in its infancy, ultrasound simulation already offers a wide range of training opportunities and likely holds the key to a broader point of care ultrasound education for medical students, practicing doctors, and other health care professionals. Despite the drawbacks of simulation, there are also many advantages, which are expanding rapidly as the technology evolves.

Evaluation of antenatal point-of-care ultrasound training workshops for rural/remote healthcare clinicians: a prospective single cohort study

BACKGROUND

There is limited access to life-saving antenatal ultrasound in low-resource rural and remote settings worldwide, including Australia, mainly due to shortages in skilled staff. Point-of-care ultrasound (PoCUS) offers a viable solution to this service deficit, however, rural clinicians face many barriers accessing training and professional development critical to advancing their clinical practice. Standards for PoCUS training and competency assessment are unclear. Regulation is lacking globally, allowing untrained and inexperienced clinicians to practice PoCUS clinically.

METHODS

This prospective single cohort study aimed to evaluate antenatal PoCUS training workshops for General Practitioners (GPs) and Midwives/Nurses (M/Ns) from rural/remote Australia, assessing the impact of the training on trainees' knowledge, confidence and translation of PoCUS into clinical practice. Two-day antenatal ultrasound workshops were delivered at the University of South Australia (UniSA) in 2018 and 2019 to 41 rural/remote clinicians . The training was designed and evaluated using the New world Kirkpatrick Evaluation Framework. Sixteen GPs and 25 M/Ns with mixed prior ultrasound experience were funded to attend. The course consisted of lectures interspaced with hands-on training sessions using high-fidelity simulators and live pregnant models. Pre- and post-knowledge assessments were performed. Post-workshop evaluation and follow-up surveys (3- and 6-month post-training) assessed the workshops and changes to trainees' clinical practice. A 2-day follow-up training session was conducted 12 months after the workshops for 9 trainees.

RESULTS

Pre/post knowledge testing demonstrated a 22% mean score improvement (95% CI 17.1 to 27.8, P < 0.0001). At 6 months, 62% of trainees were performing PoCUS that had assisted in patient management and clinical diagnosis, and 46% reported earlier diagnosis and changes to patient management. 74% of trainees had increased scanning frequency and 93% reported improved scanning confidence.

CONCLUSION

This study demonstrated intensive 2-day workshops can equip clinicians with valuable antenatal PoCUS skills, offering a viable solution to assist in the assessment and management of pregnant women in the rural/resource-poor setting where access to ultrasound services is limited or non-existent. Geographical isolation and lack of onsite specialist supervision poses an ongoing challenge to the continuing professional development of remote trainees and the implementation of PoCUS.

A Novel Simulation Model for Training Emergency Medicine Residents in the Ultrasound Identification of Landmarks for Cricothyrotomy

Objectives The objective of this study is to describe a simple, replicable method to create neck models for the purpose of education and practice of ultrasound (US) identification of anatomic landmarks for cricothyrotomy. The second objective is to assess the model's capability in training emergency medicine (EM) residents in the US identification of anatomic landmarks for cricothyrotomy. Methods This is a cross-sectional study using a convenience sample of EM residents. Participants were taught to identify the thyroid cartilage, the cricothyroid membrane (CTM), and the cricoid cartilage using US. After an instructional period, participants performed a US examination on gel models designed to overly a live, human neck simulating various scenarios: thin neck, thick neck, anterior neck hematoma, and subcutaneous emphysema. Residents were asked to identify the thyroid cartilage, the CTM, and the cricoid cartilage as quickly as possible. The mean time to successful identification was reported in seconds. Following the scanning session, participants were asked to complete a post-survey. After the session, the video recordings were reviewed by an emergency US fellowship-trained physician to assess the visuomotor skills of each participant. Results A total of 42 residents participated in the study. Ninety-three percent (32/42; 95% CI 80.3% - 98.2%) of residents were able to obtain an optimal sagittal or parasagittal sonographic view of the anterior airway landmarks. Of these residents, 21.4% (9/42; 95% CI 11.5% - 36.2%) required minimal assistance with the initial probe placement. The visuomotor scores were recorded for each participant. Results of the pearson correlation indicated that there was a significant positive relationship between the residents' year in training with their visuomotor score (r(40) = .41, p = .007). When scanning the thin neck, 90.5% (38/42; 95% CI 77.4% - 96.8%) of residents were able to successfully identify the landmarks. The median time to completion was 27 seconds. When scanning the subcutaneous air model, 88.1% (37/42; 95% CI 74.5% - 95.3%) of residents were able to successfully identify the landmarks. The median time to completion was 26 seconds. When scanning the neck with the fluid collection 95.2% (40/42; 95% CI 83.4% - 99.5%) of residents were able to successfully identify the landmarks with a median time of 20 seconds for identification. When scanning the thick neck model, 73.8% (31/42; 95% CI 58.8% - 84.8%) of residents were able to successfully identify the landmarks taking a median time of 26 seconds. After the training session, 76.2% of residents reported that they felt either "confident" or "extremely confident" in identifying the CTM using US. Conclusion The novel anterior neck gel models used in this study were found to be adequate for training EM residents in the US identification of anterior neck anatomy. Residents were successfully trained in identifying the important anterior neck landmarks that are useful when predicting a difficult anterior airway and planning for surgical cricothyrotomy. Residents overall felt that the models simulated the appropriate anatomic scenarios. The majority felt confident in identifying the CTM using US.

Evaluation of a Novel Point-of-Care Ultrasound Curriculum for First-Year Pediatric Residents

OBJECTIVE

The aim of the study is to evaluate a novel point-of-care ultrasound (POCUS) educational curriculum for pediatric residents.

METHODS

The cohort study in graduate medical education was completed from January 2017 to March 2019. Postgraduate year 1 (PGY1) pediatric residents attended the educational curriculum that consisted of 3 half-day sessions over a 3-month period. Each session consisted of a lecture (introduction, extended focused assessment with sonography for trauma, soft tissue/musculoskeletal, cardiac, and resuscitative applications) followed by supervised hands-on scanning sessions. Group ratio was 3 learners to 1 machine/expert instructor. Main outcome measures included pre- and post-written test scores, as well as objective structured clinical examination (OSCE) scores.

RESULTS

Forty-nine PGY1 residents (78% women) completed the curriculum. The mean (SD) pretest score was 68% (8.5), and the mean posttest score was 83% (8.3) with a difference of 15 (95% confidence interval, 12.5-17.6; P < 0.001). Mean (SD) focused assessment with sonography for trauma OSCE score after the curriculum was 88.7% (11.9). The number of PGY1 pediatric residents that were comfortable performing POCUS examinations increased from pretraining to posttraining for soft tissue/musculoskeletal (14%-61%, P < 0.001), extended focused assessment with sonography for trauma (24%-90%, P < 0.001), and cardiac (18%-86%, P < 0.001). All participants found the curriculum useful, and 42 of 49 (86%) stated the curriculum increased their ability to acquire and interpret images.

CONCLUSIONS

Postgraduate year 1 pediatric residents learned the basics of POCUS through 3 brief educational sessions. The increase in posttest scores demonstrated improved POCUS knowledge, and the high OSCE score demonstrated their ability to acquire ultrasound images. Point-of-care ultrasound guidelines are needed for pediatric residency programs.

Optical ultrasound simulation-based training in obstetric sonography

Ultrasound is an imaging modality that is highly operator dependent. This article reviews the challenges in learning how to perform obstetric sonography, as well as the processes necessary to acquire expert performance skills in sonography. Simulation-based education and learning, and the value of medical simulation are also discussed. Ultrasound simulators are an effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. We review evidence that simulation can improve performance in obstetric ultrasound examination, review current simulators, and discuss the current problems/gaps in ultrasound simulation. Optical positioning ultrasound simulation is a novel high-fidelity simulation learning system, which addresses many of these problems/gaps and is introduced for the first time here.

Simulation in Perioperative Liver Transplant Anesthesia: A Systematic Review

Due to the complexity of liver transplant patients and the variability in exposure to transplantation by anesthesia trainees, simulation is often required as an adjunct to clinical experience. This systematic review identifies current simulation models in the literature that pertain to perioperative liver transplant anesthesia.

Data were collected by performing an electronic search of the PubMed and Scopus databases for articles describing simulation in transplant anesthesia. Abstracts were screened using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Three reviewers analyzed 16 abstracts found in the search and agreed upon articles that met the inclusion criteria for the systematic review.

A total of five publications met the inclusion criteria; they could be grouped as cognitive skills and technical skills simulators. Cognitive skills simulators utilized high-fidelity mannequins and animal models combined with traditional educational material to enhance pattern recognition of critical complications during liver transplantation. One manuscript focused on a technical skills acquisition by utilizing transesophageal echocardiography (TEE) to identify intraoperative pathologies.

There is a heterogeneity in the exposure to liver transplant care during anesthesia training. Simulation provides low-stakes exposure to the high-stakes skills required in the operating room. Hence, it can be used as an adjunct to improve both cognitive and technical skill acquisition for perioperative transplant anesthesia. The goal of these simulation programs is to improve patient outcomes and produce more capable anesthesiologists.

Cost-Effective Training Models in Point-of-Care Ultrasound for Medical Students in Emergency Medicine: An Evaluation of Current Resources

Background

Ultrasound is becoming more widely utilized in clinical practice; however, its effectiveness is limited by the operator’s skills. Simulation models are attractive options for developing skills because they allow inexperienced users to practice without the risk of endangering patients.

Objective

The purpose of this study was to identify commercially available and homemade ultrasound models to describe them in terms of materials, cost, and whether they are high- or low-fidelity for medical student education.

Methods

This is an investigational study on cost-effective ultrasound training methods for medical students. Our study was performed using search engines in Google, Google Scholar, and PubMed to search for models for the following five modalities: foreign body identification, intravenous (IV) injection training, abdominal ultrasound, ocular ultrasound, and ultrasound-guided lumbar puncture training.

Results

Most homemade models for foreign body identification, IV injection training, and ocular ultrasound could be created for less than $20. IV injection training models were the cheapest commercially available models. There are multiple commercially available options for abdominal ultrasound models, but no options were found for homemade construction. The construction cost for lumbar puncture models was larger due to the need to purchase an anatomically accurate set of lumbar vertebrae.

Conclusions

This study provides initial guidance and suggestions for ultrasound training models that are currently available. Ultrasound models that can be cheaply made or purchased increase accessibility for medical students to gain early exposure in a cost-effective and safe manner.

Upper gastrointestinal bleeding from a Mallory-Weiss tear associated with transesophageal echocardiography during successful cardiopulmonary resuscitation: A case report

BACKGROUND

In recent years, it has been recognized that transesophageal echocardiography (TEE) is of great value in resuscitation of cardiac arrest. However, its safety has rarely been reported.

CASE SUMMARY

We present a 59-year-old male patient scheduled to undergo cardiac surgery for rheumatic heart disease. Upper gastrointestinal bleeding from a Mallory-Weiss tear appeared following cardiopulmonary resuscitation, TEE, and percutaneous cardiopulmonary bypass resuscitation when he suffered from aesthesia-related cardiac arrest. Gastrointestinal injury was diagnosed promptly and treated effectively. However, the exact etiology of gastrointestinal injury was unclear; the interaction of closed-chest cardiac massage and the application of TEE may be involved as a most possible mechanism of injury.

CONCLUSION

Serious complications should be considered when TEE is used in patients with special pathophysiological conditions.

Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice

Introduction

Transthoracic echocardiography (TTE) is a standard procedure for emergency physicians (EPs). Transesophageal echocardiography (TEE) is known to have great utility in patients who are critically ill or in cardiac arrest and has been used by some EPs with specialized ultrasound (US) training, but it is generally considered outside the reach of the majority of EPs. We surmised that all of our EPs could learn to perform focused TEE (F‐TEE), so we trained and credentialed all of the physicians in our group.

Methods

We trained 52 EPs to perform and interpret F‐TEEs using a 4‐h simulator‐based course. We kept a database of all F‐TEE examinations for quality assurance and continuous quality feedback. Data are reported using descriptive statistics.

Results

Emergency physicians attempted 557 total F‐TEE examinations (median = 10, interquartile range = 5–15) during the 42‐month period following training. Clinically relevant images were obtained in 99% of patients. EPs without fellowship or other advanced US training performed the majority of F‐TEEs (417, 74.9%) and 94.3% (95% confidence interval [CI] = 91.4%–96.3%) had interpretable images recorded. When TTE and TEE were both performed (n = 410), image quality of TEE was superior in 378 (93.3%, 95% CI = 89.7%–95%). Indications for F‐TEE included periarrest states (55.7%), cardiac arrest (32.1%), and shock (12.2%). There was one case of endotracheal tube dislodgement during TEE placement, but this was immediately identified and replaced without complication.

Conclusion

After initiating a mandatory group F‐TEE training and credentialing program, we report the largest series to date of EP‐performed resuscitative F‐TEE. The majority of F‐TEE examinations (75%) were performed by EPs without advanced US training beyond residency.

Credentialing Pediatric Emergency Medicine Faculty in Point-of-Care Ultrasound: Expert Guidelines

ABSTRACT

As point-of-care ultrasound (POCUS) becomes standard practice in pediatric emergency medicine (PEM), it is important to have benchmarks in place for credentialing PEM faculty in POCUS. Faculty must be systematically trained and assessed for competency in order to be credentialed in POCUS and granted privileges by an individual institution. Recommendations on credentialing PEM faculty are needed to ensure appropriate, consistent, and responsible use of this diagnostic and procedural tool. It is our intention that these guidelines will serve as a framework for credentialing faculty in PEM POCUS.

Assessment of OB/Gyn Residents’ Knowledge of Basic Obstetric Sonography and Psychomotor Skills Posttraining on a Computer-Based Simulator

Objective:

This study sought to evaluate how a high-fidelity computer-based sonography simulator (FCBSS) can be used in training obstetrics and gynecology residents and evaluate efficacy of high-fidelity CBSS in enhancing resident’s sonographic knowledge, psychomotor skills, and level of confidence in performing sonographic fetal assessments.

Materials and Methods:

Eleven postgraduate year 1 residents (PGY1s) and ten PGY2s were assessed on sonographic performance by measuring psychomotor skills and evaluating the accuracy of the sonographic images. PGY2s received traditional sonography training while PGY1s received three individualized training sessions on a high-fidelity CBSS. At the conclusion, all residents received feedback and completed a survey to establish their current confidence level in performing and interpreting sonograms.

Results:

PGY2s scored a median of 33/66 points on the assessment, while PGY1s scored a median of 64/66 points. Statistical analysis performed from motion analysis metrics between cohorts revealed a statistically significant difference, with PGY1s demonstrating higher psychomotor skills. Interquartile ranges of PGY1s’ scores were smaller than PGY2s’, revealing consistency in knowledge and skills among the PGY1 cohort.

Conclusion:

Findings suggests that high-fidelity CBSS can be used effectively in training residents. It also demonstrates that implementation of formalized sonography training, using a high-fidelity CBSS, can be achieved and potentially expedite and enhance the learning of novice learners.

Virtual multispecialty point-of-care ultrasound rotation for fourth-year medical students during COVID-19: Innovative teaching techniques improve ultrasound knowledge and image interpretation

OBJECTIVES

Point-of-care ultrasound (PoCUS) has been integrated into undergraduate medical education. The COVID-19 pandemic forced medical schools to evolve clinical rotations to minimize interruption through implementation of novel remote learning courses. To address the students' need for remote clinical education, we created a virtual PoCUS course for our fourth-year class. We present details of the course's development, implementation, quality improvement processes, achievements, and limitations.

METHODS

A virtual PoCUS course was created for 141 fourth-year medical students. The learning objectives included ultrasound physics, performing and interpreting ultrasound applications, and incorporating PoCUS into clinical decisions and procedural guidance. Students completed a 30-question pre- and posttest focused on ultrasound and knowledge of clinical concepts. PoCUS educators from 10 different specialties delivered the course over 10 days using video-conferencing software. Students watched live scanning demonstrations and practiced ultrasound probe maneuvers using a cellular telephone to simulate ultrasound probe. Students completed daily course evaluations that were used as a continuous needs assessment to make improvements.

RESULTS

A total of 141 students participated in the course; all received a passing grade. The mean pre- and posttest scores improved from 58% to 88% (p < 0.001) through the course duration. Daily evaluations revealed the percentage of students who rated the course's live scanning sessions and didactic components as "very well" increased from 32.7% on day 1 to 69.7% on day 10. The end-of-course evaluation revealed that 91% of students agreed they received effective teaching.

CONCLUSIONS

In response to the COVID-19 pandemic, our multispecialty faculty expeditiously developed a virtual PoCUS curriculum for the entire fourth-year class. This innovative course improved students' ultrasound knowledge, image interpretation, and clinical application while utilizing novel techniques to teach a hands-on skill virtually. As the demand for PoCUS instruction continues to increase, the accessibility of virtual training and blended learning will be beneficial.

Longitudinal accuracy analysis of ultrasound performed during a four-year emergency medicine residency

BACKGROUND

The objective of this study was to analyze patterns of point-of-care ultrasound (POCUS) performance over 4 years of emergency medicine (EM) residency. Specifically, we aimed to study how accuracy and adherence to standards of scanning changed by postgraduate year (PGY).

METHODS

This was a retrospective observational study of resident-performed POCUS at an academic emergency department over 6 years. We reviewed records of POCUS scans performed by PGY-1 to -4 residents that had been collected for quality assurance purposes. Data that were collected about EM residents' performance included the total number and type of scans per year, rate of technically limited scans (TLS), and accuracy on interpreting ultrasound images. Resident performances in each year (PGY-1 to -4) were independently evaluated and reported.

RESULTS

During a 6-year period, 137 different EM residents performed 50,815 ultrasound scans. The median number of scans was 177 for PGY-1, 124 for PGY-2, 118 for PGY-3, and 76 for residents in PGY-4. The accuracy of scan interpretations were high across all PGY levels (>97%), but slight degradation was observed as residents progressed through residency. The TLS rate increased from 4.7% among PGY-1s to 13.6% as PGY-4s.

CONCLUSIONS

In this large cohort of POCUS studies by EM residents, POCUS accuracy rates decreased and rates of TLS significantly increased as residents progressed through residency.

Evaluating a Web-based Point-of-care Ultrasound Curriculum for the Diagnosis of Intussusception

OBJECTIVES

Intussusception is a pediatric medical emergency that can be difficult to diagnose. Radiology-performed ultrasound is the diagnostic study of choice but may lead to delays due to lack of availability. Point-of-care ultrasound for intussusception (POCUS-I) studies have shown excellent accuracy and reduced lengths of stay, but there are limited POCUS-I training materials for pediatric emergency medicine (PEM) providers.

METHODS

We performed a prospective cohort study assessing PEM physicians undergoing a primarily Web-based POCUS-I curriculum. We developed the POCUS-I curriculum using Kern's six-step model. The curriculum included a Web-based module and a brief, hands-on practice that was developed with a board-certified pediatric radiologist. POCUS-I technical skill, knowledge, and confidence were determined by a direct observation checklist, multiple-choice test, and a self-reported Likert-scale survey, respectively. We assessed participants immediately pre- and postcourse as well as 3 months later to assess for retention of skill, knowledge, and confidence.

RESULTS

A total of 17 of 17 eligible PEM physicians at a single institution participated in the study. For the direct observation skills test, participants scored well after the course with a median (interquartile range [IQR]) score of 20 of 22 (20-21) and maintained high scores even after 3 months (20 [20-21]). On the written knowledge test, there was significant improvement from 57.4% (95% CI = 49.8 to 65.2) to 75.3% (95% CI = 68.1 to 81.6; p < 0.001) and this improvement was maintained at 3 months at 81.2% (95% CI = 74.5 to 86.8). Physicians also demonstrated improved confidence with POCUS-I after exposure to the curriculum, with 5.9% reporting somewhat or very confident prior to the course to 76.5% both after the course and after 3 months (p < 0.001).

CONCLUSION

After a primarily Web-based curriculum for POCUS-I, PEM physicians performed well in technical skill in POCUS-I and showed improvement in knowledge and confidence, all of which were maintained over 3 months.

Web-Based GPU-Accelerated Application for Multiplanar Reconstructions from Conventional 2D Ultrasound

PURPOSE

 In ultrasound education there is a need for interactive web-based learning resources. The purpose of this project was to develop a web-based application that enables the generation and exploration of volumetric datasets from cine loops obtained with conventional 2D ultrasound.

MATERIALS AND METHODS

 JavaScript code for ultrasound video loading and the generation of volumetric datasets was created and merged with an existing web-based imaging viewer based on JavaScript and HTML5. The Web Graphics Library was utilized to enable hardware-accelerated image rendering.

RESULTS

 The result is a web application that works in most major browsers without any plug-ins. It allows users to load a conventional 2D ultrasound cine loop which can subsequently be manipulated with on-the-fly multiplanar reconstructions as in a Digital Imaging and Communications in Medicine (DICOM) viewer. The application is freely accessible at (http://www.castlemountain.dk/atlas/index.php?page=mulrecon&mulreconPage=sonoviewer) where a demonstration of web-based sharing of generated cases can also be found.

CONCLUSION

 The developed web-based application is unique in its ability to easily perform loading of one's own ultrasound clips and conduct multiplanar reconstructions where interactive cases can be shared on the Internet.

Point-of-care ultrasound in urology: Design and evaluation of a feasible introductory training program for Canadian residents

INTRODUCTION

Point-of-care ultrasound (POCUS) is an increasingly used bedside tool. Applications in urology include the assessment of an undifferentiated acute scrotum, renal colic, and the guidance of suprapubic catheter placement. However, the user-dependent nature of this modality necessitates appropriate use and competence. The objective of this study was to develop and evaluate a low-cost, feasible, and guideline-based introductory POCUS program for Canadian urology residents.

METHODS

Residents from McMaster University's urology program completed a three-hour online course, followed by a three-hour hands-on seminar. Course material was developed by ultrasound educators based on national guidelines. Low-cost testicular phantoms and suprapubic catheter insertion models were constructed. Pre- and post-course surveys focused on participant skill confidence, while multiple-choice questionnaires assessed theoretical knowledge.

RESULTS

Fourteen residents participated in the course. Theoretical knowledge in POCUS improved significantly (p<0.001, d=2.2) and mean confidence scores improved for all skills, including performing kidney, bladder, and testicular POCUS (all p<0.001; d=3.4, 1.9, 2.9, respectively). Participants indicated that the course increased their confidence and likelihood of using POCUS in clinical practice, and that POCUS training should be integrated into urology training curricula.

CONCLUSIONS

This novel study included the development of an inexpensive, feasible, guideline-based introductory training program for urological POCUS, developed in collaboration with ultrasound educators. Participants significantly improved in theoretical knowledge and skill confidence. Although this study was limited to one residency program, the basis of this course may serve as a foundation for the development of competency-based training for urological POCUS in Canada.

Didactic education in paediatric cardiology during the COVID-19 pandemic: a national fellow survey

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on medical educational curricula. We aimed to examine the impact of these unprecedented changes on the formal education of paediatric cardiology fellows through a nationwide survey. A REDCap™-based voluntary anonymous survey was sent to all current paediatric cardiology fellows in the United States of America in May, 2020. Of 143 respondents, 121 were categorical fellows, representing over one-fourth of all categorical paediatric cardiology fellows in the United States of America. Nearly all (140/143, 97.9%) respondents utilised online learning during the pandemic, with 134 (93.7%) reporting an increase in use compared to pre-pandemic. The percentage of respondents reporting curriculum supplementation with outside lectures increased from 11.9 to 88.8% during the pandemic. Respondents considered online learning to be "equally or more effective" than in-person lectures in convenience (133/142, 93.7%), improving fellow attendance (132/142, 93.0%), improving non-fellow attendance (126/143, 88.1%), and meeting individual learning needs (101/143, 70.6%). The pandemic positively affected the lecture curriculum of 83 respondents (58.0%), with 35 (24.5%) reporting no change and 25 (17.5%) reporting a negative effect. A positive effect was most noted by those whose programmes utilised supplemental outside lectures (62.2 versus 25.0%, p = 0.004) and those whose lecture frequency did not decrease (65.1 versus 5.9%, p < 0.001). Restrictions imposed by the COVID-19 pandemic have greatly increased utilisation of online learning platforms by medical training programmes. This survey reveals that an online lecture curriculum, despite inherent obstacles, offers advantages that may mitigate some negative consequences of the pandemic on fellowship education.

Implementing the transvaginal ultrasound simulation training (TRUSST) programme for obstetric registrars

BACKGROUND

Transvaginal ultrasound (TVUS) training opportunities are limited due to its intimate nature; however, TVUS is an important component of early pregnancy assessment. Simulation can bridge this learning gap.

AIM

To describe and measure the effect of a transvaginal ultrasound simulation programme for obstetric registrars.

MATERIALS AND METHODS

The transvaginal ultrasound simulation training (TRUSST) curriculum consisted of supported practice using virtual reality transvaginal simulators (ScanTrainer, Medaphor) and communication skills training to assist obstetric registrars in obtaining required competencies to accurately and holistically care for women with early pregnancy complications. Trainee experience of live transvaginal scanning was evaluated with a questionnaire. Programme evaluation was by pre-post self-reported confidence level and objective pre-post training assessment using Objective Structured Assessment of Ultrasound Skills (OSAUS) and modified Royal Australian and New Zealand College of Obstetrics and Gynaecology assessment scores. Quantitative data was compared using paired t tests.

RESULTS

Fifteen obstetric registrars completed the programme. Numbers of performed live transvaginal ultrasound by trainees were low. Participants reported an increase in confidence level in performing a TVUS following training: mean pre score 1.6/5, mean post score 3/5. Objective assessments improved significantly across both OSAUS and RANZCOG scores following training; mean improvement scores 7.6 points (95% CI 6.2-8.9, p < 0.05) and 32.5 (95% CI 26.4-38.6, p < 0.05) respectively. It was noted that scores for a systematic approach and documentation were most improved: 1.9 (95% CI 1.4-2.5, p < 0.05) and 2.1 (95% CI 1.5-2.7, p < 0.05) respectively.

CONCLUSION

The implementation of a simulation-based training curriculum resulted in improved confidence and ability in TVUS scanning, especially with regard to a systematic approach and documentation.

Usefulness of an Intrapartum Ultrasound Simulator (IUSim™) for Midwife Training: Results from an RCT

INTRODUCTION

We conducted a randomized study to determine whether a training session on a dedicated simulator (IUSim™) would facilitate the midwives in learning the technique of transperineal intrapartum ultrasound.

METHODS

Following a 30-min multimedia presentation including images and videos on how to obtain and measure the angle of progression (AoP) and the head-perineum distance (HPD), 6 midwives with no prior experience in intrapartum ultrasound were randomly split into 2 groups: 3 of them were assigned to the "training group" and 3 to the "control group." The midwives belonging to the former group were taught to measure the 2 sonographic parameters during a 3-h practical session conducted on IUSim™ under the supervision of an expert obstetrician. In the following 3 months, all the 6 midwives were asked to independently perform transperineal ultrasound during their clinical practice and to measure on the acquired images either the AoP or the HPD. The sonographic images were examined in blind by the teaching obstetrician who assigned a 0-3 score to the image quality (IQS) and to the measurement quality (MQS).

RESULTS

A total of 48 ultrasound images (24 patients) from 5 midwives were acquired and included in the study analysis. A midwife of the "training group" declined participation after the practical session. Independently from the randomization group, the image quality score (IQS + MQS) was significantly higher for the HPD compared with the AoP (2.5 ± 0.66 vs. 1.79 ± 1.14; p = 0.01). In the training group, the MQS of either AoP (2.66 ± 0.5 vs.1.46 ± 1.45. p = 0.038) and the HPD (2.9 ± 0.33 vs. 1.87 ± 0.83 p = 0.002) was significantly higher in comparison with the control group, while the IQS of both measurements was comparable between the 2 groups (1.91 ± 1.24 vs. 2.25 ± 0.865; p = 0.28).

CONCLUSION

The use of a dedicated simulator may facilitate the midwives in learning how to measure the AoP and the HPD on transperineal ultrasound images.

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Background

In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally.

Methods

This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement.

Results

Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties.

Conclusions

Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

Clinical Integration of Point-of-care Ultrasound by Emergency Medicine Residents: A Single-center Mixed-methods Study

BACKGROUND

Point-of-care ultrasound (POCUS) competence consists of image acquisition, image interpretation, and clinical integration. Limited data exist on POCUS usage patterns and clinical integration by emergency medicine (EM) residents. We sought to determine actual POCUS usage and clinical integration patterns by EM residents and to explore residents' perspectives on POCUS clinical integration.

METHODS

We conducted an explanatory sequential mixed-methods study at a 4-year EM residency program. In phase 1, EM ultrasound (US) attendings observed PGY-4 EM residents' clinical integration of POCUS in real time while on shift in the emergency department (ED). EM US attendings evaluated residents on their intent to perform POCUS, actual POCUS usage, and competence per patient encounter. We used logistic regression to analyze these parameters. In phase 2, we conducted semi-structured interviews with the observed PGY-4 residents regarding POCUS usage and clinical integration in the ED. We analyzed qualitative data for themes.

RESULTS

Emergency medicine US attendings observed 10 PGY-4 EM residents during 254 high-acuity patient encounters from December 2018 to March 2019. EM US attendings considered POCUS indicated for 26% (66/254) of patients, possibly indicated for 12% (30/254) and not indicated for 62% (158/254). Of the 66 patients for whom EM US attendings considered POCUS indicated, PGY-4s intended to perform POCUS for patient management 61% (40/66) of the time. PGY-4s subsequently incorporated POCUS into patient management 73% (48/66) of the time. EM US attendings considered PGY-4s entrustable to perform POCUS independently 81% (206/254) of the time. We did not find a statistically significant association between shift volume, shift type, or POCUS application, and resident intent to perform POCUS nor competence. Interviews identified three factors that influence PGY-4's POCUS clinical integration: motivations to use POCUS, barriers to utilization, and POCUS educational methods.

CONCLUSIONS

This mixed-methods study identified a significant gap in POCUS utilization and clinical integration by PGY-4 EM residents for clinically indicated cases identified by EM US attendings. As clinical integration is a cornerstone of POCUS competence, it is important to ensure that EM resident POCUS curricula emphasize training on clinical utilization and indications for POCUS while on shift in the ED.

Effectiveness of High-Fidelity Simulation in Training Emergency Medicine Physicians in Point of Care Ultrasonography in Pakistan: A Quasi-Experimental Study

Background Point-of-care ultrasound (PoCUS) is frequently utilized in emergency medicine (EM), with an extended-focused assessment with sonography in trauma (e-FAST) being the most widely used PoCUS modality. This modality is not only time- and cost-efficient, but it is highly accurate in the diagnosis and management of surgical patients in the emergency department, as well as being highly predictive of patient outcomes. Targeted training is essential to ensure a learner's confidence in image acquisition, interpretation, and translation of knowledge to making clinical decisions. High-fidelity simulation offers a uniquely safe and "mistake-forgiving" environment to teach and train medical professionals. The present study evaluated the effectiveness of a high-fidelity simulator to train EM physicians in e-FAST at a tertiary care teaching hospital in a lower-middle-income country. Methods This quasi-experimental study was performed at a state-of-the-art simulation center of a multidisciplinary university hospital in Karachi, Pakistan. Subjects were included if they were EM physicians who volunteered to participate and were available for the entire training and testing period. The educational intervention included lectures and hands-on practice on a high-fidelity simulator (SonoSim, Santa Monica, CA). Knowledge and image interpretation on e-FAST were evaluated using a questionnaire, administered before and after the training course. Each participant's ability to acquire and interpret satisfactory images was assessed by experienced EM physicians and recorded. Participants were also administered a needs assessment survey and a course evaluation. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). All the tests were two-sided, and p-values ≤0.05 were considered significant. Baseline characteristics and outcome variables were recorded and compared by Wilcoxon signed-rank tests. Results A total of 31 EM physicians, 12 (38.7%) men and 19 (61.3%) women, were enrolled in the study, with 24 (77.3%) having one to three years of EM experience. Mean and percentage group performance improved from 6 and 40% before the intervention to 14.5 and 96.6% after the intervention (Z=4.867, p≤0.05). Most improvement in image acquisition on high-fidelity simulation was observed in the upper right quadrant of the suprapubic window (29/31; 93.5%), followed by the upper left quadrant (27/31; 87%) and the subxiphoid window (21/31; 67%). All 31 participants reported improvements in comfort and confidence level with PoCUS after attending the workshop. Conclusions EM physicians who attended a brief workshop incorporating simulation demonstrated improvements in knowledge and image acquisition skills in all domains tested. High-fidelity simulation training is an effective modality for training EM physicians in e-FAST.

Developing Neuraxial and Regional Pain Procedural Skills Through Innovative 3-Dimensional Printing Technology

Context

Various forms of simulation-based training, including training models, increase training opportunities and help assess performance of a task. However, commercial training models for lumbar puncture and epidural procedures are costly.

Objective

To assess medical students’ and residents’ perception of 3-dimensional (3D)-printed lumbar, cervical, and pelvic models for mastering joint injection techniques and to determine the utility of ultrasonography-guided needle procedure training.

Methods

Osteopathic medical students and residents used in-house 3D-printed gel joint models during an injection ultrasonography laboratory for mastering lumbar epidural, caudal epidural, sacroiliac, and facet joint injection techniques. After the laboratory, they answered a 17-item survey about their perception of the importance of the models in medical education and future practice. The survey also evaluated comfort levels with performing joint injections after using the models, overall satisfaction with the models, and likelihood of using models in the future.

Results

Thirty-six medical students and residents participated. Both students and residents agreed that 3D-printed models were easy to use, aided understanding of corresponding procedures, and increased comfort with performing joint injections (all P<.001). Most participants (35 [97.2%]) believed that the models were reasonable alternatives to commercial models. Over half felt capable of successfully performing cervical or pelvic (22 [61.1%]) and lumbar epidural (23 [63.9%]) injections. The majority of participants (34 [94.4%]) would like to use the models in the future for personal training purposes. Overall, 100% believed that the 3D-printed models were a useful tool for injection training.

Conclusions

Results suggest that 3D-printed models provided realistic training experience for injection procedures and seemed to allow participants to quickly master new injection techniques. These models offer a visual representation of human anatomy and could be a cost-saving alternative to commercial trainers.

SnappySonic: An Ultrasound Acquisition Replay Simulator

SnappySonic provides an ultrasound acquisition replay simulator designed for public engagement and training. It provides a simple interface to allow users to experience ultrasound acquisition without the need for specialist hardware or acoustically compatible phantoms. The software is implemented in Python, built on top of a set of open source Python modules targeted at surgical innovation. The library has high potential for reuse, most obviously for those who want to simulate ultrasound acquisition, but it could also be used as a user interface for displaying high dimensional images or video data.

Introducing point-of-care ultrasound through structured multifaceted ultrasound module in the undergraduate medical curriculum at the University of Hong Kong

Incorporation of point-of-care ultrasound in the undergraduate medical curriculum is of great importance to ensure early exposure and safe use of the modality. We aimed to assess the students' learning experiences following implementing an ultrasound module in the medical curriculum at the University of Hong Kong. Medical students in semester 6 (n = 221) were enrolled in the module in 2018. It consisted of 1 hour of didactic lecture, followed by 3 hours of hands-on session. The students had the opportunity to enroll into a four-week Special Study Module to further practice their skills. The students had access to an e-learning platform to assist in their learning. Outcome measures include task-based performance, quizzes, feedback, and round-table discussion to assess the learning experiences. The module was highly rated by over 90% of students (response rate of 96%). Students practiced on peer subject on upper abdominal scanning. Post-training assessment showed an increment of 16% in their understanding of the modality. Students were motivated to enroll into the Special Study Module, where they were trained and became proficient with Focused Assessment with Sonography with Trauma. More than 86% of the students found the e-learning platform easy to use and assisted the training session. Round-table discussion suggested more simulated clinical cases to be added and expansion of future modules. Ultrasound module was successfully implemented into the undergraduate medical curriculum at the University of Hong Kong through new pedagogical approaches. This integration was highly rated by the medical students with improved awareness and better understanding of point-of-care ultrasound.

Tools for Measuring Clinical Ultrasound Competency: Recommendations From the Ultrasound Competency Work Group

Competency in clinical ultrasound is essential to ensuring safe patient care. Competency in clinical ultrasound includes identifying when to perform a clinical ultrasound, performing the technical skills required for ultrasound image acquisition, accurately interpreting ultrasound images, and incorporating sonographic findings into clinical practice. In this concept paper, we discuss the advantages and limitations of existing tools to measure ultrasound competency. We propose strategies and future directions for assessing competency in clinical ultrasound.

Not Another Boring Resident Didactic Conference

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) requires that residency programs in emergency medicine plan at least 5 hours of didactic experiences per week. Instructional methods should include small-group techniques, problem-based learning, or computer-based instruction. Despite recommendations from the ACGME, many programs' conference didactics continue to include primarily lecture-based instruction.

METHODS

The authors describe instructional methods that promote active learning and may be superior to traditional lecture-based education.

RESULTS

These methods include varying instructional methods, case-based learning, team-based learning and the flipped classroom, audience response systems, simulation, "wars," oral boards, escape rooms and scavenger hunts, expert panel discussions, debates, clinical pathologic cases, and leaderboards. The authors discuss how these methods can be implemented to make emergency medicine didactic conferences more varied and interactive for learners.

CONCLUSIONS

While there is minimal research on the efficacy of these methods in graduate medical education, many have shown to improvement engagement of learners and to be effective in undergraduate medical education. Further research will be needed to determine if long-term learning outcomes can be improved with these strategies.

Simulation in Neurocritical Care: Past, Present, and Future

Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.

Orthopaedic residents demonstrate retention of point of care ultrasound knowledge after a brief educational session: a quasi experimental study

BACKGROUND

Musculoskeletal point of care ultrasound (MSK POCUS) has many uses for orthopaedic surgeons, but orthopaedic trainees are rarely exposed to this modality. The purpose of this project was to assess the usefulness in clinical education of a newly implemented MSK POCUS course in an orthopaedic surgery program.

METHODS

An MSK POCUS course for orthopaedic surgery residents was developed by an interdisciplinary team. Online videos were created to be viewed by residents prior to a half-day long practical course. An online survey covering the level of training of the resident and their previous use of ultrasound (total hours) was completed by the participants prior to the course. Resident's knowledge acquisition was measured with written pre-course, same-day post-course and six-month follow-up tests. Residents were also scored on a practical shoulder examination immediately after the course and at six-month follow-up. Changes in test scores between time points were evaluated using Wilcoxon signed-rank tests.

RESULTS

Ten orthopaedic surgery residents underwent the MSK POCUS curriculum. Pre-course interest in MSK-POCUS was moderate (65%) and prior exposure was low (1.5 h mean total experience). Written test scores improved significantly from 50.7 ± 17.0% before to 84.0 ± 10.7% immediately after the course (p < 0.001) and suffered no significant drop at 6 months (score 75.0 ± 8.7%; p = 0.303). Average post-course practical exam score was 78.8 ± 3.1% and decreased to 66.2 ± 11.3% at 6 months (p = 0.012). Residents significantly improved their subjective comfort level with all aspects of ultrasound use at 6 months (p = 0.007-0.018) but did not significantly increase clinical usage frequency.

CONCLUSION

An MSK POCUS curriculum was successfully developed and implemented using an interdisciplinary approach. The course succeeded in improving the residents' knowledge, skills, and comfort with MSK POCUS. This improvement was maintained at 6 months on the written test but did not result in higher frequency of use by the residents.

Pre- and post-review of a standardized ultrasound-guided central venous catheterization curriculum evaluating procedural skills acquisition and clinician confidence

Background:

To evaluate novice and expert clinicians’ procedural confidence utilizing a blended learning mixed fidelity simulation model when applying a standardized ultrasound-guided central venous catheterization curriculum.

Methods:

Simulation-based education and ultrasound-guided central venous catheter insertion aims to provide facility-wide efficiencies and improves patient safety through interdisciplinary collaboration. The objective of this quality improvement research was to evaluate both novice (<50) and expert (>50) clinicians’ confidence across 100 ultrasound-guided central venous catheter insertion courses were performed at a mixture of teaching and non-teaching hospitals across 26 states within the United States between April 2015 and April 2016. A total of 1238 attendees completed a pre- and post-survey after attending a mixed method clinical simulation course. Attendees completed a 4-h online didactic education module followed by 4 h of hands-on clinical simulation stations (compliance/sterile technique, needling techniques, vascular ultrasound assessment, and experiential complication management).

Results:

The use of a standardized evidence-based ultrasound-guided central venous catheter curriculum improved confidence and application to required clinical tasks and knowledge across all interdisciplinary specialties, regardless of level of experience. Both physician and non-physician groups resulted in statistically significant results in both procedural compliance ( p < 0.001) and ultrasound skills ( p < 0.001).

Conclusion:

The use of a standardized clinical simulation curriculum enhanced all aspects of ultrasound-guided central venous catheter insertion skills, knowledge, and improved confidence for all clinician types. Self-reported complications were reported at significantly higher rates than previously published evidence, demonstrating the need for ongoing procedural competencies. While there are growing benefits for the role of simulation-based programs, further evaluation is needed to explore its effectiveness in changing the quality of clinical outcomes within the healthcare setting.

Use of a Refresher Course Increases Confidence in Point-of-Care Ultrasound Skills in Emergency Medicine Faculty

Introduction All practicing emergency medicine (EM) physicians need to maintain a skillset in emergency ultrasound (US) after their initial training. EM physicians in academic practice may be supervising trainees performing ultrasound applications that they aren't comfortable with. This study investigates the effectiveness of a US refresher course. The hypothesis was that a series of short courses would increase confidence in performing and supervising US applications. Methods Nine basic emergency ultrasound applications were taught over the course of one year by ultrasound fellowship-trained EM faculty in a simulation center at a single academic institution. Each session included 30-minutes of didactics/image review and 30-minutes of hands-on practice on normal volunteers and was followed by an anonymous questionnaire evaluating comfort level performing and supervising the ultrasound application before and after the course using a Likert scale from 1 "not at all confident" to 5 "very confident". Results Thirty-six of 60 EM physicians participated in at least 1 of the 9 sessions (median 3, interquartile range 2-4). Faculty who attended had a median of 10 (interquartile range 7-15) years in practice and 61% work at both academic and community sites. For all sessions combined, confidence in performing US increased from a mean score on the Likert scale of 3.3 to 4.4 (difference 1.1, confidence interval (CI) (0.94, 1.29), p < 0.001) and confidence in supervising trainees increased from a mean of 3.4 to 4.5 (difference 1.1, CI (0.88, 1.23), p < 0.001). The largest increases were seen in musculoskeletal (MSK), nerve, and pelvic applications and the least increase was seen with the session focused on intravenous access, but confidence was increased in all sessions. Physicians in practice ≥10 years increased in confidence in performing and supervising the applications by 1.4 (CI (1.11, 1.60), p < 0.001) and 1.3, (CI (1.01, 1.49), p < 0.001), respectively. Physicians in practice <10 years increased 0.8 (CI (0.57, 1.03), p < 0.001) and 0.8 (CI (0.55, 1.05), p < 0.001), respectively. Conclusion An emergency ultrasound refresher course for EM physicians at a single institution improved self-reported confidence in both performing and supervising trainees in all applications reviewed. Those in practice ≥10 years showed the largest increases.

Long-Term Retention of Musculoskeletal Ultrasound Training During Residency

The Accreditation Council for Graduate Medical Education and the American Board of Physical Medicine and Rehabilitation developed milestones for evaluation of resident physicians that include proper musculoskeletal ultrasound examination of major joints. To date, there have been no published data demonstrating acquisition and retention of these skills and correlation with the milestone evaluation. The investigators developed and implemented a curriculum in musculoskeletal ultrasound examination for Physical Medicine and Rehabilitation residents at a large academic medical center. The investigators chose the following six joints for training and evaluation: ankle, elbow, hip, knee, shoulder, and wrist/hand. The program included: (1) didactic lectures on anatomy and ultrasound technique; (2) peer-led demonstrations of the procedure on a standardized patient (SP); (3) individual practice on standardized patients; (4) faculty observation and feedback; (5) review sessions and additional practice; and (6) assessment of skills in an objective structured clinical examination. From 2013 to 2017, 30 physical medicine and rehabilitation residents were trained and evaluated. The results, based on objective structured clinical examination scores, showed that most residents achieved the appropriate level of competency for their year. A blended, standardized curriculum in musculoskeletal ultrasound instruction with assessment by an objective structured clinical examination can be used to evaluate musculoskeletal ultrasound skills and can help align this education with residency milestones.

Accessible Personal Ultrasound Training Simulator

OBJECTIVES

Ultrasound simulators are increasingly used for teaching and training purposes, but development has been limited by the need for dedicated and often expensive hardware. The objective of this study was to develop and deploy an accessible and very low-cost personal ultrasound training simulator and obtain trainee feedback.

METHODS

An ultrasound simulator software program that uses a smartphone as a "mock-probe" and a laptop computer as a "mock ultrasound machine" was created. Spatial positional data is acquired from the smartphone's inbuilt accelerometer and gyroscope and transmitted to the laptop computer for processing and display of simulated ultrasound images in real time by the software program. After obtaining institutional review board approval and informed consent, all first-year radiology residents at our institution were provided access to the simulator program during the "bootcamp" introductory conference series, and a written survey was conducted to obtain feedback.

RESULTS

A personal ultrasound training simulator software program (Persimus) that reliably performs motion sensing along 2 axes and displays simulated ultrasound images was developed. Nine of 12 (75%) first-year residents at our institution participated in the written survey. Residents' scored values were 8.44 ± 1.33 and 8.44 ± 1.33 (mean + standard deviation) for perceived utility and overall impression and satisfaction, respectively, of the simulator on the Likert scale (1-10, with 10 being the highest score).

CONCLUSION

Personal ultrasound simulators are technically feasible. These are well received by first-year radiology residents and perceived as useful to their education.

Assessing how emergency and trauma ultrasonography is taught to medical students

Objective

To evaluate a method aimed at teaching ultrasound techniques to medical students in emergency settings.

Methods

A prospective study conducted with 66 sixth-year undergraduate medical students. Students participated in theory and practicing sessions with a 5-hour load; knowledge acquisition was assessed through pre- and post-course and 90-day tests. A questionnaire were distributed to the students after course completion for theoretical and practical knowledge assessment.

Results

Average pre-test grade in theoretical content evaluation was 4.9, compared to 7.6 right after course completion, and 5.9 within 90 days (p<0.001). Questions addressing technical aspects and image acquisition were mostly answered correctly; in contrast, questions related to clinical management of patients tended to be answered incorrectly. In practical evaluation, 54 students (81.8%) were able to correctly interpret images.

Conclusion

Ultrasound applicability and image acquisition techniques can be taught to medical students in emergency settings. However, teaching should be focused on technical aspects rather than clinical management of patients.