Prospective evaluation of point-of-care ultrasound for pre-procedure identification of landmarks versus traditional palpation for lumbar puncture

BACKGROUND: The objective of this study is to determine if point-of-care ultrasound(POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture(LP).METHODS: This was a prospective, randomized controlled trial comparing POCUS preprocedure identifi cation of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit.RESULTS: A total of 158 patients were enrolled. No signifi cant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation.CONCLUSION: Consistent with fi ndings of previous studies, our data indicate that there was no observed benefi t of using POCUS to identify pre-procedure landmarks when performing an LP.

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center

BACKGROUND:Point-of-care ultrasound(POCUS)has become increasingly integrated into the practice of emergency medicine.A common application is the extended focused assessment with sonography in trauma(eFAST)exam.The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation.The objective of this study was to conduct a review of performed,documented and billed eFAST ultrasounds on trauma activation patients.METHODS:This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center.A list comparing all trauma activations was crossreferenced with a list of all billed eFAST scans.Medical records were reviewed to determine whether an eFAST was indicated,performed,and appropriately documented.RESULTS:We found that 1,507 of 1,597 trauma patients had indications for eFAST,but 396(27%)of these patients did not have a billed eFAST.Of these 396 patients,87(22%)had documentation in the provider note that an eFAST was performed but there was no separate procedure note.The remaining 309(78%)did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance.CONCLUSION:A significant proportion of trauma patients had eFAST exams performed but were not documented or billed.Lack of documentation was multifactorial.Emergency ultrasound programs require appropriate reimbursement to support training,credentialing,equipment,quality assurance,and device maintenance.Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

A comparison of simulation versus didactics for teaching ultrasound to Swiss medical students

BACKGROUND: Point-of-care ultrasound is an increasingly common imaging modality that is used in a variety of clinical settings. Understanding how to most effectively teach ultrasound is important to ensure that medical students learn pre-clinical content in a manner that promotes retention and clinical competence. We aim to assess the effectiveness of simulation-based ultrasound education in improving medical student competence in physiology in comparison to a traditional didactic ultrasound curriculum. METHODS: Subjects were given a pre and post-test of physiology questions. Subjects were taught various ultrasound techniques via 7 hours of lectures over two days. The control group received 2 additional hours of practice time while the experimental group received 2 hours of case-based simulations. A physiology post-test was administered to all students to complete the two-day course. RESULTS: Totally 115 Swiss medical students were enrolled in our study. The mean precourse ultrasound exam score was 39.5% for the simulation group and 41.6% for the didactic group (P>0.05). The mean pre-course physiology exam score was 54.1% for the simulation group and 59.3% for the didactic group (P>0.05). The simulation group showed statistically significant improvement on the physiology exam, improving from 54.1% to 75.3%(P<0.01). The didactic group also showed statistically signifi cant improvement on the physiology exam, improving from 59.3% to 70.0%(P<0.01). CONCLUSION: Our data indicates that both simulation curriculum and standard didactic curriculum can be used to teach ultrasound. Simulation based training showed statistically signifi cant improvement in physiology learning when compared to standard didactic curriculum.

Ultrasound curriculum taught by first-year medical students： A four-year experience in Tanzania

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 postcourse 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.

Evaluation of a point of care ultrasound curriculum for Indonesian physicians taught by fi rst-year medical students

BACKGROUND: The purpose of this study was to assess the short-term efficacy of a 4-week ultrasound curriculum taught by American first-year medical students to general practitioners working in public health care clinics, or puskesmas, in Bandung, Indonesia.METHODS: We performed a prospective, observational study of Indonesian health care practitioners from public clinics in Bandung, Indonesia. These practitioners were enrolled in a 4-week ultrasound training course taught by first-year American medical students. A total of six sessions were held comprising of 38 ultrasound milestones. A pre-course and post-course written exam and practical exam was taken by each participant.RESULTS: We enrolled 41 clinicians in the course. The average pre-course exam score was 35.2% with a 2.4% pass rate, whereas the average post-course exam score was 82.0% with a 92.7% pass rate. The average practical score at the completion of the course was 83.2%(SD=0.145) with 82.9% of the class passing(score above 75.0%).CONCLUSION: Our data suggests that first-year medical students can effectively teach ultrasound to physicians in Indonesia using a 4-week intensive ultrasound training course. Future studies are needed to determine the amount of training required for proficiency and to evaluate the physicians' perceptions of the student-instructors' depth of knowledge and skill in point of care ultrasound.

Pre-hospital assessment with ultrasound in emergencies: implementation in the field

BACKGROUND: Point-of-care ultrasound(US) is a proven diagnostic imaging tool in the emergency department(ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the fi eld and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients.METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest.RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making(89%, 95%CI 67%–99%). Paramedics accurately recorded 17 cases of cardiac activity(100%, 95%CI 84%–100%) and 2 cases of cardiac standstill(100%, 95%CI 22%–100%).CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

Can an 8^(th) grade student learn point of care ultrasound?

BACKGROUND: Point-of-care ultrasound has gained widespread use in developing countries due to decreased cost and improved telemedicine capabilities. Ultrasound training, specifi cally 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 8^(th) grade student can teach peers these skills.METHODS: The 8^(th) 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 8^(th) 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 signifi cant(P-value 0.459).CONCLUSION: The majority of 8^(th) graders obtained clinically adequate FAST images after minimal training. Additionally, the student-trained group performed as well as the sonographer-trained group.

A comparison of handheld and standard ultrasound in Swiss medical students

BACKGROUND:The use of ultrasound(US)within healthcare has inspired the development of new US technology.There have been few studies comparing the use of handheld US to standard US for medical education.This research aims to determine whether a handheld US device can provide a comparable primary learning experience to that of a standard US machine.METHODS:Over two days of instruction,participants were taught and evaluated on core US fundamentals.The standard group received instruction on standard US machines,while the handheld group received instruction on handheld US devices.Participants completed a qualitative survey regarding their experience.Six hundred and four images were obtained and graded by two emergency medicine physicians.RESULTS:A total of 119 Swiss medical students were enrolled in our study.There was no statistically significant difference in the US assessment measurements,except for faster endpoint septal separation(EPSS)vascular setup time in the handheld group(P=0.001).There was no statistically significant difference in participants’perceived difficulty of US learning(P=0.198),comfort level(P=0.188),or self-estimated capability to perform US in the future(P=0.442).There was no statistically significant difference in the percentage of correctly obtained images(P=0.211)or images that were clinically useful(P=0.256).The median quality score of images obtained by the standard group was eight compared to seven in handheld group(P<0.01).CONCLUSION:Our data suggest a handheld US machine can perform as well as a standard US machine as an educational tool despite sacrifices in image quality.

Procedural simulation:medical student preference and value of three task trainers for ultrasound guided regional anesthesia

BACKGROUND: Ultrasound guided regional anesthesia is widely taught using task trainer models. Commercially available models are often used; however, they can be cost prohibitive. Therefore, alternative "homemade" models with similar fidelity are often used. We hypothesize that professional task trainers will be preferred over homemade models. The purpose of this study is to determine realism, durability and cleanliness of three different task trainers for ultrasound guided nerve blocks.METHODS: This was a prospective observational study using a convenience sample of medical student participants in an ultrasound guided nerve block training session on January 24 th, 2015. Participants were asked to perform simulated nerve blocks on three different task trainers including, 1 commercial and 2 homemade. A questionnaire was then given to all participants to rate their experiences both with and without the knowledge on the cost of the simulator device.RESULTS: Data was collected from 25 participants. The Blue Phantom model was found to have the highest fidelity. Initially, 10(40%) of the participants preferred the Blue Phantom model, while 10(40%) preferred the homemade gelatin model and 5(20%) preferred the homemade tofu model. After cost awareness, the majority, 18(72%) preferred the gelatin model.CONCLUSION: The Blue Phantom model was thought to have the highest fidelity, but after cost consideration the homemade gelatin model was preferred.

Comparison of ultrasound-measured properties of the common carotid artery to tobacco smoke exposure in a cohort of Indonesian patients

BACKGROUND: The purpose of this study was to use point-of-care ultrasound(POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery(CCA). The effect of both primary and secondary smoking on CCA properties was evaluated.METHODS: We performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness(CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease.RESULTS: We enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness.CONCLUSION: Our data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confi rm the utility of ultrasound fi ndings of cardiovascular disease and stroke.

Simpli?ed point-of-care ultrasound protocol to con?rm central venous catheter placement:A prospective study

BACKGROUND: The current standard for con? rmation of correct supra-diaphragmatic central venous catheter(CVC) placement is with plain ? lm chest radiography(CXR). We hypothesized that a simple point-of-care ultrasound(POCUS) protocol could effectively con? rm placement and reduce time to con? rmation.METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC.RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8%(95%CI 77.1%–93.5%) and speci? city of 100%(95%CI 15.8%–100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes(IQR 10–29) and 32 minutes(IQR 19–45), respectively.CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a con? rmatory CXR.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay

BACKGROUND: The study aimed to compare the time to overall length of stay(LOS) for patients who underwent point-of-care ultrasound(POCUS) versus radiology department ultrasound(RDUS).METHODS: This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department(ED) assessment.RESULTS: We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight(51%) patients were pregnant(<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS(95%CI 60–73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay(LOS)(95%CI 66–173, P<0.01)CONCLUSION: In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a signifi cant decrease in time to ultrasound and ED LOS.

A feasibility study to determine if minimally trained medical students can identify markers of chronic parasitic infection using bedside ultrasound in rural Tanzania

BACKGROUND: Parasitic infections pose a significant health risk in developing nations and are a major cause of morbidity and mortality worldwide. In the Republic of Tanzania, the CDC estimates that 51.5% of the population is infected with one or more intestinal parasites. If diagnosed early, the consequences of chronic parasitic infection can potentially be avoided.METHODS: Six first-year medical students were recruited to enroll patients in the study. They underwent ten hours of formal, hands-on, ultrasound which included basic cardiac, hepatobiliary, renal, pulmonary and FAST scan ultrasound. A World Health Organization protocol with published grading scales was adapted and used to assess for pathology in each patient's liver, bladder, kidneys, and spleen.RESULTS: A total of 59 patients were enrolled in the study. Students reported a sensitivity of 96% and specificity of 100% for the presence of a dome shaped bladder, a sensitivity and specificity of 100% for bladder thickening, a sensitivity and specificity of 100% for portal hypertension and ascites. The sensitivity was 81% with a specificity of 100% for presence of portal vein distention. The sensitivity was 100% with a specificity of 90% for dilated bowel.CONCLUSIONS: Ultrasound has shown a promise at helping to identify pathology in rural communities with limited resources such as Tanzania. Our data suggest that minimally trained first year medical students are able to perform basic ultrasound scans that can identify ultrasonographic markers of parasitic infections.

Feasibility study of first-year medical students identifying cardiac anatomy using ultrasound in rural Panama

BACKGROUND: There are over 15 million children who have cardiac anomalies around the world, resulting in a significant morbidity and mortality. Early recognition and treatment can improve the outcomes and lengthen life-expectancy of these patients. The NIH and WHO have promoted guidelines for screening for congenital cardiac anomalies using ultrasound in rural environments.METHODS: Our study took place in Bocas Del Toro, Panama where a mobile clinic was established for community healthcare screening and ultrasonographic evaluation by medical student volunteers and volunteer clinical faculty. This was a non-blinded, investigational study utilizing a convenience sample of pediatric patients presenting for voluntary evaluation. Seven first-year medical students were recruited for the study. These students underwent a training program for advanced cardiac ultrasound instruction, termed "Pediatric Echocardiography Cardiac Screening(PECS)".RESULTS: Ten patients were enrolled in the study. Nine patients had adequate images as defined by the PECS criteria and were all classified as normal cardiac pathology by the medical students, resulting in a sensitivity and specificity of 100%. A single patient was identified by medical students as having a pathologic pulmonic stenosis. This was confirmed as correct by a blinded ultrasonographer.CONCLUSIONS: In this pilot study, the first-year medical students were able to correctly identify pediatric cardiac anatomy and pathology in rural Panama after undergoing a 12-hour ultrasound PECS training session. We believe that with this knowledge, minimally trained practitioners can be used to screen for cardiac anomalies in rural Panama using ultrasound.

Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam(ROUTE)in rural Panama

BACKGROUND:Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions.Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care.Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging.The goal of this study is to determine the feasibility of teaching firstyear medical students the Rural Obstetrical Ultrasound Triage Exam(ROUTE)to help identify pathology in pregnant women of the Bocas del Toro region of Panama.METHODS:Eight first-year medical students completed ROUTE training sessions.After training,the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE.Students then performed the ROUTE in mobile clinics within Bocas del Toro.They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter,head circumference,amniotic fluid index,fetal lie and placental position.Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral.RESULTS:A total of 60 women were enrolled in the study.Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation.CONCLUSION:Based on our data,first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama.Additional studies are required to determine the optimal amount of training required for proficiency.

Assessment of clinical dehydration using point of care ultrasound for pediatric patients in rural Panama

BACKGROUND: Dehydration and its associated symptoms are among the most common chief complaints of children in rural Panama. Previous studies have shown that intravascular volume correlates to the ratio of the diameters of the inferior vena cava(IVC) to the aorta(Ao). Our study aims to determine if medical students can detect pediatric dehydration using ultrasound on patients in rural Panama. METHODS: This was a prospective, observational study conducted in the Bocas del Toro region of rural Panama. Children between the ages of 1 to 15 years presenting with diarrhea, vomiting, or parasitic infection were enrolled in the study. Ultrasound measurements of the diameters of the IVC and abdominal aorta were taken to assess for dehydration. RESULTS: A total of 59 patients were enrolled in this study. Twenty-four patients were clinically diagnosed with dehydration and 35 were classified to have normal hydration status. Of the 24 patients with dehydration, half(n=12) of these patients had an IVC/Ao ratio below the American threshold of 0.8. Of the remaining asymptomatic subjects, about half(n=18) of these subjects also had an IVC/Ao ratio below the American threshold of 0.8.CONCLUSION: Our study did not support previous literature showing that the IVC/Ao ratio is lower in children with dehydration. It is possible that the American standard for evaluating clinical dehydration is not compatible with the rural pediatric populations of Panama.