Point‐of‐Care Ultrasound Education

This article reviews the current technology, literature, teaching models, and methods associated with simulation‐based point‐of‐care ultrasound training. Patient simulation appears particularly well suited for learning point‐of‐care ultrasound, which is a required core competency for emergency medicine and other specialties. Work hour limitations have reduced the opportunities for clinical practice, and simulation enables practicing a skill multiple times before it may be used on patients. Ultrasound simulators can be categorized into 2 groups: low and high fidelity. Low‐fidelity simulators are usually static simulators, meaning that they have nonchanging anatomic examples for sonographic practice. Advantages are that the model may be reused over time, and some simulators can be homemade. High‐fidelity simulators are usually high‐tech and frequently consist of many computer‐generated cases of virtual sonographic anatomy that can be scanned with a mock probe. This type of equipment is produced commercially and is more expensive. High‐fidelity simulators provide students with an active and safe learning environment and make a reproducible standardized assessment of many different ultrasound cases possible. The advantages and disadvantages of using low‐ versus high‐fidelity simulators are reviewed. An additional concept used in simulation‐based ultrasound training is blended learning. Blended learning may include face‐to‐face or online learning often in combination with a learning management system. Increasingly, with simulation and Web‐based learning technologies, tools are now available to medical educators for the standardization of both ultrasound skills training and competency assessment.     

Point‐of‐Care Ultrasound Findings Associated With Langerhans Cell Histiocytosis in the Pediatric Emergency Department

Langerhans cell histiocytosis is a rare disease characterized by clonal proliferation of Langerhans‐type cells, causing local or systemic effects. One of the most affected sites in children is the skull. We describe 2 cases of children presenting to the pediatric emergency department with symptoms isolated to the scalp and the point‐of‐care focused skull ultrasound findings, which assisted in the diagnosis of Langerhans cell histiocytosis in both cases.     

Enhanced Point‐of‐Care Ultrasound Applications by Integrating Automated Feature‐Learning Systems Using Deep Learning

Recent applications of artificial intelligence (AI) and deep learning (DL) in health care include enhanced diagnostic imaging modalities to support clinical decisions and improve patients’ outcomes. Focused on using automated DL‐based systems to improve point‐of‐care ultrasound (POCUS), we look at DL‐based automation as a key field in expanding and improving POCUS applications in various clinical settings. A promising additional value would be the ability to automate training model selections for teaching POCUS to medical trainees and novice sonologists. The diversity of POCUS applications and ultrasound equipment, each requiring specialized AI models and domain expertise, limits the use of DL as a generic solution. In this article, we highlight the most advanced potential applications of AI in POCUS tailored to high‐yield models in automated image interpretations, with the premise of improving the accuracy and efficacy of POCUS scans.     

Point‐of‐Care Ultrasound in General Surgery Residency Training: A Proposal for Milestones in Graduate Medical Education Ultrasound

The use of point‐of‐care ultrasound (US) in the clinical setting has undergone massive growth, although its incorporation into training and practice is variable. Surgeons are interested in using point‐of‐care US and can incorporate it effectively into clinical practice. However, the current state of point‐of‐care US training in general surgery is inadequate. The Accreditation Council for Graduate Medical Education introduced the Milestones Project to evaluate resident and fellow performance. Emergency medicine is the only specialty with a point‐of‐care US milestone. We have successfully implemented a US training program into our general surgery residency curriculum and now propose milestones in point‐of‐care US for all general surgery residents.     

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective,Observational Study

Background

Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.

Objectives

Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.

Methods

We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.

Results

Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.

Conclusions

Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.     

An Easy‐to‐Make,Low‐Cost Ultrasound Phantom for Simulation Training in Abscess Identification and Aspiration

We have created a low‐cost and easy to make phantom for abscess identification using point‐of‐care ultrasound. The phantom also allows needle tracking and abscess aspiration using ultrasound guidance.     

Contrast‐Enhanced Transrectal Ultrasound for Follow‐up After Focal HIFU Ablation for Prostate Cancer

The optimal strategy for imaging after focal therapy for prostate cancer is evolving. This series is an initial report on the use of contrast‐enhanced transrectal ultrasound (TRUS) in follow‐up of patients after high‐intensity focused ultrasound (HIFU) hemiablation for prostate cancer. In 7 patients who underwent HIFU hemiablation, contrast‐enhanced TRUS findings were as follows: (1) contrast‐enhanced TRUS clearly showed the HIFU ablation defect as a sharply marginated nonenhancing zone in all patients; (2) contrast‐enhanced TRUS identified suspicious foci of recurrent enhancement within the ablation zone in 2 patients, facilitating image‐guided prostate biopsy, which showed prostate cancer; and (3) contrast‐enhanced TRUS findings correlated with multiparametric magnetic resonance imaging and biopsy histologic findings.     

A Primary Care Ultrasound Fellowship: Training for Clinical Practice and Future Educators

As ultrasound devices become smaller, more portable, and more user friendly, there is now widespread use of this technology by physicians of all specialties, yet there are currently few structured opportunities for ultrasound education outside of emergency and critical care medicine. Anticipating the rising educational demand in the primary care specialties, the University of South Carolina School of Medicine created a primary care ultrasound fellowship in 2011, the first yearlong training program in point‐of‐care ultrasonography for graduates of internal medicine, medicine‐pediatrics, pediatrics, and family medicine residencies. This paper reviews the history of point‐of‐care ultrasonography fellowships and then provides an overview of the primary care ultrasound fellowship.     

A Novel Three‐Dimensional‐Printed Ultrasound‐Guided Hip Arthrocentesis Model

When evaluating patients with hip pain, clinicians may be trained to both evaluate for a hip effusion and perform ultrasound‐guided arthrocentesis to evaluate the etiology of the effusion. We present a novel 3‐dimensional‐printed hip arthrocentesis model, which can be used to train clinicians to perform both tasks under ultrasound guidance. Our model uses a combination of a 3‐dimensional‐printed hip joint, as well as readily available materials such as an infant Ambu (Ballerup, Denmark) bag, syringe, intravenous line kit, and silicone. We present our experience so that others may use and adapt our model for their training purposes.     

A Novel Low‐Cost Ultrasound‐Guided Pericardiocentesis Simulation Model: Demonstration of Feasibility

Pericardiocentesis is a rare life‐saving procedure for patients with cardiac tamponade. Due to the infrequency of this procedure, simulation models are often used for training. Commercial models are generally expensive. Proposed homemade models offer a lower‐cost alternative but can be labor and time intensive. The purpose of this study was to determine the feasibility of a limited use, low‐cost ultrasound‐guided pericardiocentesis model as a training tool for emergency physicians. Our model proved to be a practical, easily implemented, and acceptable model for training emergency physicians, including residents and students, in ultrasound‐guided pericardiocentesis.     

Novel Contrast‐Enhanced Ultrasound Evaluation in Neonatal Hypoxic Ischemic Injury: Clinical Application and Future Directions

Sensitive, specific, and safe bedside evaluation of brain perfusion is key to the early diagnosis, treatment, and improved survival of neonates with hypoxic ischemic injury. Contrast‐enhanced ultrasound (US) imaging is a novel imaging technique in which intravenously injected gas‐filled microbubbles generate enhanced US echoes from an acoustic impedance mismatch. This article describes contrast‐enhanced US imaging in 2 neonates with hypoxic ischemic injury and future directions on developing quantitative contrast‐enhanced US techniques for improved characterization of perfusion abnormalities. The importance of studying the temporal evolution of brain perfusion in neonatal hypoxic ischemic injury is also highlighted.     

Use of a Simple,Inexpensive Dual‐Modality Phantom as a Learning Tool for Magnetic Resonance Imaging–Ultrasound Fusion Techniques

We describe an easily constructed, customizable phantom for magnetic resonance imaging–ultrasound fusion imaging and demonstrate its role as a learning tool to initiate clinical use of this emerging modality. Magnetic resonance imaging–ultrasound fusion can prove unwieldy to integrate into routine practice. We demonstrate real‐time fusion with single‐sequence magnetic resonance imaging uploaded to the ultrasound console. Phantom training sessions allow radiologists and sonographers to practice fiducial marker selection and improve efficiency with the fusion hardware and software interfaces. Such a tool is useful when the modality is first introduced to a practice and in settings of sporadic use, in which intermittent training may be useful.     

A Cost‐effective,Gelatin‐Based Phantom Model for Learning Ultrasound‐Guided Fine‐Needle Aspiration Procedures of the Head and Neck

The rise in popularity of ultrasound imaging has seen a corresponding increase in demand for effective training tools such as phantom models. They are especially useful for teaching and practice of invasive procedures, such as fine‐needle aspiration of lesions of the head and neck. We have created 2 gelatin models out of inexpensive, commonly available materials that can be used in sequence to learn head and neck fine‐needle aspiration. Fundamental skills can be learned first on the flat, rectangular model, whereas the second, cylindrical model more closely represents human anatomy and can be used to develop more advanced technique.     

Early Innovative Immersion

In preparing for medical school admissions, premedical students seek opportunities to expand their medical knowledge. Knowing what students seek and what point‐of‐care ultrasound offers, we created a novel educational experience using point‐of‐care ultrasound. The innovation has 3 goals: (1) to use point‐of‐care ultrasound to highlight educational concepts such as the flipped classroom, simulation, hands‐on interaction, and medical exposure; (2) to work collaboratively with peers; and (3) to expose premedical students to mentoring for the medical school application process. We believe that this course could be used to encourage immersive innovation with point‐of‐care ultrasound, progressive education concepts, and preparation for medical admissions.     

Applications of Transcranial Color‐Coded Sonography in the Emergency Department

Transcranial color‐coded Doppler sonography is a noninvasive bedside ultrasound application that combines both imaging of parenchymal structures and Doppler assessment of intracranial vessels. It may aid in rapid diagnoses and treatment decision making of patients with intracranial emergencies in point‐of‐care settings. This pictorial essay illustrates the technical aspects and emergency department applications of transcranial color‐coded Doppler sonography, and provides some rationale for implementation of this technique into the emergency department practice.     

Intravenous and Intracavitary Use of Contrast‐Enhanced Ultrasound in the Evaluation and Management of Complicated Pediatric Pneumonia

Pediatric pneumonia can be complicated by necrotizing pneumonia or a parapneumonic effusion either in the form of an empyema or a clear effusion. Ultrasonography (US) and computed tomography represent well‐established modalities for evaluation of complicated pediatric pneumonia. Contrast‐enhanced ultrasound (CEUS) was recently introduced and is gaining increasing acceptance in pediatric imaging. In this case series, we present our initial experience with both intravenous and intracavitary use of CEUS in children with complicated pneumonia. Intravenous CEUS accurately and confidently showed necrotizing pneumonia and delineated pleural effusions, whereas intracavitary CEUS accurately identified the chest catheter location and patency and showed the presence of loculations, suggesting the use of fibrinolytics.     

Sternal Fracture Complicated by a Subcutaneous Abscess in a 5-Year-Old Boy and Diagnosed Using Point-of-Care Ultrasound

Background

Although fractures of the sternum are rare in young children, owing to the compliance of the chest wall, these fractures are still possible and require thorough examination. We present a case that emphasizes the usefulness of point-of-care ultrasound in the diagnosis of a pediatric sternal fracture complicated by a subcutaneous abscess.

Compact Ultrasound for Improving Maternal and Perinatal Care in Low‐Resource Settings

Objective. Ultrasound imaging, a front‐line diagnostic tool for perinatal care, is rarely available in the developing world, where maternal and newborn mortality rates are starkly higher than elsewhere. The development of portable and inexpensive medical ultrasound machines (compact ultrasound) offers the possibility of broader use of ultrasound. Our objective was to assess the potential benefits and challenges of deploying compact ultrasound in developing countries for improving obstetric health. Methods. Existing literature on perinatal care, compact ultrasound, and issues in the deployments of medical technology in low‐resource settings was reviewed. Anecdotal evidence was assessed, and the authors' field experiences in Nicaragua and Mali were evaluated as a template for wider deployments. Results. Few published studies directly concerned with compact ultrasound in low‐resource settings were found. These, however, in combination with available anecdotal data, support the view that compact ultrasound in less‐developed regions is feasible and would result in a relatively low‐cost improvement in perinatal care. Conclusions. The development of lightweight, portable, and relatively inexpensive ultrasound systems offers a great opportunity for reducing maternal and neonatal mortality in low‐resource settings. Evidence‐based analysis of compact ultrasound deployments as a public‐health response to obstetric needs in less‐developed countries has been hampered by limited data in 3 key areas: maternal and perinatal mortality and morbidity in these settings, evaluations of compact ultrasound systems as reliable alternatives to full‐sized systems, and the lack of outcomes data based on actual deployments of compact ultrasound for this purpose. Field trials of compact ultrasound on a scale commensurate with public health interventions should be undertaken.     

Two‐Dimensional Speckle Tracking of the Fetal Heart

Various approaches to 2‐dimensional speckle tracking have been used to evaluate left ventricular function and deformation in the fetus, child, and adult. In 2015, because of differences in imaging devices and analytical programs, the cardiology community published a consensus document proposing standards for pediatric/adult deformation imaging using 2‐dimensional speckle tracking. The understanding and application of deformation imaging in the fetus have been limited by a lack of uniform software, terminology, techniques, and display. This article provides a practical, step‐by‐step approach for deformation analysis of the fetal heart using offline software that is independent of specific ultrasound vendors.     

Ultrasound Curricula in Undergraduate Medical Education: A Scoping Review

The clinical applications of point‐of‐care ultrasound (US) have expanded rapidly over the past decade. To promote early exposure to point‐of‐care US, there is widespread support for the integration of US curricula within undergraduate medical education. However, despite growing evidence and enthusiasm for point‐of‐care US education in undergraduate medical education, the curricular design and delivery across undergraduate medical education programs remain variable without widely adopted national standards and guidelines. This article highlights the educational and teaching applications of point‐of‐care US with a focus on outcomes. We then review the evidence on curricular design, delivery, and integration and the assessment of competency for point‐of‐care US in undergraduate medical education.