Introduction of Ultrasound into Gross Anatomy Curriculum: Perceptions of Medical Students

Background

The exposure to ultrasound technology during medical school education is highly variable across institutions.

Objectives

The objectives of this study were to assess medical students’ perceptions of ultrasound use to teach Gross Anatomy along with traditional teaching methods, and determine their ability to identify sonographic anatomy after focused didactic sessions.

Methods

Prospective observational study. Phase I of the study included three focused ultrasound didactic sessions integrated into Gross Anatomy curriculum. During Phase II, first-year medical students completed a questionnaire.

Results

One hundred nine subjects participated in this study; 96% (95% confidence interval [CI] 92–99%) agreed that ultrasound-based teaching increased students’ knowledge of anatomy acquired through traditional teaching methods. Ninety-two percent (95% CI 87–97%) indicated that ultrasound-based teaching increases confidence to perform invasive procedures in the future. Ninety-one percent (95% CI 85–96%) believed that it is feasible to integrate ultrasound into the current Anatomy curriculum. Ninety-eight percent (95% CI 95–100%) of medical students accurately identified vascular structures on ultrasound images of normal anatomy of the neck. On a scale of 1 to 10, the average confidence level reported in interpreting the images was 7.4 (95% CI 7.1–7.7). Overall, 94% (95% CI 91–99%) accurately answered questions about ultrasound fundamentals and sonographic anatomy.

Conclusions

The majority of medical students believed that it is feasible and beneficial to use ultrasound in conjunction with traditional teaching methods to teach Gross Anatomy. Medical students were very accurate in identifying sonographic vascular anatomy of the neck after brief didactic sessions.     

Perceived Effectiveness of Teaching Methods for Point of Care Ultrasound

Background

Point of care ultrasound (POCUS) is a rapidly expanding aspect of both the practice and education of emergency physicians. The most effective methods of teaching these valuable skills have not been explored.

Objective

This project aimed to identify those methods that provide the best educational value as determined by the learner.

Methods

Data was collected from pre- and post-course surveys administered to students of the introductory POCUS course provided to emergency medicine residents each year at our facility. Data were collected in 2010 and 2011. Participants were asked to evaluate the effectiveness of small- vs. large-group format, still images vs. video clips, and PowerPoint slides vs. live demonstration vs. hands-on scanning.

Results

Students felt the most effective methods to be small-group format, video-clip examples, and hands-on scanning sessions. Students also rated hands-on sessions, still images, and video images as more effective in post-course surveys as compared with pre-course surveys.

Conclusions

The methods perceived as most effective for POCUS education are small-group format, video-clip examples, and hands-on scanning sessions.     

Animal Laboratory Training Improves Lung Ultrasound Proficiency and Speed

Background

Although lung ultrasound (US) is accurate in diagnosing pneumothorax (PTX), the training requirements and methods necessary to perform US examinations must be defined.

Objective

Our aim was to test whether animal laboratory training (ALT) improves the diagnostic competency and speed of PTX detection with US.

Methods

Twenty medical students without lung US experience attended a 1-day course. Didactic, practical, and experimental lectures covered the basics of US physics, US machines, and lung US, followed by hands-on training to demonstrate the signs of normal lung sliding and PTX. Each student's diagnostic skill level was tested with three subsequent examinations (at day 1, day 2, and 6-month follow-up) using experimentally induced PTX in porcine models. The outcome measures were sensitivity and specificity for US detection of PTX, self-reported diagnostic confidence, and scan time.

Results

The students improved their skills between the initial two examinations: sensitivity increased from 81.7% (range 69.1%−90.1%) to 100.0% (range 94.3%−100.0%) and specificity increased from 90.0% (range 82.0%−94.8%) to 98.9% (range 92.3%−100.0%); with no deterioration 6 months later. There was a significant learning curve in choosing the correct answers (p = 0.018), a 1-point increase in the self-reported diagnostic confidence (7.8−8.8 on a 10-point scale; p < 0.05), and a 1-min reduction in the mean scan time per lung (p < 0.05).

Conclusions

Without previous experience and after undergoing training in an animal laboratory, medical students improved their diagnostic proficiency and speed for PTX detection with US. Lung US is a basic technique that can be used by novices to accurately diagnose PTX.     

Bedside Ultrasound Diagnosis of Acute Embolic Femoral Artery Occlusion

Background

Acute limb ischemia is both a limb-threatening and life-threatening disease process. Nontraumatic acute peripheral arterial occlusion is most commonly caused by a thrombosis or an embolism.

Objectives

There is limited evidence on the use of bedside ultrasound for the detection of acute limb ischemia, but duplex ultrasonography is standard in the diagnosis and operative planning in chronic limb ischemia. Emergency physicians may use bedside ultrasound in the evaluation of patients with symptoms and signs suggestive of this disease entity.

Case Report

A 64-year-old man with a past medical history of hypertension and an ischemic stroke presented to the Emergency Department with <2 h of severe upper left leg pain that radiated down to his foot. A bedside ultrasound of the left lower extremity was emergently performed. On B-mode ultrasound evaluation, echogenic material was visualized in the left common femoral artery, the artery was noncompressible, and there was an absence of Doppler flow signal. He was then directly taken to the operating room for an emergent limb-saving procedure.

Conclusion

A focused examination of the aorta, iliac vessels, and femoral artery bifurcation with bedside ultrasonography may help to localize peripheral arterial occlusions and can assist the emergency physician in seeking timely surgical consultation and management.     

Middle-Aged Man with Left Neck Pain and Swelling

Background

Disorders of the salivary glands can be evaluated by bedside ultrasonography and should be considered in patients presenting with undifferentiated neck swelling.

Objective

Our aim was to describe the sonographic findings present in sialolithiasis and sialadenitis.

Case Report

A 61-year-old man presented to the emergency department with 2 days of neck swelling. Initial evaluation included a bedside ultrasound that demonstrated sialolithiasis, which was later confirmed by computed tomography.

Conclusions

Bedside ultrasound can be a useful imaging modality in the evaluation of the patient with neck swelling.     

Indian and United States paramedic students: comparison of examination performance for the American Heart Association Advanced Cardiovascular Life Support (ACLS) training

Background

The American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) course is taught worldwide. The ACLS course is designed for consistency, regardless of location; to our knowledge, no previous study has compared the cognitive performance of international ACLS students to those in the United States (US).

Study Objectives

As international health educational initiatives continue to expand, an assessment of their efficacy is essential. This study assesses the AHA ACLS curriculum in an international setting by comparing performance of a cohort of US and Indian paramedic students.

Methods

First-year paramedic students at the Emergency Management and Research Institute, Hyderabad, India, and a cohort of first-year paramedic students from the United States comprised the study population. All study participants had successfully completed the standard 2-day ACLS course, taught in English. Each student was given a 40-question standardized AHA multiple-choice examination. Examination performance was calculated and compared for statistical significance.

Results

There were 117 Indian paramedic students and 43 US paramedic students enrolled in the study. The average score was 86% (± 11%) for the Indian students and 87% (± 6%) for the US students. The difference between the average examination scores was not statistically significant in an independent means t-test (p = 0.508) and a Wilcoxon test (p = 0.242).

Conclusion

Indian paramedic students demonstrated excellent ACLS cognitive comprehension and performed at a level equivalent to their US counterparts on an AHA ACLS written examination. Based on the study results, the AHA ACLS course proved effective in an international setting despite being taught in a non-native language.     

A Pilot Study Examining the Viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) Protocol

Background

Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field.

Study Objective

To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol.

Methods

This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians – paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images.

Results

All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6–9.6).

Conclusion

Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.     

Perceptions of Basic,Advanced, and Pediatric Life Support Training In a United States Medical School

Background

Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Pediatric Advanced Life Support (PALS) are integral parts of emergency resuscitative care. Although this training is usually reserved for residents, introducing the training in the medical student curriculum may enhance acquisition and retention of these skills.

Objectives

We developed a survey to characterize the perceptions and needs of graduating medical students regarding BLS, ACLS, and PALS training.

Methods

This was a study of graduating 4^th-year medical students at a U.S. medical school. The students were surveyed prior to participating in an ACLS course in March of their final year.

Results

Of 152 students, 109 (71.7%) completed the survey; 48.6% of students entered medical school without any prior training and 47.7% started clinics without training; 83.4% of students reported witnessing an average of 3.0 in-hospital cardiac arrests during training (range of 0–20). Overall, students rated their preparedness 2.0 (SD 1.0) for adult resuscitations and 1.7 (SD 0.9) for pediatric resuscitations on a 1–5 Likert scale, with 1 being unprepared. A total of 36.8% of students avoided participating in resuscitations due to lack of training; 98.2%, 91.7%, and 64.2% of students believe that BLS, ACLS, and PALS, respectively, should be included in the medical student curriculum.

Conclusions

As per previous studies that have examined this topic, students feel unprepared to respond to cardiac arrests and resuscitations. They feel that training is needed in their curriculum and would possibly enhance perceived comfort levels and willingness to participate in resuscitations.     

Ultrasound-guided Arthrocentesis of the Elbow: A Posterior Approach

Background

Identification of fluid in the elbow joint by physical examination alone can be challenging. Ultrasound can assist in the diagnosis of elbow effusion, and guide aspiration of the effusion.

Objectives

We illustrate the anatomy and ultrasound guidance technique of a posterior approach to elbow arthrocentesis using examples of normal and pathologic elbow joint ultrasound images.

Discussion

The posterior distal humerus at the level of the olecranon fossa provides an excellent acoustic window into the joint space. This location also provides a safe path for the performance of ultrasound-guided arthrocentesis.

Conclusion

Ultrasound-guided arthrocentesis of the elbow from a posterior approach is a helpful technique to guide the aspiration of the painful swollen elbow.     

Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture

Introduction

Although ultrasound has been used in administering epidural anesthesia, it is unknown if emergency physicians (EPs) can obtain ultrasound images useful for lumbar puncture.

Objective

The objective of the study was to determine EPs' ability to apply a standardized ultrasound technique for visualizing landmarks surrounding the dural space.

Methods

Two EPs sought to identify relevant anatomy in emergency patients. Visualization time for 5 anatomical structures (spinous processes or laminae, ligamentum flavum, dura mater, epidural space, subarachnoid space), body mass index, and perception of landmark palpation difficulty were recorded.

Results

Seventy-six subjects were enrolled. Soft tissue and bony anatomical structures were identified in all subjects. Mean body mass index was 31.4 ± 9.8 (95% confidence interval, 29.1-33.6). High-quality images were obtained in less than 1 minute in 153 (87.9%) scans and in less than 5 minutes in 174 (100%) scans. Mean acquisition time was 57.19 seconds; SD, 68.14 seconds; range, 10 to 300 seconds.

Conclusion

In this cohort, EPs were able to rapidly obtain high-quality ultrasound images relevant to lumbar puncture.     

Subcapsular Liver Hematoma after Colonoscopy Diagnosed by Emergency Department Bedside Ultrasonography

Background

Hepatic subcapsular hematoma is an uncommon cause of right upper quadrant pain in the Emergency Department. It must be recognized early, as large volumes of acute blood loss and rupture into the peritoneum carry significant morbidity and mortality. In the absence of gallbladder disease, the differential diagnosis should include liver pathology. Bedside ultrasonography can be used to identify such lesions.

Objectives

To discuss the presentation, evaluation, and management options of hepatic subcapsular hematoma.

Case Report

We report a case of a 30-year-old woman who presented with the chief complaint of right upper quadrant pain radiating to the right scapula 6 h after a screening colonoscopy for intestinal polyps. Emergency physician-performed bedside ultrasound revealed a large hyperechoic mass in the right lobe of the liver. Radiology-performed comprehensive ultrasound and subsequent computed tomography scan of her abdomen and pelvis revealed a subcapsular hematoma without intestinal perforation.

Conclusion

In a patient with undifferentiated right upper quadrant abdominal pain, bedside ultrasonography is a rapid and effective modality in the diagnosis of liver masses, including subcapsular hematoma.     

Dedicated emergency department ultrasound rotation improves residents' ultrasound knowledge and interpretation skills

Background

Graduates of Emergency Medicine (EM) residency training programs are expected to be proficient in ultrasound. However, best practices for teaching residents ultrasonography has yet to be determined.

Study Objectives

To determine if a dedicated Emergency Department (ED) ultrasound rotation objectively improves residents’ EM ultrasound knowledge, interpretation accuracy, and clinical decision-making based on ultrasound findings.

Methods

EM residents completing a required ED-based ultrasound rotation were prospectively studied. Before the start of the rotation, each resident completed a 20-question pre-test. At the end of the rotation, residents completed a 20-question post-test. Both tests covered physics, trauma (focused assessment with sonography for trauma), first-trimester pregnancy, aorta, biliary, echocardiography, and vascular sonography, using a multiple-choice format. In both tests, ultrasound images were included in 11 of the 20 questions. The questions were divided into three categories: knowledge-based (8 questions), interpretation (9 questions), and clinical decision-making (3 questions), for both tests. Scores on pre-tests and post-tests were compared using a Wilcoxon signed-rank test.

Results

During the 2-year study period, 21 residents completed the rotation. The median pre-test score was 16 (interquartile range [IQR] 14.5–17), compared to a median post-test score of 19 (IQR 18–20), p < 0.001.

Conclusions

A dedicated ED ultrasound rotation improves residents’ EM ultrasound knowledge and interpretation accuracy based on ultrasound findings, as measured by improvement on ultrasound test scores.     

Specialized Early Treatment for Persons With Disorders of Consciousness: Program Components and Outcomes

Objectives

To describe a specialized early treatment program for persons with disorders of consciousness (DOC) that includes family education; to identify rates of secondary conditions, imaging used, and selected interventions; and to evaluate outcomes.

Design

A single-center, retrospective, pre-post design using electronic medical record data.

Setting

A Commission on Accreditation of Rehabilitation Facilities–accredited, long-term acute care hospital that provides acute medical and inpatient rehabilitation levels of care for people with catastrophic injuries.

Participants

Persons (N=210) aged 14 to 69 years with DOC of primarily traumatic etiology admitted at a mean ± SD of 41.0±27.2 days postinjury; 2% were in coma, 41% were in the vegetative state, and 57% were in the minimally conscious state.

Interventions

An acute medical level of care with ≥90 minutes of daily interdisciplinary rehabilitation and didactic and hands-on caretaking education for families.

Main Outcome Measures

Coma Recovery Scale–Revised, Modified Ashworth Scale, and discharge disposition.

Results

Program admission medical acuity included dysautonomia (15%), airway modifications (79%), infections (eg, pneumonia, 16%; urinary tract infection, 14%; blood, 11%), deep vein thrombosis (17%), pressure ulcers (14%), and marked hypertonia (30% in each limb). There were 168 program interruptions (ie, 139 surgeries, 29 nonsurgical intensive care unit transfers). Mean length of stay ± SD was 39.1±29.4 days (range, 6–204d). Patients showed improved consciousness and respiratory function and reduced presence or severity of pressure ulcers and upper extremity hypertonia. At discharge, 54% showed sufficient emergence from a minimally conscious state to transition to mainstream inpatient rehabilitation, and 29% did not emerge but were discharged home to family with ongoing programmatic support; only 13% did not emerge and were institutionalized.

Conclusions

Persons with DOC resulting primarily from a traumatic etiology who receive specialized early treatment that includes acute medical care and ≥90 minutes of daily rehabilitation are likely to show improved consciousness and body function; more than half may transition to mainstream inpatient rehabilitation. Families who receive comprehensive education and hands-on training with ongoing follow-up support may be twice as likely to provide care for medically stable persons with DOC in their homes versus nursing facility placement.     

Soccer World Cup 2010: Evaluation of portable ultrasonography for diagnosing musculoskeletal injuries

Aim

A prompt and accurate assessment of the severity of musculoskeletal injuries sustained by elite athletes is crucial, to determine whether the diagnosis requires further evaluation at a hospital facility and to predict the time to recovery. The objective is to evaluate the usefulness of portable ultrasonography in evaluating musculoskeletal injuries sustained by elite athletes (Observational study; 2010 Soccer World Cup training camps and base camp, ten locations in six countries).

Methods

Participants: Athletes selected to play in the Cameroon soccer team; there were 30 athletes for the 24-day training camp period (4 matches) and 23 athletes for the subsequent 18-day tournament period (3 matches).

Interventions

Portable ultrasonography assessment of musculoskeletal injuries sustained by the athletes during training or competition. A single physician used an Esaote MyLab™Five with a 7.5-12 MHz linear probe for all evaluations.

Main outcome measures

Number of ultrasonography assessment of musculoskeletal injuries during a single team tournament during a world cup.

Results

Over the 42-day study period, 15 ultrasound scans were performed to assess musculoskeletal symptoms that started during training or competing. Hospital referral for further evaluation was not required for any of these 15 injuries. There were 5 injuries to ligaments (lateral collateral ligament in ankle sprains, medial collateral ligament in a knee sprain, and medial collateral ligament in a sprain of the metatarsophalangeal joint of a goal keeper), 8 injuries to muscles, and 2 athletes with tendon pain.

Conclusion

A portable high-performance ultrasound machine can be used to obtain a rapid and accurate assessment of musculoskeletal injuries sustained by elite soccer players participating in a major international event that requires frequent traveling. Portable ultrasonography decreases the need for traveling to hospitals to obtain imaging studies.     

Retinal detachment due to facial gunshot wound: the utility of ultrasonography in a medically austere environment

Background

Retinal detachment is one complication of ocular trauma. Retinal detachments resulting from gunshot wounds are typically associated with significant facial trauma, orbital trauma, or globe penetration. Ultrasonography has been shown to be of diagnostic utility in the evaluation of retinal detachments.

Objectives

In this case, an atypical mechanism for retinal detachment is described. The aim is to describe the successful use of ultrasound as an aid for accurate diagnosis and disposition of a retinal detachment in practice environments with limited medical resources.

Case Report

We present a case of a low-velocity gunshot wound resulting in retinal detachment from pressure wave forces. A 21-year-old patient sustained a facial gunshot wound injury from a ricocheting AK-47 round, resulting in a closed globe retinal detachment. Portable ultrasonography was utilized as an accurate diagnostic modality in the management and disposition of this patient, allowing prompt confirmation of the diagnosis in a medically austere environment.

Conclusion

Ultrasonography can be a valuable diagnostic tool in the evaluation of ocular trauma in medically austere environments.     

Identification of intraluminal thrombus by ultrasonography in emergency department patients with acute deep venous thrombosis

Background

Traditionally, the diagnosis of deep venous thrombosis (DVT) using duplex ultrasonography (DU) has relied on the absence of venous compressibility. Visualization of an intraluminal thrombus is considered an uncommon finding.

Objectives

The purpose of this study is to determine the frequency of intraluminal thrombus in emergency department (ED) patients diagnosed with acute DVT.

Methods

Retrospective chart review of adult ED patients with DU examinations demonstrating acute DVT. Patients with chronic DVT or patients in whom DU did not demonstrate DVT were excluded from data analysis. Study reports and ultrasound images were reviewed and analyzed for the presence of intraluminal thrombus.

Results

There were 189 patients who met inclusion criteria, of which 160 (85%) were found to have intraluminal thrombus.

Conclusion

Intraluminal thrombi are present in the majority of patients in our ED in whom acute DVT is identified by DU.     

An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: An evaluation for medical student training

Objective

Widespread application of early goal-directed therapy (EGDT) and the severe sepsis resuscitation bundle is limited by clinician knowledge, skills and experience. This study evaluated use of simulation-based teaching during medical training to increase future clinician knowledge in the above therapies for severe sepsis and septic shock.

Methods

A prospective cohort study was performed with medical students at all levels of training. A 5-h course including didactic lectures, skill workshops, and a simulated case scenario of septic shock were administered to the participants. A checklist including 21 tasks was completed during the patient simulation. An 18-question pre-test, post-test and 2-week post-test were given. The participants completed a survey at the end of the course.

Results

Sixty-three students were enrolled. There was statistical difference between the pre-test and each of the post-test scores: 57.5 ± 13.0, 85.6 ± 8.8, and 80.9 ± 10.9%, respectively. 20.6% of participants thought the pre-test was too difficult, whereas all participants thought the post-test was either appropriate or too easy. The task performance during the simulated septic shock patient was 94.1 ± 6.0%. The participants noted improvements in their confidence levels at managing severe sepsis and septic shock, and agreed that the course should be a requirement during medical school training.

Conclusions

Medical simulation is an effective method of educating EGDT and the severe sepsis resuscitation bundle to medical students with limited experience in patient care. The results suggest that our course may be of further benefit at increasing clinical experience with this intensive protocol for the management of severe sepsis and septic shock.     

Targeting Paretic Propulsion to Improve Poststroke Walking Function: A Preliminary Study

Objectives

To determine the feasibility and safety of implementing a 12-week locomotor intervention targeting paretic propulsion deficits during walking through the joining of 2 independent interventions, walking at maximal speed on a treadmill and functional electrical stimulation of the paretic ankle musculature (FastFES); to determine the effects of FastFES training on individual subjects; and to determine the influence of baseline impairment severity on treatment outcomes.

Design

Single group pre-post preliminary study investigating a novel locomotor intervention.

Setting

Research laboratory.

Participants

Individuals (N=13) with locomotor deficits after stroke.

Intervention

FastFES training was provided for 12 weeks at a frequency of 3 sessions per week and 30 minutes per session.

Main Outcome Measures

Measures of gait mechanics, functional balance, short- and long-distance walking function, and self-perceived participation were collected at baseline, posttraining, and 3-month follow-up evaluations. Changes after treatment were assessed using pairwise comparisons and compared with known minimal clinically important differences or minimal detectable changes. Correlation analyses were run to determine the correlation between baseline clinical and biomechanical performance versus improvements in walking speed.

Results

Twelve of the 13 subjects that were recruited completed the training. Improvements in paretic propulsion were accompanied by improvements in functional balance, walking function, and self-perceived participation (each P<.02)—all of which were maintained at 3-month follow-up. Eleven of the 12 subjects achieved meaningful functional improvements. Baseline impairment was predictive of absolute, but not relative, functional change after training.

Conclusions

This report demonstrates the safety and feasibility of the FastFES intervention and supports further study of this promising locomotor intervention for persons poststroke.