Ultrasound Exposure During Gross Anatomy

Background

As medical schools seek to standardize ultrasound training and incorporate clinical correlations into the basic science years, we proposed that ultrasonography should have a greater role in the anatomy curriculum.

Objectives

To describe the introduction of ultrasound into the curriculum of a first-year medical student anatomy course and evaluate the utility of this introduction.

Methods

First-year medical students attended two ultrasound lectures and three small-group hands-on sessions that focused on selected aspects of musculoskeletal, thoracic, abdominal, and neck anatomy. Pre and post surveys were administered to assess student perception of their ability to obtain and interpret ultrasound images and the utility of ultrasound in the anatomy course. Understanding of basic ultrasound techniques and imaging was tested in the practical examinations.

Results

Of the 269 first-year medical students who completed the course, 144 students completed both surveys entirely, with a response rate of 53%. Students' interest and self-perceived experience, comfort, and confidence in ultrasound skills significantly increased (p < 0.001) as a result of this early introduction to ultrasonography. Objective evidence, provided by practical examination scores on ultrasound images, is consistent with this self-perceived confidence reported by students.

Conclusions

Ultrasound can be effectively incorporated into an anatomy course for first-year medical students by utilizing didactics and hands-on exposure. Medical students found the addition of ultrasound training to be valuable, not only in enhancing their understanding of anatomy, but also in increasing their interest and experience in ultrasound imaging.     

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience

Background

Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available.

Focused Cardiac Ultrasound Training: How Much Is Enough?

Background

Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency.

Objective

The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE.

Methods

Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians’ guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees’ ability to perform and interpret F-TTE.

Results

Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds.

Conclusions

A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.     

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.     

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.     

Web-based Emergency Department Patient Satisfaction Surveys May Introduce Potential for Bias

Background

Emergency departments (ED) have proposed utilizing a Web-based format to distribute patient satisfaction surveys, but the potential for bias in this distribution method has not been assessed.

Objective

The aim of this study was to evaluate the characteristics of ED patients who have access to the Internet to better understand potential bias in Web-based patient satisfaction surveys.

Methods

We distributed a 20-question survey to consenting, English-speaking adult patients presenting to the ED from December 2010 to March 2012. Patients reported demographic information and answered questions related to their access and use of the Internet.

Results

Seven hundred four patients participated in the study; 90% of Whites reported Internet access, vs. 82% of Hispanics (p = 0.034). Ninety-two percent of patients with at least some college education had Internet access, compared to 79% of those with a high school education level or lower (p ≤ 0.001). Of households reporting an income of > $22,000/year, 95% had Internet access, compared to 77% of those reporting a household income < $22,000/year (p ≤ 0.001). Ninety-four percent of participants < 40 years of age had Internet access, compared to 83% between the ages of 40 and 56 years, and 77% for those over 56 years of age (p < 0.001).

Conclusion

A Web-based distribution of ED patient satisfaction surveys may underrepresent minorities, patients without college education, those with lower income, and patients older than 40 years. This information may provide guidance in interpreting results of Web-based patient satisfaction surveys and may suggest the need for multiple sampling methods.     

Inter-rater reliability of sonographic measurements of the inferior vena cava

Background

Bedside ultrasound is emerging as a useful tool in the assessment of intravascular volume status by examining measurements of the inferior vena cava (IVC). Many previous studies do not fully describe their scanning protocol.

Objectives

The objective of this study was to evaluate which of three commonly reported IVC scanning methods demonstrates the best inter-rater reliability.

Methods

Three physicians visualized the IVC in three common views and utilized M-mode to measure the maximal and minimal diameter during quiet respiration. Pairwise correlation coefficients were determined using Pearson product-moment correlation.

Results

The most reliable pair of measurements (inspiratory and expiratory) was found to be using the anterior midaxillary line longitudinal view with a Kappa value for both at 0.692.

Conclusion

Imaging with the anterior midaxillary longitudinal approach using the liver as an acoustic window provides the best inter-rater reliability when measuring the IVC. Our findings demonstrate that IVC measurements differ based on anatomic location.     

Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management

Background

Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world.

Hypothesis

Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States.

Materials and methods

This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months.

Results

A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy.

Conclusion

Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.     

Bedside Ultrasound Maximizes Patient Satisfaction

Background

Bedside ultrasound (US) is associated with improved patient satisfaction, perhaps as a consequence of improved time to diagnosis and decreased length of stay (LOS).

Objectives

Our study aimed to quantify the association between beside US and patient satisfaction and to assess patient attitudes toward US and perception of their interaction with the clinician performing the examination.

Methods

We enrolled a convenience sample of adult patients who received a bedside US. The control group had similar LOS and presenting complaints but did not have a bedside US. Both groups answered survey questions during their emergency department (ED) visit and again by telephone 1 week later. The questionnaire assessed patient perceptions and satisfaction on a 5-point Likert scale.

Results

Seventy patients were enrolled over 10 months. The intervention group had significantly higher scores on overall ED satisfaction (4.69 vs. 4.23; mean difference 0.46; 95% confidence interval [CI] 0.17–0.75), diagnostic testing (4.54 vs. 4.09; mean difference 0.46; 95% CI 0.16–0.76), and skills/abilities of the emergency physician (4.77 vs. 4.14; mean difference 0.63; 95% CI 0.29–0.96). A trend to higher scores for the intervention group persisted on follow-up survey.

Conclusions

Patients who had a bedside US had statistically significant higher satisfaction scores with overall ED care, diagnostic testing, and with their perception of the emergency physician. Bedside US has the potential not only to expedite care and diagnosis, but also to maximize satisfaction scores and improve the patient–physician relationship, which has increasing relevance to health care organizations and hospitals that rely on satisfaction surveys.     

Evaluation of a Cornstarch-Based Ultrasound Gel Alternative for Low-Resource Settings

Background

Ultrasound is an ideal imaging modality for low-resource settings given its portability, ease of use, and wide range of applications. Commercially available ultrasound gels may be unavailable or cost prohibitive in low-resource settings.

Objective

Our aim was to investigate the quality of images obtained with an alternative ultrasound gel made from cornstarch and water in comparison with commercially available gel.

Methods

The cornstarch gel was made by heating water and cornstarch. The gel was used to obtain standard ultrasound images of the gallbladder, kidneys, bladder, heart, and neck vessels by the study investigators. Commercial gel was used as the control. Twenty-four ultrasound clips were shown to four blinded radiologists and two ultrasound-fellowship−trained emergency department physicians. They rated the images on adequacy (yes/no) and graded the images detail, resolution, and quality using a continuous 0−10 scale.

Results

A total of 144 video clips were shown to reviewers and 129 data-collection sheets were returned. There was no statistical difference in the proportion of images deemed to be of adequate quality: cornstarch-based gel = 0.97 (95% confidence interval [CI] 0.92−1.00) vs. commercially available gel = 0.85 (95% CI 0.75−0.94) (p = 0.053). The cornstarch gel was superior to commercial gel on all three image parameters: detail (p = 0.002), resolution (p = 0.018), and quality (p = 0.013).

Conclusions

In this study, a gel made from cornstarch and water was an acceptable coupling medium and provided equally adequate images as compared with commercial ultrasound gel. This inexpensive gel made from ubiquitous materials can be an acceptable alternative to commercial gel in low-resource settings.     

Ultrasound-Assisted Removal of A Fishbone Stuck in A Tongue in the Emergency Department

Background

Foreign body (FB) impaction in the oropharyngeal region—and specifically the tongue—is a common problem in the emergency department that often requires specialty consultation and admission for operative intervention. Over the years, the use of point of care ultrasound (POCUS) has increased ease and success of FB removal in other anatomic regions, but is only rarely reported for extraction of FB from the tongue outside of the operating room.

Point-of-Care Ultrasound is Associated With Decreased Length of Stay in Children Presenting to the Emergency Department With Soft Tissue Infection

Background

Point-of-care ultrasound (POCUS) is increasingly being used to differentiate cellulitis from abscess in the pediatric emergency department (ED). POCUS has also been shown to decrease length of stay (LOS) for other applications among adult patients.

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.     

A Brief Educational Intervention Is Effective in Teaching the Femoral Nerve Block Procedure to First-Year Emergency Medicine Residents

Background

Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure.

Objectives

We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session.

Methods

First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months.

Results

A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency.

Conclusion

A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients.     

Color Flow Doppler Point of Care Ultrasound to Evaluate Vessels before Infant Lumbar Puncture

Background

Infant lumbar punctures (LPs) are common procedures performed in the emergency department. However, 10% to 35% of these LPs are unsuccessful or grossly bloody, which can lead to increased hospitalization, increased costs, and prolonged exposure to antibiotics or antivirals. Point of care ultrasound (POCUS) may help to surmount the intrinsic causes of LP failure by providing a visual guide of the vascular structures in the needle path before a LP is performed.

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study

Background

Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging.

The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED

Objectives

To determine the diagnostic accuracy of emergency physician performed point-of care ultrasound (POCUS) for detecting long bone fractures compared to standard radiography.

Methods

This was a single-blinded, prospective observational study of patients presenting to two emergency departments (ED) with trauma to long bones. The study used a convenience sample of patients seen during the study investigators' scheduled clinical shifts. Patients presenting to the ED with complaints of long bone trauma were included in the study when a study investigator was available in the ED. POCUS examinations of injured long bones were performed using a standard protocol. The investigators documented their interpretation prior to radiographs being performed. After standard radiographs were performed, the final radiology reading by a radiology attending physician was obtained from the medical record.

Results

One-hundred six patients were enrolled into the study, and 147 long bone POCUS examinations were performed. Forty-two fractures were present by radiographs and the prevalence of fractures was 29%. The sensitivity was 90.2% (4/41, 95% CI: 76.9-97.3) and specificity was 96.1% (4/102, 95% CI: 90.3-98.9). The positive likelihood ratio was 23.0 (95% CI: 8.8-60.5), and the negative likelihood ratio was 0.102 (95% CI: 0.040, 0.258). The positive predictive value was 90.2% (4/41, 95% CI: 76.9-97.3) and the negative predictive value was 96.1% (4/102, 95% CI: 90.3-98.9).

Conclusions

Emergency physicians can accurately evaluate long bone fractures in the ED using POCUS. In particular, long bone fractures can be excluded with a high degree of confidence.