[Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]

Implementing ultrasound in emergency medical services: assessing physician proficiency and training requirements

BACKGROUND

Bedside ultrasound plays an important role in diagnostics and monitoring, especially in emergency medicine. Modern technology makes ultrasound available in a mobile and portable form, so it can be used even in prehospital emergency care with several interventional and diagnostic applications. This also raises the question of what kind of education and training is necessary for EMS (emergency medical services) physicians to be able to use Point-of-Care Ultrasound (POCUS) in the prehospital setting.

AIMS

This observational study investigates the use of prehospital POCUS in a rural EMS area. It focuses the question of what level of competence is needed for EMS physicians to use POCUS adequately in the prehospital emergency setting for correct application and interpretation of the findings.

METHOD

This was a quality assurance measure designed as a prospective cohort study. We investigated POCUS examinations performed by EMS physicians in the EMS Service Area of Nuremberg City, Germany between June 2021 and July 2022. Patients transported to three specific hospitals in Nuremberg city after care were followed up and the prehospital findings were compared with the in-hospital radiological results. The number of correct findings was correlated with the level of competence in POCUS examinations of the performing EMS physicians. Various classifications of competence were used to assess the influence of training and education on the safe application of prehospital POCUS.

RESULTS

Two hundred fifty-eight prehospital POCUS examinations were documented, with 108 followed up, including 268 sonographic findings. There was a wide range of indications for POCUS use. In 79.5% of cases the prehospital findings correspond with those in-hospital. By correlating the correct findings with the participants level of competence, there was no significant difference between POCUS-experienced and -inexperienced EMS physicians, even when divided into different categories.

CONCLUSION

POCUS can be used in prehospital emergency care for a wide range of indications safely, with a high number of correct diagnoses and findings. Our results suggest that emergency POCUS is easy to learn and EMS physicians do not need intensive training to perform POCUS adequately in the prehospital setting.

TAKE HOME MESSAGES

Mobile ultrasound appears to be useful in the prehospital setting It can be used by EMS physicians even without extensive prior experience and expertise POCUS is able to find important findings for prehospital patient's care with a high level of certainty.

[Cardiac resuscitation-associated lung edema (CRALE): evaluation of diagnostic and therapeutic approaches by an expert group of the German Cardiac Society]

Sudden cardiac arrest (CA) is one of the leading causes of death in Europe, with over 70,000 cases annually in Germany. This study aims to evaluate diagnostic and therapeutic approaches for pulmonary edema in the post-resuscitation phase among intensive care physicians in Germany. Methods: The Working Group on Cardiopulmonary Resuscitation (AG42) of the German Cardiac Society conducted a web-based survey among its members. The survey assessed diagnostic methods, therapeutic strategies, and risk factors related to pulmonary edema after resuscitation. Results: A total of 77 participants, with a mean age of 43.9 years (±9.6), took part in the survey. Among them, 54.5% had more than 10 years of clinical experience in acute and intensive care medicine. Most clinics have access to radiological and sonographic procedures as well as advanced hemodynamic monitoring. Diagnostic measures are predominantly performed immediately upon admission (49.4%) or within one hour (36.4%) and are typically monitored every eight hours (77.9%). The oxygenation index (paO2/FiO2) is used by 64.9% to assess the severity of pulmonary edema, followed by qualitative evaluation of chest X-rays (46.8%) and B-line scoring via lung ultrasound (33.8%). Therapeutic approaches focus on optimizing ventilation parameters, hemodynamic management, and the use of loop diuretics. To prevent pulmonary edema, participants favor a differentiated therapy involving volume and vasoactive agents, guided by invasive hemodynamic measurements. Conclusion: Pulmonary edema, alongside cardiac and cerebral dysfunctions, represents a significant challenge in managing post-resuscitation syndromes. The survey results reveal substantial variability in diagnostic and therapeutic approaches. Prospective studies are needed to better understand the complex pathological mechanisms and develop standardized protocols.

[Clinical Ultrasound (ClinUS) - Concepts and Controversies]

Clinical ultrasound (ClinUS) is the integration of ultrasound diagnostics into the clinical examination. By comparing clinical ultrasound with other models of ultrasound diagnostics, this overview presents a concept that integrates point-of-care ultrasound, comprehensive specialty-specific ultrasound examinations and specialized multiparametric ultrasound. The applications, advantages and challenges of clinical ultrasound and its special features in comparison to other cross-sectional imaging modalities are discussed using the example of gastroenterology and general medicine in particular.

[Prehospital ultrasound in emergency medicine]

Small, portable hand-held ultrasound devices nowadays enable a widespread use of prehospital point-of-care ultrasound (pPOCUS), which has so far only been used hesitantly, especially in ground-based emergency services. Many critical or even life-threatening conditions or internal injuries can often be better diagnosed or ruled out using pPOCUS, which can enable faster and more suitable goal-directed treatment and hospital transport. This article critically discusses relevant data, clinical benefits, limitations and challenges to be overcome when using pPOCUS for the most important life-threatening situations and aims to call for intensifying training and the extensive use of pPOCUS.

Development and evaluation of a point-of-care ultrasound curriculum for paramedics in Germany - a prospective observational study and comparison

BACKGROUND

Point-of-care ultrasound (POCUS) is steadily growing in use in prehospital emergency medicine. While currently used primarily by emergency physicians, POCUS could also be employed by paramedics to support diagnosis and decision-making. Yet to date, no paramedicine-targeted POCUS curricula exist in Germany. Furthermore, given time and resource constraints in paramedic training, it is unclear whether paramedics could feasibly learn POCUS for prehospital deployment. Hence, this study outlines the development and implementation of a comprehensive POCUS curriculum for paramedics. Through this curriculum, we investigate whether paramedics can attain proficiency in POCUS comparable to other user groups.

METHODS

In this prospective observational study, we first developed a blended learning-based POCUS curriculum specifically for paramedics, focusing on basic principles, the RUSH-Protocol and ultrasound guided procedures. Participants underwent digital tests to measure their theoretical competence before (T1) and after the digital preparation phase (T2), as well as at the end of the on-site phase (T3). At time point T3, we additionally measured practical competence using healthy subjects and simulators. We compared the theoretical competence and the practical competence on a simulator with those of physicians and medical students who had also completed ultrasound training. Furthermore, we carried out self-assessment evaluations, as well as evaluations of motivation and curriculum satisfaction.

RESULTS

The paramedic study group comprised n = 72 participants. In the theoretical test, the group showed significant improvement between T1 and T2 (p < 0.001) and between T2 and T3 (p < 0.001). In the practical test on healthy subjects at T3, the group achieved high results (87.0% ± 5.6). In the practical test on a simulator at T3, paramedics (83.8% ± 6.6) achieved a lower result than physicians (p < 0.001), but a comparable result to medical students (p = 0.18). The results of the study group's theoretical tests (82.9% ± 9.2) at time point T3 were comparable to that of physicians (p = 0.18) and better than that of medical students (p < 0.01). The motivation and attitude of paramedics towards the prehospital use of POCUS as well as their self-assessment significantly improved from T1 to T3 (p < 0.001). The overall assessment of the curriculum was positive (92.1 ± 8.5).

CONCLUSION

With our tailored curriculum, German paramedics were able to develop skills in POCUS comparable to those of other POCUS learners. Integration of POCUS into paramedics' training curricula offers opportunities and should be further studied.

[Clinical acute and emergency medicine curriculum-focus on internal medicine : Recommendations for advanced training in internal medicine in the emergency department]

In Germany, physicians qualify for emergency medicine by combining a specialty medical training-e.g. internal medicine-with advanced training in emergency medicine according to the statutes of the State Chambers of Physicians largely based upon the Guideline Regulations on Specialty Training of the German Medical Association. Internal medicine and their associated subspecialities represent an important column of emergency medicine. For the internal medicine aspects of emergency medicine, this curriculum presents an overview of knowledge, skills (competence levels I-III) as well as behaviours and attitudes allowing for the best treatment of patients. These include general aspects (structure and process quality, primary diagnostics and therapy as well as indication for subsequent treatment; resuscitation room management; diagnostics and monitoring; general therapeutic measures; hygiene measures; and pharmacotherapy) and also specific aspects concerning angiology, endocrinology, diabetology and metabolism, gastroenterology, geriatric medicine, hematology and oncology, infectiology, cardiology, nephrology, palliative care, pneumology, rheumatology and toxicology. Publications focussing on contents of advanced training are quoted in order to support this concept. The curriculum has primarily been written for internists for their advanced emergency training, but it may generally show practising emergency physicians the broad spectrum of internal medicine diseases or comorbidities presented by patients attending the emergency department.