Point-of-Care Clinical Ultrasound for Medical Students

Self-Learning Videos in Focused Transthoracic Echocardiography Training

BACKGROUND

Focused transthoracic echocardiography (FOTE) is crucial for patients' bedside management. However, limited opportunities exist for practical FOTE training, prompting the use of simulation and self-learning videos to overcome this constraint. This study aimed to evaluate the impact of incorporating self-learning videos into a simulation FOTE training course.

APPROACH

This was a prospective, randomized study involving University of Toronto internal medicine residents, who participated in a 2-h didactic and simulation FOTE training course before being randomized to a control group receiving written learning materials or an intervention group with additional self-directed learning videos.

EVALUATION

Twenty-eight participants were randomized, and twenty-one (75%) completed the 1-month follow-up. Participants were assessed using a written test on image acquisition techniques and structure identification, scanning time and image quality on a simulator and self-reported scanning comfort, both pre-intervention and 1-month post-intervention. The groups had no significant difference in the time spent reviewing the material (1.5 vs. 1.4 h, p = 0.76). A significant increase in post-course scores was observed in all evaluations except for the control group's written test (p = 0.07). There were no significant between-group differences across the written test (p = 0.7), image quality (p = 0.6) and comfort level (p = 0.7). Compared to the control group, the intervention group exhibited a greater reduction in the scanning time (38 vs. 72 s, p = 0.02).

IMPLICATIONS

FOTE training effectively increases theoretical knowledge and practical skills in a simulated setting. However, limited video utilization by participants precluded the inference of definitive conclusions on the impact of self-learning videos.

Simulation-based echocardiography learning contribution on training of medical residents

INTRODUCTION

Echocardiography is a pivotal exam in critically ill patients, a specific training is crucial. Medical residents often lack echocardiography practice.

AIM

This study aims to evaluate the impact of simulation-based training on medical residents' echocardiography mastery.

METHODS

This interventional study was conducted among medical residents at the Simulation Center of the Faculty of Medicine in Monastir (CeSim) in January 2022. The intervention consisted of a theoretical training and a simulator-based practical training concerning echocardiography. Residents underwent evaluation before and after training through a "Pre-Test" and a "Post-Test," respectively, using a French-language questionnaire. Participation was entirely voluntary.

RESULTS

A total of 28 medical residents participated in our study, with the majority being female (57.1%). The median age was 29 years (interquartile range: 28-31.75). Following training, the proportion of participants who reported having the necessary skills for echocardiography interpretation significantly increased (p<0.05). Respondents demonstrated significant improvements in their scores on theoretical tests and practical skills assessments. Concerning echocardiographic views, the percentage of participants who correctly identified the title of the parasternal small axis section increased from 53.6% before training to 100% after training (p <10-3). Significant enhancements were observed in all parameters evaluating the practice of echocardiographic sections by respondents on a mannequin after training, encompassing time to obtain the view, view quality, image quality, visualization of structures, interpretability, and image stability (p<10-3). There was a significant improvement in average response rates for echocardiographic clinical syndroms among medical residents before and after training. All participants emphasized the indispensability of ultrasound education in the training of physicians specializing in managing cardiopulmonary emergencies.

CONCLUSIONS

This study reports the beneficial role of simulation-based training in enhancing the mastery of medical residents in echocardiography. Incorporating such training methods into their learning curricula is advisable.

Can you teach a hands-on skill online? A scoping review of e-learning for point-of-care ultrasound in medical education

Background

There is an increasing need and interest in teaching point-of-care ultrasound (POCUS) online. The objective of this study was to systematically review the literature regarding e-learning as a method for teaching POCUS in medical education, to assess the benefits and limitations of various styles of e-learning for POCUS, and to identify gaps in the literature that could help guide future research in this field.

Methods

A literature search was conducted on three databases including MEDLINE (Ovid), EMBASE and Cochrane Central Register of Controlled Clinical Trials on October 12, 2021, retrieving a total of 1630 studies. 31 studies met the inclusion and exclusion criteria. These studies were separated into different styles of e-learning and learner outcomes were analyzed based on Kirkpatrick's hierarchy.

Results

The studies were categorized into three styles of e-learning: a) blended learning b) online-only (asynchronous or synchronous) and c) use of handheld machines or telesonography. POCUS knowledge and image interpretation were successfully taught online, however online-only learning for image acquisition was not as consistently effective. Blended learning and telesonography were beneficial for learning image acquisition skills. Generally, novice learners benefited most from e-learning.

Conclusion

E-learning for POCUS is gaining in popularity in recent years. POCUS is a complex technical skill, and depending on the individual task being taught, different styles of e-learning may be more successful. These findings can inform future POCUS educational programs.

The effect of early follow-up after open cardiac surgery in a student clinic

Objectives. Readmission rates following open cardiac surgery are high, affecting patients and the cost of care. This study aimed to investigate the effect of early additional follow-up after open cardiac surgery when 5th-year medical students conducted follow-ups under the supervision of physicians. The primary endpoint was unplanned cardiac-related readmissions within one year. The secondary outcomes were the detection of impending complications and health-related quality of life (HRQOL). Methods. Patients undergoing open cardiac surgery were prospectively included. For intervention, additional follow-up visits, including point-of-care ultrasound, were conducted by supervised 5th-year medical students on postoperative days 3, 14 and 25. Unplanned cardiac-related readmissions, including emergency department visits, were registered within the first year of surgery. Danish National Health Survey 2010 questionnaire was used for HRQOL. In standard follow-up, all patients were seen 4-6 weeks postoperative. Results. For data analysis, 100 of 124 patients in the intervention group and 319 of 335 patients in the control group were included. The 1-year unplanned readmission rates did not differ; 32% and 30% in the intervention and control groups, respectively (p = 0.71). After discharge, 1% of patients underwent pericardiocentesis. The additional follow-up initiated scheduled drainage, contrary to more unscheduled/acute drainages in the control group. Pleurocentesis was more common in the intervention group (17% (n = 17) vs 8% (n = 25), p = 0.01) and performed earlier. There was no difference between groups on HRQOL. Conclusion. Supervised student-led follow-up of newly cardiac-operated patients did not alter readmission rates or HRQOL but may detect complications earlier and initiate non-emergent treatment of complications.

Lessons Learned from POCUS Instruction in Undergraduate Medicine During the COVID-19 Pandemic

Point of care Ultrasound (POCUS) has been adopted into clinical practice across many fields of medicine. Undergraduate medical education programs have recognized the need to incorporate POCUS training into their curricula, traditionally done in small groups with in-person sessions. This method is resource intensive and requires sufficient equipment and expertise. These requirements are often cited as barriers for implementation. During the Coronavirus Disease 2019 (COVID-19) pandemic, POCUS education was required to adapt to physical distancing regulations, giving rise to novel teaching methods for POCUS. This article outlines the implementation of a POCUS teaching session before and during the pandemic. It describes how these innovations can scale POCUS teaching and overcome barriers moving forward. A flipped classroom model was implemented for all learners. Learners were given an introductory POCUS module before the scheduled in-person or virtual teaching session. Sixty-nine learners participated in conventional in-person teaching, while twenty-two learners participated in virtual teaching following the pandemic-related restrictions. Learners completed a written test before and following the teaching. In-person learners were assessed using an objective structured assessment of ultrasound skills (OSAUS) pre- and post-learning sessions. A follow-up survey was conducted three years after the teaching sessions were completed. Both in-person and virtual groups demonstrated statistically significant improvement in knowledge scores (p <0.0001). Both groups had similar post-test learning scores (74.2 ± 13.6% vs. 71.8 ± 14.5 %, respectively). On follow-up questionnaires, respondents indicate that they found our online and in-person modes of teaching helpful during their residency. POCUS education continues to face a variety of barriers, including limitations in infrastructure and expertise. This study describes an adapted POCUS teaching model that is scalable, uses minimal infrastructure and retains the interactivity of conventional small-group POCUS teaching. This program can serve as a blueprint for other institutions offering POCUS teaching, especially when conventional teaching methods are limited.

Robotic training for medical students: feasibility of a pilot simulation curriculum

While robotic procedures are growing rapidly, medical students have a limited role in robotic surgeries. Curricula are needed to enhance engagement. We examined feasibility of augmenting Intuitive Surgical (IS) robotic training for medical students. As a pilot, 18 senior students accepted an invitation to a simulation course with a daVinci robot trainer. Course teaching objectives included introducing robotic features, functionalities, and roles. A 1-h online module from the IS learning platform and a 4-h in-person session comprised the course. The in-person session included an overview of the robot by an IS trainer (1.5 h), skills practice at console (1.5 h), and a simulation exercise focused on the bedside assist role (1 h). Feasibility included assessing implementation and acceptability using a post-session survey and focus group (FG). Survey responses were compiled. FG transcripts were analyzed using inductive thematic analysis techniques. Fourteen students participated. Implementation was successful as interested students signed up and completed each of the course components. Regarding acceptability, students reported the training valuable and recommended it as preparation for robotic cases during core clerkships and sub-internships. In addition, FGs revealed 4 themes: (1) perceived expectations of students in the OR; (2) OR vs. outside-OR learning; (3) simulation of stress; and (4) opportunities to improve the simulation component. To increase preparation for the robotic OR and shift robotic training earlier in the surgical education continuum, educators should consider hands-on simulation for medical students. We demonstrate feasibility although logistics may limit scalability for large numbers of students.

Point-of-care ultrasound for acute abdomen: 5W1H (Translated version)

In this paper, point-of-care ultrasound (POCUS) for the initial diagnosis and the management of acute abdomen is discussed. POCUS is supposed to be executed mainly by doctors other than ultrasound specialists anytime and anywhere such as in the emergency room or the intensive care unit. Although it seems rather difficult to cover the wide spectrum of organs as well as diseases causing acute abdominal pain, the author advocates a "six approach" for the diagnosis and triage of acute abdomen, which consists of scanning at eight points in less than 5 min. With this method, the attending doctor can diagnose most of the diseases frequently encountered in patients with acute abdomen, which can help patients avoid unnecessary examinations or admissions. However, users of POCUS should be aware of its limitations, especially when they are using pocket-sized ultrasound equipment. Therefore, users should be careful when ruling out a disease even when they cannot find any pathological findings, and consider the need for further examinations such as US done by specialists with high-end equipment or CT. Since there has been no standard curriculum in Japan for POCUS training that should deal with basic physics and techniques for US, normal abdominal anatomy, typical pathological US findings, and interventional US, the establishment of a learning program for doctors and training of experts as instructors of POCUS are needed.

International consensus conference recommendations on ultrasound education for undergraduate medical students

OBJECTIVES

The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students.

METHODS

64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting.

RESULTS

A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care.

CONCLUSIONS

The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Ultrasonography in undergraduate medical education: a comprehensive review and the education program implemented at Jichi Medical University

The concept of point-of-care ultrasound has been widely accepted owing to the development of portable ultrasound systems and growing body of evidence concerning its extensive utility. Thus, it is reasonable to suggest that training to use this modality be included in undergraduate medical education. Training in ultrasonography helps medical students learn basic subjects such as anatomy and physiology, improve their physical examination skills, and acquire diagnostic and procedural skills. Technological advances such as simulators, affordable handheld devices, and tele-ultrasound systems can facilitate undergraduate ultrasound education. Several reports have indicated that some medical schools have integrated ultrasound training into their undergraduate medical curricula. Jichi Medical University in Japan has been providing medical students with ultrasound education to fulfill part of its mission to provide medical care to rural areas. Vertical integration of ultrasound education into a curriculum seems reasonable to ensure skill retention and improvement. However, several issues have hampered the integration of ultrasound into medical education, including a lack of trained faculty, the need to recruit human models, requisition of ultrasound machines for training, and limited curricular space; proposed solutions include peer teaching, students as trained simulated patients, the development of more affordable handheld devices, and a flipped classroom approach with access to an e-learning platform, respectively. A curriculum should be developed through multidisciplinary and bottom-up student-initiated approaches. Formulating national and international consensuses concerning the milestones and curricula can promote the incorporation of ultrasound training into undergraduate medical education at the national level.

European Respiratory Society statement on thoracic ultrasound

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Gel Rounds: Integrating Bedside Ultrasound Training for Third-Year Medical Students Into the Internal Medicine Clerkship

Despite formal ultrasound training becoming prevalent in preclinical medical student education, significant barriers remain to the continuation of this training during clinical years. We sought to develop a program for third-year medical students to continue ultrasound training after an already robust preclinical ultrasound curriculum and evaluate their scanning confidence after participation. We developed a program to facilitate bedside ultrasound scanning of patients being cared for by third-year students. Students identified appropriate patients to be scanned, obtained consent for scanning, and determined which scans were most appropriate given the patient's clinical problems. Trained facilitators met with students at the bedside in 1-hour sessions called Gel Rounds to observe and direct the students' scans of their patients. Fifty-one students were surveyed after completing Gel Rounds. Students were significantly more likely to feel comfortable with independently acquiring and interpreting images after Gel Rounds than before completing the activity. Approximately 67% of students felt that ultrasound had utility in assisting bedside clinical reasoning, and this proportion did not change significantly after completing Gel Rounds. Gel Rounds was a positive continuation of the ultrasound curriculum into the third-year clerkship environment. A minority of students reported prior ultrasound exposure in their third year, reflecting difficulty with developing a longitudinal curriculum. The activity helped students to independently acquire and interpret images in patients. Because Gel Rounds can be performed at the discretion of students and faculty, it fits naturally in a variety of existing longitudinal curricula.

Lung ultrasound in children: What does it give us?

Lung ultrasound (LUS), a non-invasive non-ionizing radiation tool, has become essential at the bedside in both adults and children, particularly in the critically ill. This manuscript reviews normal LUS patterns and the most important pathologies that LUS allows to diagnose. Normal LUS is represented by the pleural line, the lung-sliding and the A-lines and B-lines. These two last findings are artifacts derived from the pleural line. Pleural effusion appears as an anechoic collection. Pneumothorax is suspected when only A-lines are present, without lung-sliding and B-lines. Alveolo-interstitial syndrome is characterized by different degrees of confluent B-lines and can be present in different pathologies such as pulmonary edema and acute respiratory distress syndrome. The distribution of B-lines helps to differentiate between them. LUS is useful to evaluate the response to lung recruitment in pathologies such as acute respiratory distress syndrome or acute chest syndrome. The distribution of B-lines also appears to be useful to monitor the response to antibiotics in pneumonia. However, further studies are needed to further ascertain this evidence. LUS is also useful to guide thoracocentesis.

Lung-ultrasound objective structured assessment of technical skills (LUS-OSAUS): utility in the assessment of lung-ultrasound trained medical undergraduates

Purpose

Recently, some attempts have been made to integrate lung ultrasound (LUS) teaching into medical curricula. However, current education studies of LUS are extremely heterogeneous due to the lack of evidence-based guidelines on LUS education. In particular, the assessment of competencies is poorly standardized and mostly relies on non-validated scales. A new validated tool, the objective structured assessment of lung ultrasound skills (LUS-OSAUS), has the potential to overcome these limitations. Therefore, we adopted the LUS-OSAUS tool to assess the competencies of a group of LUS-trained undergraduates. Existing no prior practical applications of the LUS-OSAUS, our aim was to investigate the practical utility of this tool and its applicability in the evaluation of US-trained medical students.

Methods

Eight undergraduates (two males, six females) were enrolled on a voluntary basis to receive a theoretical and practical training in LUS. Once completed their training, each student performed an LUS examination on a different patient hospitalized for respiratory symptoms. The same eight patients were also scanned by a senior resident in emergency medicine for a comparison with students’ results. Students and the senior resident were tested by an examiner using the LUS-OSAUS tool. We compared the scores obtained by operators in all areas of competence of the LUS-OSAUS, the total scores, and the time needed to complete the sonographic task.

Results

Median students’ score in the single items of the scale was significantly lower than the ones obtained by the senior resident (4.0 [3.3–5.0] vs. 5.0 [5.0–5.0]; p < 0.0001). Students scored significantly lower than the senior resident in each item, except for B-line identification, choice of the correct transducer, and suggested focused questions. Median total score was also lower for students compared to the senior resident (70.5 [61.0–74.8] vs. 84.0 [83.5–84.3] (p = 0.0116). Median time required to complete the examination was significantly higher for students (14.1 [12.8–16.1] vs. 4.7 [3.9–5.2] min, p = 0.0117).

Conclusions

The LUS-OSAUS tool allowed for a standardized and comprehensive assessment of student’s competencies in lung ultrasound, and helped to discriminate their level of expertise from that of a more experienced operator. The scale also specifically tests the theoretical knowledge of trainees, thus making redundant the use of questionnaires designed for this purpose.

Electronic supplementary material

The online version of this article (10.1007/s40477-020-00454-x) contains supplementary material, which is available to authorized users.

Feasibility of cardiac output measurements in critically ill patients by medical students

BACKGROUND

Critical care ultrasonography (CCUS) is increasingly applied also in the intensive care unit (ICU) and performed by non-experts, including even medical students. There is limited data on the training efforts necessary for novices to attain images of sufficient quality. There is no data on medical students performing CCUS for the measurement of cardiac output (CO), a hemodynamic variable of importance for daily critical care.

OBJECTIVE

The aim of this study was to explore the agreement of cardiac output measurements as well as the quality of images obtained by medical students in critically ill patients compared to the measurements obtained by experts in these images.

METHODS

In a prospective observational cohort study, all acutely admitted adults with an expected ICU stay over 24 h were included. CCUS was performed by students within 24 h of admission. CCUS included the images required to measure the CO, i.e., the left ventricular outflow tract (LVOT) diameter and the velocity time integral (VTI) in the LVOT. Echocardiography experts were involved in the evaluation of the quality of images obtained and the quality of the CO measurements.

RESULTS

There was an opportunity for a CCUS attempt in 1155 of the 1212 eligible patients (95%) and in 1075 of the 1212 patients (89%) CCUS examination was performed by medical students. In 871 out of 1075 patients (81%) medical students measured CO. Experts measured CO in 783 patients (73%). In 760 patients (71%) CO was measured by both which allowed for comparison; bias of CO was 0.0 L min-1 with limits of agreement of - 2.6 L min-1 to 2.7 L min-1. The percentage error was 50%, reflecting poor agreement of the CO measurement by students compared with the experts CO measurement.

CONCLUSIONS

Medical students seem capable of obtaining sufficient quality CCUS images for CO measurement in the majority of critically ill patients. Measurements of CO by medical students, however, had poor agreement with expert measurements. Experts remain indispensable for reliable CO measurements. Trial registration Clinicaltrials.gov; http://www.clinicaltrials.gov; registration number NCT02912624.

Preclerkship Point-of-Care Ultrasound: Image Acquisition and Clinical Transferability

INTRODUCTION

The integration of point-of-care ultrasound (POCUS) in preclerkship medical education is currently popular and based on the notion that POCUS may improve diagnostic and procedural skills in medical students. However, empirical evidence demonstrating that POCUS can enhance clinical skills in preclerkship students has been lacking. We sought to evaluate anatomical sonographic knowledge and ultrasound generation capabilities associated with the implementation of a 3-h echocardiography training camp led by 2 emergency physicians and using a flipped classroom design.

METHODS

Preclerkship students from the University of Ottawa (n = 32) were recruited to participate. A flipped classroom model was adopted, providing students with a 3-chaptered peer-designed, expert validated ultrasound manual before the workshop, to maximize scanning times (2 h of reading). A pretest Likert-type design was used to assess student perception of the ultrasound tool. Similarly, a pretest/post-test model was used to assess sonographic anatomical identification. In addition, a subsequent Objective Structured Clinical Examination (OSCE) test was done 3 weeks after the hands-on session, to evaluate image generation (4 cardiac views: parasternal long, parasternal short, subxiphoid, and apical 4 chambers), understanding of knobology and structural labeling.

RESULTS

For the sonographic anatomy, there was a statistically significant increase (P < .001) between pretest (average = 12.12) and post-test (average = 18.85). The OSCE, which also ascertained knowledge retention, found that 81% of students were able to generate all 4 cardiac views perfectly, 6% were able to obtain 3 views, 10% obtained 2 views and 3% successfully generated a single view. The most challenging scan to generate was the apical 4-chamber view.

CONCLUSION

The positive outcomes stemming from this study reinforces the notion that formal curricular integration of POCUS at the preclerkship level has tangible benefits for medical students.

Image quality to estimate ventricular ejection fraction by last year medical students improves after short courses of training

BACKGROUND

Transthoracic echocardiography is the primary imaging modality for diagnosing cardiac conditions but medical education in this field is limited. We tested the hypothesis that a structured theoretical and supervised practical course of training in focused echocardiography in last year medical students results in a more accurate assessment and more precise calculation of left ventricular ejection fraction after ten patient examinations.

METHODS

After a theoretical introduction course 25 last year medical students performed ten transthoracic echocardiographic examination blocks in postsurgical patients. Left ventricular function was evaluated both with an eye-balling method and with the calculated ejection fraction using diameter and area of left ventricles. Each examination block was controlled by a certified and blinded tutor. Bias and precision of measurements were assessed with Bland and Altman method.

RESULTS

Using the eye-balling method students agreed with the tutor's findings both at the beginning (88%) but more at the end of the course (95.7%). The variation between student and tutor for calculation of area, diameter and ejection fraction, respectively, was significantly lower in examination block 10 than in examination block 1 (each p < 0.001). Students underestimated both the length and the area of the left ventricle at the outset, as complete imaging of the left heart in the ultrasound sector was initially unsuccessful.

CONCLUSIONS

A structured theoretical and practical transthoracic echocardiography course of training for last year medical students provides a clear and measurable learning experience in assessing and measuring left ventricular function. At least 14 examination blocks are necessary to achieve 90% agreement of correct determination of the ejection fraction.

Evaluation of the efficacy of a self-training programme in focus cardiac ultrasound with simulator

BACKGROUND

Focus cardiac ultrasound is a great tool for quick evaluation of cardiac function in acute settings with limited time and expertise in echocardiography. Adequate training is essential for physicians willing to use this imaging technique.

AIM

The goal of this study was to assess the efficacy of a self-training programme using a cardiac ultrasound simulator.

METHODS

Thirty-five trainees in cardiology, emergency medicine or anaesthesiology entered the programme, which started with an e-learning lecture on focus cardiac ultrasound, with practice on a simulator, followed by implementation on patients, and ended with self-training in image analysis on an online platform. A post-test evaluation was carried out at the end of the theoretical training, followed by a final live evaluation on patients (timed acquisition of the five reference views used in focus cardiac ultrasound, grading each view on a scale of 1 to 5). Trainees were also evaluated online regarding their interpretation of 20 video clips.

RESULTS

The median (interquartile range) interpretability scores following simulator training were 5 (4-5) for the parasternal long-axis view, 5 (4-5) for the apical four-chamber view, and 4 (4-5) for the subcostal window. Interpretability was significantly inferior in the live evaluation compared with the post-test evaluation, except for the parasternal long-axis and subcostal views. The mean score for the video clips (out of 20) was 14.5±2.4.

CONCLUSIONS

After a short self-training programme, trainees were able to acquire the main views of focus cardiac ultrasound with sufficient quality and in a short time period.

Ability of non-physicians to perform and interpret lung ultrasound: A systematic review

BACKGROUND

Lung ultrasound is a useful tool in the assessment of pulmonary congestion in heart failure that is typically performed and interpreted by physicians at the point-of-care.

AIMS

To investigate the ability of nurses, students, and paramedics to accurately identify B-lines and pleural effusions for the detection of pulmonary congestion in heart failure and to examine the training necessary.

METHODS AND RESULTS

We conducted a systematic review and searched online databases for studies that investigated the ability of nurses, students, and paramedics to perform lung ultrasound and detect B-lines and pleural effusions. Of 979 studies identified, 14 met our inclusion criteria: five in nurses, eight in students, and one in paramedics. After 0-12 h of didactic training and 58-62 practice lung ultrasound examinations, nurses were able to identify B-lines and pleural effusions with a sensitivity of 79-98% and a specificity of 70-99%. In image adequacy studies, medical students with 2-9 h of training were able to acquire adequate images for B-lines and pleural effusions in 50-100%. Only one eligible study investigated paramedic-performed lung ultrasound which did not support the ability of paramedics to adequately acquire and interpret lung ultrasound images after 2 h of training.

CONCLUSIONS

Our findings suggest that nurses and students can accurately acquire and interpret lung ultrasound images after a brief training period in a majority of cases. The examination of heart failure patients with lung ultrasound by non-clinicians appears feasible and warrants further investigation.

Effectiveness of Bedside Lung Ultrasound for Clinical Follow-Up of Primary Spontaneous Pneumothorax Patients Treated With Tube Thoracostomy

Primary spontaneous pneumothorax (PSP) is a common cause of presentation to emergency departments and subsequent hospitalization. Patients with large PSP are treated with tube thoracostomy (TT) and followed up with x-rays. In this study, we investigated the efficiency of bedside ultrasound and compared it with x-ray imaging for the clinical follow-up of PSP patients treated with TT.This is a prospective observational study. After ethical committee approval and written informed consent were obtained, patients who were treated with TT because of PSP were screened. In the follow-up of these patients, a bedside lung ultrasound (BLUS) was performed before every chest x-ray by an emergency physician experienced in performing BLUSs. The performance of BLUSs in detecting free air in the pleural cavity was compared statistically with that of x-rays.Sixty-two patients were enrolled in the study. In total, 166 BLUSs and x-rays were compared. The sensitivity of BLUS was 95.65% (85.20-99.50), specificity was 100% (79.40-100.00), positive predictive value was 100% (92-100), negative predictive value was 88.90% (65.30-98.60), and the area under the curve was 0.99 (0.974-1.000; P = 0.001) for detecting air in the pleural cavity. These results showed that there was no statistically significant difference between BLUS and x-ray methods for detecting air in the pleural cavity.Our study revealed that BLUS can be safely used for the follow-up of PSP patients treated with TT to determine if air is present in the pleural cavity. Further studies are needed.

Ultrasonography in Undergraduate Medical Education: A Systematic Review

OBJECTIVES

The purpose of this study was to conduct a systematic review of the evidence of educational outcomes associated with teaching ultrasonography (US) to medical students.

METHODS

A review of databases through 2016 was conducted for research studies that reported data on teaching US to medical students. Each title and abstract were reviewed by teams of 2 independent abstractors to determine whether the article would be ordered for full-text review and subsequently by 2 independent authors for inclusion. Data were abstracted with a form developed a priori by the authors.

RESULTS

Ninety-five relevant unique articles were included (of 6936 identified in the databases). Survey data showed that students enjoyed the US courses and desired more US training. Of the studies that assessed US-related knowledge and skill, most of the results were either positive (16 of 25 for knowledge and 24 of 58 for skill) or lacked a control (8 of 25 for knowledge and 27 of 58 for skill). The limited evidence (14 of 95 studies) of the effect of US training on non-US knowledge and skill (eg, anatomy knowledge or physical examination skill) was mixed.

CONCLUSIONS

There is ample evidence that students can learn US knowledge and skills and that they enjoy and want US training in medical school. The evidence for the effect of US on external outcomes is limited, and there is insufficient evidence to recommend it for this purpose at this time.

Lung ultrasound training: a systematic review of published literature in clinical lung ultrasound training

Background

Clinical lung ultrasound examinations are widely used in the primary assessment or monitoring of patients with dyspnoea or respiratory failure. Despite being increasingly implemented, there is no international consensus on education, assessment of competencies, and certification. Today, training is usually based on the concept of mastery learning, but is often unstructured and limited by bustle in a clinical daily life. The aim of the systematic review is to provide an overview of published learning studies in clinical lung ultrasound, and to collect evidence for future recommendations in lung ultrasound education and certification.

Methods

According to PRISMA guidelines, three databases (PubMed, Embase, Cochrane Library) were searched, and two reviewers examined the results for eligibility. Included publications were described and assessed for level of evidence and risk of bias according to guidelines from Oxford Centre for Evidence-Based Medicine and Cochrane Collaboration Tool for Risk of Bias assessment.

Results

Of 7796 studies screened, 16 studies were included. Twelve pre- and post-test studies, three descriptive studies and one randomized controlled trial were identified. Seven studies included web-based or online modalities, while remaining used didactic or classroom-based lectures. Twelve (75%) studies provided hands-on sessions, and of these, 11 assessed participants’ hands-on skills. None of the studies used validated neither written nor practical assessment. The highest level of evidence score was 2 (n = 1), remaining scored 4 (n = 15). Risk of bias was assessed high in 11 of 16 studies (68.75%).

Conclusion

All educational methods proved increased theoretical and practical knowledge obtained at the ultrasound courses, but the included studies were substantial heterogeneous in setup, learning-, and assessment methods, and outcome measures. On behalf of current published studies, it was not possible to construct clear guidelines for the future education and certification in clinical lung ultrasound, but the use of different hands-on training facilities tends to contribute to different aspects of the learning process. This systematic review proves a lack of learning studies within this content, and research with validated theoretical and practical tests for assessment is desired.

Impact of an intensive education programme of diagnostic lung and lower limb ultrasound on physiotherapist knowledge: A pilot study

INTRODUCTION/PURPOSE

Diagnostic ultrasound of the respiratory system and peripheral muscular systems is increasingly being used by clinicians. The aim of this study was to evaluate the knowledge outcomes of a bespoke one-day curriculum for physiotherapists that incorporated lung, diaphragm and lower limb muscle diagnostic ultrasound theory and practical training in image acquisition and analysis.

METHODS

A one-day course comprised of three instructors and 32 participants on key diagnostic ultrasound findings of the lungs, diaphragm and lower limb musculature included didactic lectures combined with expert-led hands-on training in practical sessions. Participants undertook pre- and post-course knowledge questionnaire covering key ultrasound findings for normal lungs, pleural/pulmonary pathologies and normal and abnormal findings for the diaphragm and key lower limb muscle groups. The pre-test and post-test questionnaire and survey results were reported using parametric descriptive statistics (means SD) as the data were normally distributed.

RESULTS

Of the 32 physiotherapists who undertook the one-day training, 25 (78%) completed the pre- and post-course questionnaires. The pre-course knowledge scores (mean percentage, SD) were 63% (21), and the post-course scores were 62% (20) after training.

DISCUSSION

This novel diagnostic ultrasound course led to limited improvements of ultrasound knowledge in the specific areas of the key ultrasound findings pulmonary system and lower limb muscle anatomy. The pre-reading material and course structure may have been too burdensome for the participants.

CONCLUSION

Combined lung and muscle diagnostic ultrasound course may require more than the standard one-day training for appropriate knowledge acquisition, and use of online pre-course video lectures may facilitate learning.

Evaluation of chest ultrasound integrated teaching of respiratory system physiology to medical students

Ultrasound imaging is a widely used diagnostic technique, whose integration in medical education is constantly growing. The aim of this study was to evaluate chest ultrasound usefulness in teaching respiratory system physiology, students' perception of chest ultrasound integration into a traditional lecture in human physiology, and short-term concept retention. A lecture about respiratory physiology was integrated with ultrasound and delivered to third-year medical students. It included basic concepts of ultrasound imaging and the physiology of four anatomic sectors of the body of a male volunteer, shown with a portable ultrasound device (pleural sliding, diaphragmatic movement, inferior vena cava diameter variations, cardiac movements). Students' perceptions of the integrated lecture were assessed, and attendance recorded. After 4 mo, four multiple-choice questions about respiratory physiology were administered during the normal human physiology examinations, and the results of students who attended the lesson and those of who did not were compared. One hundred thirty-four students attended the lecture. Most of them showed encouragement for the study of the subject and considered the ultrasound integrated lecture more interesting than a traditional one and pertinent to the syllabus. Exposed students achieved a better score at the examination and committed less errors than did nonexposed students. The chest ultrasound integrated lecture was appreciated by students. A possible association between the exposure to the lecture and short-term concept retention is shown by better performances of the exposed cohort at the examination. A systematic introduction of ultrasound into physiology traditional teaching will be promoted by the Ultrasound-Based Medical Education movement.

Evaluation of a pilot programme on diagnostic thoracic ultrasound curriculum for acute care physiotherapists

Introduction/purpose

Diagnostic thoracic ultrasound is increasingly being used by non-physicians; hence, we evaluated a curriculum for acute care physiotherapists in critical care.

Methods

The one-day course included didactic lectures combined with expert-led hands-on training. Participants undertook pre- and post-course knowledge questionnaire covering key ultrasound findings for normal lungs, pleural and pulmonary pathologies. Course participants who worked at the institution where the course was undertaken undertook a practical examination. We also did a 4- to 6-week follow-up survey of participants. The pretest and post-test questionnaire and survey results were reported using descriptive statistics (means SD or median and IQR).

Results

A total of 12 acute care physiotherapists undertook the training and questionnaire scores (mean percentage, SD, 95% CI) increased from 73.3 ± 15.5% (63.4-83.2) before the training to 86.3 ± 5.5% (82.8-89.8) after training.

Discussion

This diagnostic thoracic ultrasound training course resulted in improvements of diagnostic thoracic ultrasound knowledge including lung and pleural pathology image recognition skills in a small group of acute care physiotherapists with nil previous diagnostic thoracic ultrasound skills. Two-thirds of the participants who responded to the survey undertook only one to three scans in clinical practice, and the most frequent barrier to clinical use of diagnostic thoracic ultrasound was time constraints.

Conclusion

Further investigation of such a diagnostic thoracic ultrasound training programme on knowledge and skills retention and image acquisition and interpretation in real life clinical practice in a larger group of acute care physiotherapists is warranted.

Basic echocardiography for undergraduate students: a comparison of different peer-teaching approaches

BACKGROUND

The aim of this study was to assess the impact of different teaching interventions in a peer-teaching environment on basic echocardiography skills and to examine the influence of gender on learning outcomes.

METHODS

We randomly assigned 79 s year medical students (55 women, 24 men) to one of four groups: peer teaching (PT), peer teaching using Peyton's four-step approach (PPT), team based learning (TBL) and video-based learning (VBL). All groups received theoretical and practical hands-on training according to the different approaches. Using a pre-post-design we assessed differences in theoretical knowledge [multiple choice (MC) exam], practical skills (Objective Structured Practical Examination, OSPE) and evaluation results with respect to gender.

RESULTS

There was a significant gain in theoretical knowledge for all students. There were no relevant differences between the four groups regarding the MC exam and OSPE results. The majority of students achieved good or very good results. Acceptance of the peer-teaching concept was moderate and all students preferred medical experts to peer tutors even though the overall rating of the instructors was fairly good. Students in the Video group would have preferred a different training method. There was no significant effect of gender on evaluation results.

CONCLUSIONS

Using different peer-teaching concepts proved to be effective in teaching basic echocardiography. Gender does not seem to have an impact on effectiveness of the instructional approach. Qualitative analysis revealed limited acceptance of peer teaching and especially of video-based instruction.

Ultrasound-Assessed Gastric Antral Area Correlates With Aspirated Tube Feed Volume in Enterally Fed Critically Ill Patients

BACKGROUND

Enteral tube feed (ETF) intolerance occurs frequently in hospitalized patients and more so in critically ill patients. Most critical care nurses continue to assess gastric residual volume (GRV), especially among those with a history of ETF intolerance. We hypothesized that ultrasound assessment of GRV correlates directly with aspirated tube feed volume.

METHODS

This was a prospective cohort study of a convenience sample of critically ill mechanically ventilated patients admitted to an intensive care unit receiving ETF. The gastric antrum was imaged using the aorta and inferior vena cava (IVC) as landmarks concurrently and simultaneously using a curvilinear probe in the midline. All ultrasound measurements were performed at 30 degrees head up, in the supine position, and prior to the assessment of GRV by nursing staff blinding the ultrasonographer to gastric volume aspirated. Gastric antral area was determined by assessing anteroposterior (AP) and craniocaudal (CC) diameters of the gastric antrum.

RESULTS

Gastric cross-sectional area (CSA) using IVC as a landmark ( R² = 0.92, P < .0001) and aorta as a landmark ( R² = 0.86, P < .0001) correlated with aspirated volume. CC diameter of the stomach measured using the aorta as a landmark correlated with aspirated volume and increased linearly with increasing GRV ( R² = 0.78, P < .0001). A CC diameter of <10 cm using the aorta as a landmark predicted a gastric volume of <500 mL.

CONCLUSIONS

Ultrasound assessment provides accurate assessment of gastric volume in real-life settings, and the CC diameter of the gastric antrum provides a simple surrogate of GRV.