Special operator level clinical ultrasound: an experience in application and training

Point of Care Ultrasounds Obtained by Novice Physician Assistant Residents (POCUS ON PAR)

INTRODUCTION

The integration of Point of Care Ultrasound (POCUS) into the care of trauma patients, specifically the E-FAST, has improved the accuracy of initial diagnoses and improved time to surgical intervention in critically ill patients. Physician assistants (PAs) are critically important members of any military trauma resuscitation team and are often team leaders in a pre-hospital setting. They may receive training in ultrasound but there are little data to support their use or evaluate their effectiveness in using POCUS. We designed a study to evaluate the image quality of an E-FAST Exam performed by Emergency Medicine Physician Assistant (EMPA) Fellows and Emergency Medicine (EM) Interns following identical training. Our hypothesis is that image quality obtained by EMPAs will be non-inferior to those images obtained by EM Interns.

MATERIALS AND METHODS

This is a prospective single-blinded study comparing the image quality of E-FAST exams performed by first year EM interns and first year EMPA fellows. All participants completed standard POCUS training prior to enrollment in the study. A total of 8 EMPAs and 8 EM first year residents completed 10 recorded E-FAST exams to be used as study images. Participants also viewed a 15-question slide show containing images of positive (6) and negative (9) E-FAST exams and recorded their interpretations. Images were reviewed by expert reviewers who were blinded to which images were collected by which group. An image quality score was recorded for each view as well as an overall image quality score. Image quality was rated on a 1 to 5 image quality scale.

RESULTS

For overall image quality, the mean score for EMPAs was 3.6 ± 0.5 and for EM residents was 3.2 ± 0.5 with statistical significance favoring better image quality from the EMPAs. The time to completion for the EFAST exam for EMPAs was 4.8 ± 1.3 minutes and for interns it was 3.4 ± 1.4 minutes (P value = 0.02). There was no difference in image interpretation quiz scores between the groups (mean score 92% among interns and 95% among PAs).

CONCLUSIONS

POCUS is an imaging modality which is very portable and relatively inexpensive which makes it ideal for military medicine. PAs are essential members of military trauma teams, and often run an initial trauma resuscitation. Being able to correctly identify patients who have free fluid early in the course of treatment allows for more correct evacuation criteria to ensure the sickest patients get to care the fastest. Although there are limited data to support POCUS use by non-physicians, our data support a growing body of evidence that it is not the profession or baseline medical education that determines an individual's ability to use and incorporate ultrasound into bedside and clinical practice. Our study shows that with training and experience PAs or other members of the military health care team can use the EFAST to better care for trauma patients.

A Sub-Analysis of U.S. Africa Command Area of Operations Transportations for Ophthalmic Concerns, 2008-2018

INTRODUCTION

American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018.

METHODS

We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions.

RESULTS

Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary.

CONCLUSION

Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

Ultrasonography for Dorsal-Sided Wrist Pain in a Combat Environment: Technique, Pearls, and a Case Report of Dynamic Evaluation of the Scapholunate Ligament

Ultrasonography is a commonly utilized tool in orthopedic surgery for the diagnosis and treatment of a variety of musculoskeletal conditions, including pathology about the wrist. Its value should not be underestimated when other diagnostic resources are unavailable - such as in a combat setting where ultrasounds, but not X-ray, are a standard equipment item. An active duty soldier presented to an orthopedic provider in an austere environment with chronic dorsal wrist pain due to a previous fall. Physical examination and dynamic ultrasound examination allowed the deployed provider to diagnose a scapholunate ligament injury. The patient was appropriately evacuated to a higher level of care without the need for X-ray or other advanced imaging modalities. Making this readily available resource a standard tool for providers deployed to a forward location could be beneficial for efficient and appropriate patient evacuation for musculoskeletal injuries. It can also rule out injuries that would otherwise have required unnecessary soldier movement through hostile territory for diagnostic tests such as X-rays. In addition, a simple technique and pearls for ultrasonography of the wrist are provided.

Revolution or Evolution? A Proposal for the Integration of Point-of-Care Ultrasound Into Physician Assistant Clinical Practice

Advances in technology and increased affordability of machines have allowed ultrasound to become ubiquitous across the spectrum of medical care. Increasing portability has brought ultrasound to the point of care in multiple medical specialties. Formal ultrasound training is rapidly being incorporated into multispecialty residency programs and undergraduate medical education curricula, yet little formal training exists for physician assistants (PAs) on this emerging clinical adjunct. This article outlines recommendations for and barriers to the incorporation of bedside ultrasound into PA clinical practice.

Assessment of Paramedic Ultrasound Curricula: A Systematic Review

OBJECTIVE

Prehospital ultrasound is being applied in the field. The purpose of this systematic review is to describe evidence pertaining to ultrasound curricula for paramedics specifically, including content, duration, setting, design, evaluation, and application.

METHODS

Electronic searches of MEDLINE, Embase, CINAHL, and the Cochrane Center Register of Controlled Trials were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary literature describing acute care ultrasound curricula for paramedics were included. Two authors independently extracted data and assessed quality using 2 validated tools.

RESULTS

Twelve studies with 187 paramedics were included. Curricula duration varied, with effective curricula teaching focused assessment with sonography for trauma (FAST) in 6 to 8 hours and pleural ultrasound in 25 minutes. FAST, pleural, and fracture-detection ultrasound are being applied in the field by paramedics; however, no literature exists describing application to detect cardiac standstill. Curricula combined didactic and hands-on components including simulation and evaluated competency using sensitivity and specificity of paramedic-performed ultrasound.

CONCLUSIONS

Paramedic ultrasound curricula in FAST and pleural ultrasound is feasible and time effective with successful application. Although fracture detection ultrasound is being used by the special operations forces, no comprehensive curriculum was described. Curricula designed to detect cardiac standstill have been too short, and successful application by paramedics has not been shown.