I-AIM: a novel model for teaching and performing focused sonography

The design, performance and organizational impact of a point-of-care ultrasound (POCUS) elective for internal medicine residents

BACKGROUND

An educational gap for point-of-care-ultrasound (POCUS) training exists within Internal Medicine (IM) residency programs in that there is currently no standardized training paradigm. To address this need, we designed and implemented a five-day (one work week) elective for POCUS training intending to target IM resident POCUS knowledge and skills. This course integrates self-directed learning and supervised hands-on practice to deliver effective resident education in POCUS.

METHODS

IM residents completed the five-day POCUS elective. Residents who took the elective were given an elective evaluation survey, written POCUS knowledge exams at a pre-course and post-course timepoint, as well as a post-course skills assessment exam.

RESULTS

45 IM residents completed the elective in total. 47% (N = 21) of all participating residents completed the evaluation survey. 94% of those who responded to the evaluation survey reported above average or outstanding satisfaction with all aspects of the elective, including hands-on teaching and materials provided. Written knowledge exams results showed a significant increase in POCUS knowledge scores, with pre-test and post-test scores increasing from 39 to 66%, respectively (N = 30, p < 0.001). Overall, on a skills evaluation of tested residents (N = 20), 45% were deemed to acquire images independently while 40% could interpret independently, with all learners deemed able to do both with some level of supervision. Overall use of POCUS by IM residents as measured by saved ultrasound studies increased after the implementation of the elective, suggesting institutional impact.

DISCUSSION

POCUS training is a recognized need for IM residency programs. While existing POCUS training programs vary in both length of course and depth of material to suit different educational objectives, we have presented a well-received and effective POCUS training paradigm aimed at achieving knowledge acquisition for clinical practice. This POCUS elective rotation, which is integrated into trainee's patient care experiences, circumvents several known barriers to POCUS education including work-hour limitations and limited trainee hands-on experience opportunities. We propose that our elective serves as a model for IM residencies which have similar needs with respect to POCUS education.

Point-of-Care Ultrasound Competency, Credentialing and Policies

Point-of-care ultrasound (POCUS) enhances diagnostic accurate, reduces time to diagnosis, and improves patient satisfaction. Competenties encompass indications, image acquisition, interpretation, and medical decision-making. Education involves didactic methods and hands-on practice with emphasis on longitudinal training and feedback. Assessment tools target knowledge, psychomotor, attitudinal domains. POCUS portfolios and quality assurance ensure competence and continued overarching POCUS oversight and feedback. Scan numbers are often used as a surrogate for competency; however, it is important to note that learning curves vary by POCUS application. Proper POCUS use requires understanding its diagnostic power and potential limitations. POCUS indications vary by clinical scenarios and beneficial applications for training and credentialing vary by medical niche. This text underscores the importance of standardized training and evidence-based practices in POCUS utilization.

Heart in Focus: Advancing Pericardial Effusion Diagnosis With Point-of-Care Ultrasound

Pericardial effusion refers to the accumulation of fluid within the pericardial sac, the double-layered membrane surrounding the heart. It can be caused by various medical conditions and may lead to serious complications if not diagnosed and managed promptly. Point-of-care ultrasound (POCUS) has emerged as a valuable tool in the clinical evaluation of pericardial effusions, offering real-time visualization and aiding in the assessment of its size, characteristics, and potential hemodynamic impact. This comprehensive revision explores the utility of POCUS in diagnosing and managing pericardial effusions. POCUS has gained prominence as a bedside diagnostic tool due to its immediacy, accuracy, and non-invasive nature. This study investigates how POCUS can address critical gaps in current diagnostic approaches, such as delays in diagnosis using traditional imaging modalities and challenges in resource-limited settings, thereby enhancing patient outcomes and clinical decision-making. A search was conducted on PubMed in August of 2023, using the keywords "POCUS" and "pericardial" as MeSH terms and reference mining. A total of 19 articles were included in this review. Characterization and quantification of pericardial effusion (PEF) using POCUS can provide clinicians with critical clues regarding the underlying etiology. This information, combined with other hemodynamic parameters, should guide subsequent management decisions. POCUS enables the identification of key sonographic findings, such as diastolic collapse of the right chambers, abnormal septal movement, and an engorged inferior vena cava (IVC), which together raise a high clinical suspicion of cardiac tamponade. Beyond its utility in identifying tamponade, POCUS plays a significant role in detecting subtle yet life-threatening conditions, such as aortic dissection, which may manifest as pericardial effusion due to hemopericardium. While POCUS is not definitive for diagnosing aortic dissection, indirect findings such as a pericardial effusion with hemodynamic compromise, coupled with high clinical suspicion, should prompt further imaging like CT angiography for confirmation. We propose an algorithmic approach: if cardiac tamponade is confirmed on POCUS, emergent pericardiocentesis is warranted. If ruled out, further investigations should be directed toward identifying the underlying cause of the PEF, including potentially ruling out aortic dissection to avoid missing a subtle but critical condition. POCUS has revolutionized the clinical evaluation of pericardial effusions, providing clinicians with a rapid and accurate bedside tool for diagnosis and management. Its ability to assess effusion size, identify cardiac tamponade, and guide pericardiocentesis procedures has proven invaluable in improving patient outcomes. Integrating POCUS into routine clinical practice enhances diagnostic accuracy and timely intervention, ensuring better care for patients with pericardial effusions. However, it is important to acknowledge its limitations. POCUS is highly operator-dependent, with diagnostic accuracy varying based on the clinician's experience and training. Additionally, the availability of ultrasound equipment and adequately trained personnel can be a barrier, particularly in resource-limited settings. Addressing these challenges is crucial to maximizing the utility of POCUS in clinical practice.

Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies

Point of Care ultrasound (POCUS) of the lungs, also known as lung ultrasound (LUS), has emerged as a technique that allows for the diagnosis of many respiratory pathologies with greater accuracy and speed compared to conventional techniques such as chest x-ray and auscultation. The goal of this narrative review is to provide a simple and practical approach to LUS for critical care, pulmonary, and anesthesia providers, as well as respiratory therapists and other health care providers to be able to implement this technique into their clinical practice. In this review, we will discuss the basic physics of LUS, provide a hands-on scanning technique, describe LUS findings seen in normal and pathological conditions (such as mainstem intubation, pneumothorax, atelectasis, pneumonia, aspiration, COPD exacerbation, cardiogenic pulmonary edema, ARDS, and pleural effusion) and also review the training necessary to achieve competence in LUS.

Directed image review technique (DIRT): A framework for ultrasound image assessment and interpretation

Use of point-of-care ultrasound (POCUS) is integral to the practice of emergency medicine, and POCUS education is a required component of emergency medicine training. Developing POCUS skills requires iterative deliberate practice of image acquisition and interpretation. Providing feedback to learners regarding ultrasound image interpretation can be challenging for emergency medicine clinician educators. We present a framework called the directed image review technique. This framework guides learner ultrasound image interpretation and provides educators with a similar structured approach to evaluate a learner's ultrasound competency and provide targeted feedback regarding image acquisition and interpretation.

Student ultrasound education - current views and controversies

As an extension of the clinical examination and as a diagnostic and problem-solving tool, ultrasound has become an established technique for clinicians. A prerequisite for high-quality clinical ultrasound practice is adequate student ultrasound training. In light of the considerable heterogeneity of ultrasound curricula in medical studies worldwide, this review presents basic principles of modern medical student ultrasound education and advocates for the establishment of an ultrasound core curriculum embedded both horizontally and vertically in medical studies.

Assessment of the Educational and Training Modalities in Point-of-Care Ultrasound (POCUS) for Anesthesiologists

Point-of-care ultrasound (POCUS) has been developed as a critical tool for diagnostic patient evaluation and clinical management. Its transcendence into anesthesiology necessitates appropriate and effective educational strategies to assist in the development of anesthesia POCUS learners. Several professional societies, including the American Society of Anesthesiologists (ASA), American Society of Regional Anesthesia (ASRA), and Accreditation Council for Graduate Medical Education (ACGME) for anesthesiology have established minimum training standards for POCUS education for anesthesiologists, residents, and fellows.1,4 The article at hand aims to summarize and provide insight into the various educational modalities utilized in POCUS training, incorporate these strategies in the established "Indication, Acquisition, Interpretation, and Medical decision-making" (I-AIM) framework, and include recommendations on the minimum number of POCUS exams to aid in achieving competency. 3.

Is 1 Day of Focused Training in Echocardiographic Assessment Using Subxiphoid-Only (EASy) Examination Enough? A Tertiary Hospital Response to the COVID-19 Crisis and the Use of the EASy Examination to Support Unit-Wide Image Acquisition

OBJECTIVES

We assessed the efficacy of 1-day training in echocardiography assessment using subxiphoid-only (EASy) followed by supervised image interpretation and decision-making during patient rounds as a novel approach to scaling up the use of point-of-care ultrasound (POCUS) in critically ill patients.

DESIGN

Retrospective analysis of medical records and EASy examination images.

SETTING

Tertiary care academic hospital.

PATIENTS

A total of 14 adults (> 18 yr old) with COVID-19-associated respiratory failure under the care of Albany Medical Center's surge response team from April 6-17, 2020 who received at least one EASy examination.

INTERVENTIONS

Residents (previously novice sonographers) were trained in EASy examination using 1 day of didactic and hands-on training, followed by independent image acquisition and supervised image interpretation, identification of hemodynamic patterns, and clinical decision-making facilitated by an echocardiography-certified physician during daily rounds.

MEASUREMENTS AND MAIN RESULTS

We recorded the quality of resident-obtained EASy images, scanning time, and frequency with which the supervising physician had to repeat the examination or obtain additional images. A total of 63 EASy examinations were performed; average scanning time was 4.3 minutes. Resident-obtained images were sufficient for clinical decision-making on 55 occasions (87%), in the remaining 8 (13%) the supervising physician obtained further images.

CONCLUSIONS

EASy examination is an efficient, valuable tool under conditions of scarce resources. The educational model of 1-day training followed by supervised image interpretation and decision-making allows rapid expansion of the pool of sonographers and implementation of bedside echocardiography into routine ICU patient management.

Development of a hybrid point-of-care ultrasound curriculum for first year medical students in a rural medical education program: a pilot study

BACKGROUND

The field of point-of-care ultrasound (POCUS) has advanced in recent decades due to the benefits it holds for medical providers. However, aspiring POCUS practitioners require adequate training. Unfortunately, there remains a paucity of resources to deliver this training, particularly in rural and underserved areas. Despite these barriers, calls for POCUS training in undergraduate medical education are growing, and many medical schools now deliver some form of POCUS education. Our program lacked POCUS training; therefore, we developed and implemented a POCUS curriculum for our first-year medical students.

METHODS

We developed a POCUS curriculum for first year medical students in a rural medically underserved region of the United States. To evaluate our course, we measured learning outcomes, self-reported confidence in a variety of POCUS domains, and gathered feedback on the course with a multi-modal approach: an original written pre- and post-test, survey tool, and semi-structured interview protocol, respectively.

RESULTS

Student (n=24) knowledge of POCUS significantly increased (pre-test average score = 55%, post-test average score = 79%, P<0.0001), and the course was well received based on student survey and interview feedback. In addition, students reported increased confidence toward a variety of knowledge and proficiency domains in POCUS use and their future clinical education and practice.

CONCLUSIONS

Despite a lack of consensus in POCUS education, existing literature describes many curricular designs across institutions. We leveraged a combination of student initiatives, online resources, remote collaborations, local volunteers, and faculty development to bring POCUS to our institution in a rural and medically underserved region. Moreover, we demonstrate positive learning and experiential outcomes that may translate to improved outcomes in students' clinical education and practice. Further research is needed to evaluate the psychomotor skills, broader learning outcomes, and clinical performance of students who take part in our POCUS course.

FAST skill assessment from kinematics data using convolutional neural networks

PURPOSE

FAST is a point of care ultrasound study that evaluates for the presence of free fluid, typically hemoperitoneum in trauma patients. FAST is an essential skill for Emergency Physicians. Thus, it requires objective evaluation tools that can reduce the necessity of direct observation for proficiency assessment. In this work, we use deep neural networks to automatically assess operators' FAST skills.

METHODS

We propose a deep convolutional neural network for FAST proficiency assessment based on motion data. Prior work has shown that operators demonstrate different domain-specific dexterity metrics that can distinguish novices, intermediates, and experts. Therefore, we augment our dataset with this domain knowledge and employ fine-tuning to improve the model's classification capabilities. Our model, however, does not require specific points of interest (POIs) to be defined for scanning.

RESULTS

The results show that the proposed deep convolutional neural network can classify FAST proficiency with 87.5% accuracy and 0.884, 0.886, 0.247 sensitivity for novices, intermediates, and experts, respectively. It demonstrates the potential of using kinematics data as an input in FAST skill assessment tasks. We also show that the proposed domain-specific features and region fine-tuning increase the model's classification accuracy and sensitivity.

CONCLUSIONS

Variations in probe motion at different learning stages can be derived from kinematics data. These variations can be used for automatic and objective skill assessment without prior identification of clinical POIs. The proposed approach can improve the quality and objectivity of FAST proficiency evaluation. Furthermore, skill assessment combining ultrasound images and kinematics data can provide a more rigorous and diversified evaluation than using ultrasound images alone.

Point-of-Care-ultrasound in undergraduate medical education: a scoping review of assessment methods

BACKGROUND

Point-of-Care-Ultrasound (POCUS) curricula have rapidly expanded in undergraduate medical education (UME). However, the assessments used in UME remain variable without national standards. This scoping review characterizes and categorizes current assessment methods using Miller's pyramid for skills, performance, and competence of POCUS in UME. A structured protocol was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). A literature search of MEDLINE was performed from January 1, 2010, to June 15, 2021. Two independent reviewers screened all titles and abstracts for articles that met inclusion criteria. The authors included all POCUS UME publications in which POCUS-related knowledge, skills, or competence were taught and objectively assessed. Articles were excluded if there were no assessment methods used, if they exclusively used self-assessment of learned skills, were duplicate articles, or were summaries of other literature. Full text analysis and data extraction of included articles were performed by two independent reviewers. A consensus-based approach was used to categorize data and a thematic analysis was performed.

RESULTS

A total of 643 articles were retrieved and 157 articles met inclusion criteria for full review. Most articles (n = 132; 84%) used technical skill assessments including objective structured clinical examinations (n = 27; 17%), and/or other technical skill-based formats including image acquisition (n = 107; 68%). Retention was assessed in n = 98 (62%) studies. One or more levels of Miller's pyramid were included in 72 (46%) articles. A total of four articles (2.5%) assessed for students' integration of the skill into medical decision making and daily practice.

CONCLUSIONS

Our findings demonstrate a lack of clinical assessment in UME POCUS that focus on integration of skills in daily clinical practice of medical students corresponding to the highest level of Miller's Pyramid. There exists opportunities to develop and integrate assessment that evaluate higher level competencies of POCUS skills of medical students. A mixture of assessment methods that correspond to multiple levels of Miller's pyramid should be used to best assess POCUS competence in UME.

Trends in point-of-care ultrasound use among emergency medicine residency programs over a 10-year period

Background

Point-of-care ultrasound (POCUS) is increasingly utilized in emergency medicine (EM). While residents are required by the Accreditation Council for General Medical Education to complete a minimum of 150 POCUS examinations before graduation, the distribution of examination types is not well-described. This study sought to assess the number and distribution of POCUS examinations completed during EM residency training and evaluate trends over time.

Methods

This was a 10-year retrospective review of POCUS examinations across five EM residency programs. The study sites were deliberately selected to represent diversity in program type, program length, and geography. Data from EM residents graduating from 2013 to 2022 were eligible for inclusion. Exclusion criteria were residents in combined training programs, residents who did not complete all training at one institution, and residents who did not have data available. Examination types were identified from the American College of Emergency Physicians guidelines for POCUS. Each site obtained POCUS examination totals for every resident upon graduation. We calculated the mean and 95% confidence interval for each procedure across study years.

Results

A total of 535 residents were eligible for inclusion, with 524 (97.9%) meeting all inclusion criteria. The mean number of POCUS examinations per resident increased by 46.9% from 277 in 2013 to 407 in 2022. All examination types had stable or increasing frequency. Focused assessment with sonography in trauma (FAST), cardiac, obstetric/gynecologic, and renal/bladder were performed most frequently. Ocular, deep venous thrombosis, musculoskeletal, skin/soft tissue, thoracic, and cardiac examinations had the largest percentage increase in numbers over the 10-year period, while bowel and testicular POCUS remained rare.

Conclusions

There was an overall increase in the number of POCUS examinations performed by EM residents over the past 10 years, with FAST, cardiac, obstetric/gynecologic, and renal/bladder being the most common examination types. Among less common procedures, increased frequency may be needed to ensure competence and avoid skill decay for those examination types. This information can help inform POCUS training in residency and accreditation requirements.

Mixed-Model Curriculum for Nerve Block Education in Emergency Medicine Residency

Introduction With the rising opioid epidemic, there has been a push for multimodal pain management within the emergency department. Nerve blocks have been shown to be an effective pain management strategy for many conditions, with improved success when used with ultrasound. However, there is no generally accepted method for teaching residents how to perform nerve blocks. Materials and methods Seventeen residents from a single academic center were enrolled. The residents were surveyed pre-intervention regarding demographics, confidence, and use of nerve blocks. The residents then completed a mixed-model curriculum that included an electronic module (e-module) on three plane nerve blocks and a practice session. Three months later, residents were tested on their ability to independently perform the nerve blocks and resurveyed regarding confidence and use. Results Of the 56 residents in the program, 17 enrolled in the study; 16 participated in the first session, and nine participated in the second session. Each resident had < four ultrasound-guided nerve blocks prior to participation with a slight increase in the total number of nerve blocks after the sessions. Residents were able to perform, on average, 4.8 of seven tasks independently. Residents who completed the study reported feeling more confident in their ability to perform ultrasound-guided nerve blocks (p = 0.01) and to complete associated tasks (p < 0.01). Conclusion This educational model resulted in residents completing the majority of tasks independently with improved confidence in ultrasound-guided nerve blocks. There was only a slight increase in clinically performed blocks.

A Tool to Assess Competence in Critical Care Ultrasound Based on Entrustable Professional Activities

Background

Existing assessment tools for competence in critical care ultrasound (CCUS) have limited scope and interrupt clinical workflow. The framework of entrustable professional activities (EPAs) is well suited to developing an assessment tool that is comprehensive and readily integrated into the intensive care unit (ICU) training environment.

Objective

This study sought to design an EPA-based tool to assess competence in CCUS for pulmonary and critical care fellows and to assess the validity and reliability of the tool.

Methods

Eight experts in CCUS met to define the core EPAs for CCUS. A nominal group technique was used to reach consensus. An assessment tool was created based on the EPAs with a modified Ottawa entrustability scale. Trained faculty evaluated pulmonary and critical care fellows using this tool in the ICU over a 6-month study period at a single institution. An assessment of validity of the EPA-based tool is made with four sources of validity evidence: content, response process, reliability, and relation to other variables. Reliability and response process data were generated using generalizability theory analysis to estimate sources of variance in entrustment scores. Analysis of response process validity and validity by relation to other variables was performed using regression models.

Results

Fifty-four assessments were recorded during the study period, conducted on 23 trainees by 13 faculty. Content validity of the tool was demonstrated using expert consensus and published guidelines from critical care societies to define the EPAs. Response process validity was demonstrated by the low variance in entrustment scores due to evaluators (0.086 or 6%) and high agreement between score and trainee self-assessment (regression coefficient, 0.82; P < 0.0001). Reliability was demonstrated by the high "true" variance in entrustment score attributable to the trainee: 0.674 or 45%. Validity by relation to other variables was demonstrated using regression analysis to show correlation between entrustment score and the number of times a fellow has performed an EPA (regression coefficient, 0.023; P < 0.0001).

Conclusion

An EPA-based assessment tool for competence in CCUS was created. We obtained sufficient validity evidence on three of the diagnostic EPAs. Procedural EPAs were infrequently assessed, limiting generalizability in this subgroup.

Teaching the Teachers: A Flexible, Cognitive-Focused Curriculum in Point-of-Care Ultrasound Education for Hospital Medicine Faculty

OBJECTIVES

We aimed to decrease barriers to acquiring Point-of-Care Ultrasound (POCUS) knowledge among attending physicians and improve the safety of trainee POCUS use through a novel flexible and cognitive based curriculum.

METHODS

We developed three educational pathways using varied approaches to educational delivery: a novel and asynchronous cognitive curriculum to allow Educational Supervision, a hands-on pathway for Limited Practice, and a more robust pathway for Independent Practice and credentialing.

RESULTS

From November 2018 through June 2021, 102 of 116 hospitalists engaged in some portion of the curriculum. Twenty-four completed the Educational Supervision pathway, 31 completed the Limited Practice pathway, and 17 enrolled in the Independent Practice pathway with three achieving independent practice. Faculty who completed the Educational Supervision pathway had improved scores on a comprehensive POCUS knowledge assessment, 43.5% [95% Confidence Interval (CI) 38.2-48.8] versus 72.0% [95% CI 65.2-78.8], P < .001. Junior faculty were more likely to engage in the supervision pathway and senior faculty were more likely to complete an intensive course to complete the Limited Practice pathway.

CONCLUSIONS

A flexible, cognitive focused POCUS curriculum was effective in creating high levels of engagement, and a cognitive only curriculum resulted in significant improvement in hospitalists' POCUS knowledge without hands on training. Finally, we found that hospitalist engagement in the curriculum did not follow the lowest barrier to entry or time commitment and engagement varied by time in practice. Training faculty to independent practice remains a substantial challenge.

Procedures for the content, conduct and format of EULAR/PReS paediatric musculoskeletal ultrasound courses

Background

Despite the worldwide increasing request of education on paediatric musculoskeletal ultrasound (PedMSUS), content, conduct and format of PedMSUS courses have never been internationally agreed.

Objectives

To produce educational procedures for the conduct, content and format of EULAR/PReS PedMSUS courses.

Methods

After a systemic literature review and expert opinion collection, a panel of items for the development of procedures on PedMSUS courses was identified. Agreement on the items was assessed through Delphi surveys among a taskforce of 24 members, which included 18 experts in PedMSUS (8 rheumatologists, 1 radiologist, 9 paediatric rheumatologists), 1 methodologist and rheumatologist expert in MSUS, 2 patient research partners, 1 health professional in rheumatology and 2 EMEUNET/EMERGE members, from 8 different European countries. Each item was assessed through a 5-point Likert scale (0, full disagreement; 5, full agreement); agreement was reached for >75% of answers rating 4–5. All items with agreement were included in the preliminary core set of educational procedures, which underwent external assessment by a broader Consensus group (Faculty and Tutors of previous EULAR PedMSUS courses and PReS Imaging Working Party members), through Delphi survey.

Results

Two Delphi surveys produced the preliminary core set of procedures for basic, intermediate, advanced and teach-the-teachers (TTT) PedMSUS courses. A Delphi survey within the Consensus group produced agreement on the proposed procedures.

Conclusions

Shared EULAR/PReS procedures for the conduct, content and format of basic, intermediate, advanced and TTT PedMSUS courses were identified on international basis.

Point-of-Care Ultrasonography as an Extension of the Physical Examination for Abdominal Pain in the Emergency Department: The Diagnosis of Small-Bowel Volvulus as a Rare Complication after Changing the Feeding Jejunostomy Tube

Point-of-care ultrasonography (POCUS) has become the most popular modality of testing for physicians in recent years and is used for improving the quality of care and increasing patient safety. However, POCUS is not always acceptable to all physicians. To address the benefits and importance of POCUS, numerous studies have examined the use of POCUS in clinical practice and even medical education. This article aims to highlight the effects of POCUS as an extension of the physical examination, and we present a case to address the reasons it should be performed. For a man experiencing abdominal pain immediately after his feeding jejunostomy tube was changed, there was high suspicion of small-bowel volvulus after a “whirlpool sign” was observed during the POCUS, whereby mesenteric vessels presented in a whirling or spiral shape. This impression was subsequently confirmed by computed tomography. Small-bowel volvulus is a rare complication of changing a feeding jejunostomy tube. The images submitted here add to the sparse evidence from the literature on the use of POCUS as an extension of the physical examination for evaluating abdominal pain. POCUS can be used after taking the patient’s history and conducting a physical examination. The observation of a whirlpool sign may indicate the presence of a volvulus that is life-threatening.

PAs and point-of-care ultrasound: A scoping review

OBJECTIVE

Point-of-care ultrasound (POCUS) has rapidly emerged as a valuable tool in the bedside assessment of patients. This scoping review summarizes existing literature covering clinical use and educational integration of POCUS by physician assistants (PAs), with the overall goal of identifying gaps in POCUS research involving the PA profession.

METHODS

Keyword searches of PubMed, EMBASE, Medline, and Google Scholar were conducted. Studies assessing PA POCUS use or accuracy; those evaluating extent, method, or value of POCUS educational integration; and those assessing the effect of POCUS training interventions were included.

RESULTS

Of the 717 studies retrieved, 30 met inclusion criteria. Studies generally demonstrated that PAs can use a fairly wide range of POCUS applications with high accuracy, but that POCUS integration into PA programs remains limited because of a number of identified barriers.

CONCLUSIONS

Machine availability and insufficient POCUS training and education opportunities limit widespread clinical use of POCUS by PAs.

Point-of-Care Ultrasound for the Trauma Anesthesiologist

Purpose of Review

With advances in technology and availability of handheld ultrasound probes, studies are focusing on the perioperative care of patients, but a limited number specifically on trauma patients. This review highlights recent findings from studies using point of care ultrasound (POCUS) to improve the care of trauma patients.

Recent Findings

Major findings include the use of POCUS to assess volume status of trauma patients upon arrival to measure the major vasculature. Additionally, several studies have advanced the use of POCUS to identify pneumothorax in trauma patients. Finally, the ASA POCUS certification and ASRA expert guidelines are examples of international organizations establishing guidelines for utilization and training of anesthesiologists in the field of POCUS, which will be discussed.

Summary

Despite the COVID-19 pandemic, and considerable resources being diverted to fight this global healthcare crisis, advances are being made in utilization of POCUS to aid the care of trauma patients.

A Blueprint for an Integrated Point-of-Care Ultrasound Curriculum for Nephrology Trainees

Point-of-care ultrasonography (POCUS) is a limited ultrasound study performed by the clinician at the bedside as a component or an adjunct to physical examination. POCUS has multiple applications in nephrology practice, including evaluation of obstructive uropathy, objective assessment of volume status, arteriovenous access assessment, and procedural guidance. However, unlike specialties such as emergency medicine, POCUS training is not yet integrated into most nephrology fellowship curricula, and the sonographic applications taught vary widely among fellowship programs. In this article, we have used our institutional experience to provide a roadmap or blueprint for nephrology programs looking to create a POCUS program. We provide an overview of the curriculum, including the basic organization, applications taught, online resources, milestone development, and quality assessment. We also discuss the nuances of POCUS workflow and perspectives on billing for these limited studies. In addition, we share the evaluation forms and sample documentation we use in our program. Future support, in the form of endorsed nephrology society guidelines, is needed before POCUS training is universally incorporated across nephrology fellowship programs.

Teaching Ultrasound at the Point of Care in Times of Social Distancing

Point-of-care ultrasound has become an integral aspect of critical care training. The Bedside Assessment by Sonography In Critical Care Medicine Curriculum was established at the University of Toronto to train critical care trainees in basic echocardiography and general critical care ultrasound. During the coronavirus disease (COVID-19) pandemic, our program needed to adapt quickly to ensure staff safety and adherence to infection-control protocols. In this article, we share our experience and reflect on the challenges and benefits of shifting from a primarily in-person teaching model to a hybrid model of remote and in-person teaching. Curricular changes were threefold: the transition to entirely web-based interactive didactic teaching and online imaging interpretation modules, the recruitment of sonographers at multiple academic sites as instructors to facilitate in-person practices with lower instructor to trainee ratio, and the use of a mobile application for informal group case-based discussions. Challenges included lost opportunities for scanning healthy volunteers, variability in attendance at online lectures, and a lower number of study submissions for review. However, curricular changes enabled maintenance of directly observed practice, high levels of engagement with recorded content, and an expansion of our reach to a global audience. We believe that future curricula should combine high-quality online curriculum and resources with the ongoing in-person delivery of key elements of curriculum to allow for direct observation and feedback as well as the maintenance of self-directed point-of-care ultrasound portfolios.

Development of a novel pediatric point-of-care ultrasound question bank using a modified Delphi process

BACKGROUND AND OBJECTIVES

Measuring pediatric emergency medicine (PEM) fellow competency in point-of-care ultrasound (POCUS) is important for ensuring adequate training and performance. Assessment may include direct observation, image review, quality assessment, and written examination. The purpose of this study was to develop a pediatric POCUS question bank that could subsequently be used as a POCUS assessment for graduating PEM fellows.

METHODS

We organized a 10-person question writing group (QWG). Eight hold expertise in POCUS and two hold expertise in medical education. Members of the QWG created questions within four domains: interpretation/diagnosis (50% of questions), anatomy (30%), physics (10%), and pitfalls (10%). POCUS faculty ascertained content validity and the medical education faculty revised questions for syntax and readability. In 2016, we recruited 31 pediatric POCUS experts. The majority were members of the P2 Network, an international group of experts and leaders in PEM POCUS, to participate in three iterative rounds of a modified Delphi process to review, revise, and establish consensus on the question bank.

RESULTS

Thirty-one pediatric POCUS experts participated in the three rounds of the modified Delphi process and evaluated 437 questions developed by the expert panel. Forty-nine percent (n = 216) of the questions were accepted in round 1, 30% (n = 130) in round 2, and 11% (n = 47) in the final round. The final question bank included 393 questions covering 17 pediatric POCUS applications.

CONCLUSION

We developed a 393-question bank to aid in the assessment of PEM POCUS competency. Future work includes piloting the questions with PEM fellows to evaluate the response process and implementing the assessment tool to establish a minimum passing score.

Building and Maintaining an Ultrasound Program: It Takes a Village

Building and maintaining a successful point-of-care ultrasound program is a complex process that involves establishing an ecosystem between three unique but overlapping domains: ultrasound equipment, ultrasound users, and the health care system. By highlighting the different areas of focus and each of the key stakeholders and components, a group can ensure adequate attention is paid to all aspects of point-of-care ultrasound program development in nephrology.

Ultrasound Training in Radiology Residency Programs: A National Survey

OBJECTIVES

Comprehensive training in ultrasound (US) imaging during radiology residency is crucial if radiologists are expected to maintain a substantial role in this widely used imaging modality. This study aimed to evaluate the current curriculum of US training among radiology residency programs across the country via a nationwide survey.

METHODS

A 28-question survey was distributed among all academic radiology departments in the United States and their radiology residents. The survey consisted of 4 sections: general demographic information, training information, clinical competency, and adequacy of training (perspective). The Student t test and 1-way analyses of variance were performed to assess statistical significance.

RESULTS

Overall, 256 residents from 32 states completed the questionnaire. Only 114 (45%) residents reported having a dedicated rotation for performing US studies. Although 228 (89%) of trainees believed they received adequate experience for interpreting US studies, only 66 (26%) of them had the same belief about performing them. Only 116 (45%) of the residents were comfortable operating the US machines in their departments. Higher years of residency training, having a dedicated rotation for performing US studies, and having more than 10 hours per year of didactic lectures and/or more than 5 hours per year of case conferences dedicated to US had a positive impact on the residents' clinical competency and perspective (all P < .05).

CONCLUSIONS

Most radiology residents do not feel confident in performing US examinations by themselves. However, higher clinical competency was reported in the residents who had dedicated rotations for performing US studies and received more hours of US lectures and case conferences throughout their residency.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: recommendations

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part I: clinical indications

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.

Innovations with tele-ultrasound in education sonography: the use of tele-ultrasound to train novice scanners

Objectives

Point-of-care ultrasound (POCUS) has become increasingly integrated into medical education given the growing role of evaluative and procedural techniques in practice today. Tele-ultrasound is a new and promising venture that aims to expand medical knowledge and education to previously unreached or underserved areas. This study aimed to determine the non-inferiority of teaching ultrasound remotely using tele-ultrasound via the Philips Lumify (Philips Medical Systems, Bothell, WA) system, which utilizes video conferencing technology and real-time imaging that can be viewed by the operator and educator simultaneously.

Methods

Three commonly used ultrasound exams were taught and evaluated in 56 ultrasound-naive medical participants: Focused Assessment with Sonography in Trauma (FAST), Lower Extremity Deep Venous Thrombosis (LEDVT) screening, and ultrasound-guided vascular access. The participants were randomized into either in-person traditional learning or tele-ultrasound learning with the Philips Lumify (Philips Medical Systems, Bothell, WA) units. The primary outcome of interest was the ability to perform certain tasks for each exam

Results

Competency on each exam was tested across all exams and no inferiority was found between in-person and remote learning (p < 0.05).

Conclusions

Our findings support the use of tele-ultrasound in beginner ultrasound education.

Efficacy of an Integrated Hands-On Thyroid Ultrasound Session for Medical Student Education

As ultrasound has gained popularity with improving technology and ease-of-use, a push has been made to integrate ultrasound into the medical school curriculum. Many institutions are reporting one- to four-year integrated ultrasound curricula to augment anatomy and pathophysiology teaching. Our goal was to integrate a thyroid ultrasound scanning session into the endocrinology block of our institution’s medical school curriculum to enhance medical student understanding of thyroid anatomy and pathophysiology. We conducted a prospective, single-center cohort (pre-experimental) study to evaluate student performance and knowledge acquisition using a pretest-posttest design. These multimodal sessions, consisting of a didactic, hands-on scanning sessions, and knowledge integration tests, covered ultrasound technique and thyroid evaluation and advanced to diagnosing an abnormal thyroid and working up a thyroid nodule. There were 26 to 27 second-year medical students per session who rotated between three stations proctored by credentialled physicians. Students participated in hands-on scanning of patients with or without thyroid pathology at each station. Out of the 209 students who participated in the ultrasound sessions, 114 (54.5%) consented to participate in the research project and completed both the pretest and posttest. Test data from the 114 students showed a mean pretest score of 57.5% ± 14.6% and the mean posttest score of 73.9% ± 17.4%. They had a 16.5% ± 19.6% (p < 0.001) increase in score between the two tests. Our study demonstrates that a multimodal thyroid ultrasound scanning session is an effective tool to augment the medical school endocrinology curriculum and to improve students’ knowledge of thyroid anatomy, pathophysiology, and diagnostic workup of thyroid nodules.

Rethinking Residency Conferences in the Era of COVID-19

The COVID-19 pandemic requires a substantial change to the traditional approach to conference didactics. Switching to a virtual medium for conference sessions presents several challenges, particularly with regard to aspects that rely heavily on in-person components (e.g., simulation, ultrasound). This paper will discuss the challenges and strategies to address them for conference planning in the era of COVID-19.

Impact of a 4-hour Introductory eFAST Training Intervention Among Ultrasound-Naïve U.S. Military Medics

INTRODUCTION

Advances in the portability of ultrasound have allowed it to be increasingly employed at the point of care in austere settings. Battlefield constraints often limit the availability of medical officers throughout the operational environment, leading to increased interest in whether highly portable ultrasound devices can be employed by military medics to enhance their provision of combat casualty care. Data evaluating optimal training for effective medic employment of ultrasound is limited however. This prospective observational cohort study's primary objective was to assess the impact of a 4-hour introductory training intervention on ultrasound-naïve military medic participants' knowledge/performance of the eFAST application.

MATERIALS AND METHODS

Conventional U.S. Army Medics, all naïve to ultrasound, were recruited from across JBLM. Volunteer participants underwent baseline eFAST knowledge assessment via a 50-question multiple-choice exam. Participants were then randomized to receive either conventional, expert-led classroom didactic training or didactic training via an online, asynchronously available platform. All participants then underwent expert-led, small group hands-on training and practice. Participants' eFAST performance was then assessed with both live and phantom models, followed by a post-course knowledge exam. Concurrently, emergency medicine (EM) resident physician volunteers, serving as standard criterion for trained personnel, underwent the same OSCE assessments, followed by a written exam to assess their baseline eFAST knowledge. Primary outcome measures included (1) post-course knowledge improvement, (2) eFAST exam technical adequacy, and (3) eFAST exam OSCE score. Secondary outcome measures were time to exam completion and diagnostic accuracy rate for hemoperitoneum and hemopericardium. These outcome measures were then compared across medic cohorts and to those of the EM resident physician cohort.

RESULTS

A total of 34 medics completed the study. After 4 hours of ultrasound training, overall eFAST knowledge among the 34 medics improved from a baseline mean of 27% on the pretest to 83% post-test. For eFAST exam performance, the medics scored an average of 20.8 out of a maximum of 22 points on the OSCE. There were no statistically significant differences between the medics who received asynchronous learning versus traditional classroom-based learning, and the medics demonstrated comparable performance to previously trained EM resident physicians.

CONCLUSIONS

A 4-hour introductory eFAST training intervention can effectively train conventional military medics to perform the eFAST exam. Online, asynchronously available platforms may effectively mitigate some of the resource requirement burden associated with point-of-care ultrasound training. Future studies evaluating medic eFAST performance on real-world battlefield trauma patients are needed. Skill and knowledge retention must also be assessed for this degradable skill to determine frequency of refresher training when not regularly performed.

Focus on PoCUS or hocus pocus? Integrating point-of-care ultrasound into residency and clinical practice

Point-of care ultrasound (PoCUS) is a new clinical diagnostic paradigm that plays an instrumental role in the ongoing anesthesiologist’s evolving role towards a perioperative physician. Currently, there are few approved curricula that incorporate a PoCUS program into anesthesia residency. This article examines relevant PoCUS applications for anesthesiologists, presents an overview of existing international guidelines for education and training, and reflects on the need for specialty-wide standards. We present a possible framework, that could offer a first move towards a structured PoCUS pathway for Belgian anesthesia residents and facilitate its incorporation into national anesthesia practice.

Point-of-care ultrasound induced changes in management of unselected patients in the emergency department - a prospective single-blinded observational trial

Background

Point-of-Care ultrasound (POCUS) changes the management in specific groups of patients in the Emergency Department (ED). It seems intuitive that POCUS holds an unexploited potential on a wide variety of patients. However, little is known about the effect of ultrasound on the broad spectrum of unselected patients in the ED. This study aimed to identify the effect on the clinical management if POCUS was applied on unselected patients. Secondarily the study aimed to identify predictors of ultrasound changing management.

Methods

This study was a blinded observational single center trial. A basic whole body POCUS protocol was performed in extension to the physical examination. The blinded treating physicians were interviewed about the presumptive diagnosis and plan for the patient. Subsequently the physicians were unblinded to the POCUS results and asked to choose between five options regarding the benefit from POCUS results.

Results

A total of 403 patients were enrolled in this study. The treating physicians regarded POCUS examinations influence on the diagnostic workup or treatment as following: 1) No new information: 249 (61.8%), 2) No further action: 45 (11.2%), 3) Further diagnostic workup needed: 52 (12.9%), 4) Presumptive diagnosis confirmed 38 (9.4%), and 5) Immediate treatment needed: 19 (4.7%). Predictors of beneficial ultrasound were: (a) triage > 1, (b) patient comorbidities (cardiac disease, hypertension or lung disease), or (c) patients presenting with abdominal pain, dyspnea, or syncope.

Conclusion

POCUS was found to be potentially beneficial in 27.0% of all patients. High triage score, known cardiac disease, hypertension, pulmonary diseases, a clinical presentation with abdominal pain, dyspnea, or syncope are predictors of this. Future research should focus on patient-important outcomes when applying POCUS on these patients.

Trial registration

The trail was registered prior to patient inclusion with the Danish Data Protection Agency (https://www.datatilsynet.dk/ Case no: 1–16–02-603-14) and Clinical Trials (www.clinicaltrials.gov/ Protocol ID: DNVK1305018).

Ultrasound to guide the individual medical decision by evaluating the gastric contents and risk of aspiration: A literature review

Pulmonary aspiration of gastric contents is one of the most terrible complications following general anesthesia. It is important for patients to prevent this complication by obeying the preoperative fasting protocol strictly. At present, it has been reported by many studies that bedside ultrasound, as a non-invasive and convenient method, could be used to evaluate gastric contents qualitatively and quantitatively. With the advantages of reliability, accuracy and repeatability, it can greatly reduce the risk of aspiration and ensure patients' life security. But most of the data were acquired from the healthy volunteers. For the gastrointestinal disorder, the pregnant women, obesity, children, the elderly and diabetes patients, the accuracy and reliability of ultrasound to predict the risk of aspiration remains to be identified by more further studies. For these patients with increasing risk of aspiration, I-AIM (Indication, Acquisition, Interpretation, Medical decision-making) framework plays an important role in ensuring the safety of patients. It is crucial to make appropriate clinical decisions by evaluating the gastric contents with ultrasound.

Billing I-AIM: a novel framework for ultrasound billing

BACKGROUND

Point-of-care ultrasound (POCUS) has an ever-growing footprint in medicine. With this growth POCUS billing and reimbursement has become an area gaining quite a bit of attention as a means of funding and sustaining quality and education programs. Standardization across providers is needed to improve the financial viability of POCUS.

RESULTS

We created an institutional collaborative which developed a framework to identify critical POCUS billing and reimbursement checkpoints. The framework, Billing I-AIM, provides a feasible structure to enhance provider-based reimbursement and perform quality improvement efforts across variable POCUS environments.

CONCLUSIONS

POCUS billing using the Billing I-AIM technique allows administrative oversight, quality assurance, and educational functions as well. A discussion of the framework and respective application is provided.

Tools for Measuring Clinical Ultrasound Competency: Recommendations From the Ultrasound Competency Work Group

Competency in clinical ultrasound is essential to ensuring safe patient care. Competency in clinical ultrasound includes identifying when to perform a clinical ultrasound, performing the technical skills required for ultrasound image acquisition, accurately interpreting ultrasound images, and incorporating sonographic findings into clinical practice. In this concept paper, we discuss the advantages and limitations of existing tools to measure ultrasound competency. We propose strategies and future directions for assessing competency in clinical ultrasound.

Toward a Consensus for Musculoskeletal Ultrasonography Education in Physical Medicine and Rehabilitation: A National Poll of Residency Directors

OBJECTIVES

The aims of the study were to evaluate integration of musculoskeletal ultrasonography education in physical medicine and rehabilitation training programs in 2014-2015, when the American Academy of Physical Medicine & Rehabilitation and Accreditation Council for Graduate Medical Education Residency Review Committee both recognized it as a fundamental component of physiatric practice, to identify common musculoskeletal ultrasonography components of physical medicine and rehabilitation residency curricula, and to identify common barriers to integration.

DESIGN

Survey of 78 Accreditation Council for Graduate Medical Education-accredited physical medicine and rehabilitation residency programs was conducted.

RESULTS

The 2015 survey response rate was more than 50%, and respondents were representative of programs across the United States. Most programs (80%) reported teaching musculoskeletal ultrasonography, whereas a minority (20%) required mastery of ultrasonography skills for graduation. Ultrasonography curricula varied, although most programs agreed that the scope of resident training in physical medicine and rehabilitation should include diagnostic and interventional musculoskeletal ultrasonography, especially for key joints (shoulder, elbow, knee, wrist, hip, and ankle) and nerves (median, ulnar, fibular, tibial, radial, and sciatic). Barriers to teaching included insufficient expertise of instructors, poor access to equipment, and lack of a structured curriculum.

CONCLUSIONS

Musculoskeletal ultrasonography has become a required component of physical medicine and rehabilitation residency training. Based on survey responses and expert recommendations, we propose a structure for musculoskeletal ultrasonography curricular standards and milestones for trainee competency.

Point-of-Care Ultrasound in the Intensive Care Unit

Spreading beyond the realm of tertiary academic medical centers, point-of-care ultrasound in the intensive care unit is an important diagnostic tool. The real-time feedback garnered can lead to critical and clinically relevant changes in management and decrease potential complications. Bedside ultrasound evaluation in the intensive care setting with a small, portable equipment is well-suited for placement of central lines, lumbar puncture, thoracentesis or other bedside ICU procedures and in the evaluation of cardiac activity, pleural and abdominal cavity and the overall fluid volume. Formalized curriculums centering on point-of-care ultrasound are emerging that will enhance its applicability and relevance.

Point-of-care ultrasound findings in unselected patients in an emergency department -results from a prospective observational trial

Background

Point-of-care ultrasound (POCUS) can improve patient management in the emergency department (ED). However, previous studies have focused only on selected groups of patients, such as trauma, shock, dyspnea, or critically ill patients, or patients with an already known diagnosis. Most patients seen in the ED do not match these criteria. We aim to present total prevalence of positive findings when basic POCUS is applied to the broad population of patients seen in an emergency department.

Methods

We conducted a single-center prospective explorative observational study of 405 unselected patients aged 18 years or over. A structured whole-body ultrasound examination was performed on all patients within 2 h of arrival to the ED. The ultrasound examination consisted of focused cardiac ultrasound, focused abdominal ultrasound, focused assessment with sonography for trauma (FAST), and focused lung ultrasound.

Results

We managed to perform 94.5% of all planned examinations. The study revealed positive findings in 39.3% of all included patients. This study presents the prevalence of positive findings among subgroups of patients. Divided among the categories of chief complaint, we found 62 positive examinations in 58 (14.3%; 95% CI, 10.9–17.7) unique patients with orthopedic complaints, 77 positive examinations among 59 (14.6%; 95% CI, 11.1–18.0) unique patients with medical complaints, and 55 positive examinations among 42 (10.4%; 95% CI, 7.4–13.3) unique patients with abdominal surgical complaints.

Conclusion

POCUS revealed positive findings in more than one third of unselected patients in the emergency department. The study presents the findings and distribution among categories of chief complaints. Future investigations are necessary to elucidate the implication of the findings.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0211-4) contains supplementary material, which is available to authorized users.

Entrusting internal medicine residents to use point of care ultrasound: Towards improved assessment and supervision

Background: Internal medicine physicians and trainees are increasingly using, and seeking training in, diagnostic point of care ultrasound (POCUS). Numerous internal medicine training programs have described their curricula, but little has been written about how learners should be assessed, supervised, and allowed to progress toward independent practice, yet these practices are imperative for safe and effective use. Entrustable professional activities (EPAs) offer a practical method to assess observable units of professional work and make supervision decisions. Methods: An EPA for POCUS is used as a framework to assess and determine appropriate levels of supervision in an internal medicine residency program. Results: All learners have been able to advance to level 2 with a mandatory introductory boot camp course. Learners have been able to advance to higher levels of independence, often after taking formal elective programmatic coursework. However, not all learners taking the same coursework have been granted the same level of independence. Conclusions: It is feasible to assess and supervise internal medicine residents' ability to use diagnostic point of care ultrasound using an EPA.

Does the Addition of M-Mode to B-Mode Ultrasound Increase the Accuracy of Identification of Lung Sliding in Traumatic Pneumothoraces?

OBJECTIVES

It is unknown whether the addition of M-mode to B-mode ultrasound (US) has any effect on the overall accuracy of interpretation of lung sliding in the evaluation of a pneumothorax by emergency physicians. This study aimed to determine what effect, if any, this addition has on US interpretation by emergency physicians of varying training levels.

METHODS

One hundred forty emergency physicians were randomized via online software to receive a quiz with B-mode clips alone or B-mode with corresponding M-mode images and asked to identify the presence or absence of lung sliding.

RESULTS

The sensitivity, specificity, and accuracy of the diagnosis of lung sliding with and without M-mode US were compared. Overall, the sensitivities, specificities, and accuracies of B-mode + M-mode US versus B-mode US alone were 93.1% and 93.2% (P = .8), 96.0% and 89.8% (P < .0001), and 91.5% and 94.5% (P = .0091), respectively. A subgroup analysis showed that in those providers with fewer than 250 total US scans done previously, M-mode US increased accuracy from 88.2% (95% confidence interval, 86.2%-90.2%) to 94.4% (92.8%-96.0%; P = .001) and increased the specificity from 87.0% (84.5%-89.5%) to 97.2% (95.4%-99.0%; P < .0001) compared with B-mode US alone. There was no statistically significant difference observed in the sensitivity, specificity, and accuracy of B-mode + M-mode US compared with B-mode US alone in those with more than 250 scans.

CONCLUSIONS

The addition of M-mode images to B-mode clips aids in the accurate diagnosis of lung sliding by emergency physicians. The subgroup analysis showed that the benefit of M-mode US disappears after emergency physicians have performed more than 250 US examinations.