Utilization of marketing automation tools for delivery of a faculty development curriculum.

Background: Physician clinical educators play important roles in teaching, providing feedback, and evaluating trainees, but they often have variable preparation and competing demands on their time that make universal participation in workshops, seminars, or short courses designed to foster these skillsets inefficient or impossible. Methods: We designed and implemented a 52-week synchronous curriculum designed to address faculty opportunities to improve teaching skills, feedback for residents and medical students, and evaluation skills, which were delivered using marketing automation tools, including text messaging and email. We evaluated the programmatic impact and feasibility of using the implementation science framework. Results: Over a 104-week evaluation period, there were at least 10,499 total content impressions and 4558 unique recipients, indicating the significant reach of this program to approximately 120 faculty members. Faculty engagement with continuing education materials remained stable or increased over the 2-year evaluation period, indicating that programs like ours can have sustainable impacts. Resident evaluations of faculty across the six key domains also improved after the implementation of the program. Conclusions: Our experience with digital marketing tools reflects that they can be used to deliver impactful curricular content to faculty for continuing educational purposes and that faculty can use these resources in a sustainable way. However, because of the incomplete reach with any single communication, this type of content delivery is not appropriate for isolation as a material of critical importance. More research is needed to identify the best practices and additional education-related uses of this technology.

Use of Hand-motion Analysis to Assess Competence and Skill Decay for Cardiac and Lung Point-of-care Ultrasound.

OBJECTIVES: Assessment of competence in technical skills, including point-of-care ultrasound (POCUS), is required before a novice can safely perform the skill independently. Ongoing assessment of competence is also required because technical skills degrade over time, especially when they are infrequently performed or complex. Hand-motion analysis (HMA) is an objective assessment tool that has been used to evaluate competency in many technical skills. The purpose of this study was to demonstrate the feasibility and validity of HMA as an assessment tool for competence in both simple and complex technical skills as well as skill degradation over time. METHODS: This prospective cohort study included 36 paramedics with no POCUS experience and six physicians who were fellowship trained in POCUS. The novices completed a 4-hour didactic and hands-on training program for cardiac and lung POCUS. HMA measurements, objective structured clinical examinations (OSCE), and written examinations were collected for novices immediately before and after training as well as 2 and 4 months after training. Expert HMA metrics were also recorded. RESULTS: Expert HMA metrics for cardiac and lung POCUS were significantly better than those of novices. After completion of the training program, the novices improved significantly in all HMA metrics, knowledge test scores, and OSCE scores. Novices showed skill degradation in cardiac POCUS based on HMA metrics and OSCE scores while lung POCUS image acquisition skills were preserved. Novices deemed competent by OSCE score performed significantly better in HMA metrics than those not deemed competent. CONCLUSION: We have demonstrated that HMA is a feasible and valid tool for assessment of competence in technical skills and can also evaluate skill degradation over time. Skill degradation appears more apparent in complex skills, such as cardiac POCUS. HMA may provide a more efficient and reliable assessment of technical skills, including POCUS, when compared to traditional assessment tools.

Ultrasound Hypotension Protocol Time-motion Study Using the Multifrequency Single Transducer Versus a Multiple Transducer Ultrasound Device.

INTRODUCTION: Ultrasound hypotension protocols (UHP) involve imaging multiple body areas, each with different transducers and imaging presets. The time for task switching between presets and transducers to perform an UHP has not been previously studied. A novel hand-carried ultrasound (HCU) has been developed that uses a multifrequency single transducer to image areas of the body (lung, heart, abdomen, superficial) that would typically require three transducers using a traditional cart-based ultrasound (CBU) system. Our primary aim was to compare the time to complete UHPs with a single transducer HCU to a multiple transducer CBU. METHODS: We performed a randomized, crossover feasibility trial in the emergency department of an urban, safety-net hospital. This was a convenience sample of non-hypotensive emergency department patients presenting during a two-month period of time. Ultrasound hypotension protocols were performed by emergency physicians (EP) on patients using the HCU and the CBU. The EPs collected UHP views in sequential order using the most appropriate transducer and preset for the area/organ to be imaged. Time to complete each view, time for task switching, total time to complete the examination, and image diagnostic quality were recorded. RESULTS: A total of 29 patients were scanned by one of eight EPs. When comparing the HCU to the CBU, the median time to complete the UHP was 4.3 vs 8.5 minutes (P <0.0001), respectively. When the transport and plugin times were excluded, the median times were 4.1 vs 5.8 minutes (P <0.0001), respectively. There was no difference in the diagnostic quality of images obtained by the two devices. CONCLUSION: Ultrasound hypotension protocols were performed significantly faster using the single transducer HCU compared to a multiple transducer CBU with no difference in the number of images deemed to be diagnostic quality.

Predictors of False-Negative Focused Assessment With Sonography for Trauma Examination in Pediatric Blunt Abdominal Trauma.

OBJECTIVES: This study investigated associations between patient and injury characteristics and false-negative (FN) focused assessment with sonography for trauma (FAST) in pediatric blunt abdominal trauma (BAT). We also evaluated the effects of FN FAST on in-hospital mortality and length of stay (LOS) variables. METHODS: This retrospective cohort studied children younger than 18 years between January 1, 2002, and December 31, 2013, with BAT, documented FAST, and pathologic fluid on computed tomography, surgery, or autopsy. Multivariable and bivariate analyses were used to assess associations between FN FAST and patient injury characteristics, mortality, and hospital LOS. RESULTS: A total of 141 pediatric BAT patients with pathologic free fluid were included. There were no patient or injury characteristics, which conferred increased odds of an FN FAST. Splenic and bladder injury were negatively associated with FN FAST odds ratio of 0.4 (95% confidence interval [CI], 0.2-0.8) and 0.1 (95% CI, 0-0.8). Abbreviated Injury Scale score of 4 or greater to the abdomen and extremity was negatively associated with FN FAST odds ratio of 0.1 (95% CI, 0-0.3) and 0.3 (95% CI, 0.1-0.9). There was no association between FN FAST and mortality. Patients with an FN FAST had increased hospital LOS after controlling for sex, age, and Injury Severity Score. CONCLUSIONS: Clinicians need to be cautious applying a single initial FAST to patients with minor abdominal trauma or with suspected injuries to organs other than the spleen or bladder. Formalized studies to develop risk stratification tools could allow clinicians to integrate FAST into the pediatric patient population in the safest manner possible.

Emergency Ultrasound Literature and Adherence to Standards for Reporting of Diagnostic Accuracy Criteria.

BACKGROUND: Given the wide usage of emergency point-of-care ultrasound (EUS) among emergency physicians (EPs), rigorous study surrounding its accuracy is essential. The Standards for Reporting of Diagnostic Accuracy (STARD) criteria were established to ensure robust reporting methodology for diagnostic studies. Adherence to the STARD criteria among EUS diagnostic studies has yet to be reported. OBJECTIVES: Our objective was to evaluate a body of EUS literature shortly after STARD publication for its baseline adherence to the STARD criteria. METHODS: EUS studies in 5 emergency medicine journals from 2005-2010 were evaluated for their adherence to the STARD criteria. Manuscripts were selected for inclusion if they reported original research and described the use of 1 of 10 diagnostic ultrasound modalities designated as "core emergency ultrasound applications" in the 2008 American College of Emergency Physicians Ultrasound Guidelines. Literature search identified 307 studies; of these, 45 met inclusion criteria for review. RESULTS: The median STARD score was 15 (interquartile range [IQR] 12-17), representing 60% of the 25 total STARD criteria. The median STARD score among articles that reported diagnostic accuracy was significantly higher than those that did not report accuracy (17 [IQR 15-19] vs. 11 [IQR 9-13], respectively; p < 0.0001). Seventy-one percent of articles met ≥50% of the STARD criteria (56-84%) and 4% met >80% of the STARD criteria. CONCLUSIONS: Significant opportunities exist to improve methodological reporting of EUS research. Increased adherence to the STARD criteria among diagnostic EUS studies will improve reporting and improve our ability to compare outcomes.

Hand motion analysis for assessment of nursing competence in ultrasound-guided peripheral intravenous catheter placement.

INTRODUCTION: Objective measures such as hand motion analysis are needed to assess competency in technical skills, including ultrasound-guided procedures. Ultrasound-guided peripheral intravenous catheter placement has many potential benefits and is a viable skill for nurses to learn. The objective of this study was to demonstrate the feasibility and validity of hand motion analysis for assessment of nursing competence in ultrasound-guided peripheral intravenous placement. METHODS: We conducted a prospective cohort study at a tertiary children's hospital. Participants included a convenience sample of nurses with no ultrasound-guided peripheral intravenous experience and experts in ultrasound-guided peripheral intravenous placement. Nurses completed hand motion analysis before and after participating in a simulation-based ultrasound-guided peripheral intravenous placement training program. Experts also completed hand motion analysis to provide benchmark measurements. After training, nurses performed ultrasound-guided peripheral intravenous placement in clinical practice and self-reported details of attempts. RESULTS: A total of 21 nurses and 6 experts participated. Prior to the hands-on training session, experts performed significantly better in all hand motion analysis metrics and procedure time. After completion of the hands-on training session, the nurses showed significant improvement in all hand motion analysis metrics and procedure time. Few nurses achieved hand motion analysis metrics within the expert benchmark after completing the hands-on training session with the exception of angiocatheter motion smoothness. In total, 12 nurses self-reported 38 ultrasound-guided peripheral intravenous placement attempts in clinical practice with a success rate of 60.5%. DISCUSSION: We demonstrated the feasibility and construct validity of hand motion analysis as an objective assessment of nurse competence in ultrasound-guided peripheral intravenous placement. Nurses demonstrated rapid skill acquisition but did not achieve expert-level proficiency.

Effect of Emergency Physician-Performed Point-of-Care Ultrasound and Radiology Department-Performed Ultrasound Examinations on the Emergency Department Length of Stay Among Pregnant Women at Less Than 20 Weeks' Gestation.

OBJECTIVES: We sought to confirm retrospective studies that measured an approximately 20% reduction in emergency department (ED) length of stay (LOS) in early-gestation pregnant women who receive emergency physician-performed point-of-care ultrasound (US) examinations rather than radiology department-performed US examinations for evaluation of intrauterine pregnancy (IUP). METHODS: A randomized controlled clinical trial was performed at an urban academic safety net hospital and 2 Naval medical centers in the United States. The allocation was concealed before enrollment. Clinically stable adult pregnant women at less than 20 weeks' gestation who presented to the ED with abdominal pain or vaginal bleeding were randomized to receive a point-of-care or radiology US to assess for IUP. The primary outcome measure was the ED LOS. RESULTS: A total of 224 patients (point-of-care US, n = 118; radiology US, n = 106) were included for the analysis. The ED LOS was 20 minutes shorter in the point-of-care US arm (95% confidence interval [CI], -54 to 7 minutes). Adjusting for variability due to the location, the ED LOS was calculated to be 31 minutes shorter (95% CI, -64 to 1 minute) than for patients in the radiology US arm. Excluding patients in the point-of-care US arm who crossed over to radiology US after an inconclusive point-of-care US examination, the ED LOS was 75 minutes shorter than in the radiology US arm (95% CI, -97 to -53 minutes). CONCLUSIONS: Early-gestation pregnant ED patients requiring pelvic US were discharged earlier when point-of-care US was used rather than radiology US; however, this trial did not achieve our target of 30 minutes. Nevertheless, our data support the routine use of ED point-of-care US for IUP, saving the most time if a conclusive IUP is identified.

Improved medical student perception of ultrasound using a paired anatomy teaching assistant and clinician teaching model.

This study describes a new teaching model for ultrasound (US) training, and evaluates its effect on medical student attitudes toward US. First year medical students participated in hands-on US during human gross anatomy (2014 N = 183; 2015 N = 182). The sessions were facilitated by clinicians alone in 2014, and by anatomy teaching assistant (TA)-clinician pairs in 2015. Both cohorts completed course evaluations which included five US-related items on a four-point scale; cohort responses were compared using Mann-Whitney U tests with significance threshold set at 0.05. The 2015 survey also evaluated the TAs (three items, five-point scale). With the adoption of the TA-clinician teaching model, student ratings increased significantly for four out of five US-items: "US advanced my ability to learn anatomy" increased from 2.91 ± 0.77 to 3.35 ± 0.68 (P < 0.0001), "Incorporating US increased my interest in anatomy" from 3.05 ± 0.84 to 3.50 ± 0.71 (P < 0.0001), "US is relevant to my current educational needs" from 3.36 ± 0.63 to 3.54 ± 0.53 (P = 0.015), and "US training should start in Phase I" from 3.36 ± 0.71 to 3.56 ± 0.59 (P = 0.010). Moreover, more than 84% of students reported that TAs enhanced their understanding of anatomy (mean 4.18 ± 0.86), were a valuable part of US training (mean 4.23 ± 0.89), and deemed the TAs proficient in US (mean 4.24 ± 0.86). By using an anatomy TA-clinician teaching team, this study demonstrated significant improvements in student perceptions of the impact of US on anatomy education and the relevancy of US training to the early stages of medical education. Anat Sci Educ 11: 175-184. © 2017 American Association of Anatomists.

Critical care ultrasound: A national survey across specialties.

PURPOSE: Management of the critically ill patient requires rapid assessment and differentiation. Point-of-care ultrasound (POCUS) improves diagnostic accuracy and guides resuscitation. This study sought to describe the use of critical care related POCUS amongst different specialties. METHODS: This study was conducted as an online 18-question survey. Survey questions queried respondent demographics, preferences for POCUS use, and barriers to implementation. RESULTS: 2735 recipients received and viewed the survey with 416 (15.2%) responses. The majority of respondents were pulmonary and critical care medicine (62.5%) and emergency medicine (19.9%) providers. Respondents obtained training through educational courses (26.5%), fellowship (23.9%), residency (21.6%), or self-guided learning (17.2%). POCUS use was common for diagnostic and procedural guidance. Emergency medicine providers were more likely to utilize POCUS to evaluate undifferentiated hypotension (98.5%, P < .001), volume status and fluid responsiveness (88.2%, P = .005), and cardiopulmonary arrest (94.1%, P < .001) compared to other specialties. Limited training, competency, or credentialing were the most common barriers, in up to 39.4% of respondents. CONCLUSION: Study respondents utilize POCUS in a variety of clinical applications. However, a disparity in utilization still exists among clinicians who care for critically ill patients. Overcoming barriers, such as a lack of formalized training, competency, or credentialing, may lead to increased utilization.

Incidental Findings in Student Ultrasound Models: Implications for Instructors.

As ultrasonography continues to become integrated into undergraduate medical education, there have been concerns raised about the use of volunteer models and the ability to maintain patient privacy during scanning sessions. To date, there have been no reports on how instructors should manage situations in which incidental findings are made during educational ultrasonography sessions. We present three different examples of incidental findings that occurred at our institution and the various approaches taken by the instructors. Furthermore, we outline an approach that can be utilized by other medical schools to better maintain patient confidentiality.

Number of Weeks Rotating in the Emergency Department Has a Greater Effect on Ultrasound Milestone Competency Than a Dedicated Ultrasound Rotation.

OBJECTIVES: Ultrasound (US) is vital to modern emergency medicine (EM). Across residencies, there is marked variability in US training. The "goal-directed focused US" part of the Milestones Project states that trainees must correctly acquire and interpret images to achieve a level 3 milestone. Standardized methods by which programs teach these skills have not been established. Our goal was to determine whether residents could achieve level 3 with or without a dedicated US rotation. METHODS: Thirty-three first- and second-year residents were assigned to control (no rotation) and intervention (US rotation) groups. The intervention group underwent a 2-week curriculum in vascular access, the aorta, echocardiography, focused assessment with sonography for trauma, and pregnancy. To test acquisition, US-trained emergency medicine physicians administered an objective structured clinical examination. To test interpretation, residents had to identify normal versus abnormal findings. Mixed-model logistic regression tested the association of a US rotation while controlling for confounders: weeks in the emergency department (ED) as a resident, medical school US rotation, and postgraduate years. RESULTS: For image acquisition, medical school US rotation and weeks in the ED as a resident were significant (P = .03; P = .04) whereas completion of a US rotation and postgraduate years were not significant. For image interpretation, weeks in the ED as a resident was the only significant predictor of performance (P = .002) whereas completion of a US rotation and medical school US rotation were not significant. CONCLUSIONS: To achieve a level 3 milestone, weeks in the ED as a resident were significant for mastering image acquisition and interpretation. A dedicated US rotation did not have a significant effect. A medical school US rotation had a significant effect on image acquisition but not interpretation. Further studies are needed to best assess methods to meet US milestones.

Test Characteristics of Emergency Physician-Performed Limited Compression Ultrasound for Lower-Extremity Deep Vein Thrombosis.

BACKGROUND: The current literature suggests that emergency physician (EP)-performed limited compression ultrasound (LCUS) is a rapid and accurate test for deep vein thrombosis (DVT). OBJECTIVE: Our primary objective was to determine the sensitivity and specificity of LCUS for the diagnosis of DVT when performed by a large heterogeneous group of EPs. METHODS: This was a prospective diagnostic test assessment of LCUS conducted at two urban academic emergency departments. The scanning protocol involved compression at the common femoral, superficial femoral, and popliteal veins. Patients were eligible if undergoing radiology department ultrasound of the lower extremity with moderate or high pretest probability for DVT, or low pretest probability for DVT with a positive d-dimer. The enrolling EP performed LCUS before radiology department ultrasound of the same lower extremity. Sensitivity, specificity, and associated 95% confidence intervals (CIs) were calculated with the radiologist interpretation of the radiology department ultrasound as the criterion standard. RESULTS: A total of 56 EPs enrolled 296 patients for LCUS, with a median age of 50 years and 50% female. Fifty (17%) DVTs were identified by radiology department ultrasound, and another five (2%) cases were deemed indeterminate. The sensitivity and specificity of EP-performed LCUS was 86% (95% CI 73-94%) and 93% (95% CI 89-96%), respectively. CONCLUSIONS: A large heterogeneous group of EPs with limited training can perform LCUS with intermediate diagnostic accuracy. Unfortunately, LCUS performed by EPs with limited ultrasound training is not sufficiently sensitive or specific to rule out or diagnose DVT as a single testing modality.

Effect of Interventional Program on the Utilization of PACS in Point-of-Care Ultrasound.

While the implementation of Picture Archiving and Communication Systems (PACS) has revolutionized the field of radiology, there has been considerably less utilization of PACS by emergency physicians with point-of-care ultrasound. Benefits of PACS archival of images include improved quality assurance, preservation of image quality, and accessibility of images. Our objective was to determine if a simple interventional program would influence the utilization of PACS in point-of-care ultrasound. A before-after study was conducted in an urban, academic emergency department. Data was collected during a 4-week baseline period, a 12-week intervention period, and a 12-week post-intervention period. The percentage of ultrasound studies archived to PACS was recorded during each week of the study. Interventions were designed to encourage the utilization of PACS. A significant increase in the mean percentage of PACS studies was found between the baseline and intervention period (59.4 %; 95 % CI: 34.76-84.08 %; p < 0.001). Mean percentage of PACS studies at 1-month (74.3 %), 2-month (61.0 %), and 3-month (74.8 %) post-intervention periods remained elevated and were all significantly increased compared to baseline values (p < 0.001). Mean percentages of PACS studies at 1-month, 2-month, and 3-month post-intervention periods were not statistically significant from the intervention period (p = 0.977, p = 0.849, p = 0.967, respectively). A simple interventional program for emergency physicians can significantly increase and sustain the utilization of PACS for point-of-care ultrasound.

A Survey of Ultrasound Milestone Incorporation Into Emergency Medicine Training Programs.

OBJECTIVES: With the introduction of the Emergency Medicine Milestone Project in 2013, residencies now assess emergency ultrasound (US) skills at regular intervals. However, it is unclear how programs are implementing the emergency US milestones and assessing competency. With the use of the milestone tool, a survey was distributed to emergency US educators to determine when programs are providing emergency US education, when residents are expected to attain competency, and whether the milestones reflect their expectations of trainees. METHODS: We conducted a prospective cross-sectional survey study distributed electronically to designated emergency US experts at 169 programs. Participants were queried on education and competency evaluation within the context of the milestones by designating a postgraduate year when the 5 milestone levels were taught and competency was expected. Survey findings were reported as percentages of total respondents from descriptive statistics. RESULTS: Responses were received from 53% of programs, and 99% were familiar with the milestones. Most programs provide level 1 (88%) and 2 (85%) instruction during postgraduate year 1. Most programs expect level 1 competency before residency (61%) and expect mastery of level 2 by the end of postgraduate year 1 (60%). Sixty-two percent believe the milestones do not accurately reflect their expectations, citing insufficient minimum scan numbers, lack of specificity, and unattainable level 5 requirements. CONCLUSIONS: There is substantial variability in the frequency and methods of competency evaluation using the emergency US milestones. However, most responders agree that residents should obtain level 2 competency by postgraduate year 1. Variation exists regarding what year and what skills define level 3 or greater competency.

Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back.

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal "in-plane" technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.

Using Ultrasound to Enhance Medical Students' Femoral Vascular Physical Examination Skills.

OBJECTIVES: To determine whether the addition of ultrasound to traditional physical examination instruction improves junior medical students' abilities to locate the femoral pulse. METHODS: Initially, 150 second-year medical students were taught the femoral pulse examination using traditional bedside teaching on standardized patients and online didactic videos. Students were then randomized into 2 groups: group 1 received ultrasound training first and then completed the standardized examination; and group 2 performed the standardized examination first and then received ultrasound training. On the standardized patients, the femoral artery was marked with invisible ink before the sessions using ultrasound. Compared to these markers, students were then evaluated on the accuracy of femoral artery pulse palpation and the estimated location of the femoral vein. All students completed a self-assessment survey after the ultrasound sessions. RESULTS: Ultrasound training improved the students' ability to palpate the femoral pulse (P= .02). However, ultrasound did not facilitate correct estimation of the femoral vein's anatomic location (P = .09). Confidence levels in localizing the femoral artery and vein were equal between groups at baseline, and both increased after the ultrasound sessions. CONCLUSIONS: The addition of ultrasound teaching to traditional physical examination instruction enhanced medical student competency and confidence with the femoral vascular examination. However, understanding of anatomy may require emphasis on precourse didactic material, but further study is required.

Acute hematogenous osteomyelitis of the rib identified on bedside ultrasound.

BACKGROUND: Osteomyelitis is a challenging and commonly considered diagnosis in the emergency department. Early recognition and treatment with appropriate antibiotic therapy is crucial to prevent complications. OBJECTIVE: This case reviews relevant literature and typical ultrasound features of osteomyelitis. It highlights a previously undescribed and practical application of emergency department bedside ultrasonography, adding to the diagnostic armamentarium for this disease process. CASE REPORT: A 48-year-old woman presented with fever and left chest wall pain. She had been seen previously for a right axillary abscess requiring incision and drainage. Examination revealed a focal area of chest tenderness without cutaneous changes. Chest x-ray study and laboratory evaluation were nondiagnostic. Bedside ultrasound diagnosed acute hematogenous osteomyelitis of a rib. CONCLUSIONS: Bedside ultrasound holds great promise in investigating osteomyelitis when suspicion is high and traditional initial testing is nondiagnostic. Further study is required to quantify this benefit in the emergency department setting and explore utility of negative results.

Ultrasound-guided small vessel cannulation: long-axis approach is equivalent to short-axis in novice sonographers experienced with landmark-based cannulation.

INTRODUCTION: Our primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration. METHODS: This was a prospective, observational study of experienced certified emergency nurses attempting ultrasound-guided small vessel cannulation on a vascular access phantom. We conducted a standardized training, practice, and experiment session for each participant. Five long-axis and five short-axis approaches were attempted in alternating sequence. The primary outcome was time to vessel penetration. Secondary outcomes were number of skin penetrations and number of catheter redirections. We compared long-axis and short-axis approaches using multivariable regression adjusting for repeated measures, vessel depth, and vessel caliber. RESULTS: Each of 10 novice sonographers made 10 attempts for a total of 100 attempts. Median time to vessel penetration in the long-axis and short-axis was 11 (95% confidence interval [CI] 7-12) and 10 (95% CI 6-13) seconds, respectively. Skin penetrations and catheter redirections were equivalent and near optimal between approaches. The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 (95% CI 4.1-5.5) and 5.6 (95% CI 5.1-6.2) millimeters, respectively. Both axes had equal success rates of 100% for all 50 attempts. In multivariable regression analysis, long-axis attempts were 32% (95% CI 11%-48%; p=0.009) faster than short-axis attempts. CONCLUSION: Novice sonographers, highly proficient with peripheral IV cannulation, can perform after instruction ultrasound-guided small vessel penetration successfully with similar time to vessel penetration in either the long-axis or short-axis approach on phantom models.

Training peer instructors for a combined ultrasound/physical exam curriculum.

BACKGROUND: The integration of bedside ultrasound into medical school curricula is limited by the availability of skilled faculty instructors. Peer mentors have been utilized successfully to teach clinical and procedural skills and may serve as a valuable resource for potential ultrasound instructors. We describe a method to train senior medical students as peer instructors for a combined ultrasound/physical exam curriculum and assessed junior medical students' perceptions of peer instruction relative to faculty. DESCRIPTION: The University of Colorado has incorporated ultrasound into ocular, abdominal, musculoskeletal, cardiac, vascular, and pulmonary physical exam instruction for 1st-year (n=155) and 2nd-year (n=155) medical students. Fourth-year medical students who completed a 2- or 4-week bedside ultrasound elective were recruited as peer instructors. Both peer and faculty instructors received similar session training and were assigned to random groups of junior medical students. Instructor evaluation scores completed by students were collected after every session. EVALUATION: Twenty students and 29 faculty served as instructors for the curriculum. Comparisons of evaluation scores between faculty and student teachers were equivalent (α>.05) in 5 out of 6 sessions. In addition, students who taught more than 1 session showed improvement in their instructor scores and had higher average scores than students who taught only 1 session. Student instructors who completed the 4-week elective had higher average scores than students who completed the 2-week elective. CONCLUSIONS: Students' perception of peer instructors' teaching competency was equivalent to faculty instructors for the majority of sessions. Senior students who have completed an elective ultrasound rotation may serve as a useful resource for circumstances where the availability of skilled instructors is limited. However, further research is required to evaluate their effectiveness.