A Comparison of Web-Based with Traditional Classroom-Based Training of Lung Ultrasound for the Exclusion of Pneumothorax.

BACKGROUND: Lung ultrasound (LUS) is a well-established method that can exclude pneumothorax by demonstration of pleural sliding and the associated ultrasound artifacts. The positive diagnosis of pneumothorax is more difficult to obtain and relies on detection of the edge of a pneumothorax, called the "lung point." Yet, anesthesiologists are not widely taught these techniques, even though their patients are susceptible to pneumothorax either through trauma or as a result of central line placement or regional anesthesia techniques performed near the thorax. In anticipation of an increased training demand for LUS, efficient and scalable teaching methods should be developed. In this study, we compared the improvement in LUS skills after either Web-based or classroom-based training. We hypothesized that Web-based training would not be inferior to "traditional" classroom-based training beyond a noninferiority limit of 10% and that both would be superior to no training. Furthermore, we hypothesized that this short training session would lead to LUS skills that are similar to those of ultrasound-trained emergency medicine (EM) physicians. METHODS: After a pretest, anesthesiologists from 4 academic teaching hospitals were randomized to Web-based (group Web), classroom-based (group class), or no training (group control) and then completed a posttest. Groups Web and class returned for a retention test 4 weeks later. All 3 tests were similar, testing both practical and theoretical knowledge. EM physicians (group EM) performed the pretest only. Teaching for group class consisted of a standardized PowerPoint lecture conforming to the Consensus Conference on LUS followed by hands-on training. Group Web received a narrated video of the same PowerPoint presentation, followed by an online demonstration of LUS that also instructs the viewer to perform an LUS on himself using a clinically available ultrasound machine and submit smartphone snapshots of the resulting images as part of a portfolio system. Group Web received no other hands-on training. RESULTS: Groups Web, class, control, and EM contained 59, 59, 20, and 42 subjects. After training, overall test results of groups Web and class improved by a mean of 42.9% (±18.1% SD) and 39.2% (±19.2% SD), whereas the score of group control did not improve significantly. The test improvement of group Web was not inferior to group class. The posttest scores of groups Web and class were not significantly different from group EM. In comparison with the posttests, the retention test scores did not change significantly in either group. CONCLUSIONS: When training anesthesiologists to perform LUS for the exclusion of pneumothorax, we found that Web-based training was not inferior to traditional classroom-based training and was effective, leading to test scores that were similar to a group of clinicians experienced in LUS.

Trends in Point of Care Ultrasound Familiarity Among Undergraduate Medical Clerkship Educators.

OBJECTIVES: Despite growing use of point of care ultrasound (POCUS), there remains a paucity of data about familiarity with POCUS among educators who dictate curricular content in undergraduate medical education. This paper aims to longitudinally characterize the level of comfort and frequency of POCUS use among faculty involved in undergraduate clerkship education. METHODS: A web-based cross-sectional survey assessing comfort, frequency of use, and awareness of indications for POCUS among faculty involved in Internal Medicine, Family Medicine, and Surgery undergraduate clerkship education in a single urban academic medical center in 2016 and again in 2022. RESULTS: A total of 45 responses from 2016 and 30 responses from 2022 are included. The percentage of faculty "not comfortable" with performing POCUS decreased from 78% to 46%, although the overall change in comfort was not statistically significant. Comfort interpreting POCUS images, frequency of POCUS use, and familiarity with the clinical applications of POCUS all improved. Faculty identified multiple barriers to more frequent POCUS use. CONCLUSIONS: Over a six-year period at one urban, academic medical center, comfort with POCUS and frequency of use have increased slightly but remain low among core faculty responsible for clerkship education. There are still large gaps in knowledge and very few faculty regularly use POCUS, which can be attributed to multiple different barriers.

Development of a novel observed structured clinical exam to assess clinical ultrasound proficiency in undergraduate medical education.

OBJECTIVES: A pilot study was performed to develop and test an observed structured clinical exam (OSCE) for clinical ultrasound in second-year medical students. The goal was to assess a longitudinal clinical ultrasound curriculum for medical students and to help determine readiness to perform ultrasound during clinical clerkships. METHODS: The OSCE contained 40 tasks over 30 min in a one-to-one examiner to examinee environment using standardized patients covering cardiac, pulmonary, and inferior vena cava (IVC) ultrasound exams along with 6 critical diagnoses. Examinees were assessed using a binary checklist approach. A two-way ANOVA analysis was performed to determine if there were differences between the day and session the OSCE was administered. Results are presented as mean ± standard deviation. RESULTS: One hundred fifty-two students were tested with an overall mean score of 64.9 ± 17.6%. Scores between the cardiac, IVC, and lung sections varied-67.8% ± 18.8%, 62.4% ± 26.2%, and 57.1% ± 20.6%, respectively. One hundred twenty-six (82.9%) answered at least one critical diagnosis incorrectly. Students in the late session performed better than the early session (1: 60% vs 2: 69%, p = .001). CONCLUSIONS: Students performed better in later sessions. Additionally, the number of questions left blank at the end of the exam suggests that the length of the OSCE should be evaluated. Incorporating critical diagnoses was challenging for examinees. The proposed OSCE is a valuable assessment tool that could be adapted to assess student's readiness to use clinical ultrasound prior to clerkships.

Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest.

BACKGROUND: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA. MATERIALS AND METHODS: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation. RESULTS: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration. CONCLUSIONS: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.

Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department.

BACKGROUND: Transesophageal echocardiography (TEE) has been proposed as a modality to assess patients in the setting of cardiac arrest, both during resuscitation care and following return of spontaneous circulation (ROSC). In this study we aimed to assess the feasibility and clinical impact of TEE during the emergency department (ED) evaluation during out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: We conducted a prospective observational study consisting of a convenience sample of adult patients presenting to the ED of an urban university medical center with non-traumatic OHCA. TEE was performed by emergency physicians following intubation. Images and clinical data were analyzed. TEE was used intra-arrest in order to assist in diagnosis, assess cardiac activity and determine CPR quality by assessing area of maximal compression (AMC), using a 4 view protocol. RESULTS: A total of 33 OHCA patients were enrolled over a one-year period, 21 patients (64%) presented with ongoing CPR and 12 (36%) presented with ROSC. The 4-view protocol was completed in 100% of the cases, with an average time from ED arrival to TEE of 12 min (min 3 max 30 SD 8.16). Fine ventricular fibrillation (VF) was recognized in 4 (12%) cases thought to be in asystole, leading to defibrillation, and 2 cases of pseudo-PEA were identified. Right ventricular (RV) dilation, was seen in 12 (57%) intraarrest cases. Intra-cardiac thrombus was found in one case, leading to thrombolysis. The AMC was identified over the aortic root or LVOT in 53% of cases. TEE was found to have diagnostic, therapeutic or prognostic clinical impact in 32 of the 33 cases (97%). CONCLUSIONS: TEE is feasible and clinically impactful during OHCA management. Resuscitative TEE may allow for characterization of cardiac activity, including identification of pseudo-PEA and fine VF, determination of reversible pathology, and optimization of CPR quality.

Correlation of OSCE performance and point-of-care ultrasound scan numbers among a cohort of emergency medicine residents.

BACKGROUND: Point-of-care ultrasound (POCUS) is an important clinical tool for a growing number of medical specialties. The current American College of Emergency Physicians (ACEP) Ultrasound Guidelines recommend that trainees perform 150-300 ultrasound scans as part of POCUS training. We sought to assess the relationship between ultrasound scan numbers and performance on an ultrasound-focused observed structured clinical examination (OSCE). METHODS: This was a cross-sectional cohort study in which the number of ultrasound scans residents had previously performed were obtained from a prospective database and compared with their total score on an ultrasound OSCE. Ultrasound fellowship trained emergency physicians administered a previously published OSCE that consisted of standardized questions testing image acquisition and interpretation, ultrasound machine mechanics, patient positioning, and troubleshooting. Residents were observed while performing core applications including aorta, biliary, cardiac, deep vein thrombosis, Focused Assessment with Sonography in Trauma (FAST), pelvic, and thoracic ultrasound imaging. RESULTS: Twenty-nine postgraduate year (PGY)-3 and PGY-4 emergency medicine (EM) residents participated in the OSCE. The median OSCE score was 354 [interquartile range (IQR) 343-361] out of a total possible score of 370. Trainees had previously performed a median of 341 [IQR 289-409] total scans. Residents with more than 300 ultrasound scans had a median OSCE score of 355 [IQR 351-360], which was slightly higher than the median OSCE score of 342 [IQR 326-361] in the group with less than 300 total scans (p = 0.04). Overall, a LOWESS curve demonstrated a positive association between scan numbers and OSCE scores with graphical review of the data suggesting a plateau effect. CONCLUSION: The results of this small single residency program study suggest a pattern of improvement in OSCE performance as scan numbers increased, with the appearance of a plateau effect around 300 scans. Further investigation of this correlation in diverse practice environments and within individual ultrasound modalities will be necessary to create generalizable recommendations for scan requirements as part of overall POCUS proficiency assessment.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience.

INTRODUCTION: Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. METHODS: This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. RESULTS: All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. CONCLUSION: POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

Research Priorities in the Utilization and Interpretation of Diagnostic Imaging: Education, Assessment, and Competency.

The appropriate selection and accurate interpretation of diagnostic imaging is a crucial skill for emergency practitioners. To date, the majority of the published literature and research on competency assessment comes from the subspecialty of point-of-care ultrasound. A group of radiologists, physicists, and emergency physicians convened at the 2015 Academic Emergency Medicine consensus conference to discuss and prioritize a research agenda related to education, assessment, and competency in ordering and interpreting diagnostic imaging. A set of questions for the continued development of an educational curriculum on diagnostic imaging for trainees and competency assessment using specific assessment methods based on current best practices was delineated. The research priorities were developed through an iterative consensus-driven process using a modified nominal group technique that culminated in an in-person breakout session. The four recommendations are: 1) develop a diagnostic imaging curriculum for emergency medicine (EM) residency training; 2) develop, study, and validate tools to assess competency in diagnostic imaging interpretation; 3) evaluate the role of simulation in education, assessment, and competency measures for diagnostic imaging; 4) study is needed regarding the American College of Radiology Appropriateness Criteria, an evidence-based peer-reviewed resource in determining the use of diagnostic imaging, to maximize its value in EM. In this article, the authors review the supporting reliability and validity evidence and make specific recommendations for future research on the education, competency, and assessment of learning diagnostic imaging.

Health of children adopted from Ethiopia.

OBJECTIVES: Since 2000, American families have adopted 1,700 children from Ethiopia. Little is known about the health and development of these children. PATIENTS AND METHODS: Retrospective chart review of the arrival health status of all 50 (26F:24M) children from Ethiopia/Eritrea seen in the International Adoption Clinic. RESULTS: Prior to adoption, most children resided with relatives; 36% were >18 months old prior to entry into care. More than 50% were true orphans, often due to HIV. Arrival age ranged from 3 months to 15 years (mean +/- SD 4 years +/- 43.8 months). At arrival, growth z scores were near-average (weight -.59, height -.64, head circumference -.09); significantly better than adopted children Guatemala, China, or Russia seen in our clinic. However, some Ethiopian children were significantly growth delayed (WAZ < or =-2, 8%, HAZ 12%, HCZ 18%). Age at adoption did not relate to growth delays. Medical issues on arrival included intestinal parasites (53%, [14% with > or =3 types]), skin infections (45%), dental caries (25%), elevated liver transaminases (20%), latent tuberculosis (18%), and hepatitis B (2%). Age-appropriate vaccines had been administered in 15-77% of children (depending on specific vaccine). Behavior problems were uncommon. Gross/fine motor and cognitive skills were approximately 86% of expected for age. Age correlated inversely with developmental scores for cognition (r = -.49, P = .003). Five children had age reassignments. CONCLUSIONS: Ethiopian/Eritean adoptees differ from other groups of internationally adopted children: they reside for relatively long periods of time with relatives prior to institutionalization, often have uncertain ages, exhibit few behavioral problems at arrival, have better growth, and may have less severe developmental delays. Whether these differences at arrival predict better outcomes for the Ethiopian/Eritrean children is unknown.

Medical diagnoses and growth of children residing in Russian orphanages.

AIMS: Survey the health of young children residing in Russian orphanages. METHODS: Retrospective chart review of all 193 'healthy' young children (105M:88F, age range 2-72 months) residing in orphanages in Murmansk, Russia. RESULTS: Mothers of these institutionalized children had complex histories including chronic health problems (38%), use of tobacco (41%), alcohol (39%) and illicit drugs (7%). Frequent diagnoses of the children included rickets (21%), foetal alcohol syndrome (10%), anemia (6%), developmental delay (11% mild, 25% moderate, 28% severe), behavioural problems (60%) and 'perinatal encephalopathy' (46%<1 year of age). At orphanage entry, growth delays were common (underweight 34%, short stature 25%, microcephaly 34%). During orphanage residence, height z scores further decreased (p=0.01), but head circumference improved (p<0.0001, paired t-tests). Head circumferences increased significantly in 62% of microcephalic children. Smaller children (z score<-2) at entry exhibited more rapid growth (z score/month) for weight (+0.24 vs. -0.12, p=0.04), height (+0.81 vs. -0.65, p=0.0001), and head circumference (+1.02 vs. -0.10, p=0.0004). Growth correlated with child developmental status. CONCLUSIONS: Young institutionalized children in Murmansk have complex medical status, social histories and frequent growth and developmental delays. Anthropometric measurements-particularly head circumference-improved during orphanage residence in children who entered with more severe growth delays.