Novel Internal Medicine Residency Ultrasound Curriculum Led by Critical Care and Emergency Medicine Staff.

INTRODUCTION: Point-of-care ultrasound (POCUS) is an integral aspect of critical care and emergency medicine curriculums throughout the country, but it has been slow to integrate into internal medicine residency programs. POCUS has many benefits for internal medicine providers, guiding diagnostic decisions and aiding in procedures. Additionally, POCUS is a convenient and portable resource specifically for internal medicine providers in the military when practicing in deployed or critical care settings. Critical care and emergency medicine clinicians are excellent resources to lead these courses. We sought to develop a new POCUS curriculum for internal medicine residents within the Naval Medical Center Portsmouth Internal Medicine Residency program with the support of emergency medicine and critical care medicine staff to lead and oversee the training. The project's aim was to increase internal medicine resident confidence with POCUS by 20% and proficiency with POCUS as evidenced by pretest and posttest analysis by 10%. MATERIALS AND METHODS: The program consisted of a 2-day, 9-hour, introductory course, combining lecture with hands-on scanning taught by emergency medicine physicians who had completed emergency ultrasound fellowship-level training. This was followed by a longitudinal component of hands-on scanning throughout the academic year built into the residents' schedules. Emergency and critical care medicine ultrasound staff reviewed all studies for quality assurance (QA). The residents were given both precourse and post-course knowledge tests and confidence surveys, which utilized a 5-point Likert scale. The knowledge assessments were analyzed with a paired t-test, and the Likert scale data were analyzed using the Wilcoxon signed-rank test. The Naval Medical Center Portsmouth Institutional Review Board deemed this project nonhuman subjects' research. RESULTS: Twenty participants were enrolled, with 10 (50%) of those enrolled completing all course requirements. The average precourse knowledge assessment score was 76.60%, and postcourse assessment score was 80.95% (+4.35%, P = .33). The confidence survey scores were initially 73.33% and improved to 77.67% (+4.34%, P = .74). CONCLUSIONS: A curriculum comprised of a 9-hour workshop followed by a longitudinal hands-on experience can provide improvement in internal medicine resident POCUS knowledge and confidence. This model emphasizes the benefit of emergency and critical care cooperation for ultrasound training and provides an emphasis on medicine-relevant scans and longitudinal training.

Determining Intraosseous Needle Placement Using Point-of-Care Ultrasound in a Swine (Sus scrofa) Model.

OBJECTIVE: Intraosseous (IO) access is critical in resuscitation, providing rapid access when peripheral vascular attempts fail. Unfortunately, misplacement commonly occurs, leading to possible fluid extravasation and tissue necrosis. Current research exploring the utility of bedside ultrasound in confirming IO line placement is limited by small sample sizes of skeletally immature subjects or geriatric cadaveric models. The objective of this study was to investigate the potential value of ultrasound confirming IO needle placement in a live tissue model with bone densities approximated to the young adult medical or trauma patient. MATERIALS AND METHODS: In this randomized, blinded prospective study, IO devices were placed into the bilateral humeri of 36 sedated adult swine (N = 72) with bone densities approximating that of a 20-39-year-old adult. Of the 72 lines, 53 were randomized to the IO space ("correct") and 19 into the subcutaneous tissue ("incorrect"). Four emergency physicians with variable ultrasound experience and blinded to needle location independently assessed correct or incorrect needle placements based on the presence of an intramedullary "flare" on color power Doppler (CPD) during a saline flush. Participants adjusted the ultrasound beam trajectory and recorded assessments up to three times, totaling 204 separate observations. RESULTS: Overall, sensitivity for placement confirmation was 72% (95% CI: 64%-79%). Specificity was 79% (95% CI: 66%-89%). First assessment and final assessment results were similar. More experienced sonographers demonstrated greater success in identifying inaccurate placements with a specificity of 86% (95% CI: 63%-96%). CONCLUSION: Within the context of this study, point-of-care ultrasound with CPD did not reliably confirm IO line placement. However, more accurate assessments of functional and malpositioned catheters were noted in sonographers with greater than 4 years of experience. Future study into experienced sonographers' use of CPD to confirm IO catheter placement is needed.

Virtual Ultrasound Training in a Multinational Teaching Program.

INTRODUCTION: Before the COVID-19 pandemic, a 1-week in-person Clinical Ultrasound Course was taught in African nations as part of a U.S. Department of State-funded program that supports and trains African peacekeepers serving with the United Nations and African Union. In order to maintain active engagement with host nations despite the travel restrictions due to the COVID-19 pandemic, portions of the course were taught virtually in 2021 to providers in Ghana, Senegal, and Rwanda. An abbreviated course was delivered covering the Focused Assessment with Sonography in Trauma (FAST) trauma exam and vascular access. The goal of this study is to assess the effectiveness of the Clinical Ultrasound Course while taught in a virtual classroom. MATERIALS AND METHODS: Thirty-six participants enrolled in the program. Participants completed a pre-course survey before the training. Training consisted of a pre-recorded lecture followed by hands-on ultrasound instruction. After the training, participants completed a post-course survey. Eight participants were excluded from the study because they did not complete both surveys. Survey questions assessed the participants' comfort with ultrasound mechanics and the FAST exam. Participant responses were measured utilizing a visual analog scale. RESULTS: Based on survey results, all participants gained a better understanding of the indications and limitations of the FAST exam from the virtual Clinical Ultrasound Course. All participants also felt more comfortable using ultrasound in clinical practice than they did before the course. Ghanaian and Senegalese participants showed greater improvement in all areas studied than Rwandan participants. This is likely due to the fact that the Rwandan hospital system had prior ultrasound training and a higher baseline understanding than their counterparts. The Rwandan hospital system had previously completed the in-person sessions of the Clinical Ultrasound Course and therefore had some institutional knowledge, while the Ghanaians and Senegalese took the course for the first time during this study. CONCLUSION: Virtual delivery of the Clinical Ultrasound Course was successful. Participants felt more comfortable in all aspects of ultrasound taught during the course and indicated that they were more likely to use ultrasound in clinical practice. This demonstrates that virtual ultrasound teaching is a viable option for international educational programs in the future.

Petroleum Jelly: A Novel Medium for Ocular Ultrasound.

BACKGROUND: Ocular ultrasound is a useful emergency department imaging modality for evaluation of many conditions, such as retinal detachment, vitreous detachment, vitreous hemorrhage, and elevated intracranial pressure. Obtaining satisfactory ocular ultrasound images requires the use of a medium that eliminates the air interface between the patient's eye and the transducer. Ultrasound gel is most commonly used; however, the use of a transparent dressing applied to the closed eye prior to the application of gel has also been described as a suitable technique. DISCUSSION: Ocular ultrasound is performed with the high-frequency linear array transducer using a medium to eliminate the air interface between the eye and the transducer. Although ultrasound gel is most frequently used, it can cause minor eye irritation. Placing a transparent dressing over a closed eye prior to application of gel can eliminate the eye irritation. However, our experience in training >500 students in ocular ultrasound has shown that air is frequently introduced underneath the dressing, which leads to poor-quality images. This article introduces petroleum jelly as a medium for ocular ultrasound. By applying a layer of petroleum jelly over the closed eye and allowing it to warm via body heat for 30 to 45 s, this medium can both minimize patient discomfort and provide easily obtainable, high-quality ocular ultrasound images. CONCLUSIONS: This article introduces petroleum jelly as a safe, comfortable, and effective medium for ocular ultrasound examination.

Successful strategies for integrating bedside ultrasound into undergraduate medical education.

Nearly all physician specialties currently utilize bedside ultrasound, and its applications continue to expand. Bedside ultrasound is becoming a core skill for physicians; as such, it should be taught during undergraduate medical education. When ultrasound is integrated in a longitudinal manner beginning in the preclerkship phase of medical school, it not only enhances teaching the basic science topics of anatomy, physiology, and pathology but also ties those skills and knowledge to the clerkship phase and medical decision-making. Bedside ultrasound is a natural bridge from basic science to clinical science. The Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine is currently in its fourth year of implementing an integrated ultrasound curriculum in the school of medicine. In our experience, successful integration of a bedside ultrasound curriculum should: align with unique focuses of a medical schools' mission, simplify complex anatomy through multimodal teaching, correlate to teaching of the physical examination, solidify understanding of physiology and pathology, directly link to other concurrent content, narrow differential diagnoses, enhance medical decision-making, improve procedural skills, match to year-group skillsets, develop teaching and leadership abilities, and have elective experiences for advanced topics.

Emergencies of the liver, gallbladder, and pancreas.

Abdominal pain is a common presenting complaint in today's emergency department (ED). Disorders related to the liver, gallbladder, and pancreas are responsible for many of these presentations. With the increasing prevalence of gallstones, as well as alcohol use and abuse, the numbers of cases are likely to increase. This article examines hepatic emergencies including alcoholic hepatitis, spontaneous bacterial peritonitis, hepatorenal syndrome, and hepatic encephalopathy. In addition, the authors review the presentation, evaluation, and management of acute biliary tract disorders with some emphasis on bedside ultrasonography. Evaluation and treatment of pancreatitis and its complications in the ED are discussed.

Traumatic bladder rupture in a paratrooper.

A paratrooper presents after a parachuting accident with the inability to urinate. Initial emergency bedside ultrasound, followed by confirmatory abdominal CT, is carried out and demonstrates an intraperitoneal bladder rupture. The patient is taken to the operating room and a 3-layer closure with omental buttressing is carried out.