Gamification of POCUS: Are Students Learning?

INTRODUCTION: While gamification of point-of-care ultrasound (POCUS) is well received by learners, little is known about the knowledge gained from material taught during these events. We set out to determine whether a POCUS gamification event improved knowledge of interpretation and clinical integration of POCUS. METHODS: This was a prospective observational study of fourth-year medical students who participated in a 2.5-hour POCUS gamification event consisting of eight objective-oriented stations. Each station had one to three learning objectives associated with the content taught. Students completed a pre-assessment; they then participated in the gamification event in groups of three to five per station and subsequently completed a post-assessment. Differences between pre- and post-session responses were matched and analyzed using Wilcoxon signed-rank test and Fisher's exact test. RESULTS: We analyzed data from 265 students with matched pre- and post-event responses; 217 (82%) students reported no to little prior POCUS experience. Most students were going into internal medicine (16%) and pediatrics (11%). Knowledge assessment scores significantly improved from pre- to post-workshop, 68% vs 78% (P=0.04). Self-reported comfort with image acquisition, interpretation, and clinical integration all significantly improved from pre- to post-gamification event (P<0.001). CONCLUSION: In this study we found that gamification of POCUS, with clear learning objectives, led to improved student knowledge of POCUS interpretation, clinical integration, and self-reported comfort with POCUS.

Assessment of Medical Students' Ability to Integrate Point-of-Care Cardiac Ultrasound Into a Case-Based Simulation After a Short Intervention.

INTRODUCTION: While a large amount of point-of-care ultrasound (POCUS) undergraduate medical education research exists, very little assesses the effectiveness of teaching on the student's ability to utilize POCUS within a clinical context. We set out to assess the ability of pre-clinical (second year) medical students to perform and interpret a parasternal long axis (PSLA) cardiac ultrasound view, and to diagnose a pericardial effusion on POCUS in a simulated patient with hypotension. METHODS: This was a prospective study assessing second-year medical students before and after focused cardiac POCUS instruction. Pre-instruction, students completed a pre-assessment and test. They then watched a short video on cardiac ultrasound technique, anatomy, and pathology. Students then participated in 10 minutes of one-on-one hands-on instruction using a simulated patient. Immediately after didactics and hands-on instruction, students in groups of two to four completed a case simulation where they performed a PSLA view, identified pathology, and made a diagnosis. Differences between pre- and post-workshop responses were analyzed using the Chi-square test. RESULTS: We analyzed data on 132 pre-clinical second-year medical students; 126 (95%) had limited to no POCUS experience prior to the workshop. Comparing pre- to post-workshop responses, we found significant improvement in students' ability to identify a pericardial effusion (46% to 69%) (p=0.002) on a PSLA cardiac view. Of the 57 student groups (132 students), 41 (72%) groups were able to adequately obtain a PSLA view on a mannequin using an ultrasound simulator without needing guidance with probe placement or maneuvering. Thirty-five (61%) student groups were able to identify a pericardial effusion and diagnose cardiac tamponade in a simulated patient with hypotension. CONCLUSION: After short, structured training, pre-clinical medical students, novice to cardiac POCUS, showed improved knowledge with identifying a pericardial effusion on an ultrasound image. The majority of students were able to obtain a PSLA view and diagnose cardiac tamponade in a hypotensive patient during a during a case-based simulation.

Piloting a Graduate Medical Education Point-of-Care Ultrasound Curriculum.

Objective As point-of-care ultrasound (POCUS) use grows, training in graduate medical education (GME) is increasingly needed. We piloted a multispecialty GME POCUS curriculum and assessed feasibility, knowledge, and comfort with performing POCUS exams. Methods Residents were selected from the following residency programs: internal medicine, family medicine, emergency medicine, and a combined internal medicine/pediatrics program. Didactics occurred through an online curriculum that consisted of five modules: physics and machine operation, cardiac, lung, soft tissue, and extended focused sonography in trauma applications. Residents completed a pre- and post-curriculum questionnaire, as well as knowledge assessments before and after each module. One-hour hands-on training sessions were held for each module. Differences between pre- and post-participation questionnaire responses were analyzed using the Wilcoxon rank sum. Results Of the 24 residents selected, 21 (86%) were post-graduate year two or three, and 16 (65%) were from the internal medicine program. Eighteen (67%) residents reported limited prior POCUS experience. All pre- to post-knowledge assessment scores increased (p<0.05). Statistically significant increases pre- to post-curriculum were found for frequency of POCUS use (p = 0.003), comfort in using POCUS for assessing for abdominal aortic aneurysm, soft tissue abscess detection, undifferentiated hypotension and dyspnea, cardiac arrest and heart failure (p<0.025); and competency in machine use, acquiring and interpreting images and incorporating POCUS into clinical practice (p<0.001). All participants felt the skills learned during this curriculum were essential to their future practice. Conclusions In this pilot, we found using a combination of online and hands-on training to be feasible, with improvement in residents' knowledge, comfort, and use of POCUS.

Point-of-Care Ultrasound Education During a Pandemic: From Webinar to Progressive Dinner-Style Bedside Learning.

OBJECTIVE: Point-of-care ultrasound (POCUS), traditionally, requires the proximity of learners and educators, making POCUS education challenging during the COVID-19 pandemic. We set out to evaluate three alternate approaches to teaching POCUS in UME. Sessions progressed from an online seminar to a remote, interactive simulation to a "progressive dinner" style session, as precautions evolved throughout the pandemic. METHODS: This prospective study details a series of three POCUS workshops that were designed to align with prevailing social distancing precautions during the COVID-19 pandemic. Overall, 656 medical students were included. The first and second workshops used web-based conferencing technology with real-time ultrasound imaging, with the second workshop focusing on clinical integration through simulation. As distancing precautions were updated, a novel "progressive dinner" technique was used for the third workshop. Surveys were conducted after each session to obtain feedback on students' attitudes toward alternative teaching techniques and quantitative and qualitative analyses were used. RESULTS: The initial, remote POCUS workshop was performed for 180 medical students. Ninety-nine (177) percent of students felt the session was "intellectually challenging" and "stimulating." Ninety-nine percent of students (340/344), after the second workshop, indicated the session was intellectually challenging, stimulating, and a positive learning experience. Students' ability to correctly identify pathologic images increased post-session evaluation from in-session polling. For workshop three, 99% (107/108) of students indicated that the session was "informative." There was a significant improvement in pre- to post-workshop knowledge regarding image acquisition, interpretation, and clinical integration. CONCLUSION: While image acquisition skills are best conveyed at the bedside, these modified POCUS teaching techniques developed and delivered in alignment with COVID-19 pandemic restrictions during a series of three workshops were shown to be effective surrogates for traditional teaching approaches when social distancing requirements, a large learner pool, or lack of local expertise exist.

Success of implementation of a systemwide point-of-care ultrasound privileging program for emergency medicine faculty.

Objectives: Point-of-care ultrasound (POCUS) is widely used in the emergency department (ED). Not all practicing emergency physicians received POCUS training during residency, leaving a training gap that is reflected in POCUS privileging. The purpose of this study was to evaluate the success of meeting privileging criteria as well as associated factors, following implementation of a basic POCUS training and privileging program within a large emergency medicine department. Methods: We implemented a POCUS training and privileging program, based on national guidelines, for faculty physicians who worked at one of the following EDs staffed by the same emergency medicine department: a pediatric tertiary site, two tertiary academic sites, and seven community sites. POCUS examinations included aorta, cardiac, first-trimester obstetrics (OB), and extended focused assessment with sonography in trauma. Pediatric emergency medicine faculty were taught soft tissue and thoracic US instead of aorta and OB. Completion of the program required 16 h of didactics, ≥25 quality-assured US examinations by examination type, and passing a series of knowledge-based examinations. Descriptive statistics were calculated. Associations between physician characteristics and successfully becoming privileged in POCUS were modeled using Firth's logistic regression. Results: A total of 176 faculty physicians were eligible. A total of 145 (82.4%) achieved basic POCUS privileging during the study period. Different pathways were used including 86 (48.9%) practice-based, nine (5.1%) fellowship-based, and 82 (46.9%) residency-based. POCUS privileging was lower for those working in a community versus academic setting (odds ratio 0.3, 95% confidence interval 0.1-0.9). A greater number of scans completed prior to the privileging program was associated with greater success. Conclusions: Implementation of a POCUS training and privileging program can be successful in a large emergency medicine department that staffs hospitals in a large-scale health care system composed of both academic and community sites. Faculty physicians with at least some prior exposure to POCUS were more successful.

Design and implementation of a basic and global point of care ultrasound (POCUS) certification curriculum for emergency medicine faculty.

Point of care ultrasound (POCUS) use in the emergency department is associated with improved patient outcomes and increased patient satisfaction. When used for procedural guidance, it has been shown to increase first pass success and decrease complications. As of 2012, ultrasound has been identified as a core skill required for graduating emergency medicine (EM) residents. Despite this, only a minority of EM faculty who trained prior to 2008 are credentialed in POCUS. Half of all EM training programs in the United States have less than 50% of their faculty credentialed to perform and teach POCUS to learners. As the use of POCUS continues to grow in medicine, it is especially important to have a pathway for faculty to attain competence and become credentialed in POCUS. The goal of this paper was to outline an implementation process of a curriculum designed to credential EM faculty in POCUS.

The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey.

PURPOSE: The primary aim of this study was to evaluate the current state of point-of-care ultrasound (POCUS) integration in undergraduate medical education (UME) at MD-granting medical schools in the United States. METHOD: In 2020, 154 clinical ultrasound directors and curricular deans at MD-granting medical schools were surveyed. The 25-question survey collected data about school characteristics, barriers to POCUS training implementation, and POCUS curriculum details. Descriptive analysis was conducted using frequency and percentage distributions. RESULTS: One hundred twenty-two (79%) of 154 schools responded to the survey, of which 36 were multicampus. Sixty-nine (57%) schools had an approved POCUS curriculum, with 10 (8%) offering a longitudinal 4-year curriculum. For a majority of schools, POCUS instruction was required during the first year (86%) and second year (68%). Forty-two (61%) schools were teaching fundamentals, diagnostic, and procedural ultrasound. One hundred fifteen (94%) schools identified barriers to implementing POCUS training in UME, which included lack of trained faculty (63%), lack of time in current curricula (54%), and lack of equipment (44%). Seven (6%) schools identified no barriers. CONCLUSIONS: Over half of the responding medical schools in the United States had integrated POCUS instruction into their UME curricula. Despite this, a very small portion had a longitudinal curriculum and multiple barriers existed for implementation, with the most common being lack of trained faculty. The data from this study can be used by schools planning to add or expand POCUS instruction within their current curricula.

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.

Development and implementation of a point of care ultrasound curriculum at a multi-site institution.

In 2014, over 60% of medical schools were incorporating point of care ultrasound (POCUS) into their curriculum. Today, over 6 years later, many more schools are teaching POCUS or are in the planning stages of implementing a POCUS curriculum. In 2019, the AAMC reported that 53 schools or over one-third of US medical schools have multi-site campuses for undergraduate medical education. Implementation of a POCUS educational initiative at a multi-site campus presents unique challenges for teaching a uniform curriculum statewide. This article will discuss the POCUS curriculum and implementation process at a large multi-site institution.

A Narrative Review of Common Uses of Ophthalmic Ultrasound in Emergency Medicine.

BACKGROUND: The timely evaluation of ocular conditions in the emergency department (ED) can be difficult due to a general lack of specialized equipment, trained personnel, and the time-sensitive nature of emergent ocular conditions. Recently, the use of ocular point-of-care ultrasound (POCUS) has been shown to be particularly useful in the ED. POCUS can be used to promptly diagnose various ocular pathologies, which include ocular trauma, vitreous hemorrhage, central retinal artery occlusion, and retinal detachment. OBJECTIVES: This narrative review seeks to inform the reader of current literature regarding the use of POCUS for the assessment of various ocular emergencies in the ED. The goal of this review is to provide the emergency physician with succinct and up-to-date information and instruction regarding the current uses of POCUS for patients presenting with particular ocular emergencies. Ocular pathologies that are common (ocular trauma) or for which ultrasound is particularly useful (such as retinal detachment) are discussed. Other ocular pathologies are also briefly discussed, such as central retinal artery occlusion, which is a promising new application for ultrasound evaluation. DISCUSSION: There have been many studies that provide evidence for the utility of POCUS in the evaluation of trauma and other ocular pathologies, including vitreous hemorrhage, retinal detachment, and central retinal artery occlusion. CONCLUSIONS: Ocular POCUS is a useful modality in the evaluation of acute ocular complaints in the ED. Emergency physicians should be aware of these findings and feel confident in the utility of ocular POCUS in the ED.

Systematic Sonography Looking for Occult Wounds: accuracy of an abdominal ultrasound adjunct in penetrating trauma.

BACKGROUND: Systematic Sonography Looking for Occult Wounds (SSLOW) in trauma is a novel technique for the evaluation of intra-abdominal wounds in penetrating trauma. No data exist regarding the effectiveness. The objective of this study was to evaluate the accuracy of the SSLOW exam. METHODS: This is a prospective collected case series conducted over a period of 10 months and took place at the Accident and Emergency Department (A&E) of the Georgetown Public Hospital Corporation (GPHC). The study enrolled patients presenting to the A&E who were 16 years old or greater with penetrating abdominal trauma. All patients with penetrating trauma received an E-FAST examination. If the E-FAST examination was negative, a SSLOW examination was completed. The sonographer evaluated for free fluid collection between the loops of bowel. The results of the SSLOW were compared to usual care (surgery consult, serial abdominal and E-FAST exams, laparotomy, and 7-day follow-up) and then categorized into four groups: true positive, false positive, true negative, and false negative. These results lead to four categorical values. From these results, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratios were calculated. RESULTS: There were 5 (12%) true positives, 1 (2%) false positive, 37 (86%) true negatives, and zero (0%) false negative. The SSLOW was 100% sensitive (95% CI 5-100%) and 97% specificity (95% CI 74-96%). There was an 80% positive predictive value (95% CI 1.0-64% 95% CI) and 100% negative predictive value (95% CI 88-100%). The positive likelihood ratio was 8.4 (95% CI 3.69-19.1) and negative likelihood ratio was 0. CONCLUSION: The SSLOW examination may be a useful tool in the evaluation of penetrating abdominal injuries.

Training the Trainer: Faculty From Across Multiple Specialties Show Improved Confidence, Knowledge and Skill in Point of Care Ultrasound After a Short Intervention.

Objectives  Lack of faculty skill and confidence in performing and teaching point-of-care ultrasound (POCUS) remains a significant barrier to implementation of a longitudinal ultrasound curriculum in undergraduate medical education. Our objective was to assess faculty comfort, knowledge and skill with performing and teaching POCUS before and after a focused workshop. Methods  This was a prospective study assessing faculty from multiple specialties. Faculty completed a pre- and post-workshop survey and ultrasound knowledge assessment, and a post-workshop objective structured clinical examination (OSCE) to assess ability to perform POCUS. Differences between pre- and post-workshop responses were analyzed using Fisher's Exact and Wilcoxon tests, and statistical significance was accepted for p<0.05. Results We analyzed data on 78 faculty from multiple disciplines. Faculty had a median of 7.5 years of experience with medical student teaching. Sixty-eight percent of faculty had performed <25 prior ultrasound (US) examinations. Comparing pre- to post-workshop responses, we found significant reductions in barriers to using US, and improved confidence with using, obtaining and interpreting POCUS (p<0.01). Faculty felt significantly more comfortable with the idea of teaching medical students POCUS (p<0.01). POCUS knowledge improved from 50% to 86% (p<0.01). On the post-workshop OSCE, 90% of anatomic structures were correctly identified with a median image quality of 4 out of 5. Conclusion After attending a six-hour workshop, faculty across multiple specialties had increased confidence with using and teaching POCUS, showed improved knowledge, and were able to correctly identify pertinent anatomic structures with ultrasound while obtaining good image quality.

Using the Retrobulbar Spot Sign to Assist in Diagnosis and Management of Central Retinal Artery Occlusions.

Point-of-care ultrasound has become an integral part of the evaluation of monocular vision loss. Most commonly, it has been used to evaluate retinal detachment, vitreous hemorrhage, and posterior vitreous detachment. Point-of-care ultrasound can also be used to evaluate central retinal arterial occlusion, whereby a retrobulbar spot sign is present. We present a case series of 4 patients presenting with monocular vision loss who were found to have central retinal artery occlusion. We describe what a retrobulbar spot sign is and how its presence or absence can assist in the evaluation and treatment of these patients.

Emergency Ultrasound Training Program in Guyana: Systematic Credentialing Process in a Resource-limited Setting.

Ultrasound has become an important skill for emergency physicians. Ultrasound is more crucial in resource-limited settings where diagnostic testing may not be as timely or available at all. In 2015, an emergency medicine ultrasound curriculum was implemented at Georgetown Public Hospital Corporation in Georgetown, Guyana. Implementing an ultrasound-training curriculum in Guyana had four main challenges: limited ultrasound equipment, lack of informational technology infrastructure to record and review ultrasound examinations, availability of local emergency ultrasound expertise, and competing educational needs within the curriculum. These challenges were met with creative solutions and the formation of a formalized curriculum and credentialing process. The experience of creating the program is described along with the curriculum, credentialing process, and plan for sustainability. Since implementation, every graduating resident has displayed competency on final assessment.

Cardiac Tamponade Diagnosed by Point-of-Care Ultrasound.

We present a case involving a 12-year-old boy who presented to the emergency department and was diagnosed with a pericardial effusion with tamponade physiology by point-of-care ultrasound. The diagnosis resulted in prompt treatment and definitive therapy.

Extravasation Risk Using Ultrasound-guided Peripheral Intravenous Catheters for Computed Tomography Contrast Administration.

OBJECTIVE: Ultrasound-guided intravenous catheter (USGIV) insertion is increasingly being used for administration of intravenous (IV) contrast for computed tomography (CT) scans. The goal of this investigation was to evaluate the risk of contrast extravasation among patients receiving contrast through USGIV catheters. METHODS: A retrospective observational study of adult patients who underwent a contrast-enhanced CT scan at a tertiary care emergency department during a recent 64-month period was conducted. The unadjusted prevalence of contrast extravasation was compared between patients with an USGIV and those with a standard peripheral IV inserted without ultrasound. Then, a two-stage sampling design was used to select a subset of the population for a multivariable logistic regression model evaluating USGIVs as a risk factor for extravasation while adjusting for potential confounders. RESULTS: In total, 40,143 patients underwent a contrasted CT scan, including 364 (0.9%) who had contrast administered through an USGIV. Unadjusted prevalence of extravasation was 3.6% for contrast administration through USGIVs and 0.3% for standard IVs (relative risk = 13.9, 95% confidence interval [CI] = 7.9 to 24.6). After potential confounders were adjusted for, CT contrast administered through USGIVs was associated with extravasation (adjusted odds ratio = 8.6, 95% CI = 4.6 to 16.2). No patients required surgical management for contrast extravasation; one patient in the standard IV group was admitted for observation due to extravasation. CONCLUSIONS: Patients who received contrast for a CT scan through an USGIV had a higher risk of extravasation than those who received contrast through a standard peripheral IV. Clinicians should consider this extravasation risk when weighing the risks and benefits of a contrast-enhanced CT scan in a patient with USGIV vascular access.

Novel ultrasound guidance system for real-time central venous cannulation: safety and efficacy.

INTRODUCTION: Real-time ultrasound guidance is considered to be the standard of care for central venous access for non-emergent central lines. However, adoption has been slow, in part because of the technical challenges and time required to become proficient. The AxoTrack(®) system (Soma Access Systems, Greenville, SC) is a novel ultrasound guidance system recently cleared for human use by the United States Food and Drug Administration (FDA). METHODS: After FDA clearance, the AxoTrack(®) system was released to three hospitals in the United States. Physicians and nurse practitioners who work in the intensive care unit or emergency department and who place central venous catheters were trained to use the AxoTrack(®) system. De-identified data about central lines placed in living patients with the AxoTrack(®) system was prospectively gathered at each of the three hospitals for quality assurance purposes. After institutional review board approval, we consolidated the data for the first five months of use for retrospective review. RESULTS: The AxoTrack(®) system was used by 22 different health care providers in 50 consecutive patients undergoing central venous cannulation (CVC) from September 2012 to February 2013. All patients had successful CVC with the guidance of the AxoTrack(®) system. All but one patient (98%) had successful cannulation on the first site attempted. There were no reported complications, including pneumothorax, hemothorax, arterial puncture or arterial cannulation. CONCLUSION: The AxoTrack(®) system was a safe and effective means of CVC that was used by a variety of health care practitioners.