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Clinical Ultrasonography (aka Point of Care Ultrasound or POCUS) is broad in scope and its clinical applications are far-reaching.  As early as 2014, half of Canadian medical schools had already implemented some form of clinical ultrasound education into their undergraduate medical education (UGME) programing (1). Six years later, national standards have yet to be established. Educators at the undergraduate medical level are struggling to determine what ultrasound skills to include, exclude, or defer to residency – a challenging balance given an already crowded UGME curriculum. Clearly, there is a need for national curricular guidelines in clinical ultrasonography. Accordingly, the Canadian Ultrasound Consensus for Undergraduate Medical Education (CanUCMe) group was formed in 2018 comprising 21 ultrasound experts and educational leaders from 15/17 Canadian medical schools (2). CanUCMe’s experts aimed to determine which curricular objectives should be taught to ensure a foundational understanding of clinical ultrasonography. Using a modified Delphi method, these experts submitted their recommendations for curricular goals and after three rounds of rigorous review and voting, the group reached consensus on 85 ultrasound objectives to include as minimum requirements at the UGME level. 

The University of Saskatchewan’s UGME ultrasound curriculum is now in its 6^th year. As such, it seems appropriate to check in and evaluate our program alongside CanUCME’s proposed standards and objectives. This review was undertaken by the authors, medical students at USask. It includes a comprehensive review of all clinical ultrasound education throughout pre-clerskship and clerkship, as well as a review of all program evaluations over the past 5 years. This article was peer reviewed by both USASK Faculty as well as external experts for accuracy and clarity. 

Ultrasound-Guided Medical Education (the other UGME!)

The USASK UGME ultrasound curriculum includes educational US in the Anatomy course in first term, followed by induction into clinical US in the clinical skills courses of terms 2 through 4. This exposure in pre-clerkship translates to ~ 9 hours of hands-on supervised US training. Clerkship exposure is rooted in the core EM rotation, but is also found on other services to varying degrees .While introducing a skill such as ultrasound can be challenging, the transition from didactic lectures to learning practical skills is well facilitated through a flipped-classroom model that includes video tutorials and hands-on scanning sessions with standardized patients and an interprofessional team of instructors (physicians, nurses, paramedics). Student group sizes during scanning sessions are kept small (typically 2-4 students to each machine/patient) in an effort to maximize hands-on scanning time for each learner.

The curriculum is designed to enhance longitudinal learning of the curricular elements through spaced repetition and practice. 37 elements are revisited in pre-clerkship and only 7 elements are not re-visited in clerkship. With 92% of students passing their POCUS OSCE (able to perform the scan with little to no prompting, OSCE results for MS2 class, 2017), the U of S ultrasound curriculum appears to be effective at achieving foundational POCUS skills.

Things USASK does well

As indicated in evaluative feedback forms, students are happy with the bedside preceptors as their supportive attitude enables students to comfortably experiment with ultrasound. We believe that this is crucial when learning a spatially challenging practical skill. Additionally, preceptors have extensive POCUS experience and can challenge students to think about what they are doing from a clinical perspective. Finally, students find that groups are small enough that they are still able to receive individually tailored feedback while also learning from watching their peers and discussing skills as a group.

The USASK ultrasound curriculum meets 77 (90%) of the final 85 Consensus-Based Recommended Curricular Elements for Ultrasound in Canadian UGME. Indeed, only 12 of the 85 elements are not met during pre-clerkship years 1 and 2, with four of those being later introduced in clerkship, leaving 8 elements: ALARA, potential bioeffects, proximal inguinal regional vessels, heart sound generation in physiology, consolidation, ultrasound-guided peripheral intravenous insertion, general needle guidance technique using ultrasound, and use of small-group scanning on patients. The U of S ultrasound curriculum appears to be effective at achieving the desired curricular elements. in addition to providing a welcoming environment for medical students to learn ultrasound.

Clerkship students are also eligible to apply for the Clinical Ultrasound Elective in Clerkship (CUSEC) in their second year of clerkship. This is a 2-week intensive rotation which includes a competency assessment. The first week is non-clinical and focuses on hands-on scanning time as well as seminars which have received exceptional feedback. The second week allows the students to choose a rotation/discipline and develop an approach to integrating ultrasonography into everyday care (3). All but one element – “heart sound generation” – are subsequently covered in the 4^th year Clinical UltraSound Elective in Clerkship.

More Than Meets the Eye

In addition to the ultrasound curriculum, USASK medical students benefit from the efforts and hard work of the USASK Ultrasound Interest Group as well as the annual SASKSONO conferences (established in 2016).

The U of S Ultrasound (USUS) student group provides additional scan time to students throughout the year. This student-led group provides a low-pressure environment for medical students to reinforce scanning techniques taught through the curriculum. The group hosts “scan-night” sessions on-campus. Students have the opportunity to practice on each other and gain additional time with the probe in hand. Approximately 40 students attend each scan night and students are given one hour to practice each night. The group hosts around five events per year. A notable event for the group is the OSCE review night which focuses on preparing students for an OSCE station requiring the use of ultrasound. In previous years the OSCE review night has had more than 60 attendees. A great review of USUS can be found here.

Our annual SONO-conference explores the role clinical ultrasonography in improving patient outcomes and system efficiencies. Our conferences include a range of learning experiences including short lectures, hands on workshops for beginners as well as those already familiar with the basics, supervised scanning with top level coaching, as well as rapid oral abstracts and the always entertaining SONOlympiad. Check out the details from our previous 4 conferences here.

Overall, we would grade the USask ultrasound curriculum as a B+. The sessions themselves include the majority of the CanUCME recommended curricular elements and are delivered efficiently.

Room for Improvement

The College of Medicine at the University of Saskatchewan already meets most objectives and is working to integrate outstanding items in order to improve the delivery of the Clinical Ultrasound teaching. Currently, gaps in respiratory ultrasound (specifically B lines, consolidation, and pneumothorax) are being addressed through new modules at the clerkship level (core EM rotation).

Student Feedback

Moreover, we analyzed student feedback and found that a point for improvement relates to the frequency of ultrasound sessions. Students consistently self-rated their ultrasound skills as poor before a teaching session, but described significant improvement afterwards; nevertheless, their improvement was felt to be largely lost by the time the next teaching session occurred the following term. We feel the curriculum could slow this perceived regression by implementing more frequent scanning sessions. This infrequency was the most commonly commented critique during session evaluations: students want more ultrasound sessions. 

While students strongly appreciated and valued the audiovisual learning materials that accompanied ultrasound teaching sessions, students frequently noted in evaluations that they would appreciate more concise reference material. We suggest digital visual aids/summaries that outline the correct probe position, along with the appropriate landmarks for each scan. In turn, students will have a concise means of reviewing before quizzes and OSCEs. The final area we recommend for improvement is increasing POCUS exposure in other core rotations such as pediatrics, anesthesia, general surgery and family medicine.

Conclusion

The USask US program has gradually taken shape over the course of several years, guided by local expertise, support from university administration, and most recently, the CanUCMe’s recommendations. The program has established a number of longitudinal training strategies delivered in class and on rotation with both real and standardized patients. The curriculum meets nearly all of the of the curricular elements of the CanUCME recommendations. Ultrasound relating to the respiratory system and opportunities for hands-on self-directed learning are areas for improvement. As the use of ultrasound continues to grow and clinical ultrasonography becomes more prevalent in clinical practice, we encourage our peers at other institutions to evaluate their own ultrasound curriculum as a means of bringing all Canadian medical schools in alignment with expert-guided standards such as the CanUCME recommendations.

Authors

Mars Zhao, Michael Durr, and Michael Thatcher are in their 2^nd year at the College of Medicine at USASK

Dr. Paul Olszynski is the lead for UGME Ultrasound at the University of Saskatchewan, and Dr. Ali Turnquist is a regular POCUS instructor and lecturer with the UGME Ultrasound program.

External Reviewers

Dr. Irene Ma (University of Calgary) and Dr. Brian Buchanan (University of Alberta)

References

1. Steinmetz P, Dobrescu O, Oleskevich S, Lewis J. Bedside ultrasound education in Canadian medical schools: a national survey. Can Med Educ J. 2016;7(1):e78–86
2. Ma I, Steinmetz P, Weerdenburg K, Woo M, Olszynski P, Heslop C et al. The Canadian Medical Student Ultrasound Curriculum. Journal of Ultrasound in Medicine. 2020;39(7):1279-1287.
3. Olszynski, P., Russell, M., Neufeld, A., & Malin, G. (2020). The Clinical Ultrasonography Elective in Clerkship (CUSEC): A pilot elective for senior clerkship students at the University of Saskatchewan. Canadian Medical Education Journal, 11(1), e144-e146. https://doi.org/10.36834/cmej.61810

CAEP will be releasing a formal document shortly but in the meantime, here are some key considerations:

A) Is the scan clinically indicated and will the results change management?

1. In Non-Respiratory concerns/low-risk COV-19 patients – standard indications apply BUT you must now do a terminal clean after use (wiping down all surfaces touched during the scan) with Accel wipes after exiting the room. Wet-time must be 1 minute.
2. In Resp/COVID suspected cases,  POCUS use is more nuanced. While POCUS can be used to triage and monitor COVID patients – it may or may not have a direct impact on patient disposition in your ED. In Saskatoon for example, a Hx consistent with viral URTI combined with WOB and O2 sats will likely do the trick for admission to either Medicine or ICU. POCUS may be indicated when diagnostic uncertainty and/or shock state exists. Procedural guidance should be determined on a case by case basis. In any of these instances, the machine may be exposed to aerosolized environment and a higher level of decontamination may be required (see below).

POCUS Preparation and cleaning in AGMP rooms.

1. For the duration of the pandemic, remove all unnecessary equipment from your cart-based machines (we have done this at all three sites in Saskatoon)
2. Consider designating certain machines as COVID-19 specific.
3. Use sheaths to cover the probe and cord. These do not need to be sterile in the setting of diagnostic applications.
4. Utilize single use ultrasound gel packets.
5. Cover non-essential components of the ultrasound machine with drapes, gown, or plastic covering, like a plastic bag.
6. Perform the scan.
7. Remove drapes or bag after use and leave in the patient’s room, being mindful of not dispersing virus while disposing of the cover.
8. Wipe down the entire surface of the machine with designated wipes after use inside the patient’s room, prior to doffing.
9. Move the machine out of the patient room. Doff contaminated PPE and don new gloves. Then wipe down the entire surface of the machine again.

B) Do i have time to properly drape the machine and then clean it afterwards?

Take cleaning and preparation time into consideration as you decide whether or not you will use POCUS. As the list shows, you are looking at an additional 10 minutes for preparation and cleaning. Also – now is generally not the time to learn totally NEW POCUS applications. The use of a COV-19 lung protocol (linked below) is within the scope of any credentialed POCUS user and may be helpful when conventional imaging like CXR are limited.

C) Should i get a handheld POCUS device since they are easier to clean?

Health Canada has recently approved the newest handheld devices (Butterfly IQ) in light of the pandemic (and how much more easily they can be cleaned). Some departments are buying these in large numbers. My understanding is that these departments (some in Sask) have clearly defined the use and cleaning parameters for these devices. With the right processes and procedures in place , we can keep our staff and patients safe during these very challenging times.

Should you have any question, please don’t hesitate to connect sasksonic@gmail.com

COVID POCUS Protocol

COVID-19 — The POCUS Atlas

Placing a line with ultrasound? Blocking a nerve? Checking for pneumothorax? Assessing LV function? Confirming intra-uterine pregnancy? Sorting out shock with TEE?

EVERYTHING IS POCUS!

Meet our amazing faculty from Internal Medicine, Critical Care, Emergency Medicine, Pediatrics, and Paramedicine! Join us for engaging lectures,  productive workshops, and  hands-on coaching!

Detailed conference agenda found here: schedule_sono20

To register, click here!

As always, we’ll be hosting our annual SONOlympiad where our medical students compete for the SonoCup!

To register your team – details are as follows:

Teams of 3-4 should submit a 5-10 minute creative video highlighting:
– member skills (clips of scanning or image interpretation)
– team name and outfits
– unique team strengths

Content covered at this year’s games is listed within the proposed Canadian Medical Student Ultrasound Curriculum by Ma et al. https://doi.org/10.1002/jum.15218  (specifically Table 4)

Team videos should be submitted to sasksonic@gmail.com

Selection Criteria:
– clear demonstration of image generation skills (clip shows team member scanning while also showing the POCUS image all in a single frame) with the above curriculum in mind
– case integration to show knowledge of indications and how to integrate findings with the above curriculum in mind
– creativity
– team name
– unique team strengths?

Submission deadline will be March 9th.