This year we’re hosting a POCUS educator’s summit – a SONO-SUMMIT!
With increasing demands for POCUS training within the medical education spectrum, there are growing calls for guidance on curricular aspects like choosing what to teach, how to assess it, and how to define and determine competence in POCUS at all stages of training. Overall learner objectives include presenting the best available medical education evidence on POCUS in UGME, PGME and CME.
1) Best practices/evidence in UGME POCUS highlighting the Canadian Medical Students’ Ultrasound Curriculum (CanUCME group) as well as exploring key challenges including integration into the broader curriculum, equipment needs, and assessment. Link to the article found here!
2) Best practices/evidence in PGME POCUS with focus on competency based medical education (CBME) including entrustable professional activities, assessment with entrustment scores, and competency committees. Link to the Ultrasound Competency Assessment Tool validation found here!
3) Best practices/evidence in CME POCUS highlighting the need for longitudinal learning opportunities with CME recognition, supervision (both direct and indirect), scanning bootcamps, and the role of assessment for credentialing.
From Top Left Clockwise: Dr. Michelle Clunie, Dr. Paul Olszynski, Dr. Dan Kim, Dr. Gillian Sheppard, Dr. Irene Ma, Dr. Colin Bell
Each of the three main topics will be followed by a set of interactive workshops/break-out rooms (virtual) helping participants put ideas to paper/laptop while also getting a chance to ask/discuss challenges or questions with our experts. Workshops will include topics such as: Giving a good POCUS lecture, Teaching POCUS during clinical work, Preparing POCUS curriculum proposals, Using POCUS assessment tools, Completing EPA scores and narratives.
Save the date: Saturday morning, April 17th, 2021. Registration coming soon!
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 6th 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 4th 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).
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.
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.
Mars Zhao, Michael Durr, and Michael Thatcher are in their 2nd 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.
Dr. Irene Ma (University of Calgary) and Dr. Brian Buchanan (University of Alberta)
- 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
- 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.
- 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
The COVID19 pandemic has had profound effects on healthcare delivery and education. From the clinical side, we see yet again how POCUS plays an important role in patient triage, assessment and monitoring. From the education side, we are seeing a swell of interest in simulation not only as a teaching technique, but also as a process testing tool that can help refine our approach to novel challenges in acute care. As we move into the next phases of the pandemic, both POCUS and simulation will continue to play their roles.
From a teaching perspective, as we adapt some of our students’ clinical experiences during the pandemic, increased use of simulated clinical care seems reasonable. With that in mind, we are thrilled to release our newest update of USASK’s Emergency Department UltraSound Simulator (edus2), now downloadable to any windows laptop and much easier to use through the power of Java!
If you want to run edus2j on your laptop (for your sim lab, or small group teaching sessions, in-situ sim, wherever) here are the steps:
Once the hardware is ready, plug in the probe and create an edus2 folder on your desktop. In that folder, create sub-folders for 1) video library 2) saved scenarios 3) saved mannequins
Download Java, edus2j and our video library here
Download Java: https://www.java.com/en/download/
Download edus2j: https://github.com/camauser/edus2j/releases/download/1.3/edus2j.jar
Download our edus2 video library: https://www.dropbox.com/sh/55zd96yda694amc/AACcsAV2kYtXhMlS8QO1ec_ka?dl=0
Then watch our instructional videos:
1Watch video 1 on downloading Java and the edus2j program onto your computer (for free) https://vimeo.com/427519450
2. Watch video 2 on running the simulator, designating mannequins, and uploading videos https://vimeo.com/427519524
3. Video 3 creating scenarios and exporting mannequins. https://vimeo.com/427519597
Let us know if you need a hand!
Cameron Auser, BSc @camauser
Malcolm Whyte, BSc
Paul Olszynski, MD @olszynskip
Huge thanks to the team at the USASK CLRC for their patience and feedback during beta testing!
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?
- 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.
- 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.
- 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)
- Consider designating certain machines as COVID-19 specific.
- Use sheaths to cover the probe and cord. These do not need to be sterile in the setting of diagnostic applications.
- Utilize single use ultrasound gel packets.
- Cover non-essential components of the ultrasound machine with drapes, gown, or plastic covering, like a plastic bag.
- Perform the scan.
- Remove drapes or bag after use and leave in the patient’s room, being mindful of not dispersing virus while disposing of the cover.
- Wipe down the entire surface of the machine with designated wipes after use inside the patient’s room, prior to doffing.
- 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 email@example.com
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 firstname.lastname@example.org
– 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
– team name
– unique team strengths?
Submission deadline will be March 9th.
There has been A LOT of talk about POCUS governance lately – and at USASK we are right in there with a recent publication in The Ultrasound Journal on our efforts to develop a consensus-based multidisciplinary POCUS framework.
This Saturday @USASKEM and @usask_CME are hosting the 11th Saskatchewan Emergency Medicine Annual Conference (SEMAC XI) in Saskatoon, SK. We will be reviewing the recently adopted (province wide) Saskatchewan Emergency Ultrasound Guidelines: STANDARDS FOR EMERGENCY ULTRASOUND Final
These are in keeping (and in fact exceed) the above USASK POCUS Framework and are also well aligned with CAEP’s recent EM POCUS Position Statement.
Here’s the Executive Summary for the Sask EUS Guidelines:
Emergency ultrasound (EUS) comprises a set of focused applications utilized to diagnose life-threatening conditions, guide invasive procedures, and treat emergency medical conditions.  The proposed standards take into account that emergency care, and thus EUS, is within the scope of emergency physicians, family physicians and nurse practitioners. Given the significant contextual and resource differences between urban/tertiary centres and rural/regional sites, recommendations related to training, privileging and quality assurance are tailored accordingly.
- Scope includes use of ultrasound during emergency care to aid in diagnosis and procedures. Diagnostic applications include (but are not limited to) use of ultrasound in resuscitation (including focused cardiac and thoracic scans), in expediting diagnosis (including biliary, renal, venous applications), and in the assessment of musculoskeletal complaints (joints, fractures and soft tissue).
- Training (and proof thereof) should include a clear induction to the ultrasound application(s) in question, followed by a supervised apprenticeship, and an objective assessment of knowledge and skill. This standard, when applied to core/basic applications, is attainable throughout all sites in the province. However, with many of the extended applications where clinicians in rural/regional sites may have little local expertise to rely on, exceptions are warranted. In these cases, rural clinicians who already have credentials in basic EUS are advised to develop clear plans (in consultation with their site/area EUS lead) for ongoing practice and self-audit. Residents who have received robust emergency ultrasound training are encouraged to submit supporting documents that outline the details of their performance within their residency-based ultrasound training program.
- Privileges should be determined with the above training recommendations in mind, in recognition that not all credentials are created equally.
- Documentation of emergency ultrasound should include a note in the patient’s chart that is trackable for review. Major teaching centers are encouraged to make use of image capture technologies.
- Quality assurance and improvement are now routine aspects of clinical practice. In urban/tertiary centres, this means continuous audits of group practice with feedback being provided to both individuals and the department from the site lead. In rural and regional centres where clinicians must balance a wide range of competing demands on time, emergency ultrasound should be included within broader quality improvement programs.
- Leadership will include emergency ultrasound leads (site and/or area) and the Director of Emergency Ultrasound, in collaboration with all members of the Department of Emergency Medicine. These leaders will work collaboratively to support excellence in emergency ultrasound training, clinical care and research.
These standards represent one of many initiatives developed to help ensure high quality training in, and use of, EUS in the province of Saskatchewan.
The USASK experience with logging scans and the EchoLog App