Eric J. Adkins

Integrated medical school ultrasound: development of an ultrasound vertical curriculum

BackgroundPhysician-performed focused ultrasonography is a rapidly growing field with numerous clinical applications. Focused ultrasound is a clinically useful tool with relevant applications across most specialties. Ultrasound technology has outpaced the education, necessitating an early introduction to the technology within the medical education system. There are many challenges to integrating ultrasound into medical education including identifying appropriately trained faculty, access to adequate resources, and appropriate integration into existing medical education curricula. As focused ultrasonography increasingly penetrates academic and community practices, access to ultrasound equipment and trained faculty is improving. However, there has remained the major challenge of determining at which level is integrating ultrasound training within the medical training paradigm most appropriate.MethodsThe Ohio State University College of Medicine has developed a novel vertical curriculum for focused ultrasonography which is concordant with the 4-year medical school curriculum. Given current evidenced-based practices, a curriculum was developed which provides medical students an exposure in focused ultrasonography. The curriculum utilizes focused ultrasonography as a teaching aid for students to gain a more thorough understanding of basic and clinical science within the medical school curriculum. The objectives of the course are to develop student understanding in indications for use, acquisition of images, interpretation of an ultrasound examination, and appropriate decision-making of ultrasound findings.ResultsPreliminary data indicate that a vertical ultrasound curriculum is a feasible and effective means of teaching focused ultrasonography. The foreseeable limitations include faculty skill level and training, initial cost of equipment, and incorporating additional information into an already saturated medical school curriculum.ConclusionsFocused ultrasonography is an evolving concept in medicine. It has been shown to improve education and patient care. The indications for and implementation of focused ultrasound is rapidly expanding in all levels of medicine. The ideal method for teaching ultrasound has yet to be established. The vertical curriculum in ultrasound at The Ohio State University College of Medicine is a novel evidenced-based training regimen at the medical school level which integrates ultrasound training into medical education and serves as a model for future integrated ultrasound curricula.

How we use social media to supplement a novel curriculum in medical education

Background: The millennial learner is reliant on technology to gain knowledge. Social media in the form of Twitter and Facebook provide a unique way to reach these learners. Aims: To demonstrate a supplement to a curriculum using “push technology” via Twitter and Facebook to deliver educational content to mobile devices. Methods: A curriculum consisting of high-yield ultrasound concepts was developed and posted to Twitter @EDUltrasound daily. Followers received tweets “pushed” directly to their mobile devices. Following the year-long program, followers were surveyed regarding the programs effectiveness. To determine the ways in which tweets were reaching users, followers were categorized demographically. Results: Daily “tweets” were posted each morning beginning on July 1, 2010. By the end of the year, there were 87 followers on Twitter and 78 on Facebook. The majority of followers (55.6%) had not previously used Twitter. The majority of followers (88.9%) found Twitter user-friendly, while most (81.5%) found the information useful. Conclusions: Due to ease of use and widespread applicability, Twitter and Facebook are excellent applications of “push technology” as a means to deliver educational content. This pilot project demonstrates the potential of social media to both supplement and enhance traditional educational methods.

Obesity and Acute Lung Injury

Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) are common indications for ICU admission and mechanical ventilation. ALI/ARDS also consumes significant health care resources and is a common cause of death in ICU patients. Obesity produces changes in respiratory system physiology that could affect outcomes for ALI/ARDS patients and their response to treatment. Additionally, the biochemical alterations seen in obese patients, such as increased inflammation and altered metabolism, could affect the risk of developing ALI/ARDS in patients with another risk factor (eg, sepsis). The few studies that have examined the influence of obesity on the outcomes from ALI/ARDS are inconclusive. Furthermore, observed results could be biased by disparities in provided care.

Prospective evaluation of intravascular volume status in critically ill patients: does inferior vena cava collapsibility correlate with central venous pressure?

BACKGROUND In search of a standardized noninvasive assessment of intravascular volume status, we prospectively compared the sonographic inferior vena cava collapsibility index (IVC-CI) and central venous pressures (CVPs). Our goals included the determination of CVP behavior across clinically relevant IVC-CI ranges, examination of unitary behavior of IVC-CI with changes in CVP, and estimation of the effect of positive end-expiratory pressure (PEEP) on the IVC-CI/CVP relationship. METHODS Prospective, observational study was performed in surgical/medical intensive care unit patients between October 2009 and July 2013. Patients underwent repeated sonographic evaluations of IVC-CI. Demographics, illness severity, ventilatory support, CVP, and patient positioning were recorded. Correlations were made between CVP groupings (<7, 7–12, 12–18, 19+) and IVC-CI ranges (<25, 25–49, 50–74, 75+). Comparison of CVP (2-unit quanta) and IVC-CI (5-unit quanta) was performed, followed by assessment of per-unit &Dgr;IVC-CI/&Dgr;CVP behavior as well as examination of the effect of PEEP on the IVC-CI/CVP relationship. RESULTS We analyzed 320 IVC-CI/CVP measurement pairs from 79 patients (mean [SD] age, 55.8 [16.8] years; 64.6% male; mean [SD] Acute Physiology and Chronic Health Evaluation II, 11.7 [6.21]). Continuous data for IVC-CI/CVP correlated poorly (R2 = 0.177, p < 0.01) and were inversely proportional, with CVP less than 7 noted in approximately 10% of the patients for IVC-CIs less than 25% and CVP less than 7 observed in approximately 85% of patients for IVC-CIs greater than or equal to 75%. Median &Dgr;IVC-CI per unit CVP was 3.25%. Most measurements (361 of 320) were collected in mechanically ventilated patients (mean [SD] PEEP, 7.76 [4.11] cm H2O). PEEP-related CVP increase was approximately 2 mm Hg to 2.5 mm Hg for IVC-CIs greater than 60% and approximately 3 mm Hg to 3.5 mm Hg for IVC-CIs less than 30%. PEEP also resulted in lower IVC-CIs at low CVPs, which reversed with increasing CVPs. When IVC-CI was examined across increasing PEEP ranges, we noted an inverse relationship between the two variables, but this failed to reach statistical significance. CONCLUSION IVC-CI and CVP correlate inversely, with each 1 mm Hg of CVP corresponding to 3.3% median &Dgr;IVC-CI. Low IVC-CI (<25%) is consistent with euvolemia/hypervolemia, while IVC-CI greater than 75% suggests intravascular volume depletion. The presence of PEEP results in 2 mm Hg to 3.5 mm Hg of CVP increase across the IVC-CI spectrum and lower collapsibility at low CVPs. Although IVC-CI decreased with increasing degrees of PEEP, this failed to reach statistical significance. While this study represents a step forward in the area of intravascular volume estimation using IVC-CI, our findings must be applied with caution owing to some methodologic limitations. LEVEL OF EVIDENCE Diagnostic study, level III. Prognostic study, level III.

Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET) Quantifying Quality in Ultrasound Imaging

Ultrasound image interpretation and education relies on obtaining a high‐quality ultrasound image; however, no literature exists to date attempting to define a high‐quality ultrasound image. The purpose of this study was to design and perform a pilot reliability study of the Brightness Mode Quality Ultrasound Imaging Examination Technique (B‐QUIET) method for ultrasound quality image assessment.

Trained simulated ultrasound patients: medical students as models, learners, and teachers.

Medical educators must develop ultrasound education programs to ensure that future physicians are prepared to face the changing demands of clinical practice. It can be challenging to find human models for hands‐on scanning sessions. This article outlines an educational model from a large university medical center that uses medical students to fulfill the need for human models.

The ultrasound challenge 2.0: introducing interinstitutional competition in medical student ultrasound education.

The Ultrasound Challenge was developed at The Ohio State University College of Medicine to introduce focused ultrasound to medical students. The goal was to develop experience in ultrasound through practice and competition. Initially this competition was held between Ohio State University College of Medicine students from years 1 through 4. The Ultrasound Challenge 2.0 was held in 2013. The event expanded on the previous structure by including students from the Wayne State University College of Medicine. The goal of this article is to describe our experiences with expansion of our interinstitutional ultrasound event. The challenge consisted of 6 stations: focused assessment with sonography for trauma, aortic ultrasound, cardiac ultrasound, pelvic ultrasound, musculoskeletal ultrasound, and vascular access. The participants were given a handbook outlining the expectations for each station ahead of time. Vascular access was graded in real time using the Brightness Mode Quality Ultrasound Imaging Examination Technique (B‐QUIET) method. The remainder were timed, saved, and graded after the event by 3 independent faculty members using the B‐QUIET method. The highest score with the fastest time was the winner. The Ultrasound Challenge 2.0 included 40 participants: 31 from The Ohio State University College of Medicine and 9 from the Wayne State University College of Medicine. The makeup of the winners in all categories consisted of 1 first‐year medical student, 7 second‐year medical students, 3 third‐year medical students, and 10 fourth‐year medical students. The Ultrasound Challenge 2.0 was a success for those who participated. It provided the first known interinstitutional medical student ultrasound competition. Students from both institutions were able to practice their image acquisition skills, demonstrate abilities in a competitive environment, and develop collegiality and teamwork.

Sonographic evaluation of intravascular volume status: Can internal jugular or femoral vein collapsibility be used in the absence of IVC visualization?

Introduction: Inferior vena cava collapsibility index (IVC-CI) has been shown to correlate with both clinical and invasive assessment of intravascular volume status, but has important limitations such as the requirement for advanced sonographic skills, the degree of difficulty in obtaining those skills, and often challenging visualization of the IVC in the postoperative patient. The current study aims to explore the potential for using femoral (FV) or internal jugular (IJV) vein collapsibility as alternative sonographic options in the absence of adequate IVC visualization. Methods: A prospective, observational study comparing IVC-CI and Fem- and/or IJV-CI was performed in two intensive care units (ICU) between January 2012 and April 2014. Concurrent M-mode measurements of IVC-CI and FV- and/or IJV-CI were collected during each sonographic session. Measurements of IVC were obtained using standard technique. IJV-CI and FV-CI were measured using high-frequency, linear array ultrasound probe placed in the corresponding anatomic areas. Paired data were analyzed using coefficient of correlation/determination and Bland-Altman determination of measurement bias. Results: We performed paired ultrasound examination of IVC-IJV (n = 39) and IVC-FV (n = 22), in 40 patients (mean age 54.1; 40% women). Both FV-CI and IJV-CI scans took less time to complete than IVC-CI scans (both, P < 0.02). Correlations between IVC-CI/FV-CI (R 2 = 0.41) and IVC-CI/IJV-CI (R 2 = 0.38) were weak. There was a mean -3.5% measurement bias between IVC-CI and IJV-CI, with trend toward overestimation for IJV-CI with increasing collapsibility. In contrast, FV-CI underestimated collapsibility by approximately 3.8% across the measured collapsibility range. Conclusion: Despite small measurement biases, correlations between IVC-CI and FV-/IJV-CI are weak. These results indicate that IJ-CI and FV-CI should not be used as a primary intravascular volume assessment tool for clinical decision support in the ICU. The authors propose that IJV-CI and FV-CI be reserved for clinical scenarios where sonographic acquisition of both IVC-CI or subclavian collapsibility are not feasible, especially when trended over time. Sonographers should be aware that IJV-CI tends to overestimate collapsibility when compared to IVC-CI, and FV-CI tends to underestimates collapsibility relative to IVC-CI.

Educating the delivery of bad news in medicine: Preceptorship versus simulation

Simulation experiences have begun to replace traditional education models of teaching the skill of bad news delivery in medical education. The tiered apprenticeship model of medical education emphasizes experiential learning. Studies have described a lack of support in bad news delivery and inadequacy of training in this important clinical skill as well as poor familial comprehension and dissatisfaction on the part of physicians in training regarding the resident delivery of bad news. Many residency training programs lacked a formalized training curriculum in the delivery of bad news. Simulation teaching experiences may address these noted clinical deficits in the delivery of bad news to patients and their families. Unique experiences can be role-played with this educational technique to simulate perceived learner deficits. A variety of scenarios can be constructed within the framework of the simulation training method to address specific cultural and religious responses to bad news in the medical setting. Even potentially explosive and violent scenarios can be role-played in order to prepare physicians for these rare and difficult situations. While simulation experiences cannot supplant the model of positive, real-life clinical teaching in the delivery of bad news, simulation of clinical scenarios with scripting, self-reflection, and peer-to-peer feedback can be powerful educational tools. Simulation training can help to develop the skills needed to effectively and empathetically deliver bad news to patients and families in medical practice.

Cultural Transformation After Implementation of Crew Resource Management: Is It Really Possible?

Crew resource management (CRM) has the potential to improve safety culture and reduce patient safety errors across different hospitals and inherent cultures, but hospital-wide implementations have not been studied. The authors examined the impact of a systematic CRM implementation across 8 departments spanning 3 hospitals and 2 campuses. The Hospital Survey on Patient Safety Culture (HSOPS) was administered electronically to all employees before CRM implementation and about 2 years after; changes in percent positive composite scores were compared in pre-post analyses. Across all respondents, there was a statistically significant increase in composite score for 10 of the 12 HSOPS dimensions (P < .05). These significant results persisted across the 8 departments studied and among both practitioners and staff. Consideration of score changes across dimensions reveals that the teamwork and communication dimensions of patient safety culture may be more highly influenced by CRM training than supervisor and management dimensions.