Rib fractures account for a significant number of emergency department visits each year. A patient’s disposition often depends on the severity of rib fractures, comorbidities, and ability to achieve adequate analgesia. We present a 44-year-old male patient with severe pain secondary to rib fractures. The initial disposition was to admit for pain control. However, upon performing a serratus anterior plane block, patient was functionally appropriate for discharge with proper return precautions. Serratus anterior plane block is within the skillset of the emergency physician and can be used to achieve analgesia for rib fractures without the sedative and respiratory depressive effects associated with opioids.

BACKGROUND: Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients. METHODS: This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was crossreferenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented. RESULTS: We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance. CONCLUSION A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

BACKGROUND: Point-of-care ultrasound is an increasingly common imaging modality that is used in a variety of clinical settings. Understanding how to most effectively teach ultrasound is important to ensure that medical students learn pre-clinical content in a manner that promotes retention and clinical competence. We aim to assess the effectiveness of simulation-based ultrasound education in improving medical student competence in physiology in comparison to a traditional didactic ultrasound curriculum. METHODS: Subjects were given a pre and post-test of physiology questions. Subjects were taught various ultrasound techniques via 7 hours of lectures over two days. The control group received 2 additional hours of practice time while the experimental group received 2 hours of case-based simulations. A physiology post-test was administered to all students to complete the two-day course. RESULTS: Totally 115 Swiss medical students were enrolled in our study. The mean pre-course ultrasound exam score was 39.5% for the simulation group and 41.6% for the didactic group (P>0.05). The mean pre-course physiology exam score was 54.1% for the simulation group and 59.3% for the didactic group (P>0.05). The simulation group showed statistically significant improvement on the physiology exam, improving from 54.1% to 75.3% (P<0.01). The didactic group also showed statistically significant improvement on the physiology exam, improving from 59.3% to 70.0% (P<0.01). CONCLUSION Our data indicates that both simulation curriculum and standard didactic curriculum can be used to teach ultrasound. Simulation based training showed statistically significant improvement in physiology learning when compared to standard didactic curriculum.

BACKGROUND: Point-of-care ultrasound has gained widespread use in developing countries due to decreased cost and improved telemedicine capabilities. Ultrasound training, specifically image acquisition skills, is occurring with more frequency in non-medical personnel with varying educational levels in these underdeveloped areas. This study evaluates if students without a high school education can be trained to acquire useful FAST images, and to determine if an 8th grade student can teach peers these skills. METHODS: The 8th grade students at a small middle school were divided into two groups. One group received training by a certified medical sonographer, while the other group received training by a peer 8th grade student trainer who had previously received training by the sonographer. After training, each student was independently tested by scanning the four FAST locations. A blinded ultrasound expert evaluated these images and deemed each image adequate or inadequate for clinical use. RESULTS: Eighty video image clips were obtained. The overall image adequacy rate was 74%. The splenorenal window had the highest rate at 95%, followed by retrovesical at 90%, hepatorenal at 75%, and subxiphoid cardiac at 35%. The adequacy rate of the sonographer-trained group was 78%, while the adequacy rate of the student-trained group was 70%. The difference in image adequacy rate between the two groups was not significant (P-value 0.459). CONCLUSION The majority of 8th graders obtained clinically adequate FAST images after minimal training. Additionally, the student-trained group performed as well as the sonographer-trained group.

BACKGROUND: Dehydration and its associated symptoms are among the most common chief complaints of children in rural Panama. Previous studies have shown that intravascular volume correlates to the ratio of the diameters of the inferior vena cava (IVC) to the aorta (Ao). Our study aims to determine if medical students can detect pediatric dehydration using ultrasound on patients in rural Panama. METHODS: This was a prospective, observational study conducted in the Bocas del Toro region of rural Panama. Children between the ages of 1 to 15 years presenting with diarrhea, vomiting, or parasitic infection were enrolled in the study. Ultrasound measurements of the diameters of the IVC and abdominal aorta were taken to assess for dehydration. RESULTS: A total of 59 patients were enrolled in this study. Twenty-four patients were clinically diagnosed with dehydration and 35 were classified to have normal hydration status. Of the 24 patients with dehydration, half (n=12) of these patients had an IVC/Ao ratio below the American threshold of 0.8. Of the remaining asymptomatic subjects, about half (n=18) of these subjects also had an IVC/Ao ratio below the American threshold of 0.8. CONCLUSION Our study did not support previous literature showing that the IVC/Ao ratio is lower in children with dehydration. It is possible that the American standard for evaluating clinical dehydration is not compatible with the rural pediatric populations of Panama.

BACKGROUND:Diagnostic imaging is an integral aspect of care that is often insufficient, if not altogether absent, in rural and remote regions of low to middle income countries (LMICs) such as Tanzania. The introduction of ultrasound can significantly impact treatment in these countries due to its portability, low cost, safety, and usefulness in various medical assessments. This study reviews the implementation of a four-week ultrasound course administered annually from 2013–2016 in a healthcare professional school in Mwanza, Tanzania by first-year allopathic US medical students. METHODS:Participants (n=582, over 4 years) were recruited from the Tandabui Institute of Health Sciences and Technology to take the ultrasound course. Subjects were predominantly clinical officer students, but other participants included other healthcare professional students, practicing healthcare professionals, and school employees. Data collected includes pre-course examination scores, post-course examination scores, course quiz scores, demographic surveys, and post-course feedback surveys. Data was analyzed using two-tailed t-tests and the single factor analysis of variance (ANOVA). RESULTS:For all participants who completed both the pre- and post-course examinations (n=229, 39.1％ of the total recruited), there was a significant mean improvement in their ultrasound knowledge of 42.5％, P<0.01. CONCLUSION:Our data suggests that trained first-year medical students can effectively teach a point of care ultrasound course to healthcare professional students within four weeks in Tanzania. Future investigation into the level of long-term knowledge retention, impact of ultrasound training on knowledge of human anatomy and diagnostic capabilities, and how expansion of an ultrasound curriculum has impacted access to care in rural Tanzania is warranted.

BACKGROUND:Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama. METHODS:Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral. RESULTS:A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation. CONCLUSION:Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%–93.5%) and specificity of 100% (95%CI 15.8%–100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10–29) and 32 minutes (IQR 19–45), respectively. CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

BACKGROUND:The purpose of this study was to use point-of-care ultrasound (POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery (CCA). The effect of both primary and secondary smoking on CCA properties was evaluated. METHODS:We performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness (CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease. RESULTS: We enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness. CONCLUSION:Our data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confirm the utility of ultrasound findings of cardiovascular disease and stroke.

BACKGROUND: The purpose of this study was to assess the short-term efficacy of a 4-week ultrasound curriculum taught by American first-year medical students to general practitioners working in public health care clinics, or puskesmas, in Bandung, Indonesia. METHODS: We performed a prospective, observational study of Indonesian health care practitioners from public clinics in Bandung, Indonesia. These practitioners were enrolled in a 4-week ultrasound training course taught by first-year American medical students. A total of six sessions were held comprising of 38 ultrasound milestones. A pre-course and post-course written exam and practical exam was taken by each participant. RESULTS: We enrolled 41 clinicians in the course. The average pre-course exam score was 35.2% with a 2.4% pass rate, whereas the average post-course exam score was 82.0% with a 92.7% pass rate. The average practical score at the completion of the course was 83.2% (SD=0.145) with 82.9% of the class passing (score above 75.0%). CONCLUSION: Our data suggests that first-year medical students can effectively teach ultrasound to physicians in Indonesia using a 4-week intensive ultrasound training course. Future studies are needed to determine the amount of training required for proficiency and to evaluate the physicians' perceptions of the student-instructors' depth of knowledge and skil in point of cаre ultrаsound.