Assessing how emergency and trauma ultrasonography is taught to medical students

Cruvinel Neto, José; Marcondes, Vinicius Rinaldi Vieira; Ribeiro Junior, Marcelo Augusto Fontenelle

doi:10.31744/einstein_journal/2019AO4469

José Cruvinel Neto

Universidade de Santo Amaro, São Paulo, SP, Brazil.

http://orcid.org/0000-0003-3486-0845

Vinicius Rinaldi Vieira Marcondes

Universidade de Santo Amaro, São Paulo, SP, Brazil.

http://orcid.org/0000-0001-8065-0465

Marcelo Augusto Fontenelle Ribeiro Junior

Hospital São Luiz, São Paulo, SP, Brazil.

http://orcid.org/0000-0003-0247-494X

Corresponding author: José Cruvinel Neto. Rua Prof. Enéas de Siqueira Neto, 340 Jardim das Imbuias Zip code: 04829-300 − São Paulo, SP, Brazil Phone: (55 11) 2141-8555 E-mail: jcruvinel@prof.unisa.br

Conflict of interest: none.

Figures (1)
Tables (5)

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Figure 1
Test grade distribution per quartile. Black, red and blue plots represent pre-course, post-course and 90-day test grades, respectively

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Table 1
Syllabus content

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Table 2
Distribution of responses, by topics of questions

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Table 3
Distribution per selected skills (66 cases)

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Table 4
Results of evaluation questionnaire after class, considering weighted averages from the Likert scale

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Appendix 1 – QUESTIONS 1. As regards the technical aspects of ultrasound, which of the following is incorrect? a) The M-mode is the motion mode. b) The B mode is the most widely used. c) The ultrasound effect is achieved by pulsing a crystal and sending energy waves to the patient. d) In Doppler US, arteries are depicted in red. 2. As regards transducers: a) High frequency transducers are ideal for abdominal cavity assessment. b) The higher the frequency, the lower the tissue-penetrating capability. c) Low frequency transducers are better suited for venipuncture, as the procedure requires low depth penetration. d) Transducers consist of zinc and copper crystals. 3. A patient was admitted after having been hit by a car. Physical examination revealed clear airways, normal breathing sounds, BP 120/80mmHg, HR 86bpm, painful abdomen with no signs of peritonitis and Glasgow 15. The best approach is to: a) Perform FAST. b) Recommend exploratory laparotomy. c) Perform diagnostic peritoneal lavage. d) Request abdominal CT. 4. As regards FAST: a) The procedure should only be carried out on hemodynamically unstable patients. b) The perivesical window is the site of greater fluid accumulation. c) The procedure can be used to define hepatic and splenic injuries. d) The procedure allows detection of free abdominal fluid from 250mL. 5. A patient with a history of fall presents with a penetrating lesion at the level of the 7th left intercostal space. Ultrasound examination reveals lung sliding and negative FAST. What is the next course of action? a) Perform laparoscopy. b) Drain the chest at the level of the fifth intercostal space. c) Request contrast-enhanced abdominal CT. d) Stich the wound and send the patient home with appropriate prescriptions. 6. Choose the correct alternative: a) Detection of lung sliding sign is consistent with pneumothorax. b) A-lines are consistent with pulmonary edema. c) Ultrasound is less sensitive and specific as compared to radiography. d) The lung point is useful in determining the size of the pneumothorax. 7. Patient admitted to ICU with pulmonary source of infection, BP 80/40mmHg, HR 134bpm and receiving noradrenaline 0.8mcg/kg/minute. Bedside US revealed collapsed vena cava, good cardiac contractility and presence of A-lines on lung surface. What is the next course of action? a) Increase noradrenaline dose. b) Start dobutamine. c) Perform crystalloid fluid resuscitation. d) Add vasopressin. 8. Ultrasound-guided vascular puncture: a) Is ideal for peripherally inserted central venous catheter. b) Is not applicable to arterial puncture aimed at invasive arterial pressure monitoring. c) Is limited to the internal jugular vein. d) Has no benefit over conventional punctures. 9. Changes in inferior vena cava diameter: a) Are useful to assess hypovolemia. b) Cannot be used in peritoneal dialysis patients. c) Are reliable in patients under mechanical ventilation with high PEEP. d) None of the above. 10. In which of the following situations would FAST be more sensitive to assess hemoperitoneum? a) Hypotensive patient sustaining blunt abdominal trauma. b) Stab injury patient with evisceration. c) Hemodynamically stable patient with open book pelvic fracture. d) None of the above. ANSWERS 1 D 6 D 2 B 7 C 3 D 8 A 4 D 9 A 5 A 10 A

Description	Category	Hour load (minutes)
Basic aspects of ultrasonography and transducers	Theory session	40
FAST	Theory session	40
Pulmonary ultrasound	Theory session	40
Practical session	Practical session	40
Hemodynamic evaluation - cardiac windows and vena cava	Theory session	40
Guided vascular access	Theory session	20
Practical session	Practical session	40
Case discussion	Interactive session	40
Total		300

Topics of questions	Answers	Tests

		Pre	Post	90-day	p value
		n (%)	n (%)	n (%)
Technical aspects	Wrong	46 (69.7)	6 (9.1)	28 (43.1)	<0.001
	Correct	20 (30.3)	60 (90.9)	37 (56.9)
Technical aspects	Wrong	43 (65.2)	7 (10.6)	19 (29.2)	<0.001
	Correct	23 (34.8)	59 (89.4)	46 (70.8)
Clinical application	Wrong	37 (56.1)	55 (83.3)	50 (76.9)	<0.001
	Correct	29 (43.9)	11 (16.7)	15 (23.1)
FAST	Wrong	36 (54.6)	2 (3.0)	25 (38.5)	<0.001
	Correct	30 (45.4)	64 (97.0)	40 (61.5)
Clinical application	Wrong	48 (72.7)	60 (90.9)	54 (83.1)	0.018
	Correct	18 (27.3)	6 (9.1)	11 (16.9)
Lung	Wrong	62 (93.9)	9 (13.6)	36 (55.4)	<0.001
	Correct	4 (6.1)	57 (86.4)	29 (44.6)
Clinical application	Wrong	22 (33.3)	3 (4.6)	18 (27.7)	<0.001
	Correct	44 (66.7)	63 (95.4)	47 (72.3)
Vascular access	Wrong	16 (24.2)	10 (15.2)	10 (15.4)	<0.001
	Correct	50 (75.8)	56 (84.8)	55 (84.6)
Hemodynamic evaluation	Wrong	14 (21.2)	1 (1.5)	8 (12.3)	<0.001
	Correct	52 (78.8)	65 (98.5)	57 (87.7)
FAST	Wrong	13 (19.7)	6 (9.1)	9 (13.8)
	Correct	53 (80.3)	60 (90.9)	56 (86.2)	<0.001

Practical skill	Concept

	Yes	No
	n (%)	n (%)
Skill I – hepatorenal window	10 (90.9)	1 (9.1)
Skill II – splenorenal window	8 (66.7)	4 (33.3)
Skill III – perivesical window	13 (81.2)	3 (18.8)
Skill IV – pulmonary window	12 (100.0)	0
Skill V – parasternal long-axis window	11 (73.3)	4 (26.7)
Total	54 (81.8)	12 (18.2)

Question	Min-Max	Average
The training time was ideal for acquiring knowledge	2-5	4.06
I acquired basic and technical knowledge of ultrasound	3-5	4.42
I am able to operate an ultrasound machine for bedside evaluation	2-5	3.56
I feel confident in operating an ultrasound machine	2-5	3.33
The course improved my patients’ care	3-5	4.36
Ultrasound training should be part of the undergraduate syllabus	2-5	4.89
I consider a portable ultrasound machine useful in my daily life	1-5	4.52
The course met my expectations	3-5	4.74
The course provided knowledge that is important for my future professional training	3-5	4.68
The course served as motivation to make decisions about my future medical specialty		3.17

[1] Corresponding author: José Cruvinel Neto. Rua Prof. Enéas de Siqueira Neto, 340 Jardim das Imbuias Zip code: 04829-300 − São Paulo, SP, Brazil Phone: (55 11) 2141-8555 E-mail: jcruvinel@prof.unisa.br

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Assessing how emergency and trauma ultrasonography is taught to medical students

ABSTRACT

Objective

Methods

Results

Conclusion