Pediatric Emergency Ultrasound: We’ve Come a Long Way, Baby

My first rotation as a pediatric emergency medicine (PEM) fellow was on the adult trauma service. It was 2006 and in West Philadelphia there was no shortage of patients with gun shot wounds, stabbings, and motor vehicle crashes. The trauma surgeons were hard on the surgery trainees, and generally nice to the PEM fellows. We weren’t training to be surgeons on the front line after all. One attending, however, was indiscriminate in his wrath and unbiased in his intent to humiliate.

dreamstime_xs_59669332A few days into the rotation, during a trauma alert, he chose me: “Jennifer, the FAST, do the FAST!” I was completely puzzled and looked at him blankly. This, of course, made him angrier. “Do the FAST exam!”

Unable to admit at the time that I had never heard of the FAST exam, I remained silent. Seeking to avoid any fear, shame, or humiliation that would certainly accompany future traumas, I immediately read everything I could about it, and the surgery fellows taught me at the bedside.

I returned to the children’s hospital wanting to learn more about ultrasound. Unfortunately, at the time, no one in PEM knew much about it. In fact, none of my colleagues or mentors had any experience with it. I sought guidance from my general emergency medicine colleagues next door who welcomed me and trained me as one of their own.

In time, I proposed a research study in the pediatric emergency department: point-of-care ultrasound for pediatric soft tissue infections. At the time, the radiology faculty weren’t keen on this. They were unaware of non-radiologists using ultrasound and didn’t understand why emergency physicians would need to use it. It was a slippery slope, they argued, and might result in indiscriminate and “unregulated” usage. We compromised–I could use ultrasound in the emergency department solely for research purposes. The machine, literally under lock and key, was off limits to anyone but those involved in the study.

As I found out, my experience was not unique. Many of my PEM colleagues around the country faced similar obstacles from specialists outside of the emergency department. Point-of-care ultrasound at that time was simply not the standard of care.

Nearly a decade later, I practice in a very different climate. Point-of-care ultrasound is a mainstay in my patient care practice; and I now have the support (and collaboration) of my radiology colleagues and others outside of emergency medicine.

More broadly, PEM ultrasound is a recognized subspecialty. Notably:

  • There are approximately 10 dedicated 1-year fellowships in pediatric point-of-care ultrasound.
  • Pediatric point-of-care ultrasound is part of the American Board of Pediatrics core content for pediatric emergency medicine fellowship training, and has been incorporated into the PEM subspecialty board examination.
  • Landmark publications include the American Academy of Pediatrics Policy Statement and Technical Report for PEM point-of-care ultrasound.
  • There is a PEM ultrasound international organization (www.p2network.com).
  • AIUM invited me to write this blog.

We certainly have come a long way.

Do you have a similar ultrasound story? What other areas have come a long way when it comes to ultrasound? What areas are poised to be next? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jennifer R. Marin, MD, MSc, is Director of Emergency Ultrasound in the Division of Pediatric Emergency Medicine as well as Quality Director, Point-of-Care Ultrasound at Children’s Hospital of Pittsburgh of UPMC.

Simulators Role in Ultrasound Training

I believe the future of health care will involve the expanded use of diagnostic ultrasound, which will be accomplished through the use of an enhanced version of today’s handheld ultrasound scanner. I envision this “sono-scope” to be a wireless, lightweight, handheld imaging device with a long battery life and high-quality image capture that will expand the capabilities of the stethoscope.

The compact, portable ultrasoundpedersen_image scanners began entering the medical imaging marketplace around year 2000. Since then the market has grown dramatically, and the portable scanners have bifurcated into two broad groups: (i) The pocket-sized or handheld scanners (HHUS) and (ii) the larger, full-featured point-of-care ultrasound systems (POCUS).

These devices provide doctors with an extension of their senses and augment existing tools. But to be truly transformational, users need to receive ultrasound training from the beginning of their medical career, which will allow them quickly to “rule in” and “rule out” possible diagnoses and lead to earlier treatment decisions and/or more relevant further tests.

I maintain that the main barrier for making the HHUS (and POCUS) every clinician’s examination tool of choice, is not the technology, but rather the lack of opportunity to acquire and develop the needed scanning skills.

Thus, finding training strategies that enable the integration of ultrasound into medical schools is an essential step in overcoming this barrier. If the next generation of doctors had ultrasound for diagnosis and guided procedures as a vital part of their training, they would quickly develop a natural comfort with this tool and, with time, increasing sophistication. A parallel can be drawn regarding the attitude toward acquiring computer skills. As recent as 40 years ago, the operation of computers was thought to be limited to a select, carefully trained group of specialists. Today, nearly everyone is able to operate computers at some level.

Effective training in medical ultrasound requires both clinical knowledge (understanding of anatomy, physiology, and pathology) and scanning skills (psycho-motor skills, which are the integration of motion and the mental processes of recognizing anatomic structures in 3D from the 2D images). While both clinical knowledge and scanning skills are essential, the former is often emphasized at the expense of the latter because clinical knowledge can be delivered cost effectively and in flexible formats through online courses (including MOOCs), self-study, and in traditional classroom courses. Scanning skills, on the other hand, are acquired through hands-on experience, by examining patients, preferably both healthy and with symptoms, under the guidance of an experienced sonographer. Here, the medical educational enterprise does not currently have the capacity to meet this training need. There are too few scanners available for learners to use. There are too few patients or human subjects in general available for scanning. Last but not least, there are too few qualified instructors who can guide the learning.

There exists a potentially effective approach to overcoming this limitation in delivering scanning skills training: The use of ultrasound training simulators. Simulation provides a controlled and safe practice environment to promote learning. The efficacy of the simulator-based training is well-established. For example, human errors related to airline accidents have decreased in large part due to flight simulator training. Likewise, high-fidelity medical simulations have been shown to be educationally effective, as evidenced by the strong correlation between surgical simulator training and improved outcomes. Several studies have demonstrated the learning value of simulator-based training in diagnostic ultrasound.

Just as HHUS and POCUS have proliferated over the last 15 years, so have ultrasound simulator products. Some training simulators cover multiple clinical specialties, while others are designed for a specific application. Typically, the learner scans a physical manikin with a realistic-looking sham transducer, which produces an image on the display corresponding to the position and orientation of the sham transducer on the manikin, along with an anatomy display of the location of the image plane through the body.

An important component of the simulator design is the degree to which the simulator provides structured learning with guidance, interaction, and assessment. While all simulators include educational modules, only a few offer self-paced learning and competence verification. All in all, today’s ultrasound simulators are sophisticated devices that are capable of meeting training needs on basic and even intermediate levels. However, because the purchase price is sufficiently high (from $10K to more than $100K) sonography programs and simulation centers at larger hospitals are typically the only facilities able to acquire this technology.

When the medical community is ready to embrace ultrasound as an imaging modality of first choice for doctors from all specialties, I am convinced that technological innovation will lead to affordable, yet customizable and realistic training simulators. In particular, what is needed are portable and lightweight simulators that run on ordinary, modern PC/laptops, making personal ownership of a simulator possible as well as allowing medical schools to purchase such simulators in large quantities. For individualized training, it is essential that the simulator be task-based and able to verify the acquired skills level. To deliver the best realism, the image material should preferably be acquired directly from human subjects, and to provide the optimal development and assessment of psychomotor skills, the scanning practice on the simulator should resemble actual patient scanning as closely as possible. Such low-cost training simulators can lay the groundwork for building up such ultrasound skills both among practicing specialists and students enrolled in medical schools.

Have you/do you use simulators in your ultrasound training? What are the advantages or disadvantages? What would make simulation training better? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Peder C. Pedersen is Professor of Electrical and Computer Engineering at Worcester Polytechnic Institute.