Title: Point-of-care ultrasound in Emergency medicine. Is it worth to start educating medical students?
Tytuł: Ultrasonografia point-of-care w medycynie ratunkowej. Czy warto zacząć edukować studentów medycyny?

List of the authors:
Jakub Wiśniewski*‡, Hanna Garnier*, Andrzej Pomiećko*, Bogna Kałaska*

*Students Ultrasonography Association, Department of Paediatrics, Haematology, Oncology and Endocrinology, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland

‡correspondence author
Jakub Wiśniewski
wisniewski.j@gumed.edu.pl

Lista autorów:
Jakub Wiśniewski*‡, Hanna Garnier*, Andrzej Pomiećko*, Bogna Kałaska*

*Studenckie Koło Ultrasonografii przy pracowni Diagnostyki Ultrasonograficznej i Biopsyjnej Kliniki Pediatrii, Hematologii i Onkologii, Gdański Uniwersytet Medyczny, ul. Dębinki 7, 80-211 Gdańsk

‡autor korespondencyjny
Jakub Wiśniewski
wisniewski.j@gumed.edu.pl

Keywords: education, undergraduate, medical students, ultrasonography, FAST
Słowa kluczowe: edukacja, studenci medycyny, ultrasonografia, FAST



Abstract
Introduction:
Ultrasonography thanks to its availability and relatively low cost is a popular diagnostic tool in emergency medicine. A novel sonography education program for medical students of 3rd, 4th and 5th year of studies was performed. The course, focused on sonography in Emergency Medicine, consisted of 2 parts, 20 hours of the theoretical classes and 20 hours of the practical activities, all trained and evaluated by experienced doctors of medicine. The aim of this study was to check possibilities and usefulness of the complex courses dedicated to the medical students.
Materials and methods:
Forty voluntarily enrolled students completed 20-questions test about the theoretical knowledge of ultrasonography before and after the course. Practical skills were examined during the Focus Assessment with Sonography for Trauma (FAST) examination.
Results:
Final test scores were significantly higher (55% before vs 80% after p < 0.01) than in test before the classes. After the course 87,5% of the participants completed a correct FAST scan in under 100 seconds.
Conclusions:
Participants significantly extended their knowledge and practical skills. Integrating basic sonography classes into medical school curriculum should be considered.


Streszczenie:
Wstęp:
Ultrasonografia dzięki łatwej dostępności oraz względnie niskich kosztów staje się szeroko stosowanym narzędziem diagnostycznym w medycynie ratunkowej. Przeprowadzono nowatorski kurs dla studentów III, IV oraz V roku medycyny. Szkolenie skupiające się na zastosowaniu ultrasonografii w medycynie ratunkowej składało się z dwóch części. Pierwsza 20-godzinna część teoretyczna, oraz druga 20-godzinna część praktyczna. Kurs został przeprowadzony przez doświadczonych lekarzy ultrasonografistów. Celem niniejszej pracy jest sprawdzenie przydatności i użyteczności tego rodzaju kursów przeznaczonych dla studentów medycyny.
Materiały i Metody:
40 dobrowolnie zapisanych studentów rozwiązywało test składający się z 20 pytań kontrolnych obejmujących tematykę zastosowania ultrasonografii w medycynie ratunkowej przed oraz po odbyciu kursu. Po odbyciu kursu zmierzono umiejętności praktyczne uczestników podczas badania FAST (Focus Assessment with Sonography for Trauma).
Wyniki:
Wyniki testu po odbyciu kursu były istotnie statystycznie wyższe (55% przed vs 80% po; p< 0.01). Po odbyciu kursu 87,5% uczestników wykonało poprawnie badanie FAST w mniej niż 100 sekund.
Wnioski:
Uczestnicy kursu znacząco poszerzyli swoją wiedzę i umiejętności praktyczne. Włączenie tematycznych kursów ultrasonografii do toku studiów lekarskich powinna być brana pod uwagę przez uczelnie.


Introduction
Ultrasonography as an easy available, cheap, risk-free and non-invasive method is widely used in Emergency Medicine. Therefore it is often called “a modern stethoscope” [1]. The increasing number of ultrasound pilot studies are currently reported. This kind of activities, used as a supplement to gross anatomy courses, can be beneficial even during the first years of studies [2–5]. Moreover, many studies shows that teaching ultrasonography to 3rd, 4th and 5th year students can effectively support and develop their clinical knowledge [6–8]. Ultrasonography use in Emergency Medicine seems to be one of the most important aspects. Only two days (16 hours) of the course are needed to complete a correct Focus Assessment with Sonography for Trauma (FAST) scan [9]
We found that there are no studies about the use of point-of-care ultrasonography [10] in Emergency Medicine. Except of the studies about FAST trainings [11] we have not found any other reports about pilot courses concerning a complex use of the ultrasonography in Emergency Medicine).
We have decided to check if it is possible to teach medical students about theoretical and practical use of the ultrasonography in different aspects of Emergency Medicine in 40 hours. We conducted 6 days course teaching about extended FAST (EFAST), Bedside Lung Ultrasound in Emergency (BLUE; [12]), Focus Assessed Transthoracic Echocardiography (FATE; [13], monitoring of central venous access, ocular ultrasound in trauma [14], sonographic estimation of body fluid status assessment [15]. In this study we would like to present an intensive course point-of-care ultrasound in Emergency Medicine dedicated to the 3rd, 4th and 5th year students of medicine. As we mentioned before, this is the first publicised program training of its kind worldwide.


Methods
First, we divided 40 voluntarily enrolled medicine students of Medical University of Gdańsk (3rd, 4th and 5th year of study) into two 20-persons groups for the theoretical classes. All of the students declared that they have never had any ultrasonography training before. Moreover we did not inform them about the course program. Each group was then divided into 4 teams for practical training. We prepared a comprehensive, 6-days course for the medical students focused on the use of an ultrasound in emergency medicine. The course consisted of 2 parts, 20 hours of the theoretical classes and 20 hours of the practical activities, all trained and evaluated by six experienced doctors of medicine in the Medical University of Gdańsk. Every day, after theoretical classes students were working at cart-based ultrasonography machines such as GE Logiq 7 and Philips: Sparq, ClearView, CX50, iU22.
Before the course started, students were obliged to write a multiple choice test consisting of 20 questions about the use of ultrasound in Emergency Medicine. Eleven questions from the test involved knowledge about EFAST/FAST. The same test was held after the course. We analysed all of the results from both of the tests (pre and post-course) using paired samples t-test of statistical significance at the 0.01 level. Statistical analyses were run using the STATISTICA 10 software (StatSoft Inc, Tulsa, OK).

Results
All forty participants of the course were present in the pre- and final test. The mean final score (80%) was significantly higher (p <0.01) than the mean result before the course (55%). We found that most of the answers for the questions connected with FAST and EFAST were correct irrespective of completed course. After the course a question regarded to sonographic evaluating body fluid incontinence turned out to be the most difficult. After the course 87,5% (35 from 40 students) completed an FAST scan at an adequate level of performance in under 100 seconds.




Conclusions & Discussion
We discovered that our 6 days, intensive, point-of-care ultrasound course in Emergency Medicine, held in Medical University of Gdańsk, turned out to be very effective. As the results show, medical students significantly extended their knowledge about point-of-care Emergency Medicine ultrasound and acquired practical skills during the course. According to that, we can conclude that integrating emergency ultrasonography classes into medical school curriculum should be taken into consideration.
The first test results show that undergraduate participants already had basic knowledge about ultrasonography before the course. We can suspect that they acquired some informations during radiology or emergency medicine classes. It proves that the point-of-care ultrasound courses should be recommended as an additional training which helps to order and supplement the students knowledge. The ultrasound courses for students are not only a practical training, but also a valuable theoretical preparation to make its own diagnostic decisions. It should be noticed that ultrasonography, being cheap and easy-to-use tool, can be also a “modern stethoscope” during everyday ward round. It can have a particular meaning, especially in the places where elder staff has a sceptical opinion about the use of ultrasound in a daily practice. This in turn can contribute to modernization of the hospital departments. Moreover we would like to emphasize that ultrasonography has a broad spectrum of use (such as fast lung diagnostic using the BLUE protocol).
Regardless of numerous reports concerning the usefulness of ultrasonography in different educational stages – from studying anatomy support up to elder medical students education – is still not entered into the curriculum [16]. More studies are needed, especially prospective, describing the effects of integrated ultrasonographic courses on the clinical practice. Medicine as a fast developing science, should pay attention especially to constant actualization of the students curriculum. Thanks to that, young doctors will skilfully use their medical knowledge in the future work.
The idea of the point-of-care ultrasound in Emergency Medicine courses was born thanks to the Students Ultrasonography Association. At present our association has almost three hundred active members. Students can practise on the professional ultrasonography machines in any moment. This increasing interest in ultrasonography among the medical students inspired us to prepare number of courses, similar to the described above. This kind of activity not only fosters the students' interest, but also prepare future doctors to work with the professional ultrasonography equipment. It turned out that a peer-support can be an effective method of education [17,18]. It means that Students Ultrasonography Associations and sonography courses are invaluable introductions to the other similar activities.
“We must use time as a tool, not as a couch”. These well-known words, uttered by John F. Kennedy, have started to have a particular meaning. Emergency department is often the place where young doctors start to make their first, independent decisions. They are frequently responsible for patients lives. As the research shows, ultrasonography can have a significant influence on diagnostic process in every one-fourth patients in the Emergency Department [19]. More than 6% of the patients delivered to the Emergency Departments are diagnosed with pneumothorax [20], which can be confirmed and localized, with the comparable efficacy as Computer Tomography [21], in less than 4 minutes using ultrasound [22]. All of the facts mentioned thereof have a great impact not only on the patients, but also on the doctors, especially those not experienced, who start off their working life.

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