SAMPLE POCUS (POINT OF CARE ULTRASOUND) USES THROUGHOUT CURRICULUM

The following examples are suggested uses from a few programs curriculum. This is not meant as a formal syllabus or curriculum. There is variance of how each program approaches integrating ultrasound as there is no standardized curriculum structure. Use these examples for ideas on how and where to integrate into your own program. The example below as a policy on incidental findings is Important to incorporate into the syllabus and inform students.

Incidental Findings It is possible that during a student’s course of study, incidental medical findings may be noted. These incidental findings may include previously known or previously unknown pathological findings or normal variants. These discoveries may occur in physical examination, point of care ultrasound, or laboratory sessions, among other educational settings. When an incidental finding is noted, faculty should maintain confidentiality and instruct the student to follow up with his/her primary care provider, student health, or emergency services, as indicated for diagnosis and consideration of management. It is important to note that the UNC-CH PA Program Faculty, the Program Director and the Medical Director are not allowed to provide the student medical care or access to the student’s health records unless in the event of an emergency but may facilitate referrals to health facilities. CURRICULAR EXAMPLE #1 POCUS training will be integrated as an adjunct to courses throughout the PA program to introduce students to ultrasound principles, techniques and interpretation to advance patient care. Through online modules, classroom lectures and hands-on labs students will become knowledgeable of the benefits and uses of a focused ultrasound examination to assist in medical decision-making. The skills learned in this curriculum in no way replaces the need to consult radiology for a comprehensive ultrasound examination. This integration of US throughout the curriculum is meant to provide the students with familiarity and confidence with ultrasound principles and is not expected to develop competency. Learning Objectives: 1. Know the indications, limitations and benefits of POCUS 2. Understand anatomy, physiologic principles and pathology using POCUS 3. Demonstrate ultrasound techniques to guide medical decision-making 4. Learn image acquisition to record and archive 5. Communicate and document preliminary findings to patients and medical personnel Course development Train the trainers for faculty development Integrate throughout all curriculum Introduce US lectures/labs into relevant courses US rounds with ICU PA’s (Didactic: Summer A / Clinical: Optional Thursdays/Friday clinical days back) Develop US focused clinical rotations

Course Work/Objectives/Labs:

All image acquisition will be evaluated based on the following criteria: o Can the organ and anatomy of interest be identified? o Is the proper transducer being used with the correct indicator orientation? o Was the image obtained at the proper depth, gain, and frequency? o Were the correct measurements taken? o Were the correct applications used?

GROSS ANATOMY AND RADIOGRAPHIC ANATOMY

Lecture: Physics, Basic instrumentation and knobology/ Image orientation

Understand physics of ultrasound

Describe the layout of the ultrasound system in terms of button location and functionality

Understand the concepts of frequency, depth, and gain effect on the image.

Recognize artifacts of low attenuation, high attenuation, refraction, reverberation and mirror image.

Be able to identify which transducer is best to be used in respect to exam.

Describe the orientation of the transducer with respect to the image on the screen.

Demonstrate basic skills of using the probes

Apply basic scanning skills to identify anatomical structures

LAB: Small group introductory ultrasound session to understand knobology and basic scanning

techniques

Ultrasound Basics Lab Worksheet – 3-5 machines/ 5-6 per machine for 1 hour

Scan cadavers for specific anatomical structures

INTRODUCTION TO MEDICINE Cardiology

Visualize heart sounds

Visualize Murmurs and how they relate to the cardiac cycle

Identify cardiac anatomy

Understand cardiac physiology

Identify cardiac images used

LAB: Cardiac Bedside echo

Obtain subcostal, parasternal long, parasternal short, and apical 4-chamber views of the heart.

Trace the pericardium in all four views of the heart Identify the mitral valve, tricuspid valve, and

aortic valve Identify the descending aorta in parasternal long axis. Parasternal Long Axis (PSL)

Activate the cardiac software setting

Choose the correct transducer to image the heart in the parasternal long axis

Place the patient in the correct position to obtain a PSL view

Aim the indictor in the correct direction

Demonstrate the RV, LV, LA, Mitral and Aortic valves

Appreciate the contractility of the LV and measure LVOT diameter

Verify how the anterior septal leaflet of the mitral valve contacts the septum (EPSS)

Parasternal Short Axis (PSS)

Aim the indictor in the correct direction to obtain a PSS view

Demonstrate the aortic valve, mitral valve, and papillary muscles

Identify the LV and the RV Apical Four Chamber (A4C)

Aim the indicator to the correct position to obtain A4C

Trace the LV, RV, LA, RA and identify the septum

Appreciate the chamber size differences (RV 2/3 of LV)

Apical “fifth” Chamber (A5C) o From A4C, tilt transducer anteriorly to obtain A5C

Activate pulsed wave Doppler over Aortic valve and note the cardiac output Sub-Costal View (SC)

Aim the indictor in the correct direction to obtain SC view and instruct patient to inhale deeply while flattening out transducer

Identify the RA, LA, RV, LV

Trace the pericardium

LAB: Heart sounds and ECHO (laboratory) Students work in pairs – one captures PLAX view

showing both the aortic valve and mitral valve while other student listens with stethoscope and

notes relationship of heart sounds and valve closure. Students then reverse roles. Students

relate the heart sounds to the cardiac cycle, as well as study physical principles like HOCM, PMI,

LVH, valvular physiology, diastolic and systolic failure.

Vascular- Aortic scan for AAA

Chooses appropriate ultrasound transducer

Identifies aorta, associated inferior vena cava and surrounding local anatomy via compression and/or color flow or pulse wave Doppler

Identifies Transverse proximal aorta view obtained with appropriate depth and gain to visualize celiac trunk or superior mesenteric artery and vertebral stripe

Identifies Transverse middle aorta view obtained with appropriate depth and gain to visualize superior mesenteric artery, left renal vein, splenic vein and spinal stripe

Identifies Transverse distal aorta view obtained with appropriate depth and gain to visualize aortic bifurcation.

Longitudinal view of aorta obtained moving the transducer from superior to inferior, visualizing celiac trunk, SMA and spinal stripe

Identifies abdominal aortic aneurysm or normal aortic diameter.

Performs a caliper measurement of each anatomic area from the outer wall to the outer wall of the vessel in anterior-posterior and transverse planes.

Identifies the aorta and vena cava, their relationship to each other and the bifurcation of the vessels at the umbilicus.

Vascular- DVT screen

Understands the progression of thrombotic disease as it relates to superficial phlebitis, which vessels are deep vessels and their paired arteries, and the difference between proximal and distal DVTs.

Two point compression for DVT (Can also be done during surgery section) Vascular- Neck Ultrasound

Carotid artery – B-mode and color flow mode

Trace from common carotid to bifurcation, transverse and longitudinal views, basic principles of color flow Doppler of Internal jugular vein; anatomic differences of internal jugular vein and carotid artery, shape, vessel wall, collapsibility

Perform valsalva to note changes

Pulmonology

Demonstrate the windows necessary to view the lung fields in their entirety.

Identify the pleural line in its location between each rib level.

Appreciate the diaphragmatic excursion using coronal planes.

Locate the cupula of the lung and the proximity to the subclavian vein. LAB: Lung Lung- PNEUMOTHORAX

Choose the correct transducer to assess for pneumothorax

Place the patient in the correct position to assess for pneumothorax, on most anterior portion of chest wall and how free air, free fluids and organs in the thorax behave.

Identify bilateral lung sliding in 2D and M-Mode

Describe “ants marching” and “sky-ocean-beach” , “bar code sign”

Demonstrate m-mode tracing. Lung- PLEURAL EFFUSION

Choose the correct transducer to assess for pleural effusion

Place the patient in the correct position to assess for pleural effusion

Identify the diaphragm and the mirror image artifact. Lung- PULMONARY EDEMA

Choose the correct transducer to assess for pulmonary edema

Demonstrate the 8 locations (4 per chest)

Identify A-lines in these locations Lung- PNEUMONIA

Choose the correct transducer to assess for pneumonia

Place the patient in the correct position

Identify the locations of the transducer needed to assess for pneumonia

Understand the exact location of the diaphragm, the lung tissue and the retroperitoneal space.

Place the transducer in the suprasternal notch, identify the esophagus and it's relationship to the trachea. Swallow water to view the esophagus

Identify the cricothyroid cartilage with ultrasound. Use cadavers to practice surgical airway.

Understands the relationship of fluid resuscitation and the vena cava- as this relates to sepsis, pulmonary edema, and the different types of shock.

Venous return Curve- The student is able to visualize the physiology of the diaphragm lowering during deep inspiration, lowering the thoracic pressure and allowing air to fill the lungs and heart. Downward pressure of the diaphragm on the abdominal organs increases intraabdominal pressure, which results in decreased venous return (Valsalva) and engourges the vena cava an the vessels of the neck. Breathing out causes a collapse of the vena cava.

Understanding the caval index. Gastroenterology

Image the Right and left upper quadrants (laboratory session). Obtain images of and identify: Liver, gall

bladder, duodenum, right/left kidney, Morison’s pouch, diaphragm, and right costophrenic angle – B-

mode

LAB: GI physiology

Trace the liver as it lies under the skin.

Appreciate the gallbladder in its position within the main interlobar fissure of the liver.

Understand the anatomy of the portal triad and utilize color Doppler to enhance visualization.

Identify and trace the spleen.

View the proximal esophagus adjacent to the trachea and observe saliva and air during swallowing. Turn model to right lateral decubitus and eat, drink water and carbonated soda to identify the gastric antrum, pylorus, and see effects of air in stomach.

Perform "mowing the lawn" compression technique to observe intestinal loops. Gall Bladder

Choose the correct transducer to assess the hepatobiliary system

Place the patient in the correct position to assess the hepatobiliary system

Demonstrate the gallbladder in long and short axis using both approaches: o SubcostalSweep o X minus 7 technique

Demonstrate the portal vein, hepatic veins, and IVC

Measure the common bile duct

Measure the long and short axis of the spleen

Choose the correct transducer to assess the intestinal system

Demonstrate the esophagus and observe saliva being swallowed

Demonstrate compression of the abdominal wall musculature down to psoas muscle in an effort to visualize the appendix

Understand the relationship of the large colon, the cecum the iliac vessels, the psoas and McBurney's Point, as it relates to the variable anatomy of the appendix.

Infectious Disease

FASH exam for HIV, lymph node evaluation, cellulitis vs abscess, Necrotizing Fasciitis, Pediatrics Discussion on how ultrasound relates to the following disease process:

Pneumonia-POCUS has a much higher sensitivity for PNA (95%) than the CXR (47%).

Pyloric Stenosis-gold standard

Intussusception-gold standard

Bowel obstruction-higher sensitivity (92%) vs. xray (45%)

Appendicitis-standard in pediatrics

Septic joint Neurology Use ultrasound to identify proper patient positioning and indications for nerve blocks. Should be aware of nervous distribution in order to select the correct block. Complete pre-block motor and sensory documentation for:

Radial Nerve

Ulnar Nerve

Median Nerve

Axillary and Musculocutaneous Block

Scalene/Brachial Plexus

Superficial Cervical Plexus

Suprascapular and axillary Nerve

Serratus Block

Femoral Nerve/Iliacus Block

Penile Block

Sciatic popliteal Block

Tibial Nerve

Fibular nerve block

Dental / ENT / Ophthalmology

Demonstrate the anterior segment of the eye, differentiating lens from iris

Demonstrate the posterior segment of the eye locating the optic nerve sheath Ultrasound

measurement of optic nerve sheath diameter for assessment of increased intracranial pressure

Ultrasound assessment of direct and consensual pupillary light reflex

Ultrasound assessment of ocular movement for patients with marked orbital swelling, Retinal detachment, FB, lens dislocation, vitreous hemorrhage, retro bulbar hematoma.

Lab: Ocular US (bring in faculty to perform)

Hematology / Oncology

Evaluation of lymph nodes.

Lab: DVT recognition (Advanced lab for PDX or ACP) Endocrinology

Lab: Thyroid gland – B-mode; thyroid (both lobes and isthmus); echotexture, nodules, cysts, measurements, label structures, thyroid lobe volume estimation

Obstetrics/ Gynecology

Evaluation of first trimester pregnancy and VB, to rule in ectopic pregnancy.

Transvaginal ultrasound to evaluate the menstrual cycle, ovarian cysts, ovarian torsion. Evaluate the types of miscarriage-Missed, spontaneous, septic, incomplete, threatened.

Urology / Nephrology

Kidney and bladder ultrasound (laboratory session) Hydronephrosis, Urinary bladder – B-mode;

identify bladder, measure bladder volume, note artifacts like posterior acoustic enhancement

Ureteric jets – Color flow mode; test of total ureteric obstruction.

Testicular torsion, as well as varicocele, hydrocele, epididymitis, orchitis,

Medical Management of the Surgical Patient Two point compression to Evaluate for DVT, Pleural effusion Orthopedics LAB

o knee – B-mode, and the appearance of muscle, tendon, fat, and bone. o Hand- B-mode, Demonstrate median nerve as separate from flexor tendons

In long axis of wrist identify distal radius, lunate, and capitate bones Identify the pulley system of the digits and observe their function under the

long axis o Identify supracondylar/radial head fractures in pediatric patients and how this relates to

the anterior fat pad/sail sign on xray. o Place linear transducer in transverse view of the olecranon fossa, ultrasound image of

the "overflowing cup" sign. o AC separation o Sternal fracture o Pelvic fracture o Shoulder dislocation o Hip effusion and pediatric patient

Soft tissue

Soft tissue ultrasound for abscess (fluid consolidation) vs cellulitis (cobble stoning).

Emergency Medicine Clinical protocols POCUS clinical protocols are systematic exams that serve as an adjunct to improve diagnostic acumen. Clinical protocols do NOT substitute for an appropriate history, physical exam, or other tests, such as ECG, blood tests, and other appropriate radiographic modalities.

FAST/E-FAST: Focused assessment with sonography for trauma

RUSH: Rapid ultrasound for shock and hypotension

BLUE: Bedside lung ultrasound in emergency

CLUE: Cardiac limited ultrasound exam

FEEDS criteria for OB/GYN

CLINICAL PROCEDURES

Line insertion (IV, central, etc..), Lumbar puncture, surgical airway, shoulder dislocation, Joint aspiration CLINICAL YEAR

Incorporate more simulation as well as develop online site.

Simulation skills OSCE to include US / suturing / IV access

Consider rotation specific experiences to reinforce US skills: Critical care US rotation (Shands) ER- US rotation Shands

Utilize electives to develop US skills (possible certification)

US rounds with the ICU PA’s – also brief introduction to the ICU, what to expect when on rotations.

CURRICULAR EXAMPLE #2 This is a comprehensive rotation composed of a four week rotation of Ultrasound in the Emergency Department.

GOALS o Describe the principles of ultrasonography (US) o Describe the application of the Focused Abdominal Sonographic Examination

(FAST) in assessing trauma patients

o Describe the application of ultrasonography in assessing first-trimester pregnancies

OBJECTIVES o Describe the fundamentals of ultrasonography o Describe the primary indications for ultrasonography studies in the

Emergency Department

o Incorporate bedside ultrasonography to patient care in the Emergency Department

IMPLEMENTATION o Clinical rotations –complete a four-week rotation through the Emergency

Department. Duties will be coordinated by the rotation preceptor. o Lectures – There will be formal lectures on ultrasonography methodology for

Focused Abdominal Sonographic Examinations (FAST) by Staff Emergency Medicine Physicians. During the academic year, there will be formal Ultrasound Conferences hosted by the Ultrasound Department.

o Procedure laboratory – Monthly procedure labs will be conducted emphasizing skills required.

Reading assignments – Emergency Medicine A Comprehensive Study Guide Seventh ed., Section Twenty-seven pages 1865-1890.

The Ultrasound of Emergency Medicine Fourth ed. Selected journal articles will be given to each resident to compliment the objectives.

Ultrasound Competency

ROTATION REQUIREMENTS (must complete and initial all sections)

1) Complete required reading.

Required Reading Initials

Manual of Emergency and Critical Care Ultrasound (Noble)

2) Complete modules on www.learn.emsono.com. Your login and password will be emailed to you separately. Click on “My courses,” “Residents,” and “Resident Sonobridge Curriculum.” Requires a download of latest Adobe Flash player and a high-speed Internet connection (best to do at home).

3) Perform a single proctored ultrasound exam with the US faculty or fellow sometime in the first week. The US fellow should provide you with a faculty/fellow schedule. This is where we demonstrate what your exams should look like.

Proctored Exam Initials

EFAST

Aorta

RUQ

Renal

DVT

Cardiac

Pelvic

Ocular

Vascular access

Soft tissue/MSK

Lung

4) Complete 15 Scanning Shifts. Three of your scanning shifts will be for 3 hours after Grand Rounds. Note, if you take 6-7 days of leave, you will only be responsible for 12 scanning shifts. Just denote “Leave” on the grid below for those dates and initial.

5) Attend and participate in four quality assurance sessions and one ultrasound specific journal club.

6) Complete total number of ultrasound examinations as required by the ED Ultrasound faculty utilizing all ACEP core applications (technically limited studies will not count towards total).

7) Pass the US Rotation Competency Assessment (OSCE) with a score of 80% or higher.

8) Create from scratch and deliver a 15-minute ultrasound presentation to the US faculty in

PowerPoint. You will choose the topic. It must be Grand Rounds level quality; if it is not, you will be required to redo it. You will most likely be “pimped” by the ultrasound faculty (so know the ultrasound application you are discussing inside and out). You must include multiple ultrasound images in your talk, and the format should generally be as follows:

a. Goals and Objectives b. Begin with a case c. Discuss indications for the ultrasound

d. Describe proper technique e. Review the limitations/pitfalls

f. Discuss ultrasound findings (normal versus pathology) g. Brief literature review of topic (landmark articles) h. Return to your case (what happened and what was the role of ultrasound)

i. Summary/conclusions

j. Close with 5 Challenging Quiz Questions that pertain to your topic

9) Procedure Minimum Number

Trauma(E-FAST) 25

Aorta/AAA 25

RUQ/Biliary 25

Renal/Urinary Tract 25

DVT (each leg counts for 1) 25

Cardiac (with IVC) 25

Pelvic (Use blue phantoms on US rotation) 25

Ocular 25

Vascular Access/Procedural Guidance (on blue

phantoms)

25

Soft tissue/MSK (examples may include abscess, tendons, joint effusion, long bones,

airway/trachea, muscles, nerves)

25

Lung (pneumothorax, pleural effusions, B- lines, pneumonia)

25

CURRICULAR EXAMPLE #3

Year 1: Anatomy Lab Students are shown US images of relevant structures 7 hours to augment their understanding of the structures they learning in that section. They also scan these structures as a first exposure to POCUS. Medical Imaging Introduction to POCUS 2 hours Course This lecture presents the concept of POCUS as an adjunct to physical exam and clearly distinguishes POCUS from traditional US. It also emphasizes the importance of using this new tool to decrease time-to-treatment intervals, reduce costs, and improve outcomes.

Clinical Procedures Basic POCUS Hands-On Skills Course 18 hours And Surgical Skills (CPSS) Goal: To provide the first year PA students with a basic introduction to POCUS exams and hands on instruction in preparation for their clinical rotation year. Objectives: Upon completion of this basic course, the students should be able to: Ultrasound Physics and Useful Artifacts: Demonstrate a working knowledge of rudimentary ultrasound physics and artifacts necessary to acquire and interpret useful images. Instrumentation: Demonstrate knowledge of the basic ultrasound machine keyboard and probes for interpretable image acquisition. POCUS Indications: Demonstrate knowledge of the indications for each POCUS exam learned in this course. Image Acquisition: Demonstrate competence in obtaining interpretable POCUS images. Image Interpretation: Demonstrate knowledge of normal and abnormal POCUS images in order to make useful medical decisions. Pre-class Required Reading and Videos: There will be POCUS exam presentation packets with videos and reading assignments that you must complete prior to each class in order to assure maximal scanning time. These assignments present the evidence supporting POCUS for the particular exams, a brief review of the anatomy, normal sonographic characteristics, scanning protocols and, sonographic findings of pathology. Each POCUS exam packet contains a video demonstrating the exam that follows the protocol section of the packet. PLEASE WATCH THESE VIDEOS. These videos are also listed separately in the assignment section for each class for your convenience. Recommended Texts: Soni NJ, Arntfield R, Kory Pierre. Point-of-Care Ultrasound. Philadelphia, PA: Elsevier Saunders; 2015. Hofer M. Ultrasound Teaching Manual: The Basics of Performing and Interpreting Ultrasound Scans. 3rd ed. Stuttgart, Germany: Thieme Publishers; 2013. Session 1: Basic Ultrasound Physics, Knobology, and Probe Techniques (4 hours) Please read the reading assignments prior to class to allow for more scanning time. Bahner DP, Blickendorf M, Bockbrader M, et al. Language of transducer Manipulation: codifying terms of effective learning. J Ultrasound Med 2016; 34:183-188. Soni NJ, Arntfield R, Kory Pierre. Point-of-Care Ultrasound. Philadelphia, PA: Elsevier Saunders; 2015. Chapters 2- 6 pp. 9-45. No videos for this class

8:00 – 8:45 Pretest and Pre-Course Survey 8:45 – 10:30 Hands-on Basic Scanning Techniques: Cardinal Transducer Movements, and Optimizing

Movements. Live scanning Internal Jugular Vein using the Cardinal Transducer Movements

10:30 -11:00 Break 11:00 – 12:00 Ultrasound Physics and Artifacts Knobology 12:00 – 12:30 Image Interpretation Session 2: Cardiac and Abdominopelvic Ultrasound (4 hours) Please read the reading assignments and watch the videos prior to class to allow for more scanning time. 1. POCUS exam packets on kidney/bladder, pelvic ultrasound, basic heart, and the FAST exam 2. Videos: Kidney/Bladder https://youtu.be/p5Wot8Llqnc Uterus https://youtu.be/gh_bwPjqQpg Basic Heart https://youtu.be/3GdCGLFjHzM FAST Exam https://youtu.be/9vGklwzixko 8:00 – 9:00 Kidney/Bladder Ultrasound 9:00 – 9:30 Pelvic Ultrasound (Uterus, IUP) 9:30 – 10:30 Basic Heart (PSLAX, PSAX, Sub-xiphoid, A4C) 10:30 – 11:00 Break 11:00 – 12:00 FAST Exam 12:00 – 12:30 Image Interpretation Session 3: Gallbladder, Lung, and Vascular Ultrasound (4 hours) Please read the reading assignments and watch the videos prior to class to allow for more scanning time. 1. POCUS exam packets on Lung ultrasound, DVT, and Aorta 2. Videos: Lung https://youtu.be/zER3QR9uXUk DVT https://youtu.be/ZH_fy1XVkgw Aorta https://youtu.be/rOmbOpLzLdw 8:00 – 9:30 Gallbladder and Lung Ultrasound 9:30 – 11:00 Vascular: DVT Scan + Phantom 11:30 – 11:30 Break 11:30 – 12:00 Aorta Scan and IVC 12:00 – 12:30 Image Interpretation Session 4: Soft-Tissues and Procedures (6 hours) Please read the reading assignments prior to class to allow for more scanning time. 1. POCUS exam packets on Soft-tissues and Procedures 2. Krackov R, Rizzolo D. Real-time ultrasound-guided thoracentesis. JAAPA 2017; 30(4):32-37. 3. Dietrich CF, Lorentzen T, Appelbaum L, et al. Ultrasound-Guided Paracentesis. In: EFSUMB Guidelines on interventional ultrasound (INVUS), Part III- Abdominal treatment procedures (Long version) Ultraschall Med 2016;37(1):E1-E32 4. Videos: Soft Tissues https://youtu.be/AVE2tfgpO40

Ultrasound-Guided Central Venous Access https://youtu.be/5ZGHBjVQD9Y Ultrasound-Guided Thoracenstesis https://youtu.be/ukg0r9TSYFk Ultrasound-Guided Paracentesis https://youtu.be/bWxv_a9CkBs 8:00 – 9:30 Soft-Tissue/Abscess vs Cellulitis; Identification of Muscle, Tendons, and Nerves 9:30 – 10:00 Break 10:00 – 12:00 Procedures: Seldinger Technique for Line Placement, Paracentesis, Thoracentesis, 12:00 – 12:30 Post-test/Post-Course Survey 1:00 – 3:00 Shark SonoSlam POCUS Competition Students break into teams and compete in 3 rounds. The winning team goes on to compete in AAPA Yes iScan national competition Year 2: End of Rotation Students return from rotations and learn the 3 remaining major POCUS

protocols. They learn eFAST in the basic skills course. Students practice these protocols through clinical scenarios and scanning sessions.

EOR 3 BLUE Protocol for Acute Decompensated Dyspnea 3 hours EOR 5 RUSH Protocol for Acute Decompensated Hypotension 3 hours EOR 6 CASA Protocol for Cardiac Arrest 3 hours EOR 8 Mass Casualty Incident Simulation 2 hours

Students go to a mass casualty simulation center participate in a mock MCI. They are expected to use POCUS where indicated to diagnose

and treat trauma patients. All 4 protocols are used. Total POCUS Hours 38 hours Faculty Training Program Part of the POCUS initiative requires that faculty at each campus be trained. The POCUS initiative Director is a Registered Sonographer as well as a certified PA. The Director is responsible for devising and implementing the faculty training program. The POCUS Director will co-teach with the US coordinators and other faculty at each campus until they feel confident with their scanning and teaching abilities. To date there has been one 8-hour Faculty POCUS boot camp and several online lectures written specifically for these faculty members focusing on US physics, artifacts, instrumentation, and image interpretation. Individual faculty hands-on sessions will take place at each campus on a quarterly basis as well as masterclasses focusing on the more difficult exams such as MSK and Echo. The masterclasses will be taught by experienced sonographers. Once confident with their hands-on skills, each faculty member will submit a series of POCUS images representative of the common POCUS exams performed by PAs to our in-house radiologist for quality assessment. Each faculty member will also be trained in POCUS image interpretation. Voice over presentations with POCUS images will be sent to each faculty member quarterly. After completing these sessions, they will take an image review exam which is sent to our in-house radiologist for review.

CURRICULAR EXAMPLE #4

Ultrasound integration in this program has been mostly limited to one course, Procedural

Skills. To extend integration an introductory lecture was given in the radiology course the

preceding semester, but all hands-on practice was still in the procedures course.

Procedural Skills and Special Populations Ultrasound Schedule

Week 1 Monday:

11 am – 12:30 pm – Lecture: Ultrasound Review, DVT and Aorta

1 pm – 4 pm – Ultrasound Lab Wednesday:

10 am – 12 pm – Lecture: Ultrasound of Gallbladder, Kidneys and Bladder

1 pm – 4 pm – Lab: Ultrasound of Gallbladder, Kidneys and Bladder Week 2 Wednesday:

10 am – 12 pm – Lecture: Ultrasound of Heart, Lungs and IVC

1 pm – 4 pm – Lab: Ultrasound of Heart, Lungs and IVC

Week 3 Wednesday:

10 am – 12 pm – Lecture: Ultrasound of the Eyes, Neck and Musculoskeletal System

12:30 pm – 4 pm – Lab: Ultrasound of the Eyes, Neck and Musculoskeletal System Week 4 Monday:

12:30 pm – 4 pm – Lecture/Lab: FAST and RUSH Examinations Friday:

1 pm – 2 pm – Exam #1 Week 5

Ultrasound is utilized in lab during IV/Central Line practice

Students attend a fetal ultrasound lab where they scan a patient in her 2nd trimester

Week 6

Ultrasound is utilized for esophagus vs. trachea identification during intubation lab

Students give an ultrasound demonstration to our undergraduate pre-PA students Week 7

Ultrasound is utilized in lab covering LPs, Pericardiocentesis, Thoracentesis, Paracentesis, Chest Tubes

Week 8

Ultrasound is utilized for bladder volume during foley catheter lab Week 11

Students give an ultrasound demonstration during an IPE session with our speech language pathology students

Week 12

Ultrasound use is discussed for cellulitis vs. abscess during our I&D lecture/lab Week 14 Wednesday:

1 pm – 3 pm – Arterial Lines and ABGs Lecture Objectives – Ultrasound Related Objectives

1. LPs, Pericardiocentesis, Thoracentesis, Paracentesis, Chest Tubes a. Understand the indications, contraindications and complications of lumbar puncture,

pericardiocentesis, thoracentesis, paracentesis and chest tubes b. Describe the anatomical considerations in performing the above procedures, including

use of ultrasound for landmark identification

2. Venipuncture, IVs and Central Lines a. Recognize the indications for use of ultrasound in placement of peripheral and central

3. Airway Basics and Intubation a. Perform the following skills: endotracheal intubation, identification of esophagus vs.

trachea on ultrasound 4. Ultrasound

a. Understand the physics and “knobology” of commonly used ultrasound systems, including image optimization and hand control

b. Perform abdominal ultrasound with the recognition of normal anatomy and common emergent pathology of the aorta, gallbladder, kidneys and bladder

c. Perform lower extremity venous ultrasound with the recognition of normal anatomy and the evaluation of suspected DVT

d. Perform focused cardiac ultrasound with attention to global systolic function, chamber size and the findings associated with pericardial effusion and tamponade

e. Perform focused lung ultrasound with recognition of the findings of pneumothorax f. Understand the principles associated with ultrasound guidance in central and peripheral

venous access, foreign body identification and removal and abscess drainage g. Perform ultrasound of the eye, neck and musculoskeletal system h. Integrate ultrasound into the care of the critical patient with focus on FAST and RUSH

examinations 5. Foley Catheter Placement

a. Understand the basics of bladder ultrasound for volume assessment 6. Casting and Splinting

a. Describe the indications, contraindications, complications and basic anatomical landmarks for arthrocentesis

7. Incision and Drainage, Biopsies and Cryosurgery a. Identify the sonographic appearance of abscess versus cellulitis

CURRICULAR EXAMPLE #5 Point of Care Ultrasound (POCUS) Anatomy Lab Integration Curriculum Introduction: As the use of point-of care ultrasound (POCUS) is increasing among medical and surgical specialties, a growing need for clinicians to gain exposure to this clinical tool in their pre-clinical phase of education has been identified. Furthermore, POCUS has been demonstrated its value as a tool to augment learning human anatomy when paired with a robust traditional anatomy education curriculum. POCUS has been successfully integrated into anatomy lab sessions at medical schools, however, this curriculum is geared towards the physician assistant learner. Thus, the structure and content of this PA-specific is derived and adapted from programs integrated into medical school settings, specifically the Pilot POCUS Curriculum at Harvard Medical School. This POCUS integration curriculum is comprised of four experiential learning sessions, one each exploring the general categories of 1) upper extremity musculoskeletal & vascular, 2) cardiac & pulmonary, 3) abdominal, and 4) head & neck anatomy. The sessions will correlate with relevant topics/dissections presented and performed within the pre-defined anatomy course units. Each session will run 45 minutes, structured as hybridized didactic instruction and hands-on scanning time. To facilitate appropriate learner to instructor ratios, each session will accommodate 5 learners and 1-2 instructors. The learner groups will be based on the anatomy dissecting teams, with Team A dissecting while Team B scans and vice-versa. Learners will not be formally assessed on POCUS skills in the laboratory setting, but written assessments may include sonographic depictions of anatomical structures. The sessions themselves should be viewed as an opportunity to augment the core anatomy education. Reference: Ha A, Petscavage J. Hand and wrist ultrasound cases: a learning module. MedEdPORTAL Publications. 2012;8:9104. http://doi.org/10.15766/mep_2374-8265.9104 Rempell et al. Pilot POCUS Curriculum at Harvard Medical School. Western Journal of Emergency Medicine, Volume XVII, No. 6: November 2016

Schedule:

3:30-4:15 Knobology & Extremities

4:20-5:05 Knobology & Extremities

3:30-4:15 Cardiac & Pulmonary

4:20-5:05 Cardiac & Pulmonary

3:30-4:15 Abdomen

4:20-5:05 Abdomen

3:30-4:15 Head & Neck

4:20-5:05 Head & Neck

Session One: Unit One

Topic Objectives

Introduction, Upper Extremity Musculoskeletal and Vascular

Demonstrate basic understanding of POCUS principles, nomenclature, and techniques. Identify vasculature of the upper extremity, including differentiation between arteries & veins. Identify selected joints, bones, and tendons of the upper extremity.

Session Two: Unit Two

Topic Objectives

Cardiac & Pulmonary Identify basic cardiac ultrasound views. Identify the spatial relationship and sonographic appearance of the heart chambers and valves. Identify thoracic structures including the ribs and pleura.

Session Three: Unit Three

Topic Objectives

Abdominal Identify the spatial relationship and sonographic appearance of the kidneys and bladder. Identify the spatial relationship and sonographic appearance of the liver, gallbladder, and spleen.

Session Four: Unit Four

Topic Objectives

Neck & Head Identify the spatial relationship and sonographic appearance of the carotid artery, internal jugular vein, external jugular vein, sternocleidomastoid, and thyroid. Identify spatial relationship and sonographic appearance of ocular structures.