|Year : 2017 | Volume
| Issue : 2 | Page : 263-267
Point-of-care ultrasound training in Indian emergency medicine programs: A resident's perspective
Vimal Koshy Thomas, Siju Varghese Abraham, Jayaraj Mymbilliy Balakrishnan, S Vimal Krishnan, Ajay Amalakat, Babu Urumese Palatty
Department of Emergency Medicine, Jubilee Mission Medical College, Thrissur, Kerala, India
|Date of Web Publication||9-Jan-2018|
Dr. Vimal Koshy Thomas
Department of Emergency Medicine, Jubilee Mission Medical College, Thrissur - 680 005, Kerala
Source of Support: None, Conflict of Interest: None
Background: Emergency medicine (EM) as a specialty in India is at its infancy. Point-of-care ultrasound (POCUS) is an indispensable tool for the emergency physician (EP). We sought to determine the current experience and resources of POCUS training among EM teaching programs in India.
Methods: At a national EM board review course, a survey was carried out among 41 residents from 15 different teaching institutes across seven states of India. The survey consisted of questions pertaining to their experience and knowledge in performing basic and advanced POCUS examinations and its utilization in their department.
Results: Most residents (90.2%) were of the opinion that POCUS is an indispensable tool for the EP. All residents had access to an ultrasound (US) machine, with 90.2% having at least one dedicated machine in their department. 12.1% of the residents utilized POCUS less than five times a day while 14.6% reported using US more than twenty times a day. 68.5% of residents identified the major modality of learning POCUS was from a mentor, and about one-third were exclusively dependent on it. The least utilized sources were books and lectures (19%). Extended focused assessment with sonography in trauma (EFAST) was the most frequently performed examination (95%) and was performed with highest level of confidence. Among the advanced examinations, residents knew how to perform and interpret airway (53.7%) and renal sonography (53.7%) the most while they were least familiar with ocular sonography (19%). 70.1% residents reported that POCUS was utilized for facilitating vascular access, 53.7% for nerve blocks, and paracentesis around 19%. Only 46% reported that other departments rely on their findings to make clinical decisions.
Conclusion: POCUS was utilized by the residents for different diagnostic examinations and interventions, with the most common being EFAST. The most common learning source of POCUS was from hands-on training by a mentor. There exists a need for guidelines or standardization of POCUS in the EM curriculum to achieve resident competency.
The following core competencies are addressed in this article: Interpersonal skills and communication, Medical knowledge, Patient care, Systems-based practice.
Keywords: Emergency medicine, Point of care ultrasound, residents
|How to cite this article:|
Thomas VK, Abraham SV, Balakrishnan JM, Krishnan S V, Amalakat A, Palatty BU. Point-of-care ultrasound training in Indian emergency medicine programs: A resident's perspective. Int J Acad Med 2017;3:263-7
|How to cite this URL:|
Thomas VK, Abraham SV, Balakrishnan JM, Krishnan S V, Amalakat A, Palatty BU. Point-of-care ultrasound training in Indian emergency medicine programs: A resident's perspective. Int J Acad Med [serial online] 2017 [cited 2019 Jun 27];3:263-7. Available from: http://www.ijam-web.org/text.asp?2017/3/2/263/222478
| Introduction|| |
Emergency medicine (EM) as a specialty in India is in its infancy. The first MD EM program permitted by the Medical Council of India (MCI) began in 2010 and there are over 25 programs in EM as of 2015. All residents follow an EM curriculum developed by their respective universities, but very little has been done for its nationwide standardization and assurance of competency.
The residents during their residency learn many cognitive, psychomotor, and managerial skills. Point-of-care ultrasound (POCUS) is one of those skills in the armamentarium of an EP. Definition of emergency POCUS is different from traditional ultrasonography, but most EPs would reach a consensus in describing it as diagnostic or procedural ultrasound (US) that is performed and interpreted by the emergency physician (EP) during the initial patient encounter for the evaluation of emergent conditions.
The use of this technology is backed by position statements of most academic EM organizations.,,,, In the Indian scenario, there exists negligible guidelines about the curriculum content for POCUS training by EM residency programs, the different tests performed, and quality checks to ensure standardization. There is little doubt that the POCUS is an essential adjunct of care for patients presenting to an emergency department (ED). However, the level of competency and protocols by which POCUS used by EM residents in the country is currently unknown. We sought to determine the current competency, practices, and infrastructure of POCUS training among EM teaching programs across India.
| Methods|| |
At a national EM board review course, a survey was carried out among fifty residents. A total of 41 residents from 15 different teaching institutes across seven states of India completed the survey, which consisted of questions pertaining to their access, pattern, and proficiency of utilizing sonography in their department. The questionnaires assessed the resident's confidence levels on basic POCUS. Basic examinations included extended focused assessment with sonography in trauma (EFAST) (for detection of hemopericardium, hemoperitoneum, hemothorax, and pneumothorax), basic lung sonography (B-profiles), cardiac sonography (for detection of left ventricular dysfunction), and measurement inferior vena cava (IVC) indices (for assessing the volume status). The survey also queried if they performed various advanced POCUS skills such as renal sonography (for detection of hydronephrosis), airway sonography (intact tracheal sonoanatomy and dynamic intubation), ocular sonography (optic nerve sheath diameter measurement), Doppler sonography (detection of arterial occlusions and flows), and neurosonogram (detection of intracranial hemorrhage). The survey also queried about the various diagnostic and therapeutic procedures performed by residents where POCUS was utilized as an adjunct. The different modalities opted by the residents to learn POCUS were assessed.
The level of confidence of each basic POCUS skill was assessed using a four-point Likert scale (not confident, less confident, fairly confident, fully confident). The data were tabulated using Excel and analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp).
| Results|| |
A total of 41 out of the fifty residents from 15 academic residency programs completed the survey. Among the respondents (n = 41), 90% had at least one dedicated ultrasound (US) machine at their EDs while the rest borrowed from the radiology department. 90% of the residents felt that POCUS is an absolutely necessary technology for the ED. 14.6% of residents used POCUS more than twenty times a day while 12.1% of residents used it less than five times a day for clinical decision-making and various interventions [Figure 1]. Among the basic POCUS skills, EFAST was the most common application by the residents (95%), followed by cardiac sonography (93%), lung USG (90.2%), and IVC indices (90.2%). Among the advanced POCUS skills performed, most residents knew how to perform renal USG (56%) and airway USG (56%), followed by Doppler (36%), neurosonogram (19%), and ocular USG (12%).
[Figure 2] displays the various confidence levels at which basic POCUS skills were performed. EFAST was the examination which was performed with most confidence. [Figure 3] outlines the procedures, for which POCUS was used as an adjunct. 70.1% of residents commonly performed US to facilitate placement of central lines, 53.7% employed US for nerve blocks, and least was for paracentesis and cricothyrotomy about 22%.
|Figure 2: Variability in confidence of utilizing basic POCUS examinations among the residents|
Click here to view
|Figure 3: Ultrasonography-guided procedures used among emergency medicine residents|
Click here to view
[Table 1] displays the educational resources utilized by EM residents. Hands-on training by a mentor or a colleague was the most common modality of learning (68.5%) and one-third of these residents exclusively depended on it (26.8%). In addition, US workshops/courses and online resources (58%), radiology department (22%), and books/didactic lectures (19%) were the other modalities utilized. Less than half (46%) of the residents claim that their US findings were used to make clinical decision by other departments. POCUS was performed free of cost in all EDs as per this survey.
|Table 1: The different modalities adopted by emergency medicine residents to learn ultrasound|
Click here to view
| Discussion|| |
EM in India is a growing specialty with accredited training programs under MCI (MD) and National Board of Examinations courses providing degrees in this specialty since 2010. Emergency ultrasonography is used not only for diagnostic purposes but also as a procedural aid by the EP., POCUS has been shown to improve outcomes, decrease costs, and decrease the number of complications., There is paucity of literature when it comes to assessing the competency of POCUS among residents in India. We sought to find the current status of training in POCUS with regard to the competency and infrastructure available to the EM residents across the nation.
Out of the 240 residents currently undergoing training in EM, 41 residents who constitute 17.1% of total residents, had completed the survey. The surveyed residents commonly performed basic US skills with variable confidence. However, they did not consider themselves to be proficient in carrying out advanced skills such as ocular sonogram and neurosonogram. These results probably indicate that POCUS is more likely to be used for patients who present with true medical and surgical emergencies, where a quick decision-making is necessary such as taking a patient to the operating room. This is especially important for patients who are unstable, such as those in cardiac arrest or with severe abdominal trauma. Hemodynamically stable patients may undergo further diagnostic testing to confirm or rule out a clinical condition; hence, other consultations are placed.
In an American study conducted, most EM programs utilized lecture-based education to train their residents in US while one-third of the programs employed online education modalities. Another study reported using a combination of textbooks, journals, and instructional videos as learning options. In our study, hands-on training and mentoring were the most common learning modality used in Indian residency programs. This can be attributed to a structured learning curriculum for US in EM residencies in the west. In this survey, more than half of the residents (58.5%) had attended an US training course as part of either a conference or a 2-day program. Such a high number could be due to the fact that none of the residencies had a formal US teaching curriculum and had to resort to workshops and courses for better learning.
A POCUS training program is deemed successful if the treatment decisions and patient disposition are based on the US findings. Less than half (46%) of the residents in the survey claimed that their findings were accepted by other departments for clinical decision-making. Expertise in POCUS to train budding EPs is the need of the hour. A dedicated emergency US rotation can probably improve the learning of EM residents and would eventually have a positive impact on overall skill development.,
US machine is a recommended requirement in all EM departments., Prior studies in the country show that only 50% of the EM physicians in India had access to a US machine, whereas 90% of the participants in this survey had a dedicated US machine in their ED. This probably is due to the fact that EM departments across the country are recognizing the utility of US in aiding their decision-making and diagnosis.
POCUS is still to come of age in the Indian scenario. Positives include an improved overall awareness of POCUS in this specialty, but the full potential of this technology is yet to be tapped.
This study was conducted as a survey among EM residents hailing from seven states in the country, but the representation was mostly from the southern states. This was probably because there are lesser training programs in the northern states as of the writing of this manuscript. A subjective rather than an objective skills or knowledge assessment of the participants was done by this survey. However, this study aids in assessing the current competency, practices, and infrastructure of POCUS among EM teaching programs across the nation.
| Conclusion|| |
There currently exists a need for a formal competency assessment and testing for training in the use of US in EM. Our data suggest that discrepancies currently exist in US training programs across the country. The POCUS education provided should be structured to allow residents to incorporate ultrasonography into daily clinical practice. Frequent resident-friendly POCUS courses or workshops, implementation of emergency US residency programs, and recognition of more nodal centers for POCUS training may be a small step toward ensuring quality of the same in EM.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Aggarwal P, Galwankar S, Kalra OP, Bhalla A, Bhoi S, Sundarakumar S. The 2014 Academic College of Emergency Experts in India's Education Development Committee (EDC) White Paper on establishing an academic department of Emergency Medicine in India – Guidelines for Staffing, Infrastructure, Resources, Curriculum and Training. J Emerg Trauma Shock 2014;7:196-208.
] [Full text]
American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med 2009;53:550-70.
Henneberry RJ, Hanson A, Healey A, Hebert G, Ip U, Mensour M, et al.
Use of point of care sonography by emergency physicians. CJEM 2012;14:106-12.
Atkinson P, Bowra J, Lambert M, Lamprecht H, Noble V, Jarman B. International Federation for Emergency Medicine point of care ultrasound curriculum. CJEM 2015;17:161-70.
Kim DJ, Theoret J, Liao MM, Hopkins E, Woolfrey K, Kendall JL. The current state of ultrasound training in Canadian emergency medicine programs: Perspectives from program directors. Acad Emerg Med 2012;19:E1073-8.
Heller MB, Mandavia D, Tayal VS, Cardenas EE, Lambert MJ, Mateer J, et al.
Residency training in emergency ultrasound: Fulfilling the mandate. Acad Emerg Med 2002;9:835-9.
Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: The first sonography outcomes assessment program trial. Ann Emerg Med 2006;48:227-35.
Branney SW, Moore EE, Cantrill SV, Burch JM, Terry SJ. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma 1997;42:1086-90.
Jain M, Batra B, Clark EG, Kole T. Development of post graduate program in emergency medicine in India: Current status, scope and career pathways. Astrocyte 2014;1:218. [Full text]
Ahern M, Mallin MP, Weitzel S, Madsen T, Hunt P. Variability in ultrasound education among emergency medicine residencies. West J Emerg Med 2010;11:314-8.
Counselman FL, Sanders A, Slovis CM, Danzl D, Binder LS, Perina DG. The status of bedside ultrasonography training in emergency medicine residency programs. Acad Emerg Med 2003;10:37-42.
Adhikari S, Raio C, Morrison D, Tsung J, Leech S, Meer J, et al
. Do emergency ultrasound fellowship programs impact emergency medicine residents' ultrasound education? J Ultrasound Med 2014;33:999-1004.
Mahler SA, Swoboda TK, Wang H, Arnold TC. Dedicated emergency department ultrasound rotation improves residents' ultrasound knowledge and interpretation skills. J Emerg Med 2012;43:129-33.
Stone MB, Gupta A, Peckler B, Secko M, Murmu LR, Aggarwal P, et al.
Evaluating emergency ultrasound training in India. J Emerg Trauma Shock 2010;3:115-7.
] [Full text]
Reardon R, Heegaard B, Plummer D, Clinton J, Cook T, Tayal V. Ultrasound is a necessary skill for emergency physicians. Acad Emerg Med 2006;13:334-6.
Lewiss RE, Hayden GE, Murray A, Liu YT, Panebianco N, Liteplo AS. SonoGames: An innovative approach to emergency medicine resident ultrasound education. J Ultrasound Med 2014;33:1843-9.
[Figure 1], [Figure 2], [Figure 3]