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SGEM#153: Simulation for Ultrasound Education

SGEM#153: Simulation for Ultrasound Education

Date: May 2nd, 2016

Guest Skeptic: Dr. Chris Bond. Chris is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlight educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Case: An emergency medicine resident in your institution has learned some basics of ultrasound training, but feels uncomfortable performing ultrasound in a crashing patient. They come to ask you how they can learn to use their ultrasound skills in critically ill patients, other than doing it in real time.

Background: Point of care ultrasound (PoCUS) can be broken down into two main categories – diagnostic applications and procedural applications. There are simulators and trainers for both types.

  • Diagnostic Applications: When it comes to diagnostic ultrasound simulation the case is most compelling for the more invasive applications. These include things like transesophageal echo in shock and arrest states or transvaginal ultrasound in first trimester bleeding.
  • Procedural Applications: The procedural side of ultrasound simulation is where we find the most compelling evidence. In one study by Barsuk et al, trainees who were trained to mastery on Central Venous Line trainers with the use of ultrasound and performed far better on real patients than those trained with the more traditional approach of go read about it, then see one – do one.

There is now a movement towards hybridized simulation experiences where either diagnostic or procedural trainers are introduced into broader simulation environments. This type of bridging from simple task training to clinical integration (in a simulated setting) is now being explored more and more, especially as we move towards competency based training.

Assessing competency is not a one-time event. Seeing a trainee perform a skill like PoCUS in one instance is insufficient to say they have achieved competence. Assessment of competence requires thoughtful assessment of several instances spaced over time and ranging in complexity. It is here where these types of hybrid simulation offer a window for assessment.

Seeing when the trainee decides to reach for the transducer, how they hold it, how long they allow themselves to scan, how they interpret and then integrate the findings into care. This can serve as one of many touch points making the case for that trainee’s PoCUS competence. Eventually, with multiple assessment points over the duration of their training with the formative feedback that is associated with it, they will achieve competence in PoCUS.

Resuscitative PoCUS can be divided into three parts:

  1. Firm Grasp of Indications – Knowing when and where to scan
  2. Image Generation with Interpretation – Generating the images and knowing when the image is adequate for interpretation and data extraction
  3. Integration into Clinical Care – Making decisions based on the all the data (history, physical and PoCUS images).

High-fidelity simulation (HFS) can then be combined with PoCUS to teach residents.

  • The purpose of this study was to evaluate two comparable ultrasound simulation interventions as used during HFS. Comparing two somewhat similar but distinct interventions allowed the study team to assess and isolate for the potential value of basic probe handling and other logistical aspects associated with the use of either intervention.

Clinical Question: What ultrasound simulation method is preferred by trainees and instructors in high fidelity simulation?


Reference: Olszynski et al. Ultrasound during Critical Care Simulation: A Randomized Crossover Study. CJEM 2016

  • Population: Emergency Medicine residency program trainees and 8 instructors (5 staff physicians, 3 senior emergency medicine trainees with significant U/S experience)
  • Intervention: 1) edus2 PoCUS simulator, which is comprised of a modified ultrasound probe and laptop and 2) Laptop with ultrasound videos placed on an audiovisual cart
  • Comparison: Previous PoCUS with HFS
  • Outcome: Trainee and instructor preference

Authors Conclusions: The edus2 was identified as being a superior teaching intervention, as it allowed for greater functional integration of PoCUS into critical care, better assessment of trainee skills and had greater impact on session debriefing and formative feedback.

Quality Checklist for Observational Trials:

  1. checklistThe study population focused on those in ED. Yes, it focused on EM trainees who would normally be performing the intervention.
  2. The groups were adequately randomized. No, it was not a random allocation method, as groups were “every other” trainee based on order of arrival.
  3. The randomization process was concealed. No.
  4. The study participants were analyzed in the groups to which they were randomized. Yes, but this is a crossover study, so all participants completed both interventions.
  5. The study participants were recruited consecutively. Yes.
  6. The patients in both groups were similar with respect to prognostic factors. Yes.
  7. All participants were unaware of group allocation. No.
  8. All groups were treated equally. Yes.
  9. Follow-up was complete (>80% both groups).Yes.
  10. All important outcomes were considered. Yes.
  11. The treatment effect was large enough and precise enough to be clinically significant. Unsure.

Key Results: 25 trainees with an average pre-intervention multiple choice question exam of 72% based on the American College of Emergency Physician’s EMSONO online exam. This means they were familiar with PoCUS

Twenty-one out of twenty-five already had their level I PoCUS course or equivalent. However, they reported their HFS to date had been poor (3.26 out of 10)


Trainees and instructors rated these two studied interventions superior over-previous critical care ultrasound simulation with edus2 being the prefer method of the two.


Sim ResultsTrainees rated edus2 and laptop as a quantitatively better experience than previous experience on a Likert scale in five categories. There was also no significant difference between the two teaching interventions.

Two weeks after the course the trainees completed a qualitative assessment. All the respondents indicated they preferred the edus2. Reasons included primarily the themes of real-time handling of the U/S probe with the edus2 and hands-on use. The laptop alone was felt to be a more artificial intervention.

The instructors were also asked about intervention. Both the quantitative and qualitative data support a preference for the edus2 over the laptop intervention as well as previous experiences.

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The findings of this study seem to support the integration of PoCUS whether by a simple laptop model or an edus2 model.

Dr. Paul Olszynski

Dr. Paul Olszynski

To get a deeper understanding we have a few questions for Dr. Paul Olszynski. Paul is a Clinical Assistant Professor and Director of Emergency Department Ultrasound in the Saskatoon Health Region, Paul has recently been appointed Director of Undergraduate Ultrasound Education at the College of Medicine at the University of Saskatchewan (listen to the podcast for his full responses):

  1. Randomization: You just allocated every other trainee based on arrival
    • The challenge with randomization was that we never really knew who was coming on a given day. So we decided that we would use their order of arrival to the simulation center at Whipps Cross Hospital as part of our randomization. As they walked into the center, we provided them with an envelope that included their group allocation. We had arranged our envelopes to alternate from group A to B to A and so forth as a means of ensuring that we would have balanced groups in terms of size. It was somewhat reassuring to see that our process did result in 2 generally similar groups. In the end there were no statistically significant differences between the two groups in terms of POCUS and simulation experience so I guess our randomization worked?
  2. Quantitative vs. Qualitative Data. You used both tools. Why and what do you think they tell us about your study?
    • When it comes to education research, I think combining the two forms of data really enriches the study. It adds insight to the numbers. In our study, it also highlighted how tricky research on students and instructors can be. For example, the trainees initially rated the two interventions very similarly. Yet on the exit survey, every one of them stated they preferred the edus2 to the laptop intervention.
  3. Personal Bias: You were the lead author but also were involved in the teaching sessions. How did you try to minimize this bias?
    • Early on we realized I could not act as a teacher/instructor with any of the groups. In the end, my job was to briefly introduce the trainees to the two interventions (explaining how they work and how they would be able to activate the clips they desired during the scenarios). I was also the voice of the patient for all scenarios.
  4. Resuscitative PoCUS Competence Model. You give a conceptual framework illustrating the key concepts supporting the use of PoCUS simulation in HFS. Can you take us through that model?Resuscitation
    • Bloom’s cognitive, affective psychomotor domains:
    • Miller’s Framework:
      • In my mind it represents the earliest work around assessment of competency in Medicine. First the trainee is simply asked to write it down but as they move along in their training, we expect them to describe how to do it and show us how they would do it. Until finally, near the end of their residency we observe them do it completely independently. The hybrid simulation experience we studied represents the shows how in Millers framework
    • Kirkpatrick’s Hierarchy:
      • This is about the meaningfulness of outcomes as they relate to an educational intervention. Ideally, studies like mine would show clinically significant outcomes (better patient outcomes). But to get there, we often have to first make our way up the pyramid. I think introducing PoCUS into resuscitation simulation provides us with the opportunity to “glimpse” at transfer of knowledge into practice (albeit in a simulated setting) where we can see things like improved diagnostic accuracy or shorter time to diagnosis.
    • Zone of Proximal Development (ZPD):
      • Going back to those residents of ours – the ones who are nervous about reaching for the transducer when facing a critically ill patient: You could think of that “reach” as representing their zone of proximal development – that space between what they know how to do (for example: scanning a stable trauma patient) and what they have not done yet (but have some of the basic skills already) like performing resuscitative PoCUS. The ZPD is the space the trainee could move through IF they have the proper guidance. Practicing resuscitative POCUS in HFS offers a safe environment for them to reach into their ZPD prior to doing so in real life.
  5. Patient Oriented Outcomes: Do you have any plans for demonstrating this PoCUS HFS has a positive impact on patient oriented outcomes?
    • It keeps coming up but it would have to be multi-centered. If anyone is interested, please get a hold of me.

Is there anything else you wanted to mention Paul?

  • The CAEP Emergency Ultrasound Committee’s Education Working Group is working hard to establish some national objectives and milestones for PoCUS EM in Canadian EM residency. We’re also hoping to introducing CAEP first ever SONOGAMES to CAEP17! We’ll be meeting at CAEP16 to review our progress thus far while also setting our compass for the coming year. Check us out at CAEPultrasound.ca to get in touch with us whether you are interested in being involved or just interested in being kept up to date!

Comment on authors conclusion compared to SGEM Conclusion: We agree with the authors’ conclusions.


SGEM Bottom Line: Consider integrating PoCUS into your high fidelity simulation program.


Case Resolution: You suggest that PoCUS be integrated into a high fidelity simulation case, either by creating an edus2 type trainer with an ultrasound probe and laptop, or simply putting a laptop with ultrasound clips at the bedside.

Clinically Application: PoCUS skills are useful at the bedside in real patients and this integration into high fidelity simulation is the last step prior to using them in real patient encounters.

What do I tell my learners? We know that use of PoCUS during simulation is beneficial for your learning and will help develop your knowledge of PoCUS indications, and your skills of image interpretation, clinical integration of ultrasound images and resuscitation choreography.

Keener Kontest The last winner was Eric Schneider. He knew the tallest building in the world is Burj Khalifa in Dubai, United Arab Emirates. It is 829.8m and 160 stories tall

Listen to the podcast to hear this weeks’ question. Send your answer to TheSGEM@gmail.com The first correct answer will win a cool skeptical prize.

Screen Shot 2015-11-29 at 3.19.26 PMSkeptics’ Guide to Emergency Medicine Hot Off the Press: Now it is time for the SGEMers to join the conversation. What do you think about this SGEMHOP episode? What questions do you have for Paul and his team on PoCUS and high fidelity simulation? Reach out to us on Twitter (#SGEMHOP), Facebook or the SGEM blog. The best social media feedback will be published in Canadian Journal of Emergency Medicine.


Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.


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