Publications by authors named "Keith Boniface"

58 Publications

Utilization of Automated Keyword Search to Identify E-Scooter Injuries in the Emergency Department.

Cureus 2021 Nov 13;13(11):e19539. Epub 2021 Nov 13.

Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

Background and objective Accurate identification and categorization of injuries from medical records can be challenging, yet it is important for injury epidemiology and prevention efforts. Coding systems such as the International Classification of Diseases (ICD) have well-known limitations. Utilizing computer-based techniques such as natural language processing (NLP) can help augment the identification and categorization of diseases in electronic health records. We used a Python program to search the text to identify cases of scooter injuries that presented to our emergency department (ED). Materials and methods This retrospective chart review was conducted between March 2017 and June 2019 in a single, urban academic ED with approximately 80,000 annual visits. The physician documentation was stored as combined PDF files by date. A Python program was developed to search the text from 186,987 encounters to find the string "scoot" and to extract the 100 characters before and after the phrase to facilitate a manual review of this subset of charts. Results A total of 890 charts were identified using the Python program, of which 235 (26.4%) were confirmed as e-scooter cases. Patients had an average age of 36 years and 53% were male. In 81.7% of cases, the patients reported a fall from the scooter and only 1.7% reported wearing a helmet during the event. The most commonly injured body areas were the upper extremity (57.9%), head (42.1%), and lower extremity (36.2%). The most frequently consulted specialists were orthopedic and trauma surgeons with 28% of cases requiring a consult. In our population, 9.4% of patients required admission to the hospital. Conclusions The number of results and data returned by the Python program was easy to manage and made it easier to identify charts for abstraction. The charts obtained allowed us to understand the nature and demographics of e-scooter injuries in our ED. E-scooters continue to be a popular mode of transportation, and understanding injury patterns related to them may inform and guide opportunities for policy and prevention.
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http://dx.doi.org/10.7759/cureus.19539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8667961PMC
November 2021

Point-of-Care Ultrasound in the Diagnosis of an Incarcerated Inguinal Hernia.

Cureus 2021 Jul 9;13(7):e16281. Epub 2021 Jul 9.

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA.

Emergency physicians can use point-of-care ultrasound to diagnose inguinal hernias as well as their potential complications, including small bowel obstruction, incarceration, and even strangulation. We provide an overview of the sonographic appearance of inguinal hernias, as well as the diagnostic criteria of serious complications. In this case report, point-of-care ultrasound findings included a non-reducible inguinal hernia associated with significant bowel dilation in multiple loops without signs of intestinal ischemia or necrosis.
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http://dx.doi.org/10.7759/cureus.16281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349524PMC
July 2021

eFAST exam errors at a level 1 trauma center: A retrospective cohort study.

Am J Emerg Med 2021 Nov 21;49:393-398. Epub 2021 Jul 21.

Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, United States. Electronic address:

Objectives: Extended Focused Assessment with Sonography for Trauma (eFAST) ultrasound exams are central to the care of the unstable trauma patient. We examined six years of eFAST quality assurance data to identify the most common reasons for false positive and false negative eFAST exams.

Methods: This was an observational, retrospective cohort study of trauma activation patients evaluated in an urban, academic Level 1 trauma center. All eFAST exams that were identified as false positive or false negative exams compared with computed tomography (CT) imaging were included.

Results: 4860 eFAST exams were performed on trauma patients. 1450 (29.8%) were undocumented, technically limited, or incomplete (missing images). Of the 3410 remaining exams, 180 (5.27%) were true positive and 3128 (91.7%) were true negative. 27 (0.79%) exams were identified as false positive and 75 (2.19%) were identified as false negative. Of the false positive scans, 7 had no CT scan and 8 had correct real-time trauma paper documentation of eFAST exam results when compared to CT and were excluded, leaving 12 false positive scans. Of the false negative scans, 11 were excluded for concordant documentation in real-time trauma room paper documentation, 20 were excluded for no CT scan, and 2 were excluded as incomplete, leaving 42 false negative scans. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam were the most common source of errors.

Conclusion: The eFAST exams in trauma activation patients are highly accurate. Unfortunately poor documentation and technically limited/incomplete studies represent 29.8% of our eFAST exams. Pelvic fluid, double-line sign, pericardial fat pad, and the thoracic portion of the eFAST exam are the most common source of errors.
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http://dx.doi.org/10.1016/j.ajem.2021.07.036DOI Listing
November 2021

Images in Primary Care Medicine: Point-of-Care Ultrasound in Gout.

Cureus 2021 May 18;13(5):e15096. Epub 2021 May 18.

Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

Gout is the most common crystal arthropathy and is frequently diagnosed and managed by primary care physicians. Point-of-care ultrasound (POCUS) is a valuable tool to aid in the diagnosis of gout via the identification of the double contour sign, aggregates of crystals, tophi, and erosions. In addition, POCUS can aid in the management of gout by recognizing early signs of gout, monitoring the effectiveness of urate-lowering therapy, and guiding aspiration and corticosteroid injection.
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http://dx.doi.org/10.7759/cureus.15096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211301PMC
May 2021

Mortality in patients with hepatic gas on point-of-care ultrasound in cardiac arrest: Does location matter?

J Clin Ultrasound 2021 Mar 23;49(3):205-211. Epub 2020 Nov 23.

Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.

Purpose: Prior research has suggested an association of hepatic venous gas with mortality in cardiac arrest. As point of care ultrasound (POCUS) is frequently used in the context of resuscitation, we sought to evaluate if the presence of hepatic gas on POCUS had a similar mortality association.

Methods: A retrospective review was conducted of patients who experienced nontraumatic cardiac arrest. Archived ultrasound images were independently reviewed to determine the presence of gas in the hepatic parenchyma and vasculature. Electronic medical records were then reviewed to collect remaining clinical data.

Results: From 1 January 2017 through 16 June 2019, 87 patients met inclusion criteria. Among them, 68 (78.2%) patients died. Among those who died, 40 (58.8%) had hepatic gas, while 28 (41.2%) had none. Only a single survivor demonstrated hepatic venous gas (11%). While the difference in mortality with respect to presence of undifferentiated hepatic gas was not significant (P = .37), there was a significant difference with respect to the presence of venous gas (P = .004).

Conclusion: Our study demonstrated that the incidence of postarrest hepatic gas on POCUS was common, and that the presence of hepatic venous gas during cardiac resuscitation was associated with increased mortality, while hepatic parenchymal gas alone was not.
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http://dx.doi.org/10.1002/jcu.22952DOI Listing
March 2021

Minimizing Pulse Check Duration Through Educational Video Review.

West J Emerg Med 2020 Oct 20;21(6):276-283. Epub 2020 Oct 20.

George Washington University, Department of Emergency Medicine, Washington DC.

Introduction: The American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend pulse checks of less than 10 seconds. We assessed the effect of video review-based educational feedback on pulse check duration with and without point-of-care ultrasound (POCUS).

Methods: Cameras recorded cases of CPR in the emergency department (ED). Investigators reviewed resuscitation videos for ultrasound use during pulse check, pulse check duration, and compression-fraction ratio. Investigators reviewed health records for patient outcomes. Providers received written feedback regarding pulse check duration and compression-fraction ratio. Researchers reviewed selected videos in multidisciplinary grand round presentations, with research team members facilitating discussion. These presentations highlighted strategies that include the following: limit on pulse check duration; emphasis on compressions; and use of "record, then review" method for pulse checks with POCUS. The primary endpoint was pulse check duration with and without POCUS.

Results: Over 19 months, investigators reviewed 70 resuscitations with a total of 325 pulse checks. The mean pulse check duration was 11.5 ± 8.8 seconds (n = 224) and 13.8 ± 8.6 seconds (n = 101) without and with POCUS, respectively. POCUS pulse checks were significantly longer than those without POCUS (P = 0.001). Mean pulse check duration per three-month block decreased statistically significantly from study onset to the final study period (from 17.2 to 10 seconds [P<0.0001]) overall; decreased from 16.6 to 10.5 seconds (P<0.0001) without POCUS; and with POCUS from 19.8 to 9.88 seconds (P<0.0001) with POCUS. Pulse check times decreased significantly over the study period of educational interventions. The strongest effect size was found in POCUS pulse check duration (P = -0.3640, P = 0.002).

Conclusion: Consistent with previous studies, POCUS prolonged pulse checks. Educational interventions were associated with significantly decreased overall pulse-check duration, with an enhanced effect on pulse checks involving POCUS. Performance feedback and video review-based education can improve CPR by increasing chest compression-fraction ratio.
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http://dx.doi.org/10.5811/westjem.2020.8.47876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673890PMC
October 2020

Learner-centered Survey of Point-of-care Ultrasound Training, Competence, and Implementation Barriers in Emergency Medicine Training Programs in India.

AEM Educ Train 2020 Oct 27;4(4):387-394. Epub 2019 Dec 27.

Department of Emergency Medicine The George Washington University Washington DC.

Background: Point-of-care ultrasound (POCUS) is important to the practice of emergency medicine (EM), but requires training to achieve competence. The purpose of this study was to describe the current state of POCUS practice and perceived barriers to the implementation in EM training programs in India.

Methods: A cross-sectional survey consisting of 28 questions was administered to 378 faculty and residents in postgraduate EM training programs across India.

Results: Data were collected from 159 physicians from 16 institutions; 76% of them were EM residents, with a response rate of 42%. Respondents overwhelmingly reported high interest (91%) in learning POCUS topics. Respondents identified highest levels of comfort with the performance and interpretation of trauma ultrasound (US) and echocardiography. Conversely, there was a scarce interest and low levels of competence in performing obstetric US, which may be a result of the practice of triaging these complaints to obstetricians and gynecologists. Lack of US equipment and dedicated training were the highest rated barriers by a significant margin, which 56% of respondents ranked as "very important."

Conclusions: While significant interest in POCUS exists among the Indian EM physicians, comfort and competence were limited to trauma and echocardiography applications. Expansion of and comfort with POCUS use in these settings may be sought through improvement of access to US equipment and a dedicated US curriculum.
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http://dx.doi.org/10.1002/aet2.10423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592833PMC
October 2020

Optic Nerve Sheath Diameter Measured by Point-of-Care Ultrasound and MRI.

J Neuroimaging 2020 11 8;30(6):793-799. Epub 2020 Sep 8.

Department of Radiology, The George Washington University Medical Center, Washington, DC.

Background And Purpose: Ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) and optic nerve diameter (OND) is a method frequently used to screen for an increased intracranial pressure. The aim of this study was to assess the accuracy of US measurements of ONSD and OND, when compared to magnetic resonance imaging (MRI) measurements as the criterion standard.

Methods: In this prospective, single-institution study, orbital US was performed for those patients requiring an emergent brain MRI. ONSD and OND of both eyes were measured in the axial and coronal planes in straight gaze by US. ONSD and OND from brain and orbital MRI were measured by two neuroradiologists. Correlation and agreement between readings were assessed using Pearson's correlations.

Results: Eighty-two patients met inclusion criteria. The mean axial and coronal ONSD in the MRI examinations was 5.6 and 5.7 mm at 3-5.9 mm behind the globe, respectively. The mean ONSD from the US measurements was 6.22 and 5.52 mm in the axial and coronal planes, respectively. The mean OND in US examinations was 4.31 mm (axial) and 3.68 mm (coronal). Axial versus coronal measurements of ONSD had a modest correlation in US assessment with an r of .385 (P < .001) but there were no correlations between any of the US and MRI measurements.

Conclusions: In measuring ONSD and OND, US measurements showed a modest correlation between axial and coronal measurements, but no concordance was found between US and MRI in our setting.
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http://dx.doi.org/10.1111/jon.12764DOI Listing
November 2020

Utility of point-of-care ultrasound in patients with suspected diverticulitis in the emergency department.

J Clin Ultrasound 2020 Jul 1;48(6):337-342. Epub 2020 May 1.

Department of Emergency Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA.

In emergency department (ED) cases with clinically suspected diverticulitis, diagnostic imaging is often needed for diagnostic confirmation, to exclude complications, and to direct patient management. Patients typically undergo a CT scan in the ED; however, in a subset of cases with suspected diverticulitis, point-of-care ultrasound (POCUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management.We review the main sonographic features of diverticulitis and discuss the diagnostic accuracy and potential benefits of a POCUS First model.
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http://dx.doi.org/10.1002/jcu.22857DOI Listing
July 2020

A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound.

Int Marit Health 2020 ;71(1):42-45

The George Washington University, 2120 L Street NW, Suite 450, 20037 Washington, DC, United States.

Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literaturę of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support.
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http://dx.doi.org/10.5603/IMH.2020.0010DOI Listing
December 2020

Point-of-care Ultrasound Diagnosis of Bilateral Patellar Tendon Rupture.

Clin Pract Cases Emerg Med 2020 Feb 24;4(1):29-31. Epub 2020 Jan 24.

George Washington University, Department of Emergency Medicine, Washington, District of Columbia.

Musculoskeletal complaints are one cornerstone of urgent issues for which orthopedic and emergency physicians provide care. Ultrasound can be a useful diagnostic tool to help identify musculoskeletal injuries. We describe a case of bilateral patellar tendon rupture that presented after minor trauma, and had the diagnosis confirmed at the bedside by point-of-care ultrasound. Physicians caring for patients with orthopedic injuries should be familiar with the use of ultrasound to diagnose tendon ruptures.
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http://dx.doi.org/10.5811/cpcem.2019.10.44194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012541PMC
February 2020

Point-of-Care Ultrasound for the Detection of Hip Effusion and Septic Arthritis in Adult Patients With Hip Pain and Negative Initial Imaging.

J Emerg Med 2020 Apr 22;58(4):627-631. Epub 2020 Jan 22.

Department of Emergency Medicine, George Washington University, Washington, District of Columbia.

Background: Acute or recurrent hip pain in adults can be a challenging presentation in the emergency department. While ultrasound is routinely used in the evaluation of pediatric patients with hip pain and a new limp, it is not commonly used for this purpose in adult emergency medicine. This case series demonstrates the clinical utility of point-of-care ultrasound (POCUS) in adult patients with acute or recurrent hip pain because performance of POCUS was the critical action that led to the identification of pathologic hip effusions in this series of adults.

Case Series: This case series includes 5 patients in whom clinical suspicion existed for the presence of a hip effusion and possible septic arthritis, despite nondiagnostic radiographic findings. Ultrasound was used to detect the effusion and guide subsequent arthrocentesis, imaging, or surgical intervention. In all patients, computed tomography scans or magnetic resonance imaging scans were later used to confirm the presence of effusion. In all 5 patients (2 women and 3 men, with a mean age of 47.4 years), POCUS accurately detected the presence of hip effusion. Two of 5 synovial collections were caused by septic arthritis as confirmed by synovial fluid microbiologic examination. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case series emphasizes the clinical utility of POCUS in adult patients with acute and recurrent hip pain to detect a hip effusion, particularly in patients with significant risk factors for septic arthritis. POCUS can also be used to guide further imaging, arthrocentesis, surgical consultation, and intervention.
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http://dx.doi.org/10.1016/j.jemermed.2019.11.036DOI Listing
April 2020

Utility of the DIVA score for experienced emergency department technicians.

Br J Nurs 2020 Jan;29(2):S35-S40

MD, Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics and Emergency Medicine, George Washington University, Washington, DC, USA.

Background: The DIVA score is validated for predicting success of the initial attempt at peripheral intravenous insertion by nurses and physicians. A score of 4 or greater is 50% to 60% likely to have a failed first attempt. The study objective was to assess the validity of this score for emergency department technicians.

Methods: This study used a prospective convenience sample of 181 children presenting to the emergency department with intravenous access attempt by one of 29 emergency department technicians. DIVA score, total number of attempts, and median time to successful intravenous cannulation were obtained.

Results: Comparing patients with a DIVA score <4 to ≥4, first-time IV placement failure rates were lower (9% [95% CI, 3-24] vs. 41% [95% CI, 33-49]) and median time to IV placement was shorter (75 [interquartile range (IQR) 42-157] vs. 254 [IQR 91-806]) seconds. In patients with scores ≥4, emergency department technicians with ≥5 years of experience were significantly more likely to be successful on the first attempt (OR 2.8; 95% CI, 1.03-7.63). For every year of technician experience, the time to catheter placement, adjusted for DIVA score, decreased by 25 minutes (≤0.05, =0.05). Comparing our receiver operating curve to the derivation study, the areas were similar (0.67 vs. 0.65).

Conclusions: This study provides preliminary evidence for the validity of the DIVA score when applied to IVs placed by emergency department technicians. For patients with high DIVA scores, ≥5 years of IV experience was associated with higher odds of successful first-time IV placement and shorter time to placement. The difficult intravenous access (DIVA) score may be generalizable to IVs placed by experienced emergency department technicians (EDTs) Higher odds of first-time success in difficult patients with ≥5 years EDT experience Early identification of difficult access may allow for aid of alternative technology Likely first study to evaluate EDTs IV skills in patients with varying DIVA scores.
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http://dx.doi.org/10.12968/bjon.2020.29.2.S35DOI Listing
January 2020

Development of a nomogram to predict small bowel obstruction using point-of-care ultrasound in the emergency department.

Am J Emerg Med 2020 11 16;38(11):2356-2360. Epub 2019 Dec 16.

Department of Pharmacy, Kaiser Permanente Colorado Region, Aurora, CO & Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, UT, United States of America.

Objective: Early diagnostic prediction in patients with small bowel obstruction (SBO) can improve time to definitive management and disposition in the emergency department. We sought to develop a nomogram to leverage point-of-care ultrasound (POCUS) and maximize accuracy of prediction of SBO diagnosis.

Methods: Using data from a prospective cohort of 125 patients with suspected SBO who were evaluated with POCUS in the ED, we developed a nomogram integrating age, gender, comorbidities, prior abdominal surgery, physician's pre-test probability, and POCUS findings to determine post-test risk of SBO. The primary outcome was to develop a nomogram to allow calculating output probabilities for predictive models using POCUS findings. The discriminative ability of the nomogram was tested using a C-statistics, calibration plots, and receiver operating characteristic curves.

Results: The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: small bowel diameter (odds ratio [OR] per 1 mm increase, 1.10; 95% CI, 1.03-1.17; P = 0.001), positive free intraperitoneal fluid between bowel loops (OR, 8.19; 95% CI, 2.62-25.62; P < 0.001), clinician's moderate (OR, 5.94; 95% CI, 0.83-42.57; P = 0.08) or high pretest probability (OR, 11.26; 95% CI, 1.44-88.25; P = 0.02), and patient age (OR per 1 year increase, 1.03; 95% CI, 1.00 to1.07; P = 0.08).The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C-statistic of 0.89 for the SBO diagnosis.

Conclusion: A unique nomogram incorporating patient age, physician pretest probability of SBO, and POCUS measurements of small bowel diameter and the presence of free intraperitoneal fluid between bowel loops was developed to accurately predict the diagnosis of SBO in the emergency department. The nomogram should be externally validated in a novel cohort of patients at risk for SBO to better assess predictability and generalizability.
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http://dx.doi.org/10.1016/j.ajem.2019.12.010DOI Listing
November 2020

Pseudo-pulseless electrical activity in the emergency department, an evidence based approach.

Am J Emerg Med 2020 02 14;38(2):371-375. Epub 2019 Oct 14.

Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037, United States. Electronic address:

Introduction: A great deal of the literature has focused specifically on true pulseless electrical activity (PEA), whereas there is a dearth of research regarding pseudo-PEA. This narrative review evaluates the diagnosis and management of patients in pseudo-PEA and discusses the impact on emerging patient outcomes.

Discussion: Pseudo-PEA can be defined as evidence of cardiac activity without a detectable pulse. Distinguishing pseudo-PEA from true PEA is important for emergency physicians as the prognosis and management of these patients differ. POCUS is the tool most commonly used to diagnose pseudo-PEA and there are varying treatment strategies to manage these patients. Identifying patients in pseudo-PEA can help guide resuscitation decisions, and ultimately impact emergency response systems, patients, and families.

Conclusions: The incidence of pseudo-PEA is increasing. Effective care of these patients begins with early diagnosis of this condition and immediate treatment to warrant the greatest chance of survival. There is a need for further prospective studies surrounding pseudo-PEA as evidenced by the lack of research in the current literature.
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http://dx.doi.org/10.1016/j.ajem.2019.158503DOI Listing
February 2020

Diagnostic Accuracy and Time-Saving Effects of Point-of-Care Ultrasonography in Patients With Small Bowel Obstruction: A Prospective Study.

Ann Emerg Med 2020 02 23;75(2):246-256. Epub 2019 Jul 23.

The George Washington University Medical Center, Washington, DC; Massachusetts General Hospital-Harvard Medical School, Boston, MA. Electronic address:

Study Objective: We evaluate the accuracy of point-of-care ultrasonography compared with computed tomographic (CT) scan and assess the potential time-saving effect of point-of-care ultrasonography in diagnosing small bowel obstruction.

Methods: This was a prospective observational study of a convenience sample of patients with suspected small bowel obstruction in an academic emergency department (ED). Physician sonographers were blinded to clinical data, laboratory results, and CT scan findings. Point-of-care ultrasonographic findings of small bowel obstruction was the primary outcome, defined as bowel-loop diameter greater than or equal to 25 mm with abnormal peristalsis. Maximum bowel dilatation, visible peristalsis, interluminal free fluid, and bowel wall thickness were evaluated. Time to completion of imaging results was abstracted from the medical records for each imaging modality.

Results: The study included 125 patients (median age 54.0 years [interquartile range 43 to 63 years]; 46% men), of whom 32 (25.6%) had small bowel obstruction, and 9 (7.2%) underwent surgery for it. Overall, the sensitivity of point-of-care ultrasonography for small bowel obstruction was 87.5% (95% confidence interval 71.0% to 96.5%), and specificity was 75.3% (95% confidence interval 65.2% to 83.6%). The area under the receiver operating characteristic curve to accurately predict small bowel obstruction was 0.74 (95% confidence interval 0.66 to 0.82). Results were similar across evaluated subgroups, including physician training level. The average time to obtain a CT scan report was 3 hours, 42 minutes; obtaining an abdominal radiograph took 1 hour, 38 minutes; and the mean elapsed time to complete point-of-care ultrasonography was 11 minutes.

Conclusion: In ED patients with suspected small bowel obstruction, point-of-care ultrasonography has a reasonably high accuracy in diagnosing small bowel obstruction compared with CT scan, and may substantially decrease the time to diagnosis.
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http://dx.doi.org/10.1016/j.annemergmed.2019.05.031DOI Listing
February 2020

Direct Observation Assessment of Ultrasound Competency Using a Mobile Standardized Direct Observation Tool Application With Comparison to Asynchronous Quality Assurance Evaluation.

AEM Educ Train 2019 Apr 19;3(2):172-178. Epub 2019 Feb 19.

Department of Emergency Medicine The George Washington University Washington DC.

Objectives: Competency assessment is a key component of point-of-care ultrasound (POCUS) training. The purpose of this study was to design a smartphone-based standardized direct observation tool (SDOT) and to compare a faculty-observed competency assessment at the bedside with a blinded reference standard assessment in the quality assurance (QA) review of ultrasound images.

Methods: In this prospective, observational study, an SDOT was created using SurveyMonkey containing specific scoring and evaluation items based on the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound: Consensus Document for the Emergency Ultrasound Milestone Project. Ultrasound faculty used the mobile phone-based data collection tool as an SDOT at the bedside when students, residents, and fellows were performing one of eight core POCUS examinations. Data recorded included demographic data, examination-specific data, and overall quality measures (on a scale of 1-5, with 3 and above being defined as adequate for clinical decision making), as well as interpretation and clinical knowledge. The POCUS examination itself was recorded and uploaded to QPath, a HIPAA-compliant ultrasound archive. Each examination was later reviewed by another faculty blinded to the result of the bedside evaluation. The agreement of examinations scored adequate (3 and above) in the two evaluation methods was the primary outcome.

Results: A total of 163 direct observation evaluations were collected from 23 EM residents (93 SDOTs [57%]), 14 students (51 SDOTs [31%]), and four fellows (19 SDOTs [12%]). The trainees were evaluated on completing cardiac (54 [33%]), focused assessment with sonography for trauma (34 [21%]), biliary (25 [15%]), aorta (18 [11%]), renal (12 [7%]), pelvis (eight [5%]), deep vein thrombosis (seven [4%]), and lung scan (5 [3%]). Overall, the number of observed agreements between bedside and QA assessments was 81 (87.1% of the observations) for evaluating the quality of images (scores 1 and 2 vs. scores 3, 4, and 5). The strength of agreement is considered to be "fair" (κ = 0.251 and 95% confidence interval [CI] = 0.02-0.48). Further agreement assessment demonstrated a fair agreement for images taken by residents and students and a "perfect" agreement in images taken by fellows. Overall, a "moderate" inter-rater agreement was found in 79.1% for the accuracy of interpretation of POCUS scan (e.g., true positive, false negative) during QA and bedside evaluation (κ = 0.48, 95% CI = 0.34-0.63). Faculty at the bedside and QA assessment reached a moderate agreement on interpretations noted by residents and students and a "good" agreement on fellows' scans.

Conclusion: Using a bedside SDOT through a mobile SurveyMonkey platform facilitates assessment of competency in emergency ultrasound learners and correlates well with traditional competency evaluation by asynchronous weekly image review QA.
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http://dx.doi.org/10.1002/aet2.10324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457355PMC
April 2019

The Utility and Survivorship of Peripheral Intravenous Catheters Inserted in the Emergency Department.

Ann Emerg Med 2019 09 27;74(3):381-390. Epub 2019 Mar 27.

Health Policy and Management and Emergency Medicine, George Washington University, Washington, DC.

Study Objective: We compare the use and survivorship rate of peripheral intravenous catheters placed in the emergency department (ED) by insertion method.

Methods: We analyzed a prospective cohort of ED patients who received a peripheral intravenous catheter in the ED by ultrasonographically guided or landmark insertion. Research assistants recorded the uses of the ED-inserted catheters during the ED visit and hospitalization. Among subjects admitted, research assistants tracked catheter survivorship for 72 hours or hospital discharge, whichever came first. Research assistants documented reason for catheter removal and whether it was replaced during hospitalization. Premature removal was defined as catheters that were replaced because of mechanical failure, complication, or discomfort. We used multivariate binomial regression to estimate the relative risk of insertion method on premature removal and a Kaplan-Meier curve to compare survivorship duration by insertion method.

Results: A cohort of 1,174 patients with a mean age of 45 years and 63% female predominance was analyzed. Catheter use was 73% and 78% in the ED and hospital for the administration of fluids, medications, or contrast agents (and 96% if blood drawn for testing was included). Peripheral intravenous use did not differ significantly in the ED or hospital by insertion method. For 330 patients who were admitted, 132 of 182 patients (73%) in the ultrasonographically guided group and 117 of 148 (79%) in the landmark group had 72-hour catheter survival. Premature removal was not significantly more likely to occur if the catheter was inserted by the ultrasonographically guided method compared with the landmark one (relative risk 1.26; 95% confidence interval 0.88 to 1.80).

Conclusion: ED-inserted peripheral intravenous catheters were frequently used in the ED and hospital. Peripheral intravenous use and hospital survivorship of ED-inserted peripheral intravenous catheters were similar by insertion method.
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http://dx.doi.org/10.1016/j.annemergmed.2019.02.003DOI Listing
September 2019

Assessment of Point-of-Care Ultrasound Training for Clinical Educators in Malawi, Tanzania and Uganda.

Ultrasound Med Biol 2019 06 21;45(6):1351-1357. Epub 2019 Mar 21.

Department of Emergency Medicine, George Washington University Medical Center, Washington, DC, USA.

Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013-2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2019.01.019DOI Listing
June 2019

The Global Health Service Partnership's point-of-care ultrasound initiatives in Malawi, Tanzania and Uganda.

Am J Emerg Med 2019 04 27;37(4):777-779. Epub 2018 Aug 27.

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA; and The George Washington University Medical Center, Washington DC, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2018.08.065DOI Listing
April 2019

The utility of point-of-care ultrasound in targeted automobile ramming mass casualty (TARMAC) attacks.

Am J Emerg Med 2018 08 29;36(8):1467-1471. Epub 2018 May 29.

Disaster and Operational Medicine, Department of Emergency Medicine, George Washington University, Washington DC, United States.

As terrorist actors revise their tactics to outmaneuver increasing counter-terrorism security measures, a recent trend toward less-sophisticated attack methods has emerged. Most notable of these "low tech" trends are the Targeted Automobile Ramming MAss Casualty (TARMAC) attacks. Between 2014 and November 2017, 18 TARMAC attacks were reported worldwide, resulting in 181 deaths and 679 injuries. TARMAC attack-related injuries are unique compared to accidental pedestrian trauma and other causes of mass casualty incidents (MCI), and therefore they require special consideration. No other intentional mass casualty scenario is the result of a blunt, non-penetrating trauma mechanism. Direct vehicle impact results in high-power injuries including blunt trauma to the central nervous system (CNS), and thoracoabdominal organs with crush injuries if the victims are run over. Adopting new strategies and using existing technology to diagnose and treat MCI victims with these injury patterns will save lives and limit morbidity. Point-of-care ultrasound (POCUS) is one such technology, and its efficacy during MCI response is receiving an increasing amount of attention. Ultrasound machines are becoming increasingly available to emergency care providers and can be critically important during a MCI when access to other imaging modalities is limited by patient volume. By taking ultrasound diagnostic techniques validated for the detection of life-threatening cardiothoracic and abdominal injuries in individuals and applying them in a TARMAC mass casualty situation, physicians can improve triage and allocate resources more effectively. Here, we revisit the high-yield applications of POCUS as a means of enhanced prehospital and hospital-based triage, improved resource utilization, and identify their potential effectiveness during a TARMAC incident.
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http://dx.doi.org/10.1016/j.ajem.2018.05.058DOI Listing
August 2018

International Scope of Emergency Ultrasound: Barriers in Applying Ultrasound to Guide Central Line Placement by Providers in Nairobi, Kenya.

Emerg Med Int 2018 7;2018:7328465. Epub 2018 May 7.

George Washington University, 2120 L Street NW, Suite 450, Washington, DC 2003, USA.

Background: While ultrasound (US) use for internal jugular central venous catheter (CVC) placement is standard of care in North America, most developing countries have not adopted this practice. Previous surveys of North American physicians have identified lack of training and equipment availability as the most important barriers to the use of US.

Objective: We sought to identify perceived barriers to the use of US to guide CVC insertion in a resource-constrained environment.

Methods: Prior to an US-guided CVC placement training course conducted at the Aga Khan University Hospital in Nairobi, Kenya, physicians were asked to complete a survey to determine previous experience and perceived barriers. Survey responses were analyzed using summary statistics and the Rank-Sum test based on different specialty, gender, and previous US experience.

Results: There were 23 physicians who completed the course and the survey. 52% (95% CI: 0.30-0.73) had put in >20 CVCs. 21.7% (95% CI: 0.08-0.44) of participants had previous US training, but none in the use of US for CVC insertion. The respondents expressed agreement with statements describing the ease of the use and improved success rate with US guidance. There was less agreement to statements describing the relative convenience and cost effectiveness of US CVC placement compared to the landmark technique. The main perceived barriers to utilization of US guidance included lack of training and limited availability of US equipment and sterile sheaths.

Conclusion: Perceived barriers to US-guided CVC placement in our population closely mirrored those found among North American physicians, including lack of training and limited availability of US machines and equipment. These barriers have the potential to be addressed by targeted educational and administrative interventions.
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http://dx.doi.org/10.1155/2018/7328465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964574PMC
May 2018

Ultrasound-guided intravenous access in adults using SonoStik, a novel encapsulated sterile guidewire: A prospective cohort trial.

J Vasc Access 2018 Sep 12;19(5):441-445. Epub 2018 Mar 12.

1 Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC, USA.

Purpose: We evaluated the performance of an encapsulated guidewire designed for single-handed use with ultrasound-guided vascular access (SonoStik) with Seldinger technique, as compared with conventional intravenous catheters placed under ultrasound guidance in healthy subjects.

Methods: This is a prospective cohort trial in healthy subjects in which each subject served as his/her own control by having a SonoStik ultrasound intravenous cannulation placed in one arm and a conventionally placed, standard ultrasound intravenous cannulation placed in the other arm. The basilic vein was used because it is a non-visible and non-palpable vein. Emergency department technicians with extensive experience in ultrasound-guided intravenous access performed the procedures. The first-attempt success rate of intravenous-guided intravenous by using the SonoStik was compared to the standard ultrasound intravenous cannulation in adult healthy subjects. The secondary outcomes including time of procedure, technicians' and subjects' satisfaction, and complications were compared in both arms of the study.

Results: A total of 24 volunteers with a mean age of 22.7 years were enrolled. Four emergency department technicians with extensive prior experience with ultrasound-guided intravenous access but with no prior experience using the SonoStik device performed the procedures. The first-attempt success was 83.3% with the use of SonoStik ultrasound intravenous cannulation compared to 95.8% with the standard ultrasound intravenous cannulation. There was a mean of 1.14 insertions per each successful placement in the SonoStik group compared to 1.04 insertions by using the standard catheters (mean differences = -0.1; 95% confidence interval = -0.6 to 0.4). There were no complications in either SonoStik or the standard ultrasound intravenous cannulation group. The mean time of insertion using SonoStik was slightly longer compared to standard ultrasound intravenous cannulation (143.3 vs 109.7 s).

Conclusion: This study demonstrated that emergency department technicians skilled in ultrasound-guided intravenous access could successfully place SonoStik 83.3% of the time in vessels that were unable to be palpated or visualized. Compared to standard ultrasound intravenous cannulation, the odds ratio of successful cannulation with SonoStik was 0.91 (95% confidence interval = 0.04-17.5). In all cases, the time required to successfully insert SonoStik was less than 4 min from tourniquet application to catheter advancement to hub, with a mean time of less than 2.5 min.
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http://dx.doi.org/10.1177/1129729818758228DOI Listing
September 2018

An Echocardiography Training Program for Improving the Left Ventricular Function Interpretation in Emergency Department; a Brief Report.

Emerg (Tehran) 2017 15;5(1):e70. Epub 2017 Jun 15.

Department of Emergency Medicine, George Washington University, Washington DC. USA.

Introduction: Focused training in transthoracic echocardiography enables emergency physicians (EPs) to accurately estimate the left ventricular function. This study aimed to evaluate the efficacy of a brief training program utilizing standardized echocardiography video clips in this regard.

Methods: A before and after design was used to determine the efficacy of a 1 hour echocardiography training program using PowerPoint presentation and standardized echocardiography video clips illustrating normal and abnormal left ventricular ejection fraction (LVEF) as well as video clips emphasizing the measurement of mitral valve E-point septal separation (EPSS). Pre- and post-test evaluation used unique video clips and asked trainees to estimate LVEF and EPSS based on the viewed video clips.

Results: 21 EPs with no prior experience with the echocardiographic technical methods completed this study. The EPs had very limited prior echocardiographic training. The mean score on the categorization of LVEF estimation improved from 4.9 (95% CI: 4.1-5.6) to 7.6 (95%CI: 7-8.3) out of a possible 10 score (p<0.0001). Categorization of EPSS improved from 4.1 (95% CI: 3.1-5.1) to 8.1 (95% CI: 7.6- 8.7) after education (p<0.0001).

Conclusions: The results of this study demonstrate a statistically significant improvement of EPs' ability to categorize left ventricular function as normal or depressed, after a short lecture utilizing a commercially available DVD of standardized echocardiography clips.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703747PMC
June 2017

Point-of-care ultrasound leads to diagnostic shifts in patients with undifferentiated hypotension.

Am J Emerg Med 2017 Dec 26;35(12):1984.e3-1984.e7. Epub 2017 Aug 26.

Department of Radiology, George Washington University Medical Center, United States.

Objective: To assess the impact of an ultrasound hypotension protocol in identifying life-threatening diagnoses that were missed in the initial evaluation of patients with hypotension and shock.

Methods: A subset of cases from a previously published prospective study of hypotensive patients who presented at the Emergency Department in a single, academic tertiary care hospital is described. An ultrasound-trained emergency physician performed an ultrasound on each patient using a standardized hypotension protocol. In each case, the differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. This is a case series of patients with missed diagnoses in whom ultrasound led to a dramatic shift in diagnosis and management by detecting life threatening pathologies.

Results: Following a published prospective study of the effect on an ultrasound protocol in 118 hypotensive patients, we identified a series of cases that ultrasound protocol unexpectedly determined serious life threatening diagnoses such as Takotsubo cardiomyopathy, pulmonary embolism, pericardial effusion with tamponade physiology, abdominal aortic aneurysm and perforated viscus resulting in proper diagnoses and management. These hypotensive patients had completely unsuspected but critical diagnoses explaining their hypotension, who in every case had their management altered to target the newly identified life-threatening condition.

Conclusions: A hypotension protocol is an optimal use of ultrasound that exemplifies "right time, right place", and impacts decision-making at the bedside. In cases with undifferentiated hypotension, ultrasound is often the most readily available option to ensure that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential.
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http://dx.doi.org/10.1016/j.ajem.2017.08.054DOI Listing
December 2017

Sonographic localization of a retained urethral foreign body in an elderly patient.

J Clin Ultrasound 2018 May 27;46(4):296-298. Epub 2017 Jun 27.

Section of Emergency Sonography, Department of Emergency Medicine, George Washington University Medical Center, 2120 L Street NW, Suite 450, Washington, DC, 20037.

A retained urethral foreign body is an uncommon presentation in the Emergency Department. The diagnosis and treatment of retained urethral foreign bodies are determined by their size, location, shape, and mobility and often require specialty consultation and operative intervention. In this case of a 74-year-old man with a self-inserted, retained urethral foreign body, we present the utility of a bedside ultrasound to detect the depth, size, and distance from the meatus of the object to guide the approach to extraction of the object at the bedside in the Emergency Department. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:296-298, 2018.
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http://dx.doi.org/10.1002/jcu.22515DOI Listing
May 2018

The Utility of Bedside Lung Ultrasound Findings in Bronchiolitis.

Pediatr Emerg Care 2017 Feb;33(2):97-100

From the *Division of Emergency Medicine, Children's National Medical Center; †School of Medicine and Health Sciences, The George Washington University; ‡Center for Community and Clinical Research, Children's National Medical Center; and §Department of Emergency Medicine, The George Washington University Hospital, Washington, DC.

Objectives: Recent literature suggests that bedside lung ultrasound may have a role in the evaluation of infants with bronchiolitis. B lines, which are multiple and diffuse vertical artifacts spreading from the lung pleural interface to the edge of the ultrasound screen, have been associated with thickened interlobular septa, extravascular lung water, and diffuse parenchymal disease. The aims of this study were (1) to describe the prevalence of B lines in children younger than 24 months presenting to the emergency department with wheezing, (2) to determine the interrater reliability of lung ultrasound findings in this setting, and (3) to determine the association of B lines with atopy and other clinical findings.

Methods: This was a pilot, prospective, observational study of a convenience sample of patients younger than 2 years presenting with wheezing to a large academic pediatric hospital emergency department. Investigators performed lung ultrasound examinations, and a second provider reviewed the ultrasound examinations to determine interrater reliability. We performed univariate analyses to test for associations between ultrasound findings and atopy, acute illness severity, age, and treatment response.

Results: Studies were obtained on 29 patients (mean [SD] age, 291 [187] days; 62% male). Twenty-one patients (72%) had compact B lines. B lines were significantly associated with older age and an absence of atopic features. There was poor correlation of lung ultrasound examination interpretation among enrolling providers.

Conclusions: In this small sample of patients with bronchiolitis, B lines were associated with older age and an absence of atopic features. Lung ultrasound interpretation had poor interrater reliability.
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http://dx.doi.org/10.1097/PEC.0000000000000820DOI Listing
February 2017

Young Man With Dyspnea.

Ann Emerg Med 2016 Sep;68(3):275-97

Department of Emergency Medicine, George Washington University Medical Center, Washington, DC.

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http://dx.doi.org/10.1016/j.annemergmed.2016.02.006DOI Listing
September 2016

An Experiential Learning Model Facilitates Learning of Bedside Ultrasound by Preclinical Medical Students.

J Surg Educ 2016 Mar-Apr;73(2):208-14

Department of Emergency Medicine, The George Washington University, Washington DC.

Objective: To examine the effects of an experiential learning model of ultrasound training on preclinical medical students' knowledge and practice of Focused Assessment with Sonography for Trauma (FAST) examination.

Methods: The study was conducted in 2 phases. In phase 1, first- and second-year medical students participated in a 45-minute didactic presentation and subsequent 1-hour hands-on practice followed by 3-5 precepted FAST examinations in the emergency department. A pretest or posttest design was used to examine the participants' knowledge interpreting ultrasound images of the FAST examination. In phase 2, students performed FAST scans on patients with abdominal complaints under the supervision of emergency ultrasound faculty over a 1-year period. The participants were scored based on window acquisition, quality of images, accuracy of FAST scan interpretation, confidence level rated by participant, and supervising attending physician.

Results: In phase 1, 68 novice medical students participated in 11 training sessions offered over a 1-year period. Students showed significant improvement in basic ultrasound and abdominal anatomy knowledge. The mean score improved from a pretest score of 5.8 of 10 (95% CI: 5.3-6.2) to a posttest score of 7.3 of 10 (95% CI: 7-7.6). The students also demonstrated a significant improvement in FAST image interpretation (pretest of 6.2 [95% CI: 5.9-6.6] and posttest of 7.6 [95% CI: 7.1-7.9]). In phase 2, 22 students performed 304 FAST examinations on patients. At the beginning of their training when they performed less than 10 FAST scans, students were able to complete the right upper quadrant view in 88.9%, left upper quadrant view in 69.7%, subxiphoid in 64.7%, and pelvic view in 70% of scans. Across all views of the FAST examination, increasing level of practice was associated with improvement in successfully completing the examination. The absolute increase in the proportion experiencing success in the right upper quadrant view was 1.6%, 3.6%, and 6.2% for the 10-19, 20-29, and >30 groups, respectively, of which none were statistically significant. However, the improvements in the left upper quadrant view was 12.7%, 11.6%, 15.7% for the 10-19, 20-29, and >30 groups, respectively. In all views, performing >30 examinations more than doubled the odds of successfully completing the examination.

Conclusion: An experiential learning model of ultrasound training consisting of brief didactic presentation, practice FAST examinations on normal models, and proctored examinations on patients is an effective way to teach preclinical medical students basic ultrasound skills.
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http://dx.doi.org/10.1016/j.jsurg.2015.10.007DOI Listing
December 2016

Bedside Ultrasound Reduces Diagnostic Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension.

Crit Care Med 2015 Dec;43(12):2562-9

1Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC. 2Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA. 3Department of Critical Care Medicine and Anesthesiology, The George Washington University Medical Center, Washington DC. 4Department of Emergency Medicine, Shiekh Khalifa Medical City, Abu Dhabi, United Arab Emirates.

Objectives: Utilization of ultrasound in the evaluation of patients with undifferentiated hypotension has been proposed in several protocols. We sought to assess the impact of an ultrasound hypotension protocol on physicians' diagnostic certainty, diagnostic ability, and treatment and resource utilization.

Design: Prospective observational study.

Setting: Emergency department in a single, academic tertiary care hospital.

Subjects: A convenience sample of patients with a systolic blood pressure less than 90 mm Hg after an initial fluid resuscitation, who lacked an obvious source of hypotension.

Interventions: An ultrasound-trained physician performed an ultrasound on each patient using a standardized hypotension protocol. Differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. Blinded chart review was conducted for management and diagnosis during the emergency department and inpatient hospital stay.

Measurements And Main Results: The primary endpoints were the identification of an accurate cause for hypotension and change in physicians' diagnostic uncertainty. The secondary endpoints were changes in treatment plan, use of resources, and changes in disposition after performing the ultrasound. One hundred eighteen patients with a mean age of 62 years were enrolled. There was a significant 27.7% decrease in the mean aggregate complexity of diagnostic uncertainty before and after the ultrasound hypotension protocol (1.85-1.34; -0.51 [95% CI, -0.41 to -0.62]) as well as a significant increase in the absolute proportion of patients with a definitive diagnosis from 0.8% to 12.7%. Overall, the leading diagnosis after the ultrasound hypotension protocol demonstrated excellent concordance with the blinded consensus final diagnosis (Cohen k = 0.80). Twenty-nine patients (24.6%) had a significant change in the use of IV fluids, vasoactive agents, or blood products. There were also significant changes in major diagnostic imaging (30.5%), consultation (13.6%), and emergency department disposition (11.9%).

Conclusions: Clinical management involving the early use of ultrasound in patients with hypotension accurately guides diagnosis, significantly reduces physicians' diagnostic uncertainty, and substantially changes management and resource utilization in the emergency department.
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http://dx.doi.org/10.1097/CCM.0000000000001285DOI Listing
December 2015
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