Page 59 - JSOM Winter 2021

interactive Apple iBook (Apple Inc., https://www.apple.com/) manual skills on the simulators based on a global rating
on the respective topics for each day. The online modules scale assessing image finding, image optimization, image
(about 20–25 minutes each) were self-paced and included in- acquisition speed, final image quality, and overall perfor-
teractive content and practice questions on specific ultrasound mance (global assessment). Each of these elements of per-
topics. These interactive modules were designed to build a formance was rated on a 4-point Likert scale where 1 =
satisfactory fund of knowledge prior to live instruction and Novice level (needing attention), 2 = Pre-trained novice
included the following topics: (1) basic ultrasound physics, (2) (could make adjustments), 3 = Better than novice (signif-
lung ultrasound, (3) basic TTE, (4) abdominal ultrasound, (5) icant improvement), and 4 = Almost expert. The partici-
RUSH examination, (6) ultrasound-guided regional anesthe- pants were also surveyed for their subjective overall level of
sia, and (7) ultrasound-guided vascular access. comfort with ultrasound applications on a 5-point Likert
scale (1 = Very poor; 5 = Excellent) at the beginning and
Live Instruction end of the course.
Live workshops were conducted over 5 days with two ses- 3. Workflow understanding: Taking into account the objec-
sions per day (each lasting about 4 hours). Each workshop tives of the course, a previously validated OSCE was used
13
consisted of a 30- to 60-minute lecture/review by a faculty to assess workflow understanding at the end of the course.
member, followed by hands-on practice on live models and The transesophageal echocardiography station was ex-
simulators capable of simulating both normal and pathological cluded from the OSCE as it was not covered in the ultra-
findings. Considering the use of portable ultrasound devices sound course for the medics. The five stations of the OSCE
by the medics in the field, the hand-held ultrasound probes were composed of military operational scenarios and spe-
used for live model practice included Butterfly iQ (Butterfly cific tasks to assess participants’ execution of the appropri-
Network Inc., https://www.butterflynetwork.com/), SonoQue ate practical steps to perform TTE, lung ultra sound, RUSH,
( Sonoque, https://www.sonoque.com/), and Vscan (GE Health- and ultrasound-guided vascular access and regional anes-
care, https://www.vscan.rocks/ ) probes. The simulators used in thesia (Appendix 1). Every station had a trained examiner
the course included CAE VIMEDIX (CAE Healthcare, https:// to rate participants using an objective scoring sheet com-
13
www.caehealthcare.com) and Heartworks (Inventive Medical, prising of dichotomous items (Yes/No). The maximum
https://www.inventivemedical.com) simulators, commercial scores for the stations were as follows:
phan tom models such as Blue Phantom (CAE Healthcare,
https://www.caehealthcare.com), SimuLab regional anesthesia • Ultrasound-guided regional anesthesia: 8
(https://www.simulab.com) and SimuLab vascular access mod- • Lung ultrasound: 8
els, and SimuLab venipuncture pads. The windows taught • RUSH: 11
for TTE were the parasternal long and short axis, the apical • Ultrasound-guided vascular access: 5
four-chamber, and the subcostal four-chamber and inferior vena • TTE: 10
cava (IVC) views. Both normal anatomy and common cardiac
pathologies were encountered by the medics. Lung evaluation Statistical Analysis
was focused on identifying pneumothorax and evidence for Statistical analysis was performed using Stata/Special Edition
pleural effusions and edema. The abdominal scans covered the 12.1 (StataCorp, https://www.stata.com/company/). Because
standard three-views (right upper quadrant, left upper quad- the scores on the knowledge exam were normal based on a
rant, and pelvis) of a focused assessment with sonography in Shapiro-Wilk test, a paired t-test was used to compare pre-
trauma (FAST) exam to evaluate free fluid. Specific views in- course scores to post-course scores. A p-value < .05 was con-
corporated the space between the liver and kidney (hepatorenal sidered significant. For manual skills, expert ratings of each
space or Morison pouch), the area around the spleen, and the aspect (image finding, image optimization, image acquisition
area around and behind the bladder (pouch of Douglas). These speed, final image quality, and global assessment) were ana-
workshops were supervised by attending anesthesiologists with lyzed by comparing participants’ average ratings on their first
considerable ultrasound experience and relevant certifications. three trials (baseline) to their average ratings on their last three
trials on day 4 of the course using a Wilcoxon-signed rank test.
Course Evaluation Because of multiple (5) comparisons, a Bonferroni correction
The evaluation of the course was based on the three compo- was applied, so a p-value of < .01 was considered significant.
nents of ultrasound proficiency: knowledge, manual skills, The participants’ perceived levels of comfort with ultrasound
and workflow understanding. applications before and after the course are expressed as mean
± standard deviation. For workflow understanding, the partic-
1. Knowledge: Prior to starting the course, participants were ipants’ scores on each OSCE station are expressed as mean ±
asked to complete a pre-course knowledge exam consisting standard deviation.
of multiple-choice questions on the various topics of ultra-
sound covered during the course to identify a baseline level
of knowledge. The knowledge exam was adapted from a Results
4
previously published exam. On the last day of the course, Knowledge
participants were asked to complete the post-course knowl- The knowledge exam scores of the medics improved signifi-
edge exam, which was identical to the pre-course exam to cantly from baseline with an average pre-course exam score of
maintain the same level of difficulty; the participants were 56% ± 6.8% compared to an average post-course exam score
not provided with the correct answers after completion of of 80% ± 5.0% (Figure 1, p < .001).
the pre-course exam. Performance on the knowledge exam
was scored out of a total of 28 points. Manual Skills
2. Manual skills: The expert instructors observed and pro- Based on expert ratings, the manual skills of the medics im-
vided feedback daily on the participants’ progression of proved significantly from baseline to day 4 for image finding

Ultrasound for Special Operations Medics | 57