CAEP FEI | Emergency Department Ultrasound Simulator (edus2)

In Featured Education Innovations (FEI) by Paul Olszynski8 Comments

Dr. Bowles is an avid simulation enthusiast. She enjoys adding an extra edge to her cases by adding an agitated family member or an unhelpful consultant, or by integrating images of chest radiographs and electrocardiograms. Recently, she has had the idea of integrating ultrasound images but has been limited by her presentation software to either use still images or embed a video file to play asynchronously with her learners’ use of the ultrasound probe, neither of which are ideal. She wonders whether there is a higher-fidelity way to integrate ultrasound into her simulation cases. 

Simulation and point-of-care ultrasound have revolutionized education and practice in Emergency Medicine. Combining the two is a natural extension of this momentum. This Feature Educational Innovation (FEI) was originally posted by the CAEP EWG FEI Team on January 23, 2015 and answers the question: “Is there a high-fidelity way to integrate point-of-care ultrasound into critical care simulations?” A PDF version is available here. A CAEP cast is available here.

Description of the Innovation

Background

The Emergency Department Ultrasound Simulator (edus2) is a simulated portable ultrasound device that allows for the integration of emergency department ultrasound (EDUS) into critical care simulations. Trainees using the edus2 gain the opportunity to determine whether to use EDUS (indications), demonstrate how to properly hold and place the probe (basic image generation) and interpret real patient scans (image interpretation), all within the context of a real case scenario illustrating the logistical challenges of clinical integration.

 The Innovation

The edus2 plays pre-recorded video clips of real patient scans through the coupling of those video files to specific radio frequency identification device (RFID) cards placed under the skin of the simulation mannequin. Passing the simulated probe (a USB based RFID scanner placed within a hollowed curvilinear probe) over the RFID card under the mannequin’s skin initiates the corresponding video. Multiple scans are possible during any given scenario including various thoracic, abdominal and pelvic pathologies. To our knowledge, this is the first such EDUS simulator that allows for actual use of a probe on any available manufactured High Fidelity Simulation (HFS) mannequin resulting in near seamless incorporation of EDUS into all HFS scenarios.

Conceptual Frameworks

Several key educational frameworks support the integration of EDUS during critical care simulation. Learning takes place according to Bloom’s three domains as students engage in the task through hands on use of the edus2 (1). Skill development is paired through interplay between the trainee and the instructor/preceptor. As per Cognitive Load Theory, as trainees become more proficient with EDUS (relying less on short-term memory and more so on both long-term and motor memory), they become increasingly capable of focusing on the clinical picture before them (2). Faculty may identify aspects of trainee EDUS use that require further development and subsequently can create opportunities for deliberate practice. Simultaneously, clinical competence can be assessed using Miller’s framework while recognizing the challenges inherent to the assessment of critical care skills (namely the infrequency and inability to standardize critical care encounters) (3). Lastly, Kirkpatrick’s Hierarchy of evidence allows one to assess whether transfer of learning has taken place and may help with determining whether the intervention will have any impact on actual patient care (4).

Limitations

The edus2 is not appropriate for teaching image generation – the skill of generating quality images is best learned on real patients while under the direction of a qualified instructor.
We have made this educational innovation available to other training institutions on a not-for-profit basis (creative commons copyright). In hopes of achieving greater collaboration we have designed a website (www.edus2.com) at which other departments and programs can access all software and instructions required to run an edus2 at their own site while also being able to offer feedback and add to the video library. New users can freely download the software code and accompanying videos for use in their own institution. Additionally, each site is responsible for supplying its own laptop, USB based RFID scanner, RFID cards and machine stand.

References

1. Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals.  Handbook I:Cognitive domain. New York: David McKay Company.
2. van Merrienboer, J. J., & Sweller, J. (2010). Cognitive load theory in health professional education: design principles and strategies. Med.Educ., 44(1), 85-93.
3. Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Acad.Med., 65(9 Suppl), S63-S67.
4. Kirkpatrick, D. (1996). Revisiting Kirkpatrick’s four-level model. Training and Development, 50, 54-59.

What are ways you throw “curveballs” to your learners during simulation to increase the level of complexity? Does your institution have ultrasound machines available in the simulation lab and how have you used them?

More About the CAEP FEI

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers. 

Daniel Ting
Daniel Ting is an emergency medicine resident at the University of British Columbia. His interests include narrative writing, professional identity formation and mentorship. Daniel leads the “Great Evidence in Medical Education Summary” series on CanadiEM.
Paul Olszynski

Paul Olszynski

Emergency Medicine Physician at Saskatoon Health Region
Canadian emergency physician and a fan of all things ultrasound, simulation, and #FOAMed! Pursuing MEd and promoting POCUS EM while on a short sabbatical in London, UK.
Paul Olszynski

@OlszynskiP

MD, MEd, CCFP (EM) Emergency physician, Director of Clinical Ultrasonography (UGME, PGME & CME), promoting Clinical Ultrasound, Simulation, and FOAMed!
RT @AstroKatie: Be like Daphnis. https://t.co/b2JSsH6hUm https://t.co/NDpYHUqGMq - 22 hours ago
  • Brandon Ritcey

    We just finished building out own edus2 simulator at the University of Ottawa thanks to the great work by Olszynski et al. We’re extremely grateful for all the work you’ve put into designing this software and can’t wait to integrate it into our simulation program!

    • That’s great to hear! Any creative examples/plans of how you plan to integrate it into the learner curriculum?

      • Brandon Ritcey

        Nothing hugely creative yet, we’ll be starting with the basics by adding to the pre-existing set of simulation cases that our simulation program uses on a rotating basis. I think what comes next is building new, more challenging cases where the ultrasound findings are key to guiding the resuscitation to highlight the uses of ultrasound in these difficult scenarios. I’m also hoping to integrate it into our in-situ simulation program where we do simulation “drills” right in the department with our usual department staff.

        • Brandon Ritcey

          For anyone else thinking of building an edus2 simulator, it was actually very easy despite the initially intimidating appearance of the instructions on http://www.edus2.com. I built a working model in one evening with a 10 year old decrepit laptop and about $50 worth of materials ordered off the internet (which are listed on the website).

          It took a few more days to built something that looked like an ultrasound probe to fit as a casing over the RFID reader, and then we spent another $150 on another used laptop to just enjoy the benefits of a bigger screen. But altogether it took a few evenings of work and about $200 to build our machine, which is seriously worth the effort and cost.

          • Great to hear! I’ll have to bring it up with my group.

          • @brandonritcey @adamthomas I smell a multicentre trial here… We should let Paul know!

          • Adam Thomas

            Now thats a good idea!

    • Adam Thomas

      Victoria too! Such an awesome tool to really bring SIM to the next level!!!

      Thanks guys for all the work!