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?
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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. [bg_faq_end]
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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.
Daniel Ting is an Emergency Physician and Clinical Assistant Professor at the University of British Columbia, based in Vancouver. He is the Editor-in-Chief of CanadiEM and a Decision Editor at the Canadian Journal of Emergency Medicine. He completed the CanadiEM Digital Scholarship Fellowship in 2017-18. No conflicts of interest (COI).
