1. Learning FAST Sharon Yellin MD Pediatric Emergency Medicine SUNY Downstate Fellow’s Conference March 1, 2010 Special Thanks to Dr. Jennifer Chao

2. Background Ultrasound (US) is a mandatory part of Emergency Medicine (EM) training, yet to date there is no formal Pediatric Emergency Medicine US curriculum. ACEP guidelines - EM residents must perform a minimum of 25 FAST exams before they are considered certified in this area. (1)

3. Background Many Pediatric ED’s have an US machine available, yet there is still resistance to utilize it despite its proven ability to facilitate patient care. (14) Ideal imaging modality for children -Rarely requires sedation -No ionizing radiation. (1) Specifically, the Focused Abdominal Sonography for Trauma (FAST) exam has shown great promise as a bedside diagnostic tool. (13)

4. Background Limited studies in adults have vaguely described the training residents receive as “number of hours and hands on practice” which they feel is required to learn and become confident in performing FAST. (5-8) None of these studies have been performed with children. No studies to date delineate the number of proctored FAST exams necessary to become proficient.

5. Question: How many proctored FAST exams are required to give the novice sonographer the skills necessary to accurately perform the 4 views of the FAST exam in children?

6. Methodology This will be a prospective observational study in which the subjects are 4 th year medical students interested in learning the FAST exam.

7. Methodology Inclusion Criteria -Fourth year medical students rotating in EM. -Novice sonographer. Exclusion Criteria Any student who is: - RDMS certified. - Performed more than 5 FAST exams.

8. Methodology All students will receive a two hour didactic course on basic ultrasound and FAST. At this time we will not provide any hands-on experience.

9. Methodology Patient Selection Criteria Consent from parents Age 4-12 yrs old Patient is cooperative Non-trauma patients

10. Methodology Students will be randomly divided into one of three groups: Group 1 - Will perform 5 proctored exams Group 2 - Will perform 10 proctored exams Group 3 – Will perform 15 proctored exams

11. Methodology Proctored exams will give students a chance to have hands on practice with the guidance of a trained ultrasonographer. Proctored exams will be limited to 10 minutes to standardize the training sessions. At the end of each student’s set of proctored exams he/she will be tested on performing the FAST exam without assistance.

12. Testing Each student will be given 5 min to perform 3 supervised FAST exams. –Time will begin as soon as they pick up the probe. –They must state when they have completed the exam before the supervisor can intervene. –They will then be scored on completion, accuracy and speed.

13. Methodology Scoring The student will be tested on three exams in a row. In order to achieve accuracy, student must complete all requirements on all three tested exams.

14. Scoring Sheet Methodology Did student complete exam? Y N Was exam completed within 2 min? Y N RUQ View – Completed Y N LUQ View – Completed Y N Cardiac View – Completed Y N Pelvic View – Completed Y N Did student request assistance? Y N Was probe pointed correctly Y N CARDIAC  Subxiphoid view showing both atria and ventricles Or  Parasternal long view LUQ (Perisplenic)  Show spleno-renal space (ant,post,sup,inf parts)  Show spleen diaphragm interface (Most fluid here)  Inf pole of Lt kid PELVIC  Show entire bladder and fan through (MC loc FF in kids)  Transverse & sagittal views RUQ (Perihepatic)  Show Morrison’s Pouch (area bet liver & Rt kidney)  Show area between liver and diaphragm (above/below)  Inf pole of Rt kid (paracolic gutter)

15. Methodology Proctors Must be RDMS certified OR Have completed and EM residency within the last 10 years, and certified in US based on ACEP guidelines.

16. Methodology Data collection Subject demographics; Name, age, sex, medical specialty of interest, ultrasound background (number of courses taken, lecture & hands-on practice) Scoring sheet for tested exams; Student’s name Patient Age, Sex, Wt, Ht Time to perform each FAST exam Diagram evaluating exam performance Additional comments by reviewer

17. Methodology Sample size Total of 45 students -15 in each group Sample size based on power study with the assumption that; -40% of people would achieve accuracy after 5 exams. -80% after 10 exams. -90% after 15 exams.

18. Outcomes Using descriptive statistics we will be able to provide a minimal number of proctored exams that a novice ultrasonographer requires to perform an accurate pediatric FAST exam. We will also provide information on which views may require more time and focus to learn.

19. References 1.Board of Directors. ACEP Ultrasound Guidelines Policy Statement Revised Edtion: American College of Emergency Physicians 2008; 1-38 2.Davis DP, Campbell CJ, Poste JC, et al. The association between operator confidence and accuracy of ultrasonography performed by novice emergency physicians. J Emerg Med. 2005; 29:259-264. 3.Mandavia DP, Aragona J, Childs J, et al. Prospective evaluation of standardized ultrasound training for emergency physicians. Acad Emerg Med. 1999; 6:382. 4.Bahner MD, David. AIUM Practice Guideline for the Performance of the Focused Assessment With Sonography for Trauma (FAST) Examination: J.Ultrasound Med 2007;27:313-318.. 5.Jang T, Aubin C, Hall J. Accuracy of emergency physician-performed focused abdominal sonography in trauma scan for the detection of free fluid and need for laparotomy. Ann Emerg Med. 2002; 40 :S18. 6.Jang T, Aubin C, Sineff S, et al. Resident confidence and accuracy of abdominal ultrasonography. Ann Emerg Med. 2003; 42:S88. 7.Davis DP, Campbell C, Wang J, Poste J. The influence of operator confidence on the accuracy of emergency department ultrasound. Acad Emerg Med 2003; 10:486-487. 8.Noble V,Nelson B, Sutingco N, Marill K, Cranmer H. Assessment of Knowledge Retention and the value of proctored Ultrasound exams after the introduction of an emergency ultrasound curriculum. BioMed Central. 2007;7:40. 9.Bahner D, Limperos R, Rund D. Ultrasound educational competency hierarchical outcomes: A report on the novice ultrasound user, the first year medical student. Ann Emerg Med. 2005; 46:22t. 10.Levy J, Noble V. Bedside ultrasound for pediatric emergency medicine. Pediatrics. 2008; e1404-1412 11.Chen L, Baker MD. Novel applications of ultrasound in pediatric emergency medicine. Ped Emerg Care. 2007; 23:225-233. 12.Branford J, Brown A, Rodney R. How People Learn ;Brain,mind,experience, and school. Committee on Developments in the Science of Learning. 1998;1-307 13.McGahan J, Richards J. Blunt Abdominal Trauma in Children;Evaluation with Emergency US. Radiol Clin North Am 2002; 222,749-754 14.Ramirez-Schrempp D, Dorfman D, et.al. Bedside Ultrasound in Pediatric Emergency Medicine Fellowship Programs in the United States: Little Formal Training. Ped Emerg Care. 2008; 10: 664-667.