A novel approach to physician assistant ultrasound education: the fast eFAST

Abstract

Purpose

This study evaluated a novel method of teaching physician assistant (PA) students the Extended Focused Assessment with Sonography in Trauma (eFAST) point-of-care ultrasound (POCUS) examination and sought to determine the optimal workshop duration and gain feedback on workshop administration, format, and application by PA students in future clinical scenarios.

Methods

Prospective cohort analysis evaluating a POCUS eFAST training modality administered to first-year PA students. Students completed a pre-test evaluating experience and comfortability with POCUS, principles of imaging and optimization, and the eFAST exam. Researchers delivered didactic training on the use of eFAST and hands-on sessions. Students completed a post-test evaluation and demonstrated proficiency with the modality by performing an eFAST scan. The evaluation of the effectiveness of this training on knowledge and hands-on skills was determined through a statistical comparison of scores between a pre-and post-test.

Results

The cohort consisted of 16 PA students with the majority completing both the pre- and post-tests (response rate: 94%, n = 15). Post-training scores showed a significant improvement in knowledge with an increase of 77.6% (p < 0.01). All respondents (n = 14) reported that POCUS would be “Somewhat to Very Beneficial” in their future practice as PAs, with a moderate increase from Somewhat Beneficial to Very Beneficial post-training.

Conclusions

These results indicate that our novel training was effective at teaching the eFAST procedure, normal anatomy, pathology, and clinical decisions based on findings. Participants agreed that POCUS could be a valuable tool for emergency care provided by PAs.

Background

The Extended Focused Assessment with Sonography in Trauma (eFAST) is regularly used to rule out intra-abdominal or thoracic bleeding and injury [1]. Physician Assistant (PA) students rarely have opportunities as part of their curriculum to receive formal training in point-of-care ultrasound (POCUS), which includes the eFAST exam, due to the volume of material they are expected to complete in their two-to-three-year programs, yet they are expected to function in emergency settings using the latest clinical tools to make decisions [2]. However, the American Association of Physician Assistants is making efforts to create opportunities for PA students to learn these ultrasound skills [3].

Portable ultrasound has been proven to be an effective tool in diagnosing traumatic injuries and evaluating patients in a variety of prehospital and hospital settings [4]. Portable ultrasound has gained popularity, as well, in the form of a variety of handheld probes that can be used anywhere in the world. With a low-weight and portable imaging solution, clinicians can rapidly evaluate musculoskeletal injuries, assess for intra-abdominal or thoracic injury, and perform extended focused assessment with sonography in trauma examinations for cases of chest and abdominal trauma of unknown significance [5].

PAs are seeing increased employment in settings such as the Emergency Department where they can perform various procedures on patients, many of which require knowledge of complex pathophysiology, as well as in-depth knowledge of advanced practice skills and procedures [6]. Moreover, with this increase in employment and skillset, there are several PA-centric emergency medicine postgraduate training programs now available to keep up with this demand, as well as an increasing need to reduce wait times in urgent care [7, 8]. As such, PAs may find themselves in situations where eFAST could be a useful tool in making a diagnosis or performing a procedure. Therefore, receiving formal training on this modality may be advantageous for these PAs. Physician Assistant is not a title that is recognized worldwide, however many countries including the United Kingdom, Ireland, the Netherlands, and Bulgaria are utilizing PAs in ways that are similar to the United States, although some differ in scope, supervision, and independent practice [9, 10]. Some European countries do not allow PAs to order ionizing radiation, due to the lack of ionizing radiation in ultrasound, POCUS could be a valuable tool for these countries to expand diagnostic capability in primary care by PAs [2].

Ultrasound has been demonstrated to be a valuable tool in the rapid and non-invasive diagnosis of many conditions in the Emergency Room [11]. Additional studies have shown potential advantages of the eFAST in the prehospital and hospital setting including improved triage of patients, guidance of patient management, and expedited time to definitive care from the prehospital setting [4].

With our pilot of an abbreviated 2-h workshop for PA students, we hope to demonstrate the effectiveness of this training. Prior studies have shown that a mix of lecture-based and hands-on instruction of ultrasound has been effective in teaching medical students, surgical and emergency medicine residents, and military trainees, but this is the first abbreviated lecture, didactic, and competition-based 2-h instruction for a cohort of PA students [12, 13]. The current research could pave the way to extending the eFAST training workshop into PA curriculum and expanding the exposure to this portable imaging modality that is gaining popularity at the bedside and will in the near future become prerequisite knowledge to enter clinical emergency care.

Methods

IRB approval

A novel approach to physician assistant ultrasound education: the fast eFAST

IRB: 2023–260. Informed consent was collected from all participants.

Test development and data collection

We designed pre-test and post-test questions. The pre-test collected demographic information from participants and asked questions to ascertain previous experience with ultrasound, prior formal training with ultrasound, and desire to utilize ultrasound in their practice moving forward.

The pre-and post-tests both contained questions designed to test knowledge of the eFAST procedure, identify normal anatomy, identify pathology, and identify correct responses to POCUS findings. Question types included cine clips, still frames of ultrasound images, and text questions on ultrasound knowledge. The pre and post-tests included identical questions, except for the initial demographic questions. An “I don’t know” option was made available for each question on both tests to control for random-response bias.

We defined novice users as those who have never used ultrasound before and new learners as those who had used ultrasound in a casual, classroom, or otherwise nonclinical setting. Both categories indicate that a learner has never had a formal ultrasound training program, either in school or in a clinical position prior to PA school.

The test asked 14 questions (Q) that assessed individuals on (1) visualization of structures in the eFAST (Q1), (2) general pathology trends in acute abdominal trauma and eFAST application (Q2 and Q3), (3) positioning and skill for eFAST cardiac views (Q4), (4) pathognomonic findings for pathology in eFAST (Q5), (5) general abnormal findings in abdominal ultrasound (Q6), (6) evaluation of POCUS findings during eFAST (Q7), (7) limitations of eFAST (Q8), (8) identification of pathology/normal anatomy on eFAST cine clips (Q9 and Q10), (9) clinical correlations using case vignettes and POCUS cine clips (Q11), (10) clinical action decisions based on eFAST findings via cine clips (Q12 and Q13), and (11) general ultrasound knowledge (Q14).

Participants completed pre- and post-tests. These tests were web-based and used Qualtrics XM to collect responses. These tests were distributed to participants via a QR code link before any instruction and then directly after instruction occurred Table 1.

Table 1.

Test question category and specific questions with response breakdown

Participants

All Rocky Vista University (RVU) PA Students were invited to participate. There was no monetary or academic incentive other than individual education offered to students. The study utilized multiple machines for the point-of-care ultrasound scanning. These included: (1) Mindray MX-7 Ultrasound (Mindray, USA), (2) Chison Eco 5 Ultrasound (Chison Medical Technologies Co, USA), (3) Butterfly IQ + Handheld Ultrasounds (Butterfly Network Inc., USA), (4) Mindray M7 Ultrasound (Mindray, USA), and (5) Medsong Co Ltd Handheld Ultrasound (MedSong Co Ltd. China).

This study took place between December 2023 and March 2024 in the Clinical Skills Lab at RVU.

The workshop activities included:

• (1) Students completed a pre-test asking about their experience and comfortability with POCUS, demographic information, knobology (manipulation of ultrasound knobs to obtain the best images), general principles of practice and imaging, normal anatomy, pathologic images on ultrasound, and the eFAST.

• (2) Researchers then conducted didactic training on the use of eFAST, as well as a hands-on component allowing students to put the training into practice. The training modality was divided into four individual sections: lecture, group assessment, individual hands-on scanning, and group competition-style assessment. All components of the training were overseen by an emergency medicine physician.

The lecture consisted of a PowerPoint presentation that was simultaneously accompanied by a demonstration. As portions of the eFAST were displayed on the screen, an instructor demonstrated the view on a human model (volunteer). The PowerPoint included (1) an overview of POCUS, (2) an overview of eFAST, (3) an overview of normal anatomy, (4) indications and limitations of eFAST, (5) eFAST procedure, and (6) cine clips demonstrating normal anatomy and pathology.

• (3) To ensure individuals arriving at a definitive answer for multiple choice questions, a competition-style “spot the pathology” exercise was played following the PowerPoint presentation. The students were randomly divided into two groups via a randomizing formula in Excel based on their sign-in and were then tasked with arriving at the correct answers to questions faster than the other group. Each question included four normal anatomy and one pathologic cine clip. Participants had 15–30 s to identify which cine clip had pathology, what the eFAST view was, and what the relevant organs were.

• (4) After the exercise, students participated in live scanning of human volunteers with an instructor (researchers, under the supervision of a board-certified Emergency Medicine Physician and/or Trauma Surgeon). This hands-on instruction lasted for 50 min. Each student had the opportunity to complete at least 2 eFAST scans on their own and to view with an instructor present at least 6 eFAST scans with an opportunity ask questions in real time while other students were completing their eFAST scans.

• (5) Next, the students were again separated into two teams for a competition-style live scanning event. Instructors at each team had a series of 16 views that needed to be obtained by the students. Each student was tasked with obtaining a randomly assigned view (of the 16) by demonstrating proper probe positioning and identifying what they were looking at on the machine’s screen to the instructor before the next student could begin. The first team to successfully obtain all the eFAST views would win. This competition was an effort to increase the stress levels of participants, and in part emulate the pressures one might encounter in an urgent situation that requires the use of the eFAST. Each individual was not able to receive help in locating or identifying an ultrasound view and relevant anatomy, an individual was randomly assigned (name out of a hat) a view and must locate it and describe the image to the instructor before the next individual could begin. Both teams finished in under 10 min and anecdotally described their confidence in finding the images in a more time-constrained situation, and felt their confidence was increased in finding the views and anatomy in a time-constrained environment following the quiz and hands-on scanning practice. There was no time limit on this section and the individuals scanning had the opportunity to continue looking for images if another team had previously located them. The competition required that both teams find all the views to complete the competition.

Ultrasound views required for the competition: Morrison’s pouch, splenorenal recess, splenic tip, liver tip, costophrenic angle, bladder short axis, bladder long axis, kidney, pericardium, 4 chamber cardiac view, subxiphoid cardiac view, parasternal long cardiac view, retrovesicle pouch, lung slide (M/B mode).

• (6) Following the competition, students then completed a post-test which was identical to the pre-test, excepting demographic information, evaluating their knowledge of the procedure and POCUS in general.

Data analysis and assessment tool

We used Microsoft Excel (Redmond, WA) to run descriptive statistics of the data, specifically mean, standard deviations, and two-tailed t-tests. Statistical significance was set at a p-value < 0.05.

Results

Study participants

Among 35 individuals from the Rocky Vista University PA cohort, 16 individuals consented to be a part of the study and training program. Of the 19 individuals who could not participate, all cited that time conflicts due to an upcoming preclinical exam barred their attendance. Informed consent was obtained from those 16 PA students in the study. Of those 16 individuals, 15 participants completed both the pre-test and the post-test (94% completion rate, Fig. 1). One individual did not completely finish the pre-survey due to a late arrival; their post-survey results were discarded but they were allowed to undergo the ultrasound training and scanning.

Fig. 1.

Spot the pathology slide set which depicts one 2–5 s cine clip with pathology (LUQ free fluid between spleen and liver in this slide) among 4 non-pathologic eFAST cine clips. Participants had 20 s as a team to review the images and identify the positive eFAST view, identify where the free fluid was, and identify relevant organs to score the point for their team. The teams with the most points at the end of the spot the pathology exercise won.

Source: ThePocusAtlas.com (Normal FAST-RUQ, Normal FAST-LUQ, and Normal FAST- Pelvis Transverse, captured by Dr. Justin Bowra, Subxiphoid view captured by Hannah Kopinksi and Dr. Lindsay Davis—NYU Emergency Medicine)

Ultrasound experience

Of the 15 participants, the majority rated themselves as “new learners” in terms of ultrasound experience (n = 11, 73%) while the remaining participants rated themselves as “novices” (n = 4, 17%)

Perception of utility of point of care ultrasound in practice as a physician assistant

Participants were then asked if POCUS training would be beneficial in PA education. All selected the highest choice, “Very Beneficial” out of the five Likert sections (n = 15, 100).

Procedural Component, Understanding, and Knowledge Retention

On average there was a 77% increase in test score when comparing the pre-test to the post-test. The average increase in scores was determined to be statistically significant (two-tailed t test, P < 0.005). Figure 2 shows this comparison of pre-test to post-test scores by each question. Questions displayed in this figure are identical on the pre-and post-test. Results show a significant increase in correct responses in every question regarding ultrasound basic knowledge, utilization, and clinical decision-making because of the 2-h workshop.

Fig. 2.

Compilation of all pathologic cine clips used in the group competition style “spot the pathology”. All clips were between 2 and 5 s long and grouped among non-pathologic cine clips for individuals to identify the pathology.

Source: Thepocusatlas.com (Positive FAST-RUQ-Morison’s Pouch, Positive FAST- LUQ, Positive FAST Pelvis- Transverse cine clips captured by Dr. Justin Bowra, Acute traumatic cardiac tamponade captured by Dr. Sarah Medeiros, Sacramento CA)

Each participant was asked if ultrasound is a tool they would like to utilize in their future practice. Following the training “strongly agree” responses increased by 26% (from n = 9 to n = 13) and “somewhat agree” responses decreased by 27% (n = 6 to n = 2). Zero responses were recorded for the “strongly disagree”, “somewhat disagree”, or “neither agree nor disagree” options.

Test responses were separated into descriptive categories and further separated by individual questions. The table shows the average percent correct in the pre-test, the average percent correct in the post-test, and the average increase in scores separated by a question from the pre-test to the post-test.

Discussion

POCUS comprises a multitude of exams and studies, we chose to focus on the eFAST exam which utilizes basic transducer movements, looks at a variety of organs and anatomic structures, and highlights simple pathology (blood viewed as hypo-echogenicity). One of the main goals of this study was to develop a workshop that can be administered to novice users (never used ultrasound before) or new learners (had used ultrasound in a casual, classroom or otherwise nonclinical setting) of the eFAST. We developed a concise workshop, including didactic training on the use of eFAST, as well as a hands-on component allowing students to put the training into practice. Our results show that this workshop is effective, and participants rated this activity positively.

The 2 h allowed for a lecture, an interactive imaging session, 50 min of hands-on scan time in small groups with an instructor with ample time for questions and a competition exercise to reinforce skills. The effectiveness of this condensed 2-h workshop delivered to naïve ultrasound users illuminates the relative ease with which such instruction could be implemented into the PA curriculum. It also implies that an applicability for abbreviated ultrasound courses that may be extrapolated to other types of medical providers including paramedics, prehospital providers, military medicine providers, nurses, and other medical staff.

The material used to instruct represented a typical skills session in emergency medicine training, beginning with a broad overview of the skill, anatomy of the body and of the machine, normal utilization, pathology, and clinical correlations. The images sourced for the study are headline cine clips from popular POCUS learning websites which are widely used in the instruction and reference of POCUS learners new and old. These images also introduce additional resources and cine clip repositories for students to use following the training to familiarize learners with current resources and reinforce continued learning.

While this modality consisted of two hours of training, shorter than comparable workshops, other studies have shown related efficacy achieved with similar-length or longer training courses. The effectiveness of current workshop supports previous studies [14, 15] further exemplifying that a 2-h workshop was sufficient in this population. Lolar showed that PA students in an ultrasound interest group retained knowledge on eFAST after online training and hands-on scanning, but other studies have not focused on an abbreviated workshop to teach eFAST to PA students as a part of the curriculum [16].

Responses to the “Perception of Utility of Point of Care Ultrasound in Practice as a PA” question indicated that some type of ultrasound training with a focused point of care would be necessary to enhance PA education. This is in line with previous research by Parker et al. [17] and Rizzolo et al. [3] that surveyed 280 PA program directors and found that 73% had a high agreement for [ultrasound training] inclusion in curricula, this study demonstrates an opportunity for educators to include US in PA curricula. Our findings indicate that the agreement to include ultrasound in PA curricula is shared by students as well as practicing PAs and PA program directors.

Dana Miles, a PA and clinical advisor concluded that “although adding skills to the PA repertoire (especially new graduates) has added value and makes them more marketable to employers, the current barriers to POCUS training suggest that postgraduate CME or fellowship may be the best option for PAs entering a specialty that uses POCUS”. Given the academic rigor and time demands that exist in PA education, brief and effective modalities should be prioritized to optimize education. With advancements in technology and demand for more Physician Assistants to enter the workforce, we recommend integrating eFAST training in PA curriculum utilizing an abbreviated course format such as the one we present, after general instruction of anatomy and physiology of emergencies associated with trauma in the normal PA curriculum. This abbreviated format enables exposure to ultrasound while still in educational years and enables PAs to enter the workforce with a general understanding of ultrasound and the ability to perform this critical exam.

Limitations

This study has several limitations that we intend to address in future studies. First, this study is limited by sample size, we aim to increase the sample size by opening more ultrasound training to the PA class and reaching out to other schools to better represent PA education in general (power of 0.8). Additionally, the Rocky Vista University PA program does not provide hands-on ultrasound education to PA students, so the data might change at a PA program that provides ultrasound lectures and hands-on scanning time. Each member of the PA cohort that participated in the study was a first-year or early second-year student. The data might change if second-year students who have participated in clinical rotations become involved, which is a goal of subsequent studies.

The evaluation of subjects by multiple choice exam inherently contains bias, as individuals can assume there is a singular correct answer, and rather than selecting “I don’t know” may select a guess. Future studies may choose to evaluate individuals with a free response answer choice so they must determine if and what the pathology in an ultrasound image is without prompting. Additionally, individuals were not quantitatively evaluated on their ability to obtain ultrasound images on live subjects. Although everyone demonstrated a full eFAST exam without prompting by a researcher, they were not graded on their skill, nor were the live patients demonstrating any pathology. In the future, we suggest that in evaluating competency with obtaining and interpreting ultrasound images, the physical competency of the skill should also be quantitatively assessed.

The lack of follow-up further limits this study. The post-test was administered directly following the training so it is recognized that recency bias may exist in artificially inflating the post-test scores. Further research by the authors aims to evaluate the long-term retention of ultrasound skills and knowledge. The authors plan to continue trials with Rocky Vista University PA and medical school students and test long-term retention of knowledge and skills.

The authors acknowledge that with the limitations placed on time (2 h), students may maintain short-term retention of these skills, and the authors encourage follow-up studies to test the length of retention and applicability of this training to practicing healthcare workers who will be using the skill on real patients following the training. Utilizing students demonstrates a theoretical retention of skill and knowledge base, however, this skill must be applied in a clinical setting for clinical significance.

Conclusion

Point-of-care ultrasound is a rapidly emerging diagnostic tool including the eFAST as well as countless other screening and diagnostic exams and procedures. It is also widely accepted as a noninvasive, non-irradiating method of imaging patients. To expand access and availability of this tool, we have demonstrated that PA students can retain and effectively utilize ultrasound following the administration of a brief 2-h training program that covers the basics of ultrasound to the hands-on procedure of the eFAST. Our work provides evidence to integrate ultrasound training into preclinical and clinical education of Physician Assistant programs, increasing exposure to ultrasound so that by the time these students are providers they have both the understanding and the hands-on experience to utilize eFAST in their practice.

Funding

This work was supported by the Rocky Vista University Shark Tank Research Competition Grant (Grant 1). This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Rocky Vista University Institutional Review Board (March 2023, IRB: 2023-260).

Data availability

Data is available for review upon contact to the authors.

Declarations

Conflict of interest

The authors have no relevant financial or non-financial interests to disclose.

Consent to participate

Informed consent was obtained from all individual participants included in the study.