Table 1 Integrated ultrasound curriculum (iUSC)

Orientation week: before classes begin

1. 50-min hands-on introductory ultrasound session: scan the neck

Fall semester: in conjunction with anatomy

1. Introductory lecture and demonstration: history of ultrasound, basic physics, definitions/terms, screen orientation, technique, “knobology”

2. Introduction to cardiac ultrasound (laboratory session)

 Left parasternal long axis view (PLAX): B-mode only; identification of heart chambers, valves, review screen orientation, knobology, depth, focus, frequency, gain

3. Neck ultrasound (laboratory session)

 Carotid artery: B-mode and color flow mode—trace from common carotid to bifurcation, transverse and longitudinal views, principles of color flow

 Internal jugular vein: B-mode and color flow mode; anatomic differences of internal jugular vein and carotid artery, shape, vessel wall, collapsibility, perform valsalva

 Thyroid gland: B-mode; thyroid (both lobes and isthmus); texture, cysts, measurements, label structures

4. Pelvic ultrasound (laboratory session)

 Urinary bladder: B-mode; identify bladder, measure volume, note artifacts like acoustic enhancement

 Ureteric jets: color flow mode; test of obstruction

5. Right and left upper quadrants (laboratory session)

 Liver, gall bladder, right/left kidney, Morison’s pouch, diaphragm, and spleen: B-mode

6. Ultrasound OSCE: scan and identify right kidney/liver/Morison’s pouch, left kidney/spleen, PLAX of the heart, carotid/internal jugular; student is also evaluated on their interaction with the standardized patient

Spring semester: in conjunction with physiology

1. Introduction to vascular ultrasound-vascular hemodynamics (laboratory)

 Common carotid artery analysis

  B-mode: transverse and longitudinal views

  Color flow: direction of flow, high quality images

  Spectral Doppler/pulse wave: principles of measuring velocity, arterial and venous pulse wave forms

2. Heart ultrasound: hemodynamics (laboratory)

 Apical 4 and 5 chamber views (B-mode and color flow mode): wall motion, valve motion, cardiac cycle with color flow

3. Cardiogenic shock: cardiac views: PLAX, apical four-chamber, subcostal (laboratory session)

 Cardiomypoathy: assess wall motion and shape of the left ventricle (LV) during cardiac cycle

 Cardiac tamponade: assess for pericardial effusion, the right ventricle (RV) size and compression with cardiac cycle

 Pulmonary embolism: assess for RV strain: size and compression with cardiac cycle; assess for RV/RA for thrombosis

Assessment: Questions are added to the physiology written examination to test understanding of physiology/ultrasound concepts in the context of a clinical case

Fall semester: in conjunction with Introduction to Clinical Medicine (ICM)

1. Ultrasound physics (review lecture): ultrasound wave formation, piezoelectric effect, tissue interfaces, common artifacts, ultrasound safety issues, ALARA (as low as reasonably achievable) principle, etc.

2. Cardiac ultrasound: standard cardiac views (laboratory session)

 Parasternal long and short axis, apical 4 and 5 chamber, subcostal; chambers, valves, wall thickness and motion

3. General abdomen (laboratory session)

 Liver, gall bladder, kidneys, spleen, urinary bladder, aorta, inferior vena cava (IVC); identify structures and measure organ size

4. Abdominal aorta assessment (laboratory session)

 AAA screening; transverse and longitudinal, B-mode, color flow and pulse wave, three measurements, characteristics that differentiate aorta from IVC

5. Lower extremity venous ultrasound (laboratory session)

 Rule out deep venous thrombosis (DVT) in femoral, saphenofemoral junction, and popliteal vein: compression test, color flow

6. Ultrasound OSCE: apical four-chamber view and identify all structures, multiple views of the abdominal aorta with measurements

Spring semester: in conjunction with ICM

1. Female pelvic ultrasound: transabdominal (laboratory session)

 Uterus, ovaries, pouch of Douglas

2. Doppler (lecture): color Doppler, spectral Doppler, power Doppler

3. Vascular ultrasound (laboratory session)

 Inferior vena cava assessment and volume status/central venous pressure estimation

4. Ultrasound-guided procedures (laboratory session with ultrasound phantoms)

 Central venous access (internal jugular vein)

 Pleural effusion detection and pleurocentesis

 Ascitic fluid/free fluid in peritoneal cavity: detection and paracentesis

5. Assessment of patient with undifferentiated shock (laboratory session)

 RUSH protocol: rapid ultrasound for shock/hypotension—assess LV function, rule out pericardial effusion/tamponade, assess for RV strain from pulmonary embolus (PE), volume status from IVC size and dynamics, scan abdomen and pelvis for free fluid, assess lungs for pneumothorax and pulmonary edema, assess aorta for rupture, assess femoral vein for DVT

Open ultrasound labs

During the first 2 years (M1 and M2) open laboratory sessions are held weekly during a time when no other classes are scheduled. Students are encouraged to come in pairs or small groups and practice their ultrasound skills on each other. At least one ultrasound faculty member is available to help with scanning and answer questions.

Pathology and problem-based learning

Ultrasound images are used in pathology lectures and in small group sessions in both pathology and problem-based learning to enhance clinical case presentations. These are opportunities to correlate clinical findings, pathological findings, and ultrasound images as they relate to clinical practice.

Hands-on training and objective structured clinical examinations (OSCE) at the end of each clerkship

1. Internal medicine

 Thyroid ultrasound: patient with a history of thyroid symptoms, after the focused history and physical exam, each student must properly scan the thyroid, identify, and measure a cyst

 Septic patient who needs central-line placement for intravenous access

2. Family and preventive medicine

 Abdominal aortic aneurysm (AAA) screen—elderly patient with risk factors for AAA, student must discuss the procedure with the patient, perform the ultrasound examination, discuss results, and educate the patient about AAA

3. OB/GYN

 OB ultrasound exam: patient is 27 weeks pregnant with a history of vaginal bleeding, student must perform an obstetrical ultrasound and determine fetal number, heart rate, placental location, and fetal position

4. Pediatrics

 Assess volume status/dehydration: 9-year old with history of nausea/vomiting and poor oral intake, student must assess volume status using the aorta/inferior vena cava ratio

5. Surgery

 Assess a trauma patient using the FAST exam (focused abdominal sonography for trauma): each student must scan a patient for trauma and assess for fluid in the chest (pleural, pericardial), abdomen, and pelvis

6. Critical care medicine

 Two-week rotation in the critical care unit: three formal teaching sessions plus daily opportunities to scan for pathology. Pathology and scanning (heart, lung, abdomen) to assess volume status with static and dynamic scans of IVC, heart function, pericardial effusion, evidence of pulmonary embolus (parasternal long and short axis, apical four-chamber view, subcostal view), pneumothorax and pulmonary edema (lung sliding, multiple B lines)

Four-week emergency medicine ultrasound elective: students spend most of their time scanning patients in the emergency room. Attending physicians ultrasound fellows work with students and review images

“Hands-on” ultrasound sessions have been added to the traditional fourth-year radiology elective

Ultrasound independent study: students can spend 4 weeks with the ultrasound faculty developing their knowledge and skill in ultrasound, assist with M1 and M2 ultrasound labs, perform literature searches, and participate in original research

Two-day Capstone ultrasound course offered at the end of the 4th year: this course stresses ultrasound skills most important for students as they prepare for internship (ultrasound-guided procedures, FAST exam, RUSH exam)

Web-based learning modules

Throughout all 4 years students have access to a series of ultrasound learning modules (topics include: history of ultrasound, physics, instrumentation, liver, cardiac, AAA, etc.)