This is a longitudinal educational curriculum initiated by the organizers of CES. CES recruits motivated Mexican physicians who are entering a government-required social service year (pasantes) to staff each of the 10 rural clinics. The supervisors in the organization are physicians who have completed their social service requirement are responsible for the education of the pasantes, administrative responsibilities, arranging transfer of patients, and oversight of the clinics. There are 6–8 supervisors each year and each one oversees 1–3 clinics. The ultrasound curriculum focuses on the supervisors since they are retained in the organization for a longer periods of time, travel between the clinics that they oversee, and are responsible for teaching the pasantes.
The instructors for the educational sessions included a Pediatric Emergency Medicine (PEM) physician, an Emergency Medicine (EM) physician, a PEM fellow, and two upper level EM residents from the University of Louisville. An Obstetrician from Harvard University/Brigham and Women’s Hospital was the instructor for the session on obstetric ultrasound. Both faculty members from the University of Louisville have extensive bedside ultrasound experience and have taught ultrasound at major national and international conferences.
The course lasted 4 days and it recurred every 3–4 months with different topics at each course. All the material was presented in English because all of the participants were fluent in English. The first 1.5 days were spent in the main offices with lectures (4 h) and hands on training (5 h) on healthy volunteers. The class ratio was 6–10 learners per two instructors. Then, they split up into two groups, each led by one of the ultrasound instructors, and went to the rural community clinics to ultrasound patients with known relevant pathology for the next 2 days (approximately 6–7 h each day). Prior to initiation of the course work, a needs assessment was conducted with the local physicians to determine the most relevant topics and the regional pathologies that are commonly encountered. The curriculum was then adjusted accordingly. All topics were covered over the 12 total months of the curriculum (four sessions). The total lecture time over the four sessions was 16 h and total hands-on time with healthy volunteers was 20 h. In addition, the trainees also received a total of 8 days, 6–7 h per day of hands-on training and bedside POCUS training on patients with known relevant diagnoses over the entire course. This added another 48–56 h of hands-on training to the course. The intent of breaking the course up into multiple sessions was to avoid overwhelming the learners and giving them time to master a couple POCUS topics before moving to the next ones. Multiple trips also allowed the opportunity to review interesting cases, technique, and individual competency from the previous topics. As most supervisors remain in their positions for several years, they re-review the material annually.
The investigators helped CES obtain four refurbished Sonosite nanomaxx ultrasound machines, each with low frequency (phased array) and high frequency (linear) probes. The supervisors were responsible for the ultrasound machines and took turns taking the machines with them to the clinics which they oversaw. Each supervisor had a machine for 2 weeks at a time and brought it to the clinics he or she supervised. While there, they worked with the pasante to schedule ultrasounds at the clinic for patients in the community who would benefit from imaging. They could also ultrasound patients if needed as they came into be evaluated. This gave the supervisors the opportunity to show the pasantes some concepts and uses of POCUS. Occasionally there would be case when ultrasound was urgently needed in one of the clinics and the supervisors would communicate and coordinate a way to get the machine to that clinic for that specific patient.
The first teaching session was in September 2015 and focused on introduction to ultrasound, care and use of the machine, focused assessment with sonography in trauma (FAST), evaluation of the kidney and bladder, and basic obstetrics. The next session was in February 2016 and it included lung ultrasound, skin and soft tissue, and musculoskeletal. The third session was conducted at the end of April 2016 by an OB/GYN physician and was focused on obstetrics. The fourth session was July 2016 and it reviewed ultrasound basics and then focused on cardiovascular, advanced abdomen, and ocular. The presentations from each session were left with the participants for their reference and review. At the completion of the curriculum, the investigator continued with two trips per year as a review and had 3–4 web based series of cases with images to review and discuss to promote long term competency.
There was an ultrasound log with each machine which documents the type of ultrasound conducted, reason for the study, presumed diagnosis, and if the ultrasound findings confirmed or changed the presumed diagnosis for the patient. The information included the patient’s initials, age, gender, and date of study. Lastly, the log contained the initials of the physician performing the ultrasound and site of the study. By providing the type of ultrasounds, it allowed the investigators to track the number of the different studies that were conducted and where more or less time should be spent in the future curriculum. By tracking the number of ultrasounds for each supervisor, the investigators could provide additional resources to those who were not as comfortable using the machines. Every 1–2 months, the supervisors brought the ultrasound logs to the monthly educational conferences where they were compiled from all the clinics, copied, and sent back to the primary investigator for review. The primary investigator transferred the information into a spreadsheet and each study was given a de-identified number and the initials of the person who received the study removed.
De-identified images were loaded onto a Google drive folder for review and feedback. The primary investigator reviewed the images for technique, quality and findings. Feedback was provided at each of the sessions or sooner via email as necessary. The primary investigator was available to review any images urgently if requested for clarification. This educational intervention was reviewed by the University of Louisville Institutional Review Board and deemed to be exempt. In addition, the study was reviewed by CES research committee and received approval to conduct this educational intervention.