Trauma Ultrasound Training for Latin American Countries

Abstract

Objective: The Pan-American Trauma Society (PTS) developed a Trauma and Emergency Ultrasound Course
(USET) in response to the requirement for trauma ultrasound training for low-and middle-income countries. The
objective of this study was to evaluate the efficiency of this course.
Method: Pre- and post- course tests were used. And interval estimation of proportions was calculated at 95% CI.
Theoretical and practical pre- and post-course knowledge were assessed with the Wilcoxon Signed Rank test at
0.05 level of statistical significance.
Result: Between 2005 and 2007, 114 students, including general surgeons, emergency medicine physicians,
anesthesiologists, critical care physicians, and residents of these specialties, were trained in seven countries
(Uruguay, Peru, Mexico, Venezuela, Aruba, Colombia, and Ecuador). The difference on complete knowledge ranked
scores before and after the course was statistically significant (p

Full text

Trauma Ultrasound Training for Latin American Countries
Estebanez G, Rubiano AM*, Sánchez AI, Ulloa J and Puyana JC
Trauma and Emergency Service, Department of Neurosciences, Neiva University Hospital, South Colombia University, Colombia
*Corresponding author: Andres M Rubiano, Neurosurgeon and Critical Care Physician, Chief of Trauma and Emergency Service, Professor of Department of
Neurosciences, Neiva University Hospital, South Colombia University, Colombia, Tel: +573006154775; Fax: +5788723885; E-mail: andresrubiano@aol.com
Rec date: Jul 16, 2016; Acc date: Nov 26, 2016; Pub date: Nov 28, 2016
Copyright: © 2016 Estebanez G, et al. This is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Objective: The Pan-American Trauma Society (PTS) developed a Trauma and Emergency Ultrasound Course
(USET) in response to the requirement for trauma ultrasound training for low-and middle-income countries. The
objective of this study was to evaluate the efficiency of this course.
Method: Pre- and post- course tests were used. And interval estimation of proportions was calculated at 95% CI.
Theoretical and practical pre- and post-course knowledge were assessed with the Wilcoxon Signed Rank test at
0.05 level of statistical significance.
Result: Between 2005 and 2007, 114 students, including general surgeons, emergency medicine physicians,
anesthesiologists, critical care physicians, and residents of these specialties, were trained in seven countries
(Uruguay, Peru, Mexico, Venezuela, Aruba, Colombia, and Ecuador). The difference on complete knowledge ranked
scores before and after the course was statistically significant (p<0.001). After the course, almost all participants
(97.4%) demonstrated complete knowledge in final evaluation.
Conclusion: The USET course is an effective approach for trauma ultrasound training. Specific training
programs for trauma care providers that work in low-and middle-income countries are necessary and could be
performed with low cost training programs.
Keywords: Competency; Education; Emergency; Latin América;
Training; Trauma; Ultrasound
Introduction
e successful management of trauma patients depends heavily
upon the ability of the trauma doctor to perform rapid and accurate
assessments to identify the need for, and expedite, potentially life-
saving interventions. Physical examination alone, even when
encompassing the monitoring and interpretation of patient’s vital signs,
may not provide evidence of the presence of intra-abdominal bleeding
necessitating emergency laparotomy [1].
e past 20 years has seen the utilization of FAST (Focused
assessment sonography in trauma), in the immediate assessment of the
trauma patient, become widespread [2]. is widespread acceptance,
particularly in the United States, Asia, Australia and parts of Europe,
was reected by the American College of Surgeons’ (ACS)
incorporation of FAST into the ATLS curriculum. e appeal of FAST
is that it provides a rapid, accurate and easily repeated method of
detecting, or “Ruling in”, the presence of free uid within the
pericardium or peritoneum [3]. Unlike diagnostic peritoneal lavage
(PDL), FAST represents a non-invasive investigation that is without
contraindication and yet has been shown to have similar accuracy in
multiple studies [4,5].
In the developing world, or countries with low and middle income,
FAST has the potential to play an even greater role in guiding trauma
management as oen CT scans may not be readily available [6]. e
World Health Organization’s (WHO) guidelines for essential trauma
care highlight the availability of ultrasound as “desirable”, however they
also emphasize the importance of the presence of sta skilled in
performing the procedure [7]. When considering that the accuracy,
and thus the value, of FAST is largely operator dependent it is not
surprising to discover that in numerous low income locations
ultrasound machines are present but, due to lack of training, they are
oen not utilized [8].
Whilst organized and structured training programs in the use of
ultrasound in the trauma setting are well founded in high-income
countries there is a distinct lack in low and middle-income nations,
particularly in Latin American countries (LAC). Whilst individuals in
LAC may attend ATLS courses, these only discuss the theoretical
application of ultrasound in the trauma scenario and thus only
minimal, if any, practical experience of ultrasound in trauma may be
acquired from attendance at these courses.
It was in response to this deciency in training that the Pan-
American Trauma Society (PTS) developed the Trauma and
Emergency Ultrasound Course (USET). e aim of USET was to
provide standardized and high quality ultrasound training to health
care workers, of low-middle income countries, who may frequently be
confronted with victims of trauma and medical emergencies.
e objective of this article is to evaluate the ecacy of the FAST
module from the USET course in teaching course participants in seven
countries (Uruguay, Peru, Mexico, Venezuela, Aruba, Colombia, and
Ecuador) the theoretical and practical skills of ultrasound use in the
trauma patient.
Journal of Trauma & Treatment Estebanez, et al., J Trauma Treat 2016, 5:4
DOI: 10.4172/2167-1222.1000346
Research Article OMICS International
J Trauma Treat, an open access journal
ISSN: 2167-1222
Volume 5 • Issue 4 • 1000346

Methods
e FAST module of the USET is a one-day course that was
developed by members of the PTS including a trauma surgeon, a
neurosurgeon, a vascular surgeon and an emergency physician. e
USET course is structured as two separate modules. e rst module
consists of 8 hours of training (2 hours theory, 6 hours practical) in
Focused Assessment by Sonography in Trauma (FAST); the second
module (additional 8 hours) provides theoretical and practical
teaching on the use of ultrasound in assisting the undertaking of
various emergency room procedures including paracentesis, thoracic
puncture, peripheral and central vascular access, novelty techniques for
pneumothorax and intracranial pressure detection. Additionally a
companion 187 pages USET handbook was developed for course
participant reading. e chapters include: basic concepts of ultrasound
(US), FAST, vascular US, venous thrombosis, arterial diagnose,
abdominal aorta US, emergency procedures, general surgery US,
emergency echocardiography, non-traumatic shock and US, pediatric
US, so tissue US, skeletal and muscle US, gallbladder US, gynecologic
US, obstetric US, renal US, trans-cranial Doppler and future uses of
US.
We analyzed the performance of 114 students to have undertaken
the FAST module of the USET course, throughout seven LAC. Pre-
course assessments were undertaken to evaluate the existing level of
knowledge and practical skills of the course participants. To assess the
eectiveness of the course, with specic reference to this FAST module,
post course assessments were undertaken. We evaluated student pre-
and post-course performance with 10-question examinations.
Likert Scale Meaning
Don't have any degree of
knowledge
0 appropriate answers
Have an incomplete partial
knowledge
1-3 appropriate answers
Have a partial knowledge 4-6 appropriate answers
Have a partial almost complete
knowledge
7-9 appropriate answers
Have a complete knowledge 10 appropriate answers
Likert Scale Description (Practical station)
Likert Scale Meaning
Incomplete knowledge Inappropriate maneuvers in the 4 windows
view
Complete knowledge Appropriate maneuvers in the 4 windows
view
Table 1: Likert Scale description (Pre and post-test).
Course participant’s pre and post-course tests results were analyzed
using a Likert scale. A Likert scale for the knowledge degree was
developed with choices from 1 to 5 (Table 1). Practical performance
was evaluated by instructors using a Likert scale with possible choices
of 1 to 2 during two practical sessions, one at the beginning of the
course and the second one at the end.
Regarding assessment of participants’ practical skills, instructors
completed appraisal forms which evaluated the ability of the course
participant to successfully and independently obtain adequate views of
all four FAST windows. A Likert scale ranging from 1 (uncomplete
knowledge) to 2 (complete knowledge) was allocated to each
participant according to whether all four FAST window views (Peri-
Spleen, Peri-Liver, Pelvic and pericardium) were eectively
demonstrated. e course instructors determined scores in the skills
stations by personal monitoring during the procedure.
We dened
eectiveness
of the course as the ability to improve
student performance, through comparisons of post course and pre
course assessments. Pre- and post-course knowledge tests’ results were
summarized by reporting means, standard deviations (SD), medians,
and inter-quartile ranges (IQR) and compared using non-parametric
tests (Wilcoxon and Mann-Whitney). To provide a more useful and
relevant interpretation, a description of all participants’ pre- and post-
course tests’ results in the Knowledge tests and in the Practical skills
tests were performed using absolute and relative frequencies for each
of the Likert scale scores. Dierences in proportions in Likert scale
scores before and aer the course were assessed with the Fisher exact
test. An alpha threshold of 0.05 was set to determine statistical
signicance.
Results
Between 2005 and 2007, 114 students, including general surgeons,
emergency medicine physicians, anesthesiologists, critical care
physicians, and residents of these specialties, were trained in seven
countries (Uruguay, Peru, Mexico, Venezuela, Aruba, Colombia, and
Ecuador). All participants were evaluated before and aer the course in
both knowledge and practical skills.
Before the course, four participants (3.5%) obtained the worst score
and demonstrated lack of any knowledge during the initial evaluation
(Likert scale score equal to 1), 18 participants (15.8%) scored
incomplete partial knowledge (Likert scale score equal to 2), 53
participants (46.5%) scored partial knowledge (Likert scale score equal
to 3), 35 participants (30.7%) scored almost complete knowledge
(Likert scale score equal to 4), and four participants (3.5%)
demonstrated a complete knowledge (Likert scale score equal to 5)
(Table 2).
Aer the course, three participants (2.6%) demonstrated partial
knowledge (Likert scale score equal to 3), 69 participants (60.5%)
demonstrated an almost complete knowledge (Likert scale score equal
to 4), and 42 participants (36.8%) demonstrated a complete knowledge
(Likert scale score equal to 5) during the posttest. e dierences in
the proportions of participants scoring in the Likert scale scores
between the pre and post-test were statistically signicant (p-
value<0.001).
Among all participants, the median Likert scale score in the
knowledge evaluation before the course was 3 (inter quartile range
[IQR], 3-4) and the median Likert scale score in the knowledge
evaluation aer the course was 4 (IQR, 4-5) (p-value<0.001) (Table 2).
Before the course, appropriate maneuvers during the practical skills
evaluation were observed in 24 participants (21.5%). Aer the course,
all 114 participants (100%) demonstrated appropriate maneuvers
during the practical skills evaluation (p-value<0.001) (Table 2).
Citation: Estebanez G, Rubiano AM, Sánchez AI, Ulloa J, Puyana JC (2016) Trauma Ultrasound Training for Latin American Countries. J
Trauma Treat 5: 346. doi:10.4172/2167-1222.1000346
Page 2 of 5
J Trauma Treat, an open access journal
ISSN: 2167-1222
Volume 5 • Issue 4 • 1000346

Likert Scale Pretest Posttest P-value
Knowledge test
Mean (SD) 3.14 (0.85) 4.34 (0.52) <0.001
Median [IQR] 3 [3-4] 4 [4-5]
Don’t have any degree of knowledge 4 (3.5%) 0 (0.0%) <0.001
Incomplete partial knowledge 18 (15.8%) 0 (0.0%)
Partial knowledge 53 (46.5%) 3 (2.6%)
Partial almost complete knowledge 35 (30.7%) 69 (60.5%)
Have a complete knowledge 4 (3.5%) 42 (36.8%)
Practical skills test
Incomplete knowledge 90 (78.9%) 0 (0.0%) <0.001
Complete knowledge 24 (21.1%) 114 (100%)
SD: Standard Deviation; IQR: Inter Quartile Range
Table 2: Likert scale scores in knowledge test and practical skills test before and aer the course.
Discussion
Much like the stethoscope, ultrasound is a genuinely useful, portable
and rapidly useable diagnostic tool [9]. Emergency ultrasound can be
utilized to diagnose acute life-threatening conditions, guide invasive
procedures, treat emergency medical conditions and has ultimately
improved the care of countless patients worldwide [10]. e
widespread acceptance of the FAST exam in the trauma curriculum
was conrmed with its inclusion within the ATLS course.
With improvements in the accessibility, speed and image quality of
modern multi-detector CT scans, there is a growing body of opinion
that CT should supersede FAST as the rst line imaging of
haemodynamically stable patients with blunt abdominal trauma (BAT)
[11-13]. However, whilst FAST does not claim to rival the accuracy of
CT in the detection of abdominal visceral injuries it does provide a
rapid and accurate means of triaging patients based upon the detection
of free abdominal uid [2].
is is emphasized by several studies, which found that the use of
FAST signicantly decreased the time from arrival at the emergency
department to arrival in the operating theatre [14-16]. Not only is
ultrasound safe, rapid, and portable, it is also non-invasive, painless
and unlike CT can be performed on haemodynamically unstable
patients in the resuscitation area unlike CT [17]. Unlike formalized
radiological investigations such as CT, the accuracy of ultrasound is
heavily dependent upon operator competence and the adequacy of the
training that they have received.
e USET course was established to provide formalized training in
the use of ultrasound in trauma patients in low-middle income LAC
areas that were previously without credentialed training on this topic.
e FAST module of the USET training program is a one day course
consisting of both didactic teaching and practical training in which
positive ndings of FAST are replicated using patients with peritoneal
dialysis (PD).
It should be acknowledged that the use of PD patients in the
teaching of FAST is not perfect, in that oen the kidneys may be
atrophied thus increasing the diculty with which the typical FAST
landmarks (Morrison’s and Keller’s pouches) are identied [18].
However, the benets of using PD patients for the simulation of
haemoperitoneum in FAST training are well appreciated and
additionally its application has actually been shown to improve the
learning curve of course participants [19].
e results of our study revealed that almost all (97.4%) of the 114
course participants demonstrated complete knowledge in the post-
course theoretical and practical assessments. rough the assessment
of participants post course practical skills, in addition to their
theoretical knowledge, this enabled a comprehensive assessment of the
ecacy of USET, compared to a similar smaller study in which only
theoretical knowledge assessment was conducted [6]. Our results
suggest that the USET course is eective in the education of both
theoretical and practical aspects of ultrasound use in trauma.
e ideal structure and duration of eective FAST teaching is the
subject of much debate. Recommendations regarding the duration of
time required to teach participants in the use of FAST vary from 1
hour of practical experience to educational programs lasting 32 hours
[20,21]. However, most studies support our ndings that FAST can be
taught eectively and eciently during courses lasting only one day
[22].
Whilst credentialed trauma ultrasound courses exist in high-income
nations such as the USA, Canada and the United Kingdom, the
participation costs are oen in excess of $500. e costs of travel and
course fees can be prohibitive to physicians and surgeons from Low
and middle-income countries attending and attaining formalized
credentialed ultrasound training. However, USET provides an
aordable ($150) and locally undertaken quality standardized course
through which they can eectively be taught the theoretical and
practical aspects of ultrasound use in trauma.
Citation: Estebanez G, Rubiano AM, Sánchez AI, Ulloa J, Puyana JC (2016) Trauma Ultrasound Training for Latin American Countries. J
Trauma Treat 5: 346. doi:10.4172/2167-1222.1000346
Page 3 of 5
J Trauma Treat, an open access journal
ISSN: 2167-1222
Volume 5 • Issue 4 • 1000346

Although we revealed that participants successfully demonstrated
almost complete post course theoretical and practical trauma
ultrasound knowledge, a limitation of this study is its lack of provision
of any long term, post-course follow up. Obtaining objective data
regarding the course participants’ utilization of FAST in their own
clinical environment would be valuable to analyze the accuracy of
FAST scans performed following course attendance.
e authors of this study are aware that whilst the USET course
provides a comprehensive introduction of the use of ultrasound in
trauma, upon completion of the course, participants are by no means
experts in the application of this tool. us a signicant amount of
emphasis needs to be placed on ensuring that the participants continue
to build on their acquired knowledge of FAST and hone their skills
under quality supervision within their own clinical environments.
It is recommended that aer completion of a FAST training course
that participants must perform several observed examinations prior to
being certied as competent in the application of this technique [23].
However, the required number of proctored exams is subject to much
contention. One international consensus recommends that 200
supervised FAST examinations are required whereas other studies have
concluded that satisfactory levels of accuracy are attained aer
performing only 10 supervised assessments [24,25]. is lack of clarity
has highlighted the belief that certication of competence in the use of
FAST should be based upon the individual’s competence in performing
the skill and not on the number of times it has been performed [2].
Whilst we are unable to dictate the level of post course supervision
that the participants of USET receive in their own clinical
environment, we can conclude that upon completion of the course
almost all were deemed as competent in both the theoretical and
practical aspects of FAST. Reassuringly, it has shown that in developing
countries, once the instructors have le, that participants of training
courses continue to utilize their newly acquired ultrasound skills
frequently and with a high level of accuracy [26].
Conclusion
With the increasingly prominent role of ultrasound in the
management of trauma patients there is an apparent need for
standardized and cost eective teaching on FAST and the use of
ultrasound in the trauma patient, particularly in countries with low
and middle income [10,27].
We have demonstrated that the FAST module of the USET course is
a cost eective and ecient means of teaching the use of FAST to large
numbers of individuals, within low middle income LAC, and has the
potential to improve the wide scale management of trauma patients.
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Citation: Estebanez G, Rubiano AM, Sánchez AI, Ulloa J, Puyana JC (2016) Trauma Ultrasound Training for Latin American Countries. J
Trauma Treat 5: 346. doi:10.4172/2167-1222.1000346
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J Trauma Treat, an open access journal
ISSN: 2167-1222
Volume 5 • Issue 4 • 1000346

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Citation: Estebanez G, Rubiano AM, Sánchez AI, Ulloa J, Puyana JC (2016) Trauma Ultrasound Training for Latin American Countries. J
Trauma Treat 5: 346. doi:10.4172/2167-1222.1000346
Page 5 of 5
J Trauma Treat, an open access journal
ISSN: 2167-1222
Volume 5 • Issue 4 • 1000346