Dr. Dan Katz and Dr. Eric Savitsky describe how they created a cloud based training solution for ultra sound training.

This is a three-part series that uses a case study to describe the introduction of disruptive innovation into medical education and training. The first installment describes identifying an unmet need in medical education and creating a cloud-based training solution. The second installment reports the process of successfully guiding a nascent educational technology from an idea into a successful commercial product. In the final installment, the authors detail the rapidly changing dynamics of medical education and how next-generation simulation products will need to address future challenges.

A stab-wound victim is rolled onto a gurney by paramedics within a trauma bay, while physicians, nurses, techs, and other emergency healthcare providers stand by waiting to go to work. “We have a twenty-four year-old-male here with multiple stab wounds to the chest and abdomen. He was stable en route but is now decompensating!” shouts the paramedic over a sea of voices and noises. “Most recent vitals are a heart rate of 115, respiratory rate of 34, blood pressure of 60 over palp, and 85 percent oxygen saturation on a non-rebreather mask.”

The trauma team springs into action placing intravenous catheters and assessing the patient. Various medical equipment and devices flood the trauma bay: ventilators, infusion machines, vacuum devices, equipment carts, and tubes of all shapes and sizes. Upon completing the primary survey, a team member immediately reaches for an ultrasound machine and begins to perform an eFAST (extended Focused Assessment with Sonography in Trauma) examination. She applies ultrasound gel to select points along the patient’s body, places the probe on the gel, and, in a matter of seconds, assesses the patient’s internal anatomy and discerns pathologic findings.

The initial eFAST scan shows evidence of a left-sided pneumothorax and hemoperitoneum. “We need to insert a left-sided chest tube and initiate a massive transfusion protocol immediately,” announces the physician. While the rapid transfusion of blood products is initiated, a hiss of air is heard as the chest tube is inserted into the patient’s left pleural cavity. Within moments, the patient’s oxygen saturation and other vital signs begin to improve and the patient is promptly transferred to the operating room for an exploratory laparotomy. This physician was able to rapidly integrate information obtained from an eFAST exam and make a correct and expedient therapeutic decision that resulted in a favorable patient outcome. Similar life-threatening situations play out on an hourly basis in emergency departments throughout the world, with point-of-care ultrasonography as a focal point in the evolution of patient care.

The eFAST exam is a very important application of point-of-care ultrasound. Point-of-care ultrasound refers to the use of portable ultrasonography at a patient’s bedside for diagnostic (e.g., symptom or sign-based examination) or therapeutic (e.g., image guidance) purposes. Kendall et al. defined the characteristics of point-of-care ultrasound (Table 1) (Kendall, 2007). Point-of-care ultrasound is rapidly becoming the preferred imaging modality for discrete indications across multiple clinical specialties. Advances in ultrasound technology have fueled the emergence of point-of-care ultrasonography, including improved ease-of-use, superior image quality, and lower cost ultrasound units.

Table 1: Characteristics of Point-of-Care Ultrasound
·       Exam is for a well-defined purpose linked to improving patient outcomes
·       Exam is focused and goal-directed
·       Exam findings are easily recognizable
·       The exam is easily learned
·       Exam is quickly performed
·       Exam is performed at the patient’s bedside
Some medical experts have suggested that personal ultrasound machines will one day replace the iconic physician stethoscope (Wittenburg, 2014). Like the stethoscope, ultrasonography is safe, noninvasive, and highly operator dependent. While traditional methods of performing a physical examination will remain critically important, practitioners that become skilled in the use of point-of-care ultrasonography also become uniquely empowered. Conditions such as cardiac valvular disorders that are inferred by auscultation can be visualized and quantified by ultrasound. Time-sensitive definitive diagnoses such as a ruptured abdominal aortic aneurysm or cardiac tamponade are made in minutes rather than hours. Kobal et al. demonstrated the value of attaining competence in ultrasonography during medical school. He found that first-year medical students with only 18 hours of ultrasound training outperformed seasoned cardiologists in detecting various cardiac abnormalities (Kobal, 2005).

Ultrasound procedural guidance has been shown to limit infection rates and decrease discomfort for patients during vascular access procedures and prevent iatrogenic complications during invasive procedures (AHRQ, 2001). Ultrasonography is among the safest imaging modalities in modern medicine. In fact, ultrasound is used to image delicate structures such as unborn children, in part because ultrasound waves contain no ionizing radiation. Comparatively, X-rays and CT scans are typically contraindicated in pregnant patients. Point-of-care ultrasonography has the potential to save hundreds of millions of dollars on an annual basis across health systems. It has the capacity to revolutionize patient care and improve procedural efficacy, decrease complications, and limit patient discomfort (Kendall 2007, Moore 2011, AHRQ 2001, Kobal 2005, Wittenburg 2014).

Bedside Ultrasound’s Unfulfilled Promise

In recognition of ultrasound’s potential to improve health care, the American Medical Association passed resolution #802 in 1999, asserting that all medical specialties have the right to use ultrasound in accordance with specialty-specific practice standards. Despite decreases in the cost and physical size of ultrasound units, as well as improvements in image quality and functionality, widespread adoption of ultrasound by practitioners has continued to lag. For example, in recent surveys, point-of-care ultrasound was only used in 34 percent of emergency departments in California and in only 19 percent of nonacademic emergency departments in the United States. (Moore, 2006, Stein 2009) If ultrasound has so many benefits, why have so few healthcare providers integrated it into daily practice?

There are several significant barriers that have historically hindered widespread ultrasound adoption. Point-of-care ultrasound is a highly operator-dependent modality. A practitioner must be able to acquire a desired ultrasound image, optimize the image, interpret the image, and integrate the information into clinical decision-making. Developing ultrasound competency and applying ultrasound findings towards clinical care is a complex process. It requires integrated psychomotor (optimal image window acquisition) and cognitive (image interpretation) skills. The extremely high opportunity cost of training healthcare providers is another critical barrier to ultrasound adoption. Optimal training requires: (1) a qualified instructor; (2) trainees; (3) an ultrasound machine; and (4) a patient with a pathologic (abnormal) condition. All of these elements must come together in one physical space and time, and the process must repeat itself, with new patients representing alternative pathologic conditions presenting over time. It may take months or even years before a care provider is able to scan a sufficient number of patients with certain pathologic conditions (e.g., leaking abdominal aortic aneurysm) to develop competence, especially if these clinical presentations are rarely encountered. The inability to train on sufficient numbers of pathologic cases is a recognized impediment to ultrasound competency. Similarly, the assessment of ultrasound competency is another obstacle to ultrasound adoption, which requires a similar set of resources.

The Groundwork for Future Success

A seemingly unrelated grouping of disparate activities provided a solution to these longstanding barriers to ultrasound adoption. Dr. Eric Savitsky, a UCLA Professor of Emergency Medicine, was heavily involved in international humanitarian efforts upon becoming a UCLA faculty member in the late 1990’s. He founded and served as Executive Director of the UCLA Center for International Medicine (CIM), a non-profit organization dedicated to improving global health through education, training, and technology. The UCLA CIM initially specialized in sending volunteer healthcare providers overseas to provide medical education and training. After organizing multiple medical missions, he recognized the limitations of relying upon short two- to four-week “train-the-trainer” trips. Specifically, it was difficult to maintain long-term impact when training staff returned to the United States.

In response, the UCLA CIM began developing computer-based, medical training programs that sought to provide a portable, cost-effective, and sustainable training experience. The UCLA CIM evolved into a leading developer of computer-based, “train-the-trainer” medical education programs that were used by a variety of international and non-governmental organizations, including the United Nations, International Rescue Committee, and Project HOPE.

One challenge that presented itself was how to successfully train international staff to perform invasive procedures. Computer-based training was ideal for didactic instruction, but was not conducive to developing psychomotor procedural skills. At the time, the need for hands-on training still dictated the need for in-country training resources. Through his international work, Dr. Savitsky also witnessed first-hand the tremendous global potential for ultrasound to save lives in resource-constrained settings. This strong foundation in computer-based medical education and experience with digital multimedia programming would prove highly instrumental in the years that followed.

Concurrently, in his role as the UCLA Emergency Medicine Director of Trauma Services and Education, Dr. Savitsky was an early adopter of ultrasound at the UCLA Medical Level I Trauma Center. Apart from expediting the care of trauma patients, Dr. Savitsky appreciated the tremendous value of ultrasound in a skilled operator’s hands, including superior clinical acumen and diagnostic accuracy. In 2001, his belief in the potential of point-of-care ultrasound motivated him to spearhead an effort to train his fellow colleagues on performing FAST exams in trauma settings. However, Dr. Savitsky was rapidly confronted with the high opportunity costs associated with ultrasound training, and recognized that limited access to certain pathologic conditions would hinder the development of ultrasound competence amongst healthcare providers. He also identified additional unmet challenges to the successful integration of ultrasound into clinical practice including maintaining ultrasound skills, assessing for ultrasound competency, and ensuring quality assurance.

An Unusual Source of Inspiration

While attending an E3 Consumer Electronics Show in Los Angeles, in attempt to stay abreast of the latest digital multimedia technologies, Dr. Savitsky had an epiphany. He was able to identify a group of seemingly unrelated technologies that could all operate at the intersection of digital media, health, and education. He used this inspiration to team with a group of UCLA researchers and scientists to begin work on a computer-based tool for procedural training. He was hopeful that providing computer-based, hands-on skill training would solve the procedure training difficulties encountered by the UCLA CIM in a scalable and sustainable way.

By 2004, Dr. Savitsky had invented a novel approach to providing integrated didactic instruction, hands-on training, and knowledge assessment using a laptop computer. It involved interweaving traditional storytelling with digital multimedia elements, real-patient ultrasound imagery, and motion sensing technology. This advance in medical education would help address the problem of how to efficiently train, assess, and provide refresher training for large numbers of individuals seeking to learn how to perform ultrasonography.

The newly developed intellectual property was successfully transitioned by Dr. Savitsky to the UCLA Office of Intellectual Property and Technology Transfer, and subsequently into the private sector. Over the ensuing years, through a combination of federal research dollars and multiple Small Business Innovation Research (SBIR) awards and grants, the invention transitioned into a full-fledged consumer product. The end result was the development of the SonoSim® Ultrasound Training Solution, which was taken to market by a company called SonoSim. The SonoSim® Ultrasound Training Solution is marketed as a breakthrough product that overcomes the longstanding barriers to ultrasound education by providing integrated didactic instruction, hands-on training (simulation), and knowledge assessment. It has a cloud-based architecture that enables delivery of anytime-anywhere ultrasound education via Mac or PCs.

The Evolution of an Ultrasound Training Solution

In 2011, the National Center for Research on Evaluation, Standards, and Student Testing (CRESST) performed an independent study comparing the effectiveness of SonoSim’s SonoSimulator® versus live instructor-based FAST ultrasound learning (Chung, 2011). The study found that “participants who received simulation-based practice scored significantly higher on interpreting ultrasound images,” and that “there were no statistical differences between the two conditions on scan time, window acquisition, and window interpretation.” The study concluded that the SonoSimulator® was a promising new ultrasound training tool.

The SonoSim® Ultrasound Training Solution was able to overcome the historical barriers to ultrasound training. SonoSim’s didactic courses are streamed to end-users from a cloud-based server in an interactive multimedia format using still and dynamic ultrasound imagery, audio narration, computer graphic imagery, and animation. Ultrasound cases obtained from real patients allow for an on-demand, authentic ultrasound scanning experience. End-users learn the exact probe movements expert sonographers used to scan the original patients. The training replicates the tactile experience of using an actual ultrasound probe to scan a real patient. User interactions can be tracked, analyzed, and reported for purposes of competency assessment and refresher training.

Medical institutions and physicians are under constant pressure to deliver more specialized and efficient patient care. In response, undergraduate medical education programs will need to seek alternatives to traditional time-based approaches to curricular design to prepare students for these challenges. Recent technological advances have provided an opportunity to simultaneously usher in an era of performance-based medical school curricula. In response, SonoSim’s cloud-based architecture enables rapid scaling and worldwide delivery of digital content. Cloud-based simulation has important performance tracking and assessment implications that will help educational institutions address future challenges. These issues will be further explored in future articles of this series.

About the Authors

Dr. Dan Katz is an Emergency Medicine Physician at Cedars Sinai Medical Center in Los Angeles, CA and is VP of Business Development for SonoSim. Eric Savitsky, MD is a Professor of Emergency Medicine at the University of California at Los Angeles (UCLA) and is the inventor of the SonoSimulator®. Brian Bernstein is a Marketing Associate at SonoSim, Inc., and holds a B.A. degree in economics from the University of California, Los Angeles. Brady Grover is the Sales and Marketing Coordinator at SonoSim, Inc., and holds a B.S. degree in business management from Pepperdine University.

References

Agency for Healthcare Research and Quality (AHRQ). Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment, no. 43, 2001.

Chung GKWK, Gyllenhammer RG, Baker EL. The effects of practicing with a virtual ultrasound trainer on FAST window identification, acquisition, and diagnosis. Los Angeles (CA): National Center for Research on Evaluation, Standards, and Student Testing (CRESST); 2011. Report No. 787.

Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med. 2007 May;35(5 Suppl):S126-S130.

Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005 Oct1; 96(7) 1002-1006.

Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med 2006; 47:147-153.

Moore CL, Copel JA. Point-of-Care ultrasonography. N Engl J Med. 2011 Feb 24; 364(8): 749-757.

Stein JC, River G, Kalika I, et al. A Survey of Bedside Ultrasound Use by Emergency Physicians in California. J Ultrasound Med 2009; 28:757-763.

Wittenburg M. Will ultrasound scanners replace the stethoscope? BMJ. 2014 May 29; 348:g3463.