Educational standards for training paramedics in ultrasound: a scoping review

Meadley et al. BMC Emergency Medicine (2017) 17:18 DOI 10.1186/s12873-017-0131-8 RESEARCH ARTICLE Open Access Educational standards for training paramedics in ultrasound: a scoping review Ben Meadley*, Alexander Olaussen, Ashleigh Delorenzo, Nick Roder, Caroline Martin, Toby St. Clair, Andrew Burns, Emma Stam and Brett Williams Abstract Background: Paramedic-performed out-of-hospital ultrasound is a novel skill that has gained popularity in some services in recent years. In this setting point-of care ultrasound (POCUS) can provide additional information that can assist with management and guide transport to the most appropriate facility. We sought to explore the different educational approaches used for training paramedics in ultrasound in the out-of-hospital setting. Methods: Ovid MEDLINE, EMBASE, EBM Reviews, The Cochrane Library, CINAHL plus, The Monash University Research Repository and the British Thesis Library were searched from the 1st of January 1990 to the 6th of April 2016. Google Scholar was searched and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital and POCUS educational approaches for paramedics. Results: A total of 2002 unique articles were identified of which 18 articles met the inclusion criteria. Most articles reported combined cohorts of emergency providers with varying years of experience though most operators were POCUS naïve. The most common clinical assessment for which paramedic POCUS curricula was described was the focused assessment sonography for trauma (FAST) examination. Education programs varied from two-minutes to two-days with all studies including both didactic and practical training. Conclusion: Education programs for POCUS for paramedics vary considerably, and do not appear to align with qualification level or clinical experience. Further research investigating education and subsequent clinical application of POCUS by paramedics is required, as well as prospective, outcome based studies in order to measure the clinical utility of out-of-hospital POCUS. Keywords: Out-of-hospital, Paramedic, Ultrasound, Education, Training Background The modern-day Emergency Medical Services (EMS) system is a complex network of coordinated services. Due to the challenging environment and ever-changing nature of work encountered by paramedics, the profession is continually expanding to include a greater range of clinical skills [1]. For example, recent advances have included the addition of point-of-care ultrasound (POCUS) to assist with improved patient outcomes, clinical decision making and triage [2–4]. Balancing over-triage and under-triage is important for the health-care system as a whole and the patient as an individual [5]. Clinical diagnoses alone are * Correspondence: Department of Community Emergency Health and Paramedic Practice, Monash University – Peninsula Campus, PO Box 527McMahons Road, Frankston, VIC 3199, Australia often insufficiently sensitive, leading to misdiagnoses and under-triage of some clinical conditions. In the out-ofhospital setting POCUS can provide additional information, such as earlier detection of intra-abdominal free fluid in patients with blunt trauma, and pericardial effusion in patients with penetrating thoracic trauma [2, 3]. This information can assist with management strategies, guide transport to the most appropriate facility, and potentially expedite time to definitive intervention [3]. Clinical applications of POCUS in the out-of-hospital setting include enhancing assessment of a wide range of patient cohorts, including but not limited to medical and traumatic patients [2]. For example, the Focused Assessment Sonography for Trauma (FAST) exam is used to detect free fluid in the intra-abdominal compartment [4]. The application of FAST by paramedics, emergency © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Meadley et al. BMC Emergency Medicine (2017) 17:18 physicians and flight nurses has been reported with greater sensitivity and specificity, compared to physical assessment alone, when assessing for hemoperitoneum in patients with penetrating and blunt trauma [6, 7]. Moreover, the extended FAST examination (eFAST) also includes thoracic assessment to detect for haemothorax and pneumothorax [8]. This is a time effective procedure particularly when faced with the challenges of auscultating breath sounds in the out-of-hospital environment, such as in a moving ambulance or during aeromedical transport. A diagnostic accuracy of over 90% when using POCUS to assess for pneumothorax has been reported, suggesting POCUS may be superior to other clinical assessment tools [8]. Correct identification of the presence or absence of pneumothoraces can help guide urgent interventions during resuscitation. Alternatively, this may also prevent unnecessary procedures such as pleural decompression thereby avoiding an invasive procedure that carries potential complications [9, 10]. Other applications of POCUS performed by paramedics include modified cardiac echocardiography to assess for pericardial fluid and tamponade physiology in the setting of trauma and assessing intra-arrest cardiac wall motion [2, 3]. The ability to accurately perform and interpret sonography is likely dependent on appropriate training and education of paramedics [2]. General paramedic training can vary considerably, from vocational basedtraining through to formal tertiary education at the postgraduate level. With regard to demonstrating competence in POCUS, dependence on background education appears most apparent in EMS systems that use non-physician providers, including paramedics and nurses [2]. Most studies report on EMS providers from a range of clinical backgrounds, and evidence pertaining to the clinical utility of paramedic use of POCUS is limited. A systematic review identified multiple training programs with various delivery methods, duration, and assessment [9]. Similarly, El Sayed et al. [2] and Nelson et al. [4] also discussed POCUS curricula for EMS providers in the out-of-hospital setting. These reviews report POCUS to be feasible and time effective with successful application. However, variations in training duration, and the quality of POCUS examinations by different providers are yet to be compared [4]. Presently, it appears there is no agreed curricula standards for the training of par (...truncated)