ORIGINAL ARTICLE | Case series: Point-of-Care Ultrasound Conducted by Medical Students During their First Clinical Rotation Changes Patients’ Primary Diagnosis and Management

BACKGROUND

Point of care ultrasound (POCUS), a rapidly evolving area in medicine, has become an integral element of the physical examination, leading to its integration in medical schools’ curricula. As POCUS is an operator-dependent modality, it is essential that the POCUS operator is highly skilled to correctly achieve the different ultrasound views and interpret them accurately. Therefore, introducing POCUS training as early as during medical school may be beneficial.

Ben-Gurion University of the Negev (BGU, Israel) has become invested in educating its medical students to perform POCUS at a sufficient level of expertise. Since 2017, each class takes an eight-hour-long POCUS course taught by senior intensive care unit (ICU) physicians and cardiologists. The purpose of the course is to integrate POCUS into the physician’s daily practice and to teach how to improve the traditional physical examination utilizing the POCUS exam. In this course, medical students are trained to perform ultrasound exams in echocardiography as well as focus assessment sonography in trauma (FAST) exams and lung ultrasound.

Thus, recently graduated physicians acquire POCUS skills that senior doctors may not possess, and therefore putting the former in a unique position. Senior medical staff might not be familiar with POCUS or have the awareness of the advantages this resource provides in early diagnosis and treatment.

The purpose of this manuscript is to describe certain cases where the use of POCUS augmented the physical examination and changed the primary patient diagnosis and management. The objective of this case series is to provide a glimpse into the capabilities of POCUS even when used by medical students.

METHODS

This case series was initiated retrospectively by 3 fourth-year medical students at Ben-Gurion University in Be’er Sheva, Israel, who recorded their POCUS exams during their internal medicine rotation.

Pre-internal Medicine Rotation POCUS Course

The training focuses mainly on the principle of transthoracic echocardiographic views providing the capability to perform and analyze all basic cardiac ultrasound views and included:

• Two-hour-long lecture of cardiac ultrasound anatomy
• Two hours of cardiac ultrasound pathologies interpretation
• Four hours of hands-on training of cardiac ultrasound and
• Two hours of lung ultrasound views, including pathologies and focused assessment sonography for trauma (FAST) performance and interpretation

Students practiced on cardiac and lung simulators and on their colleagues using pocket and cardiovascular ultrasound devices. At the end of the 10-hour course students’ proficiency was evaluated based on a 6-minute views test described elsewhere.

Internal Medicine Ward Rounds

During the fourth year of medical school (a six-year program), all students rotate through internal medicine for three months. This was their first clinical rotation and was taken in various wards at Soroka University Medical Center.

Students Performing POCUS During Their First Clinical Rotation

Students were encouraged to incorporate POCUS in their first patient assessment as part of the physical examination. After the students completed the admission process, they were required to present their patients to the medical resident taking care of the patient as well as presenting the POCUS findings to ultrasound experts at the time of the examination or via recorded video of the examination, when available. In most internal medicine wards, physicians were not trained in POCUS and therefore, the physicians presented in this study did not go through similar training.

RESULTS

In this case series, the authors present four cases in which medical students contributed to the assessment and treatment of these patients by adding important clinical findings as a direct result of POCUS. This review summarizes one of these cases.

Case 1

A 40-year-old female with medical history of hypertension was admitted and diagnosed with Cushing Syndrome. She was eventually discharged and then readmitted to the hospital one month later due to dyspnea on exertion and dizziness, presumably unrelated to the diagnosis of Cushing Disease.

She was examined by a fourth-year student during the first clinical rotation, who also performed a POCUS examination, which showed significant global right ventricular (RV) hypokinesis and enlargement that was not known to the primary team. The medical team was notified by the student; the POCUS findings, concomitant leg edema, and relative immobilization raised the concern for a pulmonary embolism. A pulmonary CT angiography test was ordered, revealing significant bilateral pulmonary embolisms. Appropriate treatment was initiated. Three days later, the patient improved significantly and was discharged from the medical center.

CONCLUSION

The authors point out that we practice medicine in a transitional time where POCUS has entered the curriculum of some medical schools, but many senior and experienced physicians do not hold this new bedside capability. This created a reality where medical students can use ultrasound to ‘see into their patients’ when other physicians may only be comfortable to auscultate, palpate or percuss.

They describe how medical students in their first clinical rotation were able to change diagnoses of four internal medicine patients when POCUS was incorporated into the traditional physical examination. Their findings altered medical therapy and management.