College of Medicine Evolution of Clinical Anatomy with Ultrasonography Past Present and Future Andrew F. Payer, Ph.D. Human Body Structure and Function Module Director Christine Bellew, M.D., Caridad Hernandez, M.D., Juan Cendan, M.D. Alfredo Tirado-Gonzalez, MD Health Sciences Campus at Lake Nona
Goals of Presentation Describe: the historical evolution of medical imaging and ultrasonography in anatomy education the successes and challenges of infusing ultrasonography into anatomy education Relationships with other modules in the curriculum Future directions of ultrasonography in an integrated structure and function module
Spectrum of Curricular Experiences 100+ year old medical school 1973-2001 Traditional curriculum PBL curriculum track Hybrid curriculum New Medical school -2001-2006 Hybrid curriculum New Medical school 2006 - present Integrated/hybrid curriculum
Anatomy Education Evolution Past Classical Anatomy course in traditional curriculum little or no medical imaging Anatomy consultant for PBL Track medical imaging in most in clinical cases Anatomy course in hybrid curriculum clinical cases with medical imaging and rarely ultrasound imaging
Anatomy Education Evolution Past Anatomy course in new medical school more clinical cases with medical imaging and more ultrasound imaging 1 Sonosite portable unit in lab Ultrasonographer in lab each week Few exam questions with ultrasound imaging Disclaimer that ultrasound is for educational purposes and not diagnostic
Anatomy Education Evolution Past Another new medical school Human Body Structure and Function module Anatomy, microanatomy, physiology, neuroanatomy, embryology and medical imaging 17 wks. Began with 1 Sonosite unit and emergency medicine physician, then added an ultrasonographer
Anatomy Education Evolution to the Present 6 ultrasound units 2 Sonosite units and 4 GE Venue units Using structured time in simulation labs for ultrasonography during anatomy lab sessions Including simulated patients Increased clinical faculty participation i.e. - Internist, general surgeon, pediatric nephrologist, emergency medicine, endocrinologist, Ob/Gyn Include self learning modules
Layout of the laboratory experience
Whole-body CT imaging of every cadaver in the laboratory Dr. Richard Ramnath
Anatomy Laboratory Assignments Red Team 3 members ½ lab team Responsible for dissections of the week Responsible to teach the Blue Team members Blue Team 3 members ½ lab team Responsible for medical Imaging and ultrasonography for the week Responsible to teach the Red Team members Teams change roles each week
Ultrasonography sessions 16 medical imaging teams would cycle as four groups through a 1 hr. hands on imaging session during a 4 hour lab session Regional anatomy over 2 weeks so all student were able to do ultrasonography of a region For each student group - One standardize patient, an ultrasound unit and one clinical faculty for each group during the hour session Provide an ultrasound check list for a region Faculty included: surgeon, general internist, emergency medicine and pediatrician Occasionally sports medicine, cardiologist, endocrinologist
Simulation Center Fridays from 8am - 12pm Ultrasonography Schedule 8am - 8:50am 9am - 9:50 am 10am - 10:50am 11am - 11:50am October 19 1-4 5-8 9-12 13-16 October 26 13-16 1-4 5-8 9-12 November 2 13-16 1-4 5-8 9-12 Nomember 9 9-12 13-16 1-4 5-8 November 16 9-12 13-16 1-4 5-8 November 23 - NO LAB None None None None November 30 5-8 9-12 13-16 1-4 December 7 5-8 9-12 13-16 1-4 December 14 1-4 5-8 9-12 13-16 December 21 1-4 5-8 9-12 13-16 January 11 13-16 1-4 5-8 9-12 January 18 13-16 1-4 5-8 9-12 January 25 9-12 13-16 1-4 5-8 February 1 9-12 13-16 1-4 5-8 February 8 5-8 9-12 13-16 1-4
Neck Ultrasound Checklist Session Objectives 1. Select appropriate ultrasound transducer for viewing structures in the neck. 2. Demonstrate the ability to obtain ultrasound images of the thyroid, vasculature, and muscles in the neck. 3. Identify and differentiate structures in the neck (thyroid, carotid artery, internal jugular vein etc.) as seen on ultrasound. Tasks to be completed A. Knobology 1. Turn on machine 2. Locate key buttons (mode, Doppler, gain, calipers, freeze ) 3. Select appropriate settings 4. Choose the correct transducer to image the neck 5. Adjust settings (depth, frequency, gain) as necessary B. Neck Structures 1. Thyroid a. Right and left lobe (transverse and longitudinal plane) b. Isthmus 2. Common carotid artery a. Longitudinal and transverse plane b. Bifurcation 3. Internal jugular vein a. Longitudinal and transverse plane 4. Muscles a. Sternocleidomastoid b. Anterior and middle scalene 5. Brachial plexus 6. Trachea C. Bonus Structure 1. Esophagus Done
Abdominal Ultrasound -1 Checklist Session Objectives 1. Select appropriate ultrasound transducer for viewing abdominal structures. 2. Demonstrate the ability to obtain ultrasound images of the liver, spleen and gallbladder. 3. Identify and differentiate intra-abdominal structures (liver, spleen etc.) as seen on ultrasound. Tasks to be completed A. Knobology 1. Turn on machine 2. Locate key buttons (mode, Doppler, gain, calipers, freeze ) 3. Select appropriate settings 4. Choose the correct transducer to image the abdomen 5. Adjust settings (depth, frequency, gain) as necessary B. Intra-abdominal structures 1. Liver a. Describe hepatic echotexture b. Hepatic vein confluence c. Liver / diaphragm interface 2. Gallbladder a. Sagittal and transverse plane b. Portal triad 3. Spleen a. Sagittal and transverse plane b. spleen / diaphragm interface C. Bonus Structures 1. Duodenum Done
Abdominal Ultrasound -2 Checklist Session Objectives 1. Select appropriate ultrasound transducer for viewing abdominal structures. 2. Demonstrate the ability to obtain ultrasound images of the kidneys, abdominal aorta and inferior vena cava. 3. Identify and differentiate retroperitoneal structures (kidneys, aorta etc.) as seen on ultrasound. Tasks to be completed A. Knobology 1. Turn on machine 2. Locate key buttons (mode, Doppler, gain, calipers, freeze ) 3. Select appropriate settings 4. Choose the correct transducer to image the abdomen 5. Adjust settings (depth, frequency, gain) as necessary B. Retroperitoneal structures 1. Kidneys a. Describe echotexture of the kidney (cortex vs medulla) b. Right kidney 1. Longitudinal and transverse views 2. Hepato- renal recess c. Left Kidney 1. Spleno-renal recess 2. Abdominal Aorta a. Transverse and longitudinal view b. Branches 1. Celiac trunk 2. Superior mesenteric artery 3. Bifurcation of the aorta 3. Inferior vena cava a. Transverse view b. Longitudinal view (junction with right atrium) C. Bonus Structures 1. Pancreas 2. Right and left renal arteries 3. Left renal vein Done
Ultrasonography during anatomy laboratory sessions
Ultrasonography in Practice of Medicine module
Charts created to illustrate transducer placement and angle
Ultrasound Pathology???? Most students and standardized patients will have normal findings Challenge was --- how to show some pathologic ultrasound images Current solution use SonoSim to demonstrate abnormal images
Use of ultrasound simulator to demonstrate pathology
Evaluation of Ultrasound Knowledge Questions in the laboratory practical examination Questions in the module written examination Exercises in the Practice of Medicine module occurring concurrently with Structure and Function module
. What innervates the structure at the arrow?
. Name the main hormone that affects the function of the structure labeled with a star?
. The blood in the structure labeled with a star will drain into what structure next?
Plans for the future in the structure and function module Continue the anatomy ultrasound experience Include ultrasound pathology Further integration with the Practice of Medicine physical examination section Include integration of physiology into the ultrasound experience
Ultrasound Physiology Cardiovascular physiology: Demonstrate normal hemodynamic function of wall and valve motion, contractility and flow through all cardiac chambers. Vascular physiology: Introduce basic concepts of color flow and Doppler to demonstrate direction of flow; recognize of arterial and venous waveforms.
Ultrasound Physiology continued Hepatobiliary system: Demonstrate gallbladder function from fasting to postprandial state. Genitourinary system: Assess bladder function, by measuring bladder in different planes and estimating volumes before and after fluid intake. Observe bladder jets as they empty into the bladder by use of power flow Doppler with a very low pulse repetition frequency.
Assessment of Ultrasound Knowledge and Skills Anatomy laboratory practical examination Structure and Function module written examination OSCEs in the Practice of Medicine module Senior electives in ultrasonography, i.e., emergency medicine, cardiovascular, genitourinary.
Successes Successes and Challenges Applied clinical anatomy in medical imaging complimented by ultrasound experience More clinical faculty becoming comfortable with using/teaching anatomical and clinical ultrasonography Students relating ultrasonography skills to clinical experiences with their clinical preceptors Application of clinical anatomy ultrasound experiences to learning the physical examination High satisfaction level of students and faculty
Successes and Challenges continued Challenges Early reluctance of clinical faculty to participate because of: Unfamiliarity with ultrasonography Not able to recognize the differences between normal and abnormal ultrasound images Training sessions for clinical faculty Cost for ultrasound units and simulators Increasing medical student enrollment
Use of clinical equipment for teaching and learning and not for diagnostic purposes Clinical Equipment and Procedures Used During the University of Central Florida College of Medicine Curriculum I understand that a variety of clinical equipment and procedures (i.e. physical examination, ultrasonography, ECG, spirometry) will be made available as a part of the educational program in the College of Medicine. The use of such equipment between medical students is for the purpose of learning how to properly use the equipment for procedures on future patients. I understand that this equipment and the procedures will be done only as teaching and learning tools, and are not designed to be utilized to diagnose disease or organ abnormalities. I further understand that the use of this equipment and the procedures on my own body is voluntary. My participation or non-participation of having ultrasonography on my body will not affect my evaluation in the respective module(s), nor be considered as part of my final grade. The medical students doing these procedures or using such equipment are not licensed physicians or practicing medicine. College of medicine faculty will be supervising these activities. Student signature Print student name Date
Reports include findings; Gross pathology Microscopic pathology CT images No ultrasound images of cadaver, but related images from literature Module ends with cadaver autopsy reports
Questions Andrew F. Payer, Ph.D. Professor of Anatomy Univ. Central Florida College of Medicine 6850 Lake Nona Blvd. Orlando, FL 32827-1131 Phone 407-266-1131 Phone 850-294-4217 cell Fax - 407-266-1199 E-mail andrew.payer@ucf.edu