The use of simulators for training in echocardiography is not novel. The use of simulator for measuring technical (psychomotor) skill in surgery is also not novel.
The feature that we introduce is using simulation to measure competence in the technical skill of image acquisition. Current practice is for faculty to visually gauge trainee competence in ultrasound. The simulator now permits quantitative and objective measurement of technical skill in acquiring images. Cognitive skill in making the correct diagnosis from images can also be evaluated.
Left: The simulator comprises a mannequin, a mock transducer, and a computer. In this first version, the transducer position and orientation on the mannequin are tracked using a magnetic field system.
As a user ŇscansÓ the mannequin, a three-dimensional (3D) ultrasound data set is cut into a two-dimensional (2D0 ultrasound cine loop at the plane that corresponds to the position of the transducer on the mannequin. Each 3D data set was previously recorded from a patient and registered to the mannequin. The 2D image is displayed on the computer monitor. For training, a 3D reconstruction of the patientŐs heart chambers is also displayed to help users understand the anatomy they are seeing in their 2D images. The 3D display also shows where the transducer is scanning in the heart.
Left: Example of 2D ultrasound image cut from a 3D data set, with inset showing the mannequin, 3D heart reconstruction, and pointer to the view plane. In the reconstruction, the left atrium and left ventricle are in red and the right atrium and right ventricle are in blue. The pointer indicates the position and orientation of the mock transducer. In this example, the parasternal long axis view that was acquired (light blue plane) differs from the correct, anatomically defined view (green plane) by only 0.7 mm in location but the angular error is 29.1ˇ.
The competence assessment measures the positional accuracy of each view plane in terms of location and angle. The correct view plane is defined using anatomic landmarks from the 3D reconstructions. For example, the 4-chamber view is the plane that contains the centroid of the mitral annulus, the centroid of the tricuspid annulus, and the apex of the left ventricle. Error in location is measured as distance in the center of the view between the acquired view and the correct view.
Left: The acquired image is displayed side by side with the optimal image for each view for visual comparison.
Image interpretation is performed after the user has finished imaging the heart, as is the clinical routine. The images are displayed for review, and questions on findings and diagnoses are presented.
This simulator was developed with funding from:
The Edward J. Stemmler, MD, Medical Education Research Fund of the National Board of Medical Examiners
The Coulter Foundation for Translational Research
The objective of this project was to develop a method to measure procedural competence in an objective and quantitative manner. The procedure targeted was osteotomy for repair of femoral malunion, a condition in which the femur failed to heal properly following a fracture and the patient is left with a deformed and dysfunctional leg.
The training interface presents a clinical case to the user along with antero-posterior (AP) and lateral x-rays of the leg. The first task is to measure the deformity in terms of the angular deviation from the contralateral leg, which is assumed to be normal.
Left: User interface for calculating angle of deformity.
The user then performs the osteotomy on a simulated bone by sawing out a wedge. The plane of the cut is measured from a three-dimensional (3D) reconstruction of the bone generated by imaging laser lines projected onto the cut bone while rotating the bone.
Left: Imaging apparatus. The bone is secured in a vertical position on a rotating stage. The laser and camera are behind the door.
Left: Surface mesh of cut bone with plane of cut identified at top (gray plane). The anatomically defined correct cut is also shown (red plane). Error is measured in terms of the difference between the planes in angle and position.
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