World J Surg DOI 10.1007/s00268-013-2408-8

Focused Assessment Sonography for Trauma (FAST) Training: A Systematic Review Alshafi Mohammad • Ashraf F. Hefny Fikri M. Abu-Zidan



Ó Socie´te´ Internationale de Chirurgie 2013

Abstract Background The aim of this study was to systematically review the different methods for training Focused Assessment Sonography for Trauma (FAST), course design, and requirements for hospital credentialing. Methods We searched MEDLINE/PubMed, EMBASE, and the Cochrane database and performed a manual search of selected papers. All papers and abstracts written in English that studied training and education of FAST were included. Papers were critically evaluated, looking into training methods and models of FAST, their advantages and disadvantages, number and type of training hours, practice exams in the course, and number of cases advised to achieve hospital credentialing. Results A total of 52 studies were critically analyzed. The theoretical part of the courses lasted over a median (range) of 4 (1–16) h (n = 35 studies), while the practical part lasted over a median (range) of 4 (1–32) h (n = 34 studies). The participants performed a median (range) of 10 (3–20) FAST exams during the courses (n = 13 studies). The most commonly used model was the normal human model (65 %), followed by peritoneal dialysis patients (27 %). The least used models were animal (4 %) and cadaveric models (2 %). Each of these models had their advantages and disadvantages. The median number (range) of FAST exams needed for credentialing was 50 (10–200) (n = 19 studies).

A. Mohammad  A. F. Hefny  F. M. Abu-Zidan (&) Trauma Group, Department of Surgery, College of Medicine and Health Sciences, UAE University, PO Box 17666, Al Ain, United Arab Emirates e-mail: [email protected]

Conclusion Standardization of FAST training is important to improving the clinical impact of FAST. Different models used in FAST training are complementary; each has its own advantages and disadvantages. It is recommended that FAST courses be at least 2 days (16 h) long. The first day should include 4 h of theory and 4 h of training on normal human models. The second day should enforce learning using animal models, case scenarios including video clips, or simulators.

Introduction Focused Assessment Sonography for Trauma (FAST) is a fast, accurate, and useful bedside diagnostic tool for the management of blunt trauma [1, 2]. It differs from the more comprehensive ultrasound examination because it answers a specific question: ‘‘Is there fluid in the abdomen or pericardium of this injured patient?’’ [3, 4]. FAST training, credentialing, and performance improvement have been widely advised [5]. FAST training is now included in postgraduate residency programs and undergraduate education [6, 7]. Actually, FAST courses are the most common courses for general surgeons compared with laparoscopic, breast, endocrine, and vascular courses [8]. Those who are not radiologists and have no previous experience in sonography can achieve good results after training. Nowadays, even paramedics and nurses are competent in FAST [9, 10]. There are different strategies and models that can be used in the FAST training courses, each has its own advantages and disadvantages. We aimed in this study to systematically review the different methods for FAST training, their course design, and requirements for hospital credentialing.

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Methods Three databases were searched for articles on FAST training, including MEDLINE/PubMed, EMBASE, and the Cochrane Library, which includes four databases: Cochrane database of systematic reviews (CDSR), database of abstracts of reviews of effectiveness (DARE), Cochrane controlled trials register (CCTR), and Cochrane review methodology database (CRMD). A manual search of the References section of the hard copy of the selected papers was performed at a later stage. The search included articles in the period from 1966 to 2013. The inclusion criterion was papers or abstracts written in English that were on the training and education of ‘‘Focused Assessment Sonography for Trauma,’’ defined as a ‘‘focused study to detect free intraperitoneal, pericardiac, or pleural fluid.’’ Articles with the primary objective of developing models or training for detection of pneumothorax were excluded. Due to the specific definition of FAST and possibly the small number of papers in this area, we decided to use general terms to widen our search. Terms used were ultrasound, training, teaching, FAST, ‘‘Focused Assessment Sonography for Trauma’’. This search was first done in January 2012. Since retrieving, critically reading, analyzing, and summarizing the papers takes time, this search was repeated twice in July 2012 and January 2013 so as to find new published papers. Appendix 1 shows the terms used for searching and the number of articles found. Selection of papers Abstracts of all the articles found using the search strategy in Appendix 1 were downloaded and read and all possibly relevant articles to FAST training were selected. Articles that did not have an abstract initially were included in the study list. Relevant articles that were available on the website were downloaded. Articles not available on the website were retrieved through The National Medical Library, College of Medicine, UAE University. All selected articles could be retrieved through our library. The final list of articles included 38 that were located through MEDLINE, and another 14 additional studies, including seven abstracts, were retrieved through EMBASE and the Cochrane Library. Finally, a manual search of the references of the selected papers was performed but it did not yield any additional articles. Thus, a total of 52 articles and abstracts were used for this review (Appendix 2). Data extraction and analysis Papers were critically evaluated, looking into the different training methods and models of FAST, their advantages and disadvantages, number and type of training hours,

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practice exams in the course, and the number of cases that different authors advise to handle to achieve hospital credentialing.

Results and discussion Aims and objectives of FAST training courses The purpose of FAST training programs is to introduce the principles of FAST, familiarize trainees with the technology, give them an opportunity to handle the ultrasound machine in a proper way, discuss the debate about FAST, and let the trainees practice and perform FAST exams [11–13]. Structure of the FAST courses FAST training should consist of didactic training (ultrasound physics, indications, and technique), practical handson training, and real-life clinical training by scanning trauma patients [3, 14]. There are important technical factors that should be considered during training, including identifying sonographic artifacts [15]. Trainees should identify the difference between ‘‘noninterpretable’’ images if the anatomic structures are not clearly seen, and ‘‘misinterpretation’’ when the findings are present but are missed by the operator. Furthermore, ‘‘poor gain’’ is the result of unclear views of anatomical structures, while ‘‘poor depth’’ is when the area of interest is outside the focal range of the probe [16]. During training sessions, image interpretation should be done under supervision and in accordance with specialty-specific goals [17]. There is great variation with respect to the hours recommended for didactic, hands-on training and the number of exams performed in these courses. Forty papers and abstracts had data for analysis of the structure of these courses. The theoretical part of the courses lasted a median (range) of 4 (1–16) h (n = 35 studies) (Fig. 1a). The practical part of the courses lasted a median (range) of 4 (1–32) h (n = 34 studies) (Fig. 1b). The participants performed a median (range) of 10 (3–20) FAST exams in these courses (n = 13 studies) (Fig. 1c). Training methods Different methods and models that have been used for FAST training are listed in Table 1. The most commonly used model was the normal human model (65 %), followed by peritoneal dialysis patients (27 %) and patients with pathological intraperitoneal fluid-like ascites (23 %). The least used models were animal and cadaver models. Table 2 summarizes the advantages and disadvantages of these models which are discussed in detail below.

World J Surg Table 1 Different models used for Focused Assessment Sonography for Trauma (FAST) training Model type

No. of studies

Percentage (%)

Normal model

31

64.5

Peritoneal dialysis

13

27

Pathological fluid

11

23

Videotape

11

23

Simulator

7

14.5

Animal model

2

4

Cadaver Not specified

1 4

2 8.3

Total number of studies, n = 48

stripe views [22] are used to teach ultrasound basics and demonstrate how to perform the examination [23]. Video can test the student’s ability to identify positive and negative exams [20]. Trainees considered dynamic human videos more relevant and realistic compared with porcine models because the porcine abdominal anatomy is different from humans [24]. Videos are easily available and are inexpensive [24, 25]. Nevertheless, their image quality is relatively low compared with the real clinical FAST exams [22]. Furthermore, video clips demonstrate pathological findings but do not teach practical skills. Animal models

Fig. 1 Number of courses with a different theoretical hours (n = 35 studies), b practical hours (n = 34 studies), and c FAST exams performed by participants (n = 13 studies)

Human models FAST educators usually use normal human models for practical training. These models are easily available and helpful for demonstrating normal anatomical landmarks. They are excellent for hands-on training in viewing the pericardium, right and left upper quadrants, and pelvis [12, 18]. Students trained on human models achieve good results in image acquisition, interpretation, and acquisition time [19, 20]. The ability to detect intraperitoneal and pericardial fluid improved after training using normal human models [21]. Nevertheless, these models do not have abnormal findings. Video clips Video tapes and clips are used as an educational tool to show anatomical landmarks, and different-sized anechoic

The pig is the most commonly used animal for teaching FAST [23]. It is useful for training surgeons to detect different volumes of fluid in the thoracic and abdominal cavities despite its limitations [26]. Different amounts of saline can be infused into the peritoneal and abdominal cavities to simulate different degrees of difficulty. One liter of saline is enough to obtain good-quality FAST images in a 20-kg pig. More experienced sonographers may detect a minimum amount of 50 ml of intra-abdominal fluid and 25 ml of intrathoracic fluid [23, 26]. Nevertheless, the pig is anatomically different from humans: its pelvis is shallow, the liver occupies most of the left upper quadrant, the spleen is thin and long, and the kidneys are not adjacent to the spleen and the liver as in humans, which causes difficulty in identifying anatomical landmarks [23, 24, 26]. Peritoneal dialysis models One advantage of the peritoneal dialysis model is that the sonographic appearance of dialysate is similar to that of blood in a positive FAST study [14, 18]. Different amounts of dialysate can be instilled and drained so as to improve the student’s skill in estimating the amount of free fluid [5, 27]. Therefore, peritoneal dialysis models are a reasonable

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World J Surg Table 2 Advantages and disadvantages of different FAST training models Training model

Advantages

Disadvantages

Normal human [3, 19, 20, 33, 49–51]

Best anatomic landmark study, excellent hands-on model, highly suitable for better image interpretation and image acquisition, practice can be translated into real-life, safe and easily available

Not enough to be completely skilled. Ability to detect pathologic features can’t be obtained

Videotapes [20, 22–25]

To show anatomic landmarks, different sized anechoic stripe views, show ultrasound artifacts, test the ability to identify positive and negative exams, cheap and easily available

No practical or Hands-on skill can be obtained, image quality is not as clear or sharp as in real time bedside exam

Animal (swine) [23, 24, 26, 52]

Feasible to learn US principles relative to FAST, different amount of fluid can be infused into thoracic and abdominal cavity to detect different degrees of difficulty, excellent for detailed intra-thoracic and intra-abdominal studies, clinically relevant

Less ideal, anatomically different, fluid distribution different from humans, shallow pelvis, liver occupies most of LUQ, long and thin spleen, kidney are not adjacent to liver and spleen as in human, difficulty to identify landmarks in RUQ

Peritoneal dialysis [5, 14, 18, 27]

Dialysate mimics hemoperitoneum, different amount of dialysate can be instilled and drained so both small and large amount of intraperitoneal fluid can be observed, positive studies can be experienced, a reasonable substitute for injured patients

Non-standard anatomy, atropic or polycyctic kidneys, some don’t make urine or have small volume bladders causing poorer acoustic window, dialysate needs to be removed and re-instilled periodically, the rheology of dialysate compared with blood might affect the results

Cadaver [28]

Excellent as an anatomic landmark and hands-on education model, detailed intra- abdominal study can be obtained, different amount of fluid can be instilled for a good positive study, eliminates the risk of patient, provides same information and experience as a trauma patient

Intra-abdominal fluid volume can only be tested in sequential aliquots and can’t reliably be removed during a test

Simulator [18, 19, 29]

Impersonates scanning experience, stores’ patient data in 3-D images, real time images can be reconstructed by scanning on mannequin, repeatedly introduce normal and abnormal images, eliminates the need of normal and abnormal models

Difficulties with acquiring proper image in real-life, difficult to mimic rib artifact when spleen is visualized, not suitable for detailed intra-abdominal study

Computerbased [30–32, 53]

Does not require much time in scheduling or introducing topics, provides multimodal educational environment, can be repeated without any cost, provides potential to teach learners with great flexibility, advantage to access lectures on an individual computer, view presentations online many times

Trainees can be distracted by other applications in the computer, technical difficulties might be observed, not possible to ask questions during the lecture presentation, unable to track the time passed between viewing the online lectures and completion of posttest, less effective in an individual with no prior FAST training

Studies that did not highlight the advantages and disadvantages of the models were not included in the table

substitute for injured patients [27]. Hands-on training using these models improved the ability to detect small volumes of intraperitoneal fluid [18, 27]. Nevertheless, many peritoneal dialysis human models have atrophic or polycystic kidneys, and some have no urine causing a poor acoustic window [5]. Furthermore, the rheology of dialysate might affect the results [5]. These disadvantages, besides the low availability of humans on dialysis, limit the use of this training model [18]. Cadaver training models Using fresh cadavers for FAST training by introducing different amounts of fluid into the abdominal cavity improves the student’s skill in performing and interpreting a positive FAST scan. A fresh cadaver simulates the real trauma patient better than plastic models or computer simulators. Therefore, trainees can translate acquired skills into a real clinical scenario [28]. Nevertheless, the fluid

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inserted cannot be reliably removed. Furthermore, cadavers for training are not widely available. Simulators Simulators can store a patient’s data as three-dimensional images. With a simulator trainees can view real-time images while scanning a mannequin and they provide an objective method for teaching and evaluation. Normal and abnormal images can be shown repeatedly [19]. Residents trained on simulators were as good as those trained on patients. Simulators reduce the need for patient models and allow training in a safe environment [19, 29]. This technology provides a standardized educational experience [18]. Nevertheless, it has its own limitations. Some practical tips, like avoiding the rib artifacts, cannot be taught. Furthermore, simulators are not suitable for studying the details of intra-abdominal organs which can be done in human or animal models [26].

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Computer-based training Computer-based training is a new way to teach didactics instead of attending traditional lectures. Classroom-based teaching is labor-intensive and can be restricted by time. Computer-based training does not require much time in scheduling or introducing topics. It is effective, provides a multimodal educational environment, and can be repeated without any additional cost. Moreover, it provides great flexibility for learning [30, 31]. Trainees can repeatedly observe the online lectures. Nevertheless, they can be distracted by other computer applications or experience technical difficulties. It is also not possible to ask questions during the lecture presentation or track the time passed between viewing the online lectures and completing the post-test. Furthermore, didactic sessions in traditional classrooms are more enjoyable and more effective, especially for individuals who have had prior FAST training. Students pay more attention during classroom lectures and can freely ask questions [30–32]. Recommendations for credentialing Criteria for training and credentialing vary widely in the published articles and include the number of examinations and the quality of training required for credentialing [33– 35]. We found 19 papers and abstracts that addressed the number of FAST exams needed to be performed for credentialing, with the median (range) being 50 (10–200) (n = 19 studies). The accuracy of FAST results improves with increased experience [36, 37]. There is evidence that a number as few as ten clinical examinations is enough to pass the learning curve of FAST [3, 35]. In contrast, Vassiliadis et al. [38] have shown that trainees who had done fewer than 15 FAST examinations had higher false-negative results. At the other extreme, the majority of participants of an international consensus recommended 4 h of didactic training and 4 h of practical training and a minimum of 200 supervised FAST exams for credentialing [33]. A surgeon cannot learn sonography without seeing some positive examinations [18, 19, 33]. Therefore, a minimum number of positive FAST exams is necessary for trainees to gain the ability to detect pathological findings [27, 33]. We have to point out that sonographic learning skills and confidence in them vary widely among trainees, especially when it comes to making critical decisions. Trainees should be evaluated by continuous monitoring and auditing. Jang et al. [39] found that the operator’s confidence correlated well with improved accuracy in sonographic examinations and suggested that trainees should pursue more extensive training to gain confidence. Eighty percent of Canadian residents indicated that they need at

least 20 practice examinations to be confident about their FAST exams [34]. Therefore, training guidelines should not only focus on the minimum number of prior examinations but should also account for the operator’s confidence. An individual cumulative sum analysis curve that individualizes the learning curve of each trainee may be the best way for judge the development of the learning curve [35, 40]. Sequential measurements of success (correct diagnosis of FAST) or failure (wrong diagnosis of FAST) on a graph gives an objective assessment of performance accuracy of an individual over time. The slope will go up when the number of failures is more than the accepted failure rate while it goes down when the observed number of failures is lower than the accepted failure rate [40]. Limitations of the study We have to acknowledge that we did not critically evaluate papers published in all databases or data that were not published; this may have caused a sampling bias [41]. The minimum requirement for an accepted systematic review is to review two databases [42]. We searched three databases in addition to hand searching the references of the studied papers; we hope that this reduced the sampling bias. It is important to stress that we have studied only the educational methods of teaching ultrasound detection of free fluid in the chest and abdomen, which is the easiest skill to learn. FAST has evolved over time. Initially, it was 3P-FAST that looked for fluid in three regions (perihepatic, perisplenic, and pelvis). The pericardiac region was then added and FAST became 4P-FAST [1]. Later on, the use of FAST was extended to both pleural recesses and it became a 6P-FAST [43]. Finally, detection of the pneumothorax was added and FAST became an extended FAST (E-FAST) [31]. Different alternative expanded protocols for ultrasound in trauma patients have been developed and tailored for different specialties. For critical care physicians, E-FAST PLUS focused on the trachea, lungs and pleural pathology, and rib fractures [44]. The RUSH (Rapid Ultrasound in SHock) protocol was developed to evaluate the heart, lung, abdomen, inferior vena cava (IVC), and aorta in shock patients [45]. Ultrasound has been used in the prehospital setting. The FASTER trial evaluated the value of FAST when performed by critical care retrieval physicians whilst in-flight [46]. The CAVEAT protocol was developed for the use of portable ultrasound in mass casualty situations and includes evaluation of the chest, abdomen, vena cava, and extremities for acute triage [47]. Finally, The World Interactive Network Focused on Critical Ultrasound (WINFOCUS) is presently developing a multifocused FAST ABCDE protocol with an approach similar to that of the ABCDE of the Advanced Trauma Life Support (ATLS) course [48]. The evaluation of these different educational courses was beyond the aim of the present study.

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It is important to note that we did not evaluate the clinical effect of FAST training on trauma mortality, which is the final goal of this educational activity. The results of FAST will depend on three factors: the operator’s experience, the quality of the ultrasound machine, and the patient population. The results of FAST differ depending on the prior probability of injury. The probability that a person with a positive FAST actually has bleeding (positive predictive value) will increase with increased prior probability of bleeding (e.g., in a hypotensive patient). In contrast, the positive predictive value of FAST will significantly drop if FAST is routinely performed in mild trauma cases. This argues against the routine use of FAST in all trauma patients. The outcome of routine use of FAST will vary between a level I trauma center (treating patients with high prior probability of injury) and community hospitals receiving patients with low probability of injury.

Table 3 continued Database

EMBASE

Cochrane

Terms

Results (articles)

1. Ultrasound trauma training

779

2. Ultrasound trauma teaching

493

3. FAST trauma training

348

4. FAST trauma teaching

115

5. ‘‘Focused Assessment Sonography for Trauma’’ and training

2

6. ‘‘Focused Assessment Sonography for Trauma’’ and teaching

Nil

1. Ultrasound trauma training

3

2. Ultrasound trauma teaching

4

3. FAST trauma training

1

4. FAST trauma teaching

4

5. ‘‘Focused Assessment Sonography for Trauma’’ and training

3

6. ‘‘Focused Assessment Sonography for Trauma’’ and teaching

2

Conclusions Standardization of FAST training is important to improve the clinical impact of FAST. Different models used in training FAST are complementary; each has its own advantages and disadvantages. It is recommended that FAST courses be at least 2 days (16 h). The first day should include 4 h of theory and 4 h of training on normal human models. The second day should reinforce learning using animal models, case scenarios including video clips, or simulators. This will assure that trainees are properly prepared to go through a planned credentialing process to optimize the clinical outcome. Conflict of interest The authors have no conflicts of interest or financial ties to disclose.

Appendix 1 See Table 3. Table 3 Search strategy Database

Terms

Results (articles)

PubMed

1. Ultrasound trauma training

774

2. Ultrasound trauma teaching

520

123

3. FAST trauma training

305

4. FAST trauma teaching

180

5. ‘‘Focused Assessment Sonography for Trauma’’ and training

62

6. ‘‘Focused Assessment Sonography for Trauma’’ and teaching

38

Appendix 2 List of the studied articles and abstracts in alphabetical order Abu-Zidan FM, Dittrich K, Czechowski JJ, Kazzam EE (2005) Establishment of a course for Focused Assessment Sonography for Trauma. Saudi Med J 26:806–811. Abu-Zidan FM, Sio¨steen AK, Wang J, al-Ayoubi F, Lennquist S (2004) Establishment of a teaching animal model for sonographic diagnosis of trauma. J Trauma 56:99–104. Adkins EJ, Nunley D, Dresbach S, Bahner DP (2012) Incorporation of focused ultrasonography into a critical care training fellowship: Validation of an educational model. Acad Emerg Med 19 Suppl 1:S249–S250. Ali J, Campbell JP, Gana T, Burns PN, Ochsner MG Jr (1998) Swine and dynamic ultrasound models for trauma ultrasound testing of surgical residents. J Surg Res 76:17–21. Ali J, Rozycki GS, Campbell JP, Boulanger BR, Waddell JP, Gana TJ (1996) Trauma ultrasound workshop improves physician detection of peritoneal and pericardial fluid. J Surg Res 63:275–279. Arafat R, Golea A, Da˘ra˘mus¸ I, Badea R (2011) Medical education for emergency physician focused on basic competence (Focused Assessment with Sonography in Trauma). Evaluation of the Romanian national program: ‘‘Regional Emergency Medical Services Systems’’. Med Ultrason 13:283–291. Berg DA, Milner RE, Demangone D, Ufberg JW, McKernan E, Fisher CA, Gaughan JP, Grewal H,

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Dempsey DT, Goldberg AJ (2005) Successful collaborative model for trauma skills training of surgical and emergency medicine residents in a laboratory setting. Curr Surg 62:657–662. Blackstock U, Munson J, Yeboah N, Szyld D (2012) Bedside ultrasonography knowledge and image interpretation gains by medical students on emergency medicine rotation. Ann Emerg Med 60:4 Suppl 1:S111–S112. Bowra J, Forrest-Horder S, Caldwell E, Cox M, D’Amours SK (2010) Validation of nurse-performed FAST ultrasound. Injury 41:484–487. Brenchley J, Walker A, Sloan JP, Hassan TB, Venables H (2006) Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emerg Med J 23:446–448. Brooks A, Davies B, Smethhurst M, Connolly J (2004) Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum. Emerg Med J 21:580–581. Cadigan BA (2011) Accomplishing introductory training for the focused assessment with sonography for trauma: An innovative curriculum for teaching exam performance and interpretation. Ann Emerg Med 58:4 Suppl 1:S332. Crouch AK, Dawson M, Long D, Allred D, Madsen T (2010) Perceived confidence in the FAST exam before and after an educational intervention in a developing country. Int J Emerg Med 3:49–52. Damewood S, Jeanmonod D, Cadigan B (2011) Comparison of a multimedia simulator to a human model for teaching FAST exam image interpretation and image acquisition. Acad Emerg Med 18:413–419. Favot M, Amponsah D, Manteuffel J (2012) Medical student assessment of point of care ultrasonography training as part of the emergency medicine clerkship. Ann Emerg Med 60:4 Suppl 1:S78. Freeman P (1999) Ultrasound assessment of the trauma patient. Aust N Z J Surg 69:592–593. Frezza EE, Solis RL, Silich RJ, Spence RK, Martin M (1999) Competency-based instruction to improve the surgical resident technique and accuracy of the trauma ultrasound. Am Surg 65:884–888. Gogalniceanu P, Sheena Y, Kashef E, Purkayastha S, Darzi A, Paraskeva P (2010) Is basic emergency ultrasound training feasible as part of standard undergraduate medical education? J Surg Educ 67:152–156. Gracias VH, Frankel HL, Gupta R, Malcynski J, Gandhi R, Collazzo L, Nisenbaum H, Schwab CW (2001) Defining the learning curve for the Focused Abdominal Sonogram for Trauma (FAST) examination: implications for credentialing. Am Surg 67:364–368.

Gracias VH, Frankel H, Gupta R, Reilly PM, Gracias F, Klein W, Nisenbaum H, Schwab CW (2002) The role of positive examinations in training for the focused assessment sonogram in trauma (FAST) examination. Am Surg 68:1008–1011. Han DC, Rozycki GS, Schmidt JA, Feliciano DV (1996) Ultrasound training during ATLS: an early start for surgical interns. J Trauma 41:208–213. Hillingsø JG, Svendsen LB, Nielsen MB (2008) Focused bedside ultrasonography by clinicians: experiences with a basic introductory course. Scand J Gastroenterol 43:229–233. Hsu JM, Joseph AP, Tarlinton LJ, Macken L, Blome S (2007) The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: experience of an Australian major trauma service. Injury 38:71–75. Ingeman JE, Plewa MC, Okasinski RE, King RW, Knotts FB (1996) Emergency physician use of ultrasonography in blunt abdominal trauma. Acad Emerg Med 3:931–937. Jang T, Kryder G, Sineff S, Naunheim R, Aubin C, Kaji AH (2012) The technical errors of physicians learning to perform focused assessment with sonography in trauma. Acad Emerg Med 19:98–101. Jang T, Sineff S, Naunheim R, Aubin C (2004) Residents should not independently perform focused abdominal sonography for trauma after 10 training examinations. J Ultrasound Med 23:793–797. Jones PG, Peak S, McClelland A, Holden A, Higginson I, Gamble G (2003) Emergency ultrasound credentialling for focused assessment sonography in trauma and abdominal aortic aneurysm: A practical approach for Australasia. Emerg Med (Fremantle) 15:54–62. Kaufmann C, Liu A (2001) Trauma training: virtual reality applications. Stud Health Technol Inform 81:236–241. Kern SJ, Smith RS, Fry WR, Helmer SD, Reed JA, Chang FC (1997) Sonographic examination of abdominal trauma by senior surgical residents. Am Surg 63:669–674. Kirkpatrick AW, Hamilton DR, Nicolaou S, Sargsyan AE, Campbell MR, Feiveson A, Dulchavsky SA, Melton S, Beck G, Dawson DL (2003) Focused Assessment with Sonography for Trauma in weightlessness: a feasibility study. J Am Coll Surg 196:833–844. Knapp B, Byars D, Stewart V, Ryszkiewicz R, Evans D (2012) Emergency medical services focused assessment with sonography in trauma and cardiac ultrasound in cardiac arrest: The training phase. Acad Emerg Med 19 Suppl 1:S189. Knudson MM, Sisley AC (2000) Training residents using simulation technology: experience with ultrasound for trauma. J Trauma 48:659–665.

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Focused Assessment Sonography for Trauma (FAST) training: a systematic review.

The aim of this study was to systematically review the different methods for training Focused Assessment Sonography for Trauma (FAST), course design, ...
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