Ultrasonography Guided Musculoskeletal Infiltrations Teaching Model for Rheumatologist Training: An Experience Report

Abstract

BACKGROUNDInfiltrations of the musculoskeletal system, in their various techniques, constitute a valuable therapeutic option, being a fundamental skill for the rheumatologist. The use of ultrasound in Rheumatology has been consolidating itself as an accessible complementary assessment method, with the possibility of use at the bedside in real time and to guide joint infiltrations, increasing its accuracy and safety. However, training and improvement for its use can be complex, with no recommendations or uniformity regarding its teaching, in addition to scarce and concentrated literature on vascular and anesthetic procedures. We present an ultrasound-guided infiltration training model aimed for teaching Rheumatology residents. METHODSThe schedule is carried out during the medical residency program in Rheumatology, initially with theoretical classes on infiltrations, physical principles and musculoskeletal assessment by ultrasonography (USG), and on guided procedures. Subsequently, practical training is carried out in models of refrigerated pieces of meat (chicken), for the improvement of psychomotor and visual skills. The training continues with the performance of procedures in patients with rheumatological pathologies under supervision. RESULTSThe training model started in 2020, with scheduled classes and training, with successful reproduction of the models and later implementation in outpatients. There are several common USG-guided techniques for arthrocentesis, of which are several in-plane and out-of-plane techniques. For convention, in-plane refers to a position with the needle directly below the USG transducer with the full length of the needle in constant view on the USG screen. Out-of-plane technique refers to a USG view in which a portion of the needle, ideally the tip, will be visualized on the USG screen. For the out-of-plane technique, the needle will be perpendicular to the USG probe and inserted at a steep angle with triangulation to introduce the needle tip at a depth of the effusion as seen on the USG screen. A general rule to adhere to with the out-of-plane technique is that the needle tip should never be advanced beyond the probe. The figures show different stages of the teaching model. CONCLUSIONHands-on bedside ultrasound instruction is a unique component of ultrasound education. It provides the opportunity for the learner to become facile with the ultrasound equipment, develop hand-eye coordination, gain exposure to different ultrasound exam core competencies, and practice obtaining the standard views with an instructor. We present the profile of the procedures performed at the infiltration outpatient clinic of a referral service in rheumatology in the interior of São Paulo, their main characteristics and outcomes.