Ultrasound Simulation Research Articles

Faculty Development in Proficiency and Application of Point-Of-Care Ultrasound

Introduction: Point-of-care ultrasound (POCUS) continues to be integrated into medical school and residency curriculums with objectives to increase proficiency and utilization in practice. Implementation of a targeted curriculum with faculty can increase proficiency of ultrasound. Methods: We created a POCUS pilot program at a small academic center to assess faculty members’ knowledges and perception about ultrasound in surgical settings. We conducted an observational cross-sectional study to test the hypothesis and hypothesized members would have increased confidence in their proficiency. Participants attended a 2-hour session with expert faculty. Our session consisted of a pre-test assessment survey, one-hour of didactic lecture, hands-on workshop with an ultrasound simulation machine and live standardized patient, and a post-test assessment survey. Faculty were given the option to return for further self-directed learning with ultrasound simulation machine after the pilot program if desired. Results: There was a statistically significant difference in pre- and post-survey questions that addressed comfort using ultrasound in clinical setting and critical care setting, comfort in using ultrasound at bedside rounds, comfort teaching medical student and residents, comfort performing FAST (Focused Abdominal Sonogram for Trauma) exam and comfort in doing basic bedside echocardiography. Faculty indicated time, availability of ultrasound equipment to faculty and house staff, and cost of equipment as important barriers to utilization of ultrasound in the clinical setting. Discussion: Our pilot POCUS course showed improved confidence in ultrasound skills among faculty members. It is important to address barriers such as limited availability of equipment and adequate time preparation for future POCUS curriculums.

Ultrasound Simulation for Training Trainees when the Luxury Becomes Essential: Opinion and Evidence Obtained during the Latvian Research Council Project Implementation.

Simulation as a proxy tool for conditional clinical training became a powerful technique for introducing trainees to the ultrasound imaging world, allowing them to become a trained sonographer taking into consideration different rates of progress in completing a specific task against the time and ensuring the long-lasting maintenance of the obtained practical skills. Adding a costly, but effective high-fidelity simulator to the residency program justified the expense, demonstrating efficiency of training for improving the clinical performance and confidence of trainees. A pilot study in Riga Maternity Hospital within the framework of the study "Role of metabolome, biomarkers and ultrasound parameters in successful labor induction" (Fundamental and Applied Research Programme lzp-2021/1-0300) was performed between March 1st 2022 and 31st April 2022. A virtual-reality simulator (ScanTrainer, MedaphorTM, Cardiff, UK) was used with the teaching module for assessment of the uterine cervix. Five trainees in obstetrics and two young specialists included in the study. None of them had Fetal Medicine Foundation certificate of competence in the assessment of the uterine cervical lenght before. The time used on the simulator, the number of simulations and a mean confidence in cervical length assessment before and after simulation were recorded. The study on assesment of uterine cervical lenght demonstrated statistically significant increase in confidence (p=0.008) and statistically significant decrease in time needed to complete correctly the same tasks for the trainees (p=0.008) that shows a positive learning curve over the time of training on ScanTrainer, Medaphor. The simple task allows to become a certified specialist in uterine cervical assessment in the short period of time. That support the productiveness of the simulation-based education. The training program should be updated taking into consideration simulation curriculum.

Interprofessional Trauma Team Training: Leveraging Each Specialties’ Expertise to Teach Procedural-Based Skills

The goal of this study was to utilize interprofessional trauma team training to teach procedural-based skills, teamwork, and assess the impact on the procedural comfort and interprofessional collaboration. Interdisciplinary skills sessions were created to focus on chest tube placement and advanced ultrasound techniques. Chest tube sessions were taught by senior general surgery (GS) residents and faculty. Ultrasound sessions were taught by emergency medicine (EM) fellows and faculty. Mock trauma simulations for EM and GS residents and EM nurses, were developed to also focus on improving interprofessional trauma-bay collaboration. Sessions were held throughout the year for 2 consecutive academic years. After completing skills sessions and trauma scenarios, participants were surveyed on skill comfort, session utility, and willingness to collaborate with the other specialty. Likert scale responses were analyzed by specialty cohort and in aggregate. Free-text feedback responses were analyzed for common themes. Large, tertiary, urban academic medical center PARTICIPANTS: Forty seven EM residents and 32 GS residents completed instructional chest tube and ultrasound simulations, respectively. Twenty two EM residents, 24 GS residents, and 29 EM nurses participated in interprofessional trauma simulations. For chest tube placement: 71% of EM residents reported feeling uncomfortable with the procedure prior to the session, with 100% reporting improved confidence afterwards. Seventy percent stated the model was realistic. One hundred percent thought it improved their procedural skills. All participants thought it was worthwhile, should be offered again in future years, and planned to incorporate what they learned in their future practice. For the ultrasound sessions: 61% of GS residents felt uncomfortable with the Focused Assessment with Sonography in Trauma prior to the simulation. Ninety four percent reported the improved skill and confidence, and felt the model was realistic. All participants felt sessions were worthwhile, should be offered again, and planned to incorporate what they learned in their future practice. For trauma simulations: 97% of participants felt scenarios were realistic and clinically relevant and planned to incorporate lessons learned in their future clinical practice. All participants thought participation was worthwhile. Ninety seven percent thought it improved their confidence with trauma clinical management and 56% reported it improved their skills. Many participants reported they appreciated learning from the other specialty's perspective, with greater than 95% of all participants reporting improved comfort and willingness to collaborate across disciplines when caring for future trauma patients. All participants requested the simulation sessions continue in future academic years. Interprofessional trauma simulation sessions can harness the unique skill sets of different disciplines to teach procedural-based skills and improve interprofessional collaboration within the trauma bay.

Study on In-Service Inspection of Nuclear Fuel Assembly Failure Using Ultrasonic Plate Wave.

As protection for nuclear power plants is quite necessary, the nuclear fuel is sealed in zirconium alloy thin wall cladding. During service, fuel rods might be damaged caused by wall-thickness thinning, cladding corrosion and cracking, etc. This will cause the coolant to enter into the fuel rod, which may lead to the failure of the fuel assembly. However, current diagnostic methods have limitations due to the special structure of the fuel assembly and the underwater and radioactive environment. In this paper, a novel inspection method is proposed to recognize the failure of a fuel rod. The fuel rod failure can be detected based on the presence or absence of coolant inside the fuel rod by using an ultrasonic plate wave. The inspection model and process algorithm are proposed for in-service inspection. The relationship between signal and scanning position is established and analyzed. Both ultrasound field simulation and experiment have been carried out for validation. The corresponding results illustrate that the failed nuclear fuel rod of the whole fuel assembly (including the internal rods) can be effectively detected without the influence of the near-field region by using the proposed method.

On-the-Fly Calculation of Time-Averaged Acoustic Intensity in Time-Domain Ultrasound Simulations Using a k-Space Pseudospectral Method.

This article presents a method to calculate the average acoustic intensity during ultrasound simulation using a new approach that exploits compression of intermediate results. One of the applications of high-intensity focused ultrasound (HIFU) simulations is the calculation of the thermal dose, which indicates the amount of tissue destroyed using a state-of-the-art k-space pseudospectral method. The thermal simulation is preceded by the calculation of the average intensity within the acoustic simulation. Due to the time staggering between the particle velocity and the acoustic pressure used in such simulations, the average intensity calculation is typically executed offline after the acoustic simulation consuming both disk space and time (the data can spread over terabytes). Our new approach calculates the average intensity during the acoustic simulation using the output coefficients of a new compression method which enables resolving the time staggering on-the-fly with huge disk space savings. To reduce RAM requirements, the article also presents a new 40-bit method for encoding compression complex coefficients. Experimental numerical simulations with the proposed method have shown that disk space requirements are up to 99% lower. The simulation speed was not significantly affected by the approach and the compression error did not affect the prediction accuracy of the thermal dose. From the standpoint of supercomputers, the new approach is significantly more economical. Saving computing resources increases the chances of real use of acoustic simulations in practice. The method can be applied to signals of a similar character, e.g., for electromagnetic radio waves.

Classical and Learned MR to Pseudo-CT Mappings for Accurate Transcranial Ultrasound Simulation.

Model-based treatment planning for transcranial ultrasound therapy typically involves mapping the acoustic properties of the skull from an X-ray computed tomography (CT) image of the head. Here, three methods for generating pseudo-CT (pCT) images from magnetic resonance (MR) images were compared as an alternative to CT. A convolutional neural network (U-Net) was trained on paired MR-CT images to generate pCT T images from either T1-weighted or zero-echo time (ZTE) MR images (denoted tCT and zCT, respectively). A direct mapping from ZTE to pCT was also implemented (denoted cCT). When comparing the pCT and ground-truth CT images for the test set, the mean absolute error was 133, 83, and 145 Hounsfield units (HU) across the whole head, and 398, 222, and 336 HU within the skull for the tCT, zCT, and cCT images, respectively. Ultrasound simulations were also performed using the generated pCT images and compared to simulations based on CT. An annular array transducer was used targeting the visual or motor cortex. The mean differences in the simulated focal pressure, focal position, and focal volume were 9.9%, 1.5 mm, and 15.1% for simulations based on the tCT images; 5.7%, 0.6 mm, and 5.7% for the zCT; and 6.7%, 0.9 mm, and 12.1% for the cCT. The improved results for images mapped from ZTE highlight the advantage of using imaging sequences, which improves the contrast of the skull bone. Overall, these results demonstrate that acoustic simulations based on MR images can give comparable accuracy to those based on CT.

On the effect of training simulation point spread function in deep-learning based super-resolution ultrasound imaging

Deep learning (DL)-based super-resolution ultrasound microvascular imaging (SR-UMI) has gained interest in recent years owing to the success of DL in medical imaging applications. Mainstream DL techniques require an abundance of labeled training data. Since high-quality in vivo training data are challenging to obtain for medical imaging, most of the current studies have relied on simulations to generate training data of microbubbles (MBs) flowing in vasculature. This study investigates the effect of different MB point spread function (PSF) generation methods on the performance of DL models for SR-UMI. We used Gaussian shaped PSF (Gaussian-PSF), numerical simulation software (Field II-PSF), and experimentally collected PSFs (Exp-PSF) to generate DL training sets. The training sets were used to train DL models that performed both MB localization- and non-localization-based SR-UMI. The quality of the models trained with different datasets were evaluated based on their in vivo performance (mouse brain, chicken embryo), with optical imaging as ground truth for some applications. We discovered that Exp-PSF achieved the best performance overall, due to its high resemblance to real experimental data. Finally, we present a pipeline for obtaining Exp-PSF and integrating them with ultrasound MB simulation, with a publicly available Exp-PSF dataset provided via Github.

A pipeline to enable large-scale generation of diverse 2D cardiac synthetic ultrasound recordings corresponding to healthy and heart failure virtual patients

Simulated ultrasound (US) data are widely used in echocardiography to develop and validate rapidly growing convolutional neural networks (CNNs) based learning algorithms for image processing and analysis. In this context, a large and diverse database of synthetic US scans is considered vital for CNN training purposes, as clinical US data are scarce and difficult to access. Major hurdles in creating an extensive database are the long US simulation time and unstable heart models for extreme parameter settings. Here, we developed and implemented a cardiac US simulation pipeline that kinematically connects two state-of-the-art solutions in the field of US simulation (COLE) and cardiac modelling (CircAdapt), benefiting from the fast simulation time of the convolution-based ultrasound simulator and stability of the mechanical heart model to produce 2D synthetic cardiac US recordings. Furthermore, using our pipeline, we generated diverse set of 600 2D synthetic cardiac US recordings of healthy and heart failure virtual patients with variations in the shapes, motion patterns, and functions of the heart, along with their ground truth 2D myocardial velocity profiles and deformation curves. The resulting database is a potential tool for augmenting training databases of machine learning based US image processing algorithms. [Work funded by European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No. 860745.]

PEDIATRIC AND MEDICINE RESIDENTS’ PERCEPTIONS OF ULTRASOUND VASCULAR ACCESS AND RESULTS OF AN INTERSPECIALTY, SIMULATION-BASED ULTRASOUND VASCULAR ACCESS WORKSHOP

PEDIATRIC AND MEDICINE RESIDENTS’ PERCEPTIONS OF ULTRASOUND VASCULAR ACCESS AND RESULTS OF AN INTERSPECIALTY, SIMULATION-BASED ULTRASOUND VASCULAR ACCESS WORKSHOP

Ultrasound Simulation Training for Radiology Residents-Curriculum Design and Implementation.

Medical simulation training can be used to improve clinician performance, teach communication and professionalism skills, and enhance team training. Radiology residents can benefit from simulation training in diagnostic ultrasound, procedural ultrasound, and communication skills prior to direct patient care experiences. This paper details a weeklong ultrasound simulation training curriculum for radiology residents during the PGY-1 clinical internship. The organization of established teaching methods into a dedicated course early in radiology residency training with the benefit of a multi-disciplinary approach makes this method unique. This framework can be adapted to fit learners at different skill levels or with specific procedural needs.

OP08.11: Validity of three obstetrical ultrasound simulators in the assessment of ultrasound skills

OP08.11: Validity of three obstetrical ultrasound simulators in the assessment of ultrasound skills

Benchmark problems for transcranial ultrasound simulation: Intercomparison of compressional wave models

Computational models of acoustic wave propagation are frequently used in transcranial ultrasound therapy, for example, to calculate the intracranial pressure field or to calculate phase delays to correct for skull distortions. To allow intercomparison between the different modeling tools and techniques used by the community, an international working group was convened to formulate a set of numerical benchmarks. Here, these benchmarks are presented, along with intercomparison results. Nine different benchmarks of increasing geometric complexity are defined. These include a single-layer planar bone immersed in water, a multi-layer bone, and a whole skull. Two transducer configurations are considered (a focused bowl and a plane piston operating at 500 kHz), giving a total of 18 permutations of the benchmarks. Eleven different modeling tools are used to compute the benchmark results. The models span a wide range of numerical techniques, including the finite-difference time-domain method, angular spectrum method, pseudospectral method, boundary-element method, and spectral-element method. Good agreement is found between the models, particularly for the position, size, and magnitude of the acoustic focus within the skull. When comparing results for each model with every other model in a cross-comparison, the median values for each benchmark for the difference in focal pressure and position are less than 10% and 1 mm, respectively. The benchmark definitions, model results, and intercomparison codes are freely available to facilitate further comparisons.

Assessment of Medical Students' Ability to Integrate Point-of-Care Cardiac Ultrasound Into a Case-Based Simulation After a Short Intervention.

Introduction: While a large amount of point-of-care ultrasound (POCUS) undergraduate medical education research exists, very little assesses the effectiveness of teaching on the student’s ability to utilize POCUS within a clinical context. We set out to assess the ability of pre-clinical (second year) medical students to perform and interpret a parasternal long axis (PSLA) cardiac ultrasound view, and to diagnose a pericardial effusion on POCUS in a simulated patient with hypotension.Methods: This was a prospective study assessing second-year medical students before and after focused cardiac POCUS instruction. Pre-instruction, students completed a pre-assessment and test. They then watched a short video on cardiac ultrasound technique, anatomy, and pathology. Students then participated in 10 minutes of one-on-one hands-on instruction using a simulated patient. Immediately after didactics and hands-on instruction, students in groups of two to four completed a case simulation where they performed a PSLA view, identified pathology, and made a diagnosis. Differences between pre- and post-workshop responses were analyzed using the Chi-square test.Results: We analyzed data on 132 pre-clinical second-year medical students; 126 (95%) had limited to no POCUS experience prior to the workshop. Comparing pre- to post-workshop responses, we found significant improvement in students’ ability to identify a pericardial effusion (46% to 69%) (p=0.002) on a PSLA cardiac view. Of the 57 student groups (132 students), 41 (72%) groups were able to adequately obtain a PSLA view on a mannequin using an ultrasound simulator without needing guidance with probe placement or maneuvering. Thirty-five (61%) student groups were able to identify a pericardial effusion and diagnose cardiac tamponade in a simulated patient with hypotension.Conclusion: After short, structured training, pre-clinical medical students, novice to cardiac POCUS, showed improved knowledge with identifying a pericardial effusion on an ultrasound image. The majority of students were able to obtain a PSLA view and diagnose cardiac tamponade in a hypotensive patient during a during a case-based simulation.

Ultrasound training simulator using augmented reality glasses: an accuracy and precision assessment study.

Ultrasound (US) imaging despite being safe, cost-effective, and radiation-free, presents poor quality and artifacts, requiring specific medical training in US probe handling and image evaluation. The use of simulators to train physicians has proven its effectiveness, but most of them require specific facilities and hardware. In the last few years, augmented reality has gained relevance to simulate real scenarios which can avoid large setups and broaden medical training to more physicians. This work proposes a new framework for the training of US images acquisition. It consists of a custom-made application that runs on AR glasses (Microsoft HoloLens 2) and interacts with a US simulator application. The AR glasses track the orientation of a QR code mounted on a US probe, communicating its orientation with the US simulator application. This allows the physician to interact with a US probe seeing in real-time the US image in the physician's field of view. The QR code tracking assessment of the AR glasses was conducted by measuring the orientation accuracy and precision when compared with the measures of an electromagnetic tracking device (i.e., NDI Aurora). The proposed solution presented a good performance, rendering the US image in AR glasses with real-time feedback. Moreover, it can track the QR code on the US probe with an accuracy of 0.755°, and a precision of 0.018°. Overall, the proposed framework presents promising results and the use of AR glasses as a tracking device reached a good performance. Clinical Relevance- Simulation is a relevant tool to train physicians, especially in US imaging. AR glasses can broaden the training to less trained physicians by reducing the need for complex setups. This technology allows the implementation of a more natural user interface, which can be relevant in scenarios where good coordination between the eyes and hands of the physician is necessary (i.e., Biopsies).

Biopsy Needle Segmentation using Deep Networks on inhomogeneous Ultrasound Images.

In minimally invasive interventional surgery, ultrasound imaging is usually used to provide real-time feedback in order to obtain the best diagnostic results or realize treatment plans, so how to accurately obtain the position of the medical biopsy needle is a problem worthy of study. 2D ultrasound simulation images containing the medical biopsy needle are generated, and our images background is from the real breast ultrasound image. Based on the deep learning network, the images containing the medical biopsy needle are used to analyze the effectiveness of different networks for needle localization for the purpose of returning needle positions in non-uniform ultrasound images. The results show that attention U-Net performed best and can accurately reflect the real position of the medical biopsy needle. The IoU and Precision can reach 90.19% and 96.25%, and the Angular Error is 0.40°. Clinical Relevance- Based on the deep network, for 2D ultrasound images containing medical biopsy needle, the localization precision can reach 96.25% and the Angular Error is 0.40°.

초음파용 프로브 설계의 인간공학적 분석

Objective: The present study is intended to analyze the design characteristics of ultrasonic probes in different sizes and shapes and identify the preferred design characteristics by ergonomic evaluation.<BR><BR>Background: The use of an ultrasound probe among sonographers in improper postures with high repetitions for long periods of time has resulted in a high incidence of musculoskeletal symptoms and/or disorders.<BR><BR>Method: While sonographers (n = 12) simulated ultrasound scanning tasks with two linear array probes (small-flat, SF; large-curved, LC) in different sizes and shapes by applying forces of 20±4N, EMG activities, body motions, and grip postures were measured. After completing the ultrasound simulation tasks, a comparative evaluation of subjective satisfaction with the two probe designs was conducted.<BR><BR>Results: The SF probe required a larger range of motion at the elbow (up to 9.9° on average), higher RMS EMG levels (-1.8~48.4%) during the probe rotation task at the shoulder (pectoralis and infraspinatus), neck (right/left sterno-cleido-mastoid and trapezius), and upper-arm (biceps), and larger finger joint angles (-6.3~15.8°) than the LC probe.<BR><BR>Conclusion: The SF probe was preferred to the LC probe in terms of grip fit, the opposite was found in terms of the efficiency of force transfer.<BR><BR>Application: The analysis and evaluation methods of ultrasound probe design and the identification of the preferred design characteristics of linear array probe will be of use to develop ergonomic probe designs that can reduce musculoskeletal symptoms and disorders among sonographers.

Evaluation of NDE Characteristics for Measuring the Painting Thickness in Wind Energy Turbine Power Blades Based on Ultrasonic Wave Simulation

In recent years, wind energy turbine blades have been manufactured using composite materials. Post manufacturing, these blades are painted with special coatings to protect the surface. Subsequently, they are generally tested by breaking a specimen and checking the uniform coating state using an optical microscope. A non-destructive technique is considered as an inspection tool; therefore, ultrasonic techniques are widely selected to measure thin painting thicknesses. In this study, the NDE (Nondestructive evaluation) CIVA package (CIVA 2020 software, NDE CIVA) was adopted for ultrasound simulation. The package was used to propose parameters, which brings the measurement of painting thickness based on the non-destructive ultrasonic waves. An optimal technique was also proposed with a use of the time and amplitude reflected from the surface and the back in the samples according to the blade painting thicknesses.

Ultrasound estimation of strain time constant and vascular permeability in tumors using a CEEMDAN and linear regression-based method

Ultrasound poroelastography focuses on the estimation of the spatio-temporal mechanical behavior of tissues using data often corrupted with non-stationary noise. The cumulative strain calculated from prolonged temporal acquisition of RF data can face the problem of aggregate noise. This noise can significantly affect the accuracy of curve fitting techniques necessary to estimate the clinically significant strain Time Constant (TC) and related parameters. We present a new technique, which decomposes the non-linear temporal behavior of the differential strain to extract the monotonic decaying trend by using the time-domain and data-driven Complete Ensemble Empirical Mode Decomposition with Adaptive Noise (CEEMDAN) algorithm. A linear regression scheme is then used to obtain the slope of the transformed non-linear trend, which carries information about the strain TC. Assessment of Vascular Permeability (VP), a transport parameter indicative of tumor growth, requires accurate strain TC estimations. Finite Element (FE), ultrasound simulations and in vivo experiments are used to investigate the performance of the proposed technique. Based on the simulation analysis, the average Percentage Relative Error (PRE) values of our method are 4.15% (for TC estimation) and 5.00% (for VP estimation) at 20 dB SNR level for different Percentage of Good Frames (PGF) (i.e., 20%, 50%, 75%, and 100%). These PRE values are substantially lower than those obtained using other conventional elastographic techniques. Our proposed method could become a new data-adaptive tool for analyzing the non-linear time-dependent response of complex tissues such as cancers.

Ultrasound simulation of blood with different red blood cell aggregations and concentrations

Considerable progress of ultrasound simulation on blood has enhanced the characterizing of red blood cell (RBC) aggregation. A novel simulation method aims at modeling the blood with different RBC aggregations and concentrations is proposed. The modeling process is as follows: (i) A three-dimensional scatterer model is first built by a mapping with a Hilbert space-filling curve from the one-dimensional scatterer distribution. (ii) To illustrate the relationship between the model parameters and the RBC aggregation level, a variety of blood samples are prepared and scanned to acquire their radiofrequency signals in-vitro. (iii) The model parameters are determined by matching the Nakagami-distribution characteristics of envelope signals simulated from the model with those measured from the blood samples. Nakagami metrics m estimated from 15 kinds of blood samples (hematocrits of 20%, 40%, 60% and plasma concentrations of 15%, 30%, 45%, 60%, 75%) are compared with metrics estimated by their corresponding models (each with different eligible parameters). Results show that for the three hematocrit levels, the mean and standard deviation of the root-mean-squared deviations of m are 0.27 ± 0.0026, 0.16 ± 0.0021, 0.12 ± 0.0018 respectively. The proposed simulation model provides a viable data source to evaluate the performance of the ultrasound-based methods for quantifying RBC aggregation.

Hands-on Simulation Workshop for Obstetric Ultrasound-Guided Invasive Procedures.

IntroductionDue to the introduction of cell-free DNA genetic testing options, the number of clinical ultrasound procedures has greatly diminished in recent years. With fewer real-life ultrasound-guided procedures being performed, it is difficult for OB/GYN and maternal-fetal medicine (MFM) trainees to achieve competency in doing them. Simulation can be utilized to address this issue and supplement a learner's real-life training.MethodsWe developed a simulation workshop incorporating previously described ultrasound guidance task trainers and simulators of amniocentesis and chorionic villus sampling. The workshop had three parts: needle guidance basics, targeting task performance, and procedure-specific simulation. A form of this workshop has been held at the annual meeting of the Society for Maternal-Fetal Medicine since 2015 and as a regional course for MFM fellows since 2017. During the 2019 and 2020 courses, participants completed Likert-scale surveys evaluating the course.ResultsSince the workshops began in 2015, approximately 300 people have participated. In 2019–2020, 41 MFM attending physicians, 136 MFM fellows, and three OB/GYN residents took our course and completed a postcourse survey. Participants rated the course highly and thought it was highly effective.DiscussionWe created an introductory simulation workshop for obstetric ultrasound-guided invasive procedures that participants rated highly and thought was very effective. Objective clinical assessment of skill improvement after completion of this course is needed to verify its true impact. Repeated exposure to this introductory simulation and creation of more challenging workshops are needed to achieve a sustained high level of procedural skill.