A Brooks

Andre K. Crouch

C Mock

DC Han

Deanne Long

Derrick Allred

FM Abu-Zidan

HD Banta

JM Hsu

Matthew Dawson

SP Shah

SW Melanson

T Jang

Troy Madsen

International Journal of Emergency Medicine

English

PubMed

Crossref

Perceived confidence in the FAST exam before and after an educational intervention in a developing country

Springer - Publisher Connector

BRIEF RESEARCH REPORT
Perceived confidence in the FAST exam
before and after an educational intervention
in a developing country
Andre K. Crouch & Matthew Dawson & Deanne Long &
Derrick Allred & Troy Madsen
Received: 30 July 2009 /Accepted: 23 November 2009 /Published online: 27 February 2010
# Springer-Verlag London Ltd 2010
Abstract
Background Trauma care in developing countries suffers
from many limitations related to equipment shortages,
disrepair, quality assurance, and lack of training. Health
care providers in the three principal hospitals in Cusco,
Peru have ultrasound machines, but they do not utilize this
for the focused assessment of sonography in trauma (FAST)
scan (only one of the three hospitals has a computed
tomography scanner).
Aims The goal of this study was to assess the confidence of
physicians in a developing country to conduct a FAST
exam after an educational intervention.
Methods Participants were Peruvian health care workers
who attended a 2-day conference on trauma. Participants
completed a questionnaire based on a 5-point Likert scale
(1=no confidence, 5=high confidence) to assess comfort
with the FAST scan before and after a FAST teaching
workshop, which included hands-on ultrasound training.
Thirteen individuals, eight of whom were physicians,
completed the training and survey. Results were analyzed
using paired t test statistics and are reported as pre- and
post-training mean scores (± standard error), with p<0.05
considered statistically significant.
Results Participants rated their confidence in using the FAST
exam on a trauma patient with an average score of 3.3 (± 0.3)
pre-training and 4.5 (± 0.2) post-training (p=0.007). When
asked about their comfort level in making clinical decisions
based on the FAST scan, pre-training average score was 3.5
(± 0.4) and post-training was 4.5 (± 0.2), p=0.016.
Participants also answered questions about their comfort
with the technical aspects of using the ultrasound machine:
ability to choose the correct probe (pre: 3.9, post: 4.6, p=
0.011), choosing the correct probe orientation (pre: 3.9, post:
4.6, p=0.008), and adjusting the depth and gain (pre: 3.1,
post: 4.4, p=0.001). Finally, participants rated their comfort
with the specific views of the FAST scan: ability to find the
correct subcostal view (pre: 3.3, post: 4.9, p<0.001), right
upper quadrant view (pre: 3.2, post: 4.6, p<0.001), left upper
quadrant view (pre: 3.2, post: 4.4, p=0.001), and the pelvic
view (pre: 3.2, post: 4.5, p<0.001).
Conclusion After a training session in the use of ultrasound
in trauma, health care workers in Cusco, Peru reported
increased confidence in their FAST scan ability and in their
comfort in using this exam for clinical decision-making.
Future research should include objective testing of partic-
ipants’ skill as well as longitudinal follow-up to determine
the extent to which the FAST scan has been incorporated
into participants’ evaluations of trauma patients.
Keywords Ultrasound . International medicine . Education
Introduction
Trauma is a leading cause of death and disability worldwide,
but trauma care in developing countries suffers from many
limitations. Most of these challenges relate to equipment
shortages, disrepair, quality assurance, and training. The
focused assessment of sonography in trauma (FAST) is an
area that has been identified as lacking in many developing
countries. In multiple settings it has been demonstrated that an
ultrasoundmachine is available, but due to lack of training it is
A. K. Crouch :M. Dawson :D. Long (*) :D. Allred : T. Madsen
Division of Emergency Medicine, University of Utah,
30 N. 1900 E. 1C26,
Salt Lake City, UT 84132, USA
e-mail: deanne.long@hsc.utah.edu
Int J Emerg Med (2010) 3:49–52
DOI 10.1007/s12245-009-0144-5
not utilized [1]. Indeed, the Guidelines for Essential Trauma
Care published by the World Health Organization (WHO)
consider ultrasound availability desirable as long as there is
availability of skilled staff [2]. Meeting these criteria is a
challenge as previously shown in Brazil, a relatively
advanced developing country [3].
In Cusco, Peru trauma care providers have received little
specific training. An ultrasound machine is present but not
used because of the lack of provider training. Most
hospitals in the city also lack a computed tomography
(CT) scanner, which increases the importance of the
potential use of ultrasound to evaluate for hemoperitoneum.
The FAST exam in multiple studies has been shown to
have similar accuracy to diagnostic peritoneal lavage
(DPL) [4, 5], but it is noninvasive, requires less time, and
has no contraindications. In addition, training for 2–8 h has
been shown to be adequate to teach trauma care providers
the FAST exam [6–8].
Our goal was to teach Peruvian health care providers the
FAST exam during a 2-day conference on trauma. In order
to measure progress we used a survey to measure their
confidence with the FAST before and after training. A
confidence survey was used because previous studies have
demonstrated that operator confidence correlates with
increased accuracy in abdominal ultrasound [9]. Further-
more, more accurate abdominal ultrasounds presumably
have the potential to aid diagnosis and treatment decisions
in this community where a CT scanner is not available in
most hospitals, but in which providers have access to an
ultrasound.
Methods
In April 2008, physicians from the University of Utah
Medical Center held a 2-day conference on trauma in
Cusco, Peru, with the goal of standardizing and improving
trauma care in the region. Part of the conference was aimed
at teaching the FAST exam and measuring the participants’
confidence level with the exam. The FAST exam was
taught during a 2.5-h workshop with hands-on teaching. An
emergency medicine resident who is proficient in the FAST
exam (AC) presented a 1-h lecture with Spanish translation
on the basic principles of ultrasound. The lecture included a
description of the four standard views obtained during a
FAST scan with examples of positive scans. After the
didactic, participants spent 1.5 h practicing the ultrasound
exam on volunteers using a GE Logiq e and an ultrasound
machine from the emergency department of the hosting
hospital. The participants consisted of approximately 25
health care providers, comprising local physicians and
nurses from various hospitals and clinics in Cusco, Peru
and the surrounding communities.
Participants voluntarily completed a questionnaire based
on a 5-point Likert scale (1=no confidence, 5=high
confidence) to assess comfort with the FAST scan before
and after the workshop. Thirteen individuals, eight of
whom were physicians, completed the training and survey.
The survey was completed in Spanish, but has been
included in this paper in English (Table 1).
Results were analyzed using paired t test statistics and are
reported as pre- and post-training mean scores (± standard
error), with p<0.05 considered statistically significant.
Results
FAST workshop participants reported significant increases
in their confidence in each aspect surveyed. Participants
rated their confidence in using the FAST exam on a trauma
patient with an average score of 3.3 pre-training and 4.5
post-training on the 5-point Likert scale (p=0.007). When
asked about their comfort level in making clinical decisions
based on the FAST scan, pre-training average score was 3.5
and post-training was 4.5 (p=0.016).
Participants also answered questions about their comfort
with the technical aspects of using the ultrasound machine:
ability to choose the correct probe (pre: 3.9, post: 4.6, p=
0.011), choosing the correct probe orientation (pre: 3.9, post:
4.6, p=0.008), and adjusting the depth and gain (pre: 3.1,
post: 4.4, p=0.001).
Finally, participants rated their comfort with the specific
views of the FAST scan: ability to find the correct subcostal
view (pre: 3.3, post: 4.9, p<0.001), right upper quadrant view
(pre: 3.2, post: 4.6, p<0.001), left upper quadrant view (pre:
3.2, post: 4.4, p=0.001), and the pelvic view (pre: 3.2, post:
4.5, p<0.001) (Table 2).
Limitations
This study has several limitations. Only 13 of the
participants completed the survey. Those who felt more
confident in their skill may have been more willing to
complete the survey. As such, however, the survey does
provide a sense of the response among the majority of the
workshop participants.
Another limitation of the study was the lack of objective
measure of participants’ ability to perform the FAST scan.
It is not clear what technical ability or accuracy corresponds
with a confidence level of 3 or how this differs from a
confidence level of 4. Furthermore, it is unclear if this
represents a clinically significant improvement. Objective
technical skill data were difficult to obtain because of time
constraints with the vast amount of information being
taught during the short 2-day course. However, it has been
50 Int J Emerg Med (2010) 3:49–52
shown in a previous study that operator confidence does in
fact correlate with more accurate ultrasounds [4].
The study also was performed at one site over a short
2-day course with no long-term data on provider skill and
confidence available at this time. However, it has been
objectively shown that novice ultrasonographers can learn
the FAST scan during a short 2-day trauma course [8].
Also, it has been demonstrated that in a developing
country (Rwanda in 2008) after ultrasound instructors
leave, providers who were taught the new modality
continue to use the new skill with great frequency and
accuracy [10].
Conclusion
The FAST scan is an important part of a trauma evaluation
with the ability to affect patient care and decision-making.
This importance and impact is greatly amplified in a
setting where resources are limited and no CT scanner is
available.
An important precursor to using the FAST scan correctly
is having hands-on training and developing the confidence
to use it and make decisions in a clinical setting. We have
demonstrated with our FAST workshop and confidence
surveys that trauma providers in a developing country
Table 2 Participant pre- and post-training evaluation of FAST confidence and skill
Survey question Pre-workshop confidence Post-workshop confidence p value
Overall confidence using FAST scan on a trauma patient 3.3 4.5 0.007
Ability to choose correct probe 3.9 4.6 0.011
Ability to choose correct probe orientation 3.9 4.6 0.008
Ability to adjust depth and gain 3.1 4.4 0.001
Ability to find subcostal view 3.3 4.9 <0.001
Ability to find RUQ view 3.2 4.6 <0.001
Ability to find LUQ view 3.2 4.4 0.001
Ability to find pelvic view 3.2 4.5 <0.001
Confidence in making clinical decisions based on FAST scan 3.5 4.5 0.016
RUQ right upper quadrant, LUQ left upper quadrant
Table 1 Survey used to evaluate participant subjective comfort and skill
Level of training and specialty (Ex: surgeon, nurse, health care worker): ______________ 
FAST Questionnaire 
Please complete the following questionnaire on a scale of 1-5.  1 being not at all confident, and 5 being
extremely confident. 
1.  Do you feel comfortable choosing the correct probe for a FAST exam? 
1 2 3 4 5 
2.  Do you feel you can choose the correct orientation of the probe? 
1 2 3 4 5 
3.  Do you feel comfortable adjusting the gain and depth to maximize picture quality? 
1 2 3 4 5 
4.  How do you feel visualizing the subcostal view? 
1 2 3 4 5 
5.  How do you feel visualizing the right upper quadrant view? 
1 2 3 4 5 
6.  How do you feel visualizing the left upper quadrant view? 
1 2 3 4 5 
7.  How do you feel visualizing the pelvic view? 
1 2 3 4 5 
8.  How confident would you feel doing a FAST exam on a trauma patient? 
1 2 3 4 5 
9.  How comfortable would you feel making clinical decisions based on the results of your FAST exam?
1 2 3 4 5 
Int J Emerg Med (2010) 3:49–52 51
reported increased confidence in FAST scanning with a
brief educational intervention.
More research including skill retention, more partici-
pants, translation into practice, and objective measures of
skill is needed. However, this study may provide guidance
to practitioners in performing educational interventions to
improve trauma ultrasound in developing countries with
limited resources.
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52 Int J Emerg Med (2010) 3:49–52


Establishment of a course for focused assessment sonography for trauma.

Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care.

Guidelines for essential trauma care. World Health Organization,

Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda

Medical technology and developing countries: the case of Brazil.

Operator confidence correlates with more accurate abdominal ultrasounds by emergency medicine residents.

Principles of emergency department sonography. In: Tintintinalli JE, Kelen GD, Stapczynski JS (eds) Emergency medicine: a comprehensive study guide, 6th edn.

Prospective evaluation of non-radiologist performed emer gency abdominal ultrasound for haemoperitoneum.

Tarlinton LJ et al (2007) The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: experience of an Australian major trauma service.

Ultrasound training during ATLS: an early start for surgical interns.

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Perceived confidence in the FAST exam before and after an educational intervention in a developing country

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