title: Ultrasound-guided nerve blocks--is documentation and education feasible using only text and pictures?
abstract: OBJECTIVE
  With the advancement of ultrasound-guidance for peripheral nerve blocks, still pictures from representative ultrasonograms are increasingly used for clinical procedure documentation of the procedure and for educational purposes in textbook materials. However, little is actually known about the clinical and educational usefulness of these still pictures, in particular how well nerve structures can be identified compared to real-time ultrasound examination. We aimed to quantify gross visibility or ultrastructure using still picture sonograms compared to real time ultrasound for trainees and experts, for large or small nerves, and discuss the clinical or educational relevance of these findings.
  
  
  METHODS
  We undertook a clinical study to quantify the maximal gross visibility or ultrastructure of seven peripheral nerves identified by either real time ultrasound (clinical cohort, n = 635) or by still picture ultrasonograms (clinical cohort, n = 112). In addition, we undertook a study on test subjects (n = 4) to quantify interobserver variations and potential bias among expert and trainee observers.
  
  
  RESULTS
  When comparing real time ultrasound and interpretation of still picture sonograms, gross identification of large nerves was reduced by 15% and 40% by expert and trainee observers, respectively, while gross identification of small nerves was reduced by 29% and 66%. Identification of within-nerve ultrastructure was even less. For all nerve sizes, trainees were unable to identify any anatomical structure in 24 to 34%, while experts were unable to identify anything in 9 to 10%.
  
  
  CONCLUSIONS
  Exhaustive ultrasonography experience and real time ultrasound measurements seem to be keystones in obtaining optimal nerve identification. In contrast the use of still pictures appears to be insufficient for documentation as well as educational purposes. Alternatives such as video clips or enhanced picture technology are encouraged instead of still pictures extracted from basic ultrasonograms.
authors.affiliation: Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
authors.forename: Bjarne Skjødt
authors.initials: BS
authors.lastname: Worm
authors.affiliation: Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
authors.forename: Mette
authors.initials: M
authors.lastname: Krag
authors.affiliation: Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Jensen
mesh_terms: D000328:Adult; D000776:Anesthesiology / Q000193:education* / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods*; D015588:Observer Variation; D010525:Peripheral Nerves / Q000000981:diagnostic imaging; D011446:Prospective Studies; D015203:Reproducibility of Results; D018084:Ultrasonography, Interventional / Q000379:methods*