title: Sonographic identification of peripheral nerves in the forearm.
abstract: BACKGROUND
  With the growing utilization of ultrasonography in emergency medicine combined with the concern over adequate pain management in the emergency department (ED), ultrasound guidance for peripheral nerve blockade in ED is an area of increasing interest. The medical literature has multiple reports supporting the use of ultrasound guidance in peripheral nerve blocks. However, to perform a peripheral nerve block, one must first be able to reliably identify the specific nerve before the procedure.
  
  
  OBJECTIVE
  The primary purpose of this study is to describe the number of supervised peripheral nerve examinations that are necessary for an emergency medicine physician to gain proficiency in accurately locating and identifying the median, radial, and ulnar nerves of the forearm via ultrasound.
  
  
  METHODS
  The proficiency outcome was defined as the number of attempts before a resident is able to correctly locate and identify the nerves on ten consecutive examinations. Didactic education was provided via a 1 h lecture on forearm anatomy, sonographic technique, and identification of the nerves. Participants also received two supervised hands-on examinations for each nerve. Count data are summarized using percentages or medians and range. Random effects negative binomial regression was used for modeling panel count data.
  
  
  RESULTS
  Complete data for the number of attempts, gender, and postgraduate year (PGY) training year were available for 38 residents. Nineteen males and 19 females performed examinations. The median PGY year in practice was 3 (range 1-3), with 10 (27%) in year 1, 8 (22%) in year 2, and 19 (51%) in year 3 or beyond. The median number (range) of required supervised attempts for radial, median, and ulnar nerves was 1 (0-12), 0 (0-10), and 0 (0-17), respectively.
  
  
  CONCLUSIONS
  We can conclude that the maximum number of supervised attempts to achieve accurate nerve identification was 17 (ulnar), 12 (radial), and 10 (median) in our study. The only significant association was found between years in practice and proficiency (P= 0.025). We plan to expound upon this research with an additional future study that aims to assess the physician's ability to adequately perform peripheral nerve blocks in efforts to decrease the need for more generalized procedural sedation.
authors.affiliation: The Emergency Resources Group, Baptist Medical Center, Jacksonville, Florida.
authors.forename: Saundra A
authors.initials: SA
authors.lastname: Jackson
authors.affiliation: Division of Emergency Medicine, University of South Florida, Tampa, Florida.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Derr
authors.affiliation: Department of Emergency Medicine, Bay Pines Hospital-Veterans Health Affairs, St. Petersburg, Florida.
authors.forename: Anthony
authors.initials: A
authors.lastname: De Lucia
authors.affiliation: Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, New York.
authors.forename: Marvin
authors.initials: M
authors.lastname: Harris
authors.affiliation: Division of Emergency Medicine, University of South Florida, Tampa, Florida.
authors.forename: Zuheily
authors.initials: Z
authors.lastname: Closser
authors.affiliation: Biostatistics, Department of Internal Medicine, University of South Florida, Tampa, Florida.
authors.forename: Branko
authors.initials: B
authors.lastname: Miladinovic
authors.affiliation: Biostatistics, Department of Internal Medicine, University of South Florida, Tampa, Florida.
authors.forename: Rahul
authors.initials: R
authors.lastname: Mhaskar
authors.affiliation: Gulfcoast Ultrasound Institute, St. Pete Beach, Florida.
authors.forename: Theresa
authors.initials: T
authors.lastname: Jorgensen
authors.affiliation: Gulfcoast Ultrasound Institute, St. Pete Beach, Florida.
authors.forename: Lori
authors.initials: L
authors.lastname: Green
keywords: Forearm; identification; nerves; sonographic; ultrasound