One of the most common issues when teaching needling is that the student or novice learner has not fully developed their anatomical ultrasound scanning skill for regional anesthesia. They struggle to acquire the 'perfect' anatomical image whilst at the same time trying to position a needle. Consequentially once the required anatomical landmarks are found there is a real reluctance to move the probe in case this hard fought for image is somehow lost.

Small movement of the probe is an essential part of needle visualization but often is reluctantly engaged in out of fear of losing the anatomical image. This typically leads to incorrect needling techniques, such as attempting to force the needle to find the beam or random advancement and 'waving' of the needle within the patient. More times than not this results in frustration, complete failure to visualize the needle, and unnecessary tissue trauma.

The correct approach is to use the ultrasound beam to find the needle and not to use the needle to find the beam. If care is taken initially to align the needle visually with the probe, by looking down at the hands, any probe movement required for needle visualization will be in the order of millimeters. Such small adjustments will very rarely result in a loss of anatomical references and generally should not require a reacquisition of the anatomical image.

Developing confidence in scanning takes time and practice and is something that can be done without a need to practice needling. However at some point, for regional anestesia, a needle is going to have to be introduced into the equation as this is ultimately the entire reason ultrasound is being used. If scanning skills are not fully developed and confidence is lacking then student or novice will naturally struggle to visualize the needle. They may actually loose confidence in their scanning abilities as a result of this struggle and can sometime be caught in a failure to progress loop.

How then to develop needling skills when ultrasound skills are nascent? One solution is to allow for needling practice and probe adjustment to occur without the loss of anatomical reference. This approach effectively removes the fear of image loss from the equation and allows for free probe movement that is focused solely on needle visualization.

Once a basic understanding of probe movement and ultrasound image acquisition is understood, either through 'hands on' training with a real ultrasound or didactics, students can move to the eZsimulator. This simulator has been designed to require only the most basic of scanning skills while also presenting the student with a requirement to fully engage in normal probe adjustment and movement for full needle visualization.

Once needle visualization confidence has been achieved the student can then move back to skills acquisition while practicing using the Essential Trainer before moving to anatomical landmark recognition to developing the skills and confidence that they can ultimately get the needle tip to its intended target.

· Step 1 - eZSimulator

· Step 2 - Essential Trainer

· Step 3 – Anatomical Trainer

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