The Future of Point-of-Care Ultrasound in Pediatric Emergency Medicine

Pediatrics entices practitioners with its focus on treating illness in the youngest patients, for long-term outcomes of future growth and development. When I reflect on my own journey through Pediatrics and Pediatric Emergency Medicine, helping patients in real-time through providing the best quality care given limited information, drew me to Pediatric Emergency Medicine.

Lianne Profile FinalPediatric Emergency Medicine (PEM) focuses on providing acute care to patients from the newest newborns to teenagers. With this breadth of ages comes differing pathology, physiology, and of course differences in relative and absolute size. Integration of point-of-care ultrasound (POCUS) into PEM practice offers the clinician an added tool to provide the best possible care. Children are ideal patients for POCUS scanning as they often have slimmer body habitus, fewer comorbidities, and there is increasing interest in limiting ionizing radiation amongst all patients, especially the very young.

POCUS offers direct visualization for procedures such as endotracheal tube airway confirmation, central-line insertion, and intravenous and intraosseous access. Utilizing this clinical adjunct allows for accuracy in nerve block administration, reducing the volume used of local anesthetic and decreasing the need for systemic sedation. Visualizing fractures following reduction and assessing joints and soft tissue infections prior to decision of incision and drainage or aspiration can all be achieved using POCUS.

Because our patients vary in size, optimizing planning prior to starting procedures can help to maximize success. Risk in pediatric procedures are heightened due to variable sizing, risking too-deep insertion of needles and endotracheal tubes. Direct visualization helps to support the provider in making safe choices.

Beyond procedures, POCUS allows PEM providers to optimize resuscitation, through real-time monitoring of volume status, cardiac function, and pulmonary edema. Reassessment throughout resuscitation adds additional information to vital signs and end-organ markers as patients are treated.

As machines become increasingly accurate at more portable sizes, and as cloud storage is increasingly popular among organizations, the future of POCUS offers providers along the care-continuum the opportunity to share information and images. My hope for the future of acute POCUS would be to have pre-hospital POCUS, emergency POCUS, consultative radiology imaging, and follow-up POCUS imaging in community clinics on an integrated system allowing for shared images and progressive monitoring for long-standing conditions.

The future of POCUS is bright as innovation and technology disruption move ultrasound outside of the walls of the hospital, placing transducers in the hands of those at the bedside from the helicopter to the remote health clinic. For countries such as Canada, increased portability means increasing access for those populations most at risk of health inequity, those living in the far North and remote regions of my country, who have limited access to urban care. POCUS with added portability and technological integration can help improve access, and shared decision making between urban centers and remote regions with patient safety and privacy as a priority.

I’m excited to see where POCUS integration moves in the course of the rest of my medical career, as I look forward to being an advocate for access and clinical education in addition to being an expert that maintains clinical accountability, safety, and privacy. The promotion of these critical pillars will help determine the success of the POCUS-empowered clinical experience.

 

Do you use point-of-care ultrasound in pediatric practice? If so, how has it helped you? Is there another medical field you think should use ultrasound more? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Lianne McLean, MB BCh, BAO, FRCPC, is Assistant Professor at the University of Toronto; and Staff Physician and Chair of the Council of Informatics & Technology in the Division of Emergency Medicine at the Hospital for Sick Children in Toronto, Canada.

Ultrasound in Orthopedic Practice

Point-of-care ultrasound brings great value to patient care in orthopedic practice, especially for soft tissue problems. It offers safe, cost effective, and real-time evaluation for soft tissue pathologies and helps narrow down the differential diagnosis.Pic1

There are variety of soft tissue lesions in orthopedic practice with classic clinical presentation that may not necessitate ultrasound examination for confirmation of diagnosis, for example ganglion cyst. However, there is value in performing an ultrasound scan for these common soft tissue lesions.

Ganglion cyst on the dorsum of the wrist or radial-volar aspect of the wrist are confirmed based on clinical examination and presentation. Adding ultrasound examination can help differentiate classic ganglion cyst from some rare findings like Lipoma, anomalous muscles, or soft tissue tumors. Ultrasound examination may also be helpful in finding the source of the ganglion cyst or the stalk of the ganglion cyst. This can help pre-surgical planning if resection of the ganglion cyst is desired by the patient and recommended by the surgeon, because arthroscopic or traditional surgical approach may be needed based on the location of the stalk or neck of the cyst.

Images 1 and 2 show examples of two different patients with similar presentation of slow growing mass on the digit. Image 1 from patient 1 shows a solid tumor overlying the flexor tendons of the digit, where the mass was palpated. Image 2 from patient 2, shows a cystic mass overlying the tendons of the digit. In both of the cases, masses were painless and slow growing with minimal to no discomfort. Ultrasound is a great tool in differentiating solid vs cystic lesions and can help avoid attempted aspiration of a solid mass when the mass is presented in an area of classic ganglion cyst’s usual presentation.

Another soft tissue problem, where ultrasound is a superior imaging tool is tendon pathology. Ultrasound can help differentiate tendinosis, tenosynovitis, or tendon tears.

In tenosynovitis, tendon by itself shows normal echotexture and uniform appearance but the tenosynovium that surrounds the tendon gets inflamed and appears as hypoechoic halo around the tendon, for example, in image 3, tendons of the first dorsal compartment of the wrist show uniform thickness and fibrillar echotexture, however there is hypoechoic swelling around the tendons, this is an example of tenosynovitis of first dorsal compartment of the wrist.

In tendinosis, tendon loses its fibrillar pattern and appears swollen and may show vascularity on color ultrasound, which is suggestive of neoangiogenesis or angiofibroblastic proliferation. For example, in Image 4, the tendons of the first dorsal compartment of the wrist show focal enlargement, hypoechoic swelling, and loss of normal fibrillar echotexture and tendon appears disorganized with evidence of increased vascularity on color ultrasound. This is an example of tendinopathy or tendinosis.

Focal tendon tears appear as anechoic or hypoechoic focal defects in tendon substance. Image 5 shows partial tear of the triceps tendon from the olecranon process. The partial tear appears as a focal hypoechoic defect in the tendon, which is confirmed in the long and short axis scan of the tendon.

In full thickness tears, the tendon is seen retracted proximally with no fiber attachment at the tendon foot print. Image 6 shows example of a full thickness complete tear of the supraspinatus tendon from its bony attachment at the greater tubercle. The tendon has retracted proximally and the retracted stump is not visible on ultrasound examination.

Image 6

Point-of-care ultrasound adds significant value to clinical examination in orthopedic setting. It enhances the understanding of a patient’s problem, increases confidence in care provided, and high patient satisfaction is reported.

 

In what unexpected ways do you find ultrasound to be useful? Do you have additional tips for using ultrasound in orthopedics?  Comment below or let us know on Twitter: @AIUM_Ultrasound.

Mohini Rawat, DPT, MS, ECS, OCS, RMSK, is program director of Fellowship in Musculoskeletal Ultrasonography at Hands On Diagnostics and owner of Acumen Diagnostics. She is ABPTS Board-Certified in Clinical Electrophysiology; ABPTS Board-Certified in Orthopedics; registered in Musculoskeletal Sonography, APCA; and has an added Point-of-Care MSK Soft Tissue Clinical Certificate.

Training Beyond Discipline – Developing Devotion in Ultrasound

Mathews Benji KA point-of-care ultrasound (POCUS) revolution is unfolding before our eyes, forever changing the way we interact with patients. It started with a revolution in specialties such as emergency medicine and critical care, and now it has entered into my sphere with internal medicine and hospital medicine. I see this whenever I’m on clinical service. A 3rd year medical student talks about diffuse B-lines as we stop antibiotics and start diuretics on a patient with pulmonary edema; a 3rd year resident asks to look at a patient’s kidney with ultrasound as we manage undifferentiated acute kidney injury; nursing staff curiously looking on as a patient is shown their weak heart as goals of care are discussed.

At the same time, we in internal medicine and hospital medicine are living in a medical world filled with many challenges towards implementation of POCUS. Though there are many devices in the emergency rooms and some in the critical care wards, there are not many in the inpatient wards nor in the clinics. Though numerous workshops and courses abound in POCUS, many attendees do not continue to use this skillset after training. Those that received initial training find it too challenging to discipline themselves to continue to scan.

It is that latter sentiment that caught my attention this last year. The concept of discipline and viewing POCUS through its lens. A quote by Luciano Pavarotti comes to mind,

“People think I’m disciplined. It is not discipline. It is devotion. There is a great difference.”

I’ve often heard the sentiments:

“It is so hard to learn POCUS, how do you find the time for it on a busy clinical service to get images?”

“I find it hard to set aside time during my non-clinical work days as other work and life piles up.”

I’m not sure about you, but the word discipline does not often carry an inspirational tone to it. There is a sense of drudgery, lack of passion surrounding the word. As an ultrasound director, that is the farthest from what I want my learners to experience with POCUS.

When I looked up the word discipline in the Oxford Dictionary there it was as well:

dis·ci·pline
noun
1.
the practice of training people to obey rules or a code of behavior, using punishment to correct disobedience.
“a lack of proper parental and school discipline”

2.
a branch of knowledge, typically one studied in higher education.
“sociology is a fairly new discipline”

Is it #1 that we were aiming for? Or at the very least, is that what people are sensing? Hopefully, we’re not using punishment to correct disobedience. The Pavorotti quote struck a chord in me. As a contrast to discipline, we have devotion.

The word “devotion” is defined by Oxford Dictionary as follows:

de·vo·tion
noun
1.  love, loyalty, or enthusiasm for a person, activity, or cause.
“Eleanor’s devotion to her husband”
synonyms: loyalty, faithfulness, fidelity, constancy, commitment, adherence, allegiance, dedication; More

•  religious worship or observance.
“the order’s aim was to live a life of devotion”
synonyms: devoutness, piety, religiousness, spirituality, godliness, holiness, sanctity
“a life of devotion”

•  prayers or religious observances.
plural noun: devotions
synonyms: religious worship, worship, religious observance

Devotion does have some concepts borne from religion or worship but that doesn’t make it an irrelevant word for the POCUS learner or teacher. The first definition of love, loyalty, or enthusiasm captures the essence of what most of us are hoping POCUS to be for our learners. As my good friend and POCUS enthusiast, Dr. Gordy Johnson, from Portland, Oregon, says, we need to remember “our first kiss.” What was the moment that grasped us with POCUS?

Don’t get me wrong, I’m not completely opposed to the word discipline, but it moves beyond that if we’re going to develop fully devoted clinicians in the realm of bedside ultrasound. Those that are equipped with the cognitive elements know when POCUS should be used, why it should be used, how to acquire images, and then how to clinically integrate it.

This post was originally intended as a follow-up of the AIUM webinar on the Comprehensive Hospitalist Assessment & Mentorship with Portfolios (CHAMP) Ultrasound Program with hopes to continue the conversation surrounding what makes for an effective training program. The program involved online modules, an in-person course with assessments, portfolio development, refresher training, and final assessments. The key lesson we have learned is that longitudinal training with deliberate practice of POCUS skills with individualized performance feedback is critical for skill acquisition. However, the intangible pieces of how people continued to scan was developing an enthusiasm and love surrounding ultrasound by seeing its impact in the marketplace. As they were continuing to scan, their patients, their students, the many nursing staff were partnering in a stronger way with this diagnostic powerhouse in their hands.

With all this, I cannot help but be optimistic when I see the commitment of many in the POCUS movement already. I would urge all of us to evaluate how we develop devotion in ultrasound, how to tap into the dynamism of the POCUS movement coming up the pipeline with our medical students and residents. They have the potential to disrupt inertia and be an impactful force to integrate POCUS more into internal medicine and hospital medicine.

 

If you are an ultrasound educator, how do you inspire devotion? What are some of your best practices surrounding training in POCUS? Which do you think is most important: discipline or devotion? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Benji K. Mathews, MD, FACP, SFHM, is the Ultrasound Director of the Department of Hospital Medicine at HealthPartners in St. Paul, Minnesota.

Vascular Access for Fiona

Life as a vascular access nurse can be very challenging and diverse in a pediatric hospital. A typical day is fast-paced and includes neonatal, pediatric, and adult patients. Veins may be small, tortuous and often found in unusual locations, eg an extremity or scalp vein. For many patients, imaging tools such as ultrasound are essential for successful placement of IVs, midline catheters, and PICCs. The Vascular Access Team sees patients in both the inpatient and outpatient settings. While many of our procedures are routine, a phone call in February 2017 forever changed the way we view our specialty of vascular access.

The caller on the phone was Amy from the Cincinnati Zoo Marketing Department. She described an urgent clinical situation with Fiona, a 3-week-old premature hippo who was dehydrated and needed IV access. The Zoo staff was desperate as Fiona was not taking any bottles and her IVs were only lasting 8–12 hours. Amy had previous experience with the Vascular Access Team when her daughter had surgery at our institution. She referred to our team as the “Vein Whisperer.” Amy wanted to know if we would be able to use the same tools we used on her daughter to gain IV access with Fiona.pic 8

Fiona was already a star in the eyes of the Cincinnati community. Fiona was born on January 24, 2017, the first premature hippo on record to survive. Fiona was small, around 30 pounds, and was being cared for by a specialized team of experts at the Zoo. Her day-to-day progress was being reported on social media and the local news.

My answer to Amy was, “Of course we can help Fiona!” In my mind, I was thinking of all the things we would need to bring to the Zoo. Supplies included an ultrasound machine, probe cover, ultrasound gel, skin antisepsis, varying sizes and lengths of IV and midline catheters, dressings, etc. I kept thinking…this is a premature hippo, what will we need to insert and maintain the catheter? I asked my colleague Blake to accompany me to the Zoo. Blake is an experienced vascular access nurse and is always up for a challenge! We gathered all our supplies and began our journey to the Zoo.

We arrived in the Hippo Cove area of the Cincinnati Zoo. We met two of the veterinarians who updated us on her condition. Fiona was dehydrated, on oxygen, and extremely weak. They described her condition as critical. We put on special scrubs and removed our shoes. As we were led into the small room where Fiona was, the room temperature was very warm as an effort to maintain Fiona’s body temperature. Fiona was on the floor, laying on a blanket.

Fiona was surrounded by 2–3 Hippo team specialists. Amid their worried looks, they quickly reviewed Fiona’s history, IV access issues, and her inability to take a bottle. Fiona was receiving nutrition through an intermittent naso-gastric tube.

Time was of the essence; we began setting up the 2D ultrasound machine and the necessary supplies. Initially, I scanned her head to assess for any scalp veins, there were no visible veins identified. Blake began scanning her hind leg; she was able to locate a viable vein, about 0.2 cm below the skin. The vein easily compressed and had a straight pathway. Based on her assessment and fluid requirements, we decided to use a 3Fr 8cm midline catheter.

The vein was accessed under ultrasound guidance, using a transverse approach. The midline catheter initially threaded with ease but we were unable to advance it fully. Fluids were connected to the catheter but it only lasted 20 minutes before leaking. The midline catheter was discontinued. Another vein was visualized under ultrasound guidance on the hind leg; the midline catheter was trimmed to 7 cm and threaded with ease. The midline catheter flushed and aspirated with ease.

pic1

 

Due to Fiona’s occasional activity of standing up, we really wanted a secure catheter. The midline catheter was sutured to her skin and a dressing was applied. We discussed the care and maintenance with the veterinary staff, and the decision was made to infuse continuous fluids through her midline catheter to maintain patency.

Over the next 2 days, Fiona gradually began to regain her strength. She began slowly taking her bottles and standing up. Fiona received 5 liters of fluids over 6 days through her midline catheter. The catheter was discontinued on day 6.

Fast forward and now Fiona has celebrated her 1st birthday. She did so with the Hippo team that provided the delicate care that she needed. The Vascular Access Team is so proud to have been part of her care. On that cold February day, we were able to use our 20+ years of experience and knowledge to provide the right catheter under imaging to provide her with the lifesaving fluids she needed.

 

Have you preformed ultrasound in an unusual situation? Tell us your story by commenting below or letting us know on Twitter: @AIUM_Ultrasound.

Darcy Doellman MSN, RN, CRNI, VA-BC, is Clinical Manager of the Vascular Access Team at Cincinnati Children’s Hospital.

 

Flying Samaritans, the Seed to Pediatric Point-of-Care Ultrasound

There are some experiences in life that seem to have a tremendous impact on the person you become, and the career path you decide to take. When I started working with the Flying Samaritans in medical school, little did I know that it would change the trajectory of my career.

Kids from El Testerazo Mexico

The kids I fell in love with in El Testerazo, holding the pictures I had taken and shared with them. They came by even if they weren’t sick. Of note, they are now in their 20s with families of their own.

Since the UC Irvine School of Medicine was so close to the USA-Mexico border, the UC Irvine Flying Samaritans chapter was actually a driving chapter. Each month we drove down to El Testerazo, Mexico, to give medical care and medications to an underserved community. I immediately fell in love with the community and the children of El Testerazo, Mexico. They would all laugh at my then broken high school-level Spanish, but would appreciate my trying. There was also something about the group of undergraduates (who ran the clinic), medical students, residents, and attending physicians who volunteered their time there that brought back the humanity to medicine. The experience was challenging and rewarding at the same time—to work with limited resources, but to become a trusted member of their community was priceless. Each time I went to the “Flying Sams” clinic, I remembered why I went into medicine in the first place.

During my time with the “Flying Sams,” I worked with a then Emergency Medicine resident, Chris Fox. When he told me he was going to Chicago to do a 1-year Emergency Ultrasound fellowship, I thought he was crazy.

Old ultrasound machine

The ancient beast of an ultrasound machine that we had in the “Flying Sams” clinic.

Not only was he leaving sunny Southern California, but he was going to spend a year looking at ultrasounds? When I looked at ultrasounds, I could barely make out structures; images looked like the old tube TV’s from the 1980s. When Fox returned, he said, “Steph, the next big thing will be pediatric ultrasound.” Again, I thought he was crazy. But slowly, by seeing how ultrasound impacted the management of our patients in El Testerazo, I realized the brilliance in this craziness. Chris Fox’s enthusiasm and “sonoevangelism” was infectious. I think nearly everyone in the “Flying Sams” ended up eventually doing an ultrasound fellowship. Even though the ultrasound machine in the clinic was old, and images were of limited quality, we were still able to impact the medical care of this community that became near and dear to my heart.

And so it began…my passion for emergency ultrasound (now referred to as point-of-care ultrasound) and for Global Health. My initial goal was to become good at performing ultrasounds. As I quickly realized, I was one of the only people who had experience in pediatric point-of-care ultrasound. I felt a tremendous responsibility to become as knowledgeable and skilled as possible, if I were going to teach others this powerful tool. After 4 years of undergraduate education, 4 years of medical school, 3 years of a Pediatrics residency, and 3 years of a Pediatric Emergency Medicine fellowship, I decided to do an additional 1-year fellowship in Emergency Ultrasound. With medical school loans looming and so many years without a “real job,” I was reluctant to do this. This California girl moved from sunny Southern California, to Manhattan to embark on a 1-year Emergency Ultrasound fellowship. This was a move far outside of my comfort zone for so many reasons. And that was one of the reasons why it ended up being one of the best decisions I’ve ever made. It has been a privilege to be a part of this growing community… to take better care of the most vulnerable of patients… and to give this tool to other doctors around the world. I certainly would have never had these experiences or opportunities if it weren’t for the “Flying Sams” and Chris Fox; to both I am forever grateful.

 

 Are you involved in global medical education? If so, what led to your decision to go into the field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie J. Doniger, MD, RDMS, FAAP, FACEP is the Editor of the first pediatric point-of-care ultrasound textbook “Pediatric Emergency and Critical Care Ultrasound,” and is currently practicing Pediatric Emergency Medicine and Point-of-Care Ultrasound in New York. She has additional training in Tropical Medicine and is in charge of Pediatric POCUS education for WINFOCUS Latinamerica.

Interest in Interest Groups

Ultrasound in medical education is a powerful idea whose time has come. With its value in the clinical setting being increasingly recognized, leaders of a point-of-care ultrasound (POCUS) movement are making a strong case for introducing ultrasound early in medical training. Not only is it a useful educational tool to illustrate living anatomy and physiology, but it is also an important clinical skill- guiding procedure, improving diagnostic accuracy, and facilitating radiation-free disease monitoring. As the list of POCUS applications grows exponentially across specialties, I believe that to maximize the potential impact, it is vital to introduce this skillset early during the pleuripotent stem cell phase of a young doctor’s career.

Wagner

Looking around, there are signs this movement is here to stay. Ten years after the first medical schools began integrating ultrasound into the curriculum, an AAMC report of US and Canadian schools stated that at least 101 offered some form of ultrasound education, with the majority including it into the first 2 years of the curriculum. If one visits the AIUM medical education portal (http://meded.aium.org/home), 77 medical schools list a faculty contact person involved with ultrasound curriculum development and integration.

It should be noted that the depth of content varies from school to school, as not all institutions value ultrasound to the same degree. Recommendations on core clinical ultrasound milestones for medical students have been published and results from a forthcoming international consensus conference will help improve standardization, though there will likely be much variability until it is required by LCME or included on board exams.

It is during this time of transition that the importance of ultrasound interest groups (USIGs) cannot be understated. USIGs provide a wider degree of flexibility often not possible within a formal curriculum, quickly adapting for changes not only for meeting times and group sizes but also topics and teaching strategies. Indeed, for schools without a formal ultrasound curriculum it is often how one gets started. For ultrasound faculty, USIGs provide fertile ground for experimenting with new teaching ideas and cultivating both student and faculty enthusiasm for POCUS at one’s institution. For senior students, USIGs can provide opportunities to participate in research projects, serve as near-peer instructors, and participate at regional and international meetings. The spread of local, student-run Ultrafest symposiums is a testament to the power ultrasound has to draw people in and the impact students can have beyond their own institution. The AIUM National USIG (http://www.nationalusig.com/) provides a nice resource for further collaboration while student competitions like AIUM’s Sonoslam or SUSME’s Ultrasound World Cup showcase ultrasound talent and teamwork in an anti-burnout, fun environment. I have no doubt that some of these exceptionally motivated students will become future leaders in the field, as some already have (http://www.sonomojo.org/).

While many of these students will pursue and jumpstart their careers in Emergency and Critical Care Medicine, students from varying backgrounds and interests are needed in USIGs. The frontier of Primary Care ultrasound is wide open and may become crucial as we see more emphasis on population medicine and cost containment as opposed to fee-for-service models. With the exception of in the ER, the utilization of pediatric ultrasound has been surprisingly lagging and more POCUS champions are certainly needed here. In addition, the early exposure to POCUS can increase comfort with ultrasound and help drive novel developments by future specialists. Some lesser known potential examples include advancing work already underway: gastric ultrasound for aspiration risk by anesthesiologists, sinusitis and tonsillar abscess drainage for ENTs, diagnosing and setting fractures for orthopedists, noninvasively measuring intracranial pressure by ophthalmologists and neurologists, and detecting melanoma metastasis by dermatologists. Until it is more widespread, a skillset in POCUS can be a helpful way to distinguish oneself in an application process and provides an excellent academic niche. After medical school, some USIG students will go on to form ultrasound interest groups in their specialty organizations, going beyond carving out a special area of interest for themselves and helping to advance the field and shape future policies.

Similar to other enriching things like viewing art and discussing philosophy, I believe all students should be exposed to ultrasound and given the opportunity to learn this skill. While I feel strongly that ultrasound should be a mandatory component of an undergraduate curriculum, I also recognize that not all will enjoy and excel in it, and many will settle for nothing more than the bare minimum. However, I believe the USIGs help us to motivate and empower those few individuals with the passion and grit to really help propel this movement forward and show the world what is possible. This is truly an exciting time. I hope you will join us.

Ultrafest

Are you a member of an ultrasound interest group? Has it improved your skill set? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Michael Wagner, MD, FACP, RDMS, is an Assistant Professor of Medicine at the University of South Carolina School of Medicine in Columbia. There he serves as the Director of Internal Medicine Ultrasound Education for the residency program, Assistant Director of Physical Diagnosis for the undergraduate curriculum, and faculty advisor to the student ultrasound interest group. You can view his 2017 talk for the USCSOM USIG here (https://youtu.be/FfO7SXRwjLY) and an AIUM webinar with Janice Boughton on a pocket ultrasound physical exam here (https://www.youtube.com/watch?v=ywuIeoEfG1I).

 

Patient Zero

My rock, my reminder, my inspiration, my failure

Soucy

 

Case 1
It was fall 2009 and early in my second year of residency. Having spent multiple months off service, I was excited to get back into the swing of emergency care in “critical” bay. The patient was a 44-year-old male presenting with syncope. Admittedly, he was an alcoholic who was an on-the-wagon, off-the-wagon type. His trip to the ED found him off the wagon for several weeks, deeply depressed, and outwardly self-neglected.

His story was not unfamiliar to the ED; lots of alcohol without eating or drinking much else and lots of time on the couch. Today, he got up to get something from the fridge but found himself at the bottom of a set of stairs. A housemate was kind enough to call EMS when it took more than a few minutes for him to wake up. He didn’t remember much and complained of a headache, some rib pain, and significant fatigue getting around the house recently.

It was early morning so I had a bit more time than usual to chitchat. He wore a Minnesota Twins jersey. Though I was from the northeast, I told him how I was a big Kirby Puckett fan growing up, which segued into discussion about their current season, game soon-to-be in progress, and the Vikings acquisition of Farve. “Who would have thought,” he said; “No kidding,” I reaffirmed. Our conversation was natural, comfortable, and enjoyable. Before I left the room, I recognized his oxygen saturation at 91% and blood pressure had dropped to systolics in the 90s but recovered into the low 100s.

All the usual suspects were considered but we thought his low saturations (sats) were most likely due to his smoking history and low blood pressure due to dehydration. Fluids and albuterol went in, labs came back, and time ticked by. Acute renal insufficiency, hyponatremia, hypomagnesemia, and normal chest x-ray without any improvement in vitals despite our interventions. Radiology called and said they could do the CT of the head but chest with contrast would have to wait until after fluids and a creatinine recheck. Critical bay became busy and his clock continued to tick.

I was surprised by how quickly my body reacted to the “code blue in CT” called out overhead. I didn’t know why I knew it was him, but I did. As my body turned the corner to CT, my mind was unprepared to absorb what I saw. His head and neck had turned a deep unnatural blue. He was confused and was asking for help. In between explaining that his heart had briefly stopped and quickly moving him from the scanner, a wide-eyed radiology resident appeared in the doorway, “saddle PE” (pulmonary embolism).

We rolled quickly. Sats and blood pressure were down, heart rate was up—mine included. I assured him everything was going to be okay and he believed me. “Wake me up when the Twins score doc,” he said with a smile. Intubation was smooth as lytics were mobilized.

With cardiothoracic surgery at the bedside, his tachycardia devolved into PEA (pulseless electrical activity). I ran the code while thoracics prepped ECMO (extracorporeal membrane oxygenation). Both groins were inaccessible and I was told we would do an ED thoracotomy. “Ready,” the surgeon said. “Yes,” I said confidently, not knowing what would happen next. The clamshell and cannulation were smoother and quicker than I could have imagined. The machine worked, but his body didn’t.

I still critique my conversation with his mother. It was my first time breaking bad news alone. I was inexperienced and unpolished, but honest and raw. We cried together. I wish I could have been better for him and for his mother.

Case 2
Several months and various rotations passed, including ED ultrasound, which I took a liking to. I again found myself in “critical” working with one of my favorite attendings. EMS patch was for a 78-year-old female being brought in from her rehab facility hypotensive, hypoxic, tachypnic, and ill appearing. The report did not disappoint. The patient was postoperative day 5 from a transabdominal hysterectomy for leiomyomas. The patient was doing well until the day before presentation when she felt fatigued and feverish and then in the morning when she felt shortness of breath and extreme fatigue, which had progressed. She looked like she might die any second.

My attending listened to the reports, watched my exam, and performed his own. “So, what do you think?” I hesitated. Literally any organ system or combination of systems could be failing. A trip down the wrong diagnostic or therapeutic pathway could lead to delay, decompensation, and death. I was relieved when he told me to prepare for a central line so we could start pressors and antibiotics for her septic shock. It was clear to me that she was dying and I did not know the etiology, but my veteran attending did.

The patient was sterilely prepped and ultrasound placed on the neck. The internal jugular (IJ) was plump, very plump, the plumpest IJ I had ever seen. “Cake,” I thought. Simultaneously it then dawned on me that physiologically this wonderfully plump IJ did not make sense in septic shock. I consulted my attending and given the patients worsening cardiovascular collapse despite fluid resuscitation, we proceeded.

As I secured the sutures, I ran through the types of shock, differential for each, and ways I could figure it out at the bedside. Antibiotics started and I pulled up to the bedside with the ultrasound. I was suspicious for an obstructive process; however, due to the patient’s postoperative status I performed the FAST (focused assessment with sonography for trauma) exam. “Negative belly,” I thought to myself as I quickly moved to the patients left chest. The focused cardiac exam quickly aligned all the puzzle pieces. I personally had never seen acute right ventricular strain at the bedside but the septal D-ing of her hyperdynamic heart on parasternal short and apical 4 was irrefutable.

My attending agreed and we changed our trajectory. Instead of MICU (Medical Intensive Care Unit) admission, antibiotics, fluids, and pressors, ultrasound indicated the patient needed something different. Given her recent extensive operation, an emergent CT was performed showing saddle embolus. In coordination with OB/GYN and critical care, the patient received thrombolytics. 2 weeks later, I was there when she walked out of the hospital with her children and grandchildren.

The Lesson
I could not reconcile the 2 poignantly different outcomes. Both were getting pulmonary embolism workup and I ordered all the right emergent testing. So, how could an elderly patient with every comorbidity in the throws of dying live while a middle aged otherwise fairly healthy patient who cracked a joke minutes before he arrested not? Ultrasound (and thrombolytics) of course!

Point-of-care ultrasound (POCUS) is an incredible diagnostic tool that is transforming clinical practice and medical school education. Numerous studies have shown it to be a critical component of directed resuscitation in the emergency and ICU departments’ critically ill population. In various disease processes, its use has been shown to decrease procedural complications, improve mortality, and decrease time to safe disposition. All technology is not created equal; ultrasound is unique. Instead of pulling me away from the patient, POCUS allows me to stay at the bedside gathering important information; improving my efficiency, addressing concerns, and talking with loved ones. Undoubtedly the extra time communicating and caring for the patient has improved my job satisfaction and is one of the reasons patients like it. But, there is an often overlooked significance to POCUS’s story, which has caused ripples to be felt for generations.

I believe the soul of POCUS rests firmly in what makes our profession exceptional; our willingness to self-evaluate, improve, and innovate for those we serve. POCUS stands as an early example of disruptive innovation, which has transformed the way we think about our job as clinicians. At the time of its introduction in the 70s and 80s this type of “out-of-the-box” thinking did not conform to the traditional framework. Its existence challenged many long-held beliefs and medicine’s titanic momentum perpetuated throughout generations. These innovators took the road less traveled and persevered in the face of adversity. Their gift has enabled countless others to save lives and improve patient care around the world as well as demonstrate our profession’s ability to adapt in rapidly changing times.

My path to ultrasound resulted from those emotions that remained unresolved and the process unfinished after medicine left its first mark. Feelings of inadequacy loomed, challenging my perception of the limitations of medicine and my own abilities. Painful at the time, I like to think that generations of physicians have constructively, therapeutically, applied this driving force to be better than they were the day before in whatever field their passions lie. Ultrasound is my tool, my promise to him, to her, to myself to be my best and help others be theirs.

 

What struggles have you overcome in your career? And how has ultrasound helped you overcome them? How do you think POCUS will change in the future? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Zachary Soucy, DO, FAAEM, is Assistant Professor of Emergency Medicine, Director of Emergency Ultrasound, and Co-Director of the Emergency Ultrasound Fellowship at Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, in Lebanon, New Hampshire.