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.

A Word of Encouragement

One excellent online teaching tool for emergency ultrasound states that “scientists have been fascinated by the mechanism of acoustics, echoes and sound waves for many

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centuries.”

I am not one of those scientists.

Frankly, I don’t like physics. I find it challenging to understand things I can’t see. Take gravity, for example. I know and can tell quite distinctly that it exists. The scar on my shin following a childhood attempt at flight is a faithful reminder of its existence. It still remains hard for me to understand the intricacies of this force because of its invisibility. To me, this is similar to a lot of physics concepts.

It’s therefore hilarious that I was somehow drawn to ultrasound. It must have been the enticement of being able to see more, although the ability to “see” is granted by what is unseen—ultrasound waves. The joke was definitely on me.

So how did I get here?

My journey with point-of-care ultrasound (POCUS) started with a remark by a friend of mine. At the time, she was an emergency medicine resident and she told me about a trauma patient that she had performed a “FAST” on. Close to completing 3 years of Pediatric residency, I had never heard of such a thing. I remained intrigued with the idea of quick decision-making scans performed by the provider actively involved in the patient care. Who wouldn’t want this given the chance? The challenge of course lies in acquiring the knowledge.

Things now got interesting.

During my Pediatric Emergency Medicine (PEM) fellowship, I sought to learn more about POCUS. My initiation was not spectacular to say the least. The words of my instructors bounced off the surface of my brain with very little being absorbed. This would have been OK if I were an ultrasound machine. It wasn’t very good when trying to learn how to obtain and interpret ultrasound images however.

By the second and third lesson, I was convinced that I would never learn ultrasound. But as in the majority of love stories, persistence paid off.

Gradually my images changed from what resembled a 1970s television screen after midnight to recognizable structures. By the end of my PEM fellowship, I had acquired a few rudimentary skills. I took an opportunity to pursue an Emergency ultrasound fellowship immediately after my PEM fellowship and the dread of my early ultrasound learning days came upon me again. So many applications, so little understanding.

One day as I scanned a patient, “Eureka!” I finally understood the parasternal long axis. There was hope for me yet.

How did I finally get here?

  1. Persistence – The old adage holds true. If at first you don’t succeed, try, try again.When the words or explanation didn’t make sense, I would try a video (YouTube has some great videos). I would get models of structures to understand the anatomy and relate to them to my scans. I would seek out others to explain concepts in different ways to help my understanding.
  2. Memorization – This provided a foundation and served as the means to the end. When using POCUS, there is a lot to remember and you have to put in the necessary study time.

Finally, I was able to understand what was going on and what the picture was telling or NOT telling me. I also learned not to beat myself up for not understanding everything. That is what colleagues, mentors, online resources, and practice are for.

I now understand a lot of POCUS–more than I ever imagined or thought possible. I didn’t let my dislike of physics or the challenge of image recognition stop me. I figured if others could learn this, I should at least give it a decent shot. And that’s what I ask of those I teach or anyone interested in learning.

What would you tell someone starting to learn ultrasound? What aspect was most difficult for you? How did you overcome it? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Atim Uya, MD, is the Point of Care Ultrasound Director, Division of Emergency Medicine, Department of Pediatrics, University of California, San Diego/Rady Children’s Hospital, San Diego, California.