DR THOMAS BROUGH
50yoM P/W exertion chest pain and diaphoresis.
Remote history of whitecoat, no medications; completely healthy until today; worked in business.
Inferior STEMI on ECG with some bradycardia.
450km from cath lab, in an ED where we thrombolyse STEMIs.
Aspirin downrange, about to give ticagrelor, heparin bolus, and 40mg tenecteplase.
Had a look for no reason in particular other than it was my want.
And indeed it was worth a look... (PLAX followed by suprasternal views)
Type A dissection, tPA and heparin withheld, flown to tertiary hospital, arrested a few times, survived neurologically intact
By LUKE PHILIPS: CO-CHAIRPERSON, EMUGs CENTRAL COUNCIL
Dear fellow EMUGers.
2019 has been a huge year for the EMUGS community with a large number of successful events including our Noosa conference and welcoming in both the South Australia and Tasmanian branches of EMUGs.
I’d like to take this opportunity to thank everyone who has helped to organise, assist and teach at these events. Without this grassroots support we wouldn’t be able to push our agenda of advancing Point of Care ultrasound excellence in acute care across Australia and New Zealand.
We have a number of changes at board level with Mark Rewi stepping down from the board and in doing so relinquishing his position as Co-Chairperson. Mark is being replaced as Co-Chairperson by Melody Hiew. Mark has been pivotal in getting EMUGs to where it is today particularly in New Zealand and we are thankful for all his input and support. Allan Whitehead has joined the Central Council, replacing Gaby Blecher, making Allan an official board member, as well as EMUGs secretary and treasurer.
Next year promises to be even bigger with a roadshow of events and our 2nd annual Sonic conference in Queenstown in August. We continue to collaborate and advocate for POCUS with key stakeholders including ACEM and ASUM. As part of this we are looking at how best to make ultrasound education accessible to all trainees and consultants. As part of this process we would like to gauge interest in the development of a focused ultrasound in EM certificate. If you have time and interest, please complete this survey.
In the background, we are developing a set of resources for clinical leads in ultrasound and as part of our outreach/developing country programs we are continuing to offer a scholarships to doctors from developing countries as well as exploring a handheld ultrasound education program.
I look forward to seeing you at a number of events next year and on behalf of the central council we wish you and your families all the best for Christmas and the New Year.
Dr Luke Phillips
Co- Chairperson - EMUGs Central Council
Aidan completed a Bachelor of paramedic practice at the University of Tasmania in Sydney, followed by a BSc Hons looking at ultrasound guided IV cannulation by paramedics; comparing short and long axis techniques.
Aidan was then the first paramedic in Australia to do a Graduate Certificate in Clinical Ultrasound with specialism in EM at CQ University. After that he spent a year in London as a visiting researcher and lecturer at Kingston University and St Georges University. He also took up the role of Course Director for the PoCUS UK and EU with the Prehospital Care Consultancy Ltd. Now, back home in Sydney, Aidan is a medical student, working casually as a paramedic and lecturer, and freelancing as a POCUS educator.
Aidan is a passionate believer in POCUS, particularly within EM and out of hospital care.
What drives your POCUS passion?
Once you’ve seen the impact POCUS can have, it’s hard to go back.
The first ultrasound Aidan ever did was as a volunteer simulated patient for Sydney’s Air Ambulance retrieval courses where he scanned himself after one of the formal lessons. He became fascinated and ended up learning more. The learning went from informal to formal, the fascination grew and he ended up travelling to exciting places to teach POCUS around the world, and, in a full circle, back home in Australia.
Favourite travel destination…
As yet undecided. The beauty of travel is that everywhere you go is different and doesn’t have to be compared. Too many favourite countries depending on when you ask. Nepal, India, Thailand, Austria, Ireland, and Scotland are definitely up there though
Who are you outside of work?
Aidan was a classically trainer baritone in a previous life and finds himself revisiting singing on rare occasions. He is currently enjoying being a new student to Brazilian Jiu Jitsu. Is sleeping a hobby?
What is your vision for EMUGs?
POCUS needs to become accessible, self regulating, and well governed and audited. Hopefully EMUGs are able to agitate for these changes.
What progress have you seen with regard to POCUS? What would you like to see?
POCUS has come a long way since I first started learning in 2012. The evidence base has exploded, and the technology has become ever more accessible.
‘The POCUS person’ is now a recognised asset in most departments. We need to shift from it being a special skill, to a core skill and standard of care where evidence for benefit exists, of course.
A message from Aidan for those new to POCUS...
Safe point of care ultrasonography requires that one can articulate the pretest probability which justifies the scan, and the positive and negative likelihood ratios of that specific POCUS exam performed. POCUS without a basic understanding of Bayesian clinical decision making is dangerous.
I uses a mental Fagan nomogram every single time I perform a scan.
I believe that you will likely never harm a patient with POCUS if you practice with an honest Bayesian framework.
Safe Scanning y’all.
It's 10pm and the resident comes to me having seen a 61 year old lady who presents with a sudden onset of dizziness on standing.
She is hypertensive, and not in any distress but describes a feeling of significant unsteadiness while standing from a sitting position at home.
She describes a tremor and tingling down her left hand with no complaints of headache or vomiting despite feeling nauseous.
The resident reports a 15mm Hg drop in blood pressure on standing. Other vital signs remain normal and she has a normal ECG with a normal neurological exam.
She says she had a similar episode a month back but thought nothing of it. It was transient at that time and remained transient today but tonight her symptoms persisted a bit longer, making her seek help.
Her FBC/U&E returns within the normal range and after being treated with 500ml of normal saline with 12.5mg of prochlorperazine she appeared well.
Prior to discharge I go to see her and for a sense of completeness decide to use POCUS [point of Care Ultrasound] on her carotids.
After visualising normal vasculature on the right side, it became obvious that there was a significant stenosis in the left carotid artery just distal to its origin after the bifurcation.
Having found this on my unaccredited scan, it then begs the question whether it is just a coincidental finding or the cause of her symptoms. I organised a CT angiogram which confirmed the stenosis without any other pathology.
The options were to then discharge her with an outpatient formal US request and a outpatient vascular appointment after starting her on Aspirin, Statin and an antihypertensive, or admitting her for further investigation.
After discussion with the vascular team it was decided to admit her for a formal Duplex study of her carotids as an inpatient and after quantifying the degree of stenosis a multidisciplinary team discussion can occur in the cold light of day.
She went on to have the Duplex US study the next day and was discharged remaining asymptomatic and is awaiting an outpatient clinic review by the vascular team.
The video can be viewed here.
Another rewarding use of POCUS in emergency medicine.
Dr Ash Mukherjee
A bit about Brian, professionally speaking...
Brian completed all of his medical and specialty training in Emergency Medicine in the United States. He first came out to Australia in 2001 and for good reason fell in love with the place.
Brian now very much calls Hobart home and works full time at the Royal Hobart Hospital and we are pleased to have him on our shores.
Brian wears many “hats” including Deputy Director of Emergency Medicine and clinical lead for ultrasound at the Royal Hobart Hospital.
Getting involved with EMUGs...
After meeting Dr Brian O’Connell several years ago on a bridge in Fiji drinking rum and coke (not a joke) Brian O'Connell (EMUGs founding father) told Brian about a new and exciting “EMUG’s” group that had recently been established. They obviously shared a common enthusiasm… in POCUS and not just rum and coke.
What drives the POCUS passion...
As a medical student in 1994, Brian first saw POCUS used by the eminent Dr Joe Ornato during a resuscitation. It seemed he had a skill that no other clinicians had and the patient would have likely died without it. (To be fair, he was triple board certified in EM, medicine and cardiology). Patient care is the ultimate answer… but... let’s face it... POCUS is fun!
Favourite travel destination...
Just about anywhere Latin America. Great people, great culture and an opportunity to keep maintain Spanish language skills. With kids in the mix, Brian's travels, however, seem to be a lot more local now. Fortunately, Tasmania is a fantastic place to explore and enjoy the outdoors.
Brian's vision for EMUGs...
Brian is new to EMUGs and currently establishing the EMUGs community in Tasmania and is happy to see where this goes. Brian is mostly interested in networking, learning from colleagues and gaining further enthusiasm. If you will be in Hobart on November 19th (perhaps for the ACEM Annual Scientific Meeting) join us at Grinners Dive Bar for the maiden EMUGs Tasmania meet & greet.
Progress Brian has seen with regard to POCUS and related goals for the future...
In Tasmania, it seems most of the progress in POCUS has come from junior doctors seeing the amazing benefits ultrasound brings to patient care and becoming advocates. It is interesting how it is the younger generation pushing the older ones towards embracing this modality. Brian is seeking to formalise ultrasound education in the state. Hopefully EMUGs can be instrumental in helping to attain this goal.
A message for those new to POCUS or EMUGs...
Learning POCUS is like learning a musical instrument. Nobody is good from the start. It takes many years of repetition to become an expert. So keep up the practice and bring some sweet music to our patients ears.
American nurse Marie Elizabeth Bell recently spent nine months in Papua New Guinea, where she worked at the Kunai Health Centre in the southwestern Pacific country’s remote Gulf Province. One patient left a particular impression on her: a woman named Yaniamo, who had experienced nine pregnancies — twice with twins — but had only six living children. Yaniamo was pregnant again, and when her water broke unexpectedly, she began to fear complications. She needed care from Bell’s clinic — a two-day walk from Yaniamo’s home. So she walked.
READ FULL STORY
Jacob from Ultrasound Podcast joins Kylie Baker in the GE booth at SMACC to discuss how bedside ultrasound can be used in conjunction with other tools to help manage your patients.
This podcast was sponsored by GE.
Blogs are written by our EMUGs Team from across Australasia.