Clinical Specialist Sonographer,
Waikato Hospital, Hamilton, New Zealand.
Who is MARTIN NECAS? The Official Scoop
A bit about Martin, professionally speaking...
Martin holds a Master of Medical Sonography and is an Honorary Fellow of ASUM who works as a clinical specialist sonographer in Hamilton, New Zealand. Martin completed training in general and vascular ultrasound in Seattle, USA in 1996 and subsequently attained a Masters Degree in Sonography at the University of South Australia in 2007. Martin has practiced diagnostic ultrasound in USA, New Zealand and Australia in a wide variety of clinical settings ranging from private centers to tertiary teaching hospitals. Martin is an ultrasound enthusiast, clinical instructor, university lecturer and a prolific conference speaker. He is an author of numerous peer-reviewed papers as well as a book titled Artifacts in Diagnostic Medical Ultrasound. Martin is a strong proponent to clinically targeted ultrasound and evidence-based practice underpinned by clinical research.
Martin has been involved in training sonographers, radiologists, obstetricians & gynaecologists, vascular surgeons, emergency doctors, nurses, physiotherapists and other clinician groups for over 2 decades. He is passionate about good quality ultrasound that is performed with high-level of technical skill and clinical insight and is interpreted correctly.
As a sonographer and an academic, he has a wealth of experience in clinical ultrasound and teaching that he loves to pass on, seeing it as both a duty and a privilege to share his expertise in ultrasound and help others. The EMUGs community is lucky to be able to learn from such a passionate clinician and educator.
What drives his POCUS passion?
It’s easy to be passionate about ultrasound. How much cooler can you get? A hand-held tool that allows you to look inside the patient in real-time, right here and right now. It’s almost hard to believe! It’s a tool that doctors of the past would have only dreamed of.
Favourite travel destination…
Martin grew up in the magical Czech republic and has lived in the Middle East, USA, Australia and New Zealand. He has been lucky to travel widely and loves all countries and all places. He is now a passionate Hamilton-ian, even though most people don’t give Hamilton a second look. In reality, it’s stunning. The only ugly places on Earth have, regrettably, been created by humans. So, answering this question in reverse; the garbage city in Lima, Peru is one destination that he wishes never to visit again.
Who is Martin Necas outside of work?
Martin used to be a passionate rock-climber until a recent encounter with a serious illness robbed him of the ability to continue this beautiful and exhilarating sport. "I still look at various rocky outcrops with a tear in my eye and a deep desire to don on a harness and scale them. To compensate, I have embraced a new hobby in quite a different discipline. I have learned to paint watercolor. Here is a painting of the Waikato River just down the road from my house."
What is your vision for EMUGs?
At present, the training and governance of clinician-performed ultrasound is a little fragmented with a number of interest groups offering varying levels and quality of training. EMUGS can play a pivotal role in unifying and guiding the future of clinician performed ultrasound. Like a fine gem, POCUS needs a bit of pressure and time to crystallise.
What progress have you seen with regard to POCUS? What would you like to see?
When Martin started in ultrasound some 25 years ago, ultrasound was purely a domain of radiologists and sonographers. Clinician practitioners did not exist. Nowadays, clinician-performed ultrasound is everywhere. In our centre, ultrasound is routinely performed by a broad range of clinicians including: emergency doctors, O&G, respiratory, rheumatology, intensive care, vascular, gastroenterology, renal and paediatric specialists as well as nurse practitioners, radiation therapists and a physiotherapist. Martin sees tremendous value of quality ultrasound performed by well trained clinicians at the front lines where the diagnosis can inform management decisions and the the role of “radiology ultrasound” as sorting out the complex cases.
A message for those new to POCUS:
"Get involved. Surround yourself by experts. Learn. Audit your work rigorously. After a 1000 cases, you will be reasonably good. After 10,000 cases, you will be an expert. Enjoy the journey."
A 75 yr old with a history of recently being diagnosed with gastric carcinoma, treated with a partial gastrectomy, presented with vomiting and fevers.
She had no other significant background medical history, however a recent PET scan had shown metastatic disease to her para-aortic lymph nodes.
On arrival to ED she was slightly jaundiced and was febrile at 38.5, other haemodynamics were normal.
She was very tender in the RUQ with a positive murphy’s sign.
ED ultrasound showed a very unusual looking GB, with thickened wall and hyperechoic material within the gallbladder.
I was unable to visualise the CBD (see image below).
She was treated for biliary sepsis and a CT scan was arranged.
The CT scan showed a likely ruptured GB , that had ruptured into the liver causing a liver abscess.
This was percutaneously drained in radiology, and she was admitted under the surgical team for further management.
After an approximate 3 week admission, she has been discharged for ongoing IV antibiotics
Dr Steve Korbel MBBS, BSc(med), FACEM, CCPU
St George Hospital, Sydney, NSW
This is a very unusual case.
A 74 yr old presented with constipation, he had a back- ground history of emphysema, and was otherwise well and on no medication.
He had been seen in the emergency department 1 week prior with a similar complaint of constipation, nausea and vomiting and had been discharged with laxatives.
Whilst being examined, he became unresponsive and went into cardiac arrest, and was in PEA on the monitor.
He had CPR commenced and the usual arrest protocol for PEA was commenced.
He was transferred to the resus room with ongoing CPR via our Lucas device. Bedside ultrasound in resus showed a large pericardial effusion with an echodense collection in the pericardial space which was thought to be likely organized clot.
Due to the organized clot causing tamponade, it was decided that this would not be able to be drained with a pericardial drain or pericardiocentesis, and after consultation with cardiology and cardiothoracic teams, the patient went on to have a thoracotomy in the emergency department performed by the cardiothoracic surgeon.
The heart was delivered from the pericardial sac, and there was found to be a rupture of his left ventricle.
This was sewn up, however there was only a flicker of cardiac activity, and it was decided that further intervention in theatre would be futile, and the patient was pronounced deceased.
See the subxiphoid image of the bedside ultrasound below.
Dr Steve Korbel MBBS, BSc(med), FACEM, CCPU
St George Hospital, Sydney, NSW
At 11 pm while working in our low acuity area I saw a 69 year old man with a flare up of left leg pain, swelling, and redness in upper thigh. He had complained of similar symptoms in the same leg on and off for 2 – 3 months with intermittent fevers. His family doctor had treated him with courses of antibiotics for cellulitis/lymph node infection. No immobilisation, surgeries or travel in the last year. He had also had three radiology suite-based lower limb ultrasound exams that were negative for deep vein thrombosis but one study commented on a small popliteal Baker’s cyst. He had good appetite and ate well but admitted to weight loss. No complaints of chest pain, breathlessness or cough.
On exam he was afebrile, not tachycardic nor tachypnoeic. There was erythema of the left proximal thigh, with minimal oedema to the same lower leg. Before a d.dimer result was available POCUS was performed using a standard serial compression technique from the left external iliac to the popliteal vein. This revealed loss of normal compressibility of veins throughout, with echogenic thrombus within, as shown in figure one.
Video: Non-compressible left external iliac vein with echogenic material within the vessel.
Blood test results were later released.
D.dimer 3310 mcg/L.Creatinine 221mmol/L(was 108 mmol/L, 3 months earlier).
With a diagnosis of extensive left iliofemoral and popliteal deep vein thrombosis with an acute kidney injury, once per day Clexane 1 U/Kg was started and the patient was admitted under General Medicine for further investigation of an unprovoked DVT.
Sonography, suite-based ultrasound concurred with POCUS findings, but in addition extended the exam to the inferior vena cava and beyond.
On this ultrasound thrombosis extends to the IVC in the vicinity of a large and irregular right kidney.
After IV hydration a contrast CT scan of the chest, abdomen and pelvis confirmed a large invasive right renal carcinoma with tumour extension into the (thrombus laden) IVC and bilateral renal veins. Thrombus extended to the right common iliac and femoral veins also.
The presence of multiple pulmonary nodules was reported to represent metastases. No pulmonary emboli confirmed.
This man was continued on once daily enoxaparin (persisting renal impairment) and referred to oncology and palliative care services.
In summary, despite several negative suite-based ultrasound scans a subsequent ultrasound was indicated given persistence of this man’s symptoms. Access to POCUS enabled earlier diagnosis and appropriate treatment. In this patient with only a few other ultrasound images, the origin of the thrombosis was also readily evident. Local guidelines state that 4 to 10 % of patients with unprovoked venous thromboembolism will be diagnosed with a malignancy within the next 12 months. Apart from occult malignancy some other associations of unprovoked venous thromboembolism include myeloproliferative neoplasms, nephrotic syndrome, pregnancy, antiphospholipid syndrome, and inherited thrombophilia. Specific Venous thromboembolism treatment recommendations vary depending on causes, locations of venous thromboembolism as well as other patient comorbidities. Familiarisation with up to date local guidelines for additional haematologic testing and treatment is recommended.
Case Study Provided By: Dr Mark Rewi, New Zealand FACEM
1) Venous Thrombosis Management Guideline . Counties Manukau Health.2019.
Blogs are written by our EMUGs Team from across Australasia.