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.
Blogs are written by our EMUGs Team from across Australasia.