With infection control a prominent issue for those involved in medical ultrasound practice, here is ACEM's official press release on the issue.
Contact Alistair Murray if you have any concerns that your service is compromised as a result of the ASUM document.
POCUS OUTCOMES AND SAFETY: A ‘NON-COCHRANY’ LITERATURE REVIEW
by Justin Bowra and Alan Giles
Part of ‘Tackling the tough topics’:
The POCUS Debate & Clinical Leaders Meeting
EMUGS NSW, 9 November 2018
The question we asked: What does the literature say about the actual efficacy and safety of POCUS? (IE actual real-world patient outcomes, rather than surrogate markers such as diagnostic accuracy)
Methods: we asked a bunch of POCUS nerds from around the world to send us copies of any literature they had on the subject. We supplemented this by looking up papers that caught our eye, but if it cost actual money to download the articles we only downloaded the abstracts.
Thanks to: Adrian Goudie and Paul Atkinson in particular for sending many of these papers, and also thanks to Frank Norman, Kylie Baker and Bob Jarman for their sage advice.
The summary (for those with short attention spans)
If used carefully by those who are properly trained, POCUS has been demonstrated to improve outcomes. (e.g. in BAT, penetrating cardiac injury, arrested patients)
If used carelessly by idiots or those without proper training, POCUS has been shown to be useless (e.g. in stable BAT, and in shocked patients) or even harmful.
Or to put it another way: ‘POCUS doesn’t kill people; doctors do!’
Now for a little more detail…
FAST in blunt abdo trauma:
POCUS for undifferentiated shock:
Basic cardiac (2D look) in cardiac arrest:
POCUS in respiratory disease
Below are quotes from [Crager and Hoffman editorial. But it makes sense physiologically. Annals EM 2018 .pdf
The last word: (this is a quote from Rory Spiegel, commenting on Laursen’s respiratory POCUS study, in ‘‘ED Hocus POCUS ... or Just a Hoax?’ - https://www.emlitofnote.com/?p=298 )
I’m sure we all have experienced firsthand the utility of bedside US and this is by no means a call to abandon our probes, but rather an acknowledgement of the possibility of subtle harms. We must keep in mind, all testing comes at a price no matter how non-invasive and radiation-free it appears. The cost in this case is information and how we choose to act on it. This would certainly not be the first time increased access to medical technology has lead to such unintended consequences.
To quote Dr Russell McLaughlin, Belfast POCUS tragic: ‘A fool with a stethoscope will be a fool with an ultrasound.’
Ultrasound will not make you smarter, or make you a better doctor or a nicer person.
Alan Giles & Justin Bowra
In collaboration with Developing EM, our core partners ISTIH and our partners at AIU, we are proud to announce Dr Nilanka Wickramaratne and Dr Harendra Cooray from Sri Lanka as recipients of the 2018 EMUGs Developing Countries Scholarship.
Dr Wickramaratne and Dr Cooray were nominated and selected in collaboration with The Critical Care Society of Sri Lanka. They have both demonstrated a sincere commitment to quality improvement in Sri Lanka. Their participation in this scholarship will enable significant training opportunities for Emergency Medicine doctors in training in Sri Lanka under their leadership.
The students will be attending AIU's 5 day Advanced Emergency Medicine Ultrasound (POCUS) course compliments of our generous partners at AIU.
They will also be attending as many of EMUGs Regional Events as possible either in person or via video conference so please join us in making them feel welcome and a part of our amazing EMUGs community of passionate POCUS professionals.
When I learned how to use ultrasound, I thought - wow, now I have this tool, I’ll never miss an IV again! I mean, you can see what you’re doing in real time - what could possibly go awry?
Well… plenty, as it turns out. And through trial and error (not to mention the guidance of some people cleverer than myself), I’ve refined my technique… here are some tips that you may find useful.
1) Pick your patient
There are some patients who need central lines or PICC lines off the bat. For instance, if I see a IVDU patient who has one potentially usable vein 4cm below the surface, and they’re going to need antibiotics for more than 3 days… that patient needs a PICC.
A word of caution: sometimes getting the cannula in is the easiest part - getting it to STAY IN is the challenge. In patients with a lot of loose, fatty, or freely mobile subcutaneous tissue (ie, elderly patients, or patients with a lot of adipose tissue), by the time you’ve traversed 4cm of soft tissue, only a few millimetres of cannula is in the vein. As soon as the subcut tissue moves - that cannula will be pulled out of the vein. A PICC or long line is your best bet here.
2) Comfort is key
Set up your workspace to maximise comfort - yours and the patient’s! (Take a tip from our anaesthetic colleagues - they are the masters of a good set up, as they know it’s key to the success of any procedure). A comfortable patient will stay still and hold a required position for longer. A comfortable doctor will have better fine motor control and better chance at success.
For patient comfort - use towel rolls, pay attention to positioning and use an assistant to steady the limb if available. For doctor comfort - swing the screen of the ultrasound machine to an optimal position, sit down to do the procedure (or crank the bed up so you’re not having to lean over)... and, most important of all… eat and/or go to the bathroom before you start!
My preference is to use use local anaesthetic drawn up in an insulin syringe (or 1mL syringe with 25G needle) whenever I’m doing ultrasound-guided IV cannulae. Personally, I get very distracted by patient pain, and I can work better if the patient isn’t flinching, wincing or swearing. Also, I figure that by the time I come along, there have already been several attempts at cannulation, and it’s a nice thing to do. A word of warning - if you’re using local anaesthetic, ensure that you get all the air out of the syringe before your infiltrate. Any air introduced into your field will destroy your ultrasound picture!
3) Choose your weapons wisely
This is my list of equipment for inserting IV cannulae:
4) Use whatever view suits your needs
Long axis? Short axis? What’s the best approach to cannulation? In my mind - both! Here’s a description of my technique:
After my preparations are complete and I’m comfortably seated, I insert the needle and approach the vein using a short-axis approach, with my eyes on the screen until I reach the vessel. Once on top of the vessel, I bounce the needle a little so I can confirm that the needle is indenting the vessel. I then look down at the needle and advance it into the vessel, so I can spot a flashback as soon as it occurs. Once I get a flashback, I then rotate the probe into long axis view, and reduce the angle of the needle (ie, so it’s more shallow). I then advance a millimetre or so more, so I can see I’m in the centre of the vein, and watch on the screen as I slide the cannula off and into the vessel.
5) Secure that cannula!
You’ve got it in… now make sure it stays in: tape that sucker down! Dry off the area thoroughly and secure it like you would a paediatric cannula. Hint: a bit of Friar’s Balsam (tincture of benzoin) or Cavilon (™) is particularly useful on sweaty skin, to help things to stick down.
6) Practice, practice, practice!
This is just my technique - different things work best for different people. Practice this skill, ask people for tips, and try them out! It takes practice,a little experimentation and active learning to be a master at this skill.
Acknowledgements: Many thanks to Dr Adrian Goudie, Dr Leanne Hartnett and Dr Lindsay Bridgford, for their tips and tricks which have helped me refine my IV cannulation technique!
Dr Melody Hiew
Welcome to the future where apps, AI, handheld devices and robots are taking over ultrasound education and scanning.
I’d like to introduce you to Clip De-identifier. Preparing a talk? Posting on a blog? or just storing your logbook images - This nifty program developed by Ben Smith from Ultrasound of the Week allows you to crop patient information and unnecessary data from your ultrasound images or clips as well as removing the metadata embedded in the clip.
It is simple to use with a drag and drop interface, compatible with MAC and PC and allows you to preview your images before clipping. It will save you loads of time especially with batch conversion being possible when you want to de-identify more than one ultrasound clip. Best of all it's free and open access!
Email me your tips or leads on any new or amazing ultrasound tech/apps/blogs and I will review them in the future - Luke Phillips (Victoria Co-chair).
Dr Luke Phillips
EMUGs was created to advocate for the use of POCUS in the Emergency Department and to form a collaborative learning network for all POCUS users. We believe that The EMUGs Doppler, EMUGs first digital newsletter, will allow us to further develop that network, with the latest in POCUS arriving directly to your inbox.
The Doppler is released quarterly and includes information on upcoming EMUGs and other POCUS-focused events, case studies, the latest information on POCUS technology and more.
To read Issue 1 - CLICK HERE. To subscribe - CLICK HERE
After nearly three years of preparation and regional meetings the Emergency Medicine Ultrasound Groups regional teams are coming together for the first time!
Months of planning has brought together an excellent gathering of Australian, New Zealand and international speakers to deliver a new wave of POCUS training and educational topics and approaches.
The EMUGS sessions are part of the ACEM ASM so to join one or all of our sessions register via acem2017.com/ and also via the following eventbrite registration for logistical/organisation reasons:
NOTE: The EMUGs sessions are free to all ACEM ASM attendees. Any EMUGs donations are appreciated. This enables the Admin Team to provide essential support for all EMUGs projects.
Point of Care Ultrasound is now an essential skill of Fellowship trained Emergency Physicians. It is widely supported in national and international guidelines for a host of clinical settings, most notably expediting the appropriate care of both traumatically injured and critically unwell patients as well as in the performance of needle-guided techniques such as central line insertion.
A 35 female was brought to ED by ambulance following a sudden collapse at home. At the scene – skin cold, Blood Pressure un-recordable, semi-conscious.
Blogs are written by our EMUGs Team from across Australasia.