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Ultrasound on the Ground


Natalie Ing - UOTG

General, Vascular & Cardiac Sonographer - Noosa Radiology

Content Development & Ultrasound Education - Lightbox Radiology Education

SEED East Kimberley Region - EMET/WACHS


A SPROUTING SEED


The sunrise shot blinding rays through a wall of glass at the Sunshine Coast airport as I navigated my way through security.  After months of preparation and planning I was off to begin my new work project as an ultrasound educator in emergency departments across the remote Kimberley Region of Western Australia.

 

The project grew from an idea shared, whilst chatting on the phone with my long term

friend Sebastian Rubinsztein-Dunlop (dual FACEM and GP anaesthetist ) about a year before. I thought it would be helpful to be able to show up as a sonographer in an Emergency Department and teach one-on-one

targeted sessions to doctors in their own environment, on their own machines.  Seb

immediately responded how he thought this would work well with the hands-on training he

had been regularly delivering across the Kimberley and was something that EMET

(Emergency Medicine Education and Training) would very likely be interested in funding. 

It was a beautiful moment, that pause, as simultaneously we realised, after 20 years of

friendship, our professional lives could potentially meet in a wonderful, adventurous way.   

A few weeks and a couple of emails later we got the green light on me accompanying Seb on

one of his week-long EMET teaching trips across 6 sites in the Kimberley.  I also became

aware that I was a part of a whole new wave of energy and action in this area and that there

were others like me out there, called SEEDs.


SEEDs are Sonography Educators in Emergency Departments, a role recently recognised by the Australasian College of Emergency Medicine (ACEM). I got in touch with former colleague Allison Hart, who was involved with new developments in sonography education in remote Western Queensland, and made contact with Chris Mitchell (SEED at SCUH) both of who inspired, encouraged, supported and guided me. I spoke with Suean Pascoe of Zedu ultrasound training solution who offered a wealth of knowledge and experience and I enrolled in Zedu’s TRUST course which was invaluable in making me a more thoughtful and effective educator. I also met Casey Parker (GP anaesthetist and DDU) of Broome Docs (a free online access ED education website) who is the lead ultrasound educator in the area and provided essential guidance and information in best practise. I attended the Spring Seminar in Emergency Medicine (SSEM) in Noosa and met emergency doctors with ultrasound qualifications and sonographers who had become emergency physicians. I became aware of Emergency Medicine Ultrasound Groups (EMUGs) and a whole new world of passionate POCUS enthusiasts.

Just two weeks before my big trip, I attended the ASA national conference in Brisbane. Over champagne in the trade hall at welcome drinks Bronwyn O’Hara from Mediquip offered the loan of blue phantom for vascular access training and Shelly Lord from GE jumped onboard with the loan of a V-scan handheld ultrasound to take with me. The wish list items that I had thought were a longshot were now a reality and I felt excited and very grateful to be able to extend my education with these valuable additions.

The flight to Broome seemed to be full of relaxed and interesting characters. My first impression of Broome as we began our descent was that there was a huge ribbon of high vis fabric stretched across the scrub…it wasn’t until i saw a 4wd driving along it that my brain caught up…it was a dirt road…an extraordinarily bright red dirt road!


A few hours later, after Seb finished work, we jumped into his 4wd and made it onto Cable Beach just in time to see the sun set into the Indian ocean from a spectacular pink sky. As an old pearl lugger sailed slowly past and an iconic line of camels made their way along the sand, I reflected that it’s not every day that you get to see the sunrise from one side of the country and set in the other!


A TRAVELLING SEED

Day 1: Broome

The first doctors arrived to commence training at 8am Monday morning and we were off to a very good start with one of the docs recognising me from the spoken word night I had attended the night I arrived in town (so much for not knowing anyone)!

Being the largest hospital in the Kimberley, Seb warned me that my first day at Broome was going to be my busiest. I taught 10 doctors in 1-2.5hour sessions from 8am-4.00pm. It was hectic and sometimes noisy, as we were tucked into a corner of the emergency department with patients being attended to around us. The doctors were keen and very appreciative and it was enjoyable and rewarding being able to ask specifically what they needed help with and then improving their scanning skills in targeted sessions. Areas covered included EFAST, renal, AAA, gallbladder, bile duct, pelvis, vascular access and basic echo.


Day 2: Derby

We left Broome early for the relatively short 220km drive to Derby Hospital. There was a spare office available so I was able to set up my own teaching room adjacent to the ED. There was a steady flow of doctors with varying levels of experience all day and I felt that I was able to settle confidently into my role after my baptism in Broome the day before.

My basic lesson plan consisted of first clearly defining probe moves, next showing a variety of normal and abnormal ultrasound images relevant to the scan, then covering machine basics, and finally on to scanning. Because the sessions were often one on one, I had to be both the patient and the teacher! This is where the value of teaching probe moves first, and being specific and consistent with them, became very apparent. I had learnt the importance of this concept at Zedu’s train the ultrasound trainer course only a couple of months before and now it was being tried and tested and I was gaining instant rewards from my tricky teaching position on the examination table.


Sculptures on the Marsh at sunrise in Derby


Day 3: Fitzroy Crossing

I got up before the sun and went for a quick run around the outskirts of Derby to see the sculptures on the marsh and get a bit more of a feel for the town before moving on again. Arrived at Fitzroy Crossing Hospital and was able to set up in my own room again. It was a very varied day here, there was a mix of doctors, nurses and paramedics. The doctors covered everything from eyeballs to achilles. The nurses wanted to know how to scan and measure bladder volumes as their Bladder Scanner was broken. The paramedics were very keen to improve their skills in ultrasound assisted vascular access.

One young paramedic had been the only medical officer on one side of the Fitzroy river during the recent floods

and recalled a difficult dialysis patient that he was unable to cannulate. He had an ultrasound machine available but had no idea how to use it. It felt really good to be able to deliver exactly the training he was hoping for, and having the V-scan and the blue phantom meant that he could practise as many times as he liked once I had showed him the technique. After work we checked into the local hotel on the banks of the river. The front bar was a cacophony of exuberant noise and energy with a large group of locals along with a lot of out of town construction workers from the new bridge.


Day 4: Halls Creek


After an early morning walk, a dip in the chilly pool and some yoga along the sandy banks of the Fitzroy river we were on the road again. Around 3 hours later we were greeted in the dusty red dirt at Halls Creek Hospital by the friendly security guy who had opened the gates to the carpark for us.


Shortly after my first session teaching EFAST to one of the senior doctors, it was announced that a patient was being brought in by ambulance after a high-speed rollover outside town. The skills I had just taught were put to immediate use and it was obvious what a valuable addition (and relief) the negative EFAST provided in the initial evaluation and subsequent management of the patient.


It was a super rewarding and memorable day in the emergency department here and the close knit team of down to earth characters really impressed me. There is only one paramedic in town so the ambulance was driven by the hospital orderly. There is one nurse who can take basic x-rays and we had to call him in from a council meeting across the road. I shared stories (and peach jelly) with the cook in the kitchen and a beer after work with a Scottish doctor who, when not working in Halls creek or Kununurra, lives in the south of France.








In remote communities like this EFAST and other critical care scans provide immediate information to help manage the patient. They allow clinicians to make focused decisions which dictate whether an emergency procedure (for example decompression of a pneumothorax) needs to be performed and how urgent a retrieval of the patient should be.


Day 5 and 6: Kununurra

About halfway into the 4hour drive to Kununurra, we unfortunately hit and killed a large male kangaroo. We were in the middle of nowhere so after inspecting the damage Seb used his fishing knife to cut off some of the flailing fairing, I used my hair tie to clamp a tube that was leaking water and we kicked with our boots to bend some metal that was preventing the tyre from turning and, luckily, we were able to drive the rest of the way. Kununurra felt like an urban metropolis after the previous few days crossing the Kimberley. We arrived at the hospital only a little late to begin our day of teaching. There was a dedicated education area adjacent to the emergency department so I had a spacious room where I was able to set up both the V-scan and one of their Sonosites for multiple EFAST sessions with a vibrant bunch of keen young junior doctors, some vascular access sessions with nurses, and some targeted extended learning with more experienced senior docs. Seb went off to Wyndham for his final session on Saturday but I stayed on another day in Kununurra because the demand was there.


A THINKING SEED

Focused ultrasound in emergency medicine is a different world to regular sonography and should not be thought of as the same.


A regular ultrasound is a comprehensive diagnostic imaging exam performed by an accredited sonographer and reported by a radiologist. POCUS may be performed by emergency physicians, nurses, community healthcare workers and general practitioners, who have received limited training in protocol-driven scanning and the ultrasound is used as one part of a bedside assessment. When used correctly, however, Pocus is a powerful clinical tool that has been shown to improve patient outcomes, and is especially helpful in rural and remote settings where resources are limited.

ACEM recognises that ultrasound is an important tool in emergency medicine and recommends that a FACEM with an ultrasound qualification oversees the training and I strongly agree with this. Things that we learn as sonographers may not always be relevant or helpful in the point of care world as sometimes too much information, or overconfidence without adequate experience, can be detrimental to the outcome. Having Casey craft the templates and explain to me what was most relevant for me to teach and what to avoid gave me confidence to teach in ways that would do no harm.


The small, powerful and affordable ultrasound units available today were a far off futuristic fantasy when I began my ultrasound career. Now with AI, telehealth and new technologies we are navigating rapid change in the applications of ultrasound and I think it is important to be involved in creating strategies for best practise.


My initial inspiration for UOTG was to travel to different emergency departments for targeted one on one sessions, to help improve skills and confidence in basic ultrasound techniques. To see that bloom into real on the ground usefulness, powerful teaching moments and to receive such welcoming and gratitude in return, surpassed all of my hopes for success.








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