SonoEvent&Commentary: 2013: YOU, #AIUM13 & UltrasoundFirst – when/where it should be done FIRST!

Im off! New York City, here I come! AIUM 2013 is right in the heart of Times Square: where the lighted ball drops on every new year, where Madonna was taken as a young girl after telling the cab driver “Take me to where everything happens”, and where hundreds of healthcare providers from different specialties come together this year who all believe in ultrasound, and discuss when/where ultrasound should be used FIRST – as described in the UltrasoundFirst Forum. This is a big deal this year. Why? Well, you see, and as some of you may already know, 2013 is the Year of Ultrasound (YOU)! There were quite a few events I posted about earlier speaking of this great event/year, which was so greatly put into practice by my good friend who taught me everything I know about ultrasound, Dr. Chris Fox, at UltraFest this year – a free medical student ultrasound course (yup, that’s right, FREE). 2013 – The year that we should spread the gospel of ‘sound to areas where it is so needed, in global health practice, in medical school education, to community physicians to help guide their screening, resuscitation, procedures, and diagnosis of their patients – to EVERYONE who will listen!

So, in preparation for this event, as discussed with one of my role models, Dr. Richard Hoppmann, for how he incorporated ultrasound into medical education, a curriculum that is described in the Society of US in Med ED (SUSME) website, we thought how fun it would be to get as many people as we know to wear the 2013:YOU T-shirts and post it for everyone to appreciate! He sent us the shirts, the Stanford US team put them on, and had great fun with the photo-shoot! Look out for more folks to post photos like these throughout the week! – if they so dare….

Then, it got a little fun…..

  

The great Dr. Vicki Noble and her team at Harvard/Mass General also had a fun Photo-shoot! Love the shirt on the machine!….

SonoCase and Discussion of Pelvic Ultrasound: 32yr G1P0 at 7wks, c/o vaginal spotting – in WestJEM #FOAMed

Drs. Abdi, Stacy, Mailhot, and Perera once again describe a case where ultrasound made the difference in clinical management of a patient. Their case is published in WestJEM with a great tutorial video (see below) accompanying it.

Emergency physicians perform bedside ultrasound in 1st trimester abdominal pain and vaginal bleeding to “rule in” an intrauterine pregnancy, but the better way to describe how we think about it is “ruling out” any signs of an ectopic pregnancy. By doing it in the emergency department, it has been shown to decrease length of stay of these patients, and increase their satisfaction. With a full bladder, a transabdominal pelvic ultrasound is performed with a regional assessment of the pelvic organs to visualize for confirmation of an intrauterine pregnancy (yolk sac or fetal pole within a gestational sac in the uterus). You may need to empty the bladder and perform a transvaginal ultrasound if the above does not provide the information you need (I bring the ultrasound machine with me to the bedside when I first meet them so that I can do the history, physical, and ultrasound right off the bat). If there is an identifiable pregnancy then an evaluation for a fetal heart and its rate is assessed in order to characterize it as a “live” intrauterine pregnancy. But, if there is no contents within the gestational sac (a potential pseudosac), or if there is no gestational sac, then the concern for ectopic pregnancy still exists. Of course, in a recent post, we discuss that even those cases may turn out to have a normal pregnancy despite an elevated beta hcg level, calling into question whether the “discriminatory zone” should be used to guide our management.

Let’s go back to their case: The brilliance of this case, however, isn’t that they found an ectopic or illustrate what I describe above, instead it illustrates that there are other diagnoses that may be apparent on ultrasound that is causing the pelvic pain and vaginal spotting. And, if you don’t look, or if you are unfamiliar with what you are seeing on the screen, you may miss it – or mistakingly call it an intrauterine pregnancy.

The case: 32 yrs old G1P0 known pregnant at 7weeks by last menstrual period with lower pelvic cramping and vaginal spotting. A bedside ultrasound is performed and the video below describes what they saw…. read more on the case here.

WJEM_Molar_Pregnancy_Video

►

Since “being pregnant” is a diagnosis that can be made, we shouldn’t stop there after we have identified an intrauterine pregnancy. We shouldn’t simply state “you’re pregnant” and discharge them home without further consideration of the etiology of their pelvic pain. Something else may be causing it. (to read about other cases using pelvic ultrasound, go here.) Other findings/diagnoses to consider in 1st trimester pelvic pain or vaginal spotting:

1. Ovarian cyst or torsion

2. Fibroid

3. Appendicitis

4. Mass/cancer

5. Infection – anywhere (Pelvic inflammatory disease, tubo-ovarian abscess, UTI, colitis/proctitis, etc)

6. Heterotopic pregnancy- consider in patients on fertility drugs

SonoEvents: SonoGames, Castlefest2013, and the FREE Intro to Bedside Ultrasound iBook #FOAMed

This SonoGift is amazing! I could have sworn that I sent this earlier (and I think i did on Twitter and Facebook), but for whatever reason, it is in my blog’s draft folder, and I was shocked! – How dare I keep this away from everyone who follows SonoSpot?!!!! So, I apologize… from the bottom of my subxiphoid window (…ha! yes i know, I have many of them). If you’re getting this for the second time, then take it as a friendly reminder of how awesome the UltrasoundPodcast guys are to provide this amazing gift to everyone to learn the up-to-date info on bedside ultrasound applications… for free. Now, if you are getting this for the first time, you are going to LOVE it….. Why? Well, first off, it’s free (did I say that already?). And, if that wasnt enough, it’s the pdf version of the AWESOME iPAD download-able iBook of Introduction to Bedside Ultrasound from the UltrasoundPodcast crew, with chapters written by so many of my friends. If you purchase the iPAD version (for pretty cheap, if you ask me) (including the iPAD mini and retina display), you can view all the clips and videos placed by the authors/experts in bedside ultrasound – which truly makes it the best “book” on bedside ultrasound that I know. It’s worth it.

You know what else Im excited about? SonoGames Part Deux at SAEM - this time, our crew is going to make it after the first round!!! You all better watch out! A sneak peak at SonoGames last year by the serious yet humorous, heavy yet light, good yet talented UltrasoundPodcast and their hilarious interviews:

Oh, and did I mention Castlefest2013????!! Im so excited to join them at CastleFest2013 – ultrasound, castles, wine, and festivities?—what more could a Sonogirl ask for?! You can even be there virtually! Yes, they did think of everything.

SonoCase: 40yo: cough, fever, mylagias – typical viral infection? – By Teresa Wu/Brady Pregerson in EPMonthly #FOAMed

Drs. Teresa Wu and Brady Pregerson (in the current issue of EPMonthly) once again discuss an interesting case that is more than meets the eye, and thankfully they continue their humorous sarcasm and start the case by speaking of an average day in our emergency departments these days: “This is the third time this week that you have had to close your ED. All of the beds in the hospital are full, and your ED is bulging at the seams with sick patients that aren’t going anywhere anytime soon. You are holding 10 admissions at the present moment, and the hallways are lined with patients calling “doctor” every time you walk by. As much as you hate doing so, you concede to the request to close to ambulance traffic and then walk briskly over to the chart rack to see what you can do to help improve the current situation. Your eager intern is right on your heels and says he has a new patient to present to you. “This should be a really simple case,” he spurts out. You raise your eyebrows and bite your tongue.”……

They (meaning, the intern) describe a case of a 40 year old female who has had what seems like an upper respiratory infection for 4 weeks, that’s just not going away, and now with sharp chest pain worse when coughing. While going to evaluate the patient, they give one of the best pearls that all residents  should know: ““Teaching point number one is conservation of energy. One of the best ways to be efficient is to ensure that you minimize the amount of time wasted. If you might need the ultrasound machine, take it with you so you don’t have to walk back out of the room to go get it.” They then proceed to perform the beginnings of the RADIUS study, which highlights Echo, thoracic and IVC ultrasound for the short of breath/dyspneic patient. The patient complains of pain when lying back, which causes the spide-y sense to go up and be confirmed when seeing the below picture on the echo:

To read more on the case and their great clinical pearls click here to get to EPMonthly’s online site.

To read a prior post emphasizing the need to perform an ultrasound for any presumed or confirmed pericarditis by going through a another case… and some studies, click here.

SonoStudy: Meta-analysis of 9 trials – ultrasound use for peripheral IVs in kids and adults #FOAMed

Not that we didnt already know this, but at least we have more data to say it is so – in a recent study in Annals of Emergency medicine – a meta analysis reviewed 9 trials – both kids and adults.

This concept has been getting a lot of press, and many of my ultrasound enthusiast friends have passed this around. It’s good to know the concept – and use it when you are in a conversation with someone who thinks the blind technique it still the way to go.

“Pediatric trials yielded conflicting data, the authors reported February 18 online in Annals of Emergency Medicine, but there appeared to be significantly fewer attempts and shorter procedure times when ultrasound guidance was used in the emergency department, as well as significantly decreased risk of first-attempt failure, reduced attempts, and shorter procedure time when ultrasound guidance was used in the operating room…..”Ultrasonographically guided peripheral intravenous cannulation may perform better in the pediatric population because failure rates with the traditional method are much higher in children than adults,” the researchers note. “Ultrasonography may not be as beneficial in adults, in whom target vessels are easier to locate.” – Now, these trials were from operating room patients, where the setting is a bit more controlled, the patients may be a bit different in their difficult IV access spectrum – but the authors still suggest that if faced with a difficult IV – use ultrasound.

Below is the abstract:

Study objective

Peripheral intravenous cannulation is procedurally challenging and painful. We perform a systematic review to evaluate ultrasonographic guidance as an aid to peripheral intravenous cannulation.

Methods

We searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ClinicalTrials.gov, and Google.ca. We included randomized trials evaluating ultrasonographically guided peripheral intravenous cannulation and reporting risk of peripheral intravenous cannulation failure, number of attempts, procedure time, or time from randomization to peripheral intravenous cannulation. We separately analyzed pediatric and adult data and emergency department (ED), ICU, and operating room data. Quality assessment used the Cochrane Risk of Bias Tool.

Results

We identified 4,664 citations, assessed 403 full texts for eligibility, and included 9 trials. Five had low risk, 1 high risk, and 3 unclear risk of bias. A pediatric ED trial found that ultrasonography decreased mean difference (MD) in the number of attempts (MD −2.00; 95% confidence interval [CI] −2.73 to −1.27) and procedure time (MD −8.10 minutes; 95% CI −12.48 to −3.72 minutes). In an operating room pediatric trial, ultrasonography decreased risk of first-attempt failure (risk ratio 0.23; 95% CI 0.08 to 0.69), number of attempts (MD −1.50; 95% CI −2.52 to −0.48), and procedure time (MD −5.95; 95% CI −10.21 to −1.69). Meta-analysis of adult ED trials suggests that ultrasonography decreases the number of attempts (MD −0.43; 95% CI −0.81 to −0.05). Ultrasonography decreased risk of failure (risk ratio 0.47; 95% CI 0.26 to 0.87) in an adult ICU trial.

Conclusion

Ultrasonography may decrease peripheral intravenous cannulation attempts and procedure time in children in ED and operating room settings. Few outcomes reached statistical significance. Larger well-controlled trials are needed.

For more info and a how-to for ultrasound guided procedures, including ultrasound-guided peripheral IV and central IV acces – go here.

SonoEquipment: How to make your own Ultrasound Gel – Guar gum, salt, and water #FOAMed

I saw an interesting blog post, sent to me by my ultrasound uncle, Dr. Chris Fox, that was on the: “Why Is American Healthcare so Expensive?” site entitled “How to Make Ultrasound gel: which is also sterile and edible and environmentally friendly” by Dr.Janice Boughton. Not only did the title catch my eye, but the content drew me even closer. If you are in need of gel – whether that’s because you are doing global health, disaster relief, or healthcare at any resource-limited area – there are ways to make it. Ive heard of a couple alternatives – and here is a way to make your own – that is also sterile, edible, and environmentally friendly.

As the blog post states: “Ultrasound requires an aqueous interface between the transducer and the skin or else all you see is black. Ultrasound gel is a clear goo, looks like hair gel or aloe vera, and is made by several companies out of various combinations of propylene glycol, glycerine, perfume, dyes, phenoxyethanol or carbapol R 940 polymer along with lots of water.” – not easy to find, and ot so cheap either. So, she set out and tried six different recipes – yup, that’s right – SIX! …and made the below gel (see pic) from guar gum (found in the flour section of stores), salt and water:

“Guar gum is available in the flour section of many grocery stores and costs about $10 for a 220 gram bag. It is purported to be good for diarrhea, constipation, diabetes and lowering cholesterol.” – how cool is that?!

1. Mix 2 teaspoons of guar gum with 1-2 teaspoons of salt. (The amount of salt isn’t vitally important since it is just added to keep the guar gum from clumping. Using slightly less than a teaspoon of salt per 2 cups makes a gel with which is isotonic, which would be ideal for use near eyes or other mucus membranes or on open wounds).

2. Boil two cups of water.

3. Slowly sprinkle the guar gum/salt mixture into the boiling water while stirring vigorously with a fork or whisk.

4. Boil for about 1-2 minutes until thick and well mixed.

5. Cool before using. Save lives.

To read more about her plight – click here. Thanks Janice!

Below is a video on how to do it made by her too:

SonoNews! The future of medicine -Drs. Eric Topol and Daniel Kraft talk wireless/portable medicine #FOAMed

Wireless communication in medicine, smartphones for ECG monitoring and healthcare screening, portable ultrasound use in the clinic at the bedside instead of a patient sent to an ultrasound suite on a separate date – all resulting in quicker, more efficient, and cheaper medicine. Dr. Eric Topol, a cardiologist practicing in Scripps hospital in San Diego (my hometown – oh yeah!) – tells Rock Center with Brian Williams on NBC about it all and MORE! – the future of medicine is amazing and so incredibly exciting! – wireless medicine is just the beginning – what patients can do at home to screen for various diseases wirelessly is only one part of the future – he speaks of how this all saves money too – very interesting interview! Too good not to share! http://www.nbcnews.com/video/rock-center/50582822#50582822

Dr. Topol also discusses the top 5 devices that every patient and doctor should get to know, as they will take over the world of healthcare as we get more and more digitized (of course, one of the devices is a hand-held ultrasound machine!)

And dont miss Dr. Topol on ColbertNation!:

The Colbert Report
Get More: Colbert Report Full Episodes,Political Humor & Satire Blog,Video Archive

Dr. Daniel Kraft, from Stanford, also spoke about the future of medicine in this TED talk – amazing where medicine is going!.

SonoStudy: Emergency docs detect small bowel obstruction by US – as good as radiologists #FOAMed

In a recent article in the European Journal of Emergency medicine, the authors showed that emergency physicians are just as good as radiologists in detecting small bowel obstruction by bedside US. Now, it’s not hard to do, nor is it hard to see it. First off, use your abdominal low frequency probe, and evaluate the abdomen in different quadrants. Normally, the bowel appears as a single circular hypoechoic layer (muscle layer) surrounding hyperechoic bowel contents of gas and food particles. The normal thickness of this layer during the contraction stage of peristalsis is 2-3 mm. The hypoechoic normal wall becomes thinner during peristalsis when the bowel is relaxed.

In small bowel obstruction- looking for dilated fluid filled loops of bowel with hyperechoic (bright) spots within it that may have back and forth peristalsis and a thicker intestinal wall (decreased persitalsis is a late finding) – color doppler gives info about blood flow in the walls of the intestine – and you may even see a transition point. Timothy Jang and team studied ultrasound compared to Xray for SBO and found that ultrasound is better, like WAYYYY better (higher sensitivity and specificity) – hmmm, interesting – Some things to consider: fluid-filled loops (good for US), but air-filled loops may not be so good. Ileus and SBO may appear similarly, so consider thinking of causes of ileus as well (gallstone ileus, etc), and a thickened wall may just be colitis, but that along with dilated loops and back and forth persitalsis with a transition point seen – more likely SBO.

This is what it would look like (and there are more clips to view – thanks to SonoCloud)

The abstract of the study follows:

“Objective: Our objective was to study the accuracy of emergency medicine [(EM) bedside ultrasonography (BUS)] and radiology residents performed ultrasonography (RUS) in patients with suspected mechanical small bowel obstruction (SBO).

Methods: After a 6-h training program, from January to June 2009, four EM residents used BUS to prospectively evaluate the patients presenting to the emergency department with suspected SBO. Then, patients underwent RUS. Outcome was determined by surgical findings if they were operated upon or self-reported the condition upon telephone follow-up at 1-month. BUS and RUS results were compared with χ² testing.

Results: Of the 174 enrolled patients, 90 patients were BUS-positive. Of these, surgical findings agreed with the BUS findings in 84 patients. In 78 cases, BUS was negative, and 76 of these patients had benign clinical courses. Six patients were excluded from the study. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio for BUS were 97.7, 92.7, 93.3, 97.4, and 13.4%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value for RUS were 88.4, 100, 100, and 89.1%, respectively. The diagnostic accuracy of BUS and RUS were not statistically different from each other (κ=0.81). The presence of dilated small bowel loops (>25 mm in jejunum or >15 mm in ileum) was the most sensitive (94%) and specific (94%) sonographic finding for SBO.

Conclusion: Abdominal sonography for the diagnosis of SBO is a new application of BUS in the emergency department. EM residents can diagnose SBO using BUS with a high-degree of accuracy, comparable with that of radiology residents.”

To read the UltrasoundPodcast guys speak on the subject, click here>

To see them do it, see below:

SonoLectures: Free lecture on Ultrasound in the Critically Ill -by Dr. Cliff Rice (& other free lectures)

Got an email from ACEP and thought it was too good not to share: Hear Dr. Cliff Rice, an ultrasound extraordinaire and emergency physician speak about bedside ultrasound and its use in critical care medicine. At the end of this post are even more lectures that are free. As you will hear, he states “Think about how you would use it in some of our sickest patients that come to the emergency department….. where the differential diagnosis is quite broad, and the treatment for shock might be detrimental if we are wrong.”

As ACEP states in the email: “Practicing emergency physicians need to be able to utilize ultrasound effectively in the evaluation of the critically ill patient. In this free audio recording from the 2012 ACEP Scientific Assembly, Dr. Rice highlights the use of ultrasound to perform a FAST scan, to dynamically monitor and measure the IVC in the setting of hypovolemic shock, and to detect pericardial effusion and perform ultrasound guided pericardiocentesis [in 45 minutes]. This [lecture] explains where you should start scanning, narrows your differential and guides your resuscitation.”

Other free lectures for your viewing/hearing pleasure on bedside ultrasound:

Dr. Chris Fox’s comprehensive emergency ultrasound lectures in iTunes

Dr. Phil Perera comprehensive emergency ultrasound lectures on Sound-Bytes

AIUM UltrasoundFirst lecture series on various ultrasound topics

UltrasoundPodcast with a variety of lectures on bedside ultrasound

UltrasoundVIllage website on a variety of ultrasound topics

Vanderbilt’s excellent lectures library on bedside ultrasound

SonoWorkshop: Pearls (and more!) from the Stanford CME Ultrasound Course #FOAMed

Once again, our Stanford Ultrasound Workshop was a huge success. Why? Our instructors were phenomenal and from different specialties! Our participants were faculty from emergency medicine, internal medicine, critical care, surgery, and pediatrics! The ultrasound tips and tricks just kept on coming from our lecturers  - and, everyone laughed at our jokes, which always makes things great. As always, I like to provide those tips and tricks to all of you (and maybe even some of the jokes), so that you can feel like you were there too!

Dr. Sarah Williams – First, the coordinator for the Stanford CME workshop welcomes everyone with a Star Wars phrase “Learning you are….May the force be with you, young padawans!” – always goes to a great start. She is also the creator of the Stanford Ultrasound Program and current Associate Residency Director (and the person who was kind enough to put up with my quirks and jokes to hire me as a fellow years ago). Her pearls on the EFAST: detects >600 cc (intraperitoneal) fluid, look around inferior pole in RUQ and subdiaphragm area of LUQ (free fluid develops first there!), it’s not good for pelvic fx/injuries (pelvic bleeding into pelvic cavity, and retroperitoneal, bowel gas obstructs view, bladder may be empty limiting visualization), it’s not done fast- FAST is part of RUSH, but dont rush the FAST. Look for your kidney, then look above it, around it and below it (thoracic fluid, morison’s pouch, paracolic gutter). FAST LUQ: higher, spleen smaller, stomach big -place knuckles on gurney, oblique probe in plane to ribs, free fluid can be between diaphragm & spleen.  #ultrasound detects 15-20cc fluid in thoracic cavity, better than chest Xray. Have patient take deep breath to lower diaphragm. The longer the patient is supine (or trendelenberg) the better, so if you have a walk-in trauma, perform serial FAST scan. SX view: the liver is the heart’s protector, be sure to see it in view- it allows you to see the 4chambers. gas is heart’s enemy - if gas gets in the way, you cannot see the liver: slide probe laterally to patient’s right, get that liver in your view. For pneumothorax eval – use linear probe, find your ribs, ID pleur liine, decr gain (brightness) to see sliding better. Start high in midclav line, indicator to head – - then travel thru mult rib spaces to estimate size.

Dr. Laleh Gharahbaghian (since i cannot speak about myself, I let someone else write this part and promised I wouldn’t change anything – let us pray…): “With her usual stylish self, walking all around the workshop, giving hi-fives to everyone in her path, her dance moves came in handy as she spoke (can you point her out in this video from the mid 1990s of her past job?)  - She is the current Director of the Stanford Ultrasound Program and Fellowship her pearls can be found below: Her pearls of Aorta US: use large footprint probe, if get gas, press down, takes time – as if you were reducing a hernia; start in the subxiphoid region, travel down thru to iliacs. Most AAA are infrarenal and may seem normal in size at sx and get large once you travel down. Doesnt evaluate for rupture – most AAA leak/rupture retroperitoneal – not detected by US (your FAST is neg) – correlate clinically to your patient symptoms and vital signs. Her pearls on Renal US: main indication: hydronpehrosis, but pay attention to everything (outside to inside); eval both kidneys AND bladder- without bladder, you wont know if the bilateral hydro may just be that they have to pee. If empty bladder, and bilateral hydro, then possible mass (if not chronic). If patient is >50yo with flank pain, dont forget to eval the aorta as well. Start outside to inside for pathology – free fluid around kidney, cyst from kidney, mass on kidney, stone within kidney, hydronephrosis. Her pearls on Gallbladder US: start in the subxiphoid region, indicator to patient’s right, use liver as window, fan thru it medial to lateral to find GB. Then, fan/eval in transverse & longitudinal planes. Fanning thru the GB is key- there’ll be sections where it looks normal, then you fan & a stone comes into view! See if the stone is mobile by turning patient and re-scanning to see if moved. Think of the number 4 (or multiples of it) with measurements: width 4cm, length 8-10cm, anterior GB wall <4mm, CBD 4mm at 40yrs old (adding 1mm for every decade beyond).

Dr. Phil Perera – our newest addition to the Stanford US team serving as the Director of US Research and the Associate Program Director gave quite an engaging talk on Echo and the RUSH protocol, putting it to action! As is highlighted by his Soundbytes website that is a free source of lectures for your viewing pleasure, he would keep asking the audience whether they would involve their consultants, if they would “write home to mom about this?!” The funny part is that one of the audience members responded with “I wouldn’t have to, she would call me before I get a chance.” Another participant concluded the point by saying, “You must work in a profitable community hospital.” Ah – gotta love the sarcasm! Phil continued his talk discussing when you should act fast by going through RUSH cases, giving props to others who also study and educate on resuscitation ultrasound. His pearls on Echo: PSL view is the favorite – lets you evaluate right ventricle size, left ventricle size and contractility, pericardial effusion, pleural effusion and mitral valve regurge; Echo should be done with IVC when thinking about fluid resuscitation – if hyperdynamic -can tolerate fluid; if hypocontractile, not so much; Echo can eval aorta too! PSL view visualizes ascending aorta and descending aorta; AP4 view shows descending aorta – look for aneurysm/flap. Intraperitoneal fluid and pleural effusion can be mistaken for pericardial effusion – know where your pericardium is! Pleual effusion in PSL view travels behind descending aorta; pericardial effusion travels in front of descending aorta. AP4 great for comparing RV and LV chamber size, contractility of RV and LV. To get the P4 view, slide lateral after parasternal views until get to apex, angle to body center. His pearls on RUSH: Case that inspired him: 67yo acute SOB, in shock h/o COPD/CHF/HTN, CXR neg, ultrasound showing the cause to not be sepsis, but cardiogenic shock. RUSH provides the answer to : sepsis? cardiogenic? hypovolemic? hypervolemic? tamponade? PE? trauma? tension ptx? AAA? First & most important is the cardiac echo: the PUMP, that’s why it’s first – lots of info from a single cardiac view (PSL). For semi-quantitative contractility eval: fractional shortening & EPSS are measured – PSL must be at approp long section.  tamponade on #ultrasound - RV collapse during when it should fill (diastole)-also can see RA scalloping -do pericardiocentesis. pericardiocentesis: US studies show having pt in left lateral decubitus position & an apical view better for removing pericardial effusion than traditional SX technique. IVC – can use M mode to measure in both transv and long view 2cm from RA – can use your internal jugular as an alternate. Lung ultrasound – B Lines – think of fluids and your resuscitation when evaluating etiology of shock: FALLS protocol by Lichtenstein. Although rare, if your EKG has STEMI, do an ECHO – make sure its not a dissection before you start heparin!

 and 

Dr. Zoe Howard (our Director of Medical Student and Resident US Education) and Dr. John Kugler (coordinator for the internal medicine US elective and global health US instructor) spoke about the many awesome ways ultrasound can help with procedural guidance. The dynamic duo had awesome videos to assist in their lecture and went through the many procedures that can be done with US guidance. Their pearls on Procedural US: On central line access – first look for the vein before you prep the area; it’s possible that the vein you want (or the location of the vein you want) is not the best vein for the procedure. Your indicator should be to your left, the screen dot should be on your left, that way left means LEFT when you’re guiding your needle tip to the vein. On lumbar puncture – do it when you can’t feel the landmarks, when you only have one attempt, when you’ve already had one unsuccessful attempt. Use the ALiEM trick with a paperclip for drawing the straight line. On thoracentesis and paracentesis – make sure you view the area where there is at least 2cm of fluid between the probe and the lung/bowel to avoid lung/bowel puncture – it may not always be where you think. On pericardiocentesis – look for where the fluid is most, patient to left lateral decubitus position, and you’ll find that SX is not the best anymore. On nerve blocks – learn it, do it, and teach it! Your patients deserve it! Use the in-plane approach to visualize your entire needle, and use the dental syringe holder to have control over your syringe.

      

We then had 8 different hands-on stations with 11 different instructors (and 4 chickens used for central lines deserving of props, and lots of other simulators as you will see in the below pics)!  Including those described above, we also had the above instructors (from left to right, top to bottom (hyperlinks take you to “other” images that come up when you google search their names)- Dr. Viveta Lobo – our current US fellow and future Director of the Visiting Scholars Program, Dr. Brita Zaia – our past US fellow and current Kaiser San Francisco Ultasound Director, Dr. Darrel Sutijono – US fellowship trained faculty at Kaiser Santa Clara and new to twitter and #FOAMed and the FOAM movement, Dr. Manish Asarvala – US fellowship trained at UCSF and faculty at Kaiser Santa Clara. Dr. Yoshi Mitarai – an emergency medicine/critical care specialist who recently saved a life while at the gym doing Zumba (yup, you read that right), Dr. Suzanne Lippert - a specialist in nerve blocks and international/global health who is faculty at Stanford EM. Dr. Jennifer Newberry – an MD JD (so, super smart) and one of our senior EM residents who is staying on as a fellow in healthcare/ public policy.