Volume 1 - Issue 2

Winter 2018

Welcome from EUS-AAEM

The Emergency Ultrasound Section of the American Academy of Emergency Medicine (EUS-AAEM) is founded to foster the professional development of its members and to educate them regarding point of care ultrasound. This group will serve as a venue for collaboration among medical students, residents and practitioners who are interested in point of care ultrasound. The purpose of our group is to augment the knowledge and expertise of all emergency medicine specialists and to advocate for patient safety and quality care by endorsing bedside ultrasound. Membership is not limited to fellowship trained physicians. All emergency medicine practitioners passionate about ultrasound are welcome to join and participate.

We are proud to publish our quarterly e-newsletter with original contributions from many of our members.  We encourage all members to submit for future additions. Topics include but are not limited to educational, community focus, interesting cases, resident and student section, and adventures abroad.

In this Issue:

 

Board of Directors

Michael Gottlieb, MD RDMS
Director and Education Chair

Dr. Michael Gottlieb is currently an Assistant Professor and Director of Emergency Ultrasound at Rush University Medical Center in Chicago, IL. He completed his emergency medicine training at John H. Stroger, Jr. of Cook County Hospital, where he was a Chief Resident and then completed an ultrasound fellowship at the Cook County/Rush combined fellowship. He subsequently joined Rush and created the emergency medicine resident ultrasound curriculum. He is also an active speaker and researcher with over 80 peer-reviewed publications focusing on ultrasound and medical education. He is honored to serve as the EUS-AAEM Education Chair and looks forward to an amazing year.

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Please join the EUS-AAEM at the 24th Annual Scientific Assembly in San Diego, CA from April 7-11, 2018. Once again, Drs. Michael Lambert and Joseph Wood have planned stellar pre-conference beginner and advanced ultrasound courses. Our section will be participating throughout the courses as well as contributing in the Small Group Clinics and the Pecha Kucha sessions throughout the conference.

Pre-Conference Courses

SPECIAL OFFER: Add the Ultrasound – Advanced Course when you register for no additional fee!

Small Group Clinics — Tuesday, April 10, 2018

  • 10:15am-10:45am: Ultrasound Guided Lower Extremity Nerve Blocks — Ryan Gibbons, MD FAAEM
  • 1:30pm-2:00pm: Ultrasound Guided Forearm Nerve Blocks — Ryan Gibbons, MD FAAEM
  • 2:50pm-3:20pm: Basic Echocardiogram Lab — Siamak Moayedi, MD FAAEM
  • Advanced registration for these sessions has filled. Limited onsite spots available.

Sign-up for a small group clinic when you register for Scientific Assembly. There is no additional cost for these sessions, however advanced registration is required. The clinics are open to physicians, residents, nurse practitioners, and physician assistants (medical students are not eligible to attend this session).

Pecha Kucha

  • Monday, April 9 — 4:55pm-5:05pm — Shoulder Sonography: Identifying Dislocations and Reductions at the Bedside — Michael Gottlieb, MD RDMS
  • Tuesday, April 10 — 10:55am-11:05am — What Rib Fractures? A Nerve Block to Manage that Pain in Your … Side — Mark Magee, MD

 

Community Corner

Back to Academia

Kristine S. Robinson, MD FACEP FAAEM

“How long have you been practicing?! And you went back to do an ultrasound fellowship? That's amazing! I could never do that.” This was pretty much how the conversation went when people found out about my ultrasound background. You see, after my residency training, I practiced for two years as a locum tenens physician, then an additional five years in a community emergency department (ED), before going back for an ultrasound (US) fellowship. Sure, it is an unconventional path, but I believe if you want it badly enough, you can do it, too.

To me, the biggest challenge was the salary cut. Many US fellows make somewhere around $50-70,000 annually. For most of us working in a community ED, that is a fourth or a fifth of what we could typically earn in a year. It all depends on your situation: Do you have kids? Car payments? Other significant bills? Is your mortgage reasonable? Do you have an emergency fund to fall back on? Does your spouse make a decent living? I recommend creating a realistic monthly budget. Be honest with yourself and decide what you can and cannot live without: cable with all the trimmings, the monthly wine and beer clubs, frequent international travel, the latest trend in fashion, the newest must-have gadget, and weekly trips to your favorite restaurants. If money is still tight, check to see if there is an option to moonlight.

The second challenge was going back to student mode. The assigned readings, coursework, podcasts, and post-chapter exams were time-consuming, but not daunting. Although, in the beginning, physics was giving me a bit of heartburn. I think the major adjustment I encountered was interacting with attending physicians and US faculty who were younger than me. There was also the research requirement, which most community-based emergency physicians (EPs) happily abandoned. As for the mandatory clinical hours (scanning and ED shifts), many full-time EPs would experience a reduction of two to three shifts per month. However, as a fellow, you have additional labor-intensive responsibilities that include research, helping with the US quality assurance process, weekly US conferences, medical student US labs, EM resident US lectures and labs, US teaching shifts, and so forth.

Another challenge I grappled with was work-related musculoskeletal complaints from repetitive motion. In addition to our US teaching load, we were expected to perform about four to six 9-hour scanning shifts a month, averaging about 22 to 28 scans a shift. Perhaps it was my age, but after a full day of scanning, I often had mild to moderate wrist, hip, and back pains. To be frank, I did not exactly practice good US ergonomic techniques, which in general is not often taught in EM US fellowship programs. Luckily, these were minor complaints and never progressed to anything serious.

With these challenges, you might wonder if it was all worth it. I absolutely believe so. In fact, I have often said that it was the best career decision that I had made so far. Before I even finished my fellowship, I was presented with three lucrative job offers. I instantly became a more competitive and coveted applicant. I had carved a niche for myself, and I knew that I would be vital to any ED I join. With my US experience, I improved my diagnostic and procedural skills. Not to mention, US made my shifts more fun. Lastly, if you are still not convinced, most US fellowships are only a year long, and time goes by fast.

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Ultrasound Highlights

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Ultrasound Highlights        

What is the Point … of Care?

Jordan Chanler-Berat, MD FAAEM

I tell my residents often that 80% of what we do in emergency medicine is bread and butter, the routine hum-drum of the ED. Those of us who practice, probably any specialty, know that about 15% can be utter frustration and demoralizing. It’s that remaining 5%, and the randomness of its appearance in our day, week, or month that drives us. It is the point … of care. In emergency medicine, it can be that needle (aortic dissection) you just picked up in a haystack (of chest pain patients) or an invigorating successful protection of an anaphylactic patient’s airway. For many, this 5% is the point of care. It’s why they care about their job, their specialty and the importance of the practice of medicine.

For me, an emergency physician fellowship-trained in ultrasound, I tend to agree. However, given the name of my sub-specialty “Point of care Ultrasound,” there is a duality in the significance of the “point.” To me the point of care is both figurative and literal. Placing my hands and a diagnostic tool on the patient’s body, inspecting and probing his or her innards with my magical wand creates a connection long missing in the doctor-patient relationship. A relationship that has been shattered and distorted, truncated and separated by technology.

The electronic medical record and the house of medicine’s reliance on diagnostic machines — far away from the point of care — to tell us all that ails our patient has been a disservice to what many of them need the most. Patients need to be palpated, listened to, attended to, and have their doctors spend some reasonable time at the bedside. This point  —  the physical contact and time spent pursuing concerning ultrasound findings  —  allows me to develop a bond of trust with my patients. Some studies are beginning to show the development of the patient’s trust and fulfillment when physicians use the ultrasound at the bedside.1 For those of us who practice this daily, we don’t need much peer-reviewed literature to know that it augments our holistic understanding of the patient and provides a nidus for the development of trust in what is normally a brief emergency department interaction.

Aside from improving our interactions with patients, using a diagnostic tool at the point of care opens doors to rapid diagnosis. Not by a digital robot, nor by a hard working radiologist tucked away in a dark room. For example, pressing on a firm rigid abdomen of a young women who was just wheeled into your ED, unconscious, alerts you as a physician to a broad array of potential diagnoses. We see cases like this often in the ED, and right after that physical exam I wheel over my ultrasound machine, as I ask the nurse for a stat IV and pregnancy test. Within minutes I have found a belly full of fluid, likely blood, and no evidence of an intrauterine pregnancy. I have narrowed down what was a broad differential within minutes without this sick young girl leaving my ED.

With my mouth I ask a history, with my hands I perform my physical exam, and with my probe I make critical diagnoses right then and there at the point-of-care. That, I presume, is the point … of care.

References

  1. Howard ZD et al. Bedside ultrasound maximizes patient satisfaction. J Emerg Med. 2014 Jan; 46(1):46–53.
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Resident Corner

Ultrasound-Guided Fascia Iliaca Block: An Effective Alternative to Opioids

Alexis Salerno, MD

Given our awareness of the opioid epidemic and the potentially devastating effects of the indiscriminate use of systemic opioids, physicians are looking for alternative methods of managing severe pain. Nerve blocks are a viable option for many patients in the acute care setting. Proximal femoral fractures and femoral neck fractures have been noted to be extremely painful for patients prior to stabilization. This type of pain can be ameliorated with a fascia iliaca block, which anesthetizes the femoral, obturator, and lateral femoral cutaneous nerves. It is relatively easy to perform and has a better safety profile than a femoral nerve block.1

Traditionally, the pathway for a fascia iliaca block has been identified by anatomic landmarks, and successful access was confirmed by loss of resistance, that is, a “popping” sensation as the needle penetrated the fascia lata and fascia iliaca. In a comparison of techniques with and without ultrasound, Haines and colleagues found that 82% of patients whose blocks were established with ultrasound guidance had complete loss of sensation in the anterior, medial, and lateral aspects of their thigh compared with 47% of those whose blocks were established with the traditional loss-of-resistance method.2 A meta-analysis by Haines and colleagues documented lower pain scores and a lesser need for pain medication in emergency department patients with femoral neck fractures.

Fascia iliaca block is easy to perform in the emergency department and can yield great benefit to patients experiencing pain associated with lower-extremity fractures.

Risks

This block should not be used if the patient has skin breakdown or cellulitis in the area to be accessed. Bleeding disorders constitute a relative contraindication. The risks of this procedure are the same as for any other, i.e., bleeding, infection, and pain.

Equipment

  • Standard linear probe, sterile sleeve and gel
  • Sterile gloves
  • Topical disinfectant
  • 22-gauge spinal needle
  • Two 20-cc syringes
  • 30 cc of 0.25% bupivacaine

Method

  1. Disinfect the patient’s groin area.
  2. Using a linear probe in short-axis view, identify the femoral artery and visualize the femoral nerve lateral to the femoral artery (Figure 1).
  3. Move the probe superior and lateral, parallel to the inguinal ligament. The probe should be positioned one-third of the distance from the anterior superior iliac spine to the pubic turbercle at 1 to 2 cm below the inguinal ligament (Figure 2).
  4. You can apply 1 ml of 1% to 2% lidocaine to provide surface anesthesia.
  5. Using the inline approach, with the needle lateral to the patient, insert a 22-gauge spinal needle with ultrasound guidance to visualize penetration of the fascia lata (traditional first pop) and then the fascia iliaca (traditional second pop) (Figure 2).
  6. Insert 30 cc of 0.25% bupivacaine into the space and remove the needle.
  7. Apply firm pressure and massage the area to encourage upward and medial spread.

Figure 1

Figure 2

References

  1. Pinson S. Fascia Iliaca (FICB) block in the emergency department for adults with neck of femur fractures: a review of the literature. Int Emerg Nurs 2015;23:323-328.
  2. Dolan J, Wiliams A, Murney E, et al. Ultrasound guided fascia iliaca block: a comparison with the loss of resistance technique. Reg Anesth Pain Med 2008;33:526-531.
  3. Haines L, Dickman E, Ayvazyan S, et al.Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med 2012;43:692-697.

Acknowledgement: The manuscript was copyedited by Linda J. Kesselring, MS ELS

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Student Corner

The Sound of Success: Two Student’s Impression of Ultrasound Education in the Medical School Curriculum

Jacob Shapiro and Reed Andrews

Medical students at the West Virginia University School of Medicine (WVUSOM) are given a unique and academically enriching opportunity starting their first year of study. The Morgantown, West Virginia, based medical school is at the forefront of introducing medical students to the use and widespread clinical applications of the ultrasound imaging modality within the first two months of the MD curriculum. Spearheaded by Dr. Joseph Minardi, a WVUSOM graduate and director of the Emergency Medicine Ultrasound program, first-year medical students are exposed early and often to the benefits of using the ultrasound machine to aid in efficient clinical diagnoses. Now, as I begin my second year of medical school and continue to study the mechanisms of human pathology, I feel comfortable and confident in my ability to utilize ultrasound when I eventually enter my third- and fourth-year clerkships.

The very first learning point that was presented in the ultrasound section of the first-year Human Function course was the fact that ultrasound is cheap, and it is the safest and fastest imaging modality in the acute setting. Within that context, the basics of ultrasound are explained. The various probes, settings and operational guidelines of the machine are outlined, leading into understanding the actual images. What first seemed to be amorphous blurs, like some electronic Rorschach test, soon became clear and concise anatomy: images that appeared black were hypoechoic, representative of fluid or air, while images that appeared white were hyperechoic, indicating bones, tendons, and other connective tissue. With these conventions in mind, my classmates and I were ushered into the second semester of the ultrasound curriculum: identification of anatomy.

With the Human Structure course came ultrasound simulation experiences. While simultaneously able to practice establishing rapport with standardized patients in an informal and non-threatening setting, we were also able to visualize cardiovascular, abdominal, respiratory, musculoskeletal and genitourinary structures on a diverse group of patients. This allowed us to become aware of the wide breadth of anatomical variation that we will experience in clinical practice, and be comfortable locating it on individuals of differing body habitus. These simulation experiences were accompanied by easy to follow practical guides developed by Dr. Minardi, providing my classmates and me with an easy to access reference throughout the assignment. These simulations culminated in a practical examination, which assessed our newly acquired ultrasound skills, tasking us to obtain images of a random list of structures we had learned to identify during the semester.

Not only were there curriculum ultrasound requirements, but WVUSOM also offers its students the opportunity to join the ultrasound interest group. This extracurricular student-led organization manages ultrasound based workshops, providing additional procedural education. These workshops include lumbar punctures, central line placement, acquisition of IV access, the FAST examination, the basics of the echocardiogram, determination of the structural integrity of skeletal muscle, and more. The interest group also coordinates practice sessions for the graded practical exam for the first-year students.

Now, in my second year of medical school, I am an officer of the ultrasound interest group, where my fellow officers and I are tasked with planning the yearly Ultrafest event. Ultrafest is a friendly competition open to medical students, physician faculty, residents and any others who may be interested, where ultrasound skills are put on display. Medical students from other schools nearby attend as well, as WVUSOM hopes to show the benefits of its curriculum and its passion for ultrasound education. With these skills being taught and honed throughout the first year of medical school, and reinforced with pathological concepts during the second year, WVUSOM medical students have a strong advantage when utilizing ultrasound in a clinical setting.

– Jacob Shapiro, WVUSOM 2020

 

One of the many summer opportunities offered to first-year medical students at WVUSOM is clinical externships. These externships are offered for a wide variety of specialties and provide the students with early clinical experience in fields that interest them. I applied and was fortunate enough to be accepted to participate in the emergency medicine externship during the summer 2017.

It was during the externship that I experienced first-hand the clinical applications of ultrasound for diagnostic and procedural purposes in the acute setting. I immediately felt comfortable and confident using the ultrasound equipment due to my previous education during my first-year curriculum. Not only was I able to understand what was previously a blur on a screen, but was also able to interpret the images we had obtained. I had the opportunity to perform and assist in FAST exams for trauma patients, central line placement, echocardiograms, DVT studies as well as the assessment of cholecystitis, appendicitis, ovarian blood flow integrity, muscle tears, abscesses, foreign body location, amongst others all using ultrasound.

After talking to some of the new first-year residents and other medical students on away rotations, it became apparent to me that ultrasound was not incorporated into many other medical school’s curriculums. I felt fortunate that my medical school offered such a curriculum that allowed me to aid and collaborate with those who did not have as in-depth a background.

Learning the ropes of ultrasound and seeing its vast clinical potential only drew my interest more towards teaching others. I decided to become an officer in the Ultrasound Interest Group and found great enjoyment as a tutor to the upcoming first-year medical students, undergraduate pre-medical students, as well as sparking interest in some of the undergraduate biomedical engineering students. Some of the learning tools that the WVU STEPS simulation center offer are on the forefront of educational equipment including our new ultrasound simulator Vimedix. This program gives you an ideal anatomical image on one half of the screen while mirroring what would be seen at the bedside with the standard ultrasound images. This can also be paired with the Holoscopic 3D glasses which allow you to see through the mannequin giving you a 3D representation on exactly what you are looking at in the ultrasound image. This is not only an astonishing sight that would spark the interest of anyone slightly interested in the field but is also a valuable tool in developing an understanding of the imaging modality.

As my interest in ultrasound developed, I became involved with multiple ultrasound research projects and case reports. I had the unique opportunity of presenting our case report, entitled “Complex Appendicitis: Integrating Clinical Data with Point of care Ultrasound,” at the European Society of Emergency Medicine conference in Athens, Greece. It was an incredibly educational and culturally enriching experience that gave me insight into some of the emerging techniques and other areas of research in the field.

My classmates and I feel very fortunate that we have had the opportunity to learn and expand our knowledge on an imaging modality that is at the forefront of clinical diagnosis, procedural medicine, and educational techniques. It has not only allowed us to become more comfortable in the clinical setting by understanding the images, but also with regard to patient interaction and bedside manner. I am looking forward to what the future of ultrasound will offer clinical diagnosis, and being a part of its application in clinical practice.

– Reed Andrews, WVUSOM 2020

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Follow AAEM on Twitter @AAEMinfo and use #EUSAAEM

 

Case Challenge

Point of Care Ultrasound Assessment of Acute Monocular Vision Loss

Adria Simon, MD, PGY-2

Case Presentation

A 56-year-old female with a history of hypertension and sick sinus syndrome presented to the emergency department with atraumatic, acute-onset, painless monocular visual loss of the right eye upon awakening that morning. She was otherwise asymptomatic. On exam, the right eye had clear conjunctiva and sclera, but the pupil was non-reactive to light with its afferent reflex intact. Extraocular movements were intact. Fundoscopic exam was limited and indeterminant. Examination of the left eye was within normal limits. Cranial nerves were intact otherwise. No rash was visualized, and the patient denied tenderness of her temporal arteries bilaterally.

Point of care ultrasound provided the following images. What is the diagnosis?

Figure 1: Transverse View of the Left Eye

Figure 2: Transverse Right Eye; Hyperechoic Embolus w/o Flow

Diagnosis

Bedside ocular ultrasound demonstrated a hyperechoic focus in the optic nerve sheath with absent flow on color Doppler consistent with an embolus (Figure 2). Dilated fundoscopic exam by ophthalmology was remarkable for a cherry red spot on the macula. The patient was admitted and underwent an extensive work up to determine the etiology of the embolic central retinal arterial occlusion.

Discussion

Visual disturbances are common presentations in the emergency department. The differential ranges from innocuous to vision threatening pathologies, such as retinal detachment, lens dislocation, central retinal artery occlusion, and retrobulbar hematoma. It is imperative that vision-threatening diagnoses be identified quickly and accurately to ensure timely treatment. Traditionally, fundoscopic exam has been utilized to evaluate ophthalmologic conditions. However, bedside exams are often limited as is provider skill with fundoscopy. Although limited, studies have shown that point of care ocular ultrasound is both accurate and user-friendly.1-3

References

  1. Blaivas M, Theodoro D, & Sierzenski P. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002; 9: 791–799.
  2. Shinar Z, Chan L, & Orlinsky M. Use of ocular ultrasound for the evaluation of retinal detachment. J Emerg Med. 2011; 40: 53–57.
  3. Yoonessi R, Hussain A, & Jang T. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. 2010; 17: 913–917.

 

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