2013 Ultrasound Fellow Graduation

We were proud to graduate three ultrasound fellows this year:

  • Kim Poh Chan, our international fellow who will return to Singapore and head up a new ultrasound program
  • Daniel Lakoff, who will co-direct the ultrasound program at Elmhurst Hospital, and
  • Ee Tay, our first pediatric emergency ultrasound fellow, who will remain at Sinai
Left to right: Kim Poh Chan, Daniel Lakoff, Danny Duque, Bret Nelson, Amy Sanghvi, Ee Tay
Left to right: Kim Poh Chan, Daniel Lakoff, Danny Duque, Bret Nelson, Amy Sanghvi, Ee Tay

2013 Tri-State Ultrasound Fellow Conference

The first annual Tri-State Ultrasound Fellow Conference kicked off today at Lenox Hill Hospital in New York City. The first day of this two-day course focused on administrative issues in ultrasound, featuring nationally recognized speakers from all around the area.

Bret Nelson from the Icahn School of Medicine at Mount Sinai discussed faculty development, including:

  • Creating a niche
  • The educator portfolio
  • Making connections

Here are a few references from the talk:

 

20130725-104514.jpg

20130725-104528.jpg

20130725-104543.jpg

20130725-104558.jpg

20130725-105801.jpg

20130725-105815.jpg

20130725-140224.jpg

20130725-140233.jpg

20130725-140254.jpg

20130725-143536.jpg

Making Health Care Safer II

AHRQ Logo

The AHRQ recently published an update to its landmark 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (AHRQ Evidence Report No. 43). This report advocated evidence-based practices such as root cause analysis, hand hygiene, ID bracelets for high risk patients, and time-outs prior to procedures.

The 2013 update analyzed 41 patient safety practices and identified 22 which were deemed ready for adoption. Ten were selected as “strongly encouraged” for adoption based on the strength and quality of evidence. Number nine on that list was “Use of real-time ultrasound for central line placement.

A special supplement to the March issue of Annals of Internal Medicine features articles related to many of these patient safety strategies, and is available for free online.

Looking through the top ten list, most interventions are implemented at most major hospitals, and JCAHO surveyors track adherence to guidelines such as these. Now that ultrasound use has made the top ten in two iterations of these AHRQ safety practices, it may be more difficult to argue that lack of availability or proper training absolves providers of the need to provide this service.

Introduction to Bedside Ultrasound

Introduction to Bedside Ultrasound

 

It’s been out awhile now, but if you haven’t seen it yet, take a look at Mike and Matt’s Introduction to Bedside Ultrasound.  The ultrasound pocast guys have released this excellent overview of point of care ultrasound through the iTunes Store.  This is certainly convenient as most of us have 3-12 iDevices on our person at any one time.  Caveats are that this means that it is available only on an iPad using iBooks 2 or later, and ios 5 or later.  Right now it is $29.99.

 

There is a lot of good content, but I think the best chapter in the book, is probably the RUSH chapter. :)

  RUSH Exam

Lung ultrasound goes viral for flu season

Z-linesMore lung ultrasound tips and examples from Drs. Jim Tsung and Brittany Pardue Jones!

Bacterial pneumonia will manifest as lung consolidation with air bronchograms. The A-line pattern of normal lung will begin to be replaced by B-lines in the area of affected lung:

https://gmep.org/media/12001

Here we’ve highlighted the consolidation from the above video as well:

https://gmep.org/media/11999

In contrast, subpleural consolidations and confluent B-lines are more suggestive of viral pneumonia.
So what do these look like?

Subpleural consolidation:

and another example:

Confluent B-Lines:

occur when multiple B-lines coalesce. In contrast, the next example demonstrates multiple discrete B-lines.

Multiple B-Lines:

And now for something completely different

Z-Lines:  Comet tails that arise from the pleural line but DO NOT make it to the bottom of the ultrasound screen. These are not B-lines. These artifacts have not been associated with any pathology, and they do not obliterate A-lines.

For more details on the sonographic appearance of viral lung pathology, check out this article by Jim Tsung.

FAST five ways

The FAST exam is generally described as a trauma assessment (hence the acronym). But it is often used as a metanym to mean any assessment of the peritoneum for fluid. In fact when I was a resident folks would often say, “let’s FAST that gallbladder,” or “get the FAST machine so we can put that central line in.” And we didn’t have Twitter.

Anyway, here are a few cases where the “FAST” was used in a non-trauma patient to assess the peritoneum:

Cirrhotic with abdominal pain and tenderness:

https://gmep.org/media/12027

who was found to have ascites, and spontaneous bacterial peritonitis

Lower abdominal pain in pregnancy:

https://gmep.org/media/12023

who was found to have hemoperitoneum from a ruptured ectopic pregnancy

Diffuse abdominal tenderness in a healthy ten-year-old:

https://gmep.org/media/12024

who was found to have idiopathic seromas of the peritoneum, pleura, and pericardium!

Shortness of breath and abdominal distension:

https://gmep.org/media/12025

which turned out to be massive abdominal abscesses

Diffuse abdominal tenderness and distension after hysteroscopy:

https://gmep.org/media/12026

which was complicated by a bowel perforation; hence fecal material throughout the peritoneum

Take home points:

  • Assessment of the peritoneum greatly aids medical and surgical diagnoses
  • Fluid appears black (anechoic) on ultrasound. Very difficult to tell what TYPE of fluid by appearance alone
  • Your clinical assessment must guide the differential diagnosis for your ultrasound findings