In the current issue of Global Heart (journal of the World Heart Foundation), several Mount Sinai authors have published articles on the use of point-of-care ultrasound. Phil Andrus wrote about focused cardiac ultrasound, Jennifer Huang co-authored a review of ultrasound use in IVC assessment, Daniel Lakoff described ultrasound incorporation into rapid response teams in inpatient wards, and Bret Nelson and Amy Sanghvi wrote a review of non-cardiologist use of cardiac ultrasound.
In early May, emergency ultrasound fellow Leila PoSaw and two Mount Sinai senior Emergency Medicine residents on the ultrasound track, Swathi Nadindla and Micah Nite, traveled to Haiti for an ultrasound education project.
This project was at the Bernard Mevs/ Project Medishare hospital in Port-au-Prince, which is the only trauma, critical care, and rehabilitation hospital in an entire country of ten million people. This hospital is responsible for providing lifesaving care to Haiti’s sickest adults, children and premature infants. The hospital treats 200 to 300 patients daily in the outpatient clinic and 50 inpatients daily. Two years after the earthquake of Jan 12, 2010, Project Medishare has moved to a capacity-building stage of empowering Haitians to create and sustain their own healthcare system through training, education, and employment of local medical professionals.
The goals of the project were to assess the feasibility of a permanent ultrasound program run by Haitian doctors. In such a program, Haitian doctors would use point of care bedside ultrasound to make life-changing medical decisions for their patients.
Is there a need? Is this possible?
We aimed to perform a needs assessment as an important part of the planning process to clarify and identify appropriate interventions. We also aimed to teach a mini-ultrasound course to any and all who might be interested to learn.
Two years after the earthquake we found the city to still be in a state of disrepair. We developed a flat tire on this extremely bumpy road strewn with debris. This was formerly the busy down town area. Now it looks like a ghost town.
Though there are still tents around the destroyed National Palace (which is due for demolition), many of the tents have been moved away from the center to the outskirts.
There is a single guarded gate that leads into the Bernard Mevs hospital. The clinics are open weekdays and have long wait lines. Not surprisingly, we found that the OB clinic could use an ultrasound machine!
The ultrasound course was a huge success. It was held in the cafeteria/dining hall. A total of 14 medical students and 7 staff doctors attended, including Drs. Marlon and Jerry Bitar in the blue surgical caps, and Dr. Toni Eyssallenne, the medical director.
Special thanks to Dr. Marc Jean-Baptiste, driver and navigator, Dr. Alice Baptiste, Dr. Julie Kanter, Dr. Swathi Nadindla and Dr. Micah Nite, without whom this project would never have happened.
There is no doubt that ultrasound has a lot of potential in resource-limited settings. We used ultrasound to diagnose and confirm several interesting cases, which will be highlighted on this site soon!
On November 17, 2011 Dr. Braden Hexom presented research organized by Mount Sinai and conducted at JFK Hospital in Liberia. The project,
Evaluation of Novel Obstetrics Ultrasound Curriculum for Local Healthcare Providers in Liberia
Bentley S, Hexom B, Nelson BP
described a novel ultrasound curriculum developed in concert with providers in Liberia after a needs assessment and analysis of various use models of ultrasound deployment in the area.
It was determined that among the highest-yield applications of point-of-care ultrasound was pregnancy evaluation, especially during the third trimester. According to the United Nations Population Fund, Liberia’s rate of maternal mortality is among the highest in sub-Saharan Africa (994 per 100,000 live births). Increasingly international organizations such as WINFOCUS have lauded ultrasound as a means of empowering patients and providers in under-resourced areas and improving the quality of care delivered.
A great presentation by Alberta Spreafico (Outreach and International Development Program Coordinator at Henry Ford Health Systems) highlights this topic in an eloquent and inspiring fashion. See below for her TED talk!
Here are the references and brief overview of Bret Nelson’s talk at the 2011 ACEM conference in Bangkok, Thailand on July 5.
The Focused Assessment with Sonography in Trauma (FAST) was first described decades ago and hundred of citations exist regarding its use. Although it has become a standard part of the evaluation of the trauma patient, there exists some controversy regarding its use. In 2005 a Cochrane Review was published which concluded:
There is currently insufficient evidence from RCTs [randomized controlled trials] to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.
Stengel D, Bauwens K, Sehouli J, Rademacher G, Mutze S, Ekkernkamp A, Porzsolt F. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004446
The review included four RCTs:
Arrillaga A, Graham R, York JW, Miller RS. Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound. The American Surgeon 1999; 65:31-5.
Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. Journal of Trauma 1999; 47:632-7.
Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. al. Randomized controlled clinical trial of point-of-care, limited ultrasonography in the emergency department: the First Sonography Outcomes Assessment Program Trial. Academic Emergency Medicine 2006; 48:227-35.
Rose JS, Levitt A, Porter J, Hutson A, Greenholtz J, Nobay F, Hilty W. Does the presence of ultrasound really affect computed tomographic scan use? A prospective randomized controlled trial of ultrasound use in trauma. Journal of Trauma 2001; 51:545-50.
Great debate ensued, including a literal debate between Dr. Melniker (author of study #3 above), Dr. Stengel (author of the Cochrane Review on FAST) and other prominent researchers featured during the opening session at the Second World Congress on Ultrasound in Emergency and Critical Care Medicine in New York in 2006.
Dr. Melniker also published the following rebuttal to the Cochrane Review conclusions:
Melniker LA. The value of focused assessment with sonography in trauma examination for the need for operative intervention in blunt torso trauma: a rebuttal to “emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma (review)”, from the Cochrane Collaboration. Critical Ultrasound Journal. 2009;1:73-84.
Included in the rebuttal was an analysis of FAST literature focusing on cases which required operative intervention. Dr. Melniker found the FAST exam had a false negative rate (ie. patient required operative intervention despite a negative FAST exam) in 5.8% of cases as they were initially published. Upon further review of those false negative cases (and exclusion of inadequate studies, patients who did not go to the OR during at the time of their initial evaluation, etc.) it may be that the actual false negative rate approaches 1.1%.
Thus, it is critically important to define appropriate outcome measures when we evaluate the utility of a diagnostic test. Do we care about the FAST exam’s ability to detect hemoperitoneum? The ability to detect which patients should go to the OR? And to what extent does the clinical picture (ie. mechanism of injury and hemodynamic stability) determine how we proceed? Few would argue that ultrasound has better test characteristics than CT scan; the utility of sonography is non-invasive, repeatable examinations at the point of care.
This type of discussion is incredibly important, and helps clinicians better determine how to employ the appropriate diagnostic tests in their practice. Non-operative management of blunt abdominal injury is becoming more common, and our interpretation of the FAST as well as other diagnostic tests must evolve:
- Knudson et al. Nonoperative management of solid organ injuries. Past, present, and future. Surg Clin North Am. 1999 Dec;79(6):1357-71.
- Velmahos et al. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003 May;138(5):475-80; discussion 480-1.
- Velmahos et al. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003 Aug;138(8):844-51.
- Haan et al. Nonoperative management of blunt splenic injury: a 5-year experience. J Trauma. 2005 Mar;58(3):492-8.
- Yanar et al. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunt abdominal trauma. J Trauma. 2008 Apr;64(4):943-8.
Discussions of the utility of trauma ultrasound are valuable because they force us to consider best practices in terms of clinical management of trauma, appropriate use of diagnostic tests, as well as determining appropriate outcomes-based metrics for quality healthcare delivery.
Please comment below or email me with questions.
On August 20-21, King Chulalongkorn Hospital Memorial Hospital was host to the WINFOCUS course:
Essential Ultrasound Guided Invasive Procedures in Emergency and Critical Settings
Dr. Suthaporn Lumlertgul was the director of this course, held at the hospital’s cutting edge surgical training center. Faculty including Mount Sinai’s Bret Nelson, as well as Luca Neri (past president of WINFOCUS), Yuen Chi Kit, Henry Cheng and Mok Ka Leung.
The course covered ultrasound guidance for procedures such as venous access, pericardiocentesis, thoracentesis, nerve blocks, foreign body localization, and others. Physicians from many countries were in attendance.
Upcoming WINFOCUS training courses around the world are listed here.
As promised, here are selected references from today’s talk on Airway Management Mythology. Thanks to the organizers of the International Conference on Emergency Medicine (ICEM) for the invitation to speak.
Some of the topics discussed are supported by plenty of evidence (ie the use of RSI as an intubation technique), some were simply fun to discuss (holding your breath while intubating) and some remain quite reasonably controversial (the use of etomidate for RSI in sepsis).
I highly recommend visiting Dr. Reuben Strayer’s blog for a brief and enlightening discussion of the use of rocuronium for RSI. Also, Dr. Scott Weingart’s EMCrit blog and podcasts are an excellent source for ED critical care topics. Finally, The Airway Site contains links to key airway management references as well as information on the Difficult Airway Course.
- Farmery AD, Roe PG: A model to describe the rate of oxyhemoglobin desaturation during apnoea. Br J Anaesth 1996; 76:284-91
- Naguib et al. Optimal dose of succinylcholine revisited. Anesthesiology 2003; 99:1045-1049
- Bozeman et al. A comparison of rapid sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care: 2006; 10:8-13
- Sackles et al. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31:325-332
- Li J et al. Complications of emergency intubation with and without paralysis. AJEM 1999: 17(2); 141-143
- Mallon WK et al. Rocuronium vs. succinylcholine in the emergency department: A critical appraisal. JEM 37(2); 183-188
- Strayer RJ. Rocuronium vs. succinylcholine revisited. JEM 2010 Apr 22. [Epub ahead of print]
- Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study, Lancet 369 (2007), pp. 920–926.
- Bobrow et al. Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann Emerg Med. 2009;54:656-662.
- Brimacombe JR and Berry JM. Cricoid pressure. Can J Anaesth. 1997 Apr;44(4):414-25
The second session of the 1st International Consensus Conference on Pleural and Lung Ultrasound was held in Pisa, Italy May 11-12. Ultrasound leaders from across the globe were present, including Mount Sinai’s Jim Tsung. Thwarting recent Icelandic ash clouds, Dr. Tsung teleconferenced in as the the conferences’ first virtual attendee.
Dr. Tsung joined notable faculty including:
- Roberto Copetti
- Mahmoud El Barbary
- Luna Gargani
- Daniel Lichtenstein
- Gerhard Mathis
- Andrea Reissig
- Gino Soldati
- Giovanni Volpicelli
As well as other leaders in thoracic ultrasound imaging. The conference focused on establishing common nomenclature for thoracic ultrasound anatomy, a review of literature published on the topic, and presentations of research by Dr. Roberto Copetti (neonatal & pediatric lung ultrasound) and Jim Tsung (pediatric pneumonia and bronchiolitis).