Over forty participants joined Sinai faculty Jim Tsung, Ee Tay, Bret Nelson,Â Joshua Guttman, Jacob Goertz, Turan Saul, Jenny Sanders, Kimberly Kahne, Michelle Vazquez, Joe Sorravit, and Rupi Mudan. Course Directors Ee Tay and Joshua Guttman organized great didactic content and lost of hands-on training (HOT) with pediatric models.
Participants from many pediatric and acute care specialties attended. TheyÂ left with greater scanning skills, reducedÂ reliance on CT scans,Â a multi-tool, and one lucky winner received Kaushal Shah’s new junior medical detective book, My Tummy Hurts
Our next hands-on ultrasound course will be in Ponte Vedra, Florida on June 17 at the Clinical Decision Making conference.
Many clinicians are challenged whenÂ evaluating patients for perisplenic fluid as part of the FAST or RUSH examination. Here are some common problems and how to fix them.
Fix probe location
- Make sure you are holding the probe in a longitudinal view, probe marker towards the patient’s head. Place the probe just above the costal margin, in the posterior axillary line. The knuckles of your probe hand should be touching the stretcher
Start too high (too cephalad)
- Starting with the very posterior probe position described above, slide towards the patient’s head until you clearly see pleura and rib shadows. Once you’ve established clear evidence you are over the thorax, slide the probe toward the patient’s feet along the same posterior axillary line until the pleura ends. Now you have found the diaphragm! Scan just caudal to the end of the pleura and you should see the diaphragm and spleen.
- Another way to simplify this- If you see pleura, slide towards the feet. If you see bowel gas (or “nothing”), slide towards the head.
Use a slightly oblique approach
When rib shadows obscure the view, use the “sonographic rib spreader” technique.
Rotate the probe slightly towards the patient’s back so the probe is slightly more parallel to the ribs. Do not go fully transverse.
This exposes more of the probe to the interspace, yielding a larger window through which to view the spleen.
For more tips on viewing the spleen, check out this post.
This patient presented with right upper quadrant abdominal pain. There was RUQ tenderness on exam, but no fever, rebound or Murphy sign. A point-of-care ultrasound was performed to assess for signs of cholecystitis and the following image was obtained. This prompted the operator to ask, “What the heck?”
What structures are visible here? How could you differentiate them? More after the break!
To image something which moves, you must remain still. To image something which is still, you must move.
If you think on this long enough, the point is self-evident and requires no explanation. Or, just see some examples below.
We are pretty well adapted to seeing three dimensions at a time. Thus when imaging a moving structure like the heart, we hold the probe in a fixed position to obtain standard views. This allows us to focus on the movement, and cardiac presets optimize temporal resolution at the expense of spatial resolution. We are then seeing two spatial dimensions and one temporal dimension (heart moving in time).
D Shaped Left Ventricle from Sinai EM Ultrasound on Vimeo.
It is very difficult to appreciate the anatomy and function of the heart, for example,Â when the probe is moving.
In contrast, imaging the right upper quadrant for fluid in Morison’s pouch requires a slow fan through the liver, diaphragm, and kidney. This allows us to appreciate the entire potential space where fluid can collect. Abdominal imaging is optimized for spatial resolution at the expense of temporal resolution, so be sure to move the probe slowly. Fanning through the entire structure of interest will often reveal pathology which was missed with a single-plane scan. Small gallstones, small amounts of peritoneal or pleural fluid, saccular aneurysms, and other maladies can fool a novice sonographer who isn’t thorough. In this case we are seeing three spatial dimensions.
FAST1 RUQ pos from Sinai EM Ultrasound on Vimeo.
So, keep your audience in mind when you are creating scans. Should you fan through the static anatomy, or let the movement of the structures speak for themselves?
Is ultrasound the stethoscope of the future? Is it an extension of the physical examination? Will it replace the physical exam?
Point-of-care ultrasound is a diagnostic test. It is a rapid, bedside, noninvasive, accurate, diagnostic test, but still a diagnostic test. It can certainly augment data obtained through physical examination and medical interviews, and adds to information obtained by blood assays and radiology studies.
It is performed using FDA-approved medical devices by clinicians with specialized training. Images used for medical decision-making may be archived and shared with colleagues from multiple specialties. Quality assurance programs improve clinician accuracy and accountability. These are not physical examination characteristics. These are qualities of good diagnostic tests.
There is and will continue to be debate about this issue. Whether we think about point-of-care ultrasound as a diagnostic test or part of the physical examination has ramifications for training, documentation, archiving, and billing.
We recommend checking theÂ guidelinesÂ relevant to your specialty and making up your own mind on this issue. In either camp some things remain constant: train well and use ultrasound to enhance the care you provide your patients.