Point of Care Ultrasound: Stethoscope of the 21st Century Donald F. Zimmer MD FACEP Disclosure
• I do not have any financial interest in point of care ultrasound technology. Objectives
• Inspire
• Enhance
• Improve
• Save money
• Happier patients, happier providers Case 1: 88yo F, w SOB
• Temp 100.3
• HR 123
• RR 20
• BP 96/75
• Dyspnea Worsening x3 days, orthopnea, pedal edema H & P
Medications: Coumadin, • Generally Dyspneic in Diltiazem, Vitamin D, Magnesium, appearance, perhaps slightly Miralax, Lasix, altered. Increased WOB
PMH: CHF, HTN, Afib, • Heart Irregular, moderately Osteoporsis fast, no murmur
SH: Lives independently, • Lungs have bibasilar crackles, daughter visits often, widowed, L>R non smoker • Abdomen Soft FH: HTN, CAD, DM • Ext: 1+ Pitting Edema ROS: Cough, Slight confusion, no nausea, skin changes, dysuria. • Skin Warm Denies chest pain What do we do next?
EKG Chest X-ray CBC/BMP •Testing! Lactic Acid Blood Cultures?
Sp02 91% on 2L NC
So what do we do without an Ultrasound?
Try something potentially harmful Or… Do something invasive
Even if you’re not sure what you just saw…
You’re in the same place as before. What if we see the following instead?
Two identical presentations, with completely different management Now that I have your attention
• Let’s change the topic completely and talk about something completely different. Dr. Rene Leannec Circa 1816 Monarual Ear trumpet
What Can you Do?
• Heart: murmur, split s1, gallop
• Lungs: wheeze, crackle
• Bowel Sounds: hyper/hypo
What can you really do?
• Identify
• Think
• Contact
• Connect The physical exam is a ritual
Abraham Verghese:
The ritual of the physical exam involves two people meeting in a special place, in special garments, with special instruments for the purpose of transformation; the formation of a bond, and the beginning of a therapeutic partnership. “What if we could keep all the good stuff and lose the bullsh*t?”
–Your’s truly Enter: POCKET ULTRASOUND
Butterfly Lumify GE-VScan I-VIZ The question for Modernity
• WHEN’S THE LAST TIME ANY TECHNOLOGICAL DEVELOPMENT BROUGHT US CLOSER TO OUR PATIENTS? How to up your physical exam game FLANK PAIN CHEST PAIN DYSPNEA
ABDOMINAL PAIN But I wasn’t Trained
• I won’t know what I’m looking at
• I won’t know what i’m looking for
• What if I get something wrong?
• What if I miss something important? Micromastery Concept Learn one skill
• Try assessing your patient’s volume status by looking at their IVC Getting Started
• Turn on your machine
• Select your probe (or your frequency)
• Orient your laterality
• Adjust your depth High Frequency Probe Low Frequency Probe Phase array(Cardiac) Probe Probe Orientation
• Marker is a little bump on the side, and will correspond to a dot a the top of your screen
• By convention cardiology has probe marker to the Right
• Everything else has the probe marker to the Left
• Reversing the probe will invert your image 180 degrees
• Three dimensional patient Depth Adjustment Adjusting the Gain Three Maxims
•Air is the Enemy •Press for Success •Too much Lube is almost enough
Resources
• thepocusatals.com
• 5minsono.com
• ultrasoundgel.org , gathering.evidence.literature
• youtube.com Overcoming barriers: Cost
Let’s be honest, there is a very good chance you’ll spend more on Starbucks this year. Patient Satisfaction
• Greater Understanding
• More time
• Increased confidence in Provider just a few cases from the last three months 68 YO W BLURRED VISION INFANT W/O RED REFLEX
28YO F W VOMITING, DIARRHEA
Show me some evidence
How about Liability?
• Pubmed lit search for POCUS and liability found no suggestion of increased liability.
• In fact, several papers revealed that the vast majority of legal cases involving POCUS were alleged to be a “failure to perform the bedside sonogram,” thereby violating the standard of care. Summary
• No Matter your specialty, POCUS can make a difference in your practice.
• Cost, Training, and Time should not inhibit you from learning
• Patients enjoy this. They will learn more, trust you more, and have greater faith you as a provider. Your Satisfaction
• Learn a new skill (or several)
• Spend more time, and increase the quality of time spent
• Improve accuracy of testing and treatment
Start Scanning, Stay Curious Questions? POCUS for COVID Is this potentially useful? • Fast, bedside, no radiation
• Likely more sensitive than chest xray
• Easier to disinfect equipment compared to CT scan
• Lends itself to repeat examinations for monitoring disease course
• Has already been demonstrated to be useful for other Viral pneumonias
• Is not diagnostic of COVID specifically, but can be helpful following the course What do we see? How is this different? Normal lung B-Lines Patchy B-lines Irregular Pleural Thickening Trace effusions Consolidation with Airbronchograms Skip lesions Can also see Cardiomyopathy in some cases Where’s the evidence?
• A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19) February 26, 2020
• Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic Intensive Care Medicine March 12, 2020 •