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Emergency Ultrasound Section Newsletter - September 2006, Vol 10, #3

Emergency Ultrasound Section

circle_arrow Join Us for the Annual Section Meeting in New Orleans!
circle_arrow From the Chair
circle_arrow SAEM Ultrasound Interest Group Meeting during Scientific Assembly in New Orleans
circle_arrow To Plant a Tree
circle_arrow The Sound of a Hurricane
circle_arrow Web Site Posting of Section Newsletters
circle_arrow Journal Watch
circle_arrow New Video Case Studies Initiated on Section Web Site
circle_arrow The Latin American Ultrasound Initiative: Spreading the Practice of Emergency Ultrasound Down South


Newsletter Index


Emergency Ultrasound Section

 

Join Us for the Annual Section Meeting in New Orleans!

The Emergency Ultrasound Section will meet in New Orleans at the ACEP Scientific Assembly as follows:

 

Emergency Ultrasound Section Meeting
Sunday, October 15, 2006
10:30 am – 12:30 pm
Room 395, Ernest N. Morial Convention Center

Be sure to check the schedules on site, as meeting times and location could change.

Election of officers will be held during the section meeting at Scientific Assembly. The following slate of officers and councillors has agreed to stand for election:

 

Office Candidate
Chair-elect: David Bahner, MD, RDMS, FAAEM, FACEP
Secretary/Newsletter Editor:    Gary Quick, MD, FACEP
Councillor: Larry Melniker, MD, RDMS, FACEP
Alternate Councillor: Eitman Dickman, MD, RDMS

This year’s agenda includes election of new section officers as well as an opportunity to catch up with fellow section members. The educational portion of Scientific Assembly runs from October 15-18. We hope to see everyone there. www.acep.org/sa.

 


 

 

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From the Chair

Paul R. Sierzenski, MD, RDMS, FACEP

Persistence

"Nothing in the world takes the place of Persistence."
-President Calvin Coolidge

This quote could easily serve as the credo for our section.

My primary goal for this year was straightforward: keep the section and emergency ultrasound (EUS) moving forward without losing the ground that we gained over the years. In my initial address to our members I wrote, "The values for the establishment of our section were and remain clear: provide "service" to the field of emergency ultrasound, the section members, and ACEP. We would do this by promoting and fostering the "growth" of emergency ultrasound and the EUS section. Furthermore, we would accept the responsibility to "protect" the ground and successes we have gained."

I would like to delineate our accomplishments, several current projects, as well as detail the challenges that lie ahead for emergency ultrasound, the section, and ACEP respective to EUS.

Service to the Section:

  1. Emergency Ultrasound Policies and Infrastructure
    The ACEP Board of Directors approved the Emergency Ultrasound Imaging Criteria Compendium, a project led by John L. Kendall, MD, FACEP, and the work of numerous section members and ultrasound leaders in April 2006. Published as an ACEP policy statement, this critical document can be found on the ACEP Web site under "practice resources/policy statements." This document was developed to assist members who wish to begin, retain, or expand their EUS use. This document describes recommended scanning indications, protocols, and limitations that will remain a valuable resource for anyone with interest in emergency or clinical ultrasound.
  2. Political Awareness
    Political developments and external forces continue to provide potential resistance to the acquisition and expansion of EUS. This includes third-party payers, imaging organizations, and even internal emergency medicine governing bodies. Both Michael Blaivas, MD, RDMS, FACEP, and I attended the ultrasound practice forum, which raised the discussion of how ACEP should react to the growing policy of payers to require "practice accreditation." This is an ongoing process, with a series of recommendations to be presented to the ACEP BOD with input from many of the EUS section leadership. Liaisons on behalf of ACEP and the Ultrasound Section attended several meetings specific to collaborating activities and national ultrasound issues relative to the American Institute of Ultrasound in Medicine (AIUM), the American Society of Echocardiography (ASE), and the Ultrasound Practice Forum hosted by the AIUM.
  3. Community Emergency Ultrasound Subcommittee
    The Community EUS Committee is now established and has developed several talking points and action points for ACEP to consider. The work of this group will continue towards the end goal of finding solutions to impediments in the acquisition of EUS in the community. The most powerful example of this is how the community emergency physicians helped to stimulate a vibrant discussion of expectations of EM resident training for graduates. This discussion embodied in both ACEP and the Society for Academic Emergency Medicine (SAEM) discussion lists has resulted in renewed interest by the Residency Review Committee for Emergency Medicine (RRC-EM) to expand the RRC-EM description of training and critical program elements. The goal is to assure that ALL emergency medicine graduates meet a minimum standard and that the community can be assured our graduates have a basic competency in EUS. Though this process does take time, I feel our persistence here will be fruitful.

    The committee members are:

    • Paul Sierzenski, MD, RDMS, FACEP
    • Robert A. Jones, DO, RDMS, FACEP
    • Michael Blaivas, MD, RDMS, FACEP
    • Evelyn E. Cardenas, MD, FACEP
    • Patricia (Patty) Wong, MD, (Lynwood, CA)
    • Geoffrey Renk, MD, FACEP (Charleston, SC)
    • Brian A. Moore, MD (Charlotte, NC)
    • Michael Pallaci, DO, FACEP (Columbus, OH)
    • Eric B. Schwam MD, FACEP (Attleboro, MA)
    • Bill Yount, MD, FACEP (Chicago, IL)
    • Mitch Charles, MD (Huntington, WV)

    The result of activities of this subcommittee has resulted in a document to the ACEP BOD to request a policy statement that all emergency medicine residency graduates are expected to meet ACEP Ultrasound Guidelines upon graduation, as well as recognize that the ACEP Ultrasound Guidelines and the Emergency Ultrasound Imaging Criteria Compendium are the "specialty specific guidelines" for use of ultrasound by emergency physicians.

  4. Section Grant
    The previously awarded section grant by Beatrice Hoffman, MD, to develop an EUS introductory CD-ROM for medical students is nearing completion.

    Growth:

  5. Membership
    As stated early this year, the tenth anniversary of the formation of the ACEP Ultrasound Section occurred in April 2006. My goal was to exceed 500 members, and this goal was met in August 2006. I am proud to inform you that the Ultrasound Section has a total of 503 members, a growth of 34 members from 8/31/05 to 8/31/06. While some other sections have experienced rapid gains, and some rapid loss of members, the steady growth of the EUS section represents a strong indicator of the value of the section and the stable growth of EUS.
  6. Emergency Ultrasound Promotion/Recognition
    I have drafted, with the assistance of the Washington office, a resolution requesting that the US Congress proclaim a national "Emergency Ultrasound Day!" EUS was broadly defined as bedside ultrasound performed by emergency physicians for the care of any traumatized or ill patient. This will recognize the contributions of EUS to mass casualty, disaster, and military medical care, as well as the impact of this valuable technology to the care of the over 114 million patients seen in our emergency departments each year.

    Protection of Our Accomplishments:

  7. Certification and Accreditation
    We addressed the confusion that existed between the concepts of certification and credentialing, and the section continues to follow these issues nationally, as well as how they affect our members.

The medical imaging industry, including general, vascular, and cardiac ultrasound is adopting a model of practice accreditation. Payers are driving this process as a cost containment and quality of care strategy. We are monitoring this issue closely, as well as keeping open discussions with organizations such as AIUM respective to the collective effect this would have on the use of ultrasound in medical practice. What is clear and what we must continue to demonstrate is the uniqueness of our practice environment, as well as the immediacy and time-critical aspects of the care we provide our patients with EUS. A longitudinal plan is in development to address this issue.

This has been a very busy year for the section. Several projects have met completion, with several others initiated. We remain persistent in our goal to expand and retain the availability of emergency ultrasound for the care of our patients through education, national policy, and research.

In conclusion, I would like to recognize Dr. Blaivas; Dr. Jones; Vivek S. Tayal, MD, FACEP; Diku Mandavia, MD, FACEP; Dr. Kendall; and David C. Seaberg, MD, FACEP, ACEP Board liaison to the Ultrasound Section, for their service to the section, advice, and assistance. I would like to especially thank Marilyn Bromley for her support and guidance throughout the year. The continued success of our section is a testament to her service. I look forward to continued section growth and productivity under the leadership of our Chair-elect Dr. Jones, and hope to see you at our section meetings and Scientific Assembly.

 


 

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SAEM Ultrasound Interest Group Meeting During Scientific Assembly in New Orleans

Ultrasound Interest Group Chair Daniel L. Theodoro, MD, has scheduled the USIG meeting during Scientific Assembly for Sunday, October 15, 2006, from 4:30 pm - 5:30 pm at the Melrose Room at the Hilton Hotel.*

The goal is to have a quick session regarding the completion/progress of USIG objectives set forth in San Francisco. Please note that a projector will not be available. If you wish to disseminate information, please bring handouts. Dr. Theodoro plans to e-mail an agenda about 2 weeks prior to the meeting. Anyone who has an agenda item, please e-mail ACEP staff liaison Marilyn Bromley at ultrasound.section@acep.org.

*Note that the USIG meeting does not directly follow the ACEP Ultrasound Section meeting due to scheduling conflicts, but is scheduled for the same day as the ACEP Ultrasound Section meeting.

 


 

 

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To Plant a Tree

From the Editor’s Desk
Gary Quick, MD, FACEP

Paul R. Sierzenski, MD, RDMS, FACEP

Over the years of my career, including family moves in childhood, moves due to educational demands, and practice relocations, I have planted over 150 trees. Most of the plantings have been fruit trees and shade trees. It seems fitting to decorate and outfit a new location with its own accompaniment of freshly-planted trees.

Many years ago I mentioned my tree-planting habit in the presence of a wise and gentle woman colleague who was an excellent role model and mentor for me in the first years of my career. She explained that those who plant trees come to their situation with the intention, literally, of putting down roots—that tree planting was a portent pointing toward permanence. Even now as I reflect on her insight and my own continued practice of planting trees in new locations anticipating the development of roots, I am considering an analogy between tree-planting and the development of emergency ultrasound.

Consider the way of a tree. The structure starts small with a seed and cotyledons. Then a root inserts itself into the soil to absorb nutrients and water and to attach the tree to the soil so that the seedling is not dislodged from its soil cradle. As the tree grows to a sapling, its roots spread and thicken so that the tree is anchored securely against wind and water threats. As a full-grown tree, the root system continues to nourish and stabilize the tree. At this stage of growth, the roots actually hold large areas of soil in place, lending a constancy to the environment in which the tree is thriving. The tree actually seems to guarantee its own existence and growth by the work of the roots, which continue to nourish and attach, to secure and stabilize the very soil in which the tree thrives.

Contributing high-quality articles to the medical literature is a mark pointing toward permanence. In this issue of Emergency Ultrasound, we take notice of two watershed events for bedside sonography. The "Emergency Ultrasound Imaging Criteria Compendium" initiated and completed by John L. Kendall, MD, FACEP, and the abstract of the work of Lawrence A. Melniker, MD, FACEP, and the SOAP-1 research team "A Randomized Controlled Clinical Trial of Point-of-Care, Limited Ultrasonography for Trauma in the ED: The First Sonography Outcomes Assessment Program Trial" comprise significant contributions to the literature of emergency ultrasound (EUS). In the years of effort required by both of these works, both trees have survived the seedling stage and grown through their sapling stage into maturity. As a result, bedside sonography now finds large chunks of its soil stabilized and secured with the root systems of these two works.

These two excellent publications will nourish and support the practice of emergency sonography for many years to come. They mark the arrival of a measure of maturity to the practice of bedside sonography in that the standards promulgated and the results generated emanate directly from the current practice of emergency ultrasound.

The imaging criteria define the scope of practice for emergency ultrasound by listing the current indications for eight areas of emergency ultrasound. Emergency medicine residents and attending physician alike will encounter the standards for EUS procedural performance as detailed in the Imaging Criteria. This compendium will continue the efforts of our specialty to enhance our clinical practice at the bedside for the benefit of emergency patients.

The SOAP-1 study represents a prospective, randomized trial of EUS in trauma care. As such, the study represents a new level in the foundational practice of EUS. What we suspected in trauma care, namely that patients evaluated with EUS received faster operative care and underwent fewer imaging procedures than did non-EUS patients, has now been subjected to the scrutiny of valid scientific analysis and found to be accurate. The results of SOAP-1 and the ensuing SOAP studies will strengthen the hand of emergency physicians to negotiate for commitment and resources to support the practice of outcomes-based EUS on behalf of emergency patients. In short, this study shows that EUS saves both lives and money.

Congratulations to the lead authors, Dr. Kendall and Dr. Melniker, for significantly extending and consolidating large areas of the fertile soil of EUS by the culmination of their efforts in producing these "next-generation" works for our specialty. Certainly their tree-planting skill is worthy of our appreciation and emulation and points to the permanence of EUS in our EDs.

 


 

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The Sound of a Hurricane

Lisa Mills, MD
Director, Division of Emergency Medicine Ultrasound
Assistant Professor Emergency Medicine
Louisiana State University at New Orleans

In August 2005, I was just beginning my 3rd year as the Director of Emergency Medicine Ultrasonography (US) at the Louisiana State University (LSU) emergency medicine (EM) residency in New Orleans. It had been a long 2 years. I’d had only patchy success promoting US in the emergency department (ED). The faculty struggled to find time to learn a new technology in their already busy schedules. Residents had difficulty making time during busy shifts to practice with the machine. A controlling radiology department seemed to undermine every effort that I made. Regardless of hours, the lectures, and hands-on labs, US was just not catching on. I aspired to a time when our physicians would routinely use bedside US.

When Hurricane Katrina and the subsequent flooding devastated our hospital and the health care in our entire region, EM US suddenly became a critical part of our routine patient care. In the immediate aftermath of the hurricane, our physicians practiced in isolated, makeshift medical stations. At these points of entry into the debilitated health care system, evacuees required rapid evaluation. The challenge before us was to triage hundreds of evacuees to identify those with urgent medical complaints, complaints that could result in transport by ambulance to the local hospitals operating on minimal resources, or conditions that required emergent evacuation by military helicopter to fully functional hospitals outside the area of devastation. This had to be accomplished in a parking lot without labs, radiology, or other testing.

Our dedicated residents and faculty never considered leaving. Their commitment to the community inspired them to work long hours, enduring oppressive heat and a lack of personal comforts like running water, sewage, and fresh food. Our desire was to provide the best medical care possible given our extremely limited resources.

Weeks later, the military arrived and established a Combat Support Hospital (CSH). This came equipped with rudimentary x-ray capacity and a handheld US. We continued to practice in a very isolated setting, with the nearest consultants several miles away. Initially, x-ray maintained its status as the preferred imaging study. However, wheeling patients out of the environmentally controlled tents to the radiology tent across a pockmarked parking lot in soaring temperatures and record humidity and, occasionally, tropical rain storms, dampened everyone’s enthusiasm for plain films. US became the more convenient study. Physicians who previously ordered plain films to evaluate pulmonary edema, foreign bodies, and soft tissue infections, began to routinely rely on US for these diagnostic decisions.

With the CSH came ambulances and sicker patients, patients with hypotension, significant trauma, and altered mental status. The increased acuity in a setting of extremely limited resources again challenged our physicians. We were functioning without the benefit of consultants or a hospital, but receiving critical patients. We had to make rapid assessment and disposition decisions. This was accomplished without the benefit of a portable x-ray or a CT scanner and with very limited laboratories.

Again, US formed the basis of our diagnostic strategies. The routine use of US by EM physicians began. Residents began to use US in the initial evaluation of shortness of breath and hypotension. Residents performed their own FAST. Decisions had to be made based on these studies. Kidney stones, aortic aneurysms, heart failure, and abscesses had to be diagnosed. Private consultants had to be contacted and patients transferred based on bedside US. Our residents rose to the challenge. Their confidence grew.

When the army moved out of New Orleans, so did their radiology services. We were provided with a portable x-ray machine and CT scanner. However, our radiology department suffered dramatically during the storm. As a result, the interpretation of complex radiology studies was not consistently available. Through the generous support of Zonare and Sonosite, we maintained bedside US capability.

In our makeshift hospitals, the generators frequently failed, and the CT scanner required a prolonged boot-up process after these events. The CT scanner suffered frequent breakdowns. The portable x-ray machines began to fail after being wheeled over the irregular terrain of the makeshift hospitals and suffering frequent power surges when the generators would regain power.

The bedside US retained power during generator outages (and the image improves with the lights out). These machines did not overheat in grueling temperatures. The machines still have not broken down or failed, though they wheel over rough terrain, are exposed to power surges, and are also subject to being dropped.

As our citizens moved back into the city, our health system was not prepared to meet the demand. As a result, we became quickly overwhelmed with patients. With all of these demands, the residents increasingly relied on US for rapid diagnosis of patients. After months of practicing in isolated conditions with no back-up, our residents’ confidence has grown. In addition, their skills have soared.

In the beginning, I prompted residents to use US. Residents would say, "We need a CT to…" I would respond, "With US, we can…" The residents quickly learned the standard applications of US. I achieved my goal in making US a routine step in the evaluation of patients in the ED. But the residents have again raised the bar with their commitment to providing the best care possible to our community.

They have taken EM US to a new level, applying it in novel and diverse situations with incredible results. Now, when the residents say, "Dr. Mills, let’s use US to do this." I might reply, "US is not ideal for that application." Frequently I hear, "Well Dr. Mills, we have been practicing, and if you do this, you can…" The residents continually impress me with new applications of bedside US. They have moved beyond echocardiography in hypotension, FAST, and soft tissue injury/infection to performing Doppler studies of the solid organs to assess for penetrating injury, differentiating shoulder dislocations from proximal humerus fractures, diagnosing tibial plateau fractures, identifying pyomyositis, and detecting carotid aneurysms. In a time of devastation, LSU EM residents have enriched our specialty with an unrivaled knowledge of bedside US.

The paucity of resources brought on by the destruction in 2005 has been met with a wealth of knowledge. If you have the good fortune to meet these residents, please remember that they are heroes who put aside their own needs out of dedication to their community, their profession, and their specialty, and don’t forget to ask them for US tips.

 

 


 

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Web Site Posting of Section Newsletters

Carole Prewitt, ACEP Sections Coordinator

For the past several years, a large percentage of section members have requested that the College make section newsletters available on the ACEP Web site.

I am very pleased to report that we are now able to fulfill that request, which was approved by the Board in their June budget meetings. Starting in September, we will be posting newsletters online and informing you of their availability through your section e-list. Once this new process is fully operational, ACEP will no longer send copies of section newsletters by US mail.

There are a number of advantages to this new member service: it will only take a few days to post newsletters instead of the weeks it now takes to lay out, print, and mail them; newsletters will be archived and readily available 24 hours a day, seven days a week; and of course the cost to ACEP will be reduced - an essential component to keeping section and national membership dues the same for the past nine years and in the future.

This new delivery method will not affect the great content section newsletters provide. They will still be written by section members, edited by section newsletter editors, and still an essential part of the section experience. In fact, the process of submitting newsletters will not change. The only change will happen at ACEP headquarters where newsletters are produced. And yes, you will still be able to submit photos and images.

ACEP leadership is very excited about this new member service. We believe it is a much improved way to deliver important section information, and we look forward to implementation in September.

 

 


 

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Journal Watch

Melniker LA, Leibner E, McKenney MG, et al. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: The first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235.

Reviewer: Seric Cusick, MD

Objective: The primary objective is to assess whether using a protocol inclusive of point-of-care, limited ultrasonography (PLUS), compared to usual care (control), among patients presenting to the emergency department (ED) with suspected torso trauma decreased time to operative care.

Methods: The study was a randomized controlled clinical trial conducted during a 6-month period at two Level I trauma centers. The intervention was PLUS [point of care, limited ultrasonography] conducted by verified clinician sonographers. The primary outcome measure was time from ED arrival to transfer to operative care; secondary outcomes included computed tomography (CT) use, length of stay, complications, and charges. Regression models controlled for confounders and analyzed physician-to-physician variability. All analyses were conducted on an intention-to-treat basis. Results are presented as mean, first-quartile, median, and third-quartile, with multiplicative change and 95% confidence intervals (CIs), or percentage with odds ratio and 95% CIs.

Results: Four hundred forty-four patients with suspected torso trauma were eligible – 136 patients lacked consent, and attending physicians refused enrollment of 46 patients. Two hundred sixty-two patients were enrolled: 135 PLUS patients and 127 controls. There were no important differences between groups. Time to operative care was 64% (48, 76) less for PLUS compared to control patients. PLUS patients underwent fewer CTs (odds ratio 0.16) (0.07, 0.32), spent 27% (1, 46) fewer days in hospital, had fewer complications (odds ratio 0.16) (0.07, 0.32), and charges were 35% (19, 48) less compared to control.

Discussion: This study, by way of a randomized controlled trial, provides evidence that use of the Focused Assessment with Sonography for Trauma (FAST) results in statistically significant improvements in each of the variables assessed. Time to operative intervention, use of CT, length of stay, complication rates, and hospital charges were all decreased in patients with suspected thoracoabdominal trauma randomized to receive PLUS. Important limitations identified by the authors include a high rate of eligible patients not enrolled (41%) due to lack of consent or physician refusal, and slightly higher acuity within the excluded patients (85% vs. 80% admission rate and 35% vs. 29% requiring operative care). Regardless, this study serves as a critical step in objectively demonstrating improvements in clinical outcomes using emergency ultrasound in trauma. Furthermore, the data produced regarding length of stay and hospital charges creates a foundation for future studies employing formal cost-analysis.

 



Tayal VS, Hasan N, Norton HJ, et al. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. 2006;13(4):384-388.

Reviewer: Matt Solley, MD

Objective: To evaluate the effect of diagnostic soft-tissue ultrasound on management of ED patients with clinical cellulitis.

Methods: The authors present a prospective observational study to evaluate patients with clinical cellulitis without an obvious abscess. Five experienced emergency sonographers with greater than 100 total bedside emergency ultrasounds each were trained in soft tissue ultrasound by their emergency ultrasound director. Each sonographer performed five soft tissue scans prior to enrollment. High frequency linear transducers were used, however curvilinear transducers were available for deeper evaluation. An abscess was defined as an irregularly shaped anechoic or hypoechoic fluid collection with varying degrees of echogenic material. Clinicians were asked their pretest opinion whether or not they felt that the patient would require drainage prior to the bedside ultrasound.

Results: One hundred twenty-eight patients were enrolled over a 28-month period. Of these patients, 63 (50%) had sonographic evidence of an abscess, of which 58 had a subsequent drainage procedure. The other five patients had small fluid collections and were discharged home on antibiotics. Of the 58 patients that had drainage procedures, 46 had purulent fluid, four had serous fluid, two had liquefied hematomas, and two had bloody serous fluid. Ultrasound changed the management in 71 of 128 patients (56%). In the pretest group that felt that no drainage would be necessary (n= 82), 33 underwent drainage procedures and 6 received further imaging (change in management of 48%). In the pretest group that felt that further drainage would be necessary (n= 44), 16 patients were no longer felt to require drainage and 16 had further procedure guidance, tests, or consultation prior to drainage (change in management of 73%).

Discussion: Although obvious abscesses are fairly straightforward in terms of diagnosis and management, there are a large number of patients with cellulitis in whom it is unclear whether there is an abscess present. This study gives further evidence that physician clinical judgment is not always correct, and that ultrasound can effectively guide management. Squire and Fox in July 2005 showed that ultrasound had a better sensitivity and specificity than clinical judgment (86% and 70% for clinical judgment versus 98% and 88% for ultrasound, respectively). Ultrasound for equivocal cases of cellulitis versus abscess can change management and more accurately identify abscess presence when compared to clinical impression alone. Grossly obvious abscesses probably do not require an ultrasound prior to incision and drainage.

 

 


 

Nelson BP, Basavaraju SV, Baumlin K. Sonographic diagnosis of axillary artery aneurysm presenting as painful mass. Ann Emerg Med. 2006;48(3):339-340.

Reviewer: Matt Solley, MD

Methods: This is a case report of a patient with an axillary mass that was triaged as an abscess. On further history, the patient had reported a thoracotomy for a thoracic aortic aneurysm repair previously. On exam, the patient had a warm, slightly pulsatile and painful mass; however, there was no surrounding erythema or induration, and the patient had this mass for several months. A vascular ultrasound by the emergency physician revealed a 5 cm mass with turbulent flow and was continuous with the adjacent axillary artery. Vascular surgery was then consulted immediately.

Discussion: We have all been guilty of narrowing our differential diagnosis list too quickly, focusing in on the triage or medic report, and shutting our brain down to consideration of further differentials. These authors didn’t assume that this was simply an axillary abscess, although the axilla is a common site for abscesses. They correctly hypothesized that this was likely a vascular lesion and did their own confirmatory study. The bedside procedure probably saved time by not having to call an ultrasound tech in (especially if it were at night) and provided further objective data for the consultant. In addition, it prevented them from sticking a needle into a nasty situation.

Some might not have the clinical acumen that these authors did and would have been tempted to go after this "abscess." You can always follow the sage advice of my great-grandmother that I quote from her deathbed, "Don’t stick a needle or scalpel into anything that you haven’t laid a linear transducer on first."

 


 

Drey EA, Kang MS, McFarland W, et al. Improving the accuracy of fetal foot length to confirm gestational duration. Obstet Gynecol. 2005;105:773-778.

Reviewer: Lisa Mills, MD

Objective: To determine a normal range of fetal foot length for dating pregnancies.

Methods: Fetal foot length of 1,099 aborted fetuses were measured directly. Using gestational age determined by LMP and gestational age determined by US, equations were derived to estimate fetal age from foot length. There was no significant difference based on ethnicity.

Conclusion: The authors conclude that fetal foot length should be revisited as a means of dating pregnancy by US.

Certainly, this will make our current OB software obsolete. Much more testing will be required before this becomes standard.

 

 


 

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New Video Case Studies Initiated on Section Web Site

Gary Quick, MD, FACEP

Interested in a painless but excellent way to educate yourself in the basics of emergency ultrasound? Visit the outstanding Video Case Studies section on the Emergency Ultrasound Section Web page. The case studies have been presented by Chris Moore, MD, FACEP, of Yale, and some will recognize the content from his "Case of the Week" series, which has been available on the Internet for several months. Thanks to the work of Dr. Moore, Mr. Bill Halsell, ACEP's Director of Internet Services, has been able to expertly load the case reports and image clips onto the section Web page in a very usable format.

The cases present a short history of illness, physical examination, and appropriate selected laboratory results followed by an actual video clip of the patient’s sonographic examination. The participant is asked to interpret the findings of the ultrasound exam.

The video clip is followed by a short discussion of the case providing some diagnostic rationale, the results of the bedside sonographic exam, and a labeled still image identifying the pathological condition and pertinent anatomical structures. This content is followed often by an abstract of an applicable journal article as a reference.

The bedside ultrasound images weep quality and testify to Chris’s skill with the probe. What greater compliment can I state than that I learn a new ultrasound jewel each time I work through a case.

David P. Bahner, MD, FACEP, and I have established an editorial board consisting of Dr. Bahner, Dr. Moore, Robert Blankenship, MD, FACEP, and myself. We encourage you to submit cases to me for consideration for uploading to the Web site. In the interest of maintaining high quality for the case studies, please use your best images and follow the format as exemplified in the current Video Case Study series.

We encourage you to visit the Ultrasound Section Web page and try the video cases and other offerings found on the site. Send us feedback so that we are able to customize our offerings to your needs.

 


 

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The Latin American Ultrasound Initiative: Spreading the Practice of Emergency Ultrasound Down South

Darryl J. Macias MD, FACEP
University of New Mexico (UNM)

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Caption: Enthusiastic Argentine physicians convinced of the value of ED ultrasound.

Globalization. Free trade. Cultural competency. International emergency medicine. Ultrasound advancement. Chances are that any one of you reading this article knows of at least one of these topics. The ease of use, rapidity, accuracy, and economy of ultrasound continues to make headway in emergency medical care, as its use expands throughout the North American continent. Latin America, which would benefit from this technology, is making headway in dissemination of the knowledge and practice of emergency ultrasound. Many of us practicing medicine along the border states have often been amazed at the disparity of emergency medical care south of the border, primarily because our specialty is relatively nascent, or nonexistent from Juarez to Ushuaia. Ultrasound may serve to narrow the gap and legitimize our specialty in this vast geographic region.

An initiative called the Pan American Collaborative Emergency Medicine Development program (PACEMD) http://www.pacemd.org/ was set up to address some inequalities in emergency care in Mexico. The initial purpose was primarily to train Mexican prehospital providers more effectively. This concept later metamorphosed into a modular program designed to train Mexican physicians in quality and evidence-based emergency care. Although residencies existed in a couple of large metropolitan Mexican cities, other locales were limited in emergency medicine training. While not meant to be a substitute for formal residency training, the PACEMD initiative would be instrumental in providing essential emergency medical training to physicians who might otherwise not seek additional educational opportunities.

"Well yes, that is nice for Latin America, but I don’t work down there. Why should I care?" Many of us or our loved ones travel to Latin America for business or for pleasure. Indeed, many of us would do well to have an interest in the type of training received by the medical community there, should any one of us need it. PACEMD is headquartered in San Miguel de Allende, Mexico. Since its inception in 1997, many modular EMS, airway, cardiac emergency courses, and disaster medicine courses have been taught and disseminated in collaboration with the University of New Mexico and other academic emergency medicine programs.

The idea of these modular courses were taken after the success of the first formal PACEMD/UNM emergency ultrasound course taught in August 2001, entirely in Spanish, and attended by surgeons, internists, radiologists, and obstetricians. Later courses in Guanajuato spurred the development of able and eager local students to become faculty. The course was then taken to national emergency medicine society meetings under the invitation of the Mexican Society of Emergency Medicine (SMME).

These intensive, two-day didactic and hands-on sessions have become sought after in the country, as well as other Latin American countries. Since then, courses have been given by UNM and PACEMD faculty in Panama City, Panama and most recently, at the First Interamerican Congress of Emergency Medicine in Buenos Aires, Argentina (co-taught by Nick Testa of USC and Dan Theodoro of Washington University.) This summer, several other emergency ultrasound courses were subsequently offered in Argentina, and attended with enthusiasm. Ultrasound teaching has also found its way in Quito, Ecuador, as the specialty of emergency medicine seeks a foothold in that country. PACEMD also offered the Advanced Life Support in Obstetrics course, which included Ob-Gyn ultrasound. Up to now, 245 Spanish speakers have attended these joint UNM-PACEMD courses.

What does the future hold? The practice of emergency ultrasound in some countries is only limited by whether or not emergency care facilities (Mexico) have ultrasound machine access, a specialty in emergency medicine (embryonic in Ecuador), or success in the ability to convince non-emergency medicine stakeholders of ultrasound’s validity (Argentina). Credentialing of select local faculty is being done according to ACEP guidelines. From these ultrasound courses, we have fanned the flames of interest in our specialty by emergency practitioners and government officials. Our collaborative efforts have even impressed the nay sayers. Of note, a course in Colombia is planned, and fall 2006 ultrasound courses will be taught in Nepal (to be taught in Nepali) and Cambodia, where CT scanners are not as plentiful. Besides the obvious benefits of the program for our Latin American counterparts, many residents and attendings from UNM have been all the more excited about learning and teaching ultrasound at home and abroad.

 


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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