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Emergency Ultrasound

Peter’s Pet Peeves (Special Contribution)

Peter Kumasaka, MD

You walk into the room and see the resident’s face grimacing as he struggles with the ultrasound machine. A 67 year old patient with COPD, CHF and CAD, status post total knee arthroplasty presenting with CP and dyspnea. Your resident is trying to impress you with his POC US skills. Unfortunately, he only catches a rare, brief look at the heart through the nanometer sized window that the hyperinflated lungs will afford. After a couple minutes, the resident sighs in exasperation. You grab the probe and a short while later, you are pointing out the RV dilation, D-shaped LV, plethoric IVC, absence of pericardial effusion and hyperdynamic activity. 

In the world of the Emergency Physician, we lead a double life when taking on POC US. We must don the hat of both the Sonographer and the Radiologist. The latter persona is easier to assume. We study books and FOAM, take courses, etc. We are smart and intellectual. And grasping concepts, ideas and facts is easy. It doesn’t take a special skill. But becoming the sonographer is tackling a different beast. Performing a POC US is a technical skill. A procedure. We teach proper technique about how to put a chest tube. Or how to position your patient and hold the laryngoscope. But it seems we spend little time teaching technique with POC US. Why?

Roger Federer can deftly slice the ball deep and then hit a blistering top spin down the line past his sprawling opponent. It’s not easy, but he does it with little thought, because he has complete control of every nuance of his tennis racket. And it starts with his grip.

Likewise, it IS difficult to finely maneuver the probe with a tiny tilt or rotation, staring at the US screen and not at the sole, miniscule ultrasound window the patient has. But to do this, it takes good technique. And that starts with The Grip. How many times do you teach your residents how to properly hold the probe? And worse, how many times have you seen a picture similar to Image 1 in a text or online site? Fine movements require the use of the fingertips. And keeping the probe in the one tiny US window requires anchoring their hand and probe as a unit on the patient. We need to ensure that they can hold the probe in a manner that allows them to create fine movements while keeping their “hand-probe unit” on a specific spot (Image 2).

We need to help minimize the difficulties of putting on the sonographer’s hat. And it needs to start from early on with basics. Bad practice leads to bad habits. EPs will become more adept and comfortable with POC US if they start with good fundamentals. And how we hold the probe is the most basic and fundamental lesson. You will never see a professional sonographer hold the probe like a club. They hold it like a fine tool or instrument. And that is exactly what POC US is. Let’s start treating it like one.

Fingertips  ClubGrip
Image 1. The Club Grip Image 2. Fingertips. Anchored.



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