Joshua S. Rempell

A Practical Guide to Self-Sustaining Point-of-Care Ultrasound Education Programs in Resource-Limited Settings

The value of point-of-care ultrasound education in resource-limited settings is increasingly recognized, though little guidance exists on how to best construct a sustainable training program. Herein we offer a practical overview of core factors to consider when developing and implementing a point-of-care ultrasound education program in a resource-limited setting. Considerations include analysis of needs assessment findings, development of locally relevant curriculum, access to ultrasound machines and related technological and financial resources, quality assurance and follow-up plans, strategic partnerships, and outcomes measures. Well-planned education programs in these settings increase the potential for long-term influence on clinician skills and patient care.

Pilot Point-of-Care Ultrasound Curriculum at Harvard Medical School: Early Experience

Introduction Point-of-care ultrasound (POCUS) is expanding across all medical specialties. As the benefits of US technology are becoming apparent, efforts to integrate US into pre-clinical medical education are growing. Our objective was to describe our process of integrating POCUS as an educational tool into the medical school curriculum and how such efforts are perceived by students. Methods This was a pilot study to introduce ultrasonography into the Harvard Medical School curriculum to first- and second-year medical students. Didactic and hands-on sessions were introduced to first-year students during gross anatomy and to second-year students in the physical exam course. Student-perceived attitudes, understanding, and knowledge of US, and its applications to learning the physical exam, were measured by a post-assessment survey. Results All first-year anatomy students (n=176) participated in small group hands-on US sessions. In the second-year physical diagnosis course, 38 students participated in four sessions. All students (91%) agreed or strongly agreed that additional US teaching should be incorporated throughout the four-year medical school curriculum. Conclusion POCUS can effectively be integrated into the existing medical school curriculum by using didactic and small group hands-on sessions. Medical students perceived US training as valuable in understanding human anatomy and in learning physical exam skills. This innovative program demonstrates US as an additional learning modality. Future goals include expanding on this work to incorporate US education into all four years of medical school.

Using lung ultrasound to differentiate patients in acute dyspnea in the prehospital emergency setting.

The diagnosis and treatment of dyspnea in the emergency department and in the prehospital setting is a challenge faced by the emergency physician and other prehospital care providers. While the use of lung ultrasound as a diagnostic tool in dyspneic patients has been well researched, there has been limited evaluation of its use in the prehospital setting. In the previous issue of Critical Care, Prosen and colleagues study the accuracy of lung ultrasound compared with both N-terminal pro-brain natriuretic peptide and the clinical examination for differentiating between acute decompensated congestive heart failure and chronic obstructive pulmonary disease exacerbations for patients in the prehospital setting. Their article adds to the growing body of evidence demonstrating the diagnostic efficacy of lung ultrasound in differentiating between these two disease processes in the acutely dyspneic patient.

Point-of-care ultrasonography for the diagnosis of small bowel obstruction in the emergency department

Small bowel obstruction (SBO) is a common cause of acute abdominal pain presenting to the emergency department (ED). Although the literature is limited, point-of-care ultrasonography (POCUS) has been found to have superior diagnostic accuracy for SBO compared to plain radiography; however, it is rarely used in North America for this. We present the case of a middle-aged man who presented with abdominal pain where POCUS by the emergency physician early in the hospital course expedited the diagnosis of SBO and led to earlier surgical consultation. The application of POCUS for SBO is easily learned and applied in the ED. POCUS for SBO may obviate the need for plain radiography and expedite patient care.

POSITIVE FAST WITHOUT HEMOPERITONEUM DUE TO FLUID RESUSCITATION IN BLUNT TRAUMA

BACKGROUND The focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. OBJECTIVES To describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. CASE REPORT We describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. CONCLUSION This case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination.

Emergency Ultrasound Diagnosis of Ovarian Hyperstimulation Syndrome: Case Report

BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED). OBJECTIVES OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography. CASE REPORT We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles. CONCLUSIONS This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.

Point-of-Care Ultrasound Use, Accuracy, and Impact on Clinical Decision Making in Rwanda Hospitals

Few studies of point‐of‐care ultrasound training and use in low resource settings have reported the impact of examinations on clinical management or the longer‐term quality of trainee‐performed studies. We characterized the long‐term effect of a point‐of‐care ultrasound program on clinical decision making, and evaluated the quality of clinician‐performed ultrasound studies.

Diagnosing centrally located pulmonary embolisms in the emergency department using point-of-care ultrasound

Objective: The study objective was to investigate the combined accuracy of right heart strain on focused cardiac ultrasound (FOCUS) and deep vein thrombosis (DVT) on compression ultrasound (CUS) for identification of centrally located pulmonary embolism (PE) diagnosed on computed tomography pulmonary angiography (CTPA). Methods: This was a prospective observational study using a convenience sample of patients undergoing CTPA in the emergency department (ED) for evaluation of PE. Patients received a FOCUS looking for right heart strain (McConnells sign, septal flattening, right ventricular enlargement or tricuspid annular plane systolic ejection (TAPSE) < 17 mm) and a CUS looking for DVT. Ultrasounds were interpreted by both the investigator performing the ultrasound and the principal investigator independently. Results: There were 199 patients enrolled in the study, with 46/199 (23.1%) positive for a PE. Of these, 20/46 (43.5%) PEs were located centrally. Of those with a PE, 20/46 (43.5%) had an associated DVT identified on bedside ultrasound. Among patients with a proximal PE, 18/20 (90.0%) had evidence of right heart strain and the combination of lower extremity CUS and FOCUS was 100% sensitive. Diagnostic accuracy of ultrasound was much lower for peripherally located PEs. Conclusions: Emergency physician‐performed bedside ultrasound may be sufficient to exclude the presence of centrally located PE, as the sensitivity in this study was 100%. Additionally, several patients with PE may qualify for early anticoagulation when DVT is identified, and further research in indicated to determine whether these patients ultimately require CTPA given identical treatment algorithms in the absence of RV strain or biomarker elevation.

Fever and Rigidity

*Harvard Affiliated Emergency Medicine Residency, Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, Founders 114, 55 Fruit Street, Boston, MA 02114

A Case of Syncope

CASE PRESENTATION An 88-year-old female presented to the emergency department (ED) after a syncopal event. Upon arrival, the patient was awake and complaining of chest pain. An electrocardiogram was performed showing an inferior ST-elevation myocardial infarction (STEMI). Patient’s vital signs were heart rate of 86 beats/minute, blood pressure of 83/50 mmHg, temperature of 98.8 degrees Fahrenheit, respiratory rate of 18/minute, and oxygen saturation 96% while breathing room air. Dorsalis pedis pulses were difficult to appreciate bilaterally and the patient was agitated and diaphoretic. A focused cardiac ultrasound (FOCUS), including a suprasternal notch view (SSNV), was performed (Image 1). Brown University, Warren Alpert School of Medicine, Department of Emergency Medicine, Providence, Rhode Island Cooper Medical School of Rowan University, Cooper University Hospital, Department of Emergency Medicine, Camden, New Jersey *