Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Today on Critical Matters, we will discuss the use of point-of-care ultrasound during the management of shock and hypotension.
Speaker: Our guest is once again Dr. Haney Malamud.
Speaker: Dr. Malamud is board certified in emergency medicine, internal medicine, and critical care medicine, and works in the emergency department and intensive care units at Cooper University Hospital in Camden, New Jersey.
Speaker: Dr. Malamud is a highly accomplished educator.
Speaker: He has lectured both nationally and internationally and has contributed to several emergency medicine and critical care podcasts, a true champion of the phone movement, free open access medical education.
Speaker: Furthermore, he's an education innovator and has developed a platitude of amazing educational programs and products.
Speaker: He is a firm believer in the benefits of bedside ultrasound for better patient care.
Speaker: Dr. Malamud holds academic appointments in critical care medicine and emergency medicine
Speaker: Cooper Medical School of Rowan University and has received numerous teaching awards.
Speaker: A true pleasure to have you back on Critical Matters.
Speaker: Welcome, Haney.
Speaker: Thanks for having me back.
Speaker: It's awesome to be here.
Speaker: How have you been?
Speaker: Doing great.
Speaker: Last we spoke, we talked about the use of point-of-care ultrasound and cardiac arrest specifically.
Speaker: And I think that since we spoke, if anything, the use of point-of-care ultrasound continues to grow and really is embedded in the practice of many of our
Speaker: ED departments, but also in critical care, it's becoming more and more popular.
Speaker: I think as a starting point, maybe, Haney, we can talk about where we are today with point of care ultrasound.
Speaker: I think that we were talking before we started recording about being at a tipping point where there's still a vast number of people who did not get training in critical care for ultrasound during their fellowship, but are learning.
Speaker: But now it's much more common in training programs
Speaker: but also with the availability of technology.
Speaker: Today, probably medical students are graduating from medical school and getting an ultrasound, a pocket ultrasound as a present.
Speaker: So where do we stand today?
Speaker: It's really an amazing time.
Speaker: You know, when I graduated medical school, I got a stethoscope with my name on it, and I thought it was the greatest thing ever.
Speaker: But like you said, the technology and the microprocessors and the probes are getting so cheap now,
Speaker: that medical students are getting these as graduation gifts and they're sort of showing up on the rotations, not really knowing what to do with them, but with the expectation that we're going to teach them what to do with this, because this is something that their friend in another medical school or residency program is using on a day to day basis.
Speaker: So it's, it's really a fascinating time.
Speaker: And the thing that might be an issue for some teachers and attendings is that they didn't train with this technology.
Speaker: And so you'll find some people
Speaker: who are going to the courses, who are learning how to do it because they truly believe it's a technology that can help their patients.
Speaker: And then there's those people that I don't want to use the word lazy, but they will say, I'm good without this and I don't need to use it for my patients.
Speaker: So it's a very interesting time.
Speaker: I think this will be a washout period of maybe another 10 years or so, because as the newer fellows are training and coming up through the ranks, they're all learning ultrasound.
Speaker: All the fellows here at Cooper
Speaker: are doing ultrasound from day one.
Speaker: And I got to tell you, I'm pretty decent with ultrasound and they're really giving me a run for my money.
Speaker: They're getting really good.
Speaker: And that is, like you said, I mean, I think it's a very interesting time, but we're still in that phase where there's still plenty of people in critical care, especially who do not have that training.
Speaker: And I think that that is also part of the intended audience for this episode of how they can really utilize this type of technology
Speaker: for carrying a patient's at the bedside.
Speaker: And one of the things that I wanted to get your thoughts on, Haney, before we started diving into more granular aspects of using point-of-care ultrasound for shock and hypotension is the whole concept of how this is being deployed and what's the real philosophy behind it.
Speaker: Because when I was a fellow, this was still not very prevalent.
Speaker: There were people starting to have an interest in doing echocardiography and training with cardiologists, but you would hear all the arguments that
Speaker: You have to do a full exam that what have you missed this?
Speaker: What have you missed that?
Speaker: And really what I've seen is a paradigm shift where you're using this technology as an extension of your physical exam and really to answer very specific questions, not to get all the information in the world.
Speaker: Can you talk about that difference?
Speaker: Yeah, this is where I think some of the people who don't want to learn ultrasound, this is one of the excuses that they use.
Speaker: They say, well, I'm not going to get as good of a exam as a sonographer.
Speaker: or someone else is doing the exam later or radiologist.
Speaker: And look, here's the bottom line with this.
Speaker: This has become so ingrained in what I do and many others do as part of our initial assessment of the patient that I can't do as good of a job nowadays in evaluating a patient as without it.
Speaker: If I, and I hear a murmur on a patient or I hear distant heart sounds, or I'm looking at some ancillary tests like an ECG and I see there's
Speaker: you know, low amplitude QRS complexes.
Speaker: I'm thinking about tamponade.
Speaker: I'm not waiting to call somebody up on the phone and ask them, hey, can you come tomorrow or later today and do this?
Speaker: I get the question right then and there.
Speaker: Are the images sonographer quality?
Speaker: Are they going to go in a textbook somewhere?
Speaker: No, but it doesn't matter.
Speaker: I need to answer a question quickly for my hypotensive patient because I need to go to the next step.
Speaker: And that's what ultrasound and point of care ultrasound helps you to do.
Speaker: It helps you to get to the next step.
Speaker: Even if the next step, even if the images that you get are not optimal and you're not sure, it allows you to call the sonographer and say, I need you to do the ultrasound right now because I'm worried about tamponade.
Speaker: So think about how powerful that is.
Speaker: You at least get images that say, I don't know what this is, but this is not normal.
Speaker: Come see my patient, which is something that any rookie critical care doctor who picked up an ultrasound probe on a weekend course can do.
Speaker: They can at least identify normal
Speaker: and abnormal.
Speaker: And if people who are resistant to do ultrasound just did that, their practice would improve by some magnitude.
Speaker: And I think that that's an important aspect of bedside ultrasound.
Speaker: What we're trying to answer is questions based on quality, present or absent, as opposed to do a very in-depth quantification of specific hemodynamic parameters or specific measurements, which I think is, as you said,
Speaker: better left to people with full equipment and with more time.
Speaker: But again, by identifying these problems up front, we can even move those exams a lot quicker.
Speaker: Could you talk a little bit about when do we need to get a full echocardiogram, echocardiography?
Speaker: Yep.
Speaker: I want to add to that last statement that you said and answer this question at the same time.
Speaker: The thing is, though, is that when you keep doing ultrasound and you keep learning more,
Speaker: you get to do the things that the sonographers do.
Speaker: You can answer more questions than the yes and no.
Speaker: So on a very basic level, doing yes, no algorithms makes you a much better clinician.
Speaker: But in short order, and with just a little bit of investment, but a lot of practice, you'll be able to get those questions.
Speaker: You'll be able to determine, yes, this is tamponade because of changes in your velocities through valves.
Speaker: You'll be able to look at the left ventricular function and quantify things.
Speaker: It's not that you're gonna be stuck at that same point.
Speaker: You use ultrasound every day as part of your practice and you will grow with it.
Speaker: And when do you get a formal, or some people are getting away from the term formal, a full echocardiogram?
Speaker: To be honest with you, there are very few instances where I feel as though I need to call a cardiologist to look at my images and tell me what's going on.
Speaker: Because for me during resuscitation,
Speaker: and managing my sick patient, I can answer all the questions that I need.
Speaker: I might do it for the historical documentation.
Speaker: If I was working at a place that we don't document, which now we're doing anyway, but I find that I'm calling them less and less.
Speaker: And in fact, there are certain things that we do with point of care ultrasound at the bedside that radiologists, cardiologists, they have no idea what it is.
Speaker: So if you look at something like looking for a pneumothorax with lung sliding,
Speaker: You ask a radiologist what that is and they won't know.
Speaker: So there are new applications for ultrasound that are emerging specifically through emergency medicine and critical care, new exams that people don't even know what we're doing that are asking new questions.
Speaker: Excellent.
Speaker: So I think that I would like to also take a little bit of time, Haney, to just do a very high level, broad review of available evidence because I think that as we move forward and continue to push the adoption
Speaker: of new technology or new processes for caring of patients, people rightfully so will ask, is there any evidence that supports this?
Speaker: And I would like to start by, what is the evidence that we can train intensivists to be effective with bed of ultrasound in terms of making sure that they are identifying problems and the right problems?
Speaker: So I'm going to lump all the studies that are out there
Speaker: into one general statement.
Speaker: And they all more or less say this.
Speaker: If you take a group of people, and I say people specifically because they've even done this to medical students, nurses, pre-hospital folks, and physicians.
Speaker: You take a group of people, you put them in a class of some specified number of hours of training, and you show them normals and abnormals.
Speaker: And if it's something procedural, let them do procedures on mannequins,
Speaker: or simulators, what you'll find is that there is a rapid adoption of the skill set in a very short amount of time.
Speaker: So this could be for echocardiography, where medical students can identify normal and abnormal pathology in as little as 10 clips, just reviewing 10 clips, and get very good at estimating ejection fraction in something like 40 or 50 clips, reviewing them.
Speaker: That's powerful.
Speaker: These are medical students.
Speaker: You just have to have the ability to look at something and say that's normal, abnormal, and then quantify it.
Speaker: Talking about procedures, there are plenty of studies that show that you could take a weekend course or an eight-hour course and do a couple of 10 to 20 insertions of central venous catheters and learn how to do ultrasound-guided subclavian lines and then do it practically on patients.
Speaker: So the evidence is there.
Speaker: It's not a lot.
Speaker: The key though with all these things is you need good education paired with observed practice and then QA when you're done to make sure that you're continuing to do these things and stay on the right track.
Speaker: And I think that's important.
Speaker: I mean that there's evidence that when trained, people can learn this and people like you said, includes medical students, includes non-physicians, includes fellows, includes physicians in practice.
Speaker: But there has to be some sort of training and follow-up after that.
Speaker: And in terms of the evidence, I think that what I'm also hearing, Haini, I want your comments on this, is that being able to use ultrasound to ask simple questions is something that can be done with formal training quickly.
Speaker: But being a true ultrasound expert is something that I'm sure is much harder, which is true for many things in life.
Speaker: It's totally true.
Speaker: I'm not going to auscultate someone's heart as well as the cardiologist who's been doing it for 30 years.
Speaker: I've given up on that dream a long time ago, but I don't need to.
Speaker: I have other tools.
Speaker: I have other resources that I can use.
Speaker: And I view this as not something that distinguishes me as being someone special because I can do ultrasound.
Speaker: I look at myself becoming a better clinician by having this skill set.
Speaker: And the more I put into it,
Speaker: the more I'm going to get out of it.
Speaker: And that comes with just as basic as, you know, when you're teaching medical students, the more patients you talk to and do history and physicals on, the better off you are.
Speaker: The same is true of really anything, just as you said, playing the violin, riding a bicycle, or using ultrasound.
Speaker: Excellent.
Speaker: What about the evidence that performing a point-of-care ultrasound specifically in patients who have hypotension or shock can have an impact on patient outcomes?
Speaker: My reading is that it's a mixed bag, but I just wanted to hear what are your thoughts?
Speaker: Yeah, this is something we've had some difficulty with because building off the emergency medicine literature, which till this day is still the larger bank of research that we have, focusing on patients who are being resuscitated.
Speaker: When you look at questions of yes, no, definitely ultrasound is more helpful.
Speaker: There is a study recently done called the shocked ED study, which people would think would be the study that proves that ultrasound should be used.
Speaker: And what they did in this study was they use ultrasound assessment for patients with undifferentiated shock.
Speaker: And they compare that to clinical usual care, usual skillset.
Speaker: And what they found, what they were looking for was a mortality difference, which they did not find.
Speaker: And again,
Speaker: harping on those people that refuse to use Ultron say, aha, well, there you go.
Speaker: I don't need to learn ultrasound to change the mortality in my patients.
Speaker: Now there's problems with this study, which is by the way, the first study that has looked at this clinical question.
Speaker: Every other study has just looked at whether or not you could identify things and have assumed because you can identify, therefore the patient would do better.
Speaker: This is the first study that actually randomized patients to getting point of care ultrasound
Speaker: in undifferentiated shock and patients not getting ultrasound.
Speaker: But getting back to the point of why they didn't find a mortality difference, there's a lot of problems with this study.
Speaker: Some of the problems with this study is they excluded many people who were suspected of having certain diseases or patients who had ST elevation MIs.
Speaker: They exclude those patients.
Speaker: They pretty much excluded everyone right out of the box that there was a suspicion for something.
Speaker: They didn't even include them in the study.
Speaker: My problem with that is that I use ultrasound to help me confirm things that I already thought I knew as part of my clinical gestalt.
Speaker: So if I think the person has tamponade, you better believe I'm putting the probe on their heart.
Speaker: I'm not not putting the probe on their heart.
Speaker: And that helps me to confirm.
Speaker: That helps me to call the consultants faster.
Speaker: And I believe that helps me with a mortality benefit.
Speaker: I do have a post on this podcast I recorded with someone else, but I'll give you the link to that if people want to read a little bit more about the granularity.
Speaker: the problems with this study.
Speaker: But bottom line for me is, even if I know something is going on and the ultrasound confirms it, that's a win for me.
Speaker: That tells me I'm going in the right direction and I keep traveling that direction and I stop working up other peripheral things that could have been there, but I've confirmed that they're not there.
Speaker: And I think that another issue when we're trying to capture, let's say, diagnostic procedures and link them to an outcome, right?
Speaker: You could imagine that if I did a randomized study
Speaker: where I examine the patient versus I don't examine the patient, it might also be very hard to show that there's improvement in mortality, yet in terms of what we do as clinicians, it'd be hard to argue that examining the patient is not something we should be doing or something that we should disregard.
Speaker: And I think that when I talk with people like you, Haney, who do a lot of ultrasounds, invariably you will bring up cases where something a little bit different than what you mentioned is when you didn't think it was tamponade and actually
Speaker: it was tamponade.
Speaker: And those surprises that really change management very quickly, I think are going to be hard to capture when you're randomizing 100 to 100 patients because of the number.
Speaker: Can you comment on that a little bit?
Speaker: Yeah, there's more to a study than just mortality.
Speaker: And this is a hard thing in critical care to do, as you know.
Speaker: You know, I think what a study like this doesn't
Speaker: expound upon is that it makes it seem as though the people who are using the ultrasound didn't do a thorough physical exam and the people doing the physical exam were, were, were doing it such scrutiny that the two were awash.
Speaker: And, and I don't know that I, that I buy that, you know, one of the things, one of my mentors is, is Mike Stone, who is just a phenomenal person for anyone that knows knows of him and knows his teaching.
Speaker: But,
Speaker: It's amazing how little he used ultrasound for some very obvious cases.
Speaker: So in other words, you know, we would see a knee and during my residency with an effusion and want to tap it with ultrasound.
Speaker: And he would be like, why would you use ultrasound?
Speaker: It's a knee effusion.
Speaker: And I bring up that analogy mostly to say that you do the things that you know how to do.
Speaker: Ultrasound is not trying to get you away from doing the physical exam.
Speaker: It's not trying to get away you away from doing a thorough history.
Speaker: It just augments what you do in a way that nothing else can in 2019, 2020.
Speaker: So again, my point is that a very good history, a very, very good physical exam, and then ultrasound makes you the most ruthless physician that ever lived and managed critical care patients.
Speaker: Excellent.
Speaker: So let's get a little more tactical and maybe dive into more specifics.
Speaker: of how you would do it in a case where you have suspected shock or hypotension.
Speaker: And I think that for our audience, there are a platitude of acronyms and different formats, different protocols that can be utilized.
Speaker: I mean, there's like a goal-directed echocardiography or ACES, abdominal and cardiothoracic evaluation with sonography, RUSH, rapid ultrasound for shock and hypotension, ABCDs of recess.
Speaker: So there's really, I mean, a growing number
Speaker: of protocols.
Speaker: And I think that ultimately it's not the individual protocol that's better or worse.
Speaker: I think it's just finding something that works for you and utilizing that protocol to make sure that you're thorough and that you're systematic.
Speaker: But you can do this with practice in a very short amount of time.
Speaker: And I think that the aspect that we didn't touch on, which I think is also important, is that if you are thinking about all these potential diagnostics and thinking about checking all these different aspects of a protocol,
Speaker: it's enhancing your clinical thinking of what else are you thinking about this patient, which I think is also something that's very valuable when approaching somebody.
Speaker: So why don't we dive into what Haney does when he walks into a room and a patient is hypotensive or he's worried about shock.
Speaker: And I think that maybe we could use the rapid ultrasound for shock and hypotension, the rush protocol to walk us through that.
Speaker: Go ahead, Haney.
Speaker: So, you know, if you sift through all the literature, there are
Speaker: so many different protocols that are doing the same exact thing.
Speaker: And I got to think that every person was trying to make the best protocol to build their legacy.
Speaker: I mean, I'm not going to lie to you.
Speaker: I tried to figure out a protocol that works with Malamat, but I just couldn't get the letters to line up.
Speaker: So for that reason, I've gone with the rush protocol.
Speaker: And even then, there's two different types of rush protocols.
Speaker: What I do is, and all these protocols, by the way, they boil down to this.
Speaker: You have to evaluate the pump.
Speaker: the pipes and the tank, the pump, you're looking at the heart, you're looking at the cardiac output, the pipes, you're looking to see the big vessels and the tank is the intravascular status or the volume status of the patient.
Speaker: That's what all these protocols, the common thread between all of them.
Speaker: And as you mentioned, I like the rush exam, the one that uses the acronym HIMAP, H-I-M-A-P.
Speaker: I like it because it's structured.
Speaker: It's easy to work through.
Speaker: And it starts off with the most important component and that's the heart.
Speaker: So H is for heart.
Speaker: And what that means is that I'm taking a three to four view look at the heart, paracetral long, paracetral short, apical and sub-xiphoid view.
Speaker: And I'm looking at a variety of things in there.
Speaker: I'm looking at the size of the left ventricle.
Speaker: I'm looking at the squeeze of the left ventricle.
Speaker: Is the pump down or is it hyperdynamic implying that the heart is empty?
Speaker: I'm looking at the right ventricle.
Speaker: Is the RV big and barely moving?
Speaker: Is this an acute process?
Speaker: Is this a massive PE happening?
Speaker: I'm looking at the valves.
Speaker: I'm looking at the atria.
Speaker: I'm looking at the pericardial space to make sure there's no fluid in there, no tamponade.
Speaker: Once I've I with that H, which takes the longest, by the way, and when I say long, I mean 30 seconds to a minute long, I move on to the I. The I in some protocols is IVC.
Speaker: I use it as intravascular status because
Speaker: More and more data is coming out that shows us the IVC is not predictive of volume status as we once thought it was.
Speaker: So I use intravascular status.
Speaker: And we could talk a little bit about what that means in tail.
Speaker: But essentially, that's the question that I'm asking with the eye right there.
Speaker: And again, I use IVC, but you can also use things like passive leg raise paired with VTI.
Speaker: The M is for Morrison's pouch, which those of you who are familiar with ultrasound will tell you.
Speaker: That is the FAST exam.
Speaker: We're looking for free fluid in the abdomen.
Speaker: So M reminds me about the Morrison's pouch, reminds me to look at the FAST exam.
Speaker: And I'm looking for any blood that's in the belly and also in the thoracic space if the person has a hemothorax.
Speaker: A stands for aorta, and that is me looking for any obvious dissection or any aneurysm that could have ruptured leading to the hypotension.
Speaker: And P for me is pulmonary.
Speaker: For me, that's looking for any, again, in the pleural space, but also for any tension pneumothorax that could be there.
Speaker: It helps me if there's any pulmonary edema that might be there.
Speaker: And then also I can see whether or not the person is developing ARDS.
Speaker: So again, high map, five steps to it.
Speaker: H is for heart.
Speaker: I is for the intravascular fluid status.
Speaker: M is for Morrison's pouch.
Speaker: Just to remind me to do the FAST exam, A is looking at the aorta, and P is for pulmonary to look at the lungs and the thoracic space.
Speaker: So I think that this is a great mnemonic.
Speaker: And before we start diving into each one of these in more detail and with more specifics, on average, Haney, obviously in hands like yours, which you're very well trained and have a lot of experience, how long does this take?
Speaker: So I'm going to tell you that for me, this takes me two minutes to do.
Speaker: But that's because I practice.
Speaker: Just like LeBron, and believe me, I'm no LeBron, especially at basketball, but
Speaker: I practice and I made sure that I got my times down.
Speaker: But when I look at the fellows and the trainees and I'm teaching this to people, we're doing it in under five minutes and five minutes is not a lot of time.
Speaker: It's not a lot of time to give away to your patients who are critically ill.
Speaker: So it doesn't mean that you have to be a pro or have years of training.
Speaker: You could still do this in under five minutes, which I think is very reasonable for all the time we spend our patients bed size while they're sick.
Speaker: And in fact,
Speaker: Many of the time I'm talking to the family, getting some more history as I'm doing the ultrasound.
Speaker: So, you know, I'm being efficient with my time there.
Speaker: And this is, I think, very important because it's hard to argue that even if it was 10 minutes, right, with the breadth of information that you can get of new information, of confirmation of what you're already thinking, it's not something that is 100% worthwhile to do for our patients.
Speaker: So let's dive into the H.
Speaker: And let's take a very, very beginner's approach and start by telling me what probe you would use.
Speaker: So the probe that I use for the heart is the phased array probe, which is the rectangle square probe that's there on the cart.
Speaker: Not everyone invests in this when you buy a system, but I think it's an important probe to have.
Speaker: Many people will have the curved linear probe, which is the big fat abdominal probe.
Speaker: I would trade that probe in, if you can only choose two probes, I would trade that fat probe in for the phase array probe because a lot of things you do with the curve linear probe, you could do with that phase array probe.
Speaker: But the benefit of the phase array probe is it lets you get in between those ribs on the anterior chest and the lateral chest that that big probe can't get through.
Speaker: So you start with the phase array probe.
Speaker: And what are the four or what are the actually, what are the windows that you're going to be looking at in what order and what are you looking for in each window?
Speaker: And just to be clear, I do my whole exam with that one probe.
Speaker: I don't switch probes because again, the sicker that they are, the faster I need to do this exam and I can get all the information.
Speaker: I can get all that information using that single probe, but to your question,
Speaker: The first view that I do is the parasternal long axis view.
Speaker: And it's, it's hard on a podcast to describe what that is, but that's essentially if you take the heart and you think of it as a banana, you're sliding it down the long axis, almost like a banana split would be, because I'm a big foodie analogy type of person.
Speaker: So that's the first view.
Speaker: Again, in this view, I'm looking at the pericardial space and I'm looking at the left ventricle.
Speaker: That's the big things that I'm pulling away from that.
Speaker: Then I rotate 90 degrees.
Speaker: I go to the parasternal short axis view and keeping with the food analogy, this is taking the banana and cutting it to circular slices like you put in your cereal.
Speaker: And for this, I'm looking at the relation between the LV and the RV.
Speaker: I'm looking for how well the pump is moving, but here I get to see the intraventricular septum.
Speaker: I get to see if there's a septal flattening.
Speaker: I can see if there's any RV dilation.
Speaker: So a bunch of things I can get from that in addition to the pericardial space.
Speaker: Go ahead.
Speaker: I was gonna ask you before you go on for those two views, two quick questions in terms of, I think, mistakes that I think can occur.
Speaker: One is when you're looking at the pastoral long view and you're trying to assess for a pericardial fluid, a fat pad sometimes can be confused as pericardial fluid.
Speaker: Any comments on what are some tips that we could utilize to figure that out?
Speaker: Yeah, fat pads are tricky sometimes.
Speaker: The thing that,
Speaker: typically do to decipher whether or not something's a pericardial effusion and a fat pad is I will gain up, put the gain way up.
Speaker: And if it's a fat pad, you might see some speckling of that material.
Speaker: Whereas before it looked just like it was fluid and that speckling that's moving back and forth along with the heartbeat would suggest that that is a pericardial fat pad.
Speaker: That's not absolute, but that's one thing you could do.
Speaker: And the other thing is if you have a significant pericardial effusion,
Speaker: it should wrap around and go posteriorly behind the left ventricle.
Speaker: You know, if it's a circumferential effusion, that does not mean that you can't have a loculated effusion that's causing some problems, but we're speaking in general terms here and we just want to get people off the ground.
Speaker: And then once you get advanced, there's exceptions to all these rules.
Speaker: Excellent.
Speaker: And my second question was related to the RV size.
Speaker: Clearly, this is an important aspect of trying to evaluate either potential for acute corpulmonale associated with maybe a massive PE or corpulmonale itself.
Speaker: But if you have the wrong angle, could you overestimate that?
Speaker: In the parasternal long axis view?
Speaker: In the short axis view?
Speaker: Yeah, there's some finesse to how you angle the probe.
Speaker: You certainly want to
Speaker: every time you're doing measurements, be perpendicular to the skin.
Speaker: But listen, that's part of the learning of ultrasound is to identify other structures that would orient you as to knowing that the image you're looking at is an adequate image versus looking at the image you're over or underestimating the size of something.
Speaker: So whenever I do a course or I'm teaching folks, I stress not only to recognize abnormals and normals, but to know where the landmarks are, the things that you need to line up
Speaker: before you make any interpretation of what's on the screen.
Speaker: Okay, perfect.
Speaker: So sorry, I mean, we probably already took much more time just talking about those two items that it would take you to do the whole rush exam, but let's keep going.
Speaker: So what do you do next?
Speaker: Next I move to the apical four chamber view, which is right there under the breast.
Speaker: It's essentially where you would put a chest tube in if you were to put in an open chest tube.
Speaker: And that lines up the left ventricle and the right ventricle right next to each other
Speaker: It lines up the valves.
Speaker: There's a lot of information you get on that with respect to if there's any pericardial fusion, how the RV and the LV are working.
Speaker: Is there any septal shift?
Speaker: Is there any big RV?
Speaker: Is there any massive regurgitant lesion through the mitral tricuspid valve?
Speaker: It's a very useful view.
Speaker: However, of all four views, it is the most challenging to get on some people because the lungs are right there and for a couple different reasons.
Speaker: And that's part of the benefit of the redundancy of these four views.
Speaker: Some of the fellows get really beat up about not getting all four views.
Speaker: Look, if you get three of the views, if you get two of the views, you have enough information to move forward.
Speaker: The extra views are to make sure that you're not looking at artifact in one view and redundancy of views to confirm the things that you've seen.
Speaker: And so the fourth view is the sub-xiphoid view.
Speaker: And that's the view I think that most people come to learn
Speaker: first because it's part of the FAST exam.
Speaker: You're basically looking under the ribs, looking through the liver, and this gives you a four-chamber view of the heart, much like the apical four-chamber view, just tilt it over.
Speaker: But of all the views, that's the simplest to get.
Speaker: And I think that with the apical view, Haney, also, when you look at people doing echocardiography, routine echocardiographies, their full exams, we usually will ask the patient to lie on their side, and it's a lot easier, I mean, with position,
Speaker: which is something that we can't always do with a patient who's critically ill, hypotensive, in shock, et cetera.
Speaker: Yeah, I came in to see one of my fellows who was, this person was like satting in the 80s and hypotensive.
Speaker: And they're like, it's okay, sir, just roll on your left side here.
Speaker: And I really got to get this apical view.
Speaker: You got to sacrifice some views for patient safety.
Speaker: And that's why it's better to do the views supine when you can.
Speaker: And then if you have someone who's a little bit more stable,
Speaker: who's excavated the unit, you could roll them over to the side, but you're right.
Speaker: You have to get the views in the safest position for the patient.
Speaker: And sometimes it leads to suboptimal imaging.
Speaker: But again, the goal of all this discussion we're saying today is to get answers to the questions that you have, not to produce textbook images, not to simulate what the sonographers do, not to show the cardiologist, hey, look, I'm just as good as you.
Speaker: It's just to answer a question.
Speaker: So when I go into these exams, I have questions and I'm looking for answers.
Speaker: Absolutely.
Speaker: And in terms of four things that I think you mentioned earlier that are super important with the H part of our mnemonic, the heart, is looking at the pump itself in terms of contractility, is the heart contracting appropriately or not?
Speaker: Number two is looking at the size of the ventricle, specifically comparing the right ventricle to the left ventricle.
Speaker: Number three, as you mentioned, would be in terms of can I see anything
Speaker: related to fluid around the heart and any signs of tamponade.
Speaker: And then the other thing that a lot of times people also try to make an estimate is volume just based on what they're seeing in the ventricles, which is obviously very crude.
Speaker: Could you mention which of the views would be best for each one of these and how do you think about this?
Speaker: You know, if you had to pick one view to go to that's going to get you the most bang for your buck, and I know that wasn't the question, but
Speaker: I would go for the parasternal short axis view at the level of the papillary muscles.
Speaker: You're cutting, the beam is cutting through the mid LV and you're seeing if there's any, you're seeing if there's a problems, the systolic function, you're seeing the size of the LV.
Speaker: You're looking at the RV size.
Speaker: You're looking at how the septum's performing and you're looking at the pericardial space all in one shot.
Speaker: So that of all the views, that's the one I try to get the most if I have the choice.
Speaker: and the other views, they're just gravy if I get them answering questions.
Speaker: Excellent.
Speaker: So before we go to the I, to IVC, and looking at the volume overall assessment, one thing I wanted to ask you, Haini, if you could comment, since I have no experience with this, is that traditionally we have been taught that if you have a tamponade,
Speaker: the approach in the ICU or in the ED would be a sycfoid approach to drain that fluid.
Speaker: But when people have used ultrasounds, it seems that trying to identify where the fluid is the greatest usually leads you to the apical point.
Speaker: Can you comment on that?
Speaker: Yeah, absolutely.
Speaker: It's exactly what you said.
Speaker: Whenever you're draining fluid, you want to go where the fluid is the largest and you're going through the least amount of tissue.
Speaker: So if it's a paracentesis that you're doing,
Speaker: Hopefully not a single person who's listening to this is trying to do a fluid wave and figure out where it sounds the loudest.
Speaker: You're going to put ultrasound on and poke where there is the largest amount of fluid, the least amount of bowel in the way.
Speaker: And if you're really savvy, looking to make sure there's no blood vessels that are running right across where you stick in the needle.
Speaker: And the same thing is true of pericardial fluid.
Speaker: So to me, if I have ultrasound and I see a circumferential effusion, it does not make much sense for me to go through the abdomen,
Speaker: through the liver and then try to hit the pericardial space.
Speaker: I'd much rather go for the apical four chamber view and get through that space.
Speaker: Cause the, when you do it, it's only a couple centimeters below the skin is where you need to puncture.
Speaker: There are some people that do the parasternal long and short axis views.
Speaker: I will say that there is the LAD that crosses over the LV over there.
Speaker: There's the, there's the internal mabillary artery.
Speaker: That is something that concerns me, but
Speaker: If the fluid is the greatest and the apical window is out, that's where I would go to next.
Speaker: Excellent.
Speaker: So let's go into the next step.
Speaker: So you've done this.
Speaker: And like you said, this does not take you a lot of time.
Speaker: You made an assessment of those items with the heart.
Speaker: And now you're looking at the IVC or looking at kind of the intravascular volume.
Speaker: Tell us how you approach this and what do you do next?
Speaker: Yeah, the IVC.
Speaker: Every single year, I use it less and less and less.
Speaker: And the evidence behind it for the spontaneously breathing person is helpful, if at all, at the very, very extremes.
Speaker: So if I have somebody who's spontaneously breathing and their IVC is paper thin, like I can hardly see it there when I'm looking at it, it suggests that the right atrial pressures are low, which suggests that they might be volume down.
Speaker: That's the only thing I can get from it.
Speaker: And then if it's really big and plump,
Speaker: The only thing it tells me is that their right atrial pressures are high.
Speaker: And at best, it means that volume might be the wrong thing for them.
Speaker: But there's lots of exceptions in there.
Speaker: So IVC is not a helpful tool for me in the non-intubated patient.
Speaker: In the intubated patient, it's a little bit more helpful for me.
Speaker: There is more data for it.
Speaker: Looking at something called distensibility index, which is essentially looking through the respiratory cycle to see how much the IVC is dilating.
Speaker: then coming back to its normal size.
Speaker: But just like the, just like the stroke volume variation or pulse pressure variation, there's limitations to using the sensibility index, meaning the person has to be in sinus rhythm.
Speaker: They can only be on a, a moderate amount of people, which is never defined in the studies.
Speaker: They can have no RV dysfunction.
Speaker: They cannot be spontaneously breathing above the vent.
Speaker: These are all things that I can't find a patient who meets all these criteria.
Speaker: But if you find someone that meets all these criteria, you can use the sensibility index in a mechanically ventilated person in order to determine what their volume status is.
Speaker: And then I think that really, I mean, the question of volume status ultimately is a question of do I need to give fluid or if I give fluid, will I produce benefit versus harm, right?
Speaker: And we talk about fluid responsiveness, which is a physiologic measurement, but you could be fluid responsive
Speaker: and not need fluid, right?
Speaker: So I mean, I think that that's been the dilemma.
Speaker: And the truth is that as much as people have pushed different narratives, different technologies, this is a problem that we have not solved.
Speaker: And that people do different things.
Speaker: I think what you were mentioning to with the IVC is that as we have more and more studies that show where it works and doesn't work, what has occurred, I think, at the bedside is that people extrapolate more and more
Speaker: from those studies and maybe had applied it to patients who are not really the patients that were studied.
Speaker: So we don't really know what it means at the end.
Speaker: Yeah.
Speaker: I mean, at the end of the day, in my simplest form of volume assessment, if I look at the heart and the RV and the LV are both empty and the IVC is paper thin and the person's hypotensive, yes, I'm going to go ahead and give them fluids.
Speaker: Once we start getting above that threshold where the IVC is mid-range, the RV and the LV are normal looking size and the person's still hypotensive, then I need to do some advanced maneuvers, which we don't have to necessarily get on the podcast, but we can do things like a passive leg raise or a fluid bolus match to assessing the velocity time integral or the VTI, which is a very good way of measuring how well a change in fluid styles is done to increase the cardiac output.
Speaker: But the problem is
Speaker: is that that's a maneuver that needs a bit more training.
Speaker: And I don't want to push people away from ultrasound by saying, well, if the only way to assess volume response is do this as a bad technique, I'm out of ultrasound.
Speaker: For the intravascular status, it's more of a gestalt.
Speaker: And luckily, I think this is the golden fleece of critical care is the person who's volume responsive.
Speaker: It does seem to be, at least with sepsis, that the literature is moving more and more towards volume sparing anyway, with more and more trials showing
Speaker: give less and less volume and vasopressors early.
Speaker: So maybe this question will be completely extinct in the next five to 10 years.
Speaker: Who knows?
Speaker: And I think that we can definitely talk a little bit more about it a bit later when we talk about how we follow up on patients who were treating for shock.
Speaker: But in this initial phase, really, you're not really, you're just trying to answer quick questions and you don't do like a VTIs and passive leg raising as part of this Rush protocol anyways, right?
Speaker: No, absolutely not.
Speaker: I mean, look, by the time I see the patient, the emergency room has already given 30 cc's per kg, which many people fully believe to be enough volume anyway.
Speaker: And if the person's in hemorrhagic shock, I don't need an ultrasound to help me out to resuscitate that person.
Speaker: So, yeah, it's just this is just an overall gestalt to help me to identify what type of shock this person is in.
Speaker: And before we move on, just, I mean, in terms of like the very basics,
Speaker: You do the, usually you do the subcyphoid view and then you go to the IVC.
Speaker: Where are you looking for the IVC and what do you do to find it?
Speaker: Just for the IVC, essentially I'm looking at the subcyphoid four chamber first and then I rotate while looking at it.
Speaker: What I try to do is I try to put the right atrium right in the center of the screen as I'm doing my rotation because that's what the IVC is going to dump right into.
Speaker: So if I keep my eye on the right atrium, you'll see the IVC as you're rotating come right in.
Speaker: That's a trick that I personally use and that's something I teach everyone that I show how to use ultrasound.
Speaker: Excellent.
Speaker: So as we go down our mnemonic, now you're looking at M and that's Morrison's pouch or the fast exam.
Speaker: And you mentioned earlier that you keep the same probe.
Speaker: So you're still using the same probe for this part, right?
Speaker: Absolutely.
Speaker: Part of the success or win with ultrasound
Speaker: is not going to switch between probes and say, oh, now I need a new probe.
Speaker: If you could do this all with one probe, you're saving time.
Speaker: You could resuscitate your patients a lot more efficiently.
Speaker: So yeah, I stick with this probe.
Speaker: True ultrasound enthusiasts will say to truly get a great fast exam view, you need to use the curvilinear probe, but most people will tell you, you can get all the information you need with the phased array.
Speaker: So I'm sticking with the phased array probe.
Speaker: My first move is to go to the right upper quadrant.
Speaker: and that's looking at the hepatorenal space.
Speaker: That's looking to see if there's a free fluid in the abdomen.
Speaker: The next place you're looking is the left upper quadrant, which is the splenorenal view.
Speaker: And then the last place is right at the bladder to see if there's a free fluid down there.
Speaker: Typically, the FASC exam view includes the subcyphoid view, but since we're coming off the subcyphoid view of the heart and the IVC, we don't have to duplicate that again.
Speaker: So it's really three views we're looking at here.
Speaker: And
Speaker: The next thing that I typically do for trauma patients is I'm looking at the thoracic spaces to make sure that there's no free fluid in there for any hemothorax that could be a cause of the shock.
Speaker: I typically put it in this part of my exam.
Speaker: Other people I know put it in the P or the pulmonary part of their exam.
Speaker: It doesn't really matter.
Speaker: It just has to make sense to you, and you have to do the protocol the same way every single time.
Speaker: Once you do this part, what do you go to next, Haney?
Speaker: Sorry, can you start that part over and just cut out?
Speaker: Once you finish the M, you start looking at the aorta, you said.
Speaker: How do you evaluate the aorta and what are you looking for?
Speaker: It's a really quick look at the aorta.
Speaker: All I want to know is whether or not this person is having any aneurysm, which would suggest that the person is having a ruptured AAA, or I'm looking to see if there's any dissection.
Speaker: So I'm taking that probe.
Speaker: And here's where I might switch to the curve linear because it works a little bit better here, but I still will start with the face array.
Speaker: Take a quick look at the aorta.
Speaker: If I don't see any dilation or any dissection, I'm done because it's just a screening test for me.
Speaker: And if I'm really worried about them, they're going for a CT scan anyway.
Speaker: And what is other, can you tell me where you look at the aorta?
Speaker: I know that some people usually do like four points very quickly, but I mean, just tell me what your usual practice is.
Speaker: I'll start.
Speaker: basically at the subxiphoid in cross-section, and I'll just slide it down the abdomen all the way down to the belly button.
Speaker: That's going to get me right to the bifurcation.
Speaker: And that's, again, it's really a gross bird's eye view just to make sure that there's nothing abnormal there and the aorta is not the problem.
Speaker: I suspect unless the person has a retroperitoneal bleed with the aorta, which is the typical place they will bleed, if the FAST exam is positive with blood in the abdomen and their aorta is big,
Speaker: I'm sort of zooming down and thinking that's where their problem is.
Speaker: And when you say big, can you give me a number?
Speaker: Sure.
Speaker: We're looking at things that are five or six centimeters big.
Speaker: And in terms of dissection, is that something that you think we can identify?
Speaker: So clearly, I would imagine that the specificity is high, but that with this bedside ultrasound very quickly, it's something that could be missed, right?
Speaker: Yeah, it's definitely the weakest of everything that I look at.
Speaker: And if we're talking about dissection, the ones that really kill people and cause them hypotension are the ascending ones, things that are closer to the heart.
Speaker: The distal ones don't really cause the level of shock that we'd be looking for here.
Speaker: So yeah, it's specific.
Speaker: It's definitely not sensitive.
Speaker: But like I said, if they're stable, I'm going to get them imaged if I think at the areas at play.
Speaker: I'm just looking for the person that's unstable.
Speaker: And I can't figure out why.
Speaker: And if we're talking about an ascending dissection, that's something we'd probably see on the parasternal long axis view would see a widened aortic valve or, or, or, uh, uh, what do you call it?
Speaker: A, uh, we'll cut this out.
Speaker: Well, you would also go ahead.
Speaker: I was saying we're, we're looking for, uh, a widening of the AV valve.
Speaker: I'm sorry, we're looking for a widening of the aortic valve or any new regurgitation or aortic insufficiency that would suggest that the person's having dissection, as well as any tamponade that might be at play.
Speaker: Those things together suggest an ascending dissection.
Speaker: Exactly.
Speaker: And I think that I was saying, I mean, if somebody's unstable from a dissection, usually, I mean, you would see the consequences of that, like you mentioned.
Speaker: And ultimately, if somebody has a dissection, they're going to need a CTA no matter what to try to figure out, right, or T to try to figure out do they need surgery or not.
Speaker: And that is something that you can accelerate.
Speaker: And like you mentioned, a five minute exam is not going to delay them getting that CTA in any way.
Speaker: It just might accelerate it.
Speaker: So I think it makes sense.
Speaker: And with the aneurysms, I guess what you're really thinking about in a stable patient is a ruptured aneurysm.
Speaker: And then you would see that a large one with blood in one of the pouches, right?
Speaker: If it happens to rupture intraperitoneally, unfortunately,
Speaker: some of these will rupture retroperitoneally and ultrasound is not so great for that.
Speaker: So it doesn't take ruptured aneurysm off the table if they have a large aorta, but they don't have any free fluid in the abdomen.
Speaker: But if they have a large aorta and fluid in the abdomen, I've called vascular surgery, taking people right to the OR just based on an ultrasound with that.
Speaker: Okay, perfect.
Speaker: So, and the last portion is the P, which is pneumothorax and some mnemonics, but you just say, I mean, pulmonary.
Speaker: Before we go into the P, do you look at veins?
Speaker: Is that part of your rush exam or is that something that you find less useful?
Speaker: No, it's definitely helpful.
Speaker: And part of the pulmonary assessment is if I think the person has a PE as part of their clinical, their RV is big.
Speaker: My next move is to go down and look at the lower extremity veins, look at the common femoral, make sure there's no blood clot there.
Speaker: So I add that in if my gestalt is high, otherwise I'm not going to look for veins as part of the protocol.
Speaker: Do you know what I mean?
Speaker: Yeah.
Speaker: Fair enough.
Speaker: So why don't you tell us about the P how do you look at how, what do you do next?
Speaker: So you've done the aorta and now you move to the lungs or to the pulmonary aspect.
Speaker: Yeah.
Speaker: First move is to look, to make sure there's no lung sliding.
Speaker: If I don't see lung sliding and the person's hypotensive tension pneumothorax is high on my list.
Speaker: So I'll look for lung sliding.
Speaker: Um,
Speaker: That's when the patient breathes.
Speaker: You'll see there's some movement of the visceral pariopleura.
Speaker: It's a very distinct looking thing on your ultrasound.
Speaker: If the person is mechanically ventilated, you're going to have your therapist bag for you whenever the person takes the breath.
Speaker: This is something I take them off the ventilator for because I need to bag and look at the same time rather than wait for the machine to cycle a breath.
Speaker: But that's a subtle point.
Speaker: As I'm looking at lung sliding, I'm also looking to see if the person has any evidence of a pneumonia.
Speaker: I'm looking to see if there's any B lines or interstitial fluid there in the lungs.
Speaker: And as I move down the lungs and I'm doing my assessment, I'm just gonna wait for this noise to stop here.
Speaker: Sorry, they're like outside the door.
Speaker: No, for how long?
Speaker: No, they're done.
Speaker: They're gone.
Speaker: Sorry.
Speaker: So,
Speaker: Then as I move down from the lungs, I move to the thoracic spaces.
Speaker: This is where I'm looking for any effusions, which are very distinct looking things on ultrasound.
Speaker: And for me, if a person's hypotensive, they have a diffusion, it's one of two things.
Speaker: The person either has blood or it's pus in the chest.
Speaker: Blood has a distinctive look to it.
Speaker: It kind of looks like a snow globe, if you will.
Speaker: It looks like things are just kind of showering down in the chest.
Speaker: And
Speaker: pus in the chest or an empyema has a very loculated type look to it.
Speaker: These are things that actually when you look at with ultrasound, people point them out like, is that an empyema?
Speaker: Because intuitively, you think that's how it would look and ultrasound just matches what you would see.
Speaker: But those are the things I'm looking for as I'm evaluating the P for lung, for pulmonary.
Speaker: Excellent.
Speaker: And I think that two questions I have, I mean, that I think are important relate to patients who are intubated.
Speaker: And this might be beyond the rush exam or following your initial assessment of somebody.
Speaker: But there's two things that I think are important to mention.
Speaker: One, and I wanted to hear how you do this, is you can very quickly identify somebody who has an esophageal intubation with ultrasound, correct?
Speaker: Absolutely.
Speaker: Yeah.
Speaker: So essentially, I like to do this live as the person's being intubated.
Speaker: This is where you take the linear probe.
Speaker: you put on the left side of the neck and you can look at the trachea and the esophagus in the same cross section.
Speaker: And if you see the tube going through the esophagus, there's no need to connect it to the waveform analysis or to end tidal CO2 and say, hey, let's confirm, take that tube out.
Speaker: It's in the wrong place.
Speaker: And you can reposition it and see it going through the trachea where it appropriately should be.
Speaker: If somebody came intubated to you and
Speaker: you're suspecting that the tube is in the wrong place.
Speaker: How could you figure that out with ultrasound?
Speaker: You're not watching it live.
Speaker: Yeah, so my first thing, so they're already coming in intubated.
Speaker: My first move is always waveform capnography.
Speaker: I still think that is the best way of confirming tube placement.
Speaker: But if I'm having trouble getting the device in the room or there's some malfunction, you would take the ultrasound again in cross-section and you'd look to see where that tube is.
Speaker: The good news is,
Speaker: unless someone was really forcefully it's being this person, it's only going to be in the esophagus or the trachea.
Speaker: And if the esophagus is contracted down at normal size, by definition, it should be in the trachea.
Speaker: There's some people that have protocols.
Speaker: They look for something called the double ring sign.
Speaker: I find these are good in a study type situations, but when a patient's sick, not doing well, busting through the doors with the MS, I look for the simplest,
Speaker: the simplest method of getting the images without any confounders.
Speaker: And for me, looking at the esophagus and the trachea in the same plane and looking for a contracted esophagus is the way I do that.
Speaker: Perfect.
Speaker: And my second question related to lung sliding in a patient who has a right mainstay and intubation, is that something that could maybe tip off somebody and maybe we're looking at something we think is a pneumothorax, but it really isn't?
Speaker: Such a good question because this comes up a lot for people who have gotten the initial course down.
Speaker: They feel really good about ultrasound and then they get one of these cases and they, and they don't know what it is.
Speaker: So when you have somebody who you made stem, that means you're going to be ventilating the right lung.
Speaker: The right lung should have lung sliding.
Speaker: The left lung is not being ventilated, but it doesn't, it looks on initial look to be a pneumothorax.
Speaker: But if you look very carefully, you'll notice that the, there is lung sliding that's happening periodically and it's happening because underneath the heart is beating.
Speaker: As the heart is beating, it's actually pushing the visceral and the pirata pleura, the thing that's making that lung sliding, it makes it move a little bit.
Speaker: And so if you look very carefully, you can actually see what's called lung pulse, which is the heart pushing the non-ventilated lung underneath.
Speaker: And you see these little beats happening intermittently.
Speaker: It is, I would call it like lung ultrasound 2.0.
Speaker: It's not difficult, but someone specifically has to show you how to look for that.
Speaker: But
Speaker: I have seen people call pneumothoraces on people just because they've been main stem because they don't know how to look for that side.
Speaker: Excellent.
Speaker: So I think that we took a lot longer than it would take to do the exam.
Speaker: But clearly, in terms of your initial assessment, it's something that you do routinely, Haney, and you follow the high map mnemonic, which is heart, IVC or intravascular volume, and Morrison's pouch or fast, aorta, and pulmonary slash pneumothorax.
Speaker: So this is very useful in your first assessment or diagnosis.
Speaker: It maybe helps you think about the patient and what type of shock they have.
Speaker: Is this cardiogenic?
Speaker: Is this more distributive shock?
Speaker: Is this hypovolemic?
Speaker: And start your initial diagnostic and therapeutic interventions.
Speaker: Let me ask you a little bit about how do you follow up with ultrasound maybe eight hours later, 12 hours later, maybe even day two, somebody who's on vasopressors,
Speaker: or somebody who you're still debating what to do.
Speaker: Now they're intubated, they're in the ICU.
Speaker: How does point of care ultrasound factor into your management of these patients?
Speaker: Well, there's a lot of ways, a lot of questions that we have after the person has been resuscitated.
Speaker: So for example, you might look at the person whose urine output has dropped and you're like, well, do they need more volume?
Speaker: And like the intern move is always give a liter of fluids and then call me back because it's the middle of the night.
Speaker: me i find it helpful for that person who's already gotten more than 30 cc's per kg to go look at the heart again and make sure there's no secondary issues make sure there's no systolic dysfunction to make sure that the person is euvolemic and then i'll typically i'll look at the bladder i'll look at the kidneys bladder scans are are challenging they give false positives they give false negatives because the bladder scanner is doing ultrasound but it's doing its own computation
Speaker: I go with the ultrasound, I actually visualize the bladder.
Speaker: I actually take my own measurements.
Speaker: So if the person is having an obstructed Foley, which happens more so now because I'm looking with ultrasound than before, I'll notice that their bladder is distended and will flush the Foley.
Speaker: And then lo and behold, we get flow back.
Speaker: If I see that their bladder is distended and they're getting hydronephrosis, then their bladder is really congested.
Speaker: And on the other hand, if their bladder is empty,
Speaker: and the volume is at year and output is down, then I really have to scrutinize as to whether or not this person needs more volume or just do they need some mean arterial pressure.
Speaker: And that's where I start to do things like the passive leg raise and those advanced computations.
Speaker: But my ultrasound that I'm doing for the person who's already been resuscitated is, is very limited.
Speaker: The really interesting thing is the person who I'm de-resuscitating.
Speaker: So now the person who's getting better, who thinks are starting to get, um,
Speaker: reverse, we're talking about extubating people.
Speaker: This is where I tend to use the ultrasound again, a lot more.
Speaker: So it's sort of bimodal first when I meet them.
Speaker: And then when I'm starting to de-resuscitate them and I'll just shoot out a couple of things that I look for.
Speaker: You know, if a person is volume overloaded and we're trying to figure out, should we diuresize them or not?
Speaker: You can look at the lungs and look for B lines, which suggests that the person is volume overloaded.
Speaker: A person with a lot of B lines, they're going to get some diuresis.
Speaker: I look at thoracic spaces.
Speaker: Did they third space and create pleural effusions?
Speaker: And that's why they failed the spontaneous breathing trial.
Speaker: Well, let's go ahead and drain those effusions.
Speaker: There's even something new that is so amazing that I think is actually going to stimulate people to learn ultrasound, and that's portal vein pulsatility.
Speaker: And portal vein pulsatility, just to be super brief about it, this is the golden fleece to tell us whether or not our patients need to be diureased or not.
Speaker: You're actually looking at the portal vein to determine
Speaker: whether or not that person is euvolemic or hypervolemic.
Speaker: And the data from this stuff is just really, really amazing.
Speaker: So where did you look for that?
Speaker: Can you give me just like which probe and which window do you use?
Speaker: Yeah, so you're going to, there's a couple of different ways to do it, but you're looking for the portal vein lying within the liver.
Speaker: So I'll stay with the phased array probe and you want to get the portal vein in long axis and you're going to put Doppler flow on there.
Speaker: Again, it's very, very hard on a podcast to walk you through it,
Speaker: But that's just the bottom line.
Speaker: But you don't need any special tools.
Speaker: And the best part is that it is super easy to do.
Speaker: Excellent.
Speaker: And I think that you touched on something very, very critical, which I think is also another paradigm shift that has really occurred over the last decade.
Speaker: And for many years, we were really centered on the perspective.
Speaker: initial phase of shock treatment and really on the loading phase and giving people volume and when to give more volume and how much volume to give.
Speaker: I think that more and more data now suggests that there's, I mean, different phases and that at one point, really, we probably do not serve our patients well if we're not taking that fluid away from them.
Speaker: And this whole idea of active de-resuscitation is something that is gaining a lot of a
Speaker: of interest and data that suggests that it really improves outcomes.
Speaker: And to that extent, I think that what you just said, Haney, is really just the other side of the coin.
Speaker: You can use a dynamic parameter such as VTI changes in cardiac output with passive leg raising to determine if somebody is fluid responsive, but you could also use it to identify when to stop diuresing.
Speaker: If you are diuresing somebody and they have no variation with leg raising,
Speaker: it probably means that they're still volume overloaded, right?
Speaker: So you're looking the opposite.
Speaker: And I think that the other thing that you mentioned was the presence of B lines.
Speaker: And I wanted to look into that a little bit because it also is very useful on the way up, right?
Speaker: As you're giving fluids, if you see an increasing number of B lines, maybe you've got to a point where more fluid is not going to benefit the patient, but just harm them.
Speaker: But also it could be something that once the patient's stable, you can use to kind of guide or
Speaker: force you to start diuresis.
Speaker: Any other comments on that?
Speaker: No, that was perfect.
Speaker: There are protocols by Daniel Lichtenstein, who is the godfather of lung ultrasound.
Speaker: We're actually using B-Line, the presence of B-Line to tell you to stop giving fluids because now your hydrostatic pressure is too high.
Speaker: So that literature is definitely out there.
Speaker: But yeah, I'm using ultrasound more and more to de-resuscitate patients because as you said,
Speaker: it's we sort of high five and we say, Hey, the patient's great, but then we can't get them extubated.
Speaker: We can't get them out of the unit.
Speaker: They're going to renal failure.
Speaker: They're getting delirium.
Speaker: All of this has been tied into volume overload and a really interesting study, not to belabor this, but is looking at the presence of that portal vein pulsatility, which again is a really, really good marker of being volume overloaded.
Speaker: They're actually using that to as a marker of delirium.
Speaker: So patients, cardiac surgery patients,
Speaker: in this one study who were, had a higher port of lane pulsatility, suggesting that their volume overload had higher rates of ICU associated delirium than patients who were diuresed early.
Speaker: And again, this all just comes back to congestions of end organs.
Speaker: And if we can get our patients de-resuscitated faster, we think that we get patients with a, out of the unit faster with lower morbidity and lower mortality.
Speaker: So just to clarify, and I'll put a link to the portal vein pulsatility, the increase in pulsatility is associated with an increase in intravascular volume.
Speaker: Is that the idea?
Speaker: That's correct.
Speaker: It's showing you that there's more venous congestion, and we diures our patients down until there's no portal vein pulsatility, and that's a good place to be.
Speaker: And I'm not surprised with the finding of delirium.
Speaker: I have experienced empirically that
Speaker: patients post shock and ARDS who are several leaders volume up, who are not waking up, who you start diuresing.
Speaker: And lo and behold, I mean, eventually everything starts getting better, including their mental status.
Speaker: And it probably relates to it, like you said, I mean, is that there's edema everywhere, including the brain, right?
Speaker: And as you really change that curve, it impacts the function of all organs.
Speaker: Absolutely.
Speaker: Yeah.
Speaker: And the kidneys are, you know, that's the biggest irony is, again, the intern getting the call.
Speaker: for decreased urine output, give a liter of fluids.
Speaker: You know, we're looking at this here at Cooper, where maybe those are the people who need a portal vein pulsatility.
Speaker: And the reason why they're not making urine is because there's so much venous congestion that they're not able to get enough arterial flow into the capsule.
Speaker: So these are interesting times.
Speaker: Absolutely.
Speaker: So let me ask you a more practical aspect of practicing with ultrasound
Speaker: What do you document in the chart?
Speaker: How do you handle your documentation?
Speaker: And also I would like to ask you from a billing perspective, how do you think about bedside ultrasound?
Speaker: Yeah, so this is, I'm gonna give you the two ways of looking at this because we're, Art Cooper, a guy by the name of Sherrod Patel is coming here and really transformed the way we do ultrasounds.
Speaker: We set up an online cloud service where the images go right to the cloud
Speaker: They can always be accessed.
Speaker: We are reading our fellows and our own ultrasound exams, and then we're subsequently billing for it.
Speaker: That is the Cadillac, if you will, if Cadillac is your favorite car.
Speaker: That is the Cadillac of how to do ultrasound.
Speaker: Now you're doing ultrasound, you're showing documentation, and you're billing for it.
Speaker: You're doing all the right things.
Speaker: Now you might be in a place where you're not at that level, but you still want to do ultrasound.
Speaker: Now, what I would say is that
Speaker: If you can work on getting a billing program in place, that's going to help you to buy all the fancy equipment.
Speaker: It's going to help to fund your program.
Speaker: So that's ultimately what you want to do.
Speaker: But a lack of that should not let you not do ultrasound.
Speaker: I would not let someone say to you, you can't do ultrasound because you can't take clips and therefore there's no way to prove what you found because no one's following me around with a video camera, watching me do my physical exams.
Speaker: And I see it being no different.
Speaker: If you go through the proper training, if you're credentialed by your hospital, if someone who knows what they're talking about in your hospital says you know how to do ultrasound and you should be able to do ultrasound, at the minimum, I truly believe that should be taken at face value.
Speaker: And going with the physical exam analogy, if someone said that you're good enough to do a physical exam and someone else is saying you're good enough to do it with ultrasound, why should that be any different?
Speaker: Why do I need to...
Speaker: show you every single clip that I got.
Speaker: It slows me down and subsequently what it does is it stops me from doing ultrasound because I'll get so frustrated.
Speaker: I'll say it's not worth the extra time to do this life-saving maneuver.
Speaker: Do you have a specific maybe documentation or reporting note that you use when you do a rush exam?
Speaker: Yeah, in our EMR, we have a template and we wrote the template to have just pull-down menus.
Speaker: So at the minimum, they're yes, no questions.
Speaker: But if you wanted to free text in some stuff that you thought was important, or you feel comfortable reading it at that granularity, then you could do it as well.
Speaker: But I want people to be able to do the exam and say, was there pericural effusion?
Speaker: Yes or no.
Speaker: Was the LV working?
Speaker: Yes or no.
Speaker: Was the RV big?
Speaker: Yes or no.
Speaker: And then if I'm seeing that patient subsequently,
Speaker: I know they at least did that.
Speaker: And what I'm looking at now is either a change or the person's still at that baseline when I'm doing my own ultrasound.
Speaker: Makes sense.
Speaker: So I think that the other question that I wanted to dive in really quickly, and you did talk about this a little bit, Haney, but we did mention that now there's a divide between people who have experienced ultrasound as part of their formal training during fellowship residency.
Speaker: And there's a lot of people like myself who are in practice
Speaker: who this was not part of their original training.
Speaker: So in terms of teaching old dogs like myself new tricks, what do you think is the best approach to learning?
Speaker: What do you recommend?
Speaker: Some of the pearls that you could give us.
Speaker: The first thing I would say is do not think of ultrasound as this grandiose thing where in reality you need to take time off and take two years off to do another fellowship to do it.
Speaker: It is just not that.
Speaker: And
Speaker: I see a lot of people who are very well established refusing to go and do a weekend ultrasound course, which will give you everything that you need, but very much going to a pre-conference course on doing some other procedure and, or, or going to a conference to do some CME that they already know the answers to the questions anyway.
Speaker: So what I would say is to pick a course and then go to the course.
Speaker: And then what you need to do is when you get back to your institution,
Speaker: You have to find somebody who's going to mentor you on how to do this.
Speaker: Because if you go to the course, come back and don't do it, the skills are gone.
Speaker: They're just as well gone.
Speaker: You have to come back and do it every single day on your patients and make it bite-sized.
Speaker: You know, don't try and do the entire exam on every patient that you're rounding on.
Speaker: What I tell every novice to ultrasound, whether they're a medical student or a senior faculty is pick one exam to do.
Speaker: on every patient per day.
Speaker: So if it's lung sliding and you round on a unit with 15 to 20 patients, do lung sliding on every single patient that day.
Speaker: And guess what?
Speaker: You've just done 20 exams.
Speaker: And the next day you'll look at just the parasternal long axis view, not even the tire four view that we talked about.
Speaker: Just pick one view and get through it on every single patient.
Speaker: You're gonna build up practice.
Speaker: You're gonna find pathology along the way.
Speaker: But most importantly, what you're gonna show
Speaker: is that you can do ultrasound on your own, but you just got to make it, sorry, you just have to make it in such a way that it is approachable and it's not a huge mountain in front of you.
Speaker: Are there any resources that you could recommend or any particular courses that you think would be highly recommended?
Speaker: There's a bunch of courses, including courses which I personally run myself.
Speaker: I would say that any one of the societies, they run courses.
Speaker: So if you're a member of CHESS, then go to the CHESS course.
Speaker: If you're a member of Society of Critical Care Medicine, go to their course.
Speaker: The course that I do, and this is going to sound like a shameless plug, but it's really not.
Speaker: Whatever course you pick, I would just recommend that you pick a course that optimizes the amount of hands-on time that you have.
Speaker: There are plenty of courses that will sit you in a room and
Speaker: have hours and hours of didactic lectures, and then give you an hour or two scanning patients.
Speaker: The teaching should be flipped exactly the opposite way.
Speaker: I truly believe when you go to a course, you should get little micro lectures and then get scanning on patients because you could always read later.
Speaker: A course like mine, we give you videos to go home with.
Speaker: You'll get the videos and the education later.
Speaker: I want you to be able to get to the patient, start scanning because that's the thing that you don't have access to when you go back home.
Speaker: So whatever course you pick, pick a course that
Speaker: optimizes the amount of times you have scanning those models.
Speaker: That sounds like a book, right?
Speaker: The best book is the one you read.
Speaker: The best course is the one you go to.
Speaker: But focus on courses that have a lot of hands-on time.
Speaker: And then what you really highlighted, Hayden, which I think is important, is the follow-up.
Speaker: Once you've done the course, how do you proceed from there in terms of practicing, practicing, practicing, and having the right mentorship?
Speaker: It's really hard.
Speaker: And I'm sensitive to the fact that there are places that just don't have access.
Speaker: to experts in ultrasound or point of care ultrasound in their shop.
Speaker: But what I would say is stop by the emergency department.
Speaker: They likely have somebody who is fast on ultrasound.
Speaker: If not, go to the cardiologist, talk to the sonographers.
Speaker: They will take you around.
Speaker: They love the attention and they love to teach.
Speaker: That's who taught me how to do echo was the sonographer.
Speaker: So you can find places in the hospital to teach you what to do, but just do your scans with people.
Speaker: And we're not talking about months and months of mentorship.
Speaker: We're just talking about a couple of days to get your feet off the ground.
Speaker: And then after that, just checking in every once in a while and say, hey, listen, I couldn't get this image.
Speaker: What tips would you give me?
Speaker: And they'll get you through it.
Speaker: Absolutely.
Speaker: And I think that one of the things that's really interesting, I mean, and I think very exciting these days is that like every technology, the availability of ultrasound machines is really, I mean, on such a steep curve that it seems to be a different world now than it was 10 years ago.
Speaker: So quick question, I mean, Haney, it seems that for the first time people can actually access ultrasound technology for a very reasonable price.
Speaker: And now you have all these pocket ultrasounds available.
Speaker: Could you comment on your experience with them just in general terms and what your thoughts are?
Speaker: Yeah, the bottom line is that they're all pretty good.
Speaker: I mean, the technology a few years ago was not really good enough for me to invest some money into it.
Speaker: But now,
Speaker: across all the major brands and I'll try to avoid using brands, uh, cause I don't get paid by anybody.
Speaker: But what I will say is that they're all very, very good.
Speaker: And what I would say is that those pocket devices are the devices I take with me to go evaluate rapid responses or codes on the floor.
Speaker: And they get to it 90% of the time.
Speaker: And if I really need something else, someone can go get these still very portable machines, these laptop machines from the ICU over.
Speaker: And those machines will fill in those gaps, but you have machines now that can plug into your iPhone that fit in your pocket.
Speaker: You have machine probes that could plug into your Android devices again, that fit in your pocket.
Speaker: And then you have handheld devices that come with the screen already built in, but are very lightweight and very, very portable.
Speaker: Their boot up times are instantaneous.
Speaker: And the quality of the images is just, it's just really amazing.
Speaker: And most of these offer cloud solution storage is
Speaker: So after you do the clips, they go right to a cloud.
Speaker: And if you're in a place that people worry about who's going to oversee your images, well, now you have your images in the cloud for anyone to take a look at.
Speaker: That's really cool.
Speaker: So you've been on the podcast before.
Speaker: I think this was a great conversation, Haney, and we'll have a lot of references and resources in the show notes.
Speaker: But I would like to close with asking you some questions that really do not relate necessarily to ultrasound, but just tapping into the
Speaker: your wisdom and you as an individual, would that be okay?
Speaker: Absolutely.
Speaker: I love this part.
Speaker: So last time we talked about books.
Speaker: At this time, I want to talk about music.
Speaker: If you were stranded, maybe in a desert ICU, and can only take one album, and that speaks, I mean, to how old I am of music and listen to it all the time, which one would it be?
Speaker: I love music so much.
Speaker: This is a really, really hard one.
Speaker: I'm going to say if there's one album that I could listen to only for the rest of the time on the desert island, I'm going to say it's Joshua Tree by U2.
Speaker: But that doesn't mean that there's not 10 more I could give you.
Speaker: No, and I think that's a great choice.
Speaker: And for those millennials who might not know about the Joshua Tree, we'll definitely give them a link and they can check out the videos, right?
Speaker: And I think that's very powerful.
Speaker: That's a great choice.
Speaker: I mean, definitely, I have to say a seminal...
Speaker: a seminal album in my growing up in high school and truly, I mean, a beautiful, beautiful one.
Speaker: So we'll definitely link that.
Speaker: The second question relates to failure.
Speaker: And I think that we're often very fearful of failure, but ultimately I believe that failure should be embraced since it's often the best teacher.
Speaker: Could you share with us a really good failure, one that really taught you something valuable?
Speaker: I've been thinking about this a lot recently because I'm just really into education and I'm trying to scale things up with what I do.
Speaker: I truly believe that now that I'm in my 40s, one of the things that's so important I try to tell people around me is you gotta find something that you love to do every day and just do it as hard as you can.
Speaker: So one of my things is education.
Speaker: I love teaching and I love innovative teaching.
Speaker: A couple of years ago, I ran a little course
Speaker: that I thought would be a really neat resuscitation course.
Speaker: And I got speakers who I knew and I, you know, I, there was just, let's just say there was a little trouble in the execution of the course.
Speaker: And I didn't, I think I got like six people to come to this course, which I invested a lot of money into and everything was wrong.
Speaker: And I really gave up and I said, well, that's it.
Speaker: I did it once and it's time to stop.
Speaker: But that was a big failure.
Speaker: And I, I,
Speaker: Took a couple of weeks.
Speaker: I thought about it.
Speaker: I restructured how I did it.
Speaker: The one thing I didn't do was I didn't do a course that I wanted to do.
Speaker: I did a course that I saw other people doing and just want to put my name on it.
Speaker: And so I went back to the drawing board.
Speaker: I redid everything again.
Speaker: And I did the course that I would want to go to if I was a participant in the course.
Speaker: And it took me a few years to do it.
Speaker: But last year, I just did that for the first time.
Speaker: And in my eyes, it was a huge success because when I was done, I was happy with it.
Speaker: The feedback I got from the participants was very positive.
Speaker: And it really just showed me that to trust myself, to trust my instincts, as long as you do the research and you know what you're doing is a good thing, just to just get out there and do the thing that you think is right.
Speaker: And if you're happy at the end of the day, chances are other people will be happy with you as well.
Speaker: And I think that that's a great story.
Speaker: And there's a couple of things that we can dissect, I mean, as lessons.
Speaker: One is that what you learned really was that ultimately don't try to do what other people are doing, do what you think is going to be valuable.
Speaker: And this whole concept of scratching your own itch or having an audience of one is absolutely right.
Speaker: If you do something that is interesting for you, most likely it will be interesting for other people.
Speaker: And I'm happy that despite that initial
Speaker: conference experience that you decided to go back to the drawing board, rechange it and do it again.
Speaker: And I, I know that that's been a great conference and I, from what I heard, it was very, very successful.
Speaker: Excellent.
Speaker: Well, thank you.
Speaker: The last question is relating to what would you want every listener to this episode to know?
Speaker: And this is in relation to ultrasound or, or anything at all?
Speaker: Your choice.
Speaker: All right.
Speaker: Well, I'll tell you this and I hope, uh,
Speaker: I hope he forgives me for saying this, but you know, Dr. Dellinger, who, if anyone doesn't know, should just stop listening right now because he is one of those people who has laid down so many inroads.
Speaker: And I know you are very close with Dr. Dellinger and I've become close with Dr. Dellinger while I'm here at Cooper.
Speaker: But what I'll tell you is that we have run some ultrasound courses here at Cooper and I ran my own ultrasound course, TEE course, advanced echo course in Philly.
Speaker: He came to every single course that there was.
Speaker: He is asking questions that are very tough questions.
Speaker: He is in there doing ultrasound and learning how to do it on a granular level.
Speaker: What I want everyone to walk away from and what he really exemplifies is that there is no end to your training.
Speaker: And I know we always say it, you know, we're lifelong learners and we should be doing things.
Speaker: But when I see people not adopt new technologies, when I still see people hanging on
Speaker: to the old dogma of what they trained and not open-minded to, to what medicine is or sciences in general.
Speaker: It just exemplifies, he exemplifies that, that you always have to continue to push.
Speaker: If we're in this field and we're taking care of mothers and fathers and brothers and sisters, and we're responsible for looking after people in those beds, it is up to us to make sure that we are doing the best
Speaker: care that we can give.
Speaker: And I know we always say that we give the best care, but if there's a new technology, whether it's ultrasound or the next thing that they'll invent to invest in much as much time into learning that new technology as it is to read a journal article or to do anything else that we do, it's just so imperative to embrace that Dr. D that Dr. Dellinger and all of us and really just keep chasing after that and be the best that we can be.
Speaker: That's what I think everyone
Speaker: listen to this podcast, which I know so many already are, but really that's what I want people to take away.
Speaker: And I think that's a great place to stop, Haney.
Speaker: Becoming is better than being, and we should never stop learning.
Speaker: Thank you so much for your time.
Speaker: Always a pleasure to talk with you, and hopefully we'll have you back on Critical Matter soon.
Speaker: I look forward to it.
Speaker: Thank you so much.
Speaker: Thank you for listening to Critical Matters, a Sound Critical Care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
