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POCUS For Shock
11 Plays6 years ago
Point-of-care ultrasound continues to grow in availability and is now embedded in many critical care practices. In this episode Critical Matters, we discuss the use of point-of-care ultrasound (POCUS) in the management of hypotension and shock.
Our guest is Dr. Haney Mallemat a recognized educator with a strong interest in POCUS. Dr. Mallemat holds dual academic appointments in Critical Care Medicine and Emergency Medicine at Cooper Medical School of Rowan University.
Additional Resources:
Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol: http://bit.ly/359RkgX
The Society of Point of Care Ultrasound: http://bit.ly/2senLMJ
Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients—Part II: Cardiac Ultrasonography: http://bit.ly/35b1D4r
Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators: http://bit.ly/2Ehzhd3
Rebel Cast Ep 58 - Would you be SHoC-ED if POCUS did not Improve Clinical Outcomes in Patients with Undifferentiated Shock?: http://bit.ly/345uq93
Clinical significance of portal hypertension diagnosed with bedside ultrasound after cardiac surgery: http://bit.ly/2LFJ7sY
Education Conferences:
UltraRounds: http://bit.ly/2RAgkdk
ResusX: http://bit.ly/2t86q8J
Music Mentioned in this Episode:
The Joshua Tree by U2: https://amzn.to/2sYlOnM
Recommended
Transcript
Introduction and Host Overview
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
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And now your host, Dr. Sergio Zanotti.
Episode Topic Introduction
00:00:32
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Today on Critical Matters, we will discuss the use of point-of-care ultrasound during the management of shock and hypotension.
00:00:38
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Our guest is once again Dr. Haney Malamud.
Guest Introduction: Dr. Haney Malamud
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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.
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Dr. Malamud is a highly accomplished educator.
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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.
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Furthermore, he's an education innovator and has developed a platitude of amazing educational programs and products.
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He is a firm believer in the benefits of bedside ultrasound for better patient care.
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Dr. Malamud holds academic appointments in critical care medicine and emergency medicine
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Cooper Medical School of Rowan University and has received numerous teaching awards.
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A true pleasure to have you back on Critical Matters.
00:01:28
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Welcome, Haney.
The Role of Ultrasound in Medical Training
00:01:29
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Thanks for having me back.
00:01:30
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It's awesome to be here.
00:01:31
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How have you been?
00:01:32
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Doing great.
00:01:34
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Last we spoke, we talked about the use of point-of-care ultrasound and cardiac arrest specifically.
00:01:38
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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
00:01:48
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ED departments, but also in critical care, it's becoming more and more popular.
00:01:54
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I think as a starting point, maybe, Haney, we can talk about where we are today with point of care ultrasound.
00:02:01
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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.
00:02:14
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But now it's much more common in training programs
00:02:18
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but also with the availability of technology.
00:02:22
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Today, probably medical students are graduating from medical school and getting an ultrasound, a pocket ultrasound as a present.
00:02:29
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So where do we stand today?
00:02:31
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It's really an amazing time.
00:02:33
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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.
00:02:40
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But like you said, the technology and the microprocessors and the probes are getting so cheap now,
00:02:47
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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.
00:03:03
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So it's, it's really a fascinating time.
00:03:06
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And the thing that might be an issue for some teachers and attendings is that they didn't train with this technology.
00:03:15
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And so you'll find some people
00:03:17
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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.
00:03:23
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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.
00:03:33
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So it's a very interesting time.
00:03:35
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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.
00:03:45
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All the fellows here at Cooper
00:03:46
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are doing ultrasound from day one.
00:03:48
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And I got to tell you, I'm pretty decent with ultrasound and they're really giving me a run for my money.
00:03:53
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They're getting really good.
00:03:56
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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.
00:04:06
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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
00:04:15
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for carrying a patient's at the bedside.
Ultrasound as a Diagnostic Tool
00:04:17
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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.
00:04:32
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Because when I was a fellow, this was still not very prevalent.
00:04:36
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There were people starting to have an interest in doing echocardiography and training with cardiologists, but you would hear all the arguments that
00:04:44
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You have to do a full exam that what have you missed this?
00:04:47
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What have you missed that?
00:04:48
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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.
00:05:00
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Can you talk about that difference?
00:05:02
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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.
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They say, well, I'm not going to get as good of a exam as a sonographer.
00:05:14
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or someone else is doing the exam later or radiologist.
00:05:17
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And look, here's the bottom line with this.
00:05:21
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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.
00:05:33
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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
00:05:42
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you know, low amplitude QRS complexes.
00:05:44
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I'm thinking about tamponade.
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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?
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I get the question right then and there.
00:05:53
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Are the images sonographer quality?
00:05:56
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Are they going to go in a textbook somewhere?
00:05:59
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No, but it doesn't matter.
00:06:00
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I need to answer a question quickly for my hypotensive patient because I need to go to the next step.
00:06:06
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And that's what ultrasound and point of care ultrasound helps you to do.
00:06:10
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It helps you to get to the next step.
00:06:12
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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.
00:06:24
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So think about how powerful that is.
00:06:26
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You at least get images that say, I don't know what this is, but this is not normal.
00:06:31
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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.
00:06:39
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They can at least identify normal
00:06:41
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and abnormal.
00:06:42
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And if people who are resistant to do ultrasound just did that, their practice would improve by some magnitude.
00:06:50
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And I think that that's an important aspect of bedside ultrasound.
00:06:52
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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,
00:07:08
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better left to people with full equipment and with more time.
00:07:12
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But again, by identifying these problems up front, we can even move those exams a lot quicker.
00:07:18
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Could you talk a little bit about when do we need to get a full echocardiogram, echocardiography?
00:07:23
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Yep.
00:07:24
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I want to add to that last statement that you said and answer this question at the same time.
00:07:28
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The thing is, though, is that when you keep doing ultrasound and you keep learning more,
00:07:35
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you get to do the things that the sonographers do.
00:07:38
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You can answer more questions than the yes and no.
00:07:40
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So on a very basic level, doing yes, no algorithms makes you a much better clinician.
00:07:46
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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.
00:07:53
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You'll be able to determine, yes, this is tamponade because of changes in your velocities through valves.
00:07:59
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You'll be able to look at the left ventricular function and quantify things.
00:08:04
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It's not that you're gonna be stuck at that same point.
00:08:08
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You use ultrasound every day as part of your practice and you will grow with it.
00:08:12
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And when do you get a formal, or some people are getting away from the term formal, a full echocardiogram?
00:08:20
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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.
00:08:30
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Because for me during resuscitation,
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and managing my sick patient, I can answer all the questions that I need.
00:08:38
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I might do it for the historical documentation.
00:08:41
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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.
00:08:48
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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.
00:08:58
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So if you look at something like looking for a pneumothorax with lung sliding,
00:09:02
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You ask a radiologist what that is and they won't know.
00:09:05
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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.
00:09:18
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Excellent.
00:09:19
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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
00:09:32
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of new technology or new processes for caring of patients, people rightfully so will ask, is there any evidence that supports this?
00:09:42
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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?
Training and Proficiency in Ultrasound Use
00:09:56
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So I'm going to lump all the studies that are out there
00:10:00
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into one general statement.
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And they all more or less say this.
00:10:06
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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.
00:10:16
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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.
00:10:25
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And if it's something procedural, let them do procedures on mannequins,
00:10:29
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or simulators, what you'll find is that there is a rapid adoption of the skill set in a very short amount of time.
00:10:38
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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.
00:10:59
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That's powerful.
00:11:00
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These are medical students.
00:11:01
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You just have to have the ability to look at something and say that's normal, abnormal, and then quantify it.
00:11:08
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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.
00:11:26
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So the evidence is there.
00:11:28
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It's not a lot.
00:11:30
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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.
00:11:44
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And I think that's important.
00:11:45
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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.
00:11:57
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But there has to be some sort of training and follow-up after that.
00:12:01
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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.
00:12:18
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But being a true ultrasound expert is something that I'm sure is much harder, which is true for many things in life.
00:12:25
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It's totally true.
00:12:27
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I'm not going to auscultate someone's heart as well as the cardiologist who's been doing it for 30 years.
00:12:33
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I've given up on that dream a long time ago, but I don't need to.
00:12:37
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I have other tools.
00:12:38
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I have other resources that I can use.
00:12:40
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And I view this as not something that distinguishes me as being someone special because I can do ultrasound.
00:12:48
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I look at myself becoming a better clinician by having this skill set.
00:12:52
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And the more I put into it,
00:12:55
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the more I'm going to get out of it.
00:12:56
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.
00:13:07
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The same is true of really anything, just as you said, playing the violin, riding a bicycle, or using ultrasound.
Impact of Ultrasound on Patient Outcomes
00:13:13
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Excellent.
00:13:14
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?
00:13:25
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My reading is that it's a mixed bag, but I just wanted to hear what are your thoughts?
00:13:30
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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.
00:13:46
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When you look at questions of yes, no, definitely ultrasound is more helpful.
00:13:52
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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.
00:14:00
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And what they did in this study was they use ultrasound assessment for patients with undifferentiated shock.
00:14:07
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And they compare that to clinical usual care, usual skillset.
00:14:12
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And what they found, what they were looking for was a mortality difference, which they did not find.
00:14:17
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And again,
00:14:19
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harping on those people that refuse to use Ultron say, aha, well, there you go.
00:14:23
Speaker
I don't need to learn ultrasound to change the mortality in my patients.
00:14:27
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Now there's problems with this study, which is by the way, the first study that has looked at this clinical question.
00:14:34
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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.
00:14:42
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This is the first study that actually randomized patients to getting point of care ultrasound
00:14:48
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in undifferentiated shock and patients not getting ultrasound.
00:14:51
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But getting back to the point of why they didn't find a mortality difference, there's a lot of problems with this study.
00:14:58
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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.
00:15:07
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They exclude those patients.
00:15:08
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They pretty much excluded everyone right out of the box that there was a suspicion for something.
00:15:15
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They didn't even include them in the study.
00:15:18
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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.
00:15:26
Speaker
So if I think the person has tamponade, you better believe I'm putting the probe on their heart.
00:15:30
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I'm not not putting the probe on their heart.
00:15:32
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And that helps me to confirm.
00:15:33
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That helps me to call the consultants faster.
00:15:36
Speaker
And I believe that helps me with a mortality benefit.
00:15:39
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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.
00:15:47
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the problems with this study.
00:15:49
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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.
00:15:55
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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.
00:16:05
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And I think that another issue when we're trying to capture, let's say, diagnostic procedures and link them to an outcome, right?
00:16:11
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You could imagine that if I did a randomized study
00:16:15
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.
00:16:32
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
00:16:45
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it was tamponade.
00:16:46
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.
00:16:55
Speaker
Can you comment on that a little bit?
00:16:57
Speaker
Yeah, there's more to a study than just mortality.
00:17:03
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And this is a hard thing in critical care to do, as you know.
00:17:09
Speaker
You know, I think what a study like this doesn't
00:17:14
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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.
00:17:29
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.
00:17:42
Speaker
But,
00:17:43
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It's amazing how little he used ultrasound for some very obvious cases.
00:17:47
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.
00:17:56
Speaker
And he would be like, why would you use ultrasound?
00:17:58
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It's a knee effusion.
00:17:59
Speaker
And I bring up that analogy mostly to say that you do the things that you know how to do.
00:18:06
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Ultrasound is not trying to get you away from doing the physical exam.
00:18:09
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It's not trying to get away you away from doing a thorough history.
00:18:13
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It just augments what you do in a way that nothing else can in 2019, 2020.
00:18:20
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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.
Ultrasound Protocols in Shock Management
00:18:35
Speaker
Excellent.
00:18:35
Speaker
So let's get a little more tactical and maybe dive into more specifics.
00:18:41
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of how you would do it in a case where you have suspected shock or hypotension.
00:18:45
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And I think that for our audience, there are a platitude of acronyms and different formats, different protocols that can be utilized.
00:18:55
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.
00:19:07
Speaker
So there's really, I mean, a growing number
00:19:09
Speaker
of protocols.
00:19:10
Speaker
And I think that ultimately it's not the individual protocol that's better or worse.
00:19:15
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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.
00:19:21
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But you can do this with practice in a very short amount of time.
00:19:25
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,
00:19:38
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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.
00:19:46
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.
00:19:54
Speaker
And I think that maybe we could use the rapid ultrasound for shock and hypotension, the rush protocol to walk us through that.
00:20:00
Speaker
Go ahead, Haney.
00:20:02
Speaker
So, you know, if you sift through all the literature, there are
00:20:06
Speaker
so many different protocols that are doing the same exact thing.
00:20:10
Speaker
And I got to think that every person was trying to make the best protocol to build their legacy.
00:20:14
Speaker
I mean, I'm not going to lie to you.
00:20:15
Speaker
I tried to figure out a protocol that works with Malamat, but I just couldn't get the letters to line up.
00:20:21
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So for that reason, I've gone with the rush protocol.
00:20:25
Speaker
And even then, there's two different types of rush protocols.
00:20:29
Speaker
What I do is, and all these protocols, by the way, they boil down to this.
00:20:34
Speaker
You have to evaluate the pump.
00:20:36
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.
00:20:50
Speaker
That's what all these protocols, the common thread between all of them.
00:20:54
Speaker
And as you mentioned, I like the rush exam, the one that uses the acronym HIMAP, H-I-M-A-P.
00:21:02
Speaker
I like it because it's structured.
00:21:04
Speaker
It's easy to work through.
00:21:06
Speaker
And it starts off with the most important component and that's the heart.
00:21:11
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So H is for heart.
00:21:14
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.
00:21:23
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And I'm looking at a variety of things in there.
00:21:26
Speaker
I'm looking at the size of the left ventricle.
00:21:29
Speaker
I'm looking at the squeeze of the left ventricle.
00:21:31
Speaker
Is the pump down or is it hyperdynamic implying that the heart is empty?
00:21:36
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I'm looking at the right ventricle.
00:21:38
Speaker
Is the RV big and barely moving?
00:21:40
Speaker
Is this an acute process?
00:21:41
Speaker
Is this a massive PE happening?
00:21:43
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I'm looking at the valves.
00:21:45
Speaker
I'm looking at the atria.
00:21:47
Speaker
I'm looking at the pericardial space to make sure there's no fluid in there, no tamponade.
00:21:52
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.
00:22:03
Speaker
I use it as intravascular status because
00:22:07
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.
00:22:13
Speaker
So I use intravascular status.
00:22:15
Speaker
And we could talk a little bit about what that means in tail.
00:22:19
Speaker
But essentially, that's the question that I'm asking with the eye right there.
00:22:23
Speaker
And again, I use IVC, but you can also use things like passive leg raise paired with VTI.
00:22:30
Speaker
The M is for Morrison's pouch, which those of you who are familiar with ultrasound will tell you.
00:22:35
Speaker
That is the FAST exam.
00:22:36
Speaker
We're looking for free fluid in the abdomen.
00:22:39
Speaker
So M reminds me about the Morrison's pouch, reminds me to look at the FAST exam.
00:22:44
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.
00:22:51
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.
00:22:59
Speaker
And P for me is pulmonary.
00:23:02
Speaker
For me, that's looking for any, again, in the pleural space, but also for any tension pneumothorax that could be there.
00:23:09
Speaker
It helps me if there's any pulmonary edema that might be there.
00:23:12
Speaker
And then also I can see whether or not the person is developing ARDS.
00:23:16
Speaker
So again, high map, five steps to it.
00:23:19
Speaker
H is for heart.
00:23:20
Speaker
I is for the intravascular fluid status.
00:23:23
Speaker
M is for Morrison's pouch.
00:23:25
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.
00:23:33
Speaker
So I think that this is a great mnemonic.
00:23:35
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?
00:23:49
Speaker
So I'm going to tell you that for me, this takes me two minutes to do.
00:23:54
Speaker
But that's because I practice.
00:23:57
Speaker
Just like LeBron, and believe me, I'm no LeBron, especially at basketball, but
00:24:02
Speaker
I practice and I made sure that I got my times down.
00:24:06
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.
00:24:15
Speaker
It's not a lot of time to give away to your patients who are critically ill.
00:24:19
Speaker
So it doesn't mean that you have to be a pro or have years of training.
00:24:23
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.
00:24:30
Speaker
And in fact,
00:24:31
Speaker
Many of the time I'm talking to the family, getting some more history as I'm doing the ultrasound.
00:24:36
Speaker
So, you know, I'm being efficient with my time there.
00:24:40
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.
00:24:56
Speaker
So let's dive into the H.
00:25:00
Speaker
And let's take a very, very beginner's approach and start by telling me what probe you would use.
Cardiac Assessment Techniques
00:25:08
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.
00:25:17
Speaker
Not everyone invests in this when you buy a system, but I think it's an important probe to have.
00:25:23
Speaker
Many people will have the curved linear probe, which is the big fat abdominal probe.
00:25:27
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.
00:25:39
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.
00:25:49
Speaker
So you start with the phase array probe.
00:25:52
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?
00:26:00
Speaker
And just to be clear, I do my whole exam with that one probe.
00:26:03
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.
00:26:11
Speaker
I can get all that information using that single probe, but to your question,
00:26:15
Speaker
The first view that I do is the parasternal long axis view.
00:26:19
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.
00:26:34
Speaker
So that's the first view.
00:26:35
Speaker
Again, in this view, I'm looking at the pericardial space and I'm looking at the left ventricle.
00:26:40
Speaker
That's the big things that I'm pulling away from that.
00:26:43
Speaker
Then I rotate 90 degrees.
00:26:45
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.
00:26:53
Speaker
And for this, I'm looking at the relation between the LV and the RV.
00:26:57
Speaker
I'm looking for how well the pump is moving, but here I get to see the intraventricular septum.
00:27:02
Speaker
I get to see if there's a septal flattening.
00:27:04
Speaker
I can see if there's any RV dilation.
00:27:06
Speaker
So a bunch of things I can get from that in addition to the pericardial space.
00:27:10
Speaker
Go ahead.
00:27:12
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.
00:27:20
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.
00:27:31
Speaker
Any comments on what are some tips that we could utilize to figure that out?
00:27:35
Speaker
Yeah, fat pads are tricky sometimes.
00:27:38
Speaker
The thing that,
00:27:40
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.
00:27:48
Speaker
And if it's a fat pad, you might see some speckling of that material.
00:27:53
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.
00:28:02
Speaker
That's not absolute, but that's one thing you could do.
00:28:05
Speaker
And the other thing is if you have a significant pericardial effusion,
00:28:09
Speaker
it should wrap around and go posteriorly behind the left ventricle.
00:28:14
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.
00:28:26
Speaker
And then once you get advanced, there's exceptions to all these rules.
00:28:30
Speaker
Excellent.
00:28:30
Speaker
And my second question was related to the RV size.
00:28:35
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.
00:28:46
Speaker
But if you have the wrong angle, could you overestimate that?
00:28:51
Speaker
In the parasternal long axis view?
00:28:56
Speaker
In the short axis view?
00:28:57
Speaker
Yeah, there's some finesse to how you angle the probe.
00:29:02
Speaker
You certainly want to
00:29:03
Speaker
every time you're doing measurements, be perpendicular to the skin.
00:29:06
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.
00:29:22
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
00:29:32
Speaker
before you make any interpretation of what's on the screen.
00:29:35
Speaker
Okay, perfect.
00:29:37
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.
00:29:44
Speaker
So what do you do next?
00:29:48
Speaker
Next I move to the apical four chamber view, which is right there under the breast.
00:29:51
Speaker
It's essentially where you would put a chest tube in if you were to put in an open chest tube.
00:29:57
Speaker
And that lines up the left ventricle and the right ventricle right next to each other
00:30:01
Speaker
It lines up the valves.
00:30:02
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.
00:30:09
Speaker
Is there any septal shift?
00:30:11
Speaker
Is there any big RV?
00:30:12
Speaker
Is there any massive regurgitant lesion through the mitral tricuspid valve?
00:30:17
Speaker
It's a very useful view.
00:30:18
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.
00:30:28
Speaker
And that's part of the benefit of the redundancy of these four views.
00:30:31
Speaker
Some of the fellows get really beat up about not getting all four views.
00:30:35
Speaker
Look, if you get three of the views, if you get two of the views, you have enough information to move forward.
00:30:42
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.
00:30:50
Speaker
And so the fourth view is the sub-xiphoid view.
00:30:53
Speaker
And that's the view I think that most people come to learn
00:30:56
Speaker
first because it's part of the FAST exam.
00:30:59
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.
00:31:07
Speaker
But of all the views, that's the simplest to get.
00:31:12
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,
00:31:25
Speaker
which is something that we can't always do with a patient who's critically ill, hypotensive, in shock, et cetera.
00:31:31
Speaker
Yeah, I came in to see one of my fellows who was, this person was like satting in the 80s and hypotensive.
00:31:39
Speaker
And they're like, it's okay, sir, just roll on your left side here.
00:31:42
Speaker
And I really got to get this apical view.
00:31:45
Speaker
You got to sacrifice some views for patient safety.
00:31:49
Speaker
And that's why it's better to do the views supine when you can.
00:31:53
Speaker
And then if you have someone who's a little bit more stable,
00:31:55
Speaker
who's excavated the unit, you could roll them over to the side, but you're right.
00:31:59
Speaker
You have to get the views in the safest position for the patient.
00:32:03
Speaker
And sometimes it leads to suboptimal imaging.
00:32:05
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.
00:32:19
Speaker
It's just to answer a question.
00:32:20
Speaker
So when I go into these exams, I have questions and I'm looking for answers.
00:32:24
Speaker
Absolutely.
00:32:25
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?
00:32:41
Speaker
Number two is looking at the size of the ventricle, specifically comparing the right ventricle to the left ventricle.
00:32:49
Speaker
Number three, as you mentioned, would be in terms of can I see anything
00:32:54
Speaker
related to fluid around the heart and any signs of tamponade.
00:32:58
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.
00:33:07
Speaker
Could you mention which of the views would be best for each one of these and how do you think about this?
00:33:14
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
00:33:22
Speaker
I would go for the parasternal short axis view at the level of the papillary muscles.
00:33:27
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.
00:33:37
Speaker
You're looking at the RV size.
00:33:38
Speaker
You're looking at how the septum's performing and you're looking at the pericardial space all in one shot.
00:33:43
Speaker
So that of all the views, that's the one I try to get the most if I have the choice.
00:33:51
Speaker
and the other views, they're just gravy if I get them answering questions.
00:33:56
Speaker
Excellent.
00:33:57
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,
00:34:15
Speaker
the approach in the ICU or in the ED would be a sycfoid approach to drain that fluid.
00:34:23
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.
00:34:30
Speaker
Can you comment on that?
00:34:32
Speaker
Yeah, absolutely.
00:34:33
Speaker
It's exactly what you said.
00:34:35
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.
00:34:42
Speaker
So if it's a paracentesis that you're doing,
00:34:45
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.
00:34:51
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.
00:34:58
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.
00:35:03
Speaker
And the same thing is true of pericardial fluid.
00:35:05
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,
00:35:15
Speaker
through the liver and then try to hit the pericardial space.
00:35:18
Speaker
I'd much rather go for the apical four chamber view and get through that space.
00:35:23
Speaker
Cause the, when you do it, it's only a couple centimeters below the skin is where you need to puncture.
00:35:28
Speaker
There are some people that do the parasternal long and short axis views.
00:35:31
Speaker
I will say that there is the LAD that crosses over the LV over there.
00:35:37
Speaker
There's the, there's the internal mabillary artery.
00:35:40
Speaker
That is something that concerns me, but
00:35:43
Speaker
If the fluid is the greatest and the apical window is out, that's where I would go to next.
00:35:48
Speaker
Excellent.
00:35:49
Speaker
So let's go into the next step.
00:35:51
Speaker
So you've done this.
00:35:52
Speaker
And like you said, this does not take you a lot of time.
00:35:54
Speaker
You made an assessment of those items with the heart.
00:35:58
Speaker
And now you're looking at the IVC or looking at kind of the intravascular volume.
00:36:02
Speaker
Tell us how you approach this and what do you do next?
00:36:05
Speaker
Yeah, the IVC.
00:36:07
Speaker
Every single year, I use it less and less and less.
00:36:10
Speaker
And the evidence behind it for the spontaneously breathing person is helpful, if at all, at the very, very extremes.
00:36:18
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.
00:36:32
Speaker
That's the only thing I can get from it.
00:36:33
Speaker
And then if it's really big and plump,
00:36:36
Speaker
The only thing it tells me is that their right atrial pressures are high.
00:36:40
Speaker
And at best, it means that volume might be the wrong thing for them.
00:36:45
Speaker
But there's lots of exceptions in there.
00:36:47
Speaker
So IVC is not a helpful tool for me in the non-intubated patient.
00:36:52
Speaker
In the intubated patient, it's a little bit more helpful for me.
00:36:55
Speaker
There is more data for it.
00:36:58
Speaker
Looking at something called distensibility index, which is essentially looking through the respiratory cycle to see how much the IVC is dilating.
00:37:06
Speaker
then coming back to its normal size.
00:37:09
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.
00:37:20
Speaker
They can only be on a, a moderate amount of people, which is never defined in the studies.
00:37:26
Speaker
They can have no RV dysfunction.
00:37:28
Speaker
They cannot be spontaneously breathing above the vent.
00:37:30
Speaker
These are all things that I can't find a patient who meets all these criteria.
00:37:36
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.
00:37:46
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?
00:37:57
Speaker
And we talk about fluid responsiveness, which is a physiologic measurement, but you could be fluid responsive
00:38:04
Speaker
and not need fluid, right?
00:38:05
Speaker
So I mean, I think that that's been the dilemma.
00:38:07
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.
00:38:16
Speaker
And that people do different things.
00:38:19
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
00:38:33
Speaker
from those studies and maybe had applied it to patients who are not really the patients that were studied.
00:38:39
Speaker
So we don't really know what it means at the end.
00:38:42
Speaker
Yeah.
00:38:42
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.
00:38:59
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.
00:39:28
Speaker
But the problem is
00:39:29
Speaker
is that that's a maneuver that needs a bit more training.
00:39:31
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.
00:39:42
Speaker
For the intravascular status, it's more of a gestalt.
00:39:45
Speaker
And luckily, I think this is the golden fleece of critical care is the person who's volume responsive.
00:39:51
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
00:39:59
Speaker
give less and less volume and vasopressors early.
00:40:01
Speaker
So maybe this question will be completely extinct in the next five to 10 years.
00:40:07
Speaker
Who knows?
00:40:08
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.
Protocols for Shock Diagnosis and Management
00:40:15
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?
00:40:25
Speaker
No, absolutely not.
00:40:26
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.
00:40:36
Speaker
And if the person's in hemorrhagic shock, I don't need an ultrasound to help me out to resuscitate that person.
00:40:42
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.
00:40:50
Speaker
And before we move on, just, I mean, in terms of like the very basics,
00:40:56
Speaker
You do the, usually you do the subcyphoid view and then you go to the IVC.
00:41:00
Speaker
Where are you looking for the IVC and what do you do to find it?
00:41:03
Speaker
Just for the IVC, essentially I'm looking at the subcyphoid four chamber first and then I rotate while looking at it.
00:41:10
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.
00:41:19
Speaker
So if I keep my eye on the right atrium, you'll see the IVC as you're rotating come right in.
00:41:26
Speaker
That's a trick that I personally use and that's something I teach everyone that I show how to use ultrasound.
00:41:32
Speaker
Excellent.
00:41:33
Speaker
So as we go down our mnemonic, now you're looking at M and that's Morrison's pouch or the fast exam.
00:41:41
Speaker
And you mentioned earlier that you keep the same probe.
00:41:44
Speaker
So you're still using the same probe for this part, right?
00:41:48
Speaker
Absolutely.
00:41:48
Speaker
Part of the success or win with ultrasound
00:41:53
Speaker
is not going to switch between probes and say, oh, now I need a new probe.
00:41:57
Speaker
If you could do this all with one probe, you're saving time.
00:42:01
Speaker
You could resuscitate your patients a lot more efficiently.
00:42:03
Speaker
So yeah, I stick with this probe.
00:42:06
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.
00:42:18
Speaker
So I'm sticking with the phased array probe.
00:42:19
Speaker
My first move is to go to the right upper quadrant.
00:42:22
Speaker
and that's looking at the hepatorenal space.
00:42:25
Speaker
That's looking to see if there's a free fluid in the abdomen.
00:42:28
Speaker
The next place you're looking is the left upper quadrant, which is the splenorenal view.
00:42:33
Speaker
And then the last place is right at the bladder to see if there's a free fluid down there.
00:42:38
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.
00:42:48
Speaker
So it's really three views we're looking at here.
00:42:50
Speaker
And
00:42:50
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.
00:43:03
Speaker
I typically put it in this part of my exam.
00:43:05
Speaker
Other people I know put it in the P or the pulmonary part of their exam.
00:43:09
Speaker
It doesn't really matter.
00:43:10
Speaker
It just has to make sense to you, and you have to do the protocol the same way every single time.
00:43:22
Speaker
Once you do this part, what do you go to next, Haney?
00:43:26
Speaker
Sorry, can you start that part over and just cut out?
00:43:29
Speaker
Once you finish the M, you start looking at the aorta, you said.
00:43:33
Speaker
How do you evaluate the aorta and what are you looking for?
00:43:36
Speaker
It's a really quick look at the aorta.
00:43:38
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.
00:43:49
Speaker
So I'm taking that probe.
00:43:51
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.
00:43:56
Speaker
Take a quick look at the aorta.
00:43:58
Speaker
If I don't see any dilation or any dissection, I'm done because it's just a screening test for me.
00:44:04
Speaker
And if I'm really worried about them, they're going for a CT scan anyway.
00:44:09
Speaker
And what is other, can you tell me where you look at the aorta?
00:44:13
Speaker
I know that some people usually do like four points very quickly, but I mean, just tell me what your usual practice is.
00:44:20
Speaker
I'll start.
00:44:20
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.
00:44:26
Speaker
That's going to get me right to the bifurcation.
00:44:29
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.
00:44:37
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,
00:44:49
Speaker
I'm sort of zooming down and thinking that's where their problem is.
00:44:54
Speaker
And when you say big, can you give me a number?
00:44:56
Speaker
Sure.
00:44:57
Speaker
We're looking at things that are five or six centimeters big.
00:45:01
Speaker
And in terms of dissection, is that something that you think we can identify?
00:45:05
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?
00:45:14
Speaker
Yeah, it's definitely the weakest of everything that I look at.
00:45:18
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.
00:45:27
Speaker
The distal ones don't really cause the level of shock that we'd be looking for here.
00:45:33
Speaker
So yeah, it's specific.
00:45:35
Speaker
It's definitely not sensitive.
00:45:36
Speaker
But like I said, if they're stable, I'm going to get them imaged if I think at the areas at play.
00:45:40
Speaker
I'm just looking for the person that's unstable.
00:45:43
Speaker
And I can't figure out why.
00:45:44
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?
00:45:56
Speaker
A, uh, we'll cut this out.
00:45:59
Speaker
Well, you would also go ahead.
00:46:01
Speaker
I was saying we're, we're looking for, uh, a widening of the AV valve.
00:46:06
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.
00:46:16
Speaker
Those things together suggest an ascending dissection.
00:46:19
Speaker
Exactly.
00:46:19
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.
00:46:27
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.
00:46:34
Speaker
And that is something that you can accelerate.
00:46:36
Speaker
And like you mentioned, a five minute exam is not going to delay them getting that CTA in any way.
00:46:41
Speaker
It just might accelerate it.
00:46:42
Speaker
So I think it makes sense.
00:46:44
Speaker
And with the aneurysms, I guess what you're really thinking about in a stable patient is a ruptured aneurysm.
00:46:51
Speaker
And then you would see that a large one with blood in one of the pouches, right?
00:46:57
Speaker
If it happens to rupture intraperitoneally, unfortunately,
00:47:02
Speaker
some of these will rupture retroperitoneally and ultrasound is not so great for that.
00:47:06
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.
00:47:14
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.
00:47:21
Speaker
Okay, perfect.
00:47:24
Speaker
So, and the last portion is the P, which is pneumothorax and some mnemonics, but you just say, I mean, pulmonary.
Pulmonary and Respiratory Assessment
00:47:32
Speaker
Before we go into the P, do you look at veins?
00:47:37
Speaker
Is that part of your rush exam or is that something that you find less useful?
00:47:42
Speaker
No, it's definitely helpful.
00:47:43
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.
00:47:53
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.
00:48:01
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.
00:48:10
Speaker
Do you know what I mean?
00:48:11
Speaker
Yeah.
00:48:12
Speaker
Fair enough.
00:48:13
Speaker
So why don't you tell us about the P how do you look at how, what do you do next?
00:48:16
Speaker
So you've done the aorta and now you move to the lungs or to the pulmonary aspect.
00:48:21
Speaker
Yeah.
00:48:21
Speaker
First move is to look, to make sure there's no lung sliding.
00:48:23
Speaker
If I don't see lung sliding and the person's hypotensive tension pneumothorax is high on my list.
00:48:29
Speaker
So I'll look for lung sliding.
00:48:31
Speaker
Um,
00:48:31
Speaker
That's when the patient breathes.
00:48:33
Speaker
You'll see there's some movement of the visceral pariopleura.
00:48:36
Speaker
It's a very distinct looking thing on your ultrasound.
00:48:39
Speaker
If the person is mechanically ventilated, you're going to have your therapist bag for you whenever the person takes the breath.
00:48:45
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.
00:48:54
Speaker
But that's a subtle point.
00:48:56
Speaker
As I'm looking at lung sliding, I'm also looking to see if the person has any evidence of a pneumonia.
00:49:01
Speaker
I'm looking to see if there's any B lines or interstitial fluid there in the lungs.
00:49:06
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.
00:49:18
Speaker
Sorry, they're like outside the door.
00:49:20
Speaker
No, for how long?
00:49:22
Speaker
No, they're done.
00:49:22
Speaker
They're gone.
00:49:23
Speaker
Sorry.
00:49:24
Speaker
So,
00:49:28
Speaker
Then as I move down from the lungs, I move to the thoracic spaces.
00:49:32
Speaker
This is where I'm looking for any effusions, which are very distinct looking things on ultrasound.
00:49:37
Speaker
And for me, if a person's hypotensive, they have a diffusion, it's one of two things.
00:49:43
Speaker
The person either has blood or it's pus in the chest.
00:49:46
Speaker
Blood has a distinctive look to it.
00:49:49
Speaker
It kind of looks like a snow globe, if you will.
00:49:52
Speaker
It looks like things are just kind of showering down in the chest.
00:49:56
Speaker
And
00:49:58
Speaker
pus in the chest or an empyema has a very loculated type look to it.
00:50:02
Speaker
These are things that actually when you look at with ultrasound, people point them out like, is that an empyema?
00:50:06
Speaker
Because intuitively, you think that's how it would look and ultrasound just matches what you would see.
00:50:12
Speaker
But those are the things I'm looking for as I'm evaluating the P for lung, for pulmonary.
00:50:18
Speaker
Excellent.
00:50:19
Speaker
And I think that two questions I have, I mean, that I think are important relate to patients who are intubated.
00:50:26
Speaker
And this might be beyond the rush exam or following your initial assessment of somebody.
00:50:33
Speaker
But there's two things that I think are important to mention.
00:50:36
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?
00:50:47
Speaker
Absolutely.
00:50:48
Speaker
Yeah.
00:50:49
Speaker
So essentially, I like to do this live as the person's being intubated.
00:50:54
Speaker
This is where you take the linear probe.
00:50:56
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.
00:51:03
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.
00:51:13
Speaker
It's in the wrong place.
00:51:15
Speaker
And you can reposition it and see it going through the trachea where it appropriately should be.
00:51:23
Speaker
If somebody came intubated to you and
00:51:25
Speaker
you're suspecting that the tube is in the wrong place.
00:51:28
Speaker
How could you figure that out with ultrasound?
00:51:31
Speaker
You're not watching it live.
00:51:32
Speaker
Yeah, so my first thing, so they're already coming in intubated.
00:51:36
Speaker
My first move is always waveform capnography.
00:51:39
Speaker
I still think that is the best way of confirming tube placement.
00:51:42
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.
00:51:52
Speaker
The good news is,
00:51:53
Speaker
unless someone was really forcefully it's being this person, it's only going to be in the esophagus or the trachea.
00:51:59
Speaker
And if the esophagus is contracted down at normal size, by definition, it should be in the trachea.
00:52:06
Speaker
There's some people that have protocols.
00:52:08
Speaker
They look for something called the double ring sign.
00:52:10
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,
00:52:23
Speaker
the simplest method of getting the images without any confounders.
00:52:27
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.
00:52:34
Speaker
Perfect.
00:52:35
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?
00:52:47
Speaker
Such a good question because this comes up a lot for people who have gotten the initial course down.
00:52:51
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.
00:52:56
Speaker
So when you have somebody who you made stem, that means you're going to be ventilating the right lung.
00:53:02
Speaker
The right lung should have lung sliding.
00:53:04
Speaker
The left lung is not being ventilated, but it doesn't, it looks on initial look to be a pneumothorax.
00:53:10
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.
00:53:20
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.
00:53:28
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.
00:53:37
Speaker
And you see these little beats happening intermittently.
00:53:39
Speaker
It is, I would call it like lung ultrasound 2.0.
00:53:43
Speaker
It's not difficult, but someone specifically has to show you how to look for that.
00:53:47
Speaker
But
00:53:48
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.
00:53:55
Speaker
Excellent.
00:53:55
Speaker
So I think that we took a lot longer than it would take to do the exam.
00:54:00
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.
Ongoing Patient Management with Ultrasound
00:54:17
Speaker
So this is very useful in your first assessment or diagnosis.
00:54:22
Speaker
It maybe helps you think about the patient and what type of shock they have.
00:54:26
Speaker
Is this cardiogenic?
00:54:27
Speaker
Is this more distributive shock?
00:54:29
Speaker
Is this hypovolemic?
00:54:30
Speaker
And start your initial diagnostic and therapeutic interventions.
00:54:35
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,
00:54:46
Speaker
or somebody who you're still debating what to do.
00:54:49
Speaker
Now they're intubated, they're in the ICU.
00:54:51
Speaker
How does point of care ultrasound factor into your management of these patients?
00:54:57
Speaker
Well, there's a lot of ways, a lot of questions that we have after the person has been resuscitated.
00:55:03
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?
00:55:11
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.
00:55:17
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
00:55:45
Speaker
I go with the ultrasound, I actually visualize the bladder.
00:55:48
Speaker
I actually take my own measurements.
00:55:50
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.
00:56:02
Speaker
And then lo and behold, we get flow back.
00:56:05
Speaker
If I see that their bladder is distended and they're getting hydronephrosis, then their bladder is really congested.
00:56:11
Speaker
And on the other hand, if their bladder is empty,
00:56:14
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.
00:56:23
Speaker
And that's where I start to do things like the passive leg raise and those advanced computations.
00:56:28
Speaker
But my ultrasound that I'm doing for the person who's already been resuscitated is, is very limited.
00:56:34
Speaker
The really interesting thing is the person who I'm de-resuscitating.
00:56:37
Speaker
So now the person who's getting better, who thinks are starting to get, um,
00:56:42
Speaker
reverse, we're talking about extubating people.
00:56:45
Speaker
This is where I tend to use the ultrasound again, a lot more.
00:56:48
Speaker
So it's sort of bimodal first when I meet them.
00:56:51
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.
00:56:57
Speaker
You know, if a person is volume overloaded and we're trying to figure out, should we diuresize them or not?
00:57:01
Speaker
You can look at the lungs and look for B lines, which suggests that the person is volume overloaded.
00:57:07
Speaker
A person with a lot of B lines, they're going to get some diuresis.
00:57:10
Speaker
I look at thoracic spaces.
00:57:12
Speaker
Did they third space and create pleural effusions?
00:57:14
Speaker
And that's why they failed the spontaneous breathing trial.
00:57:17
Speaker
Well, let's go ahead and drain those effusions.
00:57:19
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.
00:57:30
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.
00:57:38
Speaker
You're actually looking at the portal vein to determine
00:57:41
Speaker
whether or not that person is euvolemic or hypervolemic.
00:57:45
Speaker
And the data from this stuff is just really, really amazing.
00:57:50
Speaker
So where did you look for that?
00:57:51
Speaker
Can you give me just like which probe and which window do you use?
00:57:55
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.
00:58:01
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.
00:58:07
Speaker
Again, it's very, very hard on a podcast to walk you through it,
00:58:10
Speaker
But that's just the bottom line.
00:58:12
Speaker
But you don't need any special tools.
00:58:14
Speaker
And the best part is that it is super easy to do.
00:58:19
Speaker
Excellent.
00:58:19
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.
00:58:30
Speaker
And for many years, we were really centered on the perspective.
Fluid Management and De-resuscitation Strategies
00:58:34
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.
00:58:43
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.
00:58:56
Speaker
And this whole idea of active de-resuscitation is something that is gaining a lot of a
00:59:02
Speaker
of interest and data that suggests that it really improves outcomes.
00:59:06
Speaker
And to that extent, I think that what you just said, Haney, is really just the other side of the coin.
00:59:12
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.
00:59:26
Speaker
If you are diuresing somebody and they have no variation with leg raising,
00:59:30
Speaker
it probably means that they're still volume overloaded, right?
00:59:33
Speaker
So you're looking the opposite.
00:59:35
Speaker
And I think that the other thing that you mentioned was the presence of B lines.
00:59:38
Speaker
And I wanted to look into that a little bit because it also is very useful on the way up, right?
00:59:43
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.
00:59:52
Speaker
But also it could be something that once the patient's stable, you can use to kind of guide or
00:59:58
Speaker
force you to start diuresis.
01:00:00
Speaker
Any other comments on that?
01:00:02
Speaker
No, that was perfect.
01:00:03
Speaker
There are protocols by Daniel Lichtenstein, who is the godfather of lung ultrasound.
01:00:08
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.
01:00:17
Speaker
So that literature is definitely out there.
01:00:20
Speaker
But yeah, I'm using ultrasound more and more to de-resuscitate patients because as you said,
01:00:26
Speaker
it's we sort of high five and we say, Hey, the patient's great, but then we can't get them extubated.
01:00:30
Speaker
We can't get them out of the unit.
01:00:32
Speaker
They're going to renal failure.
01:00:33
Speaker
They're getting delirium.
01:00:34
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.
01:00:48
Speaker
They're actually using that to as a marker of delirium.
01:00:54
Speaker
So patients, cardiac surgery patients,
01:00:56
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.
01:01:08
Speaker
And again, this all just comes back to congestions of end organs.
01:01:13
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.
01:01:23
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.
01:01:33
Speaker
Is that the idea?
01:01:34
Speaker
That's correct.
01:01:35
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.
01:01:44
Speaker
And I'm not surprised with the finding of delirium.
01:01:47
Speaker
I have experienced empirically that
01:01:50
Speaker
patients post shock and ARDS who are several leaders volume up, who are not waking up, who you start diuresing.
01:01:58
Speaker
And lo and behold, I mean, eventually everything starts getting better, including their mental status.
01:02:03
Speaker
And it probably relates to it, like you said, I mean, is that there's edema everywhere, including the brain, right?
01:02:09
Speaker
And as you really change that curve, it impacts the function of all organs.
01:02:15
Speaker
Absolutely.
01:02:15
Speaker
Yeah.
01:02:16
Speaker
And the kidneys are, you know, that's the biggest irony is, again, the intern getting the call.
01:02:20
Speaker
for decreased urine output, give a liter of fluids.
01:02:24
Speaker
You know, we're looking at this here at Cooper, where maybe those are the people who need a portal vein pulsatility.
01:02:30
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.
01:02:38
Speaker
So these are interesting times.
01:02:42
Speaker
Absolutely.
Documentation and Billing for Ultrasound
01:02:43
Speaker
So let me ask you a more practical aspect of practicing with ultrasound
01:02:47
Speaker
What do you document in the chart?
01:02:50
Speaker
How do you handle your documentation?
01:02:52
Speaker
And also I would like to ask you from a billing perspective, how do you think about bedside ultrasound?
01:02:58
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.
01:03:11
Speaker
We set up an online cloud service where the images go right to the cloud
01:03:17
Speaker
They can always be accessed.
01:03:19
Speaker
We are reading our fellows and our own ultrasound exams, and then we're subsequently billing for it.
01:03:25
Speaker
That is the Cadillac, if you will, if Cadillac is your favorite car.
01:03:28
Speaker
That is the Cadillac of how to do ultrasound.
01:03:31
Speaker
Now you're doing ultrasound, you're showing documentation, and you're billing for it.
01:03:35
Speaker
You're doing all the right things.
01:03:37
Speaker
Now you might be in a place where you're not at that level, but you still want to do ultrasound.
01:03:43
Speaker
Now, what I would say is that
01:03:46
Speaker
If you can work on getting a billing program in place, that's going to help you to buy all the fancy equipment.
01:03:52
Speaker
It's going to help to fund your program.
01:03:53
Speaker
So that's ultimately what you want to do.
01:03:55
Speaker
But a lack of that should not let you not do ultrasound.
01:03:59
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.
01:04:13
Speaker
And I see it being no different.
01:04:15
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.
01:04:30
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?
01:04:40
Speaker
Why do I need to...
01:04:42
Speaker
show you every single clip that I got.
01:04:44
Speaker
It slows me down and subsequently what it does is it stops me from doing ultrasound because I'll get so frustrated.
01:04:50
Speaker
I'll say it's not worth the extra time to do this life-saving maneuver.
01:04:54
Speaker
Do you have a specific maybe documentation or reporting note that you use when you do a rush exam?
01:05:04
Speaker
Yeah, in our EMR, we have a template and we wrote the template to have just pull-down menus.
01:05:13
Speaker
So at the minimum, they're yes, no questions.
01:05:16
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.
01:05:23
Speaker
But I want people to be able to do the exam and say, was there pericural effusion?
01:05:28
Speaker
Yes or no.
01:05:28
Speaker
Was the LV working?
01:05:30
Speaker
Yes or no.
01:05:30
Speaker
Was the RV big?
01:05:32
Speaker
Yes or no.
01:05:32
Speaker
And then if I'm seeing that patient subsequently,
01:05:36
Speaker
I know they at least did that.
01:05:37
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.
01:05:44
Speaker
Makes sense.
01:05:45
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.
Advocacy for Ultrasound Use in Clinical Practice
01:06:02
Speaker
And there's a lot of people like myself who are in practice
01:06:05
Speaker
who this was not part of their original training.
01:06:11
Speaker
So in terms of teaching old dogs like myself new tricks, what do you think is the best approach to learning?
01:06:17
Speaker
What do you recommend?
01:06:18
Speaker
Some of the pearls that you could give us.
01:06:20
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.
01:06:32
Speaker
It is just not that.
01:06:34
Speaker
And
01:06:35
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.
01:06:54
Speaker
So what I would say is to pick a course and then go to the course.
01:06:58
Speaker
And then what you need to do is when you get back to your institution,
01:07:01
Speaker
You have to find somebody who's going to mentor you on how to do this.
01:07:05
Speaker
Because if you go to the course, come back and don't do it, the skills are gone.
01:07:09
Speaker
They're just as well gone.
01:07:11
Speaker
You have to come back and do it every single day on your patients and make it bite-sized.
01:07:16
Speaker
You know, don't try and do the entire exam on every patient that you're rounding on.
01:07:21
Speaker
What I tell every novice to ultrasound, whether they're a medical student or a senior faculty is pick one exam to do.
01:07:28
Speaker
on every patient per day.
01:07:30
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.
01:07:39
Speaker
And guess what?
01:07:40
Speaker
You've just done 20 exams.
01:07:42
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.
01:07:48
Speaker
Just pick one view and get through it on every single patient.
01:07:52
Speaker
You're gonna build up practice.
01:07:54
Speaker
You're gonna find pathology along the way.
01:07:56
Speaker
But most importantly, what you're gonna show
01:07:58
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.
01:08:12
Speaker
Are there any resources that you could recommend or any particular courses that you think would be highly recommended?
01:08:19
Speaker
There's a bunch of courses, including courses which I personally run myself.
01:08:24
Speaker
I would say that any one of the societies, they run courses.
01:08:28
Speaker
So if you're a member of CHESS, then go to the CHESS course.
01:08:31
Speaker
If you're a member of Society of Critical Care Medicine, go to their course.
01:08:35
Speaker
The course that I do, and this is going to sound like a shameless plug, but it's really not.
01:08:40
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.
01:08:47
Speaker
There are plenty of courses that will sit you in a room and
01:08:50
Speaker
have hours and hours of didactic lectures, and then give you an hour or two scanning patients.
01:08:55
Speaker
The teaching should be flipped exactly the opposite way.
01:08:58
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.
01:09:07
Speaker
A course like mine, we give you videos to go home with.
01:09:09
Speaker
You'll get the videos and the education later.
01:09:11
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.
01:09:17
Speaker
So whatever course you pick, pick a course that
01:09:20
Speaker
optimizes the amount of times you have scanning those models.
01:09:24
Speaker
That sounds like a book, right?
01:09:25
Speaker
The best book is the one you read.
01:09:27
Speaker
The best course is the one you go to.
01:09:29
Speaker
But focus on courses that have a lot of hands-on time.
01:09:33
Speaker
And then what you really highlighted, Hayden, which I think is important, is the follow-up.
01:09:37
Speaker
Once you've done the course, how do you proceed from there in terms of practicing, practicing, practicing, and having the right mentorship?
01:09:44
Speaker
It's really hard.
01:09:45
Speaker
And I'm sensitive to the fact that there are places that just don't have access.
01:09:50
Speaker
to experts in ultrasound or point of care ultrasound in their shop.
01:09:53
Speaker
But what I would say is stop by the emergency department.
01:09:56
Speaker
They likely have somebody who is fast on ultrasound.
01:09:59
Speaker
If not, go to the cardiologist, talk to the sonographers.
01:10:02
Speaker
They will take you around.
01:10:03
Speaker
They love the attention and they love to teach.
01:10:05
Speaker
That's who taught me how to do echo was the sonographer.
01:10:08
Speaker
So you can find places in the hospital to teach you what to do, but just do your scans with people.
01:10:12
Speaker
And we're not talking about months and months of mentorship.
01:10:15
Speaker
We're just talking about a couple of days to get your feet off the ground.
01:10:18
Speaker
And then after that, just checking in every once in a while and say, hey, listen, I couldn't get this image.
01:10:23
Speaker
What tips would you give me?
01:10:24
Speaker
And they'll get you through it.
01:10:26
Speaker
Absolutely.
01:10:27
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.
01:10:45
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.
01:10:54
Speaker
And now you have all these pocket ultrasounds available.
01:10:56
Speaker
Could you comment on your experience with them just in general terms and what your thoughts are?
01:11:01
Speaker
Yeah, the bottom line is that they're all pretty good.
01:11:05
Speaker
I mean, the technology a few years ago was not really good enough for me to invest some money into it.
01:11:12
Speaker
But now,
01:11:13
Speaker
across all the major brands and I'll try to avoid using brands, uh, cause I don't get paid by anybody.
01:11:20
Speaker
But what I will say is that they're all very, very good.
01:11:24
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.
01:11:33
Speaker
And they get to it 90% of the time.
01:11:35
Speaker
And if I really need something else, someone can go get these still very portable machines, these laptop machines from the ICU over.
01:11:42
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.
01:11:49
Speaker
You have machine probes that could plug into your Android devices again, that fit in your pocket.
01:11:55
Speaker
And then you have handheld devices that come with the screen already built in, but are very lightweight and very, very portable.
01:12:02
Speaker
Their boot up times are instantaneous.
01:12:05
Speaker
And the quality of the images is just, it's just really amazing.
01:12:09
Speaker
And most of these offer cloud solution storage is
01:12:11
Speaker
So after you do the clips, they go right to a cloud.
01:12:14
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.
01:12:21
Speaker
That's really cool.
01:12:23
Speaker
So you've been on the podcast before.
01:12:25
Speaker
I think this was a great conversation, Haney, and we'll have a lot of references and resources in the show notes.
01:12:31
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
01:12:39
Speaker
your wisdom and you as an individual, would that be okay?
01:12:43
Speaker
Absolutely.
01:12:43
Speaker
I love this part.
01:12:45
Speaker
So last time we talked about books.
01:12:47
Speaker
At this time, I want to talk about music.
01:12:48
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?
01:13:00
Speaker
I love music so much.
01:13:02
Speaker
This is a really, really hard one.
01:13:06
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.
01:13:13
Speaker
But that doesn't mean that there's not 10 more I could give you.
01:13:18
Speaker
No, and I think that's a great choice.
01:13:20
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?
01:13:28
Speaker
And I think that's very powerful.
01:13:29
Speaker
That's a great choice.
01:13:30
Speaker
I mean, definitely, I have to say a seminal...
01:13:35
Speaker
a seminal album in my growing up in high school and truly, I mean, a beautiful, beautiful one.
01:13:42
Speaker
So we'll definitely link that.
01:13:44
Speaker
The second question relates to failure.
01:13:47
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.
01:13:56
Speaker
Could you share with us a really good failure, one that really taught you something valuable?
01:14:02
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.
01:14:10
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.
01:14:24
Speaker
So one of my things is education.
01:14:26
Speaker
I love teaching and I love innovative teaching.
01:14:29
Speaker
A couple of years ago, I ran a little course
01:14:32
Speaker
that I thought would be a really neat resuscitation course.
01:14:35
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.
01:14:44
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.
01:14:51
Speaker
And I really gave up and I said, well, that's it.
01:14:54
Speaker
I did it once and it's time to stop.
01:14:56
Speaker
But that was a big failure.
01:14:59
Speaker
And I, I,
01:15:00
Speaker
Took a couple of weeks.
01:15:00
Speaker
I thought about it.
01:15:01
Speaker
I restructured how I did it.
01:15:03
Speaker
The one thing I didn't do was I didn't do a course that I wanted to do.
01:15:07
Speaker
I did a course that I saw other people doing and just want to put my name on it.
01:15:11
Speaker
And so I went back to the drawing board.
01:15:13
Speaker
I redid everything again.
01:15:14
Speaker
And I did the course that I would want to go to if I was a participant in the course.
01:15:19
Speaker
And it took me a few years to do it.
01:15:20
Speaker
But last year, I just did that for the first time.
01:15:23
Speaker
And in my eyes, it was a huge success because when I was done, I was happy with it.
01:15:30
Speaker
The feedback I got from the participants was very positive.
01:15:33
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.
01:15:47
Speaker
And if you're happy at the end of the day, chances are other people will be happy with you as well.
01:15:52
Speaker
And I think that that's a great story.
01:15:54
Speaker
And there's a couple of things that we can dissect, I mean, as lessons.
01:15:59
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.
01:16:09
Speaker
And this whole concept of scratching your own itch or having an audience of one is absolutely right.
01:16:15
Speaker
If you do something that is interesting for you, most likely it will be interesting for other people.
01:16:21
Speaker
And I'm happy that despite that initial
01:16:26
Speaker
conference experience that you decided to go back to the drawing board, rechange it and do it again.
01:16:31
Speaker
And I, I know that that's been a great conference and I, from what I heard, it was very, very successful.
01:16:36
Speaker
Excellent.
01:16:37
Speaker
Well, thank you.
01:16:39
Speaker
The last question is relating to what would you want every listener to this episode to know?
01:16:48
Speaker
And this is in relation to ultrasound or, or anything at all?
01:16:51
Speaker
Your choice.
01:16:52
Speaker
All right.
01:16:53
Speaker
Well, I'll tell you this and I hope, uh,
01:16:56
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.
01:17:09
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.
01:17:15
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.
01:17:26
Speaker
He came to every single course that there was.
01:17:29
Speaker
He is asking questions that are very tough questions.
01:17:33
Speaker
He is in there doing ultrasound and learning how to do it on a granular level.
01:17:38
Speaker
What I want everyone to walk away from and what he really exemplifies is that there is no end to your training.
01:17:46
Speaker
And I know we always say it, you know, we're lifelong learners and we should be doing things.
01:17:50
Speaker
But when I see people not adopt new technologies, when I still see people hanging on
01:17:55
Speaker
to the old dogma of what they trained and not open-minded to, to what medicine is or sciences in general.
01:18:03
Speaker
It just exemplifies, he exemplifies that, that you always have to continue to push.
01:18:08
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
01:18:23
Speaker
care that we can give.
01:18:24
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.
01:18:50
Speaker
That's what I think everyone
01:18:51
Speaker
listen to this podcast, which I know so many already are, but really that's what I want people to take away.
01:18:57
Speaker
And I think that's a great place to stop, Haney.
01:19:00
Speaker
Becoming is better than being, and we should never stop learning.
01:19:03
Speaker
Thank you so much for your time.
01:19:05
Speaker
Always a pleasure to talk with you, and hopefully we'll have you back on Critical Matter soon.
01:19:10
Speaker
I look forward to it.
01:19:11
Speaker
Thank you so much.
01:19:13
Speaker
Thank you for listening to Critical Matters, a Sound Critical Care podcast.
01:19:18
Speaker
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01:19:24
Speaker
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01:19:29
Speaker
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