Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: Today in Critical Matters, we will discuss the use of point care ultrasound during cardiac arrest.
Speaker: Our guest is Dr. Haney Malamud.
Speaker: Dr. Malamud is board certified in emergency medicine, internal medicine, and critical care medicine, and works in the emergency department and intensive care unit at Cooper University Hospital in Camden, New Jersey.
Speaker: He also holds academic appointments in critical care medicine and emergency medicine at Cooper Medical School of Rowan University and has received numerous teaching awards.
Speaker: Dr. Haney Malamud has lectured extensively both nationally and internationally and has contributed to several emergency medicine and critical care podcasts.
Speaker: He is a firm believer in the benefits of bedside ultrasound for better patient care and today we'll get to poke his brain and understand how we can use this technology in cardiac arrest.
Speaker: Haney, welcome to Critical Matters.
Speaker: Thanks for having me here.
Speaker: What an honor.
Speaker: We're very excited about this topic.
Speaker: I know that
Speaker: What I think about is right now we're doing a podcast at the brink of the generational divide.
Speaker: Me being trade before ultrasound and you in the world of after ultrasound.
Speaker: So why don't you talk a little bit about how you've seen in the last five years, ultrasound in general grow both in emergency situations in the emergency department, but also in intensive care unit.
Speaker: It's really been amazing because I first started training and I was on the cusp of the beginnings of ultrasound and the ending of
Speaker: the physical exam for doing procedures.
Speaker: So I learned how to do an IJ and a subclavian and a femoral blind.
Speaker: And I still have some of those skills, but after my first year, I learned how to use ultrasound, not only for procedures, but also how to do diagnostic stuff.
Speaker: And I have to say over the past several years, what I've noticed is a transition from people
Speaker: who go with differential diagnoses by looking at mucous membranes and capillary refill to determine whether or not someone is in shock, to just looking directly at the circulation, taking a look at the heart, taking a look at the IVC, and then doing more advanced concepts at the bedside to determine whether or not someone needs fluids, anatropes, if they need their pericardial fluid drained.
Speaker: So I've seen a shift in people who just kind of pontificate a lot to right when they're evaluating someone who's very sick,
Speaker: ruling things in and out immediately.
Speaker: And I got to tell you, it's an amazing time to be a resuscitationist in medicine right now.
Speaker: And I think that that's exactly what I perceive.
Speaker: And I'm obviously a little bit more detached from maybe the cutting edge as you are, but it seems that there's an evolution from a diagnostic imaging test modality to an extension of our physical exam at the bedside.
Speaker: Is that what you're sensing?
Speaker: Absolutely.
Speaker: And when I first started doing ultrasound and teaching ultrasound, I would say this is an extension of our physical exam.
Speaker: And I have to tell you that some of the ultrasound gurus didn't really like that analogy.
Speaker: And the reason why is because it minimizes ultrasound as being just a physical exam thing, but it's something more.
Speaker: But I truly feel that I cannot evaluate that.
Speaker: I'm patient nowadays unless I have an ultrasound in hand.
Speaker: I still think physical exam skills are very important, but if I'm pushing on someone's belly and I'm looking for right upper quadrant tenderness, why wouldn't I look under their skin with the ultrasound just to see if there's a stone?
Speaker: We're moving from looking at our physical exam findings, which are indirect associations with diseases, to just looking to see if the disease is there.
Speaker: And I think that is such a shift in our physical exam.
Speaker: And I really don't see any difference between the tests we call ultrasound and the physical exam we call ultrasound.
Speaker: It's just a new way to evaluate patients through and through.
Speaker: And what do people mean when they say POCUS?
Speaker: I hear that term thrown a lot in the literature.
Speaker: Yeah, the important thing we have to remember with ultrasound, and as much as I love it, we have to know what our limitations of ultrasound are.
Speaker: So POCUS stands for Point of Care Ultrasound, P-O-C-U-S.
Speaker: And the reason why that's an important term to emphasize for us in the emergency department or in the ICU is we're doing a very binomial dichotomous question when we're doing the ultrasound.
Speaker: We're not saying, is the EF 34%?
Speaker: Is the EF 56%?
Speaker: We're just looking for big picture yes or no.
Speaker: The person's in shock.
Speaker: Is the LV, the left ventricle, functioning properly?
Speaker: Just yes or no.
Speaker: And that's what makes things point of care, just distilling things down to very simple questions so that you can move on and do other things.
Speaker: This isn't to replace what sonographers do at the bedside.
Speaker: There's an enormous responsibility and need for the higher level of ultrasound that people are doing, but those are doing formal ultrasounds.
Speaker: What we do point of care is we're just asking, is that disease process there?
Speaker: Yes or no.
Speaker: Do I need to do this intervention?
Speaker: Yes or no.
Speaker: And we keep moving on.
Speaker: And I think that's a very important distinction because we're not trying to convince people that every intensivist resuscitationist should be a ultrasound master, but they should be able to use this tool as an extension of their evaluation at the bedside in a binary way to answer yes, no questions and direct interventions.
Speaker: Is that correct?
Speaker: Yeah, absolutely.
Speaker: And whenever I teach courses or I just get emails from people who want to learn more, their biggest hesitation to ultrasound is that they say, I just don't feel like I can learn that much.
Speaker: And what I tell them is it's actually you don't have to learn that much.
Speaker: You just have to be able to identify that something is wrong with the patient.
Speaker: and then you're gonna go on and do another diagnostic test.
Speaker: That might be doing an official ultrasound, that might be going right to CT scan.
Speaker: But the point is, is you wanna identify things and keep working them up or rule things out so you can look for other causes for their disease.
Speaker: I think this is an excellent lead way into our discussion and the meat of what we're trying to address today, which I guess is to POCUS or not to POCUS during a cardiac arrest or a code blue.
Speaker: So why don't we dive in to a specific use of ultrasound in a cardiac arrest situation?
Speaker: And I guess we could start by breaking it up into three big areas, which would be diagnostic, prognosis, and procedural.
Speaker: So before we go into the specific and nutty gritty of exactly what we're doing, why don't we address those?
Speaker: Can you tell me a little bit, Haney, of how you would use ultrasound in a situation of cardiac arrest from a diagnostic standpoint?
Speaker: Well, what we know from studies and what we know from our own personal experiences is that when we come to a code and we see somebody who is asystole or PA arrest and they don't have a pulse, one of two things is happening.
Speaker: The person is either in true electromechanical dissociation or PEN,
Speaker: a pulseless electrical activity or their pseudo PEA.
Speaker: And the only diagnostic tool that we have available to us are our fingertips, which are absolutely horrible at determining the difference between the two.
Speaker: This has been shown in studies that bedside physicians, paramedics, nurses don't have the sensitivity and specificity to determine whether or not someone has a pulse.
Speaker: And we certainly don't have that accuracy within the 10 seconds we're supposed to be figuring this out before starting CPR.
Speaker: That's the first part.
Speaker: And then we also have patients that their habitus prevents us sometimes from feeling a good pulse.
Speaker: You have that morbidly obese person who you're not feeling ephemeral or radial pulse because they may have a very weak pulse, but their adipose tissue is limiting you from doing that.
Speaker: I'm getting at is that when you come to the code you don't know if that person actually has a pulse or they don't have a pulse and the end what you're relying on is just your fingers so coming up to a code the first thing that I do is if it's non VF or non V tack what I do is I start chest compressions and I
Speaker: good chest compressions, the things that we normally do, oxygenation, epinephrine, if you believe in it.
Speaker: And what I try to do is get everything in place for the ultrasound that's going to happen during the rhythm check.
Speaker: I don't stop CPR when we first get on the scene just to do the ultrasound because I think that'd be foolish.
Speaker: We know that we have to load up the coronary arteries with good perfusion before we do an intervention anyway.
Speaker: So I try to get two to four minutes of CPR as I'm getting the machine to the bedside.
Speaker: And then when it's time for a rhythm check, then we're going to go ahead and do the ultrasound.
Speaker: So I think you pointed out that the first utility in terms of diagnosis might be in terms of determining is this really, like you said, PEA, EMD, or is it pseudo-PEA in which there's cardiac contractility?
Speaker: Now, in the case of PEA, absolute PEA, is there other things that you might be able to pick up with the ultrasound that might be helpful in terms of interventions that might make a difference?
Speaker: Yeah, so,
Speaker: The more we do ultrasound at the bedside and we find these PAs, what we find out is actually that they, most of the time, the pump is actually working.
Speaker: There's actually some sort of squeeze.
Speaker: There's a reversible cause underneath.
Speaker: So the things I'm looking for immediately when the person is having an arrest is if they're pericardial effusion.
Speaker: That's my first question because that's something easy to remedy.
Speaker: The next question is what the right ventricle size is.
Speaker: Is it a big RV?
Speaker: Are we looking at a PE happening here?
Speaker: I tried to go on and look for lung sliding to see whether or not this person could have a tension pneumothorax.
Speaker: So clearly three interventions that might have a specific therapeutic response that could make a big difference and that otherwise we might not be able to start.
Speaker: yeah absolutely i'm looking for big things that you know i don't want to wait it used to be at the end of the code the intern sticks the needle in the sub-xiphoid and gets to do pericardial synthesis well that's foolish if i know that someone has a pericardial effusion and they have tamponade and that's the reason why they're coding i don't want to wait 45 minutes into the code i want to know the first five minutes before that person has anoxic brain injury i want to get that fluid out if i know that person has a big dilated rv well
Speaker: I want to give that person TPA at the beginning of the code to restore perfusion as fast as I can.
Speaker: And then the other thing that I'm looking for sometimes during these codes, as I mentioned before, is that sometimes the heart is just not generating enough kick.
Speaker: So the heart is beating, but it's just not generating enough of a systolic, um,
Speaker: pressure with the stroke volume to generate a pulse.
Speaker: And that's why we're not feeling a pulse.
Speaker: So for those patients, I might actually start that person on low dose epinephrine rather than the, you know, the milligram that we give every three minutes.
Speaker: Maybe they just need a little inotropic kick to get their blood pressure up.
Speaker: But what I'm getting at is that I'm looking in that first or second rhythm check to find out what I can do immediately for this person to explain, you know, why on earth this person is having an arrest.
Speaker: And is there any value or any techniques that you utilize in these situations trying to ascertain what the intravascular volume might be if somebody just has severe depletion of intravascular volume and that might be contributing to the shock situation?
Speaker: Yeah, for the cases that I've seen where someone is actually arresting and they're hypovolemic, the
Speaker: Again, their volume, their chambers are empty.
Speaker: I mean, their left ventricle, the right ventricle is tachycardic.
Speaker: It's completely empty.
Speaker: It just looks like a thin muscle.
Speaker: It's something that intuitively when you see, you would say that heart looks empty.
Speaker: And so when I see those cases, again, the heart is beating.
Speaker: It's not arresting.
Speaker: They're just not able to generate a stroke volume to generate a pulse.
Speaker: So that's a person that I'm going to get immediate intravascular access and just dump fluids or if they're bleeding, then blood.
Speaker: Excellent.
Speaker: So I think that what I'm hearing is that clearly there seems to be two situations or two aspects of the diagnostic utility of ultrasound that are quite, quite dramatic.
Speaker: One is those cases in which we thought we had PEA, but there's actually a beating heart in which maybe we need to intervene with basalactives, fluids, and other interventions.
Speaker: And the other one that perhaps not as common, but clearly very dramatic in terms of the implications, is those patients that very early you identify have cardiac tamponade.
Speaker: Yeah, exactly right.
Speaker: What about using the ultrasound as a prognostic tool in patients who arrive maybe to the ED in an arrest situation?
Speaker: Yeah, so I want to make a disclaimer here because I've noticed that sometimes this literature crosses over to the ICU for a code, and all the stuff I'm about to say has only been validated in an outpatient or ED setting.
Speaker: So there have been a lot of studies that have looked at the prognostication of people who come into the department with out-of-hospital cardiac arrest.
Speaker: Initially, I think it was back in 2001 when the first study came out, there was a lot of excitement because the study showed that if someone came out of the hospital with cardiac arrest and their initial ultrasound showed cardiac standstill, their rate of survival was zero.
Speaker: And that was helpful for a long time for people because every time someone came in, they would run the code.
Speaker: An older person stands, so they say there's a 0% chance this person's going to survive.
Speaker: If they were younger, maybe they'd do a little bit, but they weren't dumping a lot of resources into it.
Speaker: Then over the years, there were a couple more studies that have come out, smaller studies, that have said, well, maybe it's not 0%.
Speaker: Maybe it's 1% or 2%.
Speaker: And so there was a lot of confusion in actually what the prognosis is for people who come in and out of the hospital cardiac arrest.
Speaker: So Romulo Gasparri, who is a real ultrasound guru and great researcher from the Northeast, I believe the Boston area, did a study where he did a multicenter academic in the United States, took about 800 patients, and he divided them up into patients who came in in PA arrest,
Speaker: or a systolic arrest.
Speaker: And no patient was included if they were ventricular tachycardia or ventricular fibrillation.
Speaker: Those patients got shocked.
Speaker: They were not in this study.
Speaker: But of the 793 patients, they, 414 had PEA and 379 had a systole.
Speaker: When you look at the 414 that had PEA, 225 of those patients actually had cardiac motion.
Speaker: So again, it's that case of the person who's just not generating enough of a kick, but their heart is clearly moving.
Speaker: And then 1809 of those people were what we think of as PEA, electrical activity and pure cardiac standstill.
Speaker: On the other end of things, it was very interesting.
Speaker: 379 people had asystole.
Speaker: 38 of those people who were asystole actually had cardiac motion.
Speaker: And the other 341 were pure cardiac standstill.
Speaker: Fascinating.
Speaker: But I think that as you very clearly warned us, this is not to be translated into the ICU or maybe the medical wards because it's a very different situation when we get called to a code blue on a floor or in the ICU, correct?
Speaker: Absolutely.
Speaker: Most of the codes that we see in the hospital, as you know, are more of a respiratory type code, and occasionally we'll see electrolyte type code.
Speaker: So I think that this is something that will be shown in hospital literature in some form, but I'm not sure if it's going to be these exact numbers.
Speaker: And, you know, the bottom line of this study, what they found, though, is that when patients come in in cardiac standstill on their first, whether it was systole or PA, they had a 0.6% chance of survival to hospital discharge, which is, you know, obviously less than 1%.
Speaker: It's exceedingly low.
Speaker: But when patients came in with
Speaker: cardiac arrest, but did have some cardiac motion, 4% of those people survived to hospital discharge.
Speaker: So that's pretty helpful, I think.
Speaker: If I have someone young come in and they have cardiac activity, I'm going to work a little harder on that person.
Speaker: And if someone comes in from a nursing home who has terminal cancer or some sort of systemic disease and they don't have motion, I can confidently say that it's time to stop the code.
Speaker: The other interesting thing they found in the study is that they found 15 of the patients who
Speaker: who came in actually had a PE and they gave TPA to those patients and two of those patients survived to admission.
Speaker: The other, there were 34 patients that had a pericardial effusion and 13 of those patients got a procedure and survived to hospital discharge.
Speaker: So it's true that you can actually find reversible causes, act on them, and you can save a life by using ultrasound quickly at the bedside.
Speaker: What about the use of ultrasound from a procedure standpoint in the context of a cardiac arrest?
Speaker: And you mentioned some of these, but maybe you can dive in a little bit more.
Speaker: There's not many procedures that I would use during a code.
Speaker: There's not many procedures that I would use ultrasound for during code.
Speaker: I like to get an arterial line in patients.
Speaker: I mean, that is one of my, that is now one of the things I try to use routinely in every code.
Speaker: And so for that, I will use ultrasound to get the arterial line in.
Speaker: I'm not doing central lines during a code.
Speaker: I'll put an IO in because I truly believe, first of all, it's chaotic.
Speaker: Someone's going to get themselves stuck.
Speaker: And if I want to have one sharp on the field, it's an A line for the person.
Speaker: That's more helpful to me.
Speaker: I can always put an IO in and give any central presser that I need.
Speaker: Other things that I would need during a coat possibly would be if someone has a pericardial tamponade, then I would use the ultrasound to help guide the needle into place.
Speaker: And then finally, although rarely, is if someone has a big tension pneumothorax, the possibility of putting in a chest tube to avoid the liver.
Speaker: But in all honesty, if someone's having that big of a tension pneumothorax, I'd probably go anteriorly and decompress them blindly.
Speaker: So even though I do love ultrasound, there's still room to do blind procedures still.
Speaker: What about intubation?
Speaker: I know that some people have talked about utilizing the ultrasound as a quick way of verifying that the ET tube is in the right place.
Speaker: And I guess in a situation where your CO2 detection might be compromised, is that something that you can comment on, Haney?
Speaker: uh i'll tell you the truth more so these days i'm not intubating people during codes uh from some of the you know the jama literature from earlier in the year i'll probably put an lma in a person but if i do have somebody who's having a difficult airway
Speaker: Yeah, you can use a linear probe on the side of the neck and watch the tube going either through the trachea or through the esophagus.
Speaker: So there are ways we can confirm tube placements.
Speaker: During a code, I haven't done that, and I probably wouldn't do that just because there's so much happening.
Speaker: And if the operator can't get the tube in within the pulse check or doing compressions, then we're just going to put an LMA in, and we're going to continue with the code.
Speaker: But during routine intubations, I'll bring out the ultrasound, especially when it's a difficult or obese person, where I want to see confirmation of the tube passing and I don't have video laryngoscopy available to me.
Speaker: Excellent.
Speaker: And just a technical question, what probe do you usually use to verify the ET tube?
Speaker: For that, you want to use a linear array probe.
Speaker: Linear array probes are good for superficial structures where you want a lot of resolution.
Speaker: So, you know, looking at veins, looking at arteries, looking at nerves, and then looking at the esophagus and the trachea, those are relatively superficial as well.
Speaker: Excellent.
Speaker: So I think that what I'm hearing is that when you do procedures, you're only going to do the procedures that are absolutely essential.
Speaker: You're going to minimize the interruption with CPR.
Speaker: And I presume that if you're doing an arterial line, you're doing it probably radially while people are doing CPR.
Speaker: Is that correct?
Speaker: No, actually, I do all my lines femorally during a code.
Speaker: And I do that because I'm out of everyone's way.
Speaker: But the other reason is I'm gearing myself up for the future when we start doing ECMO.
Speaker: Friends of mine, Joe Belezzo and Zach Shiner out in Sharp Memorial in San Diego, they're doing ECMO from the ED during cardiac arrest.
Speaker: So part of their staging of ECMO is first getting the arterial line in the femoral.
Speaker: artery because when they get that femoral line in and they decide that they're going to proceed with ECMO, all they do is they wire out that A-line and then wire the big cannula with serial dilations.
Speaker: Makes sense.
Speaker: I mean, excellent point.
Speaker: So I guess this can lead into the next question I have.
Speaker: So far, we've heard of all the advantages and pluses of bringing a ultrasound probe to the bedside during a cardiac arrest.
Speaker: Are there any potential dangers or downsides that you want to comment on?
Speaker: Well, the only dangers that I personally see are during a code, and we'll talk about that second because that's a longer discussion.
Speaker: And the biggest one that I see, and I hope this doesn't become something that our ID folks or JCO catches wind of, and that's the infectious potential of ultrasound.
Speaker: I think with good care and good cleaning, ultrasound is a very safe way with minimal transmission of disease.
Speaker: But unfortunately, what I see is as ultrasound becomes present and used more routinely is
Speaker: The cleaning is not always the best.
Speaker: The probes are bloody.
Speaker: The machines are not cleaned out.
Speaker: People get a little bit lazy.
Speaker: And I just hope that we get better ultrasound hygiene so that our patients don't start developing infections.
Speaker: And then it's a device that they take away from us with some hospital-based initiative.
Speaker: That's the only real potential worry I'm concerned about with routine ultrasound.
Speaker: But for cardiac arrest, the one thing that I think we should dive into is the dangers of getting caught up in doing ultrasound during a cardiac arrest.
Speaker: And, you know, sometimes they call this ultrasound hypnosis.
Speaker: You know, during that 10 seconds of your rhythm check, when someone should be spending time doing quick looks up with ultrasound,
Speaker: is that people get caught up in this and they're looking at the screen and they forget that they gotta get their hands back on the chest and do compressions.
Speaker: And there was a nice paper done in circulation by one of my friends down at University of Maryland that showed that the time for patients, the time that ultrasound was used, the pulse check went up to something like 21 or 23 seconds, something like that, versus the other group that had a pulse check of 11 seconds not using ultrasound.
Speaker: So ultrasound actually increases
Speaker: the amount of time you're spending off the check.
Speaker: And that's a detrimental thing to codes.
Speaker: And we can talk a little bit about some of the strategies that I use to decrease that time.
Speaker: I think that would be a great next segment.
Speaker: Why don't you just tell us in detail what are the things that you worry about and how you would actually go about doing the ultrasound during an actual cardiac arrest?
Speaker: Yeah.
Speaker: So one of the things I mentioned earlier is that I don't take my hands off the chest until the person who has the ultrasound is standing at the bedside with the machine on, with gel on the probe, and ready to put their probe down on the chest.
Speaker: There's no sense if the machine's not even in the room or coming in the room to stop doing chest compressions.
Speaker: I'd rather go five minutes of continuous chest compressions and wait for that person to come in than to do three minutes, do a rhythm check, and then go back out and wait for the person to come in the room.
Speaker: So that's essential.
Speaker: The second thing I do is I only let the most senior experienced person with ultrasound do the ultrasound.
Speaker: This is not a time for the medical student to learn how to do a couple views.
Speaker: This is not a time for the resident who's done a little bit of ultrasound.
Speaker: I need the fastest person to get on the chest,
Speaker: to get some answers and then get right back off the chest so that we can do chest compressions.
Speaker: So that's tip number two.
Speaker: Tip number three, and this is a tip not for ultrasound only, but for any rhythm check, is I tell my charge nurse as we're starting the code, whenever we get to a rhythm check, I would like you to count down backwards from 10 out loud so that
Speaker: Everyone in the room knows when we're getting down to the end of the rhythm check that we have to get ready to do chest compressions so there can be no questions in the room.
Speaker: And also for the person who's doing ultrasound to know that they better get their hands off the chest when we get to three, two, they better be off the chest because we're going to push them to the side and we're going to be doing chest compressions.
Speaker: And the very last thing that I do is I like to not pay too much attention to the clips that I'm taking.
Speaker: And what I mean by that is during the rhythm check,
Speaker: I'm not doing any analysis of the clips that are out there.
Speaker: What I'm doing is I'm just taking clips of them.
Speaker: I'm trying to get my views and just take clips.
Speaker: And I try not to think about what I'm seeing.
Speaker: What I do is that during the next round of chest compressions, I will move the machine off to the side and I will look them over and then I'll start to do an analysis.
Speaker: Is that a paracardial effusion?
Speaker: Is that LV beating strongly?
Speaker: Is that RV big?
Speaker: I ask those questions while the person is getting chest compressions, not at the time because that's what detracts from good old-fashioned chest compressions.
Speaker: And those are the tricks that I use to minimize the amount of time with hands off the chest.
Speaker: So I like that.
Speaker: I mean, we'll call them the Haney top four.
Speaker: And the Haney top four, just to remind our audiences, number one is preparation.
Speaker: Make sure that whoever's bringing in the ultrasound is turning the machine off, turning the machine on, has the lube ready, is ready to put the probe on the chest.
Speaker: And during that time, we're doing CPR till everything is ready.
Speaker: Number two is to have our nurses or people who are in charge to count down the time that we're interrupting CPR.
Speaker: So we know going down from 10, 9, 8, exactly what's going on.
Speaker: Number three would be to make sure that the person doing the ultrasound is the most senior person with ultrasound experience in the room.
Speaker: Like you mentioned, Haney, th is is not the time and it's not fair to our patients to be teaching at this moment.
Speaker: And number four would be related to the sonographer who's acquiring the images not to waste any time in trying to interpret or analyze what they're looking at.
Speaker: but just to record the clips.
Speaker: So once we resume CPR after that 10 second interruption, we can then with more detail look into those clips.
Speaker: Does that capture the Haney top four?
Speaker: That's perfect.
Speaker: Excellent.
Speaker: So let me ask you regarding some technical aspects.
Speaker: What probe are you using?
Speaker: A lot of the people who are listening to this are very naive or don't have a lot of experience.
Speaker: What windows are you utilizing usually when you're trying to look at this?
Speaker: So I'm always using a phased array probe.
Speaker: I'm not always.
Speaker: If I have a curved linear probe, then I'll use that one that's there, but I prefer to use the phased array probe.
Speaker: It gets to the rib spaces, it's easy to use, and it gets the best resolution.
Speaker: The view that I use primarily is I do the parasternal long axis view.
Speaker: It used to be that people did the sub-xiphoid view, and I used to use a sub-xiphoid view, but our patients' anatomy has been changing over the years as our diets have been changing, and I find it very difficult to get underneath some of the bellies that are very obese.
Speaker: So to avoid all that, I tend to go anteriorly to the parasternal area.
Speaker: which is a nice clean area, you get great imaging.
Speaker: The only hangups with that is that if you have a patient who's in the unit who's post-cardiac surgery, you know, all that with the sternotomy site, you might not get a good view.
Speaker: And the other thing that's a problem is that it makes it very slippery for the people who are gonna be coming in after you do chest compressions.
Speaker: So just be sure you have a towel in your other hand and wipe it down really good so people aren't sliding off the bed during chest compressions.
Speaker: Makes sense.
Speaker: And I think that you mentioned the cardiac surgery patient, and that might be a good lead way into the question I had for you in terms of is there any role or do we have any experience or data with utilizing transesophageal echocardiography in this situation?
Speaker: A lot of what we talked about obviously applies to transthoracic echocardiography.
Speaker: Yeah, there's more and more data that's coming out that's saying that TEE, transesophageal echo, in general is a better modality for any cardiac arrest.
Speaker: Certainly for our patients who are cardiothoracic surgery patients, the fact that they may have some air in the chest, the surgical scar, the
Speaker: the fact that tamponade might not really readily be seen with trans thoracic most surgeons in the perioperative phase will prefer a TEE when the patients are starting to get sick during the code situation TEE is a fantastic option and I can
Speaker: hear all the listeners right now rolling their eyes, saying there is no way that I'm going to be able to use TE during COVID because I'm not even using trans thoracic.
Speaker: So can we just have like a couple of minutes of suspend your disbelief?
Speaker: Is that allowed?
Speaker: Absolutely.
Speaker: This sounds like crazy talk.
Speaker: And you know what?
Speaker: It is crazy talk until you start doing TEEs and seeing them done.
Speaker: I will tell you right now that TEE is much easier to do and much easier to interpret than transthoracic.
Speaker: It's easier to do because we've all put in NG tubes before.
Speaker: We've all put in DOB pop tubes before.
Speaker: This one's just a little bit thicker, but there's no difference.
Speaker: You're putting a tube into a patient who's presumably already intubated,
Speaker: and you're going to go and look at the heart.
Speaker: Now, the best part about transesophageal echo during a code is that you don't have to stop chest compressions to start your evaluation because you can look at the heart continuously during chest compressions, and you can already start to get a sense of if anything's reversible.
Speaker: And then when chest compressions are held for your rhythm check, you don't have to take the full 10 seconds to do your imaging.
Speaker: You see right then and there the image on the screen and figure out whether or not anything is reversible or not.
Speaker: there's also some more benefits about it the next benefit about it is that you can see chest you could see how deeply you're compressing the chest in other words we assume that you're just pushing down on the chest
Speaker: You know, four and a half to five centimeters, I've never been able to measure it.
Speaker: But when you use TEE, during chest compressions, you can actually see how deep the chest compressions are going by following how much the sternum is moving up and down.
Speaker: And this is an area of budding research, but you can actually tell your chest, the person who's doing your chest compressions, hey, man, you got to push harder because I can clearly see from the screen you're not pushing hard enough.
Speaker: And the last thing that I think is super helpful is that we assume that when we push on the chest, on the sternum, that we're causing the left ventricle to compress.
Speaker: And what you'll see when you do TE over and over again during cardiac arrest is that not everyone's hearts lie in the same place.
Speaker: So even though this person who took ACLS is pushing right where they're supposed to be pushing,
Speaker: they're not pushing the left ventricle up and down, they're pushing it side to side.
Speaker: And you can actually tell the person who's doing your chest compressions, while they're doing chest compressions, move it a little bit to the left, move a little down on the sternum, and get it to the point where you're doing goal-directed chest compressions, and you'd say, okay, that's perfect.
Speaker: That's where I want you to do the chest compressions, because that's where you're getting the maximum compression of the LV during chest compression.
Speaker: So TEE is really, really, really, I want to say it's the future,
Speaker: But it's already happening in many centers now.
Speaker: We just have to catch everyone up to it.
Speaker: And believe me, you don't have to know trans-thoracic to do trans-esophageal echo.
Speaker: And I think that really, if you think what you're saying and the narrative here is that most people that are listening to this podcast probably are in cardiac arrest 1.0.
Speaker: And the technology is the stethoscope, which is over 200 years old, and their fingers, which is, like you said, very nonsensitive.
Speaker: humongous upgrade if we can do it right with transthoracic point-of-care ultrasound.
Speaker: And it seems that that would be cardiac arrest 2.0.
Speaker: And what you're really talking about is cardiac arrest 3.0, which is using the transesophageal probe, which is becoming smaller and cheaper and more available very quickly.
Speaker: And that really minimizes interruptions, provides guidance in terms of what we today understand to be perhaps the most important intervention in a cardiac arrest, which is proper CPR.
Speaker: So it sounds like that really is the future for a lot of our patients.
Speaker: Haney, let me ask you.
Speaker: Go ahead.
Speaker: No, no.
Speaker: I completely agree with you.
Speaker: I wanted to ask you, let's say that you're working tonight or tomorrow morning and they call a code.
Speaker: What do you take?
Speaker: Do you have like a little portable TE?
Speaker: Are you running with your trans-horacic first?
Speaker: How do you make that decision right now?
Speaker: Is TEE something you use more in the ICU right now in certain populations, like an intubated cardiac surgery patient?
Speaker: It seems like it's the obvious tool.
Speaker: But how do you decide what happens in real life in your practice right now?
Speaker: For me, if I'm going to a code on the floor, I'm taking a handheld device and I don't want to, as a CME program, I don't want to endorse one or the other, but I take something with me so that during the code, I could see what's happening.
Speaker: 98% of the time, I could see the things I need to do during the code, and I might not need to do a transesophageal echo.
Speaker: But if I'm in the emergency department or I'm in the ICU where I have my station set up, I might start off with a transesophageal call over for the TEE.
Speaker: And then during one of the rhythm checks, I'll try to pass down that TEE probe so that the next round of CPR, we can start taking a look at things.
Speaker: An interesting question that I have that I think is brought up
Speaker: Often when we talk about technology, we always say that as we rely on newer technology, we lose certain skills.
Speaker: And I think that that might or might not be true, but I want to flip that around and ask you, by doing codes for the last years, very frequently with the assistance of ultrasound, what have you learned or what skills away from the ultrasound have improved as a resuscitationist?
Speaker: Well, I think I'm spending less time contemplating
Speaker: the what ifs.
Speaker: I spend less time looking at JVD to figure out whether or not someone has tamponade and I just cut right to the chase and I just look at the heart.
Speaker: I got to say overall, the physical exam is still a beautiful thing and I think it's an art form.
Speaker: You see this attending who's been doing it for 50 years do the physical exam.
Speaker: It's really a beautiful thing and let's face it, if nothing else, it's a way for us to touch our patients and connect with our patients.
Speaker: Over the years, with ancillary testing, CT scans, and MRIs and stuff, we're touching our patients less because we just send them for tests.
Speaker: But I think what's really cool about ultrasound, and I don't mean to get all, you know, mushy on you, but I will.
Speaker: that ultrasound kind of brings us back to being next to the patient you have to touch the patient you have to sit next to the patient you have to talk to them interact with them move them around and if nothing else ultrasound it just allows you to form a closer bond with your patient so I don't know if I answered your question exactly but that's one of the benefits that I see with with bedside ultra especially for our our younger residents and fellows and attendings who are now relying on just sending people out for more and more tests and and I
Speaker: and writing on EMRs where we're getting further away from that personal touch that I think took us to medicine in the first place.
Speaker: Well, I think it's a great point because
Speaker: Another technology that has grown significantly since my resident days to now is a medical record, an electronic medical record.
Speaker: And no doubt in my mind that that has moved us away from patients.
Speaker: So maybe, I mean, this is emerging technology or newer technology that, like you said, brings us back to the bedside, which is where the magic really happens in terms of the human connection and the human interaction that we have with our patients.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: A lot of the people that are listening to our podcast, a lot of our critical care practitioners at Sound Critical Care, don't have the level of expertise, obviously, that you have, Haney, in terms of ultrasound.
Speaker: If somebody did not have the opportunity to train extensively in ultrasound, I think that more and more people are utilizing it for procedural aspects like central line insertions, A-line insertions,
Speaker: and other procedures, but if they wanted to improve and they're already in practice, what would you recommend?
Speaker: So many people ask, you know, what course should I take?
Speaker: What's the best course?
Speaker: And I definitely have my preference of courses, but I'll tell you this without telling you any courses names in particular, it doesn't really matter what course you go to.
Speaker: Because ultimately when you get to a course, what you need to do is learn how to do the views and then you need to get to practicing.
Speaker: And the best courses are the ones where you're actually scanning most of the time.
Speaker: But it doesn't end there because after the course, the most critical thing you could do is go back to the bedside when you get back to your hospital and just scan as many patients as you can.
Speaker: Now, I'll admit to you, I...
Speaker: You know, read about ultrasound, watched as many videos as I could, went to courses.
Speaker: I really went down the rabbit hole.
Speaker: But at the end of the day, I knew a lot of stuff, but I couldn't get images on the screen.
Speaker: And the way to get images on the screen is just to spend the time scanning patients.
Speaker: I used to scan every patient in the ICU.
Speaker: I wouldn't do a comprehensive scan, but I would scan every – I'd do a sub-xiphone on every patient every day.
Speaker: The next day, I would do a parasternal long axis view.
Speaker: on every patient every day.
Speaker: And by the end of the week, I had so many scans under my belt.
Speaker: So what I'm getting at is that you don't have to be a guru.
Speaker: You don't have to learn all about the fancy techniques with ultrasound, but you just have to learn how to get some basic images because at the end of the day, it's just about recognizing what looks grossly abnormal or grossly normal, and then going to the next level in your algorithm for that patient.
Speaker: Excellent advice.
Speaker: And I think that in terms of strategy, it applies to something that I've heard people talk about with books.
Speaker: When people ask, what's the best book, it's the book you read.
Speaker: And it also, I think, relays to just do it.
Speaker: You got to put the probe on patients and do it over and over again to acquire those skills.
Speaker: So I think that that's something that is very helpful.
Speaker: And I think that often we forget looking for some magic bullets.
Speaker: Yeah, and the other thing I want to say is that don't forget, back in the day when I was in medical school and I'd graduate, you know, what did your parents get you?
Speaker: They got you like a stethoscope with your name on it.
Speaker: Well, realize that these machines are getting so small and so inexpensive.
Speaker: Now these medical students are getting ultrasound machines for graduation.
Speaker: And what that means is...
Speaker: is that they're going to be running around the ICU doing scans on all your patients and start asking you questions about what this is.
Speaker: So another reason to step up your game is like you don't want to be showed up by like this, you know, 25-year-old, you know, medical student showing you up.
Speaker: So, you know, we have to pick up our skills to make sure that we're one step ahead of these guys.
Speaker: Just another reason to practice that ultrasound.
Speaker: Right there, you just made me age like 50 years.
Speaker: Well, I think that we covered a lot of very interesting points.
Speaker: I think this is obviously a fascinating topic for a lot of our listeners, something that they're aspiring to, for others, something that they're doing.
Speaker: But we have seen over the last several years that the penetration of bedside ultrasound and critical care and that the emergency department continues to grow.
Speaker: And I don't see that it's going to go away.
Speaker: It's just going to get more and more prevalent as a new generation with these skills starts coming up the ranks.
Speaker: So I think you're absolutely right in that respect.
Speaker: But one of the things that we also like to do at Critical Matters, Haney, is touch on some other aspects of practicing medicine and tap into the wisdom of our guest.
Speaker: And if it's okay with you, I would like to wrap up by asking you a series of short questions just to poke your brain a little bit.
Speaker: Would that be fine?
Speaker: That's great.
Speaker: Let's do it.
Speaker: Okay.
Speaker: Hi.
Speaker: So why don't we go with... Did you say Siri?
Speaker: Yeah.
Speaker: I did too, no.
Speaker: So why don't we go with the first question?
Speaker: And it'll be interesting to know if there is a book or books that have influenced you the most or a specific book that you have gifted the most and why.
Speaker: Oh, gosh.
Speaker: Um...
Speaker: Well, how about I give you the most recent book that I've read that's actually kind of – that's really inspired me.
Speaker: That works for me.
Speaker: I don't know.
Speaker: Maybe this is weird for a medical podcast, but I just recently read after having this gifted to me twice.
Speaker: I recently read Rich Dad, Poor Dad.
Speaker: As physicians, I'm making a general statement, but I'm pretty sure this is true.
Speaker: We're terrible at finances and planning the future.
Speaker: And so here I am, 41 years old and reading this book and really opened my eyes up to really taking care of finances and thinking about how money flows in and out of our pockets every day.
Speaker: So,
Speaker: It's kind of like one of those quintessential people have called it a real estate book, but I think it's a really good life book on how we can get our finances in order.
Speaker: I'm certainly recommending it to any resident I know or medical student just so that as they go through debt and climbing out of debt, it's a really good book to help put things into perspective.
Speaker: And I think it touches on a very pragmatic aspect of life that, like you mentioned, we're not very good at in general as physicians.
Speaker: And I think that it touches to the point that we work very hard for our money.
Speaker: Shouldn't our money be working as hard for us?
Speaker: That's right.
Speaker: Exactly right.
Speaker: Well put.
Speaker: Excellent.
Speaker: So the next question is, is there something that you believe to be true in medicine or in life that most other people don't believe?
Speaker: That's a tough one because I don't fancy myself as having any special insight that other people don't have.
Speaker: But I'll tell you something that someone told me a long time ago.
Speaker: It's really simple advice, and I believe it's taken me far.
Speaker: And I think in medicine, part of this gets forgotten.
Speaker: So the advice is work hard and be nice.
Speaker: nice you know very simple four words work hard and be nice and really you could do whatever you want to do and it's kind of corny but you know I see so many people in medicine who are young who who are super smart they're really driven and then you interact with them you get to the bedside and they're just not nice people or they lose themselves in the science or they lose themselves in being a physician or healthcare professional
Speaker: And they kind of asked me, why am I not going to the next level?
Speaker: And they're lacking part of the formula, which is to just be nice.
Speaker: We all want to be around people who make us happy, who inspire us, who we want to be around.
Speaker: And I think people in medicine, there's no physician or no nurse or no mid-level person.
Speaker: that has gone to where they are without working hard clearly there's no there's no lazy people there but what i find in some cases is that the the ability to be nice to your consultant the ability to be nice for the person who called you for the consult to forget yourself and lose yourself in the moment when it's 3 30 in the morning and they call you for a consult on an elevated lactate which you know that it's a ridiculous consult but to maintain your humanity
Speaker: And just to be a generally nice person.
Speaker: I think that sometimes gets forgotten.
Speaker: So long story short, I think that that's the advice I try to give to people.
Speaker: And that's certainly the the I try to be that role model that portrays that that no matter what, just be work very hard and just be as nice as you can to everyone else.
Speaker: Because, you know, we're all of this.
Speaker: We're all of this whatever this rigmarole together.
Speaker: I think that spot on.
Speaker: And I would argue that actually that is something that is probably true, or I believe to be true as well, that most people maybe believe, but necessarily don't act through.
Speaker: And I think that you hit it right on the nail on the head there, because in 2017, moving to 2018 soon, the knowledge that's out there, the availability of knowledge is quite a
Speaker: standardized in terms that I rarely will see somebody who comes to the bedside and has an insight clinically that nobody else could think of that really solves the case.
Speaker: So in terms of who is successful in medicine today is those people who have recognized that the only way to move forward is by making magic for others.
Speaker: And you do that with a smile in the middle of the night or with saving somebody's life.
Speaker: And I think that you're right, spot on.
Speaker: And I think that's great, great advice.
Speaker: Work hard and be nice.
Speaker: I love it.
Speaker: So finally, is there anything that you would want every sound critical care intensivist who's listening to us in this podcast to know?
Speaker: I'll tell you something I've recently taken an interest in, and that's this issue that we're all aware of.
Speaker: It's this issue of physician burnout.
Speaker: Yeah.
Speaker: Again, this is not breaking news to anybody at all, but this is something that I think we acknowledge and we just say, well, either it won't happen to me or, yeah, it's there, but I'll deal with it when it comes.
Speaker: The thing I want people to take away or just be cognizant of is just to be aware that this is a problem that we're having, that we're in the middle of potentially a
Speaker: pretty severe crisis where some surveys show that 50% of physicians go through burnout.
Speaker: And if you look at across all specialties, you know, emergency medicine, critical care are the top of the list.
Speaker: I think critical care is number one or EM is number one, but the other one is number two.
Speaker: So,
Speaker: What we do every day is a tremendous responsibility.
Speaker: We save lives.
Speaker: We make critical decisions.
Speaker: We do so much.
Speaker: If you just look at what you do on one shift, it's truly amazing.
Speaker: But the risk that we could lose it all by being burned out, by not identifying these things that we go through, is very scary to me.
Speaker: It's something I'm conscious of.
Speaker: As I'm moving forward, I'm being very conscious of the things that lead to the burnout, the EMRs, the time away from the patients, the administrative duties, the excessive nights, the lack of exercise, the not eating healthy, the family arguments or whatnot.
Speaker: I try to be very aware of those things and I try to stop them before they happen.
Speaker: I think that the sooner we identify that we're starting to have the early phases of burnout individually,
Speaker: the quicker we can stop it from happening and the quicker we can preserve our careers.
Speaker: We all know people that have burned out of medicine, but I think we all naively think that it's not going to happen to us, but I think it could happen to all of us if we don't identify those things early.
Speaker: So that's what I'd like everyone to do is just to identify that sort of internal feeling when you have it, that something is wrong, and then try to figure out what it is and try to change it as soon as you can.
Speaker: Excellent.
Speaker: I think this is a perfect point to stop.
Speaker: Haney, I really want to thank you for sharing this hour with us.
Speaker: I definitely enjoyed it thoroughly.
Speaker: It was a treat for myself, and I'm sure it will be for our listeners.
Speaker: And we hope to have you back at Critical Matters soon, maybe to discuss some other interesting topics that you're very passionate about.
Speaker: It would be an honor.
Speaker: Anytime.
Speaker: Just call, and I'll be here.
Speaker: Thank you.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
