SonoWars at SMACC – the Auckland HEMS Team perspective

This past week, several of the Auckland HEMS team travelled across the Tasman to attend the first conference on social media & critical care (SMACC)

Our fearless leader Dr. Chris Denny entered us into the ultrasound competition (SonoWars) on day 2 of the conference. Following a qualifying round of 8-10 teams, the two finalists were chosen for a 2 hour ultrasound competition in front of the entire conference. The 2 teams competed in what can only be described as madness/awesome all rolled into one.

We entered the competition not thinking that we would have much chance advancing beyond the first round but thought the process would be fun regardless.  Somehow, despite our efforts, we managed to make our way to the finals of the competition. Our team comprised of our Auckland HEMS personnel included Scott Orman, Chris Denny & me (Andrew Petrosoniak). We also had participation from Rossi Holloway.

The SonoWars competition involved a combination of skills including speed tests performing ultrasound, image review, teaching an ultrasound technique and finally performing procedural skills.

Each team was given an ultrasound topic that we had to teach to the audience. We were graded on teaching styles, content and ability to captivate the audience. Our competitors were assigned to teach ocular ultrasound while our job was to teach transvaginal ultrasound. In our unbiased opinion, we had the harder job! Transvaginal ultrasound is not a skill we use in pre-hospital ultrasound which instead focuses on abdominal, cardiac and lung imaging. Though we were up to the challenge and set forth with our plan!

Pictures can often tell a better story than words so below is a sequence of photos from the event with some commentary.

First, both teams received a 30min pre-briefing for the event. Shown here is the coordinator demonstrating ocular ultrasound using oversized teaching tools!

First, both teams received a 30min pre-briefing for the event. Shown here is the coordinator demonstrating ocular ultrasound using oversized teaching tools!

 

Our team was introduced to the teaching props we were required to use. The red figure represents a uterus with yellow ovaries while the ultrasound probe is in the foreground. We were required to incorporate these into our teaching session.

Our team was introduced to the teaching props we were required to use. The red figure represents a uterus with yellow ovaries while the ultrasound probe is in the foreground. We were required to incorporate these into our teaching session.

 

A view from the back of the auditorium as the audience was introduced to Sonowars for the first time!

A view from the back of the auditorium as the audience was introduced to Sonowars for the first time!

The ref with the flag in the air as I completed a lung exam. Once the red flag dropped I could move on to a different view

The ref with the flag in the air as I completed a lung exam. Once the red flag dropped I could move on to a different view

Going into the teaching event we were in the lead.

Our team teaching the skill of transvaginal ultrasound on stage. A challenging topic.

Our team teaching the skill of transvaginal ultrasound on stage. A challenging topic. The screen in the background has ultrasound images which correspond to what we’re teaching on stage

We gave up a few points in the teaching event but still had a 2 point lead in the final event. It was a procedural skills race that required ultrasound use to perform several procedures directly competing against the other team. Unfortunately we were so focused on the event that we didn’t take pictures and sadly we gave up 3 points and lost to our deserving opponents.

Immediately after we came 2nd...my disappointment in the refs was captured! All in good fun.

Immediately after we came 2nd…my disappointment in the refs was captured! All in good fun.

 

A team pic after the event. A great experience!

A team pic after the event. A great experience!

Overall, this was a great event with lots of learning, fun and ingenuity. The organizers should be proud as they set a standard for combining entertainment with education. It was extremely well organized which allowed it to go smoothly. We’ll be looking forward to redeeming ourselves next year at SMACC!

 

 

SMACC Sonowars – E-FAST race

Error
This video doesn’t exist

Yours truly in action

(video from prehospitalmed.com)

 

 

Case Based Learning in the New Year: pneumothorax & lung ultrasound

Last week we ran another case-based learning session. The session consisted of a short discussion based around a case that we were tasked that involved a patient with a suspected pneumothorax.

We discussed the issues and challenges of managing a patient on the ground and in-flight with a pneumothorax. In addition, we discussed then practiced how we can use ultrasound as an added tool in the diagnosis of a pneumothorax in the prehospital setting.

To briefly summarize, I’ve divided up some discussion points

Medical

  • Both paramedics and doctors discussed the most important aspect in the patient with a pneumothorax in the pre-hospital setting was the clinical status
  • The ultrasound was noted to be extremely helpful for diagnosis however, presence of pneumothorax didn’t necessarily warrant intervention
  • Clinical condition was the overwhelming driver for intervention. The question arose regarding the role of ultrasound – “if the presence of pneumothorax did not necessarily mean intervention required, why use it?” In general, clinicians felt that knowledge about the condition would help make subsequent decisions in the case of deterioration
  • One theoretical approach was proposed – in a patient with pneumothorax that was reasonably stable, consider anesthesitizing & exposing the site for a chest drain then proceed with finger thoracostomy if deterioration. Several clinicians felt that it there was such concern to proceed with local anesthesia then probably a drain should just be placed.
  • In the patient with a left sided pneumothorax, there was strong agreement that loading the patient feet first such that the clinicians would have access to the left side (of our typically starboard loaded patient)
  • The likelihood of needle decompression success is only 50% – brief discussion about an anterior approach vs. a lateral approach

Operational

  • Knowledge regarding pneumothorax is key depending on the location of the patient. In situations on the east coast of the Coromandel then altitude becomes extremely important.
  • The early rule out diagnosis that the ultrasound can provide is very useful for managing flight plans
  • Weather was decided as a key factor that would alter management and it would impact possibly both medical decision making and flight operations
  • Placement of ultrasound in the machine: crewman/paramedic at the head of patient holding the machine with doctor on the patient’s right side
A little in-situ training. Enabled us to figure out optimal ergonomics and positioning for in-flight ultrasound. In case you're wondering, I donated my chest to science for this ultrasound to be done

A little in-situ training. Enabled us to figure out optimal ergonomics and positioning for in-flight ultrasound.
In case you’re wondering, I donated my chest for this ultrasound to be done (free of charge!)

Summary

  • Overall based on our evaluations of the process, it was a successful event with more case-based learning sessions planned
  • Clinicians reluctant to intervene for pre-hospital pneumothorax unless unstable
  • Strong communication among the team about the presence of a pneumothorax is essential and ultrasound greatly aids with this – affects both medical & operational decision making
  • Ergonomics are important but dependent on each setting; however a standard approach in the machine might be appropriate for positioning of the ultrasound

 

Prehospital Ultrasound – a new tool for our HEMS community

Several months ago, our HEMS service introduced a portable ultrasound machine onto our helicopters and so far it has been a great success!  While this blog post won’t be presenting the data we’re collecting, our physicians have reported it to be extremely useful. Most often we use it in the evaluation of a trauma patient to perform an eFAST (extended focused assessment with sonography in trauma) that includes assessment for free fluid in the abdomen but also importantly, lung ultrasound for the diagnosis of pneumothorax. Recently, I was part of a mission to transport a patient who had suffered a fall and there was question of a pneumothorax as reported by the ambulance team on scene. We were quickly able to perform an ultrasound of the lungs which ruled out pneumothorax. This enabled our pilot to fly at normal altitude rather than having to fly lower. Furthermore, as a clinician, it helped with decision making during transport as the patient still required treatment in hospital for other injuries. Knowledge that a pneumothorax was virtually unlikely allowed me to focus on other treatment priorities.

Picture of a similar model portable ultrasound that is being used at ARHT by HEMS physicians

We’re using a similar model of portable ultrasound as pictured above at ARHT 

More recently, one of our physicians performed an ultrasound guided femoral nerve block to assist with pain management of a patient with a femur fracture. It worked brilliantly and the patient was transported with considerably less pain!

In the spirit of our new technology, I’ve reviewed what’s out there in the literature regarding prehospital ultrasound (and emphasis on HEMS). There’s very little but this is definitely a growing field!

A recent review of HEMS pre-hospital ultrasound feasibility was published with good results. They performed 144 pre-hospital scans. On average scans took less than 2 minutes with a symptom based approach to what region to scan. While there are some limitations in their methodology, they reported no false-positives compared with available clinical data which is important. In addition, overall sensitivity was 85% (though it should probably be reported for each indication). Nonetheless, this study adds support to the feasibility of prehospital HEMS ultrasound and documents what findings may be value in the field. In several cases, management was altered, for example when pneumothorax was diagnosed then chest drains were placed.

Another study just published, prospectively evaluated the utility of lung ultrasound in non-trauma patients with dyspnea in a pre-hospital setting. They used a focused approach (as pictured below) to specifically identify potential causes of dyspnea. In 68% of cases, physicians reported lung US as a useful tool.

Imaging sites for rapid assessment of lung using ultrasound in dyspneic patients in prehospital setting

Imaging sites for rapid assessment of lung using ultrasound in dyspneic patients in prehospital setting

They required physicians to complete the exam within 5 minutes as not to delay scene times. Pneumothorax was accurately ruled out in all cases, while a large pericardial effusion causing hemodynamic instability was properly diagnosed though it was only drained once in hospital. You might imagine however that if the patient deteriorated en route that emergent pericardiocentesis would probably be the next intervention so identification would be important.

Algorithm for evaluation of dyspneic patient in the prehospital setting with ultrasound

Algorithm for evaluation of dyspneic patient in the prehospital setting with ultrasound in conjunction with imaging sites of above picture. 

I’m not sure how to interpret their results when they reported that additional management approaches were taken in 25% of cases as a result of US. Primarily diuretics were administered after US given the diagnosis of pulmonary edema. In our setting, we don’t carry furosemide so this doesn’t directly apply though if perhaps properly delineating between pulmonary edema and COPD would be useful as nitroglycerin vs. nebulizers could be emphasized in subsequent therapy.

I believe that most of the benefit of prehospital ultrasound is in the injured patient however, as we see, there is growing evidence that it can be used similarly to how it’s used within the emergency department and ICU.

References

1.  Eur J Emerg Med. 2010 Oct;17(5):254-9. doi: 10.1097/MEJ.0b013e328336ae9e. Prehospital ultrasound in emergency medicine: incidence, feasibility, indications and diagnoses. Hoyer HX et al.

2. Eur J Emerg Med 2012 Jun;19(3):161-6. doi: 10.1097/MEJ.0b013e328349edcc. Prehospital chest emergency sonography trial in Germany: a prospective study. Neesse A et al.