Wait, what did you just say?!

Image result for what did you just say? meme anchorman

As the role of clinical ultrasonography continues to grow throughout healthcare, the need for clear communication of bedside findings has never been greater. We know that communication plays a major role in high quality healthcare, and that miscommunication has been identified as a major contributor to medical error and patient complaints.

Last year at SASKSONO17 (Breaking the Sound Barrier), we discussed the need for clear communication amongst clinicians. Our panel of experts (Internist, Intensivist, Emergentologist and Hospitalist) offered great advice on how best to communicate clinical ultrasound (aka POCUS) findings with colleagues and consultants (you can check out the 8 minute video here: https://vimeo.com/215476593).

But clear communication with colleagues is only one piece of the puzzle. The other big piece is clear communication with the patient! And while this may seem self-evident, we suggest there’s more to it than simply applying basic clinician-patient communication skills. For example, I am sure you have heard a trainee or colleague say to their patient, after having completed a bedside scan, that everything looks OK. Seems harmless doesn’t it? But to the patient, there is now a very real potential for misinterpretation of both the purpose of the scan, and the findings! Here at Sasksonic we’ve heard it first hand. Patients have returned to their primary care providers with impressive stories of whole body scans where their liver, spleen and kidneys were evaluated by ultrasound and “Great news doc, everything was OK!”

Image result for houston we have a problem

By not clearly stating the indications for the scan, or not clearly explaining the findings, clinicians may give their patients the wrong impression that they have undergone a much more comprehensive evaluation than intended or necessary. This can lead to a lot of headache and frustration by downstream providers who now find themselves rummaging through the patient’s medical record looking for the “whole body scans” (assumed to be either consultative ultrasound or CT scans) when no such studies were performed. Furthermore, in the absence of a consultative report (or worse yet, no comments regarding to the point of care ultrasound in the visit note), it can also negatively impact the status of clinical ultrasonography in the eyes of our colleagues and patients. As an important and evidence-based part of the clinical assessment (now proposed to be the 5th pillar of the bedside assessment – inspection, palpation, percussion, auscultation and insonation), we need to ensure our colleagues and patients understand the role clinical ultrasonography plays in patient care.

The solution?

Whenever possible, clearly communicate with patients about the indications, findings and limitations of the clinical ultrasound scan in question. When performing a FAST scan this means letting the patient know you are looking for free fluid in the abdomen or chest, which if seen, would suggest internal bleeding. If no free fluid is seen, instead of saying “everything looks OK” we suggest you say “I don’t see any free fluid on my scan, but this clinical application of ultrasound has limitations and sometimes we miss injuries. Keeping the clinical picture in mind, I think we should proceed with…”

And there’s more! Whenever possible, be sure to give the patient a clear understanding of what the scan will include including where the transducer will be placed. Be sure to warn them about the room temperature gel that often feels ice cold. Then, while scanning, try to talk them through the findings as much as possible (this gets easier as your image generation skills improve). For example, when scanning the gallbladder for suspected cholelithiasis, take time to show them their gallbladder, what the wall looks like and whether there are any stones. Remember, one of the advantages of clinical ultrasonography is that you are learning about your patient’s (patho)physiology in real time at their bedside. So let the patient know what’s going on in the moment, tell them in a way they will understand, and quell their curiosity while also empowering them!

For an example of good communication with a patient (and other aspects of ultrasound etiquette) , check out this short clip we’ve prepared at Sasksonic for our trainees.

cheers,

Paul Olszynski and Qasim Hussain

Peer Review: Drs. Kish Lyster and Irene Ma

 

SASKSONO18 SONOGAMES HIGHLIGHTS

Congrats to “No Pain, No Gain”, our first place team at this year’s SASKSONO conference! Big thanks to all of our participants and to the crowd for cheering the teams on as they battled it out. Also big thanks to Dr. Quinten Paterson (PGY2 EM) and Ms. Alixe Dick (MS2 USASK) for their hard work in preparing the games this year and Drs. Kawchuk and Jelic for their sound judgment!

All in all, a very successful SASKSONO18 – We hope to see you next year at SASKSONO19!Screen Shot 2018-03-27 at 1.49.53 PM.png

Rural and Regional IP Core SKanapalouza

Great news! We’re hosting an IP Core SKanapalouza for Rural and Regional Clinicians on March 10th!

This ultrasound scanning day is to facilitate clinicians seeking to obtain their Canadian Point of Care Ultrasound Society (CPoCUS) CORE Independent Practitioner certification. The intent is to provide clinicians working in rural areas an opportunity to obtain scans towards their certification that are otherwise difficult to achieve in such locations. There will be an opportunity to obtain up to 28 scans towards your certification. All standardized patients will be female to allow for maximum scanning applications. There will be a high instructor to participant ratio to ensuring a quality scanning opportunity.

For more details and to register, click on this link

cheers,

The Sasksonic Team

 

 

Are we doing CPR wrong?

Did you ever wonder why we adjust for patient age and size for almost everything (meds, devices, intubations, casts) and yet we assume everyone should get compressions in the same place?!
When we first heard about u/s-guided compressions using transthoracic echo (TTE) many of us thought it was going to be near impossible. To our surprise – up to half of patients have decent A4C views that offer a glimpse at what is happening – and we have seen ETCO2 rise from 20 to 40  with correction of CPR position.
The limited evidence (mostly animal studies) is pretty compelling… then add the potential of improved views using TEE and suddenly intra-arrest care changes dramatically!
Check out this clip to learn more: https://vimeo.com/206051789
Better yet – want to discuss it? want to try it out on a simulator? Want to practice your scans?
Then register for SASKONO18 by going to www.sasksonic.com/sasksono
Deadline to register is Feb 15th, 2018!
Please forward this to anyone you think might be interested.
The Sasksonic team

Case of the Year – Just in time for the Holidays!

As we wrap up another great year at Sasksonic, we are thrilled to learn that one of our own recently took home POCUS-Toronto’s “Case of the Year” award!

USask EM’s Dr. Puneet Kapur (PGY5 EM, @Kapurp) was recognized for his stellar case submission involving identification and test performance of several transthoracic echo findings as they relate to identifying acute pulmonary embolism. Many of you have heard of the value of each of the following findings as they relate to distinguishing acute from chronic RV strain: Screen Shot 2017-12-20 at 9.39.03 AM

Here are clips from the actual case that show RV dilation in the PSL and McConell’s sign in the A4C. Despite these – it may remain challenging to reliably determine acute vs chronic strain (see details in the cited article below).

 

 

Well, don’t give up hope – introducing RVOT systolic excursion! This measurement is obtained using the parasternal short axis view at the level of the aortic valve.

 

Screen Shot 2017-12-20 at 9.34.22 AMIt appears that measuring RVOT systolic excursion (as a percentage of end-diastolic RVOT diameter minus end-systolic RVOT diameter divided by end-diastolic RVOT diameter) is both specific and highly sensitive for acute PE. Analysis of right ventricular outflow tract systolic excursion showed that a value <24.3% can be found in acute pulmonary embolism patients with 100% sensitivity and 95.56% specificity (AUC = 0.987, P < 0.0001).

Sounds promising – looking forward to hearing and learning more about this.

We’re proud of Puneet! And while we’re at it – big thanks to the team at POCUS-Toronto for giving trainees like Dr. Kapur an opportunity to learn and excel in emergency POCUS.

Want to learn more about RVOT systolic excursion and acute RV strain? Check out the article below:

  1. Lõpez-Candales A, Edelman K. Right ventricular outflow tract systolic excursion: A distinguishing echocardiographic finding in acute pulmonary embolism. Echocardiography. 2013;30(6):649-657. doi:10.1111/echo.12120.