Prehospital Ultrasounds?

[EpiEMS]

I've been thinking about the utility of ultrasounds in the prehospital setting recently (and I'm sure there's been some discussion of it in the past).

After having a few patients who had triple-As (and one who had a thoracic aortic aneurysm), as well as a few who may have had intraperitoneal bleeding, I asked an ED doc what they did after we brought those folks in.

He indicated that one of the procedures he finds most useful (and, indeed, is required by ATLS) is the Focused Assessment with Sonography for Trauma.

For those who've done FAST exams, how complicated are they? Do you think it'd be realistic to add them to the EMT-P curriculum? How useful might it really be? Could it actually change prehospital management, or would it just be more info to give the receiving facility (or just useless, because the ED is going to do another ultrasound anyway)?

 

[Tigger]

For those who've done FAST exams, how complicated are they? Do you think it'd be realistic to add them to the EMT-P curriculum? How useful might it really be? Could it actually change prehospital management, or would it just be more info to give the receiving facility (or just useless, because the ED is going to do another ultrasound anyway)?

I'll admit I don't know a tremendous amount about portable ultrasounds and their use. We did demo a unit at the Sports Medicine gig (not a therapeutic one mind you, I do know that difference!) and I can see how it would be useful in that setting given that definitive treatment is given in this setting without further care or consultation.

I just wonder how portable ultrasound will change the treatment path for EMS? The point about the ER just doing their own is a good one too, which kind of makes it a bit of time waster.

 

[Akulahawk]

A prehospital US might drive a destination decision to a degree. Having that tool available and personnel appropriately trained in it's use may make some difference, but I'd want the back up from the hospitals to get things moving based on what those personnel see on the US. Without any hospital buy-in, it will just be mostly an expensive time waster tool.

 

[Veneficus]

For those who've done FAST exams, how complicated are they?

I use ultrasound everyday, it is an outstanding tool.

It is not complicated in the sense of technical operation, but it is entirely dependant on the skill and knowledge of the operator. Without considerable anatomy and pathophysiology, much more than a semester of A&P the tool is almost totally useless.

Do you think it'd be realistic to add them to the EMT-P curriculum?

Not as an add on or as it currently stands. You would have to up the prereq requirement to a year of gross anatomy and a year of dedicated pathophys. Otherwise you simply couldn't use the machine to its effectiveness.

It would be like thinking because you bought a really expensive gun you would go from an amateur shooter to a military sniper by virtue of the tool in your hand.

How useful might it really be? Could it actually change prehospital management,

It could be very useful from everything from terminating efforts from no cardiac wall motion, finding occult fluid or blood, transport decisions, and reducing overtreatment and airmed transport from "what if." Just to name a bit off the top of my head.

or would it just be more info to give the receiving facility (or just useless, because the ED is going to do another ultrasound anyway)?

Generally it is always a good idea to perform your own ultrasound. Since it is operator dependant, the reading of somebody better at it than yourself may be more appropriate for decision making, but it noninvasive, nonradiologic, cheap, easily repeatable, and can reasssess in real time, unlike serial xray or CT.

Actually I spent all morning looking at ultrasounds of lungs.

It is easy to distinguish a pneumo, cancer, pleural effusion, intra alveolar edema, and even interstitial edema.

One of the other things we use it for unofficially is to verify physical exam findings as a self assessment and a tool to help fine tune those abilities.

An ultrasound can do more than I could possibly list here. There is even speculation it will someday replace stethoscopes. I don't advocate that just yet, but it seems reasonable.

 

[mycrofft]

I retract my comment under pneumothoraces about mobile ultrasounds .

 

[Christopher]

For those who've done FAST exams, how complicated are they? Do you think it'd be realistic to add them to the EMT-P curriculum? How useful might it really be? Could it actually change prehospital management, or would it just be more info to give the receiving facility (or just useless, because the ED is going to do another ultrasound anyway)?

I took a class given by Jason Bowman of Keller Fire Department on the utility of Prehospital ultrasound. Keller Fire Department in Keller, TX performs prehospital ultrasounds regularly. From my talks with Jason, whom got their program started, they have 2 ALS transport units and use US on ~10-15% of their patients. They have numerous cases where it made a difference in both treatment and transport decisions.

What was even more of an interest to me was their call volume was half what my single ALS transport unit does at the fire department at which I work part-time!

 

[Dwindlin]

Sure I'll be in the minority but I don't think it's a great idea. As pointed out already fairly steep learning curve and very user dependent, especially if you aren't doing it frequently. Plus I think it just provides one more excuse to stay on scene for too long.

 

[Veneficus]

Sure I'll be in the minority but I don't think it's a great idea. As pointed out already fairly steep learning curve and very user dependent, especially if you aren't doing it frequently

This I think is a very reasonable concern and argument.

Plus I think it just provides one more excuse to stay on scene for too long.

On this, because of the rather minority of time sensitive patients, I would rather crews spend a few more minutes checking out a patient before calling in a $20K airmed for BS and "what if."

 

[Akulahawk]

This I think is a very reasonable concern and argument.



On this, because of the rather minority of time sensitive patients, I would rather crews spend a few more minutes checking out a patient before calling in a $20K airmed for BS and "what if."

If the operator is skilled and knowledgeable, there is no doubt that ultrasound is a very useful tool. The question is more of what should be looked at in the prehospital environment, and what kind of knowledge base would be required to produce an acceptable level of expertise. In any event, I completely agree with spending some additional time on scene if it results in appropriate treatment and transport destination for the patient. The end goal, of course, should be delivery of the patient to definitive care or delivery of definitive care to the patient. If you deliver the patient to the wrong level of care, additional time is required to get the patient to the appropriate facility for definitive care to be delivered. In other words, an additional 2 min. or 3 min. or 4 min. on scene may save the patient several hours later.

 

[medicsb]

For those who've done FAST exams, how complicated are they? Do you think it'd be realistic to add them to the EMT-P curriculum? How useful might it really be? Could it actually change prehospital management, or would it just be more info to give the receiving facility (or just useless, because the ED is going to do another ultrasound anyway)?

FAST is not difficult and I think it could be taught to paramedics. (My only experience is having been walked through the exam on 2 real patients and two to 3 times on volunteers.) Is there a learning curve? Sure. I would bet that it (the learning curve) is probably similar to interpreting a 12 lead ECG for STEMI. You're basically looking at the pericardium, the RUQ (liver and kidney), the LUQ (spleen), and the suprapubic region (bladder and/or uterus) and looking for something very specific - signs of free fluid in various cavities. Nothing more. Some incorporate assessing for a "sliding lung sign", for which the absence would indicate a pneumothorax.

There have already been multiple small studies demonstrating that paramedics can perform the exam and interpret the results reasonably well. Performing a FAST would not require anywhere near an additional year of anatomy and pathophys (though it would for more advanced imaging that Veneficus and others may use it for).

 

[EpiEMS]

Sounds like prehospital FAST exams could be useful for confirming the possibility of internal bleeding and pneumothorax –:censored:and ruling out the same, as needed. Certainly sounds like it could benefit patients!

 

[Veneficus]

FAST is not difficult and I think it could be taught to paramedics. (My only experience is having been walked through the exam on 2 real patients and two to 3 times on volunteers.) Is there a learning curve? Sure. I would bet that it (the learning curve) is probably similar to interpreting a 12 lead ECG for STEMI. You're basically looking at the pericardium, the RUQ (liver and kidney), the LUQ (spleen), and the suprapubic region (bladder and/or uterus) and looking for something very specific - signs of free fluid in various cavities. Nothing more. Some incorporate assessing for a "sliding lung sign", for which the absence would indicate a pneumothorax.

There have already been multiple small studies demonstrating that paramedics can perform the exam and interpret the results reasonably well. Performing a FAST would not require anywhere near an additional year of anatomy and pathophys (though it would for more advanced imaging that Veneficus and others may use it for).

I largely agree with what you say here, but I think FAST even with the pleural sliding is too narrow of a usage to justify the cost.

I was recently involved in the research and purchase of portable ultrasound and the most portable and barely useful, non diagnostic scanner I found was the VSCAN from GE. At $7800 it would be a rather heavy investment for just FAST.

Especially when you consider that it is a skill like any other and must be practiced regularly.

 

[Dwindlin]

Especially when you consider that it is a skill like any other and must be practiced regularly.

This cannot be repeated enough. I think ultrasound is both one of THE most useful imaging modalities and simultaneously one of the more difficult to become and stay proficient with.

 

[FLdoc2011]

This cannot be repeated enough. I think ultrasound is both one of THE most useful imaging modalities and simultaneously one of the more difficult to become and stay proficient with.

This is important. Keep in mind even for physicians in radiology and emergency medicine they may spend an extra year doing an ultrasound fellowship, there's definitely a steep learning curve, IMHO more so than other imaging modalities.

We have one of those VSCAN units here that the cardio guys use and it has proven useful. Usually a fellow will bring it to a code or to ER for a quick look at the heart to see if there's motion or a huge effusion that needs to be tapped.

Ultimately, the only way I see prehospital ultrasound really becoming useful/widespread is when there is robust telemedicine options where a prehospital provider in the field can throw a probe on a pt with a live feed to an ED doc or radiologist back at the hospital to make an official read right then and there.

 

[Aidey]

I think it could be extremely useful in the more rural areas who have two hospitals in opposite directions with different capabilities. Or in making the decision on whether to call HEMS. Those sort of cases.

The only thing I can think of where they would make a difference in my system is declaring PEA arrests on scene. It would show if there is truly no heart movement. I know EtCO2 has been used for this, but I haven't heard much about how reliable it is.

 

[JakeEMTP]

The people we'll see won't be that easy to ultrasound. The obese patient can challenge some of the best ER docs. I've seen some just give up trying to get a good picture of the heart during a code in the ER. Alot of the studies seem to be done in Europe with doctors in the field and where obesity isn't that widespread.

 

[Brandon O]

FAST is losing relevance in many EDs due to the widespread use of CT, but that doesn't necessarily mean it's irrelevant in the field. However, we need to clearly identify what decisions it's going to help us make and why we need help making them. US can be a really amazing magic wand, but as stated, it's not a skill you can learn in four hours at a cert. And in the end, I suspect that one of the things we'll want to use it for is as a rule-out, and I'm not sure if it has that sensitivity.

 

[usalsfyre]

FAST is losing relevance in many EDs due to the widespread use of CT

Source?

The major point FAST is it's exponetially quicker to do a bedside ultrasound to decide if the OR is immediately needed than road trip down to CT. Most patients who get "cleared" via FAST will still be irradiated till they glow for the more detailed images CT provides.

(I think I saw the estimate that 2% of all cancers are caused by CT now...)

 

[Brandon O]

Just the general impression I've gotten. Its decision-making "window" seems to have gotten pretty narrow, especially when the users aren't truly confident enough in their interpretations to make a final call on its basis. Clinically frank bleeds don't need and shouldn't get further imaging before they go to the OR, unless the surgeon insists for the sake of a roadmap, and in that case it's a CT... whereas well-appearing patients will need the CT to let us clear them, and doing a FAST first doesn't change that. I've heard quite a few ED folks say they literally do FAST mainly to maintain the skill now, particularly among the new staff.

But this is all hearsay -- not even close to my area.

 

[blindsideflank]

Don't forget line placement also some strokes, dvt but I dunno the skill level required for these. I have begun a research project on this subject am collecting data. I will be on an atls course at the end of this month.
This can open doors to pericardiocentesis
Look up tranexamic acid for internal bleeding

And this is a must read for anyone trying to argue for or against
http://www.paramedicultrasound.com/

"Physiocontrol/Medtronic has announced a project with Sonosite to incorporate sales of:censored: ultrasound machines with future cardiac monitor/defibrillators.:censored:"

Ecgs were once too expensive and paramedics were too dumb to read them. we also didn't have much of a reason to get them because we don't treat much and the dr will just get on at the hospital... Serial ultrasounds?