Teaching internationally: More than just a language barrier

I recently traveled to San Salvador to help teach a pediatric and adult ultrasound course. The course was well received and it was wonderful traveling around San Salvador.

I wanted to share some of our experiences, and discuss some challenges to educating internationally. More importantly, I want to engage you, the readers to share some of your experiences when educating internationally as well.

The language

The first challenge and major road block was attempting to lecture in a foreign language. Although I studied Spanish for many years, I was definitely rusty. While I learned the history of the Argentinian Dirty War in school, I never mastered vocabulary sufficient to discuss the physics of ultrasound. We translated the majority of the presentations into Spanish by using the aid of colleagues who were from El Salvador and Google translator. Imagine how difficult this would be for languages that are not based on the Roman alphabet or if there were no native language speaking colleagues to assist. Even with that, there were still some funny hiccups.

Delivering presentations

Creating the presentations is half the battle. Delivering the presentation is even more daunting.

We all know that good lecturers don’t read off of their slides.  They can ad-lib, interact with the crowd, and make adjustments as necessary.  This becomes more difficult in another language.  No one wants to deliver a bad presentation simply because it is in another language.  Or worse, give a bizarre answer to a question because of translation issues.  I definitely practiced my presentations more than I would usually.  The butterflies in my belly before presenting were palpable!

AV equipment

A major challenge was ensuring that the AV equipment worked properly.  Although traveling with 5 other EM physicians in my group, none of us remembered to bring a dongle to connect our laptops with the AV equipment in the hospital.  Luckily, we were able to find a store and could buy the necessary missing equipment.  However, you may not always be so lucky when traveling internationally to be near an urban center.  It is important to be organized to try to limit as much AV malfunction as possible.  Remain flexible and know that there may be some level of malfunction and be prepared to address it.  Having a backup plan such as hard copies of the lecture could be life (and reputation) saving.

Ultrasound equipment

Finally there is the challenge of traveling with the portable ultrasounds internationally.

• Customs doesn’t always know what a portable ultrasound machine is. Plus, it takes coordination to organize carry-on luggage as the ultrasound, check in your suitcase, and manage your souvenirs-- all without incurring additional travels charges.
• Don’t forget how heavy the ultrasound machines can be on your back!  
• Ultrasound machines are expensive. We always knew their locations to avoid losing them.

Ethical question
There was the ethical dilemma of using our high tech portable ultrasound donated by companies for international education versus using the machines that the hospitals already had.  Our equipment was definitely more advanced, but what purpose does it serve to not teach familiarity to what is available?  This is a thought that definitely can be pondered upon and argued over.

Lessons I learned:

•  Practice, practice, and practice again when delivering a presentation that is not in your primary language
•   Think about AV equipment - consider backups
•   Ultrasound machines are heavy and costly
•   Always consider sustainability

Please share any lessons you may have learned while traveling and educating internationally!

Trick of the Trade: Ultrasound-guided supraclavicular central line

Subclavian central lines are commonly touted as the central line site least prone to infection and thrombosis. The problem is that they are traditionally performed without ultrasound guidance. They are done blindly because of the transducer's difficulty in getting a good view with the clavicle in the way.

Trick of the Trade:
Ultrasound-guided supraclavicular approach to subclavian line

What are the surface anatomy landmarks for the supraclavicular line?

• Identify the border of the clavicle and lateral margin of the clavicular belly of the sternocleidomastoid muscle. 
• Insert the needle there and aim for the contralateral nipple, aiming anteriorly 10-20 degrees to avoid puncturing the subclavian artery and lung.
• You are trying to cannulate the near the juncture of the IJ and subclavian veins. 

If you just want to see the crux of the procedure, which uses the linear transducer to guide the long-axis needle insertion approach, start at 8:18.

Disclaimer: I do not have any commercial affiliations with Sonosite.

Reference
Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: the forgotten central line. West J Emerg Med. 2009 May;10(2):110-4. Free access to PDF

Trick of the Trade: Sterile cover for linear ultrasound probe

You decide to use ultrasonography to help you establish peripheral IV access for and obtain blood cultures from your patient. How can you ensure that you get a sterile sampling to avoid blood culture contamination? Do you need to open a full central-line ultrasound probe cover?

Trick of the Trade:
Use a sterile glove

Thanks to Dr. Haney Mallemat (Univ of Maryland, @CriticalCareNow) for the video and tip.

Live-blogging: UCSF High Risk EM Hawaii conference

Today is the pre-day for our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. Keep a lookout below as I try to live-blog some of the clinical pearls that I glean from the day (using Google Docs).

Live blogging tomorrow

Tomorrow is the beginning of our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. I'm going to try to live-blog some of the clinical pearls that I glean from the day.

Trick of the Trade: Ultrasound-guided injection for shoulder dislocation

Who loves relocating shoulder dislocations as much as I do? 

I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?




Trick of the trade:
Ultrasound guided shoulder injection

I found a great video on this technique, which is essentially a hematoma block in the joint. This screencasted talk is by Dr. Mike Stone (Highland Hospital) as part of his 2011 ACEP Scientific Assembly lecture on nerve blocks. Coincidentally, I ran into Mike at this week's UCSF Topics in Emergency Medicine course where he gave a talk on the use of ultrasound for the hypotensive patient. When I mentioned that I was going to highlight his shoulder injection trick on this blog, he whipped out his laptop and gave me the 6 minute portion of his ACEP talk. Wow, that was really nice of him.

To view his entire video on nerve blocks, check out the video here.

Things I learned about injecting the shoulder:
1. Use a spinal needle. A traditional needle often will not reach the glenohumeral joint.
2. You almost always get a flash of blood (hemarthrosis) when you are in the joint.

Also check out Dr. Stone's great ultrasound website called Point of Care:
http://pointofcare.blogspot.com/

I'm a fan.

Tricks of the Trade: Underwater ultrasonography

I've heard of underwater basketweaving, but underwater ultrasonography?

Bedside ultrasonography is a great tool to help find small foreign bodies. Commonly foreign bodies get lodged superficially in the patient's extremities. Because superficial structures (<1 cm deep) are difficult to visualize on ultrasound, you should apply a really generous, thick layer of ultrasound gel to create some distance. Alternatively, you can add a step-off pad, such as a bag of saline or fluid-filled glove, to place between the patient's skin and transducer. What's a quicker and easier way to create some distance yet preserve image quality?

Trick of the Trade:
Submerse both the body part and the ultrasound transducer under water.

For this "bath water technique", start by holding the transducer perpendicular to the wound and about 1 cm away from the skin. You can adjust the distance to optimize the image quality.

Thanks to Andy at Emergency Medicine Ireland blog for these 2 ultrasound images! 

This submersion technique has been published in American Journal of EM in 2004 as a painless alternative to gel or a step-off pad, because the transducer does not need to apply any pressure on the patient's wound.

Reference
Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Amer J Emerg Med. 2004; 22(7), 589-93 PMID: 15666267
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Paucis Verbis: Cardiac tamponade or just an effusion?

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it's relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it's equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer: Poor to average, at best. The Beck's triad of hypotension, distended neck veins, and muffled heart sounds are important to remember ... only on tests.

Solution: Think about performing a pulsus paradoxus test to see if it's >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Take a look at this helpful video demonstrating how to measure pulsus paradoxus.



Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Reference
Roy C et al. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA: The Journal of the American Medical Association. 2007; 297(16): 1810-8. DOI: 10.1001/jama.297.16.1810
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Tricks of the Trade: Ultrasound workshop setup

Have you ever been to an ultrasound workshop where each small group of attendees huddles around the small ultrasound display? Personally I think the 3 people closest to the display really see the images well. This tends to exclude the other participants.

Last week, I hosted (my first!) ultrasound workshop for the UCSF Alumni CME Conference where I showed peri-retired UCSF alumni from various specialties about the future of bedside ultrasonography. I equated it to the 21st century stethoscope. Thanks to my star team of ultrasonographers: Dr. Asaravala, Flores, Miss, Lenaghan, and Wilson.

In order to maximize engagement amongst the participants, I set up each of the 5 ultrasound stations with either a LCD projector or a large-screen TV screen so that everyone could see what was going on. While we encouraged them to do some hands-on scanning themselves, the participants were more interested in the novelty of bedside ultrasonography and how they might be able to incorporate into their practice.

What did I learn?

• Make sure each instructor has a laser pointer. I had to scramble for them last minute when I realized that the instructor couldn't actually touch the projector screen from where they were standing. It made it hard for them to point out key structures.
• Use thick masking tape to tape all the lose power cords (ultrasound machine, projectors, TV) to the ground. Bonus points if none of your participants trip and fall. 
• I liked the fact that all the stations were in the same room. This allowed participants to freely wander amongst the different tables.
• I'm glad I made a last-minute handout which showed the basic anatomy of areas being ultrasounded and a potpourri of abnormal images as a reference for the participants as they were viewing the real-time normal scans.

Trick of the Trade: Check pupillary constriction with ultrasound

In some trauma patients with head and face trauma, you will need to check their pupillary response to light. Severe periorbital and eyelid swelling, however, make this difficult. You want to minimize multiple attempts to retract the eyelids because of the risk of a ruptured globe.

What's a minimally painful and traumatic way to check for pupillary constriction?

Trick of the Trade:
Use an ultrasound with a linear transducer.

• Apply generous ultrasound gel on the patient's closed eyelid.
• Have the patient look straight ahead (with eyelids closed).
• Gently position the transducer obliquely on the eyelid in either a sagittal or transverse plane.
• Shine a light into the other eye. If the other eyelid is swollen, you can actually shine a light through a closed eyelid. The pupil can sense light through the thin upper eyelid.
• Watch for pupillary constriction on the screen.

Thanks to Dr. Miss for this tip and Drs. Kornblith and Hensley for demonstrating.

Trick of the Trade: Ultrasound-guided supraclavicular central line

Emergency physicians are procedural experts in central venous access. The subclavian vein is the best site for such access, because it has been shown to have the lowest rate of iatrogenic infections and deep venous clots.

Bedside ultrasonography has really revolutionized how we obtain vascular access over the past 10 years. Identifying the subclavian vein using ultrasonography, however, is still technically challenging. The vein is located just posterior to the clavicle, which often gets in the way of the linear transducer.

Trick of the trade:
Ultrasound-guided supraclavicular central line

Did you know that there are two approaches to access the subclavian vein -- infraclavicular and supraclavicular? The traditional approach is the infraclavicular approach, however, more studies are showing that the supraclavicular approach is just as safe and as procedurally easy as the infraclavicular approach.

The subclavian vein courses posterior to the clavicle but reaches its most superior point just lateral to the clavicular belly of the sternocleidomastoid muscle. In the above photo, the needles are pointing to insertion site for both the supra- and infraclavicular approaches.

Use the ultrasound to guide your supraclavicular line placement.

Instead of using a flat linear transducer, use the endocavitary transducer, which emits a similar high frequency signal. Its footprint is much smaller and more curved, allowing you to better visualize the subclavian vein. Position the transducer so that you get a long axis view of the vein. Often you can also see IJ vein in view, merging with the subclavian vein.

I unfortunately don't have an ultrasound image of this. If you have one, could you send and I'll post it? I'd be happy to credit you. 

There is a good, copyrighted image in the article by Mallin et al. This survey study showed that 15 residents felt more comfortable with identifying the subclavian vein using this technique after a brief training period.

Reference
Mallin M, Louis H, Madsen T. A novel technique for ultrasound-guided supraclavicular subclavian cannulation. Amer J Emerg Med, 2000, 28 (8), 966-9. 
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Retinal detachment on ultrasound

I just wanted to revisit the Trick of using bedside ultrasonography to diagnose retinal detachments. I covered this also in a previous Tricks of the Trade post last year, but I just had to reiterate how easy it can be to detect it by ultrasound. Be sure to use plenty of ultrasound gel and use the linear tranducer.

The eye should normally appear as a circular hypoechoic structure. Above is a 7-second video I recently captured of a patient's eye in transverse view. The irregular, hyperechoeic stripe (bottom of screen) that you see floating in the anechoic posterior chamber is the patient's detached retina.

Paucis Verbis card: When murmurs need echo evaluation

Have you been in a situation where you are the first to detect a cardiac murmur in a patient? If you are hearing it in a busy, loud Emergency Department, I find that it's at least a grade III.

Should you order an echocardiogram for further outpatient evaluation? It depends on the grade and characteristic of the murmur, in addition to the patient's symptoms. For instance, all diastolic murmurs require an echo. There is a useful ACC/AHA algorithm which helps you decide.

Thanks to Amy Kinard, an Emergency RN and aspiring Family Nurse Practitioner, for drafting this useful Paucis Verbis card for me during her studies. Keep the great ideas coming, everyone!

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Bonow, R., Carabello, B., Chatterjee, K., et al. (2008). 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Circulation, 118 (15) DOI: 10.1161/CIRCULATIONAHA.108.190748

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Trick of the trade: I got ultrasound gel in my eye!

Bedside ultrasonography is increasingly being used in the ED to examine the eye. For instance, it can be used to detect a retinal detachment, vitreous hemorrhage, and high intracranial pressure. The technique involves applying ultrasound gel on the patient's closed eyelid. A generous amount of gel should be used to minimize the amount of direct pressure applied on the patient's eye by the ultrasound probe.

Sometimes, however, no matter how careful you and the patient are, some gel accidentally contacts the eye itself.

Trick of the Trade:

Apply a transparent tegaderm dressing over the patient's closed eyelid. This provides an addition barrier between the gel and the patient's eye without compromising ultrasound image quality.

The trade-off with this trick, I find, is that while the patient's skin doesn't contact the gel, the removal of the tegaderm adhesive may peel off some eye makeup or a few eyelashes! Pick your poison.

Roth, K., & Gafni-Pappas, G. (2010). Unique Method of Ocular Ultrasound Using Transparent Dressings. The Journal of Emergency Medicine DOI: 10.1016/j.jemermed.2009.10.020

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Trick of The Trade: Peritonsillar Abscess Drainage 2.0

Back in September of 2009 Michelle shared valuable Tricks of The Trade regarding drainage of PTA.

Today we revisit the topic and add two more tricks to avoid hitting "big red" a.k.a. the internal carotid artery.

Numero Uno: don't go in blind!

Ultrasound is a great adjunct in the diagnosis and treatment of skin and soft tissue infections. For PTA, after local anesthesia of the pharynx, the endocavitary probe a.k.a. transvaginal probe can be used to view the size and relationship of the abscess in question and the internal carotid artery.

Numero Dos: use a rubber bumper

In order to access the deep narrow cavity of the mouth without obscuring your many recommend a 3.5 inch 18-G spinal needle. An alternative to trimming the plastic sheath of the needle is to replace it all together with a rubber bumper- the top of a lavander-top-tube.

Demian Szyld is an Emergency Physician in Boston, MA and a guest blogger at Academic Life in Emergency Medicine.

Acknowledgments: I want to thank Suraj Puttanniah who told me that about the rubber bumper trick. He in turn heard it from our legendary attending David Gaieski. The US image is credited to Michael Blaivas, MD and can be found at http://www.sonoguide.com/smparts_ent.html

Article review: Long axis view for IJ line placement

Looking for the right IJ vein under ultrasound

As bedside ultrasonography is becoming a staple in central line placement (especially of internal jugular lines), emergency physicians now can minimize complications, such as carotid artery puncture and a pneumothorax. Traditionally, the US probe is positioned along the short-axis of the IJ during the procedure (see above). The resulting image shows two circular structures, which are the carotid artery and IJ (see below image).


In an article published in Critical Care Medicine, the authors challenge providers to use the long-axis, rather than the short-axis view.

Why, you ask? Because of the risk of posterior wall puncture of the IJ vein.


QUESTION
Does anyone use the long axis view for IJ vein cannulation? I'd love to hear your thoughts.



Study design
Using a life-like human torso mannequin, 25 EM residents placed ultrasound-guided IJ lines. All had attended a 3-hour didactic and hands-on session on the procedure. Also all had placed ultrasound-guided IJ lines previously in actual patients.

The residents used the short-axis U/S view of the IJ. During this procedure, one investigator tracked the resident's needle using an endocavitary probe just inferior to the vascular probe. The convex shape of the endocavitary probe made it possible to visualize the soft tissue directly under the vascular probe.

The residents were asked to stop the procedure once they felt that the needle tip was in the middle of the IJ vein. The guidewire was not introduced.

Mannequin IJ-line placement using the vascular probe.
The endocavitary probe tracked the needle course.
(image from Crit Care Med article)


IJ vein in long view with needle puncturing lumen

Main outcome measure
The incidence of posterior wall penetration, as defined as a 2nd venous wall penetration with an antecedent anterior wall penetration by the needle and needle shaft.

Results
At first glance, the study results were very surprising. I have always had great results with the short-axis view of the IJ for line placement.

• 16 of 25 residents (64%) accidentally penetrated the posterior wall while attempting to cannulate the IJ vein with a needle.
• For 6 of 25 residents (24%), the final position of the needle tip was posterior to the venous lumen.
• For 5 of 25 residents (20%), the final position of the needle tip was in the carotid artery
• More advanced training (r=-0.41) and degree of experience with ultrasound guided central lines (r=-0.54) were inversely correlated with posterior vein wall penetration.
  

Bottom line and thoughts
Overall, while this study brings up an interesting discussion about the best view for IJ line placement, I question the clinical significance of the study findings.

1. The residents were not allowed to feed a guidewire to confirm successful IJ cannulation. For the 24% of residents who had positioned the needle tip posterior to the IJ lumen, I presume that the guidewire would not have been able to feed completely, if this were an actual patient. Consequently, the resident would have re-positioned the needle.
   
2. If someone penetrated the posterior wall while trying to cannulate the IJ vein (64% incidence in this study), does this clinically matter if the needle and guidewire eventually end up in the IJ vein? I don't think so.
3. For the 20% of residents who had the needle tip in the carotid artery lumen, presumably the bright red nature or pulsatile flow of the blood return in an actual patient would have alarmed the resident (and attending!) that the needle was in the incorrect location and required repositioning.
   

While this study brings up an interesting complication of IJ line placement using the short-axis U/S view, the next step is to do this study in actual patients.

Words of caution
If you are thinking of using the long axis view of the IJ, start by finding the IJ using the short axis view. Keeping the IJ vein on the screen at all times, rotate the probe 90-degrees into the long axis view. Be sure that you are still looking at the IJ vein and not the carotid artery. Often on the long axis view, you can only see one vascular structure at a time. Be sure it's the right one!

Also with the long axis view, try to keep your needle directed within the plane of the ultrasound. The needle easily can move in and out of the plane and thus disappear from the screen.

Reference
Blaivas M, Adhikari S. An unseen danger: Frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 2009; 37:2345–9.

Work in progress: Pediatric ultrasound videos

A few years ago, I helped a colleague of mine Dr. Ron Dieckmann build his major international, clinical-decision support software for Pediatric EM. This software is called PEMSoft. I helped build the Procedures section, which contains text, graphics, and often movies of the procedures.

PEMSoft, which is currently in CD-ROM format, is actively being converted to an online format. This allows for us (KidsCareEverywhere - a non-profit organization) to more-easily deliver this resource to underserved countries.

I am currently working with Dr. Jason Fischer (Highland EM Ultrasound Fellow), an over-achiever friend of mine who has also finished a 2-year Pediatric EM Fellowship at Children's Hospital of Oakland. We are developing an entire Pediatric Ultrasound section for PEMSoft. Pediatric bedside ultrasonography in the ED is an emerging field of EM. In the right setting, it is a great imaging modality, especially given the recent literature about CT irradiation risks.

We are writing teaching modules for:

• Pneumothorax
• Hemothorax
• Pericardial effusion
• Abdominal free fluid in RUQ , LUQ and pelvis
• Bladder sizing (for catheterization)
• FB in soft tissue
• Abscess
• Vascular access

If you would like to contribute a non-copyrighted video for any of these modules, please email me. I'd love to include and would credit you, if we use it. Your video could be helping emergency physicians and pediatricians around the world, ranging from big-city U.S. hospitals to rural villages in Vietnam.

If you would like FREE access to PEMSoft Online, Ron has temporarily opened it up for free during this beta-test phase. It is still in a relatively basic form, but you can get the gist of the software. For Mac users, you need to have the plug-in Flip4Mac to view the videos.

Website:

www.pemsoft.com

Tricks of the Trade: Diagnosing retinal detachment with ultrasound

In a sneak peak of my ACEP News' Tricks of the Trade column, Dr. Patrick Lenaghan, Dr. Ralph Wang, and I will discuss how bedside ultrasonography can significantly improve your ocular exam.

Here is a classic example. A patient presents with acute onset right eye pain and blurry vision. She possibly has a field cut in her vision. Her pupils are a teeny 2 mm in size in the brightly-lit Emergency Department. You are having a hard time getting a good fundoscopic exam to comfortably rule-out a retinal detachment.


Trick of the trade:
Ocular ultrasonography to diagnose retinal detachment

Apply a generous amount of gel on the patient's closed eyelid, such that the probe does not contact the patient's eyelid. Position a linear high-frequency ultrasound probe on the patient's upper eyelid.

• Vitreous fluid and the lens are anechoic (black).
  
• The ciliary bodies and retina are hyperechoic (white).
  

A retinal detachment appears as a hyperechoic stripe (yellow arrow) adherent to the retina.

Image courtesy of Dr. Patrick Lenaghan.

Important Note:
If the patient may potentially have a globe rupture, ocular ultrasonography is relatively contraindicated. Do not apply any pressure to the patient's orbit.

Hot off the press: New iPhone app on ultrasound

My friend and colleague at USC, Dr. Diku Mandavia, alerted me about a new iPhone app that just came out called SonoAccess, developed by Sonosite. This free app has stock photos of images, in addition to video lectures of common applications such as the FAST, aorta, pelvic, gallbladder, and many other scans. Check it out!

If you want to see movie-star-in-the-making Diku in action, check out the video on measuring the common bile duct (CBD) for gallbladder scans. Nice, Diku, nice. If only CBD's were THAT easy to find. It's my Achilles heal of ultrasonography. It always takes me forever to find the CBD, such that patients probably are wondering if (A) I know what I am doing or (B) I have found something really abnormal and looking at it more carefully. I'm going to need a private tutorial with Diku.

Check out the company's video introducing the product. I have no affiliation with the company.



If you have used this application, what do you think of it?