Awesome Ultrasound Learning

Hi All

This is a quick post to let you know about a few great Ultrasound resources that are out there.

Sure everyone knows about the Ultrasound Podcast – unless you are a subpetrous life form!

But – there are a number of really nice, lesser known, well made educational Ultrasound sites out there.  So here are a few of my favourites:

  • SONOSPOT : a really nice blog written by Dr Laleh Gharahbaghian and friends.  There are cases, educational videos and a lot of literature reviews.  She also has a really extensive blogroll on her site – with links to heaps of other ultrasound resources.
  • 5 Minute Sono: From the “southern Gentry” of ultrasound – Drs Jacob Avila and Ben Smith have put together a really slick site with, as you might expect, 5-minute videos of all the common US applications.  Really well done with excellent images and narration. Note to my JMOs – you need to watch all of these videos soon!
  • Highland Ultrasound: a blog with a range of videos – largely aimed at ED and regional nerve blocks.  Written by Dr Arun Nagdev and friends out of Highland Hospital in Oakland, California.
  • Emergency Ultrasound Teaching: another American ED US site – lots of short instructional videos and cases – similar to some others – but spaced repetition is key to learning the art of Ultrasound!
  • The mega-blog Academic Life in EM has a section devoted to Ultrasound – there are great literature reviews of the evidence and cool “US for the Win” cases.  Part of the big ALIEM machine – well done and peer reviewed for high quality.
  • The Sono Cave and US Village are sites run by my own mentors and local west Aussie mates Dr James Rippey and Adrian Goudie & co.  Educational lectures, cases and my favourite are the “report cards” which you can print out for reference or laminate and put on your machine.
  • Ultrasound of the Week – also by Dr Ben Smith. A weekly case study with US to test your sono-skillz and see how the pros do it!  Narrative is key to my learning – so I love the cases and frequency is perfect!
  • Dr Chris Fox is a legendary US teacher out of UC Irvine.  He has put a whole heap of free video lectures up on iTunes  – well worth watching on various topics.  Has a great way of explaining the phenomena you will see and how to apply it in practice.

OK.  So that is the big, tip of the US Educational iceberg – there are so many other great sites out there.

Please let me know on the comments about your site, or a site that you find really useful.  Always on the hunt for some new material and perspectives.

P.S:

If you happen to be a Broome JMO or plan to come to Broome in the future – then check out as many of these as you can.  Having a good grip on the theory and how to apply it is great before you hit the ground and start trying to make decisions.  And that stuff is best taught by experts – doctors whom are masters of the craft.  Then we will play with the probes and our patients will prosper!

Casey

Awesome Ultrasound Learning

Hi All

This is a quick post to let you know about a few great Ultrasound resources that are out there.

Sure everyone knows about the Ultrasound Podcast – unless you are a subpetrous life form!

But – there are a number of really nice, lesser known, well made educational Ultrasound sites out there.  So here are a few of my favourites:

  • SONOSPOT : a really nice blog written by Dr Laleh Gharahbaghian and friends.  There are cases, educational videos and a lot of literature reviews.  She also has a really extensive blogroll on her site – with links to heaps of other ultrasound resources.
  • 5 Minute Sono: From the “southern Gentry” of ultrasound – Drs Jacob Avila and Ben Smith have put together a really slick site with, as you might expect, 5-minute videos of all the common US applications.  Really well done with excellent images and narration. Note to my JMOs – you need to watch all of these videos soon!
  • Highland Ultrasound: a blog with a range of videos – largely aimed at ED and regional nerve blocks.  Written by Dr Arun Nagdev and friends out of Highland Hospital in Oakland, California.
  • Emergency Ultrasound Teaching: another American ED US site – lots of short instructional videos and cases – similar to some others – but spaced repetition is key to learning the art of Ultrasound!
  • The mega-blog Academic Life in EM has a section devoted to Ultrasound – there are great literature reviews of the evidence and cool “US for the Win” cases.  Part of the big ALIEM machine – well done and peer reviewed for high quality.
  • The Sono Cave and US Village are sites run by my own mentors and local west Aussie mates Dr James Rippey and Adrian Goudie & co.  Educational lectures, cases and my favourite are the “report cards” which you can print out for reference or laminate and put on your machine.
  • Ultrasound of the Week – also by Dr Ben Smith. A weekly case study with US to test your sono-skillz and see how the pros do it!  Narrative is key to my learning – so I love the cases and frequency is perfect!
  • Dr Chris Fox is a legendary US teacher out of UC Irvine.  He has put a whole heap of free video lectures up on iTunes  – well worth watching on various topics.  Has a great way of explaining the phenomena you will see and how to apply it in practice.

OK.  So that is the big, tip of the US Educational iceberg – there are so many other great sites out there.

Please let me know on the comments about your site, or a site that you find really useful.  Always on the hunt for some new material and perspectives.

P.S:

If you happen to be a Broome JMO or plan to come to Broome in the future – then check out as many of these as you can.  Having a good grip on the theory and how to apply it is great before you hit the ground and start trying to make decisions.  And that stuff is best taught by experts – doctors whom are masters of the craft.  Then we will play with the probes and our patients will prosper!

Casey

PODCAST: Pushing Pressors in the Periphery

The mantra of the Broome Docs site is “bringing great care, out there.”  And today’s topic goes right to the heart of that theme.  It is one of my pet topics – so apologies in advance if the rant is too long or detailed.

This is a discussion about the early management of septic patients.  I live and work in an area where this is a common and deadly problem.  Care is far from the idealised ICU practice.  However in recent times the playing field has been levelled by new data that suggests that maybe a simpler approach can deliver good outcomes.  So this is my attempt to deal with a wicked problem – remote resuscitation of the shocked septic patient.

Although I am talking about how I think we can do it well in remote areas, I imagine some of this discussion is just as relevant in a big city ED.  Specifically this is an attempt to make a case for the early and liberal use of vasopressors [particularly noradrenaline] in patients with septic shock.

There has been a huge amount of evidence published and paradigms shifted in the last 12 months when it comes to the early management of sepsis.  EDGT is out.  What is in?   Well –  solid, careful and timely delivery of the basics of:

  1. resuscitation,
  2. early appropriate antibiotics with
  3. aggressive source identification and control.

It has been famously stated that in the  post-EGDT era: it doesn’t matter what “shit” you give, as long as you “give a shit”.  The substantial improvements in patient outcomes over the last 12 years have come about probably as the result of clinicians being more aware of the urgency of care and being proactive in their management.   We have also likely reduced the rate of iatrogenesis in that time period.

So this discussion focuses on the first part of that triad of early care for the septic patient: RESUSCITATION.  In most small hospitals the resuscitation basically includes IV fluids and after that has failed some sort of vasopressor.  Here in rural Australia there are really only 2 commonly used ‘pressors’ – metaraminol [darling of the bush anaesthetist] and noradrenaline [norepi for my N. American readers!].  Now I know that some will argue that Norad is not just a vasopressor, and that is true.  However, at the doses it is commonly used its main effect is on the venous circulation.  So humour me!

OK – so here we go.  I am going to try and convince you that we ought to be using:

  1. Noradrenaline
  2. through a peripheral cannula (initially)
  3. early in the Resus phase
  4. in a concomitant or synergistic manner with judicious fluids

Now I realise that there are several controversial / new ideas in that list.  So have a listen to the podcast as I try to make a case for using this newish, some may say aggressive, strategy in the early management of septic patients.  I am specifically referring to patients whom are being cared for in low-resource centres – places without 24 hour cover, no Crit Care facility or ICU trained Docs.  That maybe in the middle of the Kimberley – or it could be in your local hospital between the hours of midnight and six AM!

Have a listen.

Casey

REFERENCES:

Dr John Myburgh’s excellent discussion of “FLUIDS: 2015″ on the ICN Podcast is here

Dr Paul Marik’s recent dissection of : “the demise of EGDT” [from Acta Anaesthesilogica Scandinavia ]

the NEJMs trilogy of the:

Dr Bai et al Early versus delayed administration of norepinephrine in patients with septic shock.  From Critical Care Oct 2014

Ricard’s RCT of central vs peripheral catheters in ICU

Loubani & Green systematic review of peripheral vs. central vasopressors Journ of Crit Care June 2015.

Weingart: Podcast 107 – Peripheral Vasopressor Infusions and Extravasation

PODCAST: Dr Airell Hodgkinson

Gday and welcome back to the podcast after a short hiatus as I checked out the fish in Fiji…  Ahhh.

Today’s podcast is a conversation I had with my former colleague and mentor Dr Airell Hodgkinson.  Airell is a rural GP Anesthetist based in Albany – the southern end of WA.

He is a real thinker and has similar interests in trying to ensure our rural patients get the best quality care which they deserve.  Airell has recently concluded an audit of the local Albany cohort of “fractured NOF” patients.  He has collected the data to see how this group of high risk patients fare in Albany and compared it to those whom were transferred to a metropolitan hospital for surgery / anaesthesia etc.

The data is quite interesting – but not yet published… so watch this space.

Although it is an audit of older people with NOFs – there is a lot we can learn from this review – particualry when it comes to the decsion-making around transferring rural patients to tertiary care for serious illness.  Although it seems like a good idea on first thought – one has to consider a lot of factors when making these decisions with our patients.  As there are a lot of problems associated with transfer – especially for conditions with a time-critical course and where the rate of bad outcomes can be high.

From the outset – the Broome Docs motto has been: “delivering great care, out there!”  And it is something that I think about a lot – are we doing the best thing by this patient by keeping them in a small rural cetre – or could they get better care in the city?  This is a really tough call – especially when the patient wants to stay in the bush and for you to do “your best”.

In Broome, our capacity to provide great care has increased in recent years for conditions like sepsis, mental health clients, trauma and other medical emergencies.  As such the lines have moved in terms of who we keep or whom we send “south” (or east!)  Most of my practice is shaped by anecdote and receny bias – so it is really nice to see Airell has managed to collect some hard data around a group of patients where there is no good answer often.  This is a dynamic and wicked problem – one where there are many unknowns. BUt now we have a bit of data to have htat important discussion with our patients before deciding on the best place for their care.

OK – onto the podcast!
DOWNLOAD HERE

Emergency Trauma Management Course

Are you a GP, maybe a locum who spends time moonlighting in ED?  Do you work in an area that has no dedicated trauma service – hence you may be it one day?

Or are you a trainee – a young doctor wanting to go bush or into Emergency training?

Have you done the EMST or ATLS course?

If you have answered “Yes” to any of the above questions – then I have a piece of advice for you…..

Check out the ETM Course!    EMERGENCY TRAUMA MANAGEMENT

What is it? Well the mane say it really – it is a trauma course, but not another ABC course.  You are a smart doctor – you know all about the ABCs and can recite the various mnemonics for trauma management – but can you “run a trauma”?

Can you control a team of fellow resusciteers and make stuff happen?  Have you been trained in high-fidelity Sim with emphasis on communication and crew resource management?  Are you up to date with modern imaging pathways, decision-making and life-saving procedures?  Are you able to interpret trauma imaging confidently?

The traditional courses that we have all prepped and passed represent the basic standard of care that one might be able to deliver on a roadside with the usual kit.  However, the ETM course goes to the ceiling – this is about the real-world management of severely injured people in the ED.  Ticking the ABC boxes is not enough – you need to be able to provide first-class care in your ED.

To bring your knowledge up to this level Andy and his team have pulled al the educational strings – online learning, social media, electronic course book with greta video, even some ultrasound Mad Skillz

You can get a free peak or sign up to see the course materials.  However – the best way to make yourself a trauma badass is to sign up and immerse yourself in the full experience.

So check it out.  Give Andy a buzz and tell him “Casey sent you”.

DISCLAIMER:  I do not receive anything from the ETM course, I do as a matter of routine insist that new Docs coming to Broome complete this course as I feel it is the best way to prepare for the reality of small hospital ED trauma care.

I have been involved in creating some of the educational content on the course and think it is pretty good!

OK – end of advertorial.  Go on – check it out.  Worst case you spend a rainy weekend in Melbourne and your better half gets to spend a fun time on the cafe strips ;-)

Surviving Sedation 2015

It has been a busy month behind the scenes here at Broome Docs – lots of big projects and plans going on…  wait and see what we are have in the offing.

One project that I have been working on with a group of great clinicians from all over Australia.  It is called SURVIVING SEDATION 2015. Yes – that is a deliberate pun on the “Surviving Sepsis Guidelines” – and we want to install the idea that this is a high stakes situation, with lots of potential morbidity and unfortunate track record of mortality for these patients.  The goal is to use early, goal-directed sedation to maintain a safe environment for staff and allow patients to be cared for in a standardised, safe fashion.

We have been sharing ideas, data and experience around the acute sedation of patients with psychosis or other behavioural disturbance.  If you have been following the blog from the outset – then you will know that this is something that I am passionate about.  There have been a lot of changes to the way I practice when it comes to sedating Psychiatric patients.  This set of guidelines represents the vest available evidence, interpreted by front-line clinicians and presented in as simple, usable possible format.

Our lead “author” is Dr Minh le Cong – @ketaminh – the foremost Aussie researcher in Psychiatric retrieval.  Also on the panel were Dr Tim Leeuwenburg @Kangaroobeach , Dr Andy Buck @edexam and Dr George Douros.

Pre-publication peer review was also done by Dr Amit Maini @sithlord2004, Dr Peter Fritz @pzfritz & Dr Michael Downes @ToxTalks.

It is really difficult to write a set of guidelines that can be applied to all scenarios – our panel practice everywhere from major tertiary EDs to tiny remote clinics with near-zero resources for this scenario.  There is also a lot of variation in practice depending on your location. Many practitioners are working in locations that need to transfer Mental Health clients by air to a secure facility. Others work in hospitals that can provide this care immediately [though often not…]   However, as a panel we have tried to come up with a basic toolkit of medications, a strategy and logistical considerations that may be applied in any setting.

For the full detail of the rationale – pop over to Minh’s blog on the PHARM to read his thoughts.

The actual short version (2 pages – front and back) is designed to be laminated for reference in the clinic / ED / ward etc.

You can see it HERE SURVIVING SEDATION 2015

I am going to leave it up on the blog here in the permanent top menu under clinical resources.

SO – what is new in this set of guidelines?  Nothing too controversial.  The main changes are to the way we plan the sedation.

  1. Treat any Psych sedation as a “procedural sedation” – where the procedure is the safety of the patient +/- transfer to an appropriate centre.
  2. Pharmacological minimalism – using less agents in a titrated fashion
  3. There is a specific objective sedation score (SAT) – with goals of therapy clearly laid out.
  4. Ketamine is used in several potential situations: as a 2nd line IV / IMI agent in severe agitation and also as an infusion for transfer by air.
  5. There is emphasis placed on making a pre-sedation assessment of the airway / Anaesthetic / medical risk of sedation for a given patient.
  6. We have deliberately recommended that appropriate airway equipment and personnel be present.  No more dark, back room sedation supervised by the grad nurse up the far end of the ward.
  7. You will notice that midazolam does NOT feature in the mix.  This is the result of several papers showing it can be dangerous.  Diazepam is the chosen benzo – although this was largely due to its wide availability and clinical familiarity.  [Personally I will be using long-acting benzos such as clonazepam or lorazepam in my ED.]

Now it is your turn – I know that there are a lot of experts out there – and I want to hear your thoughts on this project.  So please have a read of the guidelines and the rationale on the PHARM site. Let us know what you like, don’t like or disagree with.  If you have any evidence that you feel might be incorporated – then send me the link.

Thanks

Safe sedating team

Casey