SMACC Chicago – it’s heating up

Greetings readers

I have been on a bit of R&R on the run into Xmas and trying to avoid the Internet for a few weeks!

Today though I have come out of hibernation to remind you that the biggest and brightest conference is coming soon… in June 2015.

That may seem like a long way into the future – but the competition for tickets, workshops and hotels is getting tight.

I know that you will seriously regret leaving your planning too late – so get on over to the smacc.net.au website now and register for the conference. Check out ht awesome line up of speakers, workshops and social program.

I have just received a prompt from the organising committee to help me sharpen up my act and together we will make SMACC Chicago to most entertaining and engaging medical event that the world has ever seen!

Most importantly – my favourite part of this awesome event is the chance to meet you all, its so much fun to chat live after all your contributions to the comments and Tweets.  So come on aver and say “Hi”

Casey

SMACC PROMO

The Birthday Bet

I am working on a post about risk and decision-making and I need your help.

I am trying to get a feel for the risk numeracy of the average doctor – I realise that none of my readers is “average” but please take the time to read the following scenario and give me an honest answer.  Please try to avoid Googling the “right” answer – I am after your gut feeling.  I want to know if this were you – and you had to take a guess what would you say?  It is not about the maths – it is about how doctors think…  yes I am data mining your brains.  Sorry.  That is the sort of thing I do for fun on nights here in Broome!

OK here is the scenario;

You are invited to the Hospital Xmas Party by a nice young nurse.  Unfortunately they tell you the wrong time – so you turn up in you fancy dress Chicken Suit an hour early.  Not sure what to do – you decide to engage in idle banter with the Hospital Tea Lady who is carefully arranging her sausage rolls on a long table.  After 5 minutes you discover that you both lived on the same street in Wagga Wagga – although she was there in the 1950s, 30 years before you were born.  Nice coincidence!.

After 20 minutes the conversation stalls a bit, and during and awkward silence she proffers the following bet:

I’ll bet you that there are two people coming tonight who share the same birth date – not necessarily the same year – but the same date eg. the 6th of May…

Of course there are 500 people coming to the party – so it is a pretty easy bet.

OK, to make it interesting.  Lets ask each person as they arrive their birthdate.  And see how long it takes before we have a match i.e.  a pair with the same Birthday.

OK – sure.  How many people do you think?  Tell me how many people need to arrive at the party before it is a better than 50:50 bet that there will be a shared birthday?  That is – when would it be in your favour to take the Tea Lady’s Bet

Thanks for that – promise I will share the results soon.

Casey

Renal Colic Scans with Dr Adrian Goudie

Patients presenting to the GP or ED with flank pain, colicky pain or pain with haematuria are pretty common.  We know that a lot of these folk will turn out to have the dreaded kidney stones.  We all have our own ways of deciding how to treat these patients.  You may be aware that in September  a big paper was released in the NEJM titled Ultrasound vs. CT for Suspected Nephrolitiasis.  For many ED docs this paper just might be a game-changer.  This was the first really big trial which looked at the bedside US vs. formal US vs. CT for the initial workup of this group of patients.  And it seems to suggest that bedside US is a valid first test for most patients.

As a GP I think this is potentially a big change – if we can scan at the bedside in our clinic with the modern machines – we just might be able to do a pretty fair job of managing simple, uncomplicated renal stone disease without ever needing a hospital – that would be nice!

Anyway – I have been wanting to pick the brain of a much smarter ultrasonically-enhanced doctor about how this changes our practice in 2014 – so I managed to enlist the help of Dr Adrian Goudie [ED Physician, Ultrasound Village teacher, SMACC Sonowars combatant, Ultrasound Leadership Academy Professor and immediate past President of the Australasian Society of US in Medicine...  and great bloke! ]

We had a natter about the paper, his practice and the pragmatic approach to patients with potential stones in the ED (or GP clinic).

Here is the podcast:

DIRECT DOWNLOAD HERE

Adrian has a really nice set of “rules” to guide us when working up suspected renal colic patients.  It goes something like this:

  1. Treat the following groups with caution – you may want to be more aggressive with your imaging if the patient has:
    • Known renal failure, or new renal failure
    • Known congenital anomaly or single (transplanted etc.) kidney
    • Signs of infection / sepsis / obstructed pus is bad.
    • Extremes of age – you are just more likely to find other pathology that you don’t want to miss
  2. As a routine have a look at the aorta – this is low-hanging fruit and an important one to not “miss”.
    • You should also consider the gallbladder, uterus, ovaries, testes and even the appendix if the clinical picture fits.
    • Think outside the KIDNEY BOX – particularly if your renal scan is normal.

You can also check out an older Broome Docs Case [To Frolic with Colic: Case 035]  where we looked at the value of “haematuria” in the investigation for renal colic.  It is interesting to go back a few years and see the smart docs who anticipated this research with their comments- Dr Goudie was one of them!

Also check out the Renal Ultrasound talk from Matt Dawson at Castlefest a while back. So you can see what stones etc look like.

There is a great “Cheat sheet” for reference when scanning from my friends at the Sonocavge HERE – Thanks Dr Goudie and Dr Rippey.

Let me know if this will change your practice…. or not.

Casey

Clinical Case 109: Eyes, Air and Ultrasound

A quick case that shows how we can use ultrasound in clinical assessment of eyes and why US makes me look like a better doctor.

30 year old woman – was punched in the face 3 days ago at a disco.  She sustained a small laceration over the inferior orbital rim – but went on dancing.

The next day she awoke with a really swollen face, unable to open her eye at all.  The laceration had sealed itself  – so she decided to wait a few days to “see it it would get better”.  That is the type of people we see a lot of in Broome!

By day 3 the swelling was no better and she was beginning to get a bit annoyed by the pain and inability to open her eye…  so off to ED.

The left eye was severely swollen – despite analgesia and a firm hand – the best I could do was glimpse the sclera and a bit of cornea.  She had a small subconjunctival haemorrhage, no hyphema and a clear looking cornea [in the half second that she tolerated my prying her lids apart.]  Far from an ideal assessment.  So how do you assess an eye that is occluded by swelling in the middle of the night?  Ultrasound of course!

Here is a rough guide to looking into eye trauma using the US machine.

  1. Linear probe set to 4 – 5 cm depth.  “Small parts” preset works OK.
  2. Get heaps of gel onto he probe / upper lid (use cooled gel if you want to make a gel heap as a stand-off pad.)
  3. Easiest to have the patient supine with pillow to stop the head moving.
  4. Set the gain to make the vitreous black, however it can be useful to turn it up if you are looking for subtle intra-vitreal bleed etc
  5. Scan over the upper lid fanning from superior to inferior, then in sagittal plane from side to side.

There are some cool things you can do with ocular US when the eye is unexaminable:

– Assess range of extra ocular movement.  This is really important for assessing for rectus entrapment.

– Assess pupil response (check out the video here)

So I went through my routine and scanned the closed eye.  In trauma I look for the following injuries on my scan:

  • lens dislocation,
  • retinal tear,
  • intra-vitreal bleed / detachment,
  • globe rupture and
  • retrobulbar haematoma [tip is a "guitar pick-shaped" posterior globe]
  • Check the optic nerve sheath diameter (ONSD)

As I was scanning the orbit I kept getting this weird artefact – thought it was maybe due to some cellulitis or loss of contact – but it “just didn’t look right”.

So when I do a scan and it is “not quite right” I tend to imagine the worst case scenario.  I was seeing a normal eye with good pupil response, extra ocular movement etc. No pathology – just this odd artefact that obscured my views.  So I decided to investigate further.

Here is the CT of her orbit: Clearly an inferior orbital fracture with a nice teardrop of fat extruding into the antrum.

And you can see quite a bit of air that has escaped into the orbit – which was the sourcephoto-2 copy of my mystery artefacts.

So I thought I had just discovered a new sonographic sign – but of course I was wrong.

There was a paper published on this phenomenon way back in AJEM, 2004 from Michael Blaivas et al (here)

So I managed to fluke finding air in the orbit – though I wash’t really sure what I was seeing!

Lessons learned here:

  1. If you are not sure what you are seeing – don’t ignore it! It might be the key to the diagnosis
  2.  Air in the orbit equals blowout fracture and looks like a dirty gas shadow (kinda like bowel in the orbit)
  3.  Correlate your bedside scan with formal images and you will learn a lot faster.

Happy scanning

Casey

Lung Ultrasound with Dr. Kylie Baker

For about a year now I have been spending time “working” for the Ultrasound Leadership Academy – run by the team from the Ultrasound podcast.  It is really cool to be able to chat with enthusiastic US learners all over the globe about the clinical coal-face of US in medicine.  One question I get asked a lot: – what is the most useful US modality for me?

Well I reckon that lung US is now a clear winner.  Why?  Because it is so useful in really common, everyday scenarios.  It does guide diagnosis and also therapy and can be a life-saver from time to time.  A lot of the other uses of ED Bedside US are applied in less common situations and may not really effect outcomes in a lot of patients [I will get in trouble for saying that!].

So I feel that lung US is the thing I would teach to a keen MEd Student if they asked me to give them one US skill to make their early postgrad years go better.  But the problem is that this is a relatively new concept – unless you are from Europe – where it has been going on for 20 + years.  But for the English-speaking world it is pretty new and just making its way into clinical algorithms.

There are a few problems to overcome when learning lung US;

  1. The set-up on your machine is unlike any other that you have used before [mostly there are no pre-programmed modes.]
  2. It is all about artefacts – we are looking for things that are not really there – patterns in the smoke that represent various entities, rather tun actually visualising the “real anatomy”
  3. There is a steep learning curve… clinical correlation is required
  4. This is like many US uses – very user-dependent.  It takes practice to get consistently good images.

Luckily [for me and you] I had the good fortune of bumping into Dr Kylie Baker a few weeks ago at the ASUM [Australasian Society of US in Medicine] Conference in Melbourne.  Kylie is an ED doc from Ipswich in Queensland and has been contributing pearls to the Intensive Care Network on lung US in critical care.  So I put her on the spot and asked her some really dumb questions about lung sonography!  The result is this podcast.

I highly recommend having a listen if you are at all interested in improving your ability to treat patients with acute chest disease.

Here is a basic “How To” list that I have compiled from my discussions with Kylie.  You need to know how to make your machine do chest scans  – this is the quick guide for dummies.

(1)  Patient: enter patient ID and data for future ref and learning.  Review is crucial to learning!

(2)  Probe: select curvilinear probe initially for routine 8 zone scan

(3)  Position: patient supine / semi-supine. If they can sit for posterior scans – great. Depends on clinical context and your diagnostic goals.

(4)  Settings: TURN OFF any automated features that may decrease artefacts – e.g.. Tissue harmonics, multi beam, sonoCT, minimise greyscale range

(5)  Preset: Abdomen is OK. [NB: Lung preset on newer machines is really only optimised for pneumothorax scans - not other lung scanning.]

(6)  Depth: 10 – 12 cm in a normal sized person. You may need to adjust this if your machine has a fixed focal depth

(7)  Focus – aim to focus on the pleural line. (If this is fixed – then decrease depth to bring pleura close to mid screen.)

(8)  Frequency: push the probe to the lowest (Penetration) frequency possible.

(9)  Hand position: visualise the pleural surface and aim to keep the beam perpendicular to he pleura. [for pneumothorax - a slight angle may help] ***The absence of “A lines” suggests an incorrect setup or too large an angle on the pleura

(10)  The scan: Sample each of the zones (2 anterior, 2 lateral +/- posterobasal on each side)   If abnormalities are found – esp. focal changes – then this area can be further interrogated with a more thorough scan or a linear probe

Other great resources on Lung Scanning :

This from the Queen of Lung US – Dr Vicki Noble via Ultrasound Podcast – there are 2 parts to the lecture

Back to Basics on the Lung artefacts with Dr Mike Stone (the other Mike) of US Podcast – also a 2 part deal.

Some great pointers from Dr Rob Arntfield from Western Uni IN Canada at Western Sono tutorials. This video shows the positions of the probe well.

And guess what – all of these great lung US teachers are also “professors” with me at the Ultrasound Leadership Academy.  Check it out if you want to take your US skills to the next level.

If you have questions, comments or your own Lung US pearls – then please share on the comments below

Big thanks to Dr Baker for her time and expertise

Casey

Clinical Case 108: Planes, Drains and Pneumothoraces

Another case inspired by a Twitter debate today.

A Tweet Case was put forward by @FlyingDrBen  (Ben Darwent) who is based in Perth WA – home of LITFL. My friends Minh le Cong, Karim Brohi and Tim Leeuwenburg started a discussion around the case.  Fair to say it got way too big for twitter!  So I am posting this case to get you all thinking and source expertise on the topic.  Here we go…

Rodknee is a 27 yo. man who has presented to a remote hospital following an “incident” in which his girlfriend stabbed him in the right lateral chest with a small kitchen knife ( ~ 12 cm blade).  She apparently found out he had been sleeping with his wife despite his assurances to the contrary.  The oldest story in the book!

Rodknee is a stoic individual and managed to sober up and have a sleep before presenting to the ED about 3 hours after the injury.  There was not much blood loss at the scene and he managed to patch things up with his +1 in the meantime.

On arrival his Obs are all normal ( P = 70, BP = 125/80, RR 14, SpO2 = 99% RA, he is well perfused and alert.  He does complain of some pleuritic pain on inspiration over the site of the wound.  On inspection he has a very neat stab wound ~ 2cm long at the anterior axillary line – 6th intercostal space.  There wis no active bleeding or bubbling.

The attending Doctor is a semi-retired GP from an affluent Sydney suburb who is doing a few locums “for fun” to round out his career.  He has asked for your advice – fortunately you have a High-def VC link up to their ED which is about 250 km away.   So you have a virtual look at the patient.  He is as advertised.

Being an ultrasound enthusiast – you talk the locum through a FAST scan and look for a pneumothorax / haemothorax.  The very rough and ready images reveal a tiny right pleural fluid collection (less than a centimetre) and no clear pneumothorax – although it is hard to exclude in a mobile vertical patient who is 250 km away!  So we think he has a small haemothorax and either no pneumothorax – or a very small pneumo we have not been able to find on US.  He remains haemodynamically stable.

The locum is super keen to get Rodknee transferred out to your bigger ED ASAP – he is the solo cover and has been up all night already.  Fair call – lets get the aeromedical team in to swoop and run.  But……   what about the potential pneumothorax?  Does it need a drain before we put this chap on a small plane?  The textbook says it will expand and might cause tension effect if it does.

Just out of interest – you ask the locum if he is comfortable with placing an ICC if required…  he tells you that he last did one in 1979.  Then he starts waving a metal trocar around like the Swedish chef from the Muppets!  Hmmm, maybe not so soon!

So here is the question – is it better to perform a prophylactic intercostal catheter in a well lit ED under sterile conditions, OR should we fly him without an ICC.  What is the risk of his developing a tension pneumothorax or becoming hypoxic is his possible pneumo expands?

Is a drain mandatory for a 30 minute flight in a small aircraft that will be going to altitude?

Controversial!  Lets hear your thoughts.

Casey