Transcript
- Welcome to our webinar today.
This webinar is on point of care ultrasound,
whole body approach, the Stanford Ed experience.
Please be advised all attendees are muted.
You may type your questions into the q
and a box in the toolbar located at the bottom
or side of your screen at any time.
We will conduct a q and a session at the
end of the presentation.
This webinar will be recorded in Archive
for future reference.
Our moderator, our moderator today is Dr. DKU men. Dr.
Men join SonoSite as a medical advisor in 2007
and currently serves as Chief Medical Officer
for both Fujifilm SonoSite and Fujifilm Medical USA.
He is also a clinical associate professor
of emergency medicine at the University
of Southern California.
He received his medical degree from Memorial University in
Canada, completed his residency at Los Angeles County
and USC Medical Center
and is a graduate of the Stanford Executive Program.
Dku. I will turn it over to you.
- So today's a really exciting discussion
and I really look forward to it
and it's my pleasure to introduce a very close friend
and an expert in point
of care ultrasound for many, many years.
Dr. Lale Gargan.
She's a clinical professor
and a medical director of emergency medicine at Stanford.
She's also the director emeritus
of the emergency ultrasound program at Stanford
University School of Medicine.
Many of you may know Ally as she's been very,
very active on the CME front.
She's been doing ultrasound
and medical education for many,
many years all the way from the medical student level all
the way to the fellow level.
She's spent a lot of time doing work in simulation
and particularly ultrasound simulation
and she's done a lot of work in the phone movement
and you see her very active on Twitter as well as
with her own blog, sono spot.com.
She's been quite an innovator looking at new innovative ways
of how we learn point-of-care ultrasound
and developed an actually a ultrasound based game to learn
point of care ultrasound, as I mentioned,
she's been doing a lot of teaching now a
lot more on the digital side.
That's things like we're doing here right now.
I've had the pleasure actually working and
and teaching side by side lale.
She's a phenomenal educator
and with that lale, we all look forward
to hearing about Hope Ultrasound.
- Thank you DKU for such a nice introduction.
We have worked together for a very long time and it's,
and it's always nice to partner with you again.
So what I'd love to talk about is,
is really just a bring a case example to this topic
and this aspect of what's called whole body point
of care ultrasound and, and what does that mean.
So traditionally
and historically we utilized ultrasound on a case-based base
basis, application specific
where you have a patient
and you ask a specific question that you want the ultrasound
to answer for you.
That is still very relevant.
But now, and especially with critical patients, the approach
to ultrasound has changed a bit
where we incorporate multiple different applications not
only for diagnostic purposes
but also for resuscitative purposes, procedural guidance
and to help us be more informative about what's going on
with the patient and be able to intervene accurately
and in a timely fashion so that we can save a life
and not make the wrong decision.
Whole body ultrasound, really what
that means largely is echo IVC lung
and any other application that is relevant to the case.
And it's been shown in the literature where
various anesthesiology specialist critical care
specialists have talked about for several years now about
how whole body ultrasound impacts and benefits the patient
and patient care patient assessment in order
to have appropriate resuscitative measures
and it continues to be talked about.
And with emergency medicine
and critical care literature going through what we see
and how it's a benefit being really on the frontline
and the forefront of bedside ultrasound, we're excited
to see this approach really take off, especially
during COVID times when all you have is a few people in the
room and you have your equipment that's with you, one
of which must be an ultrasound machine in order
to be able to get what you need.
So let's talk about a case. This is a real case at Stanford.
This actually is a real picture of our Stanford team. Dr.
Pete Acker is there.
He and the other residents and nurses
and techs who are there, they're suiting up in order
to go into a room and it's someone who is a John Doe.
This patient is altered, he's 76, he's complaining
that his abdomen is hurting
and he's having difficulty breathing.
They don't really know any past medical
history on this patient.
They see the EMS vital signs that you have in front of you.
A patient obviously in shock.
They of course do a physical exam
that you know is honestly quite limited in
what they can gather, but they do see
that the abdomen is tender, is distended
and with coarse breath sounds on both sides.
They divide up and conquer
and the physician looks at the echo first
and sees in this per sternal long view,
a hypocontractile heart with no pericardial fusion,
no RV strain,
and knowing that this patient likely has
volume sensitivity for resuscitative manner.
They confirm that with the IVC where the IVC is plump,
quite plethoric, no respiratory variation at all.
And they look at the lungs
and they see that every single lung field shows these B
lines that's indicative of pulmonary edema.
So they immediately understand this patient is volume
overloaded, liters
of fluid shouldn't be given even though they're suspicious
that this patient might be either in cardiogenic shock
or septic shock.
And because of the abdominal pain, they start
with about a 250 cc bolus and then go to the abdomen
and what they see is multiple dilated
loops of bowel.
And so this concerns them that this patient has
a small bowel obstruction
and an acute abdomen given the clinical presentation
of either a closed loop bowel obstruction
or a perforation of the viscous.
And in the meantime the nurse has another ultrasound machine
where they put in an ultrasound guided IV
because they were unable to do it in their first attempt.
And so our nurses do this actually, they're quite savvy
with it and they do it every single day.
It, it has saved our
ative measures well given that we're able
to get good IV access in a, in a quick amount of time
because of our nurses being able to do this.
And the meantime we have our resident
who put in an ultrasound guided internal jugular central IV
and did it in first attempt pass seeing
that needle tip right in the center of
that internal jugular vein
and then moved on to
what could barely be felt was a pretty thready radial artery
and did an ultrasound guided radial art line.
And because of this at,
at this point then the attending started
to call consultants, they called the surgeon
and they called cardiac anesthesia,
which we have at Stanford because of what we now know
because of ultrasound, the cardiac history of this patient.
And we knew that pre-op clearance,
if this patient was a surgical candidate, would be needed
for cardiology's assistance as well.
The patient wasn't making any urine after 250 cc bolus
and there was concern about volume overload.
So before putting in a Foley, they looked
to see is this patient retaining urine,
do they have any urine in the bladder at all?
And this is what they see.
Not that full of a bladder
but definitely not in urinary retention.
And after another 250 cc bolus,
so now a total of 500 ccs,
they took a look at the heart again
and saw that the right heart was filling and
and looking a little bit more prominent than the left side.
So they decided to then switch to pressor support
and eliminate any kind of fluid volume support at this time
with cardiac anesthesia at the bedside.
We partnered and intubated this patient
because the patient started to decline
and we were able to confirm
that the ET t tube was in the trachea
by ultrasound in order to attach the patient to the vent
and get them straight to the operating room.
So to summarize POCUS impact and,
and really to illustrate the impact
of whole body ultrasound approach to patient care
in really just a 20 to 30 minute time period,
we were able to understand the volume tolerance
of the patient and know that this patient had right heart
failure given that
after fluid boluses the right side
of the heart was filling more.
We knew the patient had a heart failure history
and a preload dependent phenomenon where fluid intolerance
of the patient was a huge factor in resuscitative measures.
Obvious procedural guidance for access for art line
for endotracheal tube where there was no delay in any
of their use because we could confirm
that it was successfully placed.
We got our consultants on board, the appropriate consultants
and we got them on board early, setting up this patient
for success for their operation
and definitely diagnostic.
We knew this patient had a small bowel obstruction within 10
minutes of that patient's arrival
and we knew that patient was fluid overloaded so
that we didn't contribute to not only would've been an
very risky induction with that intubation if we were
to have given too much fluid,
but also we were able
to be accurate in our diagnostic measures so
that the surgeon will know what they're working with.
And then of course resuscitation management volume,
understanding when pressor support would be needed.
And we had the confidence to do that. So this is Dr.
Pete Acker. He was telling me the story.
He had this smile on his face
because he really did feel that
although he is a fine physician,
he is a fantastic physician.
It it really is one of those.
If, if I could take some of my, my other colleagues
who I teach with ultrasound, it,
it does make good doctors great
and he was telling me this story
and you know, we we, that
that smile on the face is the picture that I took in order
to capture the moment.
Now the reason why it's so important now, especially
with COVID times, that we're all really
suffering through right now.
This, this third wave is higher than ever.
We at Stanford,
just yesterday we saw 540 patients in our
emergency department.
That's insane.
We have to be able to care for the sickest of sick
and when there's only a few people
that go into resuscitation and we now rely on iPads
and telemedicine to have other system and
and personnel support, including here one of our physicians
who is communicating with the team that's inside in order
to be the person to call those consultants
and to ensure that pharmacy is aware of what is needed.
And here's our nurse who is communicating
to their nursing staff
that's within the room looking at the room as well
as putting in the orders that the nursing staff
that's within the room are able to do.
And you know, I'll, I'll explain it
with one picture why ultrasound is
so important at the bedside.
Because the ability
to get an x-ray has been far limited with COVID.
We now have our x-ray techs
because of preservation of PPE
and healthcare worker protection,
our x-ray techs now take chest x-rays
through the glass door.
They do not enter the room to take a chest x-ray and,
and the quality of that x-ray is fantastic.
It's, it's amazing our radiology colleagues have done a
amazing job in order to do that.
But what that means is there's gonna be a little bit
of a delay in getting that set up to do.
The nurse in the room will need to set the patient up
and position the patient in order to, to set it up for,
for being able to take an adequate chest x-ray.
So point of care ultrasound is more important than ever
during these COVID times.
And I imagine some of this will stay post COVID
but you know, we'll we'll see
what is known even pre COVID though is
how the whole body approach has really
benefited our patients.
And this patient had went to the operating room successfully
with the surgeons did well, got discharged
after about a week and a half on the service.
And I don't know that I could have had that confidence
to say that about this patient
because we didn't know anything about this patient
if we didn't set them up
for success given their past medical history
that we found out because of point of care ultrasound.
With that, I'll stop DKU and see if there's any questions.
- Well Ali, that was a really, I think, powerful case
through illustrative of how point
of care ultrasounds is is like that Swiss army knife, right?
For the clinician at the bedside.
And as I listened to you talk about whole body
and even when your last slides
of all the different applications
and you think back of point of care
and how we started doing single applications as an example,
you know, let's do the gallbladder, right?
The radiologists are doing gallbladder,
let's learn gallbladder radiologists doing aorta,
let's do aorta.
But when I hear your presentation, I hear something
so different where it's a technology
that's integrated into clinical care
where previously it was this sort
of like this imaging test modality.
And that's fascinating, right?
Because then at that point so much more impact can have,
it's like ultrasounds like learning a language and,
and you, the earlier you learn it
and I know you're teaching medical students, so tell me what
that means for training, right?
Tell me like I sort of envision this younger generation
if they learn, you know, physiology,
anatomy early in a case-based approach
they'd always be thinking about ultrasound versus let's
order an ultrasound.
So what are your thoughts about having more of
what you just described?
How do we get that out there more
and what, what are the implications for people
that are involved in point of care training?
- It's such an important question
and so very relevant given what is the current state
of practice and and also medical education.
So the ideal training environment would be
where a student is learning.
If we're talking about a medical student level,
a student is learning how
to optimize their history taking skills
because it is still the vast majority of
how you can identify which even ultrasound
application you're going to use.
Your physical exam skills have to be optimized
and you've gotta still learn your physical exam skills.
And when you're reviewing cases, when it gets
to now pathology
and matching with pathophysiology when they're talking about
how to manage patients, how to diagnose patients,
then every step along the way with the more information
that they obtain by their history and physical exam.
The next question should be that bedside ultrasound
that you have available for you.
How can that help you in ruling that out
or potentially ruling
that in depending on the application that you do.
If you are going to decide to manage a patient with
IV fluids, how are you going to know with confidence
how much fluids you can actually give that patient?
How fluid tolerant is that patient?
Can they get the liter of fluid
that you really wanna give them
or should they, like this patient
that I presented only get very small eloquence
with rechecking of that heart with ultrasound in order
to see when presses support is then immediately needed
and thinking about it not in a single application anymore.
It's really integrated such that when
before you're even going to present
to the attending physician,
whether you're a student or a resident.
And if you have ultrasound on the mind in order
to think about
what more information you can provide to
that attending in order
to make yourself feel confident in these suggestions
that you have for managing the patient,
think about ultrasound, utilize ultrasound
and provide the information
that the ultrasound will get you throughout the way.
If anyone is having right upper quadrant abdominal pain
and there's someone who's presenting a patient to me,
I expect that they will tell me along with that
what their right upper quadrant ultrasound image shows
what the aorta showed in the particular patient population,
what did that right kidney as opposed to
that left kidney show.
If they're an an an older patient
where we don't know the medical history
or someone who hasn't seen a physician in multiple many,
many years, which you know,
definitely happens in our patient population,
then did you take a look at the heart
to see do they have any aspect of heart failure?
Especially if they come in hypertensive that we need
to then worry about when, if we need to give fluids.
So I think it really involves that integrative strategy
and training them to just keep thinking about ultrasound,
your history, physical ultrasound
history, physical ultrasound.
'cause that's what's available
to you at your hands right there with the patient.
- No, I, I think you bring up some really important points
and I wonder, you know, when we learned ultrasound, right,
you sort of went off and did a course, right?
You did a, you know, a two day course
or something that you just learned ultrasound.
But as we know we're, we don't, you know,
just base clinical care on ultrasound alone, right?
It's this integration.
And so especially when you think about things like whole
body, it makes me wonder if some
of the care pathways need to change.
You mentioned a few times history,
physical ultrasound when previously it would've been history
physical lab test x-ray,
oh now get an ultrasound right in sequence like quite versus
at the bedside.
You can now quickly see I know the heart IVC
and you know, things that are,
are care pathways like the weed reflexively give like a
liter of saline, just give a liter
of saline, just automatic.
Like there's lots of protocols like that.
But I wonder with the regular sort
of integrated use, are these protocols, are we gonna need
to change how we're approaching our patients in some
of the common algorithms?
- You know, I think the way we teach it should
change as well.
Of course we need to stick with the basics
and teach the applications and how to do it.
The patient populations that deserve these applications
to be done for setting them up for success, for diagnostic
and and management needs.
And we, if we continue to think about it
with a history physical and ultrasound approach every step
of the way, then we shouldn't have it be
where just one application, it's more of the syndrome
of that patient.
The differential diagnosis is never just one organ
or one organ system when it's the undifferentiated patient,
which means it's not only just one ultrasound application,
it's multiple ultrasound applications
with multiple organ system assessment.
So I think with our teaching style,
when it is the beginners, those that are just learning the
how to and the hand skills,
then hands-on training can help it.
It gets that fear of the probe away from them
where they really see how easy it is to learn.
And you know, subsequent to that then simulation models
for case-based scenarios for them to utilize in order to,
before learning on an actual patient then use simulation.
That's one of the reasons why I developed the sono do
game.com where you go online, it's free,
and when you go on sono.game.com, you pick your specialty
and you pick one of, you know, 20 up to 20 cases
and you go through it and you manage it
and you see actual ultrasound videos
and then you have to decide what's next,
what next should you do?
And that sono.game.com, some of it is the basics
of application specific,
but the vast majority of them have multiple applications
of ultrasound and a whole body approach to it as well.
- Very interesting. So speaking about whole body
and there's certain core applications,
certainly you mentioned heart, lung, IVC, some other areas,
which ones would you say are sort of novel,
a little bit exploratory, not yet mainstream,
but could become mainstream?
Any, any thoughts on that?
- It's a good question. So I think what may become more
and more utilized are
what we currently consider a a little bit of advanced
and an advanced pulmonary evaluation with ultrasound.
And I'm talking about taps e
or VTE measurements, you know, thing, things like that
for the point of care ultrasound user.
And, and that basically is just
because first of all, it, it's, it's easy to do
and once you do it, it's easy to, to calculate and,
and knowing those calculations can help you even more.
I think that's, that's probably where it's going.
As far as other applications, you know, I, I showed one
of them, which is the small bowel obstruction.
You know, when I see a distended abdomen now the first place
I go is for my ultrasound prob
because it is so good at diagnosing small
bowel obstruction, i the fluid filled, you know,
the bowel wall edema, all of
that allows the ultrasound image to be so clear
to be able to see those dilated loops so well.
And so really the reason I get the CT is
to see the reason for the bowel obstruction.
If it's the first time having one,
otherwise, if it's recurrent small bowel obstructions,
then we don't necessarily get a ct
and that diagnostic ultrasound is sufficient enough.
You know, we, the the x-ray that is commonly given that is,
is not always great.
We get really for consultant purposes still,
however, as our consultants start utilizing ultrasound at
the bedside and using it for things like this, they,
they find that the utility of x-ray for some of these more,
you know, traditional approach for an evaluation
for diagnoses like this aren't, isn't needed anymore.
- I think that's a good point.
So we may start substituting some of our imaging
as we're getting better with point of care
and our colleagues, our peer colleagues
and other specialties also are
comfortable with that approach.
And we're seeing this with, you know, a number
of different things such as appendicitis as one example.
So those are really good applications that you know,
are better for patients at less radiation, less cost,
no contrast agents, et cetera.
All the, the good attributes of point of care.
So some of the things you mentioned are sort of driven
by the environment and we we're, you mentioned COVID and,
and certainly COVID has driven a lot of changes,
had has broken more red tape barriers than ever before.
It's some of these for really good reasons.
Tell me from your standpoint,
what do you think has ultrasound, sorry, has COVID made a,
a, a dent for point of care ultrasound?
If so, what way?
- It's, it's both positive and negative.
So I'll, I'll start with the negative.
COD has prevented medical students from, you know,
being able to see PUIs and, and healthcare worker exposure
because of the supply of PPE
because of health, the student exposure to COVID.
Now that is different to different institutions.
There are some institutions where students are there
because their workforce is compromised
and the students have to be there.
But there's other places where the protection
of the student is still present and still persists.
I don't think that's gonna last very long,
but it definitely did for several months limit the ability
for students to be able to go to the bedside
to perform an ultrasound on someone
who is A-P-U-I-A-A person under investigation for COVID.
And and that's tough when the majority
of your patients are PUIs in your emergency department.
However, the good
and the positive impact that COVID has had,
and I hate even saying that 'cause I think COVID
is, it's such a beast.
But on point of care ultrasound in particular is
that our disaster plans, the, the place that we will
locate patients after a patient comes in and,
and during their triage process, ultrasound is a part of
that to see do the lungs show signs of COVID or not.
And if they do, then they go to this area
of the emergency department or hospital.
And if they don't then they go to this area.
And like the case that I used when there's limited personnel
and all you have is the few people there
and the equipment that you have at the bedside
where you can't just go in
and out in order to get the equipment or to call someone
or you know, you have to stay in there
because you're in full PPE, then ultrasound is
so much more important in diagnostic,
in resuscitative management, in procedural guidance
because as you saw with X-rays being through a glass door,
at least at Stanford,
we can't necessarily re rely on these kinds
of things at all.
We shouldn't, we shouldn't have done that pre COVID,
but it is definitely obvious during COVID times on,
on why we shouldn't now.
- Yes. And we've heard similar stories from other
parts of the world.
Certainly I think, you know, Enrico Toti, one
of our colleagues and,
and they were inundated in the Milan area in Italy
and they used point of care ultrasound,
it immediately pivoted.
They had no choice actually that CT scanner was overwhelmed.
But yeah, so we've recognized now that certain things that,
or some care pathways certainly in COVID
and certainly lung ultrasound and, you know, the, the heart
and the IBC are become more standard.
That's what it seems like both from clinical use and,
and certainly the publications we've seen a a, a flurry
of publications, many publications coming out almost weekly
on on point of care and COVID-19.
We have one final question here.
It, it sounds like with whole body you collect a lot
of images of course.
Yes. Would you recommend with, for image management, like,
you know, w what what should a program do storing
and queuing and, and, and, and billing, et cetera?
- Well, if you're set up for it,
you should have an ultrasound director who's ultrasound
trained in order to set up the billing process
that revenue will be able to help
with any equipment needs,
any archival software purchasing needs
easily within just a, a few months if, if not a year,
depending on how big the emergency department
or unit is that you're using it for.
And, and,
and I think that having some sort
of imaging archival software not only allows you
to do quality assurance and,
and reviews when there's any kind
of patient management question,
but it also allows for consultants to be able
to view those images from wherever they are,
even if they're home call, if they have access
to the online platform
and view the images as well to ensure
that they feel confident in the
decision that they're making.
And this is particularly true for surgery colleagues
where they have to decide or, or no,
or that's a tough decision to make.
And I think when they're able to view those images
because it's archived in a way
that other physicians can view them, then all the better
before that.
Then it involves, you know, things like
either putting it on a pack system where
that is already existent in, in the institution or even
before that would be really, really technical, traditional.
But if that's all you have is saving it on the machine
and downloading it on a secure protected thumb drive
for then securing it on a hospital or,
or some sort of other institution secure
server for archiving.
- Yeah, I think those are really important points for point
of care ultrasound to actually be well developed.
You're really gonna need a, a good workflow system
and certainly for the viewers if you've not yet known,
so does have a workflow software called Synchronicity
that does everything you just mentioned Lolly.
Well actually this just brings us, I think toward the,
the end of this program.
So lolly, it's been an absolute pleasure to speak you
with you today and learn about whole body
ultrasound really informative.
On, on behalf of SonoSite, on behalf of the, the entire team
that helped put together the webinar, we wanna thank you for
educating us all today.
- Thank you so much for having me. Until next time,
- Absolutely.
Thank you.
Learn how the whole-body approach to point-of-care ultrasound is essential for safely managing patient care in the emergency medicine environment. Using POCUS for a whole-body approach expedites the diagnosis and treatment of shock, and the respiratory and multi-organ failure often encountered in patients with COVID-19.
Whether managing clinical complications or trying to perform procedures safely, the whole-body approach is a vital element in critically ill patient care.
What You'll Learn
- How the whole-body approach to point-of-care ultrasound is essential to managing patient care safely
- How a POCUS whole body approach expedites the diagnosis and treatment of shock, and the respiratory and multi-organ failure often encountered in patients with COVID-19
Dr. Gharahbaghian is an academic emergency physician who completed her fellowship in Emergency Ultrasound in 2007 at Stanford and remained on the Stanford faculty to serve as Director of the Emergency Ultrasound Program and Fellowship for 10 years. Now, she serves as Medical and Quality Director of Emergency Medicine. Her interests include ultrasound in medical education, quality improvement, resident education, and simulation-based ultrasound training, including procedural skills training and case-based learning for ultrasound interpretation and integration. Her research involves the study of various point-of-care ultrasound applications in the management of critical patients, in the screening of trauma patients, and in its education through simulation models.
She is a leader in the national bedside ultrasound educational impact, has led several very successful educational innovations in emergency ultrasound, including her internationally-known blog, SonoSpot.com with thousands of followers on Twitter (@sonospot) where she continues to engage with the FOAMed community. She is also the first to create an online ultrasound-focused case-based educational opportunity through gamification with SonoDocGame.com.
Due to her belief that adding ultrasound can enhance learning of the human body and disease while quickening diagnoses and life-saving interventions, she brought UltraFest, a free national medical student ultrasound symposium to Stanford, and has travelled internationally to provide educational sessions on ultrasound integration into emergency practice at various developed and underdeveloped countries and rural village clinics.
She has directed various ultrasound CME workshops and continues to instruct at several successful national CME ultrasound workshops, including at the national scientific assembly for the American College of Emergency Physicians (ACEP) and Stanford's Point-of-Care Ultrasound Workshop.
Dr. Mandavia, MD, FACEP, FRCPC, joined Sonosite as a medical advisor in 2007 and served as Chief Medical Officer for both FUJIFILM Sonosite, Inc. and FUJIFILM Medical USA between 2015 and 2021. He is also a Clinical Associate Professor of Emergency Medicine at the University of Southern California and was an Attending Staff Physician at Cedars-Sinai Medical Center in Los Angeles from 1998-2010.
Dr. Mandavia is a founding member and past-chair of the ACEP Ultrasound Section and co-author of the ACEP Ultrasound Guidelines. He has taught thousands of physicians worldwide, lectured at over 200 medical conferences and has been awarded ACEP’s Outstanding Speaker of the Year. Dr. Mandavia has also contributed to over 100 publications and is co-director of the national Resuscitation Conference. He received his medical degree from Memorial University in Canada, completed his residency at Los Angeles County and USC Medical Center and is a graduate of the Stanford Executive Program.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.