Asymptomatic ventricular fibrillation in continuous flow left-ventricular assist device.

Left ventricular assist devices (LVADs) have increased survival for heart failure patients. Individuals with LVADs are a growing patient population with frequent complications and Emergency Department (ED) visits. A 50-year-old female presented to the ED due to a low flow alarm on her LVAD. Upon arrival in the ED she was noted to be in ventricular fibrillation. She was defibrillated with restoration to normal sinus rhythm and was started on amiodarone. An implantable cardiac defibrillator was placed during hospital admission. Amiodarone was continued as an outpatient. Patients with continuous flow LVADs can be in dysrhythmias including ventricular tachycardia and ventricular fibrillation and remain relatively asymptomatic. We present a rare case of a patient with an LVAD and ventricular fibrillation who was completely asymptomatic in the ED.

Feasibility of sonographic localization of the inferior epigastric artery before ultrasound-guided paracentesis.

BACKGROUND: Ultrasound-guided paracentesis is commonly performed in the emergency department (ED) setting. Injury to the inferior epigastric artery (IEA) is an uncommon but potentially life-threatening complication of paracentesis. Use of anatomic landmarks has been recommended to avoid this structure. If feasible, sonographic localization of the IEA before ultrasound-guided paracentesis may provide the operator with anatomic mapping of this vascular structure. CASE REPORTS: We present 5 cases demonstrating the feasibility of identifying the IEA in ED patients with ascites. Why should an emergency physician be aware of this? Sonographic localization of the IEA before ultrasound-guided paracentesis may provide a more reliable means of avoiding iatrogenic injury to this vessel. Further study is warranted to determine whether routine IEA visualization before paracentesis results in a decreased complication rate.

Negative predictive value of excluding an embedded snake foreign body by ultrasonography.

OBJECTIVE: Numerous reputable sources for healthcare providers advocate routine imaging to rule out an embedded tooth or fang after a snake bite. The objective of this study was to determine whether these foreign bodies can be reliably excluded by bedside ultrasonography. METHODS: All emergency medicine (EM) residents and faculty at a single institution were invited to participate. Two sets of 5 ultrasound gel phantoms were prepared using a method previously validated to have the same density as human tissue. In the first set of 5 phantoms, 1 snake fang was embedded to simulate a retained foreign body. Similarly, in the second set of 5 phantoms, 1 snake tooth was also embedded. Participants were asked to identify the presence or absence of a foreign body in each phantom using bedside ultrasonography. Year of training and confidence in excluding a snake foreign body were also recorded. RESULTS: Each participant (n=27) performed ultrasound imaging on 10 phantoms for a total of 270 samples. Range of experience included postgraduate year 1 (25.9%), postgraduate year 2 (29.6%), postgraduate year 3 (33.3%), and graduates of EM residency (11.1%). The sensitivity and negative predictive value for ruling out an embedded fang was 92.6% and 98.1%, respectively. The sensitivity and negative predictive value for ruling out an embedded tooth was 77.8% and 93.7%, respectively. Among all the phantoms, there was a sensitivity of 85.2% and a negative predictive value of 96%. CONCLUSION: Bedside ultrasonography performed by an EM physician is a feasible option to rule out embedded foreign bodies after a snake bite if imaging is warranted.

Training in transvaginal sonography using pelvic ultrasound simulators versus live models: a randomized controlled trial.

PURPOSE: To compare pelvic ultrasound simulators (PSs) with live models (LMs) for training in transvaginal sonography (TVS). METHOD: The authors conducted a prospective, randomized controlled trial of 145 eligible medical students trained in TVS in 2011-2012 with either a PS or an LM. A patient educator was used for LM training. Simulated intrauterine and ectopic pregnancy models were used for PS training. Students were tested using a standardized patient who evaluated their professionalism. A proctor, blinded to training type, scored their scanning technique. Digital images were saved for blinded review. Students rated their training using a Likert scale (0 = not very well; 10 = very well). The primary outcome measure was students' overall performance on a 40-point assessment tool for professionalism, scanning technique, and image acquisition. Poisson regression and Student t test were used for comparisons. RESULTS: A total of 134 students participated (62 trained using a PS; 72 using an LM). Mean overall test scores were 56% for the PS group and 69% for the LM group (P = .001). A significant difference was identified in scanning technique (PS, 60% versus LM, 73%; P = .001) and image acquisition (PS, 37% versus LM, 59%; P = .001). None was observed for professionalism. The PS group rated their training experience at 4.4, whereas the LM group rated theirs at 6.2 (P < .001). CONCLUSIONS: Simulators do not perform as well as LMs for training novices in TVS, but they may be useful as an adjunct to LM training.

The core content of clinical ultrasonography fellowship training.

The purpose of developing a core content for subspecialty training in clinical ultrasonography (US) is to standardize the education and qualifications required to provide oversight of US training, clinical use, and administration to improve patient care. This core content would be mastered by a fellow as a separate and unique postgraduate training, beyond that obtained during an emergency medicine (EM) residency or during medical school. The core content defines the training parameters, resources, and knowledge of clinical US necessary to direct clinical US divisions within medical specialties. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear in future examinations. This article describes the development of the core content and presents the core content in its entirety.

The wire is really easy to see (WIRES): sonographic visualization of the guidewire by novices.

OBJECTIVE: To determine whether novices can distinguish between properly and improperly placed guidewires in a vascular access model after only minimal training. METHODS: This was a prospective study involving trainees with no previous training in sonographic guidewire visualization. A vascular access model was created with guidewires positioned inside or adjacent to simulated veins. Subjects were taught to scan each wire to determine its location. Afterward, participants scanned a test model of five vein-wire pairs and recorded their answers as "inside," "outside," or "unsure." The test characteristics of sonographic guidewire localization were determined using actual wire location as the criterion standard. RESULTS: Forty trainees (21 emergency medicine residents, 19 medical students) participated, and each examined five simulated veins. There were 156 true positives (intravascular wire correctly identified), 38 true negatives (extravascular wire correctly identified), 2 false negatives, 2 false positives, and 2 cases in which the participant marked "not sure," which were reclassified as false negatives. Test characteristics were sensitivity 97.5% (95% CI 93.3-99.2) and specificity 95.0% (95% CI 81.8-99.1). The overall accuracy was 97.0%. CONCLUSIONS: Sonographic guidewire visualization, a step recommended for ensuring proper vessel cannulation during central venous access, can be accomplished by novices with a high degree of accuracy.

Ultrasound-guided hip arthrocentesis in a child with hip pain and Fever.

Children presenting to the emergency department with hip pain and fever are at risk for significant morbidity due to septic arthritis. Distinguishing between septic arthritis and other causes of hip pain may be challenging. Sonographic visualization of the hip with real-time ultrasound-guided arthrocentesis may allow faster differentiation between etiologies, hastening definitive therapy and improving analgesia. This report describes the use of hip sonography in a case of Lyme arthritis. The authors review the medical literature in support of bedside hip sonography and discuss how to perform ultrasound-guided hip arthrocentesis. Clinical findings in septic and Lyme arthritis are also described.

Bedside renal ultrasound in the evaluation of suspected ureterolithiasis.

OBJECTIVE: To determine whether ultrasound changes emergency physicians' estimated likelihood of acute ureterolithiasis in patients with flank pain. METHODS: This prospective, observational study enrolled patients awaiting computed tomographic (CT) scan for presumed renal colic. Using a visual analogue scale, treating physicians estimated the likelihood of acute ureterolithiasis based first on clinical findings and urinalysis, then after ultrasound, and finally after CT. A 20% change in estimated likelihood was considered clinically significant. Test characteristics of ultrasound for any ureteral stone and for those greater than or equal to 5 mm in size were determined. RESULTS: One hundred seven patients were enrolled. Sensitivity, specificity, and negative predictive value of ultrasound for stones observed on CT were 76.3% (95% confidence interval [CI], 59.4%-88.0%), 78.3% (95% CI, 66.4%-86.9%), and 85.7% (95% CI, 74.1%-92.9%) respectively, and for stones >5 mm 90.0% (95% CI, 54.1%-99.5%), 63.9% (95% CI, 53.4%-73.2%), and 98.4% (95% CI, 90.3%-99.9%), respectively. Ultrasound significantly impacted the estimated likelihood of disease in 33 of 107 cases (30.8%, 95% CI, 22.5%-40.6%). Computed tomography further significantly changed physicians' impression of disease in 55 of 107 cases (51.4%, 95% CI, 41.6%-61.1%). CONCLUSIONS: Bedside renal ultrasound had only a limited impact on the physicians' clinical impression of patients with possible ureterolithiasis. The sensitivity of sonographic hydronephrosis was modest for detecting any ureteral stone, but much better for detecting a large stone. Further study is needed to define the precise role ultrasound should play in evaluating patients with suspected ureterolithiasis.

Needle and guidewire visualization in ultrasound-guided internal jugular vein cannulation.

STUDY OBJECTIVE: Reimbursement for ultrasound-guided central lines requires documenting the needle entering the vessel lumen. We hypothesized that physicians often successfully perform ultrasound-guided internal jugular (IJ) cannulation without visualizing the needle in the lumen and that guidewire visualization occurs more frequently. METHODS: This prospective, observational study enrolled emergency physicians performing ultrasound-guided IJ cannulations over an 8-month period. Physicians reported sonographic visualization of the needle or guidewire and recorded DVD images for subsequent review. Outcome measures were the proportion of successful procedures in which the operator reported seeing the needle or guidewire in the vessel lumen and the proportion of successful, recorded procedures, in which a reviewer noted the same findings. Procedures were deemed successful when functioning central venous catheters were placed. Fisher exact test was used for comparisons. RESULTS: Of 41 attempted catheterizations, 35 (85.4%) were successful. Eighteen of these were recorded on DVD for review. The operator reported visualizing the needle within the vessel lumen in 23 (65.7%) of 35 successful cannulations (95% confidence interval [CI], 47.7%-80.3%). In 27 cases, the operator attempted to view the guidewire and reported doing so in 24 cases (88.9%; 95% CI, 69.7%-97.1%). On expert review, the needle was seen penetrating the vessel lumen in 1 (5.6%) of 18 cases (95% CI, 0.3%-29.4%). Among recorded procedures in which the operator also attempted wire visualization, the reviewer could identify the wire within the vessel lumen in 12 (75.0%) of 16 cases (95% CI, 47.4%-91.7%). CONCLUSIONS: During successful ultrasound-guided IJ cannulation, physicians can visualize the guidewire more readily than the needle.

Motivations, job procurement, and job satisfaction among current and former ultrasound fellows.

OBJECTIVES: Over the past decade, emergency medicine ultrasound (US) fellowships have proliferated, yet there are no published data describing employment trends among fellowship graduates. This study sought to assess factors motivating emergency physicians to pursue an US fellowship and to characterize their employment and job satisfaction after graduation. METHODS: An electronic survey was conducted of US fellows and graduates representing all 35 known fellowship programs. Non-responders were contacted at 2 weeks to encourage participation. Primary outcome measurements were the importance of factors motivating individuals to pursue an US fellowship (as rated on a numeric scale), job satisfaction among US fellowship graduates, the proportion of respondents practicing in academic versus community hospitals, clinical hours per week, and the rate of procurement of one's top choice of job after graduation. The chi-square test or Fisher's exact test was used for categorical variables, and the Mann-Whitney U-test was used to compare continuous variables between two groups. RESULTS: Of 170 invitations sent, 10 were undeliverable. The response rate was 61%; 74 graduates and 23 fellows completed the survey. Enhancing job opportunities, enjoyment of US, long-term job satisfaction and gaining skills not learned in residency rated highest as reasons for pursuing an US fellowship. Among graduates, 20% are satisfied with their current job, while 78% are very satisfied or extremely satisfied. Nearly one-third of graduates (31%) work primarily in non-academic hospitals, while only 9% of current fellows aspire to work in non-academic settings in the future. There was no difference in job satisfaction between academic- and community-based graduates. In comparison to those graduating in previous years, fellows graduating in 2008 were less likely to get their top job (97% vs. 75.0%, p = 0.018). CONCLUSIONS: Job satisfaction is high among US fellowship graduates and is unrelated to academic versus community affiliation. Three-fourths of recent graduates obtain their top choice of job upon completion of fellowship.