Determining a Need for Point-of-Care Ultrasound in Helicopter Emergency Medical Services Transport.

OBJECTIVE: Point-of care-ultrasound (PoCUS) is useful in evaluating unstable emergency department patients. The portability of this technology increases its potential use in prehospital settings, including helicopter emergency medical services (HEMS) programs. Identifying useful applications may support implementing a PoCUS program that develops sonography skills for prehospital providers. The aim of this study was to determine the HEMS patient population that would benefit from prehospital PoCUS for hypotension and how commonly the extended focused assessment with sonography in trauma (E-FAST) for trauma patients or the rapid ultrasound in shock (RUSH) for medical patients could be used by HEMS. METHODS: A retrospective chart review was performed over a 1-year period of adult patients transported by a midwestern HEMS system. Charts were reviewed for episodes of hypotension. RESULTS: The chart review included 216 charts, of which 3 were excluded. Of the 213 cases, 100 were trauma patients, and 113 were medical patients. Of the trauma patients, 51% experienced hypotension, as did 73 of 113 medical patients. CONCLUSION: Fifty percent of HEMS patients may benefit from PoCUS to evaluate for hypotension in flight.

Emergency and critical care applications for contrast-enhanced ultrasound.

INTRODUCTION: Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography. METHODS: We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications. RESULTS: The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite. CONCLUSIONS: CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Point-of-care ultrasound education: the increasing role of simulation and multimedia resources.

This article reviews the current technology, literature, teaching models, and methods associated with simulation-based point-of-care ultrasound training. Patient simulation appears particularly well suited for learning point-of-care ultrasound, which is a required core competency for emergency medicine and other specialties. Work hour limitations have reduced the opportunities for clinical practice, and simulation enables practicing a skill multiple times before it may be used on patients. Ultrasound simulators can be categorized into 2 groups: low and high fidelity. Low-fidelity simulators are usually static simulators, meaning that they have nonchanging anatomic examples for sonographic practice. Advantages are that the model may be reused over time, and some simulators can be homemade. High-fidelity simulators are usually high-tech and frequently consist of many computer-generated cases of virtual sonographic anatomy that can be scanned with a mock probe. This type of equipment is produced commercially and is more expensive. High-fidelity simulators provide students with an active and safe learning environment and make a reproducible standardized assessment of many different ultrasound cases possible. The advantages and disadvantages of using low- versus high-fidelity simulators are reviewed. An additional concept used in simulation-based ultrasound training is blended learning. Blended learning may include face-to-face or online learning often in combination with a learning management system. Increasingly, with simulation and Web-based learning technologies, tools are now available to medical educators for the standardization of both ultrasound skills training and competency assessment.

Development of a pilot family medicine hand-carried ultrasound course.

BACKGROUND AND OBJECTIVES: A hand-carried ultrasound training session was organized as an initial step in developing a long-term ultrasound education program for family medicine residents and faculty. Comparative effectiveness studies examining the potential benefits, risks, and any possible cost savings associated with this technology will be predicated on having a sufficient number of primary care physicians trained and able to use hand-carried ultrasounds as part of routine care. The proposed training described here is a first step toward this broader conversation and empirical study of hand-carried ultrasound use in family medicine. METHODS: An 8-hour training consisting of didactic lectures, case review, and hands-on experience imaging standardized patients with ultrasound machines and an ultrasound simulator. The objective of the course was to introduce focused ultrasound acquisition and interpretation of the gall bladder, kidney, heart, and abdominal aorta to family medicine physicians. Participating physicians were evaluated for changes in self-perceived comfort and proficiency with the hand-carried ultrasound before and after the training. RESULTS: Statistically significant changes for most comfort and proficiency items were demonstrated. Importantly, the only item that did not show significant change dealt with basing clinical decisions on information obtained from the device. CONCLUSION: The subjective improvement suggests this approach is one potentially useful hand-carried ultrasound training framework. Future work should attempt to further develop curricula and address issues such as longitudinal training assessments and certification and the development of competency in the necessary skill sets.

Screening for intimate partner violence in medical settings.

Intimate partner violence (IPV) is associated with negative health consequences. Universal screening for IPV offers many opportunities for successful intervention, yet this practice in medical settings is controversial. This article examines the potential impact of the U.S. Preventive Services Task Force (USPSTF) recommendations for IPV screening and the emerging literature supporting measurable health benefits resulting from screening interventions in medical settings. Several screening tools and methods of administration that have been evaluated in various clinical settings, with goals to increase their sensitivity and to determine a best method of administration, are reviewed in this article. Mandatory reporting is closely linked to screening practices and may influence healthcare worker practice and patient disclosure. Mandatory reporting studies are lacking and show variable physician compliance, victim acceptance, and scant outcome data. Informed consent prior to screening, explaining the process of mandatory reporting statutes and victim options should be evaluated to increase sensitivity of screening tools.

Domestic violence among male and female patients seeking emergency medical services.

Gender differences among a cohort of injured patients seeking emergency medical services were examined with respect to their experiences as perpetrators and/or victims of domestic violence. Contextual issues, including violence initiation, emotional and behavioral responses to partner-initiated violence, and injury frequency and severity were analyzed. Women reported male partner-initiated violence more frequently than men reported female partner-initiated violence. Behavioral responses to partner initiated violence varied. Women were more likely to report using force back and to involve law enforcement. Women were more likely to be injured in a domestic assault over their lifetime, within the last year, and at the time of recruitment. Comparison of injury severity revealed that women reported higher rates of injuries than men in all possible severity categories. Women also reported experiencing more fear than men during partner-initiated violence, as well as being subjected to larger numbers of dominating and controlling behaviors, and greater intimidation secondary to their partner's size. Understanding contextual differences in partner violence for women and men has significant implications for policy development, identification, treatment, and referral of patients identified as living in violent relationships.

Tissue harmonic imaging improves organ visualization in trauma ultrasound when compared with standard ultrasound mode.

UNLABELLED: The focused abdominal sonography for trauma (FAST) examination is complicated by brightly lit trauma bays, limited time, and body habitus. Recently, new ultrasound (US) technology has become available that improves organ visualization in abdominal scans. OBJECTIVE: The hypothesis was that a new US mode, tissue harmonic (TH) imaging, improves visualization of critical organ relationships in the FAST examination by making use of previously unused frequencies. The authors performed a blind, prospective observational study to compare the images obtained in typical FAST views with those obtained in standard US and TH modes. METHODS: Blunt trauma patients presenting to a level I trauma center between April and September 2000 were enrolled on a convenience basis. Typical FAST views were obtained in standard and TH modes. The emergency ultrasonographer (EU) switched between modes for each view, optimizing the gain each time. Multiple digital still images were made with all indications of the mode used disguised. For each view on a patient, the best image in each mode was selected in a blinded fashion. Three experienced EUs, blinded to the mode used, rated each image pair for resolution, detail, and total image quality as previously defined on a ten-point Likert scale, 10 being the best for each category. Wilcoxon signed-ranks test, 95% confidence intervals (95% CIs), and interobserver correlation were calculated. RESULTS: A total of 76 image groups (39 of Morison's pouch, 20 splenorenal, and 17 bladder) from 52 patients were rated. Tissue harmonics produced improved resolution, detail, and quality when compared with the standard US mode, with median scores of 6.7 vs. 6.0, 6.7 vs. 6.0, and 6.3 vs. 6.0, respectively. The differences of 0.7 (95% CI = 0.4 to 0.93), 0.7 (95% CI = 0.4 to 0.93), and 0.33 (95% CI = 0.17 to 0.67) were statistically significant, with p = 0.0001, 0.0001, and 0.0003, respectively. There was good interobserver agreement (kappa = 0.74; 95% CI = 0.68 to 0.79). CONCLUSIONS: Tissue harmonics produced FAST images higher in detail, resolution, and total image quality than standard-mode US images.

Competency-based strategies for injury control and prevention curriculums in undergraduate medical education.

Injury, including unintentional injury and intentional injury, is the leading cause of death in people aged