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Vicki E Noble MD RDMSDirector, Emergency UltrasoundMassachusetts General HospitalAssistant Professor, Harvard Medical SchoolBoston MAPOINT OF CARE ULTRASOUND:FOR ALL CLINICIANS

Why ultrasound? Portable Safe Repeatable Digital Decision support Battery operated Cost-effective Multi-use

Why wait for specialization?Why not in medical school?

With one machineLiver and spleenHypotension, fluid statusThoracentesisPneumothoraxFASTB-lines – pulmonary fluidPregnancyAAAAbscess drainageForeign body IDCentral Line placementEcohcardiographyDVTPeripheral IV placementGallstonesParacentesisIVC- volume assessment

Usefulness scoreLapostolle F et al Am J Emerg Med 2(3):1076 Push clinician toward the right diagnosis Push clinician toward the wrong diagnosistoward wrong diagnosis- valueClinicaldiagnosistoward right diagnosis value

Objectives Clinical scenarios – making the case Literature support – but is it safe? Seeing the larger picture universal training and quality assurance issues

80 yo with dyspnea HR 110 O2 sat 88% 99F Pursed lips Scattered wheezes Decreased air movement Distended tender abdominal exam Asymmetric leg swelling

What does the clinician needto know? Differential: CHFCOPD exacerbationPTXPEHemorrhage/hypovolemiaPleural effusionsPneumoniaAnxiety BNPDdimerCXRCTLENIEKGAlbuterolLasixSteroidsHeparin

What are the pressures on theclinician? Time Accuracy Disposition Patient satisfaction Cost Quality Measures Outcomes

What does the clinician needto know? CHF vs COPD – A-lines vs B-lines

What does the clinician needto know? PTX – lung sliding yes or no

What does the clinician needto know? Hemorrhage ?

How can point of careultrasound help? PE – R heart size, DVT

How can point of careultrasound help? Bring the physician back to the bedside Education Visual teaching tool

How can point of careultrasound help? EXPEDITE CARE - Know the studies First trimester – decreased LOS Burgher et al 1998Biliary colic – decreased return visits Durston et al2001DVT – decreased LOS, Blaivas et al 2000Trauma – decreased LOS, decreased CT Melnikeret al 2003Cardiac trauma/AAA – time to OR, Plummer et al1992

BUT IS IT SAFE?

Accuracy FOCUSED QUESTIONS Know the studies First trimester – Stein et al 2010 Acad Emerg Med AAA – Tayal et al 2003 Acad Emerg Med Gallstones - Durston et al 2001 Am J Emerg Med DVT - Blaivas et al 2000 Acad Emerg Med Cardiac function – Moore et al 2002 Acad EmergMed Pericardial effusions – Alexander et al 2004 AmHeart J

Not to minimize competency Develop training program Documentation Reporting – visible and transparent Quality assurance program Use on line resources In the beginning you have to be perfect

MANDATORY FIRST STEPCHAMPION OF THE CAUSE

Know the resources www.sonoguide.com http://hqmeded.com http://pointofcare.blogspot.com/ http://www.sonoworld.com http://www.ultrasoundvillage.com http://www.echobasics.de/tte-en.html http://msksono.com/index.html Emedicine procedures

Thank youQUESTIONS?