Pre-hospital ultrasound

So I have always been the gadget guy.  Always trying to have the latest piece of tech to make life easier, the latest iPhone and the tools to make them all talk to each other. I don’t get why everyone isn’t living in the cloud??

When I started seeing ultrasound machines in emergency departments, it naturally got me interested.  This black and white grainy picture was only found in the radiology space surely?  My inquisitive nature led me to do some reading, and that led to an attack of the FOMO…there were already paramedics in parts of the world using ultrasound on the roadside!

Then luckily my favourite enabler invited me to attend an ultrasound course (Thanks Mande!).  I wandered along and did the EMSSA course, and then had to work quite hard at getting the skill practice to be able to complete the requirements.

But then an interesting realisation hit me.  What was the point?  There are ambulances running around in southern Africa without oxygen, and here’s me wanting to explore placing a device worth more than an entire ambulance into practice.  A little internal conflict ensued:  on a personal level I wanted this new technology, but at the same time I was struggling to justify WHY.

The personal side won, and I forged ahead with trying to do some roadside scans.  Two cases stand out, and will support my argument in favour of the technique

• Paediatric trauma patient with a distended and painful abdomen. Clinically the patient appeared sick, tachycardic and pale.  Another paramedic had asked for a helicopter due to the distance to a paediatric facility.  While waiting, I thought this was the perfect opportunity for an e-FAST exam.  And all that was seen was a really really full bladder. There was no free fluid seen in any view.  After allowing the patient to empty his bladder, everything changed.  The heart rate normalised, and the previously distended abdomen was now soft. The patient didn’t need that helicopter ride. He didn’t even spend a night in hospital

An adult gunshot patient, left parasternal wound. He walked to the ambulance, smiled and asked if he had to go to the hospital.  His vitals were all perfectly normal.  So while waiting for the ambulance I put a probe on.  And there on the screen was a distinct layer of fluid around the heart.  The closest trauma facility was a long way away, so I boldly drove past the local facility.  Just after arrival at the hospital he arrested. But because he was in the right place, he got the emergent thoracotomy he needed. He survived to ICU discharge.

So why do I think ultrasound does have a place on our tip of Africa?

• It’s not that expensive anymore. New devices are continually being released, with more accessible and more suitable devices hitting the market all the time.  And the price is coming down.
• The value as a triage tool is undisputed. If we compare the accuracy of pushing with your hands to feel an abdomen to looking inside; or the use of a stethoscope versus an ultrasound to look at lungs, then why wouldn’t you use it?  Getting the right patient to the right hospital is certainly important.
• In the draft EMS Clinical Practice Guidelines released by the HPCSA, it was encouraging to notice that ultrasound use has made an appearance.

The naysayers will hold that the price isn’t worth it.  It’s a first world thing – it will never happen in South Africa.  Like 12 lead ECGs.  Or ETCO2.  In the service I work for, if you don’t use ETCO2 on an intubated patient today, best you start looking for a new job.

So where do we sit now?  Yes, it’s not going to be an everyday EMS thing today or tomorrow.  But it’s made it onto the scope of practice, and the number of paramedics doing the training is growing.  We need to work on the equipment suppliers to get the best possible prices.  And then we need a local curriculum on training.

Most importantly in the pre-hospital setting is when NOT to do an ultrasound.  If it will delay transport or treatment, then don’t do it.  It needs to be performed in parallel to existing on-scene assessments, and then specifically when an answer needs to obtained.

If you are in the prehospital space, and you have any sort of drive to improve yourself, then take the opportunity to learn sooner rather than later.  Take the few minutes to watch the ultrasound done in the ED after you handover. Ask questions.

Some cool references:

Quick, J. A., et al. (2016). “In-flight ultrasound identification of pneumothorax.” Emerg Radiol 23(1): 3-7. (www.doi.10.1007/s10140-015-1348-z)

Lee, C. W., et al. (2016). “Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound.” J Crit Care 31(1): 96-100.  (www.doi.10.1016/j.jcrc.2015.09.016)

Wydo, S., et al. (2015). “Portable ultrasound in disaster triage: a focused review.” European Journal of Trauma and Emergency Surgery: 1-9.  (www.doi.10.1007/s00068-015-0498-8)

Nelson, B. and A. Sanghvi (2015). “Out of hospital point of care ultrasound: current use models and future directions.” European Journal of Trauma and Emergency Surgery: 1-12.

Booth, K. L., et al. (2015). “Training paramedics in focussed echo in life support.” European journal of emergency medicine: official journal of the European Society for Emergency Medicine.  (www.doi.10.1097/MEJ.0000000000000246)

Taylor, J., et al. (2014). “Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors.” BMC emergency medicine 14(1): 6.  (http://www.biomedcentral.com/1471-227X/14/6)

Brun, P.-M., et al. (2014). “Prehospital ultrasound thoracic examination to improve decision making, triage, and care in blunt trauma.” The American Journal of Emergency Medicine 32(7): 817. e811-817. e812.  (http://dx.doi.org/10.1016/j.ajem.2013.12.063)

Jørgensen, H., et al. (2010). “Does prehospital ultrasound improve treatment of the trauma patient? A systematic review.” European Journal of Emergency Medicine 17(5): 249-253.  (www.10.1097/MEJ.0b013e328336adce)

Post by David Stanton @davidstantonza