EMT533
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What do you all think about using ultrasound during transport? Some paramedics are using it already and have had a lot of success. What are your thoughts?
Ultrasound in EMS
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COmedic17
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Ultrasound? Or dopplers?
I could see an ultrasound being handy in critical care EMS or in a flight setting when it would assist with advanced scope interventions, but I don't think it would be useful in a typical urban EMS system.
I could see an ultrasound being handy in critical care EMS or in a flight setting when it would assist with advanced scope interventions, but I don't think it would be useful in a typical urban EMS system.
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Actually, I've found it quite useful in urban EMS. And in considering its uses, probably more so than in the critical care realm. From FAST exams, lung exams, PEA evaluation, and even stroke screening, ultrasound is very versatile and very sensitive in its findings. If they can find a way to start bringing the probe price down, I think US will start to become very prevalent in the field.
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EMT533
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Awesome! As an ultrasound student I do FAST scans and they are awesome. Sadly, I don't believe they will bring probe prices down due to the internal components. PZT crystals are very expensive and each probe has its own mathematical system.
COmedic17
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Does it really effect treatment? If a person is presenting in a way I would suspect an internal bleed, my treatment will be tailored to fit their needs. I will call a trauma alert, and a trauma surg will be there to address any immediate life threats and/or internal bleeds. If my field impression is a PE, that's what I will treat and what my field impression will be in my call in to the hospital. I just don't see it being worth it in an urban system. Maybe in rural areas where specialists are on call and not at the hospital, but when transport times are so short in most urban systems- an ultrasound seems like it would just take up time that could be used to preform medical interventions instead of just confirming suspicions.
In a flight setting I could see it being used more to assist with pericardiocentesis and chest tube placements etc, but in a typical EMS system, I just don't see a need for it.
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I've actually caught a liver laceration that wasn't yet presenting with a high suspicion of a bleed. I only checked because of a mildly suspicious mechanism and I had a new toy to play with. The new toy changed my hospital selection.
Our Trauma teams will also activate the OR with a positive FAST exam via radio report.
Have you ever had the respiratory patients that are very difficult to tell the pathology of? CHF vs COPD? I can tell you with absolute certainty whether it's broncoconstriction or fluid faster than you can apply an EtCO2 monitor (literally- my partner and i have tested it), and more definitively than EtCO2. The finding will guide treatment.
Does your patient with PEA have cardiac standstill, or just such a low cardiac output that you can't palpate a pulse? That will also guide treatment. Or a PEA with PE findings? That could make you more likely to transport immediately depending on arrest time and proximity to the ED. And your traumatic arrest with tamponade? Perform CPR on them and you're signing their death certificate. Fluid boluses, possibly pressors, and early transport greatly increases these patients' likelihood of survival. Without being able to visualize the heart, tamponades get missed quite frequently.
And I'm still a novice at US. @Jon is far more proficient and knowledgeable of the tool's usages. I'm constantly discovering new uses for ultrasound that actually help in guiding decisions.
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SpecialK
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USS is carried by HEMS who can also respond by road (albeit a limited distance) and are staffed mostly by emergency medicine specialists who are very experienced in using it.
I can see it becoming very useful and maybe making its way to selected ICPs in the near future. This is already happening in Australia and it seems the US.
I can also see blood (or fibrinogen-containing blood substitute) not being too far away as well.
I can see it becoming very useful and maybe making its way to selected ICPs in the near future. This is already happening in Australia and it seems the US.
I can also see blood (or fibrinogen-containing blood substitute) not being too far away as well.
COmedic17
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Like I stated, this may be worth it in a rural area with a longer response time, or in a flight situation, but in a typical urban system where transports are short- it's not efficient.
In terms of trauma, it sounds like we have a little different systems. Here, there's Limited trauma activations, and Full trauma activations. Limited activations pretty much mean the mechanism of injury was there, but the patient isn't having any major complications as of yet. A full trauma is a full activation of all resources - neurology, trauma surg, and CT are all in the room. For a limited, all these are done, but typically one at a time. Also, everyone is on "standby" incase it is upgraded to a full trauma activation. I also don't have a hospital selection. There's only one in town
Finding the difference between COPD and CHF might be nice, but I don't think ultrasound is the only way to quickly get a quick diagnosis. The goal is obviously going to be to decrease the work of breathing. Lung sounds, spo2, patient presentation, end tidal, etc can all be used to determine an appropriate course of treatment.
And I agree it would be useful to detect tamponade. But I also know how uncommon tamponade is in terms of call volume and frequency. I can't picture a system, specifically a private system, spending a large sum of money on equipment that isn't used often.
Example- a system created a moble CT ambulance in Denver. The thought process was earlier detection of strokes / what kind of strokes, and better treatment for what was going on. What ended up happening was patients had a worse outcome then if they were to go by a normal ambulance. The time spent to do the CT scan took away time that would of otherwise been used for transport. Getting them to a hospital where the actual problem could be fixed was more important then a slightly earlier confirmation of what was already suspected.
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And like I stated, I work downtown in a very large, metropolitan area, and we've already benefited from it many times. And that's just one unit.
COmedic17
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To each their own. It would probably be more appropriate for some systems then others.
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I'm curious what type of education you've had on US?
When I was a new flight paramedic in 2000, a handful of us were trained to do prehospital FAST exams as part of a research project put on by the area trauma center. The study never got off the ground unfortunately, due to lack of funding to put the US units on the helicopters.
No question that is true.
I think being really proficient with US requires an understanding of anatomy and a commitment to training that just doesn't exist among most paramedics and EMS systems. It's the same exact reason why lots of more advanced interventions that could theoretically be done in the field, typically aren't.
Could it happen? Of course it could. Is it likely to happen? In most systems, I doubt it. It will be a long time before prehospital ultrasound the way STX describes it will be standard paramedic level care in the US.
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We're lucky in that we have access to many different physicians and train with them at a minimum of 8hrs monthly. Our initial training on ultrasound came from an EM doc who just completed an US fellowship during a week long class. Much of my education has been self-imposed, though. While my education is far from that of someone who went to school for sonography, I've got a basic understanding of the physics of it and what I'm looking at.
AshWredberg
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I am writing a research paper about US use in EMS and I am wondering if you all could share your thoughts or concerns about the topic. Please and thank you!
NYBLS
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Good subject! It has a wide usage in EMS, from urban to rural. Many agencies say they do CCT or call themselves mobile critical care units but the fact is without imaging we are going on a lot of guess work. Its easy to use (especially for specific tests with specific goals), mobile and getting cheaper everyday.
Hopefully our new medical director sees that y'all are using this down the street. Would be a fun tool. Mostly for the county trucks though.
AshWredberg
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Thanks for the response!
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It's an awesome tool with a LOT of promise for EMS.
Yes, there's the FAST (and RUSH) exam. But that's just the tip of the iceberg. It's a great way to get peripheral IV access, "listen" to lung sounds, and even more - we can measure things that matter - like ICP or preload/afterload/fluid response, and there's even a way to identify most occlusive strokes.
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Similar topics have been merged.
ERDoc
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I can seeing it having a place in the field. As others have mentioned, it could have an affect of your choice of hospitals. Is that MVA belly pain just a seat belt contusion or a liver/spleen lac? Free fluid on US needs to go to a trauma center, no free fluid could go to any ER. Early pregnancy with pelvic pain is very common. If you see free fluid on your exam you need to go to a hospital with Ob/Gyn available. You can look at the heart in arrests as others have said. You can also use it for difficult IVs. You can look at the hydration status by checking the IVC. Although it won't affect what you do in the field, it's always fun to look for gallstones.