Prehospital Ultrasound

[TXpeds16]

Anyone on here work for a service that uses it? A recent discussion has me thinking about it.

1) When/why is the determination made to utilize it?
2) How does it affect treatment of the patient, and have your protocols changed to compliment its' use since being implemented?
3) Do you feel that patient outcomes have benefited from its use?

 

[MonkeyArrow]

The problem with prehospital ultrasound is that its expensive and has a steep learning curve. Most paramedics are not going to understand what they're looking for and how to obtain good quality images after a 8-40 hour class. Radiology is one of those things where you need to practice and revise/learn, and repeat over and over. The problem being that since its expensive, these units probably won't be on every ambulance, and there isn't an extremely large number of people amenable to prehospital ultrasound that need it. Thus, you have little unsupervised application of the device, without follow-up by a professional as to what you actually saw, and every patient is different and will present somewhat differently on US, which is why you need the large amounts of practice, to see all the variations or presentations, which a field provider will never really get. Therefore, I really believe that its application is extremely limited in EMS.

 

[VentMonkey]

I think I'm with @MonkeyArrow on this one.

It definitely seems like those one of those "nice to have" items if your service can afford, but the skill itself and it's accuracy seem questionable in the prehospital environment without proper training, and re-training, or frequency of use.

I would like to hear from others on the forum who have access to one at their service, what their protocols are for when to use it (trauma? OB? Provider description?), and how they go about staying up on this skill.

It seems like without proper training on it, one may rush to over triage a lot of otherwise stable trauma patients and perhaps forego a valued physical assessment and its finding.

 

[VinBin]

In the ED, the main purpose of ultrasound is to triage different pathology on findings (trauma/FAST exam, OB, abdominal organ pathology, etc). In EMS the focus should be on stabilization and transfer to the ED. Fooling around with an US in a seemingly benign case (questionable appendicitis, cholecystitis, etc) or a possible acute case (tension, CHF decompensation, abdominal free fluid, possible ectopic?) doesn't really serve the goal of EMS, especially in a busy service.

 

[usalsfyre]

In the ED, the main purpose of ultrasound is to triage different pathology on findings (trauma/FAST exam, OB, abdominal organ pathology, etc). In EMS the focus should be on stabilization and transfer to the ED. Fooling around with an US in a seemingly benign case (questionable appendicitis, cholecystitis, etc) or a possible acute case (tension, CHF decompensation, abdominal free fluid, possible ectopic?) doesn't really serve the goal of EMS, especially in a busy service.

So you would say there's no utility in using it to determine the correct destination?

 

[Carlos Danger]

The problem with prehospital ultrasound is that its expensive and has a steep learning curve. Most paramedics are not going to understand what they're looking for and how to obtain good quality images after a 8-40 hour class. Radiology is one of those things where you need to practice and revise/learn, and repeat over and over. The problem being that since its expensive, these units probably won't be on every ambulance, and there isn't an extremely large number of people amenable to prehospital ultrasound that need it. Thus, you have little unsupervised application of the device, without follow-up by a professional as to what you actually saw, and every patient is different and will present somewhat differently on US, which is why you need the large amounts of practice, to see all the variations or presentations, which a field provider will never really get. Therefore, I really believe that its application is extremely limited in EMS.

This. Exactly this.

 

[mttbdtd]

I like the idea. However, in large, busy systems where the hospital is 5-10 minutes away from your vehicle rollover you're just adding one more thing to get distracted by when you could have used the 5+ minutes to stabilize and drive. I also agree with monkey arrow above.

 

[VFlutter]

I learned to love Ultrasound in the ICU and would really like to have it in HEMS but agree it is a steep learning curve and not beneficial for the vast majority of prehospital providers. Personally I am very confident using US for vascular access, great for quick PIV in difficult sticks, and am pretty good with various exams. The two things I think it would be most helpful for is pneumothorax evaluation in the helicopter and then cardiac exams for cardiac arrest, undifferentiated shock, r/o massive PE.

 

[VinBin]

So you would say there's no utility in using it to determine the correct destination?

Correct destination in what regard? Are your potential transport destinations so exclusive that you could not take a patient with a couple differential diagnosis in for further evaluation?

 

[ERDoc]

Correct destination in what regard? Are your potential transport destinations so exclusive that you could not take a patient with a couple differential diagnosis in for further evaluation?

Would you take someone with blood in their belly to a non-trauma center? Or a possible ectopic to a hospital that doesn't have OB? There could be a role for EMS US, but I will admit, it would be a very narrow role.

 

[EpiEMS]

Would you take someone with blood in their belly to a non-trauma center? Or a possible ectopic to a hospital that doesn't have OB? There could be a role for EMS US, but I will admit, it would be a very narrow role.

Doc, how much training do you think it would take to teach an EMS provider to use ultrasound for just those limited purposes (some sort of FAST-type U/S, say)?

 

[VentMonkey]

I'm still not sold on this, particularly with urban EMS. There seem to be too many reasons not to do it in this setting.

I think a better tool for POC testing is an iSTAT, but even than financially makes no sense to almost every ground, and even many HEMS, services.

And IMO, I think initial training is not the issue, I think retraining, remediation, and misdiagnosis are bigger issues at hand in our environment.

 

[NomadicMedic]

I'm still not sold on this, particularly with urban EMS. There seem to be too many reasons not to do it in this setting.

I think a better tool for POC testing is an iSTAT, but even than financially makes no sense to almost every ground, and even many HEMS, services.

And IMO, I think initial training is not the issue, I think retraining, remediation, and misdiagnosis are bigger issues at hand in our environment.

Those iStat cartridges are expensive. It's a shame that Trinity had to pull the POC Troponin test before it could receive FDA approval. That would have been a valuable tool in prehospital MI activation, particularly NSTEMI or in cases where an accurate interpretation of STEMI was questionable. The lack of a POC lactate meter to replace the Lactate Pro is troublesome.

I believe in the world of short transport urban EMS, POCUS is of dubious use. However in a rural system, where a POCUS FAST exam could mean the difference between a helicopter transport or a ride to a community hospital, it seems more worthwhile.

 

[VentMonkey]

Those iStat cartridges are expensive. It's a shame that Trinity had to pull the POC Troponin test before it could receive FDA approval. That would have been a valuable tool in prehospital MI activation, particularly NSTEMI or in cases where an accurate interpretation of STEMI was questionable. The lack of a POC lactate meter to replace the Lactate Pro is troublesome.

I believe in the world of short transport urban EMS, POCUS is of dubious use. However in a rural system, where a POCUS FAST exam could mean the difference between a helicopter transport or a ride to a community hospital, it seems more worthwhile.

We had this same exact discussion in an online course I took. The general consensus was pretty much this here.

 

[SpecialK]

PHUS is being used by two of our HEMS services. One has a Doctor and can also respond by road while and the other doesn't.

Current problems with it, as I see, are:

1. Expensive,
2. Very steep learning curve (not likely to go away!)
3. Can only be used on a select cohort of patients
4. Might not change what you do to them

While I don't usually see utility in such a system (e.g. with 12 lead ECGs); it could be a useful adjunct for telemedicine, but, what I see greater utility in, is it being used by a small group of Intensive Care Paramedics (particularly, but not exclusively, on HEMS) who regularly see major trauma, such as the program running in South East Queensland. Outside of our major metropolitan areas (Auckland and Christchurch), the best use is with HEMS as they are often called to pick up major trauma and take them to a major trauma hospital.

 

[ERDoc]

Doc, how much training do you think it would take to teach an EMS provider to use ultrasound for just those limited purposes (some sort of FAST-type U/S, say)?

We teach med students to do it. How hard could it be? I think there is much more utility in a rural environment than urban. It's not difficult to learn how to do it and you can practice on most pts when you have a few minutes riding to the hospital with a not sick pt. You'd be surprised how many people would be willing to let you practice, especially when they get to see their insides. The part that is difficult is when you use it on the, shall we say, not idea pt. It's hard to find a gestational sac or gallbladder on someone who suffers from hyperadiposity.

 

[VinBin]

Would you take someone with blood in their belly to a non-trauma center? Or a possible ectopic to a hospital that doesn't have OB? There could be a role for EMS US, but I will admit, it would be a very narrow role.

I don't think your reasoning is logical or justified in the realm of EMS. You should not consider a non-OB destination for a female who is pregnant with belly pain or presents with likely symptoms of an ectopic pregnancy. Even if it presents as a classical appendicitis or cholecystitis, any chance of pregnancy should warrant a hospital with capacity for OB emergencies. An ultrasound shouldn't be the thing that dictates a destination in that situation.

And using the same logic, if the patient has ANY chance of an intra-abdominal bleed (i.e. especially after abdominal trauma), a field ultrasound shouldn't be dictating the destination. Hell, its hard to decipher small amounts of blood in the belly even in the ED with really good ultrasound, do you expect that to be a decision to be made in the field?

 

[gotbeerz001]

I don't think your reasoning is logical or justified in the realm of EMS. You should not consider a non-OB destination for a female who is pregnant with belly pain or presents with likely symptoms of an ectopic pregnancy. Even if it presents as a classical appendicitis or cholecystitis, any chance of pregnancy should warrant a hospital with capacity for OB emergencies. An ultrasound shouldn't be the thing that dictates a destination in that situation.

And using the same logic, if the patient has ANY chance of an intra-abdominal bleed (i.e. especially after abdominal trauma), a field ultrasound shouldn't be dictating the destination. Hell, its hard to decipher small amounts of blood in the belly even in the ED with really good ultrasound, do you expect that to be a decision to be made in the field?

So what does adding PHUS change if you're not going to use it to determine the most appropriate hospital? It seems that we would be adding it hoping to find an acute issue in a seemingly stable patient since that is the only situation which would change the destination (see below)

Seems acute > Is acute = Specialty
Seems acute > not acute = Specialty
Seems non-acute > Is acute = Local

I am all about neat new tools to make me more effective, but it seems that the only patient which would see true benefit would be the (seemingly) stable patient who is about to crash but has no other s/s to indicate need for a specialty center. While it can be reasoned that these may be more prevalent that is seems (since we drop them off stable and never hear feedback), I would have to guess that these are pretty rare overall.

So while I agree that there is some benefit, there is not enough to convince your standard service to make PHUS a standard. I agree that Critical Care units (HEMS etc) would have the highest chance of using the tool correctly and to demonstrable positive ends.


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[Carlos Danger]

I don't think your reasoning is logical or justified in the realm of EMS. You should not consider a non-OB destination for a female who is pregnant with belly pain or presents with likely symptoms of an ectopic pregnancy. Even if it presents as a classical appendicitis or cholecystitis, any chance of pregnancy should warrant a hospital with capacity for OB emergencies. An ultrasound shouldn't be the thing that dictates a destination in that situation.

So using this reasoning, any female of childbearing age who has abdominal pain should automatically go to an OB center?

And using the same logic, if the patient has ANY chance of an intra-abdominal bleed (i.e. especially after abdominal trauma), a field ultrasound shouldn't be dictating the destination. Hell, its hard to decipher small amounts of blood in the belly even in the ED with really good ultrasound, do you expect that to be a decision to be made in the field?

You are missing the point here, too. It's not about ruling out bleeds in patients with a good history, it's about raising your index of suspicion in someone who doesn't meet obvious criteria.

 

[ERDoc]



So using this reasoning, any female of childbearing age who has abdominal pain should automatically go to an OB center?



You are missing the point here, too. It's not about ruling out bleeds in patients with a good history, it's about raising your index of suspicion in someone who doesn't meet obvious criteria.

I wrote a response and didn't hit post before leaving. Scary thing, it was almost word for word what Remi said, especially the part about the females of childbearing age.