Central lines, routinely with or without ultrasound?

[Narcotized]

I was called to the ED last time on call to place an iv ina 5y/o with burns to one arm and both legs. Of course the AC was already blown and i had nothing in the hand so i took the US to get the AC distal to the initial puncture.

It was the first time i use US to get an iv but it was the right time.

Same experience as a resident. I thought it was abuse to call me down to the ER for an ultrasound placed IV. But the patient had been stuck numerous times, was a puffy beach whale with no visible veins, and just needed either IV antibiotics or fluids (forgot which) so a central line truly was overkill. Found a plump antecubital vein buried under some fat that took all of a minute and realized that ultrasound really helped this patient even with something as trivial as an IV.

---

Members don't see this ad.

 

[Narcotized]

Ultrasound guided IJ access is safer only in the hands of inexperienced people and trainees.

Negative. Sell the buggy; buy a Nissan 🙂🙂

I think you even admitted you use ultrasound with coagulopathy, so you might be contradicting yourself here.

 

[Narcotized]

How many of you are using US for your epidurals?

Hmmm, I had no idea. Very interesting.

 

[Rabbit Hole]

This discussion reminds me of this video clip for some reason

[YOUTUBE]http://www.youtube.com/watch?v=cEkT5uspE3c&NR=1&feature=fvwp[/YOUTUBE]

 

[Planktonmd]

Negative. Sell the buggy; buy a Nissan 🙂🙂

I think you even admitted you use ultrasound with coagulopathy, so you might be contradicting yourself here.

I never said Ultrasound is bad and I have to admit I love it in certain situations!
But you need to be able to do it either way no matter how modern and pro-technology you feel!
If you don't believe me read the post by Lucy where she complains that her ultrasound is broken and now she is afraid of doing many procedures!
This is the result of doing these procedures EXCLUSIVELY with ultrasound.
Now as for the Nissan, do you suggest any specific model???

 

[Mman]

I'm still waiting for someone to show me one of these studies that shows how much superior the safety is with the ultrasound. I'd love to see it, because it would help my argument in the hospital for purchasing more ultrasound machines.

The bottom line is that studies have not shown any difference in a meaningful outcome relating to it. And to say that the literature is better than it is for something like pulse oximetry or capnography is crazy. Those things reduced mortality in anesthesia by a huge margin. The only thing that you might be able to show with ultrasound is it takes a few number of pokes to get the line in and that you probably end up with about 0.5 per 100 fewer 25 g holes in the carotid.

You won't see a 30 day morbidity or mortality difference.
You won't see a difference in hospital length of stay.
You won't see a difference in neurologic outcome.
You won't see a difference in line infection rate.

1 month, 1 year, or 10 years later, a patient doesn't care whether you used ultrasound or not to put their central line in. The biggest determining factor in whether or not they got a complication from a central line was the decision to put the central line in and the location it was placed in and the experience of the person placing it.

 

[SocialistMD]

🙄

So, what's the "# needed to treat" with u/s to avoid one dilated carotid, given a non-resident placing an IJ using landmarks and transduction pre-dilation?

Sorry to get to this discussion so late; it appears it has been thoroughly flogged. However, pro-U/S or con, you must remember that safety measures are in place to decrease the exposure to a potential complication as much as they are to decrease the complication itself. As has been previously noted, not every blind stick results in hitting the carotid (or lung) and not every carotid stick results in an immediately identifiable complication. However, going from patient room to patient room without washing your hands doesn't always result in the transmission of bacteria, and those bacteria, if transmitted, don't always result in an infection, but we still do it because it is good practice.

You do wash your hands, don't you?

 

[proman]

3. The time to prep the probe is little compared to the time it takes to walk out of the room to wash your hands and walk back in and do a full sterile drape and all the stuff that Pronovost has researched that prevents central line-associated bloodstream infections.

You're not doing a full surgical scrub are you?

BTW there are many old school anesthesiologists who don't drape or gown for their lines, but I guess that's for another thread.

 

[bullard]

I'm washing my hands and then using the little paper towel that comes with the surgical gown to dry off. And I hand the card to my attending or circulator and spin. It's the rules around here.

 

[proman]

I'm washing my hands and then using the little paper towel that comes with the surgical gown to dry off. And I hand the card to my attending or circulator and spin. It's the rules around here.

Yeah but what are you using to wash your hands? Is it a surgical scrub at the sink or with the hand sanitizers (like Purell)?

 

[Narcotized]

Is the patient squirming about the bed in pain as the attending stabs the neck 100 times looking for a difficult brachial plexus not considered a significant complication because he or she still walked out of the hospital without significant injury? Is it any significance that he/she will refuse regional anesthesia under any circumstance in the future?

 

[pgg]

I am not going to waste anymore time arguing with you but you are wrong on almost every thing you said:
You came here accusing and criticizing.
You did not provide an opinion but rather a teaching and almost a warning as did the other guy.
This in my opinion is arrogant, bitter and motivated by things other than just your wish to share clinical opinions.
Maybe you are bitter about your compensation? work hours? our compensation? what is it?

C'mon plankton, chill out, there's no need to get defensive and angry. It's possible to argue and criticize the substance of their assertions without getting angry, telling them that the surgeon technique universally sucks, and trying to morph it into some kind of paycheck pissing contest.

 

[dhb]

Is the patient squirming about the bed in pain as the attending stabs the neck 100 times looking for a difficult brachial plexus not considered a significant complication because he or she still walked out of the hospital without significant injury? Is it any significance that he/she will refuse regional anesthesia under any circumstance in the future?

I think everyone agrees that US is a useful tool but some of us are arguing that it shouldn't be SOC for simple procedures

 

[Planktonmd]

I am not angry but I find it a little irritating when a surgery resident starts posting to this forum by warning us about violating the standard of care and some other individual visits for the first time to criticize our lack of follow up on our patients then proceeds to tell us how he taught anesthesia residents to place lines!
Don't you need to be here for a while before you act like a dick?

As for their technique I actually do believe that it is terrible and this has nothing to do with the current debate, they are taught to go low in the neck between the heads of the SCM and that is why they have problems, it is a fact not something I made up.

C'mon plankton, chill out, there's no need to get defensive and angry. It's possible to argue and criticize the substance of their assertions without getting angry, telling them that the surgeon technique universally sucks, and trying to morph it into some kind of paycheck pissing contest.

 

[jdh71]

As for their technique I actually do believe that it is terrible and this has nothing to do with the current debate, they are taught to go low in the neck between the heads of the SCM and that is why they have problems, it is a fact not something I made up.

What does anesthesia do differently?

 

[starsop93]

Check this out. When I use the ultrasound, the IJ is NEVER on top of the Carotid. NEVER. Not today, not tomorrow, not NEVER (yeah yeah, double negative, whatever).

One word: ORIENTATION.

If I said go take a random x-ray of that guy's right lung and you took it from the side, would you say "I can't, it's lying on top of the left lung." No you would reorient and take the picture from the front (Ahhhh, some of your light bulbs went on... not everyone's yet).

So, when you place the probe and say, "crap, the IJ's on top of the Carotid," then REORIENT. Slide the probe to one side still aiming back at the IJ, indent in the neck a bit if you have to to maintain probe conduction, and WahLah!, what was on top of each other is now side by side (just like a lateral vs an AP chest). Hopefully more lightbulbs flickered.

The IJ often collapses before the needle pierces and therefore goes through the IJ. With the Ultrasound you NEVER need to stick an IJ with the Carotid right behind it that is screaming "Hit me, Hit me!!"

My point was that with the neck turned to the opposite side, as most do when they place an IJ, the orientation can rotate such that the IJ will be on top of the carotid if you enter perpendicular to the skin. It's hard to appreciate this if you don't use the US frequently. Sorry I wasn't clearer. Of course you can enter from a different orientation (or not turn the neck) which will decrease this phenomenon..

 

[pgg]

Don't you need to be here for a while before you act like a dick?

Hey I agree it's kinda impolite to make those kind of SOC / followup / teaching comments, but there are probably more hearts & minds to be won by us not being dicks ... even if we've been here a while.

 

[Narcotized]

I think everyone agrees that US is a useful tool but some of us are arguing that it shouldn't be SOC for simple procedures

Oh, definitely not everyone. That's why that scene I described is played out everyday. Some of these buggy drivers I've seen would trade in their own mother before they would learn how to use the ultrasound.

 

[pgg]

You do wash your hands, don't you?

I'm not one who'll argue that a good study needs to be behind everything I do - the parachute/plane/mortality study doesn't need to be done. But u/s machines aren't free and it'd be nice to see some data comparing people like me doing the procedures the way I do them with and without u/s before I go tell the beancounters to put $20K toward an u/s machine INSTEAD of replacing anesthesia machines that have already had their service lives extended twice.

There are a LOT of things that we could spend money on to (maybe) incrementally improve patient safety.

 

[Arch Guillotti]

I was taught to enter at the junction of the two heads of the SCM.

I am not angry but I find it a little irritating when a surgery resident starts posting to this forum by warning us about violating the standard of care and some other individual visits for the first time to criticize our lack of follow up on our patients then proceeds to tell us how he taught anesthesia residents to place lines!
Don't you need to be here for a while before you act like a dick?

As for their technique I actually do believe that it is terrible and this has nothing to do with the current debate, they are taught to go low in the neck between the heads of the SCM and that is why they have problems, it is a fact not something I made up.

 

[Planktonmd]

I was taught to enter at the junction of the two heads of the SCM.

Then I suggest that you try this approach:
Feel the carotid pulse at the level of the thyroid cartilage(not the Cricoid) then move 1 cm laterally and insert your needle behind the sternal head of the SCM aiming towards the ipsilateral nipple.

 

[countingdays]

Then I suggest that you try this approach:
Feel the carotid pulse at the level of the thyroid cartilage(not the Cricoid) then move 1 cm laterally and insert your needle behind the sternal head of the SCM aiming towards the ipsilateral nipple.

That's how I do it too. Can't stick the carotid when it's under your left hand's fingers, especially when you aim the needle even further away.
I hate it when I can't feel a good carotid pulse and have to use landmarks or God forbid the ultrasound, they need that in the block room more than I do in the OR.

 

[Licoricestick]

What is FANCAZ? I read it as an anesthetist in New Zealand and Australia. Are they doctors?

FANZCA = Fellow of the Australian and New Zealand College of Anaesthetists

Yes, they most certainly are doctors. Most anaesthetists in Australia have this qualification. There are a small number of "general practitioner anaesthetists" who do a little less training and do less serious cases in rural areas, but they are a small proportion.

FANZCA requires med school, then minimum of 2 yrs general medical training (ie mostly outside of anaesthesia and ICU) and then 5yrs of specialty training in anaesthesia during which time we have to complete a bunch of clinical modules (ie across a range of areas), pass two sets of exams (first on pharmacology, physiology, physics, measurement, statistics; second is the exit exam in clinical anaesthesia) and do a few other bits and bobs. Training in ICU and/or pain medicine is additional (although there is a component of pain and ICU required as part of anaesthesia training).

As for US guided lines, they are NOT SOC in Australia as a general rule (although obviously I don't know the institutional policies of every institution in the country). Most trainees are being taught to use US routinely for IJs, and although I agree that I should be able to place a central line without US, I would also argue that said central line doesn't have to be an IJ - obviously I am perfectly comfortable doing a femoral without US. Given the phenomenal variability in neck anatomy that I have seen with the US, I actually think I will end up being uncomfortable doing IJs without US because it's such a blind technique. Eg: RIJ yesterday with US - had I gone a landmark technique I would have been trying to enter the IJ at the point where the EJ was directly on top of it and the carotid was immediately inferomedial to it. Not my idea of fun, particularly when I can see what I'm doing.

It's interesting to see how much more receptive anaesthetists are to new drugs, than to new techniques.

 

[sevoflurane]

Ireland is the same way. Longer track to become an attending anesthesiologist. If I remember correctly, it's something like 7 years. Longer if you are not considered up to par.

Once you make it in, you are golden. Lot's of vacations, lots of holidays (seems like they have a national or bank holiday every other week). OR start time 9:00am until 3PM. And... tea and scones at 12:00pm. 😀
A friend of mine out there works M-Th and has 1/2 days on Fridays (leaves most fridays by 11:00am).

While you are a "registrar" you make pretty good money. It somewhat offsets the longer track to become an attending. Registrar is their equivilant to a resident and when I was there many years ago, they were pulling in 100K+ in Euros. I don't know if this is still the case. I imagine it is.

Damn good anesthesiologists BTW. One of them was my catalyst to the field. Did my first intubations and spinals there as a med student. Before entering the "theater" aka OR, you'd meet your patient in these "induction rooms". Pretty cool. Your own mini OR. Did your IV's, A-lines, Blocks, AFO, etc... in the "induction room" which is connected by a door to the main theater. The induction room bed was the same bed you operated on.

Everything is more relaxed out there. No turn over times, OR to incision times, or dressing to pacu times. Just a totally different atmosphere IMO.

 

[drccw]

if I use landmarks, ie blind approach to central venous access; I actually prefer a supraclavicular approach (ie low approach), about 1 fingerbreath above the clavicle. The goal is to obtain access close to where the subclavian and internal jugular meet; with my goal of internal jugular access. I do believe the subclavian vein can be access at this location as well. I find that the vein is very superficial at this level, and quite quite large as well. however, there is a significant overlap of the IJ and the carotid here. When I insert my needle here I go almost perpendicular to the skin, as to not aim at the lung. I feel like for a landmark based approach, it's almost 100%. That being said, I use US for most of my lines these days.

drccw

 

[Arch Guillotti]

Then I suggest that you try this approach:
Feel the carotid pulse at the level of the thyroid cartilage(not the Cricoid) then move 1 cm laterally and insert your needle behind the sternal head of the SCM aiming towards the ipsilateral nipple.

Actually thats pretty much what I do now.

I don't think that surgery has a monopoly on teaching a particular way of inserting IJ's. I only did residency in one place so I don't really know what the rest of the anesthesiologists and surgeons out there are taught.

I think ultrasound is great for central lines but I have to say that I don't use it all the time. Have not hit the carotid or dropped a lung as an attending (knock on wood). If I have trouble or their landmarks are terrible I will slap the probe on there though.

 

[jetproppilot]

Hi everyone, when you guys put in your lines, do you use ultrasound, or go purely by landmarks? As an intern in the unit I've only done them with ultrasound. I recently asked this to one of the anesthesia residents at the hospital I work in, who said their attendings prefer they always use ultrasound. Is this the norm?

Medicine is all about

TRENDS.

i.e. do you remember when beta blockers were contraindicated for treatment of heart failure?

Trends.

Ultrasound definitely qualifies in the trend group.

A useful tool?

Absolutely.

Necessary for every central line?

Absolutely not.

I've performed literally thousands of central lines without ultrasound.

With the advent of ultrasound, I've found it very useful in the difficult ones.

Difficult central lines are not the norm.

Most are very easy.

No need for ultrasound for every line.

Great tool for when needed.

 

[GasEmDee]

I agree with everything you said.

But same thing can be said of the pulse oximeter. On a recent mission to Mexico, I did anesthesia without the benefit of a pulse oximeter. Is it necessary for every anesthetic? No.

But if it is available, why wouldn't you want to use it? There is significant variation in neck anatomy. I have stuck the carotid a few times using anatomic landmarks. Never have with ultrasound.

Why do something blind when you can do it with sight?

Just as with any new technology, there are phases of acceptances. It is definitely not standard of care now, but we are moving inexorably to the point where it is.

Medicine is all about

TRENDS.

i.e. do you remember when beta blockers were contraindicated for treatment of heart failure?

Trends.

Ultrasound definitely qualifies in the trend group.

A useful tool?

Absolutely.

Necessary for every central line?

Absolutely not.

I've performed literally thousands of central lines without ultrasound.

With the advent of ultrasound, I've found it very useful in the difficult ones.

Difficult central lines are not the norm.

Most are very easy.

No need for ultrasound for every line.

Great tool for when needed.

 

[Mman]

Not the same as a pulse ox. Pulse oximetry has lead to a measurable, significant decrease in mortality.

 

[JackADeli]

...As for their technique I actually do believe that it is terrible and this has nothing to do with the current debate, they are taught to go low in the neck between the heads of the SCM and that is why they have problems, it is a fact not something I made up.

I am just not sure who you are talking about.... There are I'm guessing some several hundred surgery residencies in the USA. I just don't get how you have globally generalized based on what? I was never taught a terrible and/or dangerous technique. I was never taught to go low.... I haven't known any surgical colleagues taught that way. I find it hard to believe you know how we were taught... especially when as you are saying, "they are taught to go low...." I know I was not taught that way! So, it can NOT be a fact that we were taught that way.

 

[Planktonmd]

I am basing my statement on my observation of the surgeons I worked with over the years, they come from every corner of the U.S. and about 90% of them accessed the IJ low in the neck as I mentioned.
It is possible that at your geographic location things are different and if that's the case then good for you.
I understand that you feel the need to get defensive and you are welcome to disagree with my statement.
As for issuing generalized statements maybe you should have thought about that before you accused all anesthesiologists of not following their patients after procedures, have you actually worked with all the 40,000 anesthesiologists that practice in the U.S.???

I am just not sure who you are talking about.... There are I'm guessing some several hundred surgery residencies in the USA. I just don't get how you have globally generalized based on what? I was never taught a terrible and/or dangerous technique. I was never taught to go low.... I haven't known any surgical colleagues taught that way. I find it hard to believe you know how we were taught... especially when as you are saying, "they are taught to go low...." I know I was not taught that way! So, it can NOT be a fact that we were taught that way.

 

[JackADeli]

....I understand that you feel the need to get defensive...
As for issuing generalized statements maybe you should have thought about that before you accused all anesthesiologists of not following their patients after procedures, have you actually worked with all the 40,000 anesthesiologists that practice in the U.S.???

I will be the first to admit being confused. I am not being defensive nor am I being bitter as you claim. Quite honestly, those are descriptors that seem more suited to your replies. It really seems as if you are just seeking to continue a forum sparring match. Your reply suggests you aren't even reading what has been said... I specifically state... I was speaking to my experience. i never... at any point referenced every/all anesthesiologists. You on the other hand made a blanket statement about general surgery residency training. You also made the comment that the follow up of lines was was the job of surgery....

...I am also amazed at how frequently lines placed by other specialties are ignored after placement. Most OR lines I have seen, it is up to the surgery resident to follow-up on the chest XRay and/or adjust the line as needed. I have not seen anesthesia follow their line post operatively or even take note when said line becomes infected 4 days post-op. Maybe some do.... I don't know that anesthesia schedules a follow-up clinic to see end results of their lines...

...As for those complaining that they have to follow the lines post-op and we don't, I have to say that I feel for you but if you want to be a surgeon then ....it is your job! Why do you want us to do it for you?

...As for their technique ... they are taught to go low in the neck between the heads of the SCM andthat is why they have problems, it is a fact not something I made up.

It is really difficult to have it both ways unles you simply ignore or fail to read with any real comprehension.

 

[Planktonmd]

I am not planning to continue arguing with you because it is obvious that it is futile.
Arrogance can not be cured.
My responses to you were specific and to the point but if you fail to see that I can't help you.
You spoke about your "experiences" and I told you mine!
Why are you unable to accept my input and comments while you assume that we should take your opinions for granted???
In your "experience" we don't follow our patients post op, and in my experience surgeons are terrible at cannulating the IJ.
You can disagree if you like, it's OK!

I will be the first to admit being confused. I am not being defensive nor am I being bitter as you claim. Quite honestly, those are descriptors that seem more suited to your replies. It really seems as if you are just seeking to continue a forum sparring match. Your reply suggests you aren't even reading what has been said... I specifically state... I was speaking to my experience. i never... at any point referenced every/all anesthesiologists. You on the other hand made a blanket statement about general surgery residency training. You also made the comment that the follow up of lines was was the job of surgery....
It is really difficult to have it both ways unles you simply ignore or fail to read with any real comprehension.

 

[JackADeli]

...In your "experience" we don't follow...

And in your words.... it's our job to do so. That's OK, I will leave it to folks to read through the replies and/or arrogance and/or bitterness and/or etc.... they can decide as they choose.

 

[Southpaw]

I will leave it to folks to read through the replies and/or arrogance and/or bitterness and/or etc.... they can decide as they choose.

I'm ashamed to admit that I did read through all the replies. The only conclusion I arrive at is that, given how closely we work in parallel, it's saddening we little respect we show one another.

 

[dhb]

I'm ashamed to admit that I did read through all the replies. The only conclusion I arrive at is that, given how closely we work in parallel, it's saddening we little respect we show one another.

And how no scientific data was brought up in the discussion.

 

[MTGas2B]

Not the same as a pulse ox. Pulse oximetry has lead to a measurable, significant decrease in mortality.

Really?
http://www.ncbi.nlm.nih.gov/pubmed/19821289

 

[Mman]

Really?
http://www.ncbi.nlm.nih.gov/pubmed/19821289

The mortality rate in anesthesia decreased significantly after the introduction of routine pulse oximetry. It was either a supreme coincidence or caused by it. You decide.

I've seen enough people with pink mucosa and a pulse ox in the 70s and dropping fast to know that it helps save lives.

 

[JackADeli]

Not the same as a pulse ox. Pulse oximetry has lead to a measurable, significant decrease in mortality.

Really?
http://www.ncbi.nlm.nih.gov/pubmed/19821289

... we have found no evidence that pulse oximetry affects the outcome of anaesthesia for patients. The conflicting subjective and objective results of the studies, despite an intense methodical collection of data from a relatively large general surgery population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness, and efficiency...

The mortality rate in anesthesia decreased significantly after the introduction of routine pulse oximetry. It was either a supreme coincidence or caused by it...

I've seen enough people with pink mucosa and a pulse ox in the 70s and dropping fast to know that it helps save lives.

Pulse-ox is viewed as a very, very important component of anesthesia to limit/decrease adverse outcomes and deliver high quality care. I don't disagree. But, there really is not much in the way of "data". That was exactly the point. Let us not simply hide behind the lack of "data" as a holey grail of obstruction to other new technologies. I have NOT at any point stated all central lines must use image guidance. I have said there are reasonable if not significant concerns with blind sticks and/or arterial puncture. There may not be perfect "data" but should we ignore these concerns? If you look through this thread, weed through some of the fire grenades and read.... some respondents report experienced attendings hitting the carotid a few times per month, some respondents report multiple sticks, etc.... These things are not necessarily looked at very closely or followed up very often. An occult injury is still an injury even if not recognized. The anger and objection to considering US is surprising. If you think a safe and ethical study can be performed.... do it. I suspect you could even get funding from sono-site or others. They would love to have anesthesia "prove" the anectdote. A good, well thought, well constructed study would get published in just about any top tier journal. The problem is, folks are very concerned about the ethics of this study and the randomization. The IRB may have concerns too.

 

[proman]

These things are not necessarily looked at very closely or followed up very often. An occult injury is still an injury even if not recognized. The anger and objection to considering US is surprising. If you think a safe and ethical study can be performed.... do it. I suspect you could even get funding from sono-site or others. They would love to have anesthesia "prove" the anectdote. A good, well thought, well constructed study would get published in just about any top tier journal. The problem is, folks are very concerned about the ethics of this study and the randomization. The IRB may have concerns too.

Jack, you've mentioned potential long term adverse events related to carotid punctures with small needles. I'm interested in this. What do you base this on? Is there long term follow-up that you've seen in the vascular surgery population (ie CEAs)? The Anesthesia Quality Institute, part of the American Society of Anesthesiology, will be launching a national registry looking at anesthetic and operative outcomes, carotid puncture could be a part of it.

 

[JackADeli]

...Is there long term follow-up that you've seen in the vascular surgery population (ie CEAs)? The Anesthesia Quality Institute, part of the American Society of Anesthesiology, will be launching a national registry looking at anesthetic and operative outcomes, carotid puncture could be a part of it.

Unfortunately, there is not "good data" as others have mentioned, only anecdote. We have seen over several years multiple patients with early carotid "plaque" and associated stenosis that just happens to be at the site where they have suture scars from IJ ~5 or so years prior. It has caught our attention as the opposite non-accessed carotid appears pristine on duplex. Further, in some situations, when doing the endarterectomy, the "plaque" is not the usual cholesterol type in appearance but more scar like. Some, we find have what appears to be a chronic disection.

We just do not have good follow-up or surveillance. There can be hematoma within the wall, etc.... Again, I know of very few incidents (surgery/anesthesia/ED/etc...) in which folks actually document or make a record of an arterial stick. I also know of no incident in which an artery stick occured and a subsequent imaging assesment has been performed pre-discharge to assess for possible occult injury. There are quite a few case reports by anesthesia about phrenic injury and some attribute this to intramural hematoma and resultant inflamation adjacent to phrenic nerve.

I strongly support a registry and follow-up. I think it is important to be aware of possible occult injuries and actively seek knowledge to make them known as opposed to occult. The discussion, speaking for myself, of US is not meant as a jab at any specialty or the pride of any practitioner. The point is:
1. Is this a reasonable and readily available technology?
2. can this technology provide better care and/or help identify if not prevent injuries (overt or occult)?