Ultrasound for everything

[cchoukal]

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I 100% agree with you guys on this, it's ridiculous. But the reality is that we have been arguing until we were blue in the face for this and guess what... it hasn't happened.

So I used CME money because the hospital won't get held to the fire for inadequate equipment in any potential lawsuits; I'll be the one getting sued and paying out.

And yes my only power in the end is using my feet and walking, but uprooting my family to go to some unknown place that will likely have its own set of different frustrations isn't an answer either.

I guess so, but in 16 years of practice, I’ve been at maybe 20 venues, from VA and academic, to community hospitals, cash-strapped ASCs, to one-room plastics offices, and I’ve never once been without immediate access to a good-or-better quality ultrasound. What you’re describing sounds really foreign to me.

 

[GassYous]

I can't imagine a vascular surgeon or interventional radiologist being like "ok well I can't get an ultrasound in my suite so I need to buy my own ****ty handheld scanner".

 

[pgg]

****, the last thing I'm going to do is buy a small expensive device for someone else to swipe and sell on ebay.

Also - my hospital doesn't permit the use of personally owned medical equipment. They argue they can't enforce or regulate quality, cleaning / infection control, liability. We had a CRNA who owned his own McGrath and they told him to **** right off out the door with it.

 

[Mman]

Nobody is 99.9 at anything, ever.

I define success rate as getting the art line in. How often do you actually abandon it when you wanted one for a case? For me, probably 1/1000 it just isn't worth the risk. I didn't say I get it on one pass of the needle 99.9% of the time.

 

[Mman]

Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine - PMC

In order to evaluate the complications and risk factors associated with peripheral arterial catheters used for haemodynamic monitoring, we reviewed the literature published from 1978 to 2001. We closely examined the three most commonly used arterial ...

pmc.ncbi.nlm.nih.gov

Data would suggest that, if you've done 10,000. Then you wouldve had approximately
8 cases of permanent ischemic dmg
10 pseudoaneurysms
13 cases of sepsis
80+ cases of local infection
1200 hematomas.

So seems amazing to me that you have rounded postop on all 10,000 of your patients to check their art lines...and managed a flawless record!

Did you assess these patients for multiple days after? Or just a check in pacu?

I have spent 15+ years on the quality committee that gets feedback on complications from all procedures in the hospital. I have never had one that resulted in permanent ischemia of a digit. Zero. Never had one implicated in causing sepsis. Hematoma? 100% of art lines have a hematoma when you remove them. Something like a pseudoaneurysm is really only relevant if you are having surgery to repair it. There is no good data looking at imaging of tens of thousands of patient wrists 6 months after they had an art line placed in it.

 

[pgg]

I define success rate as getting the art line in. How often do you actually abandon it when you wanted one for a case? For me, probably 1/1000 it just isn't worth the risk. I didn't say I get it on one pass of the needle 99.9% of the time.

Oh sure my "success" rate by that metric is probably 99.9%

I think the success rate everyone else is talking about is first pass / one stick.

If it was your arm and your artery, would you be happy with a 2 or 3 stick multiple pass approach if it was successful ... eventually?

I would not be, particularly if I was an informed enough patient to understand that the guy with the needle(s) was choosing not to use the best tool available to him, for reasons.

 

[UscGhost]

I define success rate as getting the art line in. How often do you actually abandon it when you wanted one for a case? For me, probably 1/1000 it just isn't worth the risk. I didn't say I get it on one pass of the needle 99.9% of the time.

Lol. Nobody defines success rate that way....

Otherwise i should be in the NBA. I am a 100% successful on 3s...i just dont abandon shooting them until i make one.

 

[UscGhost]

I have spent 15+ years on the quality committee that gets feedback on complications from all procedures in the hospital. I have never had one that resulted in permanent ischemia of a digit. Zero. Never had one implicated in causing sepsis. Hematoma? 100% of art lines have a hematoma when you remove them. Something like a pseudoaneurysm is really only relevant if you are having surgery to repair it. There is no good data looking at imaging of tens of thousands of patient wrists 6 months after they had an art line placed in it.

Thats because nobody tracks art lines on QC. They track central line infections, foley catheter infections and maaaaybe reintubation.

 

[Iso4ane]

Cardiology 'cleared' this patient a few days prior to surgery. Personal u/s has its' uses, as a cardiac probe is sometimes hard to find around my institution.
Had a similar case, where I told the surgical team, that if they wanted to have a easier time, an apical approach would be easier that a subxiphoid approach.

 

[CopaceticOne]

View attachment 424761
Cardiology 'cleared' this patient a few days prior to surgery. Personal u/s has its' uses, as a cardiac probe is sometimes hard to find around my institution.
Had a similar case, where I told the surgical team, that if they wanted to have an easier time, an apical approach would be easier that a subxiphoid approach.

1) what was the case?
2) why not drop a TEE?

 

[Iso4ane]

1) what was the case?
2) why not drop a TEE?

Some ENT shenanigans first thing Monday morning. Cardiology echo/clearance was Thursday prior, and already impressive,; which cardiology didn't want to tap. This was pre-induction, and was worse than the prior imaging, so no opportunity to drop a TEE.

The other case was a pericardial window. Clear apical and subxiphoid windows, fluid pocket was larger from an thoracic apical approach than a subxiphoid approach. TEE wouldn't tell you that.

 

[CopaceticOne]

Some ENT shenanigans first thing Monday morning. Cardiology echo/clearance was Thursday prior, and already impressive,; which cardiology didn't want to tap. This was pre-induction, and was worse than the prior imaging, so no opportunity to drop a TEE.

The other case was a pericardial window. Clear apical and subxiphoid windows, fluid pocket was larger from a thoracic apical approach than a subxiphoid approach. TEE wouldn't tell you that.

I would simply say no to the ENT case if that effusion existed as shown above even if smaller.

And again, I’m not dictating surgical approach to a CT surgeon or interventional cards. They need to be able to make big boy decisions without me covering for them.