Ultrasound machines

[witzelsucht]

So, I'm out on ye olde interview trail, and it seems like most programs take us over to look at their ultrasound machines that "cost as much as a mercedes S-class." The ones we looked at obviously are way nicer than my school's ww2 german submarine sonar hooked up to a probe, but I am curious about the different brands and technology which makes one machine better than another, and what is actually out on the market. Is there a quick and easy website or podcast or something that explains why one machine or brand is superior? Like how you can read about which hybrid SUV-crossover is best for you and your snotty kids in a few minutes? I'm not going to, you know, pick a residency based on this, just curious as a tech-geek.

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[shoal]

Dont worry about it too much. This shouldnt be a selling point. Now ultrasound teaching is different. Make sure you get some dedicated us teaching imho most programs do.

Sent from my VS986 using Tapatalk

 

[cbrons]

Check out us podcast on youtube

 

[hoot504]

Philips sparq > everything else

 

[DrDrummer]

Is there a quick and easy website or podcast or something that explains why one machine or brand is superior? Like how you can read about which hybrid SUV-crossover is best for you and your snotty kids in a few minutes? I'm not going to, you know, pick a residency based on this, just curious as a tech-geek.

Most of the U/S podcast and sites try to remain brand-agnostic, for understandable reasons. But if you look at the manufacturers' websites, for instance zonare or SonoSite, you can see a lot of extra features that they're starting to include for certain EM-relevant applications, for instance bedside echo. Some pretty cool stuff out there, and they put a lot of money into creating resources to highlight their offerings.

EM physicians with the right training can do speckle tracking echo & TEE too-- don't let any cardiologists tell you different. The question is will you want to, and will you do it enough for credentialing?

 

[hoot504]

The only time that a TEE seems to be at all worth the effort in the emergency room is during a code. Even then it's questionable

 

[Arcan57]

The only time that a TEE seems to be at all worth the effort in the emergency room is during a code. Even then it's questionable

Why in Hell would you do a TEE during a code?

 

[hoot504]

Because it offers superior image quality and can generate images while CPR is in progress. Ain't that much of a stretch. Do a google search, you'll find plenty of literature on it.

 

[gutonc]

Because it offers superior image quality and can generate images while CPR is in progress. Ain't that much of a stretch. Do a google search, you'll find plenty of literature on it.

But to what end? What are you doing with that information that changes your management?

I get that it's cool as hell. But, aside from calling the code a few minutes earlier, what does it do for you?

 

[hoot504]

But to what end? What are you doing with that information that changes your management?

I get that it's cool as hell. But, aside from calling the code a few minutes earlier, what does it do for you?

Say you have a PEA arrest. You can look for evidence of that PE without having to wait for the break in between chest compressions.

I understand that the utility of this is probably marginal.

Probably the coolest thing I've heard about in this arena is the guy who speculated that someone could make a TEE transducer, pacer, and defibrillator all out of one device, then stick that sucker in during a code. Is that feasible? Dunno. But it sounds, as the kids say, 'dope as hell'.

 

[gutonc]

Say you have a PEA arrest. You can look for evidence of that PE without having to wait for the break in between chest compressions.

Can you really? Is a TEE transducer somehow impervious to mechanical forces compared to a TTE transducer? I'm not very smart, and physics is definitely my scientific weakness. But I don't understand how a TEE in this scenario is less useless than a TTE.

 

[hoot504]

Can you really? Is a TEE transducer somehow impervious to mechanical forces compared to a TTE transducer? I'm not very smart, and physics is definitely my scientific weakness. But I don't understand how a TEE in this scenario is less useless than a TTE.

Don't see why it wouldn't be. I haven't done it myself but a TEE probe shouldn't be bouncing around in the esophagus, even with chest compressions. And there's nothing I'm aware of about the mechanical forces of CPR that should inherently interfere with image quality.

In a patient that's rail-thin and/or has great cardiac windows and can be continuously scanned during CPR, there probably wouldn't be much difference, but many patients wouldn't fall into that group.

 

[Arcan57]

The treatable causes of PEA that can be identified with US can be identified using TTE. I'm not going to believe that it takes less time to slip in an esophageal probe than to take a 5 second look to identify 1) pericardial tamponade and 2) large RV. I'm sure it's super cool to image the dissection flap but in a code situation that's not a resuscitatable condition.

Edit: if I'm working at a shop that is high speed enough to have a TEE probe on their standard US cart then I'm not tying up the machine doing a TEE, I'm using it to put in lines for ECMO.

 

[Transmogrifier]

Problems with TTE during codes:

- Can't do it during compressions
- Have to pause compressions to get decent images
- Patients often have significant underlying lung disease such as COPD giving poor windows
- Gastric distension making subxiphoid views difficult

Benefits to dropping a TEE during a code:

- Continuous view of the heart and compression quality
- Differentiation of PEA vs very low cardiac output or asystole vs fine v fib
- Useful for evaluating for evidence of PE and tamponade

It's pretty easy to get good views with TEE without having to worry about the chest wall. There are some interesting papers out there about TEE use in peri-operative codes in the OR where it changed management. It's easy enough to train to do it in the limited setting of a code in the ED. My program will be rolling it out soon hopefully.

 

[link2swim06]

TEE is useless for most ERs.

Physician needs to run the code
At the same time physician needs to intubate
At the same time physician needs to ensure access
At the same time physician needs to perform a TEE?

And perform any other procedures. Too much role fragmentation if you only have 1 or maybe 2 docs involved in the code.

Ok maybe if you have a huge resuscitation teams. But at most 1-2 doc ERs your efforts are probably better focused on running the code and ensure the basic (your staff is doing good CPR...etc.).

 

[DeadCactus]

Another vote for the machine doesn't matter, the focus on teaching does. Instead of asking about the machine, ask about what studies the majority of faculty credentialed to do. Are they struggling to get faculty trained beyond FAST and procedures? That's a bad sign and hopefully increasingly rare. This gives you insight into how much training you can expect in general and how feasible it will be to break out the machine on a patient or two a shift and slowly master the basic stuff and pick up some more advanced studies. Depending on how that hospital documents it's ultrasound quality improvement/monitoring, it may affect your ability to get credentialed for more advanced scans.

 

[deleted547339]

Philips sparq > everything else

Meh. We've got one I like, but it's not perfect. Hate it for MSK stuff.

 

[DrDrummer]

- Useful for evaluating for evidence of PE and tamponade

This + non-interrupted compressions (despite what the recent trial suggested, I think it likely makes a difference). Much better visualization of the RV and potentially flow through pulmonary vasculature, possibly helping you decide to push lytics, start ECMO, or move towards embolectomy if you get them back.

 

[SoCuteMD]

In theory, TEE sounds like a great idea. In reality, who's going to run the code if I'm busy putting in a TE probe?

 

[DeadCactus]

Is the paradigm of a physician "running the code" actually the best model? Why not let a nurse run through the monotony of the CPR, shocks, and epinephrine algorithm? It would leave the physician free to worry about the higher level "H's and T's" sort of management along with invasive procedures.

 

[DrDrummer]

Is the paradigm of a physician "running the code" actually the best model? Why not let a nurse run through the monotony of the CPR, shocks, and epinephrine algorithm? It would leave the physician free to worry about the higher level "H's and T's" sort of management along with invasive procedures.

You're probably already aware of this, but many others might not be - this is the model that Sharp Memorial uses, which is the hospital that has the group of docs who have gotten a lot of attention for using ECMO for cardiac arrest patients (the edecmo.org folks). They have a designated nurse code leader or something along those lines.

When you actually look at the limited numbers they've put out there, it's clear they're being appropriately conservative with who they try to put onto ECMO, but their new arrest policy allows the docs to throw in a lot more lines and potentially do/think about more interventions than if they were watching a stopwatch and tracking compression cycles. Their CARES data looks pretty good (though like any of this data, is subject to a lot of kinds of bias) so it seems to be working fine. It would be interesting to see how it changes the care of, say, the 94 year-old prolonged downtime unwitnessed PEA arrest, and whether they get a whole lot more in the way of invasive lines and procedures (and therefore cost?) for little/no change in outcome, or if in these scenarios they don't go full-court press and just let this approach prevent the entire department from shutting down with the docs are freed up to see patients while a smaller code team runs through standard ACLS.

 

[SoCuteMD]

Is the paradigm of a physician "running the code" actually the best model? Why not let a nurse run through the monotony of the CPR, shocks, and epinephrine algorithm? It would leave the physician free to worry about the higher level "H's and T's" sort of management along with invasive procedures.

The best model? I have no idea. The current model? Yes.

My point is that once you finish residency, there's no longer a cadre of doctors to help out in any code. I usually have a resident to help (or I let them run the code, whichever they would like). If I'm lucky, the other doc in my section pokes their head in to see if I need anything.

 

[DeadCactus]

And my point is that if we don't have a giant cadre of doctors, maybe we should reevaluate what they spend their time doing in a code.

 

[SoCuteMD]

And my point is that if we don't have a giant cadre of doctors, maybe we should reevaluate what they spend their time doing in a code.

I understood your point, I just don't think most residents understand what it's like to work in the community. In residency I would have absolute confidence in some of the nurses I worked with to run a code using ACLS. Where I work now, not so much. We maybe get a code a week or so, sometimes more. If I don't run the code, there's nobody to do it with confidence and experience. While it might be possible to get a small portion of the nurses the experience necessary, I expect that the time and energy involved paired with the attrition rate for nurses where I work would make this a vanishingly small effort that in the end resulted in 1-2 nurses who were capable.