Keith Cross, MD, MS, M.Sc.
University of Louisville, Assistant Professor Dept. of Pediatric Emergency Medicine
Ultrasound technology is emerging as a vital part of day to day patient care in various fields of medicine and surgery. While time constraints during a Med-Peds residency make it difficult for residents to partake in a dedicated elective time for hands-on ultrasound (US) practice, there are ways to gain the core skills with this technology. The most important step is to recognize that bedside US is most useful when it is directly integrated into the daily residency (and subsequent attending) work, rather than viewed as a standalone skill or elective rotation.
FAST Exam – This is the Focused Assessment by Sonography for Trauma (FAST), and is something you should learn to do in adult and pediatric emergency departments. Get your instructors to walk you through it on every trauma patient – especially the ones who seem fine (they make great practice subjects to learn what “normal” looks like). After a little practice, you will get very quick at it (less than 60 seconds). The traditional FAST exam includes 3 views of the abdomen (hepato-renal on the right; spleno-renal on the left; and Pouch of Douglas in the pelvis) looking for bleeding, plus one view of the heart to assess for effusion and function. The basic US skills for a FAST exam are excellent foundations for a wide variety of more advanced applications including cardiac echo, renal US, and bladder assessment, as well as evaluation for pyloric stenosis, appendicitis, biliary disease, adnexal pathology and pregnancy.
Line Placement – Numerous studies in both adults and children have shown that US guidance improves line placement procedures. If your MICU rotation does not teach US guidance for non-emergent lines, ask why not!! Pediatric settings (PICU, peds ED) tend to lag a bit, but most of them are now adopting US too. Take the time to learn this skill. Yes, it takes a bit longer on the front end to set everything up, but you save time later with fewer misses and fewer complications – especially in obese patients or otherwise difficult line procedures. It is simply much easier to hit that which you can see. The skills learned with line placement are directly applicable to several related applications: peripheral, arterial and PICC line placements, fluid aspirations (e.g. paracentesis, thoracentesis), aortic aneurysm ultrasound, Doppler studies for thrombosis, and US-guided nerve blocks.
Soft Tissue Assessment – A common clinical question for soft tissue infections is: does the patient have an abscess (drainable) or simple cellulitis (non-drainable)? For generations, this assessment was clinical, but several studies have shown significantly increased accuracy with a brief (20-second) bedside US exam. An abscess looks very different from cellulitis and is simple to spot. This application is one of the fastest and easiest to learn, and yet commonly overlooked. It has the benefit of not only showing where a drainable abscess is, but where best to incise it. It helps you avoid cutting into cellulitic tissue to no avail (and then having to explain your failure to patient and family). Once you learn this application, the same skills will help you find retained foreign bodies (or rule them out), diagnose tendon tears, see long bone fractures, and evaluate joint effusions. .
Jumping into these 3 “gateway” applications of bedside US can get you started on the path to proficiency. If your residency program provides limited training, you can augment your skills with workshops at conferences and specific CME training. There is also a wealth of on-line resources (YouTube, etc.) for motivated novice sonographers.
Like any other skill, bedside US takes persistence and practice but is highly rewarding in the end. Start today and keep at it!