Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Doctor Clark is an Acute medicine registrar at University Hospital of Sussex NHS Foundation Trust and an MSF doctor. She has worked in Zambia, South Sudan and Bangladesh and used point of care ultrasound in these low resource settings. Thank you. You. Yes. My name's Joe. I'm, I'm a new medicine registrar and this is gonna be a bit of a different flavor. It's gonna be an interactive workshop on how to do echos and sort of basic bedside ultrasounds. Um So in terms of our objectives, you've got 35 minutes all to learn how to do an ultrasound scan and we'll talk through some cases and look at different views and then I'll talk a bit more about um using point of care ultrasound to pick up signs of extra pulmonary TB in the high prevalence H I VTB settings and then run you through some of the different accreditation options. Um So sounds exciting. It can be done anywhere. So if you're an air ambulance doctor in Australia, you can take it to the roadside and look for new and free fluid. Um If you're up in the mountains and someone's dislocated their shoulder, you can use ultrasound to check if you've popped it back into place properly. Um, a bit of a plan for the tropical medicine diploma and Peru, they sometimes run a tropical medicine and ultrasound course there as well. And it's a really fantastic place if you're thinking about doing your maintenance to go. And, and also in the NHS, we're increasingly using ultrasound in our acute medical units in our emergency rooms and up on the wards. Um So two places that I've worked relatively recently. So um on the left, we've got be to South Sudan. So that's a picture of our hospital with the and a child in our malnutrition unit and he's now much, much better and set up and got enough to run around his lips. Um And then last year I spent a year working in Bangladesh at the Myanmar border refugees and the refugee camp there. Um So I just wanted to brainstorm, what sort of things podcast can be useful. Um What do you guys think we can use ultrasounds to diagnose when we're abroad and in the UK and there's no wrong answers. Effusions. Yeah. Brilliant. I'm still looking for pleural effusions. Yeah, ps Yeah. Anything else. Pregnancy. Yeah. Opic pregnancy. Very important. Um Any other things. TB Yeah. Um Any upward do. Yeah, customer access. Yeah. Tricky Cannulas. Um essentially you can use ultrasound for everything. Um So um in trauma scans, um looking for rop season free fluid, you undifferentiated, hypox, hypoxia patients. Um looking for things like pneumonia, heart failure, there's evidence of right heart strain, um picking up congenital heart disease for help with prognostic. Actually working with MSF, they've got a really good telemedicine platform. So if you're scanning um kids with heart problems, you can pop their images through to a consultant, cardiologist who can advise you about different options. Um We quite often use it in Bangladesh as well for working out if someone had ascites or if it was just adipose tissue. Um that was important in terms of our HEP C treatment program because the length of treatment, if you've got decompensated, liver disease is twice as long as if we haven't decompensated yet. Um And also sometimes we, it was difficult to tell with some of our nephrotic syndrome kids, whether they were just pushing ro from the steroids or whether they have ascites. Um for poor renal function, you can stand the kidneys. Um looking for obstruction and hydronephrosis. Um There's good evidence that point of care time for DVTs is um very sensitive. You'll pick up 95% of DVTs with a relatively simple scan, um acute jaundice looking for um sort of dilated bile duct. That's a bit beyond my skill set. But my grass in um Bangladesh was fantastic at scanning livers and then I'll talk a bit more about scanning for TB and HIV later. So the machine on the right you're probably familiar with. Um in terms of your acute medical units and emergency rooms. Um So over this side, this is my boss in Bangladesh who is brilliant and a trusty Sonia site machine, which you can sort of carry between bed spaces and you can switch in your different probes. Um These are the sort of three most popular um sort of handheld ultrasound devices. Um So if you ever go to an ultrasound course in the UK, there's usually a rep showing you the butterfly probes uh trying to get you to buy them. Um in terms of hot countries, the word on the street is they overheat quite easily and I find them quite heavy for using um I did my echo qualification mostly using the Phillips er Lumify Pro um and really liked that pro that gave nice images and people that are very good at scanning and experts are all right into the ban there, but I've never tried that one out. These are your main probes. Um So you've got your phase array probe, which is the square one which we use for doing echos. Um You've got your curvy linear probe um which is low resolution but high depth. So you use that for your lungs and for your liver and kidneys. Um and then you've got your linear probe, which will be the one that you um which is um lower depth, high resolution, which is the one you go to for popping in Cannulas on the walls and popping in central lines. It's also very good for musculoskeletal ultrasound. So, II thought we'd talked to a case. So we got a 26 year old lady. She's three months postpartum and she's come in with shortness of breath, hypoxia and a cough. So, just thinking about what are our differentials at the moment based on that history? Yeah. TT. Yeah. Infection. Yeah. Does she have pneumonia? Does she have COVID? Um, anything else? Yeah. Uh cardiom perfect. Um So you can use a very basic bedside scan to sort of help work your way through the different differentials. Um So for the next step, I want everyone to pick up their mobile phones and essentially this is gonna be your ultrasound probe and we're all gonna practice scanning ourselves as we look through the different pictures. Um So depending on which side of your phone's got buttons, choose, choose which side's got a probe marker. So I'm gonna use my off button as the marker dot And then, so these are your basic echo views. So your first one's your parasternal long axis. So find your sternum go a bit to the left and then you want your dot going towards your right shoulder and then you get this view um just up here. Um so you can see your right ventricle and your left ventricle. You get a nice view of the valve and roughly your right ventricle aortic root and left atrium, which should be a further third of third. Um And so this is the view you find around here, you then switch it 90 degrees with your dot to your left shoulder and then you cut the heart in half and you get your parasternal short axis view. And the way to remember the difference is this or there's a long view of the heart, that one's a short view of the heart. Um Sometimes I don't know how many people here have done echos before. So a hand, how often can you find the heart? So sometimes it's really difficult to find the heart. Um Ironically, um So a tip for this is zoom out lots and then just go up and down the rib spaces till you find something moving and then choose that rib space and then zoom in and then you can get better pictures. Um The other thing is getting someone to lie on to their left hand side and it just brings the heart closer to the chest wall and that also helps with optimization of images. Um So your next view is your apple four chain review. So have a feel of the apex of your apex beat and roughly around there, that's where you pop the probe. Um Sometimes it takes a little bit of findings. So sort of scan around until you get to that location. Um And then you get a nice view of all four chambers of the heart. Um And then your next view is your subcostal view. And so you sort of go under your zip sternum and point upwards towards the heart and you have to go quite superficial for that sometimes. So, in terms of no ultrasound, uh so you want your marker d up towards the ceiling and then you just sort of work from side to side, sort of going down the chest, you can do it on the back as well, depending on if your patient can sit forwards. And then the sort of point where there's quite a use useful information is the PAX point, which is very eloquently abbreviated from posterior lateral alveolar and four point syndrome. Um But essentially, it means the bottom of the lung, uh where you can see the diaphragm. Um So for that, you're sort of going around here um on the right hand side and then you can tilt down a bit and then you can get a nice view of your liver and kidney there and then same on this side. Um You can get a view of your spleen and your kidney. Um On the left hand side, the kidneys more difficult to find, often you just need to go back a bit further and then it pops into you. So this is what we see for our 26 year old with shortness of breath. Um So does anyone want to try and describe what they can see on the left on? It's not the left. Yeah. Yeah. So black is fluid and we've got a pleural effusion here. Um Anything else that you guys can see? Yeah. So you've got some consolidated collapsed lung there. Um And the resolution is not brilliant, but there's some dynamic hair bronchogram. So those are sort of the right lines that you can see that shimmer a bit. Um Anything else? Um So you've got your liver there, the diaphragm. Um And then you've got stuff going on sort of behind. So that in have a picture later, I'll show you the spine running backwards when you've got an effusion there. Um, but essentially, yeah, you've got pneumonia a bit of a parapneumonic effusion. Uh, based on these pictures, it's not safe to pop a needle in to do a tap. Um, and probably sort of not clinically needed either. Um, so what do you guys think about the picture on the left? You're right. Um, what's it a picture of? Right? Um, I can see why you've said that but not quite. Um, so that's a picture of. So which, um, where are we putting the probe for that picture on that side? Yeah. So you've got your left ventricle. So that's your para scone, I'm short axis view. So you've got your dot To your left shoulder, you've got your probe around here and then you've got your left ventricle, um, which is a bit like a donut and you've got the papillary muscles there and then you've got your right ventricle sitting on top of it like a croon. Um And what do you think about the pumping there? Is it sort of pumping in or not doing very much thumbs up or thumbs down? So we've got some thumbs down, a couple of thumbs up. Um So actually that's pumping quite nicely. So lots of thumbs up, um, left ventricle. Um, so the walls are coming in and the other thing that you can notice is the, the intervention forum, which is there is nicely rounded, it's not flattened at all. Um So based on that imaging, so we've got a nicely pumping heart and we've got a pneumonia. What would we want to do in terms of treatment for her antibiotics? Perfect. Um And so this is examples of other things you might find if you were scanning a similar sort of patient. Um So we've got our parasternal short axis view again and this is an example of right heart strain. So the right ventricle here is more than just a press on over a donut. It's much bigger. Um And you've got flat flattening of the septum um to going in towards being ad sign. Um So that's one of the things you sometimes get if you've got a big p and it's a strain on the heart, the right side of the heart gets much bigger and it starts to squishing towards the left. Um So on the other side of the screen here. We've got the Paris Dla access view. What do you think about the pumping of the heart in this view? Is it a from that part or a Fs down heart? Brilliant. So lots of fun down. Um So essentially the edges aren't coming in very well, it's not really pumping very much at all. Um And in terms of our ratios of referred. Um So that's your right ventricle actual aortic root there. And that's the left atrium, we're a little bit off access. Um But the left atrium is also a bit dilated and there's something not quite right in how the mitral valve leaflets would come all together sometimes. Um So this is an example of um a partum cardiomyopathy, any questions about the heart so far. And so in terms of lungs, um so lung ultrasound is a bit like interpretive artwork. Um So ultrasound beams don't go very well through air, they get scattered. So you have to sort of interpret the artifacts to tell you what's going on. And if you can see a solid bit of lung that's normally cos there's something wrong with it. Um So if we take our probe, the game and we want our marker do towards the ceiling and we're just gonna scan across the top of the lungs. Um And then you get a view a little bit like this one. So you've got red shadows on either side and then you've got your plural line under the, a line underneath it. Um, so a lines are reverberation artifacts and they're what you get on normal lungs. So, if someone says they've done an ultrasound and there's an, a line profile that just means there's normal a of lungs and you've got these sort of artifacts that you can pick up. Um, so the on the other side, I've got some bee lines. Um, so what do the bee lines look like to you guys? So how I think of them as looking like search beams. So bee lines and beans, search rooms. Um So bee lines are a sign of interstitial fluid. Um So if you've got lots of alveolar fluid because of heart failure or you've got a pneumonia and things are very clogged up. You can get be lines. Um You also get them in interstitial thickening. You've some fluid or fibrosis and you can use the pattern of which you see these lines um to try and work out the underlying pathology. So, if you've got B lines at the top of the lungs and they become more confluent going downwards and maybe some small bilateral pleural effusions, you'll be thinking along the lines of heart failure. If you've got one lung with an A line so far, and your other lungs got lots of these bee lines, you're thinking a bit more about a localized process could be, there's a pneumonia on just one side. If you had someone with just bee lines up the top, um, and not so much further down, you can be thinking about some of the um interstitial lung disease presentations that are affecting a bit more, just the upper lobes. Um So this is the curtain sign and um across the bottom of the screen, you've got the spine. Um, you've got the diaphragm along here and the liver and then because the normal aerated lung doesn't really look like much. It just comes across as a curtain and that's the um normal lung that you've got there. So this is another example of consolidated lung. Um So it's quite densely consolidated. You've got your dynamic hair bronchogram coming across and on this side, it's just another example of rep pleural effusion. And because um the old travels quite nicely through water, um You can see the spine at the back. Um Whereas if you had aerated lung going across, you'd lose that spine at the back there. Um So how many of you guys have done for clinics and full ultrasounds? Uh Have you seen this sort of thing before? So, um this is a patient with Hyma. Um So you can get lots of different surrounding um driven Hyers, there's a bit of um thickening there as well over the diaphragm. Um You can also sometimes malignancies as well, get sort of heavily lactated effusions. And so this is a patient that if you've got the resources for you ideally put a chest drain in and try and drain out. So, pneumothorax. Um So what you've got on this side is normal lung that's sliding nicely. Um It's almost like a bunch of ants, sort of walking along the line there and then you've got a lung point and then that transitions into your pneumothorax. So your feral pleura and parietal pleura is separated. So actually, they're no longer sort of sliding nicely over one another. Um When you first do ultrasound courses, pneumothorax seem like a really easy thing to pick up on ultrasound. But in real life, when you've got someone with quite severe respiratory distress, their intercostal muscles are moving loads. There's lots of things that can trick you into, there's lung siding when there's not. Um So, um if you've got this a transition point, that's quite helpful. But in real life, you very rarely find the lung point. So the blue protocol is a protocol that's been developed to help people uh put these different findings together. Um We've talked through most of this already, but essentially, if you've got a particularly hypoxic patient and a completely normal lung ultrasound, it suggests that you then scan the legs and work out if there's any evidence of from both veins to point you towards AP um or if everything's completely normal, think about things like CO PD and asthma as a cause of your hypoxia. Um So there's lots of different artifacts in ultrasound that can trick you. Um So we've said that fluid is black but also shadows from things that are really done to also black. So, um this is an example of the shadow you get from behind the ribs. Um You can get sort of similar shadows behind gall stones and renal stones um if they're dense enough. Um So the diaphragm is super reflective. So sometimes you get a mirror image of the liver um just above the diaphragm and you, you have to look quite carefully to grab, how is this consolidated lung I'm saying? Or is this liver? Um But there's usually other signs that can help you with that cos you'll often if it's just the reflection of the diaphragm, um the reflection of the liver and the diaphragm, you'll still get the curtain sign and things coming across. Um Another example of artifacts to think about is posterior acoustic enhancement. Um So where the sound beams travel so nicely through fluid things at the back of the um a fluid filled object are often brighter than they really are. Um So if you, your first time scanning, you might end up thinking there's something weird going on at the back of the bladder wall when they actually, in fact, this is just the way the artifacts are adding up together. Um Similarly curved objects, you get um acoustic shadows behind them, that sort of edge artifact. So this is our second case. Um So we've got Amina. She's 33 years old. She's recently started on antiretrovirals for HIV. And she's come in feeling generally unwell with fevers. What are your differentials? Iris? Brilliant. Um, any other differentials? TB? Yeah, maybe a TBI. Um, any other ideas, young lady with fever. No wrong answers. Yeah, it's my, yeah. Anything else? Oh, meningitis. Brilliant. Um, so basically she's a young lady. She's got a fever. It could be literally anything she'd want to take your sort of usual infective history. Um And common things are common. Um But actually, she's also from high prevalence H I VTB setting and recently started on antiretrovirals. So alarm bells are already ringing a bit rubbish. She's, we've missed TB and already started her A R VS and whether things have reactivated. Um But essentially, it could be any opportunistic infection as well that's flaring up. Um So, uh back in 2010, their team um did some research in South Africa looking at focused assessment with sonography for HIV associated tuberculosis. And from this, different protocols have been put together um to try and support clinicians in low resource settings in picking up signs of actual pulmonary TB. Um because often your um sputum test will be negative. Um And there's often very limited access to gene expert or TB lab or various other tests. Um So essentially, it's the same locations that you'd be using to do a fast scan. Um But with some added additional questions, um So any one of these findings means it's a possible fash scan for possible TB but obviously, there's a range of differentials for each of the findings. So firstly, you're looking at the heart to see if there's a pericardial effusion. And so in South Africa, they did a big study looking at large pericardial effusions and the vast majority were due to tuberculosis and I was in a set and they could then back up there, um sort of research go back to the test to confirm the diagnosis. Um You're looking for um pleural effusions. So, getting back to your PAP point, um looking for ascites. Um looking, this is the additional thing with the fash scanning is looking for um aortic lymphadenopathy. And then you're also looking for any lesions in the liver and focal splenic lesions. And I've got a couple of examples of different pictures. And so, in terms of the para aortic lymphadenopathy, um it essentially looks like a bunch of grapes sitting around your aorta. And so what we've got here, you've got your, your spine with the shadow behind it and then aorta and then some lymph nodes here. And similarly, along here, you've got your um aortic lymphadenopathy as well. Um And then I'll show you a picture of um so this is a um TB pericardial effusion. Um So if you pick up sort of effusions in the UK, um often they're not um there's not this sort of funky stranding in it. Um If you've got fibrin stranding within the effusion, pericardial effusion, that's the strong sign that it's a um tuberculous er pericardial effusion. Um And this is an example of um hyperechoic splenic lesions um from TB microabscesses in the spleen. Um So, in our patient, so um she's dengue malaria negative, she's got a pericardial effusion, small pleural effusions, paraaortic lymph nodes and hyper splenic lesions. So this given the clinical picture uh points you in the direction of starting TB medication um in terms of differentials. Um so if she didn't have HIV or even if she does have HIV, one of the strongest functions also is gonna be lymphoma and there's also lots of other infections that that can give you these hyper splenic lesions. So, if you had a sort of invasive fungal disease, you can get those lesions, bartonella, um non tuberculous mycobacteria, you can also get those sort of lesions. Um But if you start TB medications uh usually within three months, um if it is TB, all of the findings that have gone back to normal or are heading towards going back to normal. So I thought I talked through some spot diagnoses as this is a 21 year old man with right upper quadrant pain and jaundice. Um and to give you a head, this is the bladder. What can people see inside? Yeah. So there's a round that, so there's a um assis, well, that's um swung through the small space through the common bile ducts and migrated into the gallbladder. Um I wanted to include this because when I was studying in Lima, uh we watched some clips of the R CPS of people, um fing out worms from people's common bile ducts. Um um So depending on your settings, sort of how you treat this. So if it's an acute abdomen and you're in Bangladesh, um then you try and refer them on to a tertiary center. Um You also give antibiotics, anti helmets. Um So next, we've got a 42 year old lady with left sided loin growing pain and blood in her urine. Uh What sort of things are we thinking about in terms of differentials, renal stones? Anything else? I'm sorry? Yeah. Anything else? Just so, yeah. Any arthritis, nephritis. Yeah. And then we've assumed the blood is in her urine and it's not PV, bleeding. And depending on your translators where you're working, you won't always get a sort of clear picture of where the blood she's actually being seen and she's 42. So she's just uh still at risk of sort of miscarriages, ectopic pregnancies. Um So this is what we see. Um So I've got a normal kidney on this side and I chose this particular image because the renal pyramids are quite prominent and that's one of the things that can actually route on your neck for hydronephrosis. Um Sometimes the renal pyramids aren't prominent in this way. Um But on this side, we've got a moderate hydronephrosis. So we've got dilatation of the renal pelvis and um the can, uh, and coming into here in a second, we've got a stone and if we catch it again, we'll be able to see that um, shadow behind it as well. Um So we, in terms of grades of hydronephrosis. So, hydronephrosis is a relatively easy finding to pick up. Um So when it's mild, it's just the renal pelvis that's dilated as it becomes more moderate. Uh the KS become dilated and when it's really severe, everything's very dilated and your um the renal cortex is very thinned. Um and it looks almost a bit like a pin when you're scanning. Um the other thing to think about for her. So, although we found a stone and we found moderate hydronephrosis, I still want to do a pregnancy test for her and if she's pregnant and then get the maternity team to do an ultrasound as well just to check the location of the pregnancy. Um So this is a 26 year old man with nephrotic syndrome and left leg swelling. Does anyone want to guess what? We, this might be an image to represent DVTs? Yeah. And where do you think we're scanning? Yeah. So um with the leg, um so um looking for DVTs is quite relatively easy. Um There's the three point compression test. Um So you start up in the groin um, let staff know femoral junction, see if you can squish uh, femoral femoral vein at that level and all the way down. Um If you can, there's no clots, you then follow the femoral vein down the leg squish a vein sort of in the mid thigh. If it squishes, there's no clot and then you can come around to the back of the knee and then you scan the popliteal vein. If it squishes, there's no clot and then you go down to the teration. Um So what we've got here, we've got our femoral artery here, which is passing away. And then that movement you can see is someone squishing the probe and actually the femoral vein here is not squishing uh whereas it should fully compress and you can just about see some echogenic material in it. Um And so there's about as um there's been lots of studies in acute medicine. So an acute medical doctor should be picking up 95% of BBT S using this sort of relatively simple method. Um So in terms of accreditation options, um there's lots of different ultrasound courses out there and lots of different pathways. Um So, fusing heart is the basic sort of echo qualification where you learn to do a visual assessment of how nicely the heart is pumping. And if there's any um pericardial effusion, um and then you can upgrade that qualification or go straight in for the PSE British Society of echocardio echocardiography um to their level one qualifications that in that qualification, you learn to put color through valves and do a few extra measurements. And then the level two scans are the ones that the cardiology, writers and consultants would be doing and the trained sonographer would be doing um pharmacy. The Acute Medicine Society has its own accreditation pathway for chest abdomen and DVT scans. Um There's also emergency um scanning pathways um for A&E trainees. Um British Thoracic Society has got its own sort of long accreditation process. Um So, so clip share is a very good website. If you want to get a predation and want to share your scans with someone. There's no one sort of locally within your own NHS trust. So across KSS, some of our hospitals don't have um ultrasound training. So I know some of the trainees either use sonic clip chair or use the butterfly probes um to share their, their scans with um consultants to get feedback and in terms of my journey for developing ultrasound skills. Um So back, you know, as a foundation trainee, I did my level one emergency medicine ultrasound course and then occasionally in A&E would do some scanning um with the consultant. And then when I was doing my A CCS acute Medicine training, I did a um critical care ultrasound course and um did some scanning on the intensive care unit. Um and then worked in South Sudan doing a few scans there. But actually that really gave me motivation when I came back to the UK to get properly accredited and sort of learn how to do echos. Um So I was fortunate to be doing cardiology and the medicine just there and managed to get my advice qualification there. Um When I was working with MSF in Bangladesh, they've got um telemedicine available, which is brilliant. And my boss, there was fantastic at ultrasound and there was also a regional referent that you can share pictures with to get feedback from. Um And this year I've done the one of the Bley course, which was really good, um which was a basic ultrasound for surgeons course. So that was learning how to um ultrasound dislocated shoulders, look for achilles, tendon tears, um a bit of soft tissue ultrasound and then using a classic model to look for appendicitis. Um That was a very good course. Um So in summary, there's loads of fantastic opportunities out there. There's ultrasound probes in lots of different parts of hospitals now. Um So it's quite accessible in, in terms of learning and um yeah, happy to take any questions. Um Thank you so much. Do. That's a great case and some really good images. Um We've got some questions coming through online and then we'll go to the room as always. Um So one of the questions is around um which calls you recommend that would be enough to go away with because I know that some of different levels in some place and some of the cases, the one that you recommend that would be good enough for anyone who wanted to do it and go to a low, reasonable setting and they do. So I think the um the, the courses that are joining the car plus um and basically echos L and DVT is very good. They're usually two day courses. Um And that's a really good instruction, but the key thing is scanning and getting someone to look at your scans to build up your competencies. Um So finding a supervisor that's happy to keep looking at your pictures as you sort of draw your skills and see you're getting feedback. Uh We wait to the room now if anyone has a question in the room, OK. Um But obviously you said a lot of like right side. So a lot ultrasound in a place for ultrasound um in my, in the UK because I've never seen it. I think, um I think there definitely is, I guess it's a difference between a rule in scan and a worn out scan. So even um if we scan someone's leg and decided that we can't see a DVT because there's that 5% chance of missing something in general, they still need a departmental ultrasound. But I know there's been sort of remote acute medicine teams that have been told in different parts of the UK where they've gone out on scans on patients, then you can have a pragmatic discussion as to this is the risk of missing it. And um this is the most likely diagnosis. Um So, yeah, I think it can definitely be useful in GP practices. And do you have time for one more question before the break? Ok. Uh What do you think are the main barriers to uh what you used to ultrasound within uh kind of uh uh resource touching. Um So I think it's just training and I know MSF is going around all of its projects, kind of train up as many people as possible in the use of ultrasound, but it's not accreditation process that takes time and sort of gently building up skills so that things are interacted correctly. Um But I think, yeah, it's definitely becoming more and more common. It depends where you work if there's actually an ultrasound machine or not. Um But the projects that I've worked in, like there has been ultrasound that's been really useful and used by sort of a range of different doctors and midwives and stuff. Joy. Thank you so much.