Bedside ultrasound (US) often plays a crucial role in medical and trauma resuscitations in the emergency department (ED) [1]. Performing and interpreting bedside US studies such as the Extended Focused Assessment with Sonography for Trauma (E-FAST) during traumas or echocardiography during medical resuscitations are key skills for emergency medicine residents to learn during their training and adopt into clinical practice [2]. During trauma resuscitations timely and efficient dissemination of critical information is paramount. Information obtained via bedside US can be critical in determining further clinical actions (need for urgent thoracostomy for a pneumothorax, need for urgent exploratory laparotomy in a hypotensive patient with free fluid in the abdomen, etc.) through shared decision making between ED and trauma teams [3]. Information obtained via bedside US, however, is often difficult to convey during resuscitations given crowded rooms, simultaneous interventions, and limited viewing of the US screen. For ED and trauma providers wishing to better understand the utility of bedside US during resuscitations and how this powerful tool can change clinical management, a clearly visualized representation of what is displayed on the US screen could provide an ideal learning opportunity.

The Innovation: Wirelessly broadcasting real-time US images on large monitors in medical and trauma resuscitation bays

This innovation involves mounting a large monitor at the head of the patient’s bed in a resuscitation bay and outfitting an US system to wirelessly broadcast its image in real-time. This allows everyone who is participating in a resuscitation (attendings, residents, nurses, medical students, etc.) to view and learn from real-time US images from their station in the resuscitation bay. In addition to fostering learning, this innovation allows greater collaboration between emergency medicine and surgical colleagues during traumas, as the E-FAST exam can be viewed and interpreted by all in real-time.

ultrasound resuscitation

Figure 1: Monitor mounted at head-of-bed of resuscitation bay.

 

ultrasound resuscitation

Figure 2: Schematic of resuscitation bay.

Figure 3: US images are displayed in real-time, E-FAST right upper quadrant shown here

The Learners

This innovation targets emergency medicine residents, but also benefits surgical residents, medical students, fellows, physician assistants, and nurses.

Equipment

  • US system (most have some kind of video output, s-video utilized here)
  • Wireless HDMI transmitter
  • Adapter to connect US system to transmitter (s-video to HDMI here)
  • Adapter to connect transmitter to monitor (HDMI to DVI here)
  • Mounted flat-screen monitors (TV or computer monitor)

Figure 4: HDMI transmitter and adapter mounted to the back of the US system.

Description of the Innovation

Using simple technological advances that allow our US system to broadcast wirelessly onto a large monitor mounted over the head of the patient’s bed allows all participants of a resuscitation to visualize US findings. By doing so, this allows a clear understanding of why critical actions are performed during often chaotic and rushed resuscitations. Active learning during these periods is often difficult, but this simple solution engages all learners in the optimal care of our sickest patients. In addition to resuscitations, these monitors are also utilized for teaching common US studies or US-guided procedures (lines, nerve blocks, etc.) to multiple learners.

Lessons Learned

  • This innovation has helped facilitate teaching US to residents as well as numerous other learners. The most common use of this innovation has been the display of E-FAST exams during traumas. For example, when an ultrasound demonstrates free fluid in the abdomen, all learners can immediately visualize the images and thereby better understand how to interpret and act on them.
  • Furthermore, this allows multiple individuals, both learners and faculty, to collaboratively interpret images and make decisions regarding patient care based on them. This includes surgical colleagues, who are potentially less familiar with conducting bedside US assessments and often appreciate the opportunity to view and understand images that influence clinical management.
  • Potential barriers to implementing this project include administrative logistics of getting monitors mounted, cost of supplies (roughly $300 for transmitter and adaptors + $100 – $200 for monitor), finding the correct combination of adapters to connect equipment, and keeping equipment adequately secured and connected to the US system.

Educational Theory

This project is rooted in visual and applied learning. We believe being able to visualize US images and understand how they influence patient management in real-time is an especially effective form of learning for many individuals [4, 5]. Learning in this scenario can also be enhanced by dialogue between learner and teacher as well as immediate feedback [6]. Our hope is that by gaining this core knowledge in an active learning environment our residents will be able to better incorporate bedside US into their clinical practice. Lastly, we believe this approach will indirectly lead to non-ED services better incorporating information obtained via bedside US into their clinical decision making [7].

Closing Thoughts

Overall, this project has been well received by both faculty and learners within emergency medicine as well as trauma surgery. Our US fellows have also found these monitors particularly useful when teaching how to perform procedures such as US-guided lines or nerve blocks. We hope to continue outfitting more rooms in our emergency department with similar systems.

Learning more about ultrasound? Check out the Ultrasound For the Win archives!

Looking for more big-ticket educational practices? Check out the IDEA series archives!

References

  1. Whitson MR, Mayo PH. Ultrasonography in the emergency department. Crit Care. 2016;20(1):227. PMID: 27523885
  2. Akhtar S, Theodoro D, Gaspari R, et al. Resident training in emergency ultrasound: consensus recommendations from the 2008 Council of Emergency Medicine Residency Directors Conference. Acad Emerg Med. 2009;16 Suppl 2:S32-6. PMID: 20053207
  3. Montoya J, Stawicki SP, Evans DC, et al. From FAST to E-FAST: an overview of the evolution of ultrasound-based traumatic injury assessment. Eur J Trauma Emerg Surg. 2016;42(2):119-26. PMID: 26038031
  4. Salen PN, Melanson SW, Heller MB. The focused abdominal sonography for trauma (FAST) examination: considerations and recommendations for training physicians in the use of a new clinical tool. Acad Emerg Med. 2000;7(2):162-8. PMID: 10691075
  5. Juo YY, Quach C, Hiatt J, Hines OJ, Tillou A, Burruss S. Comparative Analysis of Simulated versus Live Patient-Based FAST (Focused Assessment With Sonography for Trauma) Training. J Surg Educ. 2017;74(6):1012-1018. PMID: 28457876
  6. Kornegay JG, Kraut A, Manthey D, et al. Feedback in Medical Education: A Critical Appraisal. AEM Educ Train. 2017;1(2):98-109. PMID: 30051017
  7. Hosseini M, Bhatt A, Kowdley GC. Effectiveness of an Early Ultrasound Training Curriculum for General Surgery Residents. Am Surg. 2018;84(4):543-546. PMID: 29712603

 

 

 

 

 

Brian Lentz, MD, MS

Brian Lentz, MD, MS

Emergency Medicine Resident
Department of Emergency Medicine
Highland General Hospital
Brian Lentz, MD, MS

Latest posts by Brian Lentz, MD, MS (see all)

Robert Farrow II, DO

Robert Farrow II, DO

Ultrasound Fellow
Department of Emergency Medicine
Highland General Hospital
Robert Farrow II, DO

Latest posts by Robert Farrow II, DO (see all)

Arun Nagdev, MD

Arun Nagdev, MD

ALiEM Guest Contributor
Director, Emergency Ultrasound
Department of Emergency Medicine
Highland General Hospital
UCSF Assistant Clinical Professor of Emergency Medicine
Arun Nagdev, MD

@NagdevArun

POCUS director, Highland ED; SoundAdvice columnist @ACEPNow