SCGH ED US Service Background

Document produced by Dr James Rippey 2010

The SCGH ED Ultrasound Service is something this Emergency Department, with the support of the hospital, has been developing since first being established in 2005. In its current form it is a nation leading service of significant national and international repute. We have particular expertise in critical care ultrasound, general emergency ultrasound, early pregnancy ultrasound and ultrasound for procedural guidance.

Over the last decade ultrasound has evolved into a clinical tool with diverse roles in many clinical settings. In the Emergency Medicine and Critical Care environment ultrasound is used to expedite care, guiding assessment and management of patients at the bedside. Many of the indications are unique and not services offered by the radiology department. In addition it is the integration of clinical understanding and expertise with immediate ultrasound findings that assists most.

Unfortunately ultrasound is a user dependent modality. This means appropriate knowledge, training, experience and credentialing are essential. There are examples where ultrasound in non-expert hands has been detrimental to patient care. SCGH realized this early and has fostered excellence by investing in appropriate training and support for the EDUS group.

Recognising the need for ultrasound expertise in Emergency Medicine, the SCGH EDUS Service was established in 2005. The aim of the SCGH EDUS Service was to create a group of highly skilled, dual trained Emergency Physicians with the Diploma in Diagnostic Ultrasound qualification. Ultimately the aim is to maximize the presence of a consultant with ultrasound expertise.

The advantage of this service is not only to provide clinical service, helping to ensure timely and appropriate patient assessment, improving safety of emergency procedures, but also to facilitate widespread clinical ultrasound understanding and education.

 

The Current Service

  • 5 x DDU FACEM

Ultrasound / Emergency Physicians

  • 1 Fellow

Early in Fellowship / Emergency Physician

  • 1 ED registrar

Learning basic emergency medicine ultrasound as per ACEM guidelines

  • Medical student attachments intermittent

 

The Roster

  • In hours EDUS Service
  • Monday to Friday 0800-1800 DDU FACEM

Rostered on for clinical ultrasound

Consultant for this shift contributes to clinical patient management, giving FACEM advice, as well as performing diagnostic and procedural emergency medicine ultrasound

Also has a teaching role – for EDUS registrar, Fellows and other ED staff as per ACEM guidelines

Ensuring a dedicated FACEM DDU with ultrasound specific time, enables this group to maintain and improve their ultrasound skill

  • Extended after hours service
  • FACEM DDUs are also rostered to their share of afterhours and weekend shifts. Having a substantial number of FACEM DDU staff means that when required afterhours, particularly in critically ill patients, this service is often available.

 

List of indications for Emergency Department Ultrasound

Emergency medicine ultrasound covers many areas of assessment that are not within the traditional realms of general radiology department ultrasound. There is however a degree of overlap.

 

Critical Care Ultrasound

Bedside focused echocardiography and lung ultrasound are performed every day in this department and frequently define life-threatening pathology, as well as guiding management.

 

  • Cardiac arrest
  • Major trauma
  • Undifferentiated hypotension
  • Chest pain
  • Collapse
  • Shortness of breath
  • Sepsis where the source is uncertain or the requirement for further fluids or inotropes is being questioned
  • Pregnancy related abdominal pain

 

Diagnostic Ultrasound

A very broad range of diagnostic ultrasound is covered by our clinicians. We do not do advanced vascular, breast, musculoskeletal, or second and third trimester pregnancy ultrasound.

 

  • Abdominal Ultrasound (usually for pain, masses, jaundice, etc)

Complete abdominal and pelvic ultrasound (including transvaginal scanning) covering pathology of the biliary system, liver, spleen, pancreas, bowel, abdominal wall, renal, bladder, groin, hernias.

  • Male and female reproductive systems

Testicular pain or swelling, pelvic pain, early pregnancy, ovarian and uterine pathology

  • Major vascular pathology

DVT upper and lower limb, major arterial occlusion, aneurysm formation and rupture, post procedural complications

  • Cellulitis vs abscess
  • Musculoskeletal ultrasound

Haematoma, tendon injury, foreign body detection, fracture detection, collections

  • Heart

For pericardial effusion and major cardiac pathology

  • Lung ultrasound

Defining pneumothorax, determining consolidation from tumour from effusion

  • Ocular ultrasound

Retinal detachment, foreign bodies

  • Lumps and bumps

Determining origin, abscess, lymph nodes, cyst, aneurysm, hernia.

 

Procedural Ultrasound

  • Vascular access, peripheral, PICC, central and arterial lines
  • Join effusion detection and drainage
  • Abscess detection and drainage
  • Ultrasound guided nerve blocks
  • Foreign body detection and removal
  • Pleural effusion detection and drainage
  • Ascites marking and drainage
  • Difficult urinary catheterisation

Service beyond the reaches of SCGH ED

Our ultrasound consultants are involved with the Australasian Society of Ultrasound in Medicine guiding national training guidelines and standards. We also provide editorial advice to the Australasian Journal of Ultrasound in Medicine and review articles for numerous emergency medicine journals.

Our members run ultrasound courses covering specific Emergency Medicine ultrasound topics including EFAST, AAA, vascular access, foreign body detection and removal, thoracic ultrasound, procedural ultrasound, echo in the periarrest situation, early and late pregnancy ultrasound. We also help the respiratory physicians run their pleural procedures course, giving advice on ultrasound guided pleural effusion aspiration and drainage.

Our courses run each year at SCGH, but also in Broome, Melbourne, and as required around the state.

Emergency physicians, intensivists, anaesthetists, respiratory physicians, general surgeons, RFDS doctors, remote and rural practitioners, midwives and junior doctors from many different areas have attended our courses which are college accredited, and feedback has been universally positive.

Members of our DDU FACEM group also coordinate ultrasound as part of medical student anatomy education.

Remote and rural practitioners wanting clinical ultrasound up-skilling have spent time in our unit, as have clinicians from other emergency departments seeking ultrasound advice and exposure. Several O&G consultants who are sitting their DDU (O&G) examinations have also come to review our practice and take part in our CME.

A fortnightly emergency ultrasound CME meeting is coordinated by our members, involving a journal club and case review. Emergency practitioners with an interest ultrasound from Fremantle Hospital, Swan District Hospital, Rockingham Hospital, Joondalup Hospital, Armadale Hospital, Royal Perth Hospital and King Edward Memorial Hospital for Women attend.

 

 

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