June 23, 2023
Just as a chair in a bedroom corner can become a dumping ground for clothes and other miscellanea, so can an old, unused ultrasound machine. Many years ago, Robert J. Tillotson, D.O., decided to put one such machine to use.
"We had the ultrasound machine, but no one in the emergency department or trauma bay really knew how to use it," says Dr. Tillotson, an emergency medicine specialist at Mayo Clinic Health System in Eau Claire, Wisconsin. "It was used for storage, not patient care. When I pulled it from the corner, there were items hanging on it," he says.
Dr. Tillotson explains that many emergency departments nationwide purchased ultrasound machines as evidence demonstrated effective use at the bedside, yet training was not always as widely available.
Dr. Tillotson's point-of-care ultrasound journey
Dr. Tillotson's emergency medicine residency did not include ultrasound training. When he took boards in 2000, he noted more ultrasound-focused radiology questions. These indicated to him that others in his field considered that ultrasound could impact frontline care. Starting with the 2003 implementation of the neglected ultrasound machine, Dr. Tillotson quickly became an early adopter of this technology in emergency medicine.
The unused ultrasound machine presented an opportunity. With proper training, he knew this tool could assist with emergency and trauma patient care at the bedside, quickly identifying injuries and medical conditions elusive to physical examination and invisible to the naked eye.
This ultrasound window into the body also could supplant invasive diagnostic procedures, such as peritoneal lavage, which emergency department and trauma specialists used to identify intra-abdominal bleeding. Beyond avoiding an invasive procedure, Dr. Tillotson noted that with ultrasound, he could see fluid around the heart or a hemothorax or pneumothorax impossible to identify with peritoneal lavage.
When Dr. Tillotson took his first ultrasound course, what he learned confirmed how ultrasound could facilitate accurate and rapid diagnosis at the bedside. This experience spurred Dr. Tillotson's desire to improve his ultrasound knowledge and teach emergency medicine and trauma staff at his facility. He enrolled in courses and achieved the Registered Diagnostic Medical Sonographer credential.
Dr. Tillotson's participation in ultrasound expanded to the national level when he realized a need for more training standards in emergency ultrasound. He envisioned training for emergency medicine residents and physicians like him who had not been trained in ultrasound during residency.
Consequently, Dr. Tillotson became a contributor to the American College of Emergency Physicians 2008 ultrasound guidelines, setting the foundation for U.S. emergency medicine residency ultrasound standards. He also served on ultrasound-related committees for the American College of Emergency Physicians.
In 2017, Dr. Tillotson arrived at the Mayo Clinic Health System in Eau Claire to develop an ultrasound program. Insights from his work there contributed to development of foundational core ultrasound competencies for emergency medicine professionals. He comments that now in Eau Claire, they use ultrasound to evaluate the whole spectrum, "from babies to eyeballs."
Following training spurred by Dr. Tillotson, the emergency department in Eau Claire and surrounding region performed over 3,000 point-of-care ultrasounds in 2022. They received accreditation from the American College of Emergency Physicians Clinical Ultrasound Accreditation Program and the top national award for ultrasound program director and supervision.
Patient benefits of point-of-care ultrasound in trauma and emergency medicine
Previously, Dr. Tillotson and emergency medicine and trauma colleagues used the landmark technique for central line insertion. They blindly targeted a vessel with a needle based on landmarks in a patient's body.
"With ultrasound, you can see the vessel and follow the needle safely down to the vessel," says Dr. Tillotson.
Ultrasound benefits patients in acute care settings in multiple ways, such as:
- Answering questions quickly at the bedside.
- Allowing more directed testing, which avoids unnecessary testing.
- Enabling rapid diagnoses that save lives.
- Giving physicians the ability to determine fetal status if the patient is pregnant.
- Making central line placement and other procedures safer with direct target structure or vessel visualization.
- Providing nerve visualization to administer blocks and relieve pain, reducing narcotic pain reliever need.
- Affording answers about bleeding or other acute injuries noninvasively.
In trauma, the focused assessment with sonography in trauma (FAST) exam is performed at the bedside when a patient arrives in the trauma bay. It provides crucial eyes into the patient, giving professionals the ability to rapidly survey a patient's body for bleeding or pericardial tamponade. Now, with extended FAST (eFAST), they also can screen for pneumothorax.
FAST also identifies occult, unexpected internal bleeding, as with an older adult who falls in the shower in whom medical professionals can only see bruises or extremity injuries.
For serious traumatic injury, called "trauma red," the team incorporates the FAST exam into the initial patient evaluation. The trauma surgeon begins the primary survey while another qualified professional performs a FAST exam to locate intra-abdominal bleeding or bleeding around the heart. If bleeding is severe and the patient unstable, the team will send the patient directly to the operating room. Thus, the FAST exam assists greatly in directing care for severely injured patients.
FAST exam use is now part of Advanced Trauma Life Support protocol. Given this protocol and acute care benefits, Dr. Tillotson suggests advancing ultrasound training for emergency medicine specialists, paramedics, flight nurses and trauma professionals. At Mayo Clinic, he assisted in emergency medical services ultrasound prioritization. Hand-held ultrasound machines now are aboard Mayo Clinic Ambulance Service helicopters, with ground ambulance expansion on the horizon.
Mayo Clinic offers ultrasound education. Trainees must acquire not only ability to obtain quality ultrasounds but also ability to interpret them, says Dr. Tillotson.
"It's like learning trap shooting," he says. "You have to practice using the machine and interpreting multiple studies to get good at it. I recommend that providers practice on normal people to recognize the range of 'normal' studies and thus help them recognize if something is abnormal."
Dr. Tillotson hopes all regional trauma centers adopt point-of-care ultrasound use.
"It would give them early awareness of injuries needing rapid attention, such as abdominal bleeding," he says. "For example, 10 minutes after I met a patient in the emergency department, I knew he had a pericardial effusion. It puts us on high alert to mobilize resources necessary for care."
Ultrasound equipment for trauma and emergency use
Ultrasound has changed the way medical professionals work through differential emergency and trauma medicine diagnoses beyond history and physical exam, says Dr. Tillotson.
The point-of-care ultrasound spectrum of use is ever expanding in most medical specialities. For example, it can help with identification and execution of:
- Retinal detachment.
- Pericardial and pleural effusion.
- Lung abnormalities.
- COVID-19 lung and cardiac sequelae.
- Foreign objects inside the body.
- Dislocated shoulder reduction nerve blocks.
Ultrasound equipment has evolved to meet point-of-care use needs, from battery-operated, high-image quality wireless cart systems to hand-held devices that interface with cellphones.
The typical cart-based point-of-care ultrasound machine cost starts around $50,000, says Dr. Tillotson. Hand-held devices are available for $3,000 to $10,000, depending on device quality. Pricing differences represent quality, speed and power, which are continually improving in portable ultrasound. Dr. Tillotson recommends purchasing the highest quality equipment that works with your hospital's system. For smaller hospitals, a hand-held ultrasound model is an option. However, most emergency departments would benefit from cart-based systems, he says. Importantly, he indicates, whichever machine is acquired should have electronic health record compatibility and system integration to save images for collaborative care.
Dr. Tillotson also indicates that some ultrasound machines now have artificial intelligence features for measurements such as ejection fraction and fetal heart rate.
"The point is not only to obtain but also to use the ultrasound machine in your practice," he says. "It doesn't benefit patients if it's sitting in the corner."
Portable ultrasound use advances daily, he says, noting that he sees opportunities for hand-held ultrasound machines to be sent home with patients for remote monitoring.
Out of the corner and now at the bedside, ultrasound has had a major impact on care Dr. Tillotson provides for patients.
"I'm not just an ultrasound zealot," he says. "I'm a zealot for quality patient care."
For more information
Refer a patient to Mayo Clinic.