GP clinic lung consolidation diagnosis

This is a case from last week – 21month old boy, one week of cough, had seen another practioner 4 days prior, started on amoxycillin/clavulinic acid, persistent fevers, up all night coughing, drinking, not eating.  Child looked unwell. T38.5, HR140, RR40, Sp02RA 93%, slight rib retraction, warm peripheries, well hydrated, nil rash. Red TM, flat tonsils, crepitations right lung base. GPPOCUS with linear probe, lung 6 region, this is region 2 on the right:

2yearShredEffusion
(guardian consent obtained for image and case use)

Demonstrating shred (breaking up of the visceral pleural line), effusion and increased density in the lung (hepatisation – the lung looks like liver in terms of echogenicity).

These are the lung zones:

LungPOCUSzonesLichenstein
Lichenstein CHEST / 134 / 1 / JULY, 2008

They went to the local ED with mother and chest radiograph confirmed right peri-hilar consolidation. POCUS did not definitely change my management here – Sp02 was low, there was persistent fever and they looked unwell.  However knowing there was right dependent lung consolidation confirmed that I wasn’t sentencing the family to an ED wait in vain.  I called family today and after a change of oral antibiotics the fever is down, eating better and more interactive.

Useful references:

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134:117–25.

Varshney T, et al. Point-of-care lung ultrasound in young children with
respiratory tract infections and wheeze Emerg Med J 2016;0:1–8.

 

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DIY US stand

My aged US (GE logiq 100) machine came without a stand, as it is 12 years old, there was not going to be any available to purchase from GE.  Time to get out the circular saw – first, a donor wheeled base from hard rubbish, a nice heavy steel base (made in Australia!):

Donor

Seat removed and recycled, a simple box with slots for probes from 12mm MDF was made and fixed to the tilting/gas lift base:

BareStand

Primed, painted and the addition of a tie down strap to prevent it leaping off and here it is in it’s natural habit of the consulting room:

GE Logiq US stand

FOAMed, MOOC’s and POCUS

In the era of the MOOC (Massive Open Online Course) what are the options for FOAMed, particularly around ultrasound? There are anatomy, psychology and ethics MOOC’s aplenty but less about clinical practice. Academic Life in Emergency Medicine have their MOOC which is obviously about EM, particularly pharmacology of EM. I have looked around and found one created by the University of Twente in the Netherlands, accessible through the British Future Learn website. It is free to register and access all the teaching material, consisting of videos and text, formative quizzes and summative MCQ exams. You can purchase a final certificate for $19, or complete the course with no certificate for no cost.
MOOC_poster_mathplourde
The course starts with some clinical vignettes and how US may be used in these settings, some physics (more detailed than a basic POCUS course – you need to calculate velocity changes in different media, doppler shift, think about resolution and lenses) then artifact description, probe varieties and then circling back over the clinical vignettes with more knowledge and detail. The overview of the six week blocks:
Course Breakdown
The course suggests it requires three hours per week of study, I have found a week takes about 2 hours.

wiendelt

Nearly all the teaching is done by Wiendelt Steenbergen who gives various overview talks in the gardens around the University and then slide type presentations.

Shadowing

There is an interesting use of the padlet website/app for digital pin boards for the students to contribute on which I found really efficient.

How useful are MOOC’s? There is discussion that not that many actually get finished (around 7%), that they do not allow previously disadvantaged people to access university  as the people actually taking them usually already have degree . However some UK universities will now accept some MOOC’s as credit to a more standard undergraduate degree .

So overall – an excellent quality MOOC for the new learner to US. Obviously there is no hands-on component and for such a skill where knobology, surface perception and spatial visualisation is so important, you still need to have time with a probe in hand, ideally while taking the MOOC.

Home brew Agar-Agar calibration phantom

With my new-old US machine, how can I check that the measurements are correct? I don’t have a proper ultrasound phantom like this one:

CalibrationPhantomNew

Which looks like this on the inside:

CalibrationPhantom

This purpose built phantom allows to to check vertical, horizontal, area measurement accuracy, density comparisons, dead zone distance, grey scale and resolution limits.

Given that the DIY ethos is alive and well in the FOAMed world , I thought I would construct my own. There are lots of DIY training phantom instructions using gelatine.  From my microbiology days I am more familiar with agar and with plenty of Asian grocers near by a quick trip gave a pack of agar.  I used 11grams of dried agar to 900mL of hot water, boiled for two minutes until all agar threads had dissolved.

agar_small

A marble into the bottom of an old yoghurt pot and the hot agar poured over. Thirty minutes later the agar had solidified to a block I could turn out and take some pictures.  Ten days on now and the agar block is still solid with no bacterial growth.

MarbleSmall

Horizontal dimensions were perfect, 16mm by the US calipers which corresponded to 16mm on the handheld vernier calipers. Depth with the US was 61mm and with the verniers 63mm.  So certainly although old, still accurate.