Rib fractures account for a significant number of emergency department visits each year. A patient’s disposition often depends on the severity of rib fractures, comorbidities, and ability to achieve adequate analgesia. We present a 44-year-old male patient with severe pain secondary to rib fractures. The initial disposition was to admit for pain control. However, upon performing a serratus anterior plane block, patient was functionally appropriate for discharge with proper return precautions. Serratus anterior plane block is within the skillset of the emergency physician and can be used to achieve analgesia for rib fractures without the sedative and respiratory depressive effects associated with opioids.

BACKGROUND: Point-of-care ultrasound (US) is a proven diagnostic imaging tool in the emergency department (ED). Modern US devices are now more compact, affordable and portable, which has led to increased usage in austere environments. However, studies supporting the use of US in the prehospital setting are limited. The primary outcome of this pilot study was to determine if paramedics could perform cardiac ultrasound in the field and obtain images that were adequate for interpretation. A secondary outcome was whether paramedics could correctly identify cardiac activity or the lack thereof in cardiac arrest patients. METHODS: We performed a prospective educational study using a convenience sample of professional paramedics without ultrasound experience. Eligible paramedics participated in a 3-hour session on point-of-care US. The paramedics then used US during emergency calls and saved the scans for possible cardiac complaints including: chest pain, dyspnea, loss of consciousness, trauma, or cardiac arrest. RESULTS: Four paramedics from two distinct fire stations enrolled a total of 19 unique patients, of whom 17 were deemed adequate for clinical decision making (89％, 95％CI 67％–99％). Paramedics accurately recorded 17 cases of cardiac activity (100％, 95％CI 84％–100％) and 2 cases of cardiac standstill (100％, 95％CI 22％–100％). CONCLUSION: Our pilot study suggests that with minimal training, paramedics can use US to obtain cardiac images that are adequate for interpretation and diagnose cardiac standstill. Further large-scale clinical trials are needed to determine if prehospital US can be used to guide care for patients with cardiac complaints.

BACKGROUND: There are over 15 million children who have cardiac anomalies around the world, resulting in a significant morbidity and mortality. Early recognition and treatment can improve the outcomes and lengthen life-expectancy of these patients. The NIH and WHO have promoted guidelines for screening for congenital cardiac anomalies using ultrasound in rural environments. METHODS: Our study took place in Bocas Del Toro, Panama where a mobile clinic was established for community healthcare screening and ultrasonographic evaluation by medical student volunteers and volunteer clinical faculty. This was a non-blinded, investigational study utilizing a convenience sample of pediatric patients presenting for voluntary evaluation. Seven first-year medical students were recruited for the study. These students underwent a training program for advanced cardiac ultrasound instruction, termed "Pediatric Echocardiography Cardiac Screening (PECS)". RESULTS: Ten patients were enrolled in the study. Nine patients had adequate images as defined by the PECS criteria and were all classified as normal cardiac pathology by the medical students, resulting in a sensitivity and specificity of 100％. A single patient was identified by medical students as having a pathologic pulmonic stenosis. This was confirmed as correct by a blinded ultrasonographer. CONCLUSIONS: In this pilot study, the first-year medical students were able to correctly identify pediatric cardiac anatomy and pathology in rural Panama after undergoing a 12-hour ultrasound PECS training session. We believe that with this knowledge, minimally trained practitioners can be used to screen for cardiac anomalies in rural Panama using ultrasound.

BACKGROUND: Parasitic infections pose a significant health risk in developing nations and are a major cause of morbidity and mortality worldwide. In the Republic of Tanzania, the CDC estimates that 51.5％ of the population is infected with one or more intestinal parasites. If diagnosed early, the consequences of chronic parasitic infection can potentially be avoided. METHODS: Six first-year medical students were recruited to enroll patients in the study. They underwent ten hours of formal, hands-on, ultrasound which included basic cardiac, hepatobiliary, renal, pulmonary and FAST scan ultrasound. A World Health Organization protocol with published grading scales was adapted and used to assess for pathology in each patient's liver, bladder, kidneys, and spleen. RESULTS: A total of 59 patients were enrolled in the study. Students reported a sensitivity of 96％ and specificity of 100％ for the presence of a dome shaped bladder, a sensitivity and specificity of 100％ for bladder thickening, a sensitivity and specificity of 100％ for portal hypertension and ascites. The sensitivity was 81％ with a specificity of 100％ for presence of portal vein distention. The sensitivity was 100％ with a specificity of 90％ for dilated bowel. CONCLUSIONS: Ultrasound has shown a promise at helping to identify pathology in rural communities with limited resources such as Tanzania. Our data suggest that minimally trained first year medical students are able to perform basic ultrasound scans that can identify ultrasonographic markers of parasitic infections.

BACKGROUND: The objective of this study is to determine if point-of-care ultrasound (POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture (LP).METHODS: This was a prospective, randomized controlled trial comparing POCUS pre-procedure identifi cation of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit.RESULTS: A total of 158 patients were enrolled. No signifi cant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation.CONCLUSION: Consistent with fi ndings of previous studies, our data indicate that there was no observed benefi t of using POCUS to identify pre-procedure landmarks when performing an LP.

BACKGROUND: The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS).METHODS: This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment.RESULTS: We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51％) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95％CI 60–73,P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95％CI 66–173,P<0.01)CONCLUSION: In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a signifi cant decrease in time to ultrasound and ED LOS.

BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%–93.5%) and specificity of 100% (95%CI 15.8%–100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10–29) and 32 minutes (IQR 19–45), respectively. CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

BACKGROUND: Ultrasound guided regional anesthesia is widely taught using task trainer models. Commercially available models are often used; however, they can be cost prohibitive. Therefore, alternative "homemade" models with similar fidelity are often used. We hypothesize that professional task trainers will be preferred over homemade models. The purpose of this study is to determine realism, durability and cleanliness of three different task trainers for ultrasound guided nerve blocks. METHODS: This was a prospective observational study using a convenience sample of medical student participants in an ultrasound guided nerve block training session on January 24th, 2015. Participants were asked to perform simulated nerve blocks on three different task trainers including, 1 commercial and 2 homemade. A questionnaire was then given to all participants to rate their experiences both with and without the knowledge on the cost of the simulator device. RESULTS: Data was collected from 25 participants. The Blue Phantom model was found to have the highest fidelity. Initially, 10 (40%) of the participants preferred the Blue Phantom model, while 10 (40%) preferred the homemade gelatin model and 5 (20%) preferred the homemade tofu model. After cost awareness, the majority, 18 (72%) preferred the gelatin model. CONCLUSION: The Blue Phantom model was thought to have the highest fidelity, but after cost consideration the homemade gelatin model was preferred.

BACKGROUND:Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama. METHODS:Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral. RESULTS:A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation. CONCLUSION:Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

BACKGROUND:The purpose of this study was to use point-of-care ultrasound (POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery (CCA). The effect of both primary and secondary smoking on CCA properties was evaluated. METHODS:We performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness (CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease. RESULTS: We enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness. CONCLUSION:Our data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confirm the utility of ultrasound findings of cardiovascular disease and stroke.