What are the barriers to ultrasound in the prehospital world?
- Cost
- Evidence (and lack thereof)
- Training and protocols for EMS
- Equipment and physical space in the ambulance
US as a potential diagnostic tool
- Airway: can use US to confirm ETT placement (although EtCO2 is still the gold standard!)
- Breathing: can assess for fluid overload and PTX (and could intervene on PTX)
- Cardiac arrest: can use femoral doppler for pulse checks vs parasternal views for organized cardiac activity
- FAST: some debate on use of this prehospital
- Pregnancy: could be used as screening tool for pregnancy leading to transport to OB capable facility
- PE: prehospital POCUS revealing enlarged RV could lead to decreased scene time and transport to thrombolytic capable center
US as a potential procedural skill
- US guided peripheral IV placement: while this may be a useful skill, may be worth considering if this is worth the extra time, especially when IO is available.
US for potential triage
- MCI: There may be some value in doing US on patients in mass casualty in order to more appropriately triage patients and intervene appropriately.

Inflammatory biomarkers (i.e. CRP, ESR, and PCT) can assist clinical reasoning in determining probability of infection, but they are not stand-alone diagnostic tools in the emergency department
PCT and CRP are markers of acute inflammation compared to ESR which better reflects chronic inflammation.
There is mixed evidence regarding PCT-guided antibiotic therapy for PNA, but PCT is not recommended to guide antibiotic therapy for sepsis.
Please see the following link for more details and associated blog post on inflammatory markers in the ED: ***

Don't blow off hiccups that last for > 2 days! Have a high index of suspicion for undifferentiated badness.
Hiccups are brought on by a reflex arc that includes both peripheral nerves and midbrain/brainstem structures, so keep your thinking broad as to identify possible causes.
If a benign cause is identified, treat the cause. Otherwise, know your first line physical maneuvers (supra-supramaximal inhalation) and second line therapies (baclofen or reglan preferred).

Medicine is an art, there is usually not just one way to do something right
Ultrasound can be particularly useful for procedural guidance in certain patients.
Everyone with epigastric pain should prompt you to at least consider ACS.
Patients with new onset psychiatric illness should be a yellow flag and prompt consideration of further testing.
Consider non-mechanical etiologies of back pain, particularly in acute presentations.
Everyone deserves GOOD return precautions, tailored to their level of understanding.
Acknowledging failure is tough, but both part of the learning and teaching process.
There are more options for disposition than immediate discharge or admit.
Consider the utility of repeating an ultrasound, even if the first is normal.
Just because someone is boarding in the ED and not your responsibility, doesn’t mean you should not care and/or help them.
Considering reviewing your own images when able, especially when clinically concerned.
All patients presenting with significant trauma or altered/agitated deserve a full body exam.
Agitation can be a sign of severe pathology.
Sometimes less is more, the hospital can be a dangerous place.
Know your institutional guidelines, and document well.
Think outside the box, and ask yourself why not when considering alternative paths.
You can’t succeed alone, learn from those around you. Everyone has something to teach you.

Mastering intubation takes many repetitions (to estimate a 90% success rate, you need over 190 intubations).
Video laryngoscopy has been shown to lead to highest first pass success rates.
In order to develop direct laryngoscopy skills while still doing right for our patients, we need to be adamant about employing adjunct skills including:

Optimize patient position prior to intubation attempt.
Perform head manipulation to align axes.
Tongue sweep should be performed with all standard geometry blades
Think about operator positioning including obtaining the “cheap seats” view by stepping back and often lower to the ground.
BURP! (Backwards, upwards, rightward pressure of the larynx by either the operator or an assistant with direction from the operator).

Taming the SRU

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