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BACKGROUND: Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations. METHODS: A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview. RESULTS: In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language. CONCLUSIONS: The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.
Asunto(s)
Procesamiento de Imagen Asistido por Computador/instrumentación , Traumatismo Múltiple/diagnóstico por imagen , Transferencia de Pacientes/métodos , Consulta Remota/instrumentación , Resucitación/instrumentación , Telemetría/instrumentación , Ultrasonografía/instrumentación , Adulto , Alberta , Traumatismos en Atletas/diagnóstico por imagen , Síndrome de Aplastamiento/diagnóstico por imagen , Diseño de Equipo , Estudios de Factibilidad , Femenino , Hemoperitoneo/diagnóstico por imagen , Hospitales Rurales , Humanos , Internet/instrumentación , Masculino , Grupo de Atención al Paciente , Proyectos Piloto , Neumotórax/diagnóstico por imagen , Sensibilidad y Especificidad , Esquí/lesiones , Programas Informáticos , Telecomunicaciones/instrumentación , Centros Traumatológicos , Adulto JovenRESUMEN
OBJECTIVES: To determine whether focused abdominal sonogram for trauma (FAST) in a rural hospital provides information that prompts immediate transfer to a tertiary care facility for patients with blunt abdominal trauma who would otherwise be discharged or held for observation. METHODS: Prior to the study, participating emergency physicians underwent a minimum of 30 hours of ultrasound training. All patients who presented with blunt abdominal trauma to our rural hospital between Mar. 1, 2002, and Apr. 30, 2003, were eligible for study. Following a history and physical examination, the emergency physician documented his or her disposition decision. A FAST was then performed, and the disposition reconsidered in light of the FAST results. RESULTS: Sixty-seven FAST exams were performed on 65 patients. Three examinations (4.5%) were true-positive (95% confidence interval [CI] 0.9%-12.5%); 60 (89.6%) were true-negative (95% CI 79.7%-95.7%), 4 (6%) were false-negative (95% CI 1.7%-14.6%) and none (0%) were false-positive (95% CI 0%-5.4%). These values reflect sensitivity, specificity, negative predictive value and positive predictive values of 43%, 100%, 94% and 100% respectively. FAST results did not alter the decision to transfer any patient (0%: 95% CI 0.0%-5.4%), although one positive FAST may have led to an expedited transfer. One of 38 patients who was discharged after a negative FAST study returned 24 hours later because of worsening symptoms, and was ultimately found to have splenic and pancreatic injuries. CONCLUSIONS: This study failed to demonstrate that FAST improves disposition decisions for patients with blunt abdominal trauma who are evaluated in a hospital without advanced imaging or on-site surgical capability. However, the study is not sufficiently powered to rule out a role for FAST in these circumstances, and our data suggest that up to 5.4% of transfer decisions could be influenced by FAST. Rural emergency physicians should not allow a negative FAST study to override a clinical indication for transfer to a trauma centre; however, positive FAST studies can be used to accelerate transfer for definitive treatment.
RESUMEN
INTRODUCTION: Current recommended treatment for middle-third clavicle fractures is limited to the use of ice, analgesics, a sling, and rest. Radiography for these fractures would be superfluous if physicians could accurately identify them by clinical examination alone. The primary purpose of this study was to determine whether emergency physicians can accurately diagnose clavicle fractures, and whether they can differentiate middle-third fractures from medial- or lateral-third fractures by clinical assessment alone. METHODS: We enrolled a convenience sample of patients who presented to our rural emergency department with possible clavicle fracture between Nov. 1, 2001, and Apr. 30, 2002. Prior to viewing radiographs, physicians scored their clinical certainty of diagnosis on a 10-cm visual analogue scale. When certain of fracture, physicians determined the location of the fracture, the nature of the fracture and their hypothetical comfort in treating the injury without radiography. RESULTS: In 51 of 77 enrolled patients (66%; 95% confidence interval [CI], 54.6%-76.6%), treating physicians were certain of the diagnosis of clavicle fracture prior to radiography. In these 51 cases, radiography revealed a fracture in 50 cases (98.0%; 95%CI, 89.6%-99.9%). The physicians were 100% accurate for 4 fractures clinically identified as lateral-third fractures (95% CI, 39.7%-100%) and for 41 fractures identified as middle-third fractures (95% CI, 91.4%-100%). They were correct on only 1 of 5 injuries (20%; 95% CI: 1%-72%) they clinically identified as medial-third fractures. Despite high clinical accuracy with middle-third fractures, they stated in 27 of 42 cases (64%; 95%CI, 48.0%-78.5%) that they would have been uncomfortable treating the patient without a radiograph. CONCLUSIONS: This study provides evidence that experienced emergency physicians are highly accurate when they are clinically certain of clavicle fracture. Further, when emergency physicians do clinically diagnose clavicle fracture, they can accurately identify the patient subgroup that will be responsive to conservative treatment. Routine radiography of obvious middle-third clavicle fractures does not appear to improve diagnostic accuracy or treatment decisions.
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OBJECTIVE: Research has demonstrated that experienced emergency physicians can identify a subgroup of patients with shoulder dislocation for whom pre-reduction radiographs do not alter patient management. Based on that research, a treatment guideline for the selective elimination of pre-reduction radiographs in clinically evident cases of anterior shoulder dislocation was developed and implemented. The primary objective of this study was to prospectively determine whether the treatment guideline safely eliminates unnecessary radiographs. METHODS: We enrolled a convenience sample of patients who presented to our rural emergency department with possible shoulder dislocation between November 2000 and April 2001. Physicians scored their level of clinical diagnostic certainty on a 10-cm visual analogue scale prior to viewing pre-reduction radiographs (if obtained). Data were collected on clinical scoring and evaluation, compliance with the guideline, and outcomes. RESULTS: A total of 63 patients were enrolled, ranging in age from 17 to 79 years (mean = 33); 87.3% were male. Emergency physicians were certain of shoulder dislocation in 59 (93.7%) patients (95% CI, 84.5%-98.2%) and complied with the treatment guideline in 52 patients (82.5%). Most deviations from the treatment guideline involved the elimination of post-reduction radiographs (which the guideline recommends for all patients). The treatment guideline eliminated 56 (88.9%, 95% CI, 78.4%-95.4%) pre-reduction radiographs, as compared to the standard practice of obtaining pre-reduction films for all cases of suspected shoulder dislocation (p < 0.0001) CONCLUSIONS: Experienced emergency physicians are frequently certain of the diagnosis of anterior shoulder dislocation on clinical grounds alone and can comfortably and safely use this guideline for the selective elimination of pre-reduction radiographs. Compliance with the guideline substantially decreases pre-reduction radiographs. Validation of the guideline in other settings is warranted.