Page 82 - Journal of Special Operations Medicine - Spring 2015

these skills and providing adequate quality assurance re­ Superficial evaluations: abscess/cellulitis
mains at the unit level. To address these challenges, the and soft-tissue foreign bodies
authors have compiled resources for providers to assist The ultrasound evaluation of superficial infections to
with this process. We understand that each community, assess for abscess should be included in the routine
including civilian EMS professionals, may be at differ­ clinical workup. The decision to perform incision and
ent stages of program development and maturity, and drainage during sick call should be made with ultra­
we hope that some of these recommendations will be ap­ sound assistance. Studies have shown that POCUS can
plicable to your specific setting. First we will address op­ change the management decision in skin infections in
portunities to improve POCUS skills through hands­on more than 50% of cases. A large percentage of sick­
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experience while in a fixed medical facility. We will then call complaints include superficial skin infections, and
discuss options for simulation­based training. Finally, a SOM should be encouraged to use the opportunity to
list of online resources will be provided to review these evaluate these infections with ultrasound. The appear­
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examinations, often as individually paced, online learn­ ance of cellulitis on ultrasound is basically the same as
ing modules. the appearance of soft­tissue edema. Therefore, evaluat­
ing patients with significant lower extremity edema is
adequate to simulate the appearance of cellulitis on ul­
Building Examination Experience trasound. These evaluations should be included during
any rotation through the emergency department.
Musculoskeletal: long-bone fractures
When trying to build proficiency with ultrasound ex­ Procedural guidance:
aminations, it is important to recognize both pathologic IV access, regional anesthesia
conditions and normal anatomy. For example, when Procedural guidance for IV access and regional anes­
teaching your SOM how to use POCUS in the evalu­ thesia is another important skill with significant op­
ation of fractures, showing only normal intact bone is portunity for skill proficiency sustainment. 19,20 While
not sufficient. Most major US­based SOF instillations performing or recertifying on regional anesthesia tech­
are within a short distance of a military treatment fa­ niques, senior medical leadership should encourage the
cility (MTF). All MTFs have an orthopedics depart­ use of POCUS. Ultrasound should be used to directly
ment, which will likely include a fracture clinic. While visualize the target nerves in addition to the vessels to
it is common practice to learn basic splinting and cast­ be avoided while using anatomic landmarks. Peripheral
ing techniques from the orthopedics clinic, these clinics IV access in our young healthy population is not typi­
also present an opportunity to practice using POCUS cally difficult, but it provides an excellent opportunity
to identify the location and type of radiograph­verified to become familiar with ultrasound­guided IV access.
fractures. Another possible learning opportunity exists This should be practiced in both the clinical setting as
in the emergency department, where SOM can focus on well as under field conditions during predeployment
performing POCUS on all eligible patients, including training. Specific access sites of focus should include the
those with known fracture on radiograph. external jugular vein and the basilic and deep brachial
veins. These may be the only reasonable peripheral IV
Trauma: eFAST, evaluation of pneumothorax access options in the patient in shock when intraosseous
When teaching the eFAST examination, providers should or central venous access is not available.
ensure the SOM perform an adequate number of exami­
nations to feel confident they can attain and record the Ocular evaluation, obstetrical evaluation
appropriate images. Having your SOM perform eFAST for fetal heart rate
examinations on at least 25 normal, healthy volunteers Ocular ultrasound examinations are gaining ground for
can be easily accomplished in 1 week of seeing basic sick their predictive ability in diagnosis of increased intracra­
call. The images captured should be reviewed by an ex­ nial pressure. We recommend performing at least 10
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perienced provider to ensure images are evaluating the ocular ultrasound examinations on normal sick­call pa­
appropriate regions and are labeled correctly. Once an tients to measure optic nerve sheath diameter (ONSD).
operator has gained sufficient skills to identify normal Visiting your MTF intensive care unit is often the only
anatomy, options for exposing them to pathology will place to find abnormal examinations, and these patients
again include visiting the MTF or community emergency with true head injury and increased intracranial pres­
department. Trauma centers are also a good location to sure have usually been treated operatively or with place­
see regular use of eFAST examinations. In addition, con­ ment of a drain. The most important concept to master
sider coordinating with a gastroenterology clinic on days is capturing the image of where to measure the ONSD,
when the provider will be seeing patients with known and this can be accomplished on healthy patients. Ocu­
ascites. This will allow appreciation of what fluid in the lar examinations can also be useful in the evaluation of
abdomen should look like on ultrasound in real time. acute vision loss to help evaluate for retinal detachment.

72 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015