Page 99 - Ultrasonography in Prehospital and Emergency Medicine - Rein Ketelaars

Implementing ultrasound in Dutch emergency departments after a two-day training 97
Introduction
In trauma patients, diagnostic ultrasound (US) used by non-radiologists is becoming com- monplace. It is used successfully in trauma victims and critically ill patients in the emergency department (ED), operating theatre, and in out-of-hospital settings. Also, it is used in re- mote locations such as the battlefield and outer space.1,2
US is used in the ED to answer simple yes/no questions that could make the difference de- tecting or ruling out life-threatening conditions such as pneumothorax, pericardial effusion, and intra-abdominal bleeding.3–5 Therefore, life-saving interventions such as a tube thoracos- tomy may be performed more expeditiously, or prevented if deemed unnecessary.6 Also, US may lead to a reduced usage of other imaging techniques such as chest X-rays and computed tomography (CT) scans.7–10
Various emergency US examination protocols are used. The extended focused assessment with sonography for trauma (eFAST) protocol assesses for free abdominal and pericardial fluid, and pneumothorax. In the Netherlands, the similar polytrauma rapid echo-evaluation program (PREP) protocol is widely used in EDs and in the prehospital setting.11 Originally from Nîmes, France, it is taught and used in many European countries and Canada. It offers a uniform and fast five-step method to assess an injured or critically ill patient.12
During a two-day PREP course, the candidates are taught ultrasound theory and they will perform at least 20 supervised US examinations on fellow candidates, simulated patients in an ED or prehospital scenario, and peritoneal dialysis patients. The latter group of subjects carry a significant amount of fluid in the peritoneal cavity, resulting in a positive US scan mimicking intraperitoneal bleeding.
Non-radiologists can be effectively trained in a brief training to perform eFAST or PREP examinations.13 Nonetheless, this skill needs to be maintained and improved by routinely using it in everyday practice. Its learning curve is estimated to level off at 30–100 US exam- inations.14
Although PREP-trained emergency physicians (EPs) are well prepared they are facing bar- riers. Emergency medicine is a young specialty in Dutch health care; in 1999 the Dutch as- sociation of emergency physicians (Nederlandse vereniging van spoedeisendehulpartsen, NVSHA) was formed and one year later the first three-year training programs started.15 Implementation of US on the ED is frequently hampered by so called turf battles—about who should perform US on the ED—between radiologists and other medical specialists on
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