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Enabling the Mission Through Trans-Atlantic Remote Mentored Musculoskeletal Ultrasound: Case Report of a Portable Hand Carried Tele-Ultrasound System for Medical Relief Missions


 

 
 
 

Simple, almost anywhere, with almost anyone:  Remote low-cost tele-mentored resuscitative lung sonography conducted wherever there is internet access


Novice nurse conducting first lung ultrasound examination on-site from Sunshine Mountain in Banff, Alberta being remotely mentored by an experienced clinical sonograher in Rome, Italy.  Video-recording of the Rome sonographer's screen projection


Supplemental Images:

Image 1: On-site Responder at Lake Louise transmitting to Mentor in Calgary, Alberta

Image 2: On-site 7 year-old Responder in Calgary transmitting to Mentor in Pisa, Italy

Image 3: On-site Responders in Calgary being guided by an Emergency Ultrasound Director in the cafeteria of the United Nations Building, New York, New York

Image 4a, 4b: On-site Responder On-Board a Cesna C-172 orbiting Calgary being Directed from Cumming, Georgia

Image 5: Novice in Whistler, British Columbia being guided by a surgical resident in Calgary, Alberta



IAH Made Easy - ACS for Dummies

Can we do anything about intra-abdominal pressure?  (What to do every day and how to avoid worry?):  Evacuation of abdominal fluid collections  
AW Kirkpatrick, ML Cheatham

The Image of Trauma

Percutaneous embolization of an angiographically inaccessible pulmonary artery pseudoaneurysm following blunt chest trauma:  A Case report and Review of the Literature
  SK Sridhar, D Sadler, SD McFadden, CG Ball, AW Kirkpatrick, M Mercado

Online Supplementary Appendix of Ultrasound Videos for The Surgeon’s Use of Ultrasound in Thoracoabdominal Trauma in Cameron’s Current Surgical Therapy, 10th Edition  Chapter Authors:  Scott A Dulchavsky, Detroit, MI
Andrew W Kirkpatrick, Calgary, AB
Webmaster:  Michelle Mercado, Calgary, AB

Video 1 - Cardiac exam revealing modest amount of pericardial fluid




Video 2 - Free fluid abdominal FAST exam seen contrasted between liver and right kidney

Video 3 - Trace free fluid seen around kidney, noting relative location of left kidney and spleen

Video 4 - Free fluid seen contrasted next to the bladder wall during the pelvic phase of the FAST exam

Video 5 - Physiologic sliding of the visceral upon the parietal pleura with respiration, known as "lung-sliding" is seen just deep to two intercostal shadows representing two contiguous ribs.  Vertical lines of reverberation emanating from the visceral pleura and crossing the entire field below known as comet-tail artifacts are also seen

Video 6 - No lung sliding is seen when air in the pleural space (pneumothorax) separates the visceral and pleural space.  Thus absent lung sliding is consistent with but not definitive evidence of a pneumothorax (see text)

Video 7 - The "lung point" sign demonstrated.  This consists of the physical point at which the lung sliding pattern becomes absent and replaced by a distinct hyperlucent pleural interface without sliding.

Video 8 - Vertical lines of reverberation arising from the pleural interface that emanate off the lung field and which move with sliding are known as comet-tail artifacts.  They both confirm pleural apposition as well as potentially indicate lung water, being the sonographic equivalent of Kerley B lines

Video 9 - Color power Doppler function used to physically enhance the depiction of lung sliding at the pleural interface

Video 10 - Pleural fluid collection in constophrenic sulcus cephalad to liver and diaphragm with atelectatic lung well seen

Video 11 - Free pericardial fluid see posterior to heart (left ventricle to be specific)

Video 12 - US confirmation of complete cardiac standstill

Correct the Coagulopathy and Scoop it Out: Complete reversal of anuric renal failure through the operative decompression of extra-peritoneal hematoma-induced abdominal compartment syndrome

Intra-peritoneal gas insufflation will be required for laparoscopic visualization in space:  A comparison of laparoscopic techniques in weightlessness Andrew W Kirkpatrick, Marilyn Keaney, Leanne Kmet, Chad G Ball, mark R Campbell, Chris Kindratsky, Michelle Groleau, Michelle Tyssen, Jennifer Keyte, Timothy J Broderick.  March 2009 American College of Surgeons

Video 1 - In-flight illustration of reduced overall pelvic laparoscopic visualization upon entering weightlessness despite potentially increased intra-peritoneal domain due to the unrestrained viscera spontaneously transiting to fill the potential space during a parabola in which abdominal wall retraction was used (see text for further discussion).  the effective gravitational force being experienced is reflected in the in-laid "g-meter" display noting a several second delay between the actual and displayed gravity.




Video 2 - In-flight illustration of increased overall pelvic laparoscopic visualization upon entering weightlessness during a parabola in which standard insufflation in 15 mmHg was used (see text for further discussion).  Note how both the bowels and fluid obscure visualization in gravity, but the bowels are easier to retract and the fluid internally cohesive due to surface tension improving overall pelvic visualization in weightlessness (0g).  The effective gravitation force being experience is reflected in the in-laid "g-meter" display noting a several second delay between the actual and displayed gravity.

Video 3 - In-flight illustration of increased overall pelvic laparoscopic visualization upon entering weightlessness during a parabola in which standard insufflation in 15 mmHg was used (see text for further discussion).  The effective gravitation force being experience is reflected in the in-laid "g-meter" display noting a several second delay between the actual and displayed gravity.

Video 4 - In-flight illustration of increased overall pelvic laparoscopic visualization upon entering weightlessness during a parabola in which standard insufflation in 15 mmHg was used (see text for further discussion).  The effective gravitation force being experience is reflected in the in-laid "g-meter" display noting a several second delay between the actual and displayed gravity.

The dynamic sonographic air bronchogram: A simple and immediate bedside diagnosis of alveolar consolidation in severe respiratory failure Andrew W Kirkpatrick, Larence Gillman, Nova Panebianco, Michael Blaivas.  J Trauma In Press

Video 1 - Sonographic depiction of right flank of a critically ill patient with respiratory failure, refractory hypoxemia, and a PaO2/FiO2 ratio under 50. The image demonstrates the consolidated lung to the left (cephalad) of the diaphragm with the liver and adjacent kidney to the right (caudad) of the diaphragm.





Video 2 - Sonographic depiction of right lower chest of a critically ill patient with respiratory failure, refractory hypoxemia, and a PaO2/FiO2 ratio under 50. The image demonstrates the densely consolidated lung parenchyma. Multiple linear hyperechoic areas corresponding to intra-bronchial air densities are seen within the substance of the consolidated lung.

Video 3 - Sonographic depiction of right lower chest of a critically ill patient with partially improved respiratory failure and a PaO2/FiO2 ratio over 225. The hepatisation has resolved and the dynamic air bronchogram sign has disappeared. No internal echos are seen deep to the visceral-parietal pleural interface which is the expected normal anatomy.

Mock Trauma Tele-Ultrasound Simulation Devon Island, Nunavut - Calgary, Alberta

The Clinical and Technical Evaluation of a Remote Telementored Telesonography System During the Acute Resuscitation and Transfer of the Injured Patient Dianne Dyer, Jane Cusden, Chris Turner, Jeff Boyd, Rob hall, David Lautner, Douglas R. hamilton, Lance Shepherd, Michael Dunham, Anre Bigras, Guy Bgras, Paul McBeth, Andrew W. Kirkpatrick J Trauma. 2008;65:1209-1216

(high resolution in zip  file)

Sonographic Depiction of Intra-Peritoneal Free Air Michael Blaivas, Andrew W. Kirkpatrick, Monica Rodriguez-Galvez, Chad G. Ball. J Trauma 2009;67

Sonographic Depiction of a Posttraumatic Alveolar-Interstitial Disease:  The Hand-Held Diagnosis of a Pulmonary Contusion Ball CG, Ransom KM, Rodriguez-Galvez MR, Lall R, Kirkpatrick AW. J Trauma 2009;66:962

Left Lung:  Resuscitative sonographic examination of left upper lung revealing only occasional comet-tail artifacts at the parietal-visceral pleural interface, consistent with normal lung.

Right Lung:  Sonographic examination of right upper lung revealing multiple comet-tail artifacts at the parietal-visceral pleural interface, consistent with a clinical diagnosis of pulmonary contusion.



Sonographic Depiction of the Needle Decompression of a Tension Hemo/ Pneumothorax Kirkpatrick AW, Ball CG, Rodriguez-Galvez MR, Chun R. J Trauma 2009;66:961

Sonographic examination of the right anterior chest of a traumatized victim reveals no lung sliding, nor moving comet tail artifacts.  After needle (not seen) is inserted in to the pleural cavity, visceral pleural sliding progressively appears from behind a disappearing "curtain" of intra-pleural air to become visible throughout the entire field of view

Focused assessment with sonography for trauma in weightlessness.  Kirkpatrick AW, Hamilton DR, Nicolaou S, Sargsyan AE, Campell MR, Feiveson A, Dulchavsky SA, Melton S, Beck G, Dawson DL.  J Am Coll Surg 2003;196:833-844.

Note:  In-flight sonography demonstrating the enhancement of a small amount of intraperitoneal fluid during the transition from hypergravity (1.8g) to weightlessness (0g).

Sonographic diagnosis of a pneumothorax inapparent on plain radiography:  confirmation by computed tomography.  Kirkpatrick AW, Ng AKT, Dulchavsky SA, Lyburn I, Harris A, Torregianni W, Simons RK, Nicolaou S.  J Trauma 2001;50:750-752.

Note:  Sonographic images of thoracic examination performed on a 20 year-old motorcycle rider.  The left anterior chest is first examined, followed by the left posterior, right posterior, and right anterior.  Lung sliding and comet-tail artifacts were not seen in the left anterior location only, suggesting an occult pneumothorax.

Enhanced recognition of "lung sliding" with power color Doppler imaging in the diagnosis of pneumothorax.  Cunningham J, Kirkpatrick AW, Nicolaou S, Liu D, Hamilton DR, Lawless B, Lee M, Brown DR, Simons RK.  J Trauma 2002;52:769-771.

Sonographic image of left lung, illustrating the presence of the color power Doppler signal ("power slide") from the normal visceroparietal pleural interface.

Sonographic image of right lung, illustrating the presence of the color power Doppler signal ("no power slide") from the normal visceroparietal pleural interface.



Where’s the tube? Hand-held sonographic correlation of endotracheal tube placement.  Chun R, Kirkpatrick AW, Sirois M, Sargsyan A, Nicolaou S, Melton S, Hamilton DR, Dulchavsky SA.  Prehosp Disat Med 2004;19:366-369.

Note:  Graphic Depiction of left chest wall pleural interface during intubation in which pharmocologic paralysis was used.

Ultrasound detection of right diaphragmatic injury;  The "liver sliding" sign. Kirkpatrick AW, Ball CG, Nicolaou S, Ledgerwood A, Lucas C.  Am J Emerg Med 2006;24:251-252.

 

 

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