This was a patient I saw a while back now, not long after we got our US machine in the place I used to work.
My experience with US is mainly self-taught when I spent long ICU shifts performing echos on every patient in the unit. I’ve done my level 1 course but the accreditation process ain’t that easy in Ireland, and particularly where I worked it’s all very new. Trail blazing is hard work.
Anyhow.
This guy came in with an infected hand and admitted the possibility that he might have got something in it.
Previously looking for an FB was either some LA and hoking around with a blade and forceps or we got radiology to scan them (a challenge in itself) and they’d leave us a nice x marks the spot and then we’d start digging on it.
This is hardly ideal.
I’d read some stuff on locating FBs with US and figured I’d just have a go (this is common though perhaps worrying trend in my practice…)
I got these images
Having used long-axis to view needles on line insertions and femoral nerve blocks I placed a needle under visualisation till the tip was on the FB (sorry no image – didn’t have the third hand to hold probe, place needle and capture the image!)
I then just made an incision along the shaft of the needle till I found the FB
I’ll confess that I was much more impressed with myself than the patient was.
I’m pretty sure I’d picked up the idea of using the needle to cut down onto from somewhere but I’ve no idea where. Anyone know anything published or on the web about that?
There’s a fair amount already published on the use of usltrasound FBs but I’m not aware of any randomised trial out there. Not that I’m really sure we need one but it’d be nice to know.
Ultrasound Village have a similar case (with a much more substantial FB!)
And this paper is worth a read too if you can get it.
UPDATE: @e_med_doc suggested this great paper. It has lots of nice images of using the needle to get down on the FB.
Welcome to the EM blogosphere, great posts!
Really like your approach of self-learn and go… I am in the same situation. The clinic has paid me a FAST course but I will never in my life have all the courses to learn all the applications of ultrasound that I want to learn. By learning from online texts and videos and doing some self-experimenting I’m getting on the learning curve. It’s just like the stethoscope – examine hundreds of patients until you know the difference from pathological and normal. I am careful not to use the ultrasound for definitive diagnosis or rule-out but a rule-in so that I can make a better plan on how to approach the patients symptoms. I cannot see any difference in doing this with the sonar or the old stethoscope where all doctors are falsely assumed to be skilled masters hearing every heart sound and murmur there is. At least, the online educational material for US is much better and easier to replicate by storing the images!
Regards,
David
ps my blog is a bit empty after having my third child this winter, I’m slowly getting back to normal life – and blogging
Hi David
thanks for the welcome, I’d had a look at your site in the past and noted the lack of activity but the third child certainly explains things!
there is some cracking stuff on the net on US isn’t there
rule-out stuff is a bit tricky with the US so i agree that certainly for now I’ll only be using it in the rule-in or procedural way
andy
Really like the pics. Any idea what the FB was or how it got there?
Hi
Thanks for the comment.
The fb was a thorn off a branch when he was gardening. About 2mm long.
Funnily enough I had a fairly similar case today. I’ll try and post the scan from it. I’ve taken to dunking hands in basins of water and scanning them in the water and it gives a far nicer picture.
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