This week a little attempt at #dogmalysis for USS education in the UK. I want this to make you think about the links between what we teach and learn vs patient outcomes. In an ideal world the two should be linked, but what happens when they start to diverge? Let’s take something (FAST scanning) that is held dear to many UK EPs.
We can sum this problem up in the two reasons why clinicians ‘like’ performing procedures. In an ideal world both reasons occur at the same time….., but not always.
[learn_more caption=”Reason number 1.”] The patient requires the procedure.[/learn_more] [learn_more caption=”Reason number 2.”] The clinician ‘wants’ to do it.[/learn_more]
The ever busy Natalie May recently cajoled me into a practical teaching session for our trainees on ED ultrasound. I spent a really great afternoon with colleagues to go through the basics. The session was focused around them gaining the skills needed for their level 1 accreditation in ultrasound. This is an important qualification in the UK as it is something they should really achieve before gaining their first consultant post. So, all well and good then…., but is it? Let’s just remind ourselves of what the level 1 competencies are for a UK EP to gain certification and thus the nod for independent practice. It comes down to 4 areas.
- 1. Central vascular access. I have no problem with this as there is good evidence that USS aids the placement of central lines.
- 2. Abdominal Aortic Aneurysm detection. Again, quite happy with this as it’s an easy diagnosis to miss without USS, and it’s a good time to remember Dr Osler’s thoughts in this area (pre USS) There is no disease more conducive to clinical humility than aneurysm of the aorta.
- 3. ECHO in life support. The most recent addition to the quartet makes sense as there is evidence that ECHO during cardiac arrest can identify useful information.
- 4. …..and then there is FAST scanning. Focused Abdominal Sonography in Trauma, a technique to detect the presence or absence of intraperitoneal fluid in trauma. It is only taught in the UK as a ‘rule in’ test. EPs are told that they cannot ‘rule out’ intra-abdominal injury and that further imaging will be required. The idea behind the technique is that through the early detection of fluid in the peritoneal cavity the emergency physician will be able to influence the patient journey and thus improve outcome. In the days of old this was a laudable pursuit, a positive FAST scan would guarantee the interest of the surgeons and radiologists leading to an easy request for abdominal CT, but that was then, and this is now… I was a vigorous enthusiast of FAST in the resus room during the early days. I really ‘liked’ doing it and felt that it did make a difference – I could get my patients to CT easily if there was a positive FAST – I felt good and clever 🙂 Time goes by though and whilst reflecting about the role of a trauma team leader in the resus room I’m less convinced of it’s role as a core skill for the emergency physician.
In recent years we have really been pushing to get our major trauma patients to the CT sanner as quickly as possible. There is good evidence for pan-scanning (known as the Afghani-scan here in Virchester) trauma patients to detect injuries early in the patient’s journey. The target in the UK is that patients get to the scanner within an hour of arrival. This can be tough and when introduced it certainly made us think hard about what is truly useful pre-CT. Here’s a list of things that we have changed (or are in the process of change) in order to streamline the arrival to CT time.
- Stop doing Chest X-rays
- Stop doing lateral C-spines
- Stop doing Pelvic X-rays
- Start using pelvic binders
- Stop 90 degree log rolls
- Stop catheterising
- Stop putting a-lines in unless needed
- Thoracostomy vs tube drainage in ventilated patients
- Removal from spine boards onto vacuum mattress
- Do they really need a PR???
So there is a balance of things we have started doing and things we have stopped doing. Remembering that we are against a time target then it is important that we only retain procedures that are going to contribute to patient outcome, and that’s got me thinking about FAST scanning. Perhaps we just need to stop and think about how FAST ‘fits in’ to the the management of trauma in a UK trauma centre. Let’s just pause and not assume that everyone gets a FAST ‘because that’s we do’. Let us instead consider where it is ‘useful’ in a diagnostic strategy for abdominal trauma. Useful must mean that it makes a difference to patients, wither in terms of their disposition from the ED or in terms of identifying an injury that would not have been found otherwise. I’ve thought about this and in reality I think we can map out the process as follows for our major trauma patients…….
In UK trauma centres we are encouraged (mandated almost) to CT all major trauma patients within the hour following arrival. If we are going to do this anyway then the role of FAST scanning must then be confined to those patients in whom an ultra-early diagnosis is needed, or in those too unstable to go to CT. With early access to CT I would suggest that both groups where FAST can make a contribution are rare.
When FAST scanning first came into my world there may have been reasonably good arguments for teaching everyone how to do it. However, as time goes on I’m not so sure that it is really functioning as a game-changer of an investigation in the ED. There are several reasons for this, here are just a few.
- Regional trauma centre networks mean a greater understanding of trauma.
We are much happier continuing resuscitation as we go to and through the CT scanner
CT scanners are much faster and we are slicker at getting people into and out of them.
The number of patients who are too unstable to go to the CT scanner, but are fit enough to go to theatre (it’s still a ride down the corridoor in most places) is tiny.
I find less need to ‘convince’ my surgical colleagues of the need to actively manage abdo trauma. The surgical teams have done a lot of work in educating themselves and their teams in how to manage these injuries.
We pan-scan pretty much anyone so the chances of missing an injury through not investigating is increasingly slim.
So, in the last 5 years I cannot personally recall a patient where an ED FAST scan has significantly changed a patient outcome. Sure, I’ve spotted some blood in a stable patient and sent them to CT, I’ve also spotted blood in the abdomen of someone with their guts hanging out….., but I cannot convince myself that such cases really made a difference to the patient, their destination out of the ED or to the surgical decision making. It may have given us a ‘heads-up’ about what we might find on the CT scan, but in all the time I’ve been doing it I can’t think of a single one.I know that the cases may be out there, perhaps it is just me and the quirks and chances inherent in our lives that means that the patients who really benefited just did not come to town on the days that I was around, but I suspect not.
Should we therefore abandon FAST scanning at level 1 training and change it to something more relevant to us as emergency physicians in the resus room? I think we might, and here are my suggestions for how we might better spend our time….
- 1. Basics of Thoracic USS: Pneumothorax, effusion, consolidation and oedema
- 2. Basic of CVS assessment: Long and short axis heart & IVC characteristics (a small extension from ECHO in life support IMHO).
Would we use these skills more often? Absolutely!
Would these be decision changing investigations for patient benefit? Of course!
So why are we not doing this? Well partly it is historical. FAST came to the fore at a time when we were not that good at getting sick patients through the CT scanner, it established itself in the curriculum and has remained there ever since. These days CT for trauma patients should be an extension of the resus room with active patient management continuing as investigations take place.
So should we abandon FAST at level 1?
All curricula suffer from middle age spread. As new and interesting techniques arrive we stuff ever more into a curriculum that gets larger and more unwieldy, so whilst I would really advocate the inclusion of thoracic and CVS USS we can only achieve this if we drop something that’s already there. It’s time for a new diet in my opinion. Let’s stop teaching FAST and instead teach techniques that will influence patient care in our resus rooms.
Should I stop doing FAST in the resus room?
It’s up to you really. I have stopped doing it in some patients if I don’t think it’s going to help. So long as it is not going to delay transfer then I allow it in resus, and I am still looking out for the patients where it’s going to make a massive difference. Similarly we need to ask ourselves whether we should keep teaching it. This is tricky. If we have lots of time and training then great. If time for this element of training then perhaps we need to think about whether this is the most helpful in terms of ‘time/effort’ vs. ‘usefulness’. In my practice we have a radiologist as part of the trauma team, so if I really need a scan……
What if I can’t get to CT in an hour?
OK. You’re Casey Parker in Broom WA. You’re nearest CT scanner is miles away. You need FAST, it’s all that you have, so clearly you should use it. Similarly, in the prehospital setting you might argue that FAST has a role and Cliff Reid has a great summary of the evidence around this. Should this have a role outside of trauma centres? Perhaps, though how often is a true game changer elsewhere? I’d love to hear.
For Nat, Dave, Katie, KP, and all my other colleagues I am still delighted to do more sessions on how to get through the level 1 assessments, but don’t be too surprised if we move through the FAST scanning quite quickly so that we can get onto the really valuable stuff 😉
Let’s abandon the abdomen for level 1 USS and move to teaching our trainees how to USS the chest and cardiovascular system. Who’s with me……?
1. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009; 373: 1455-1461. Summary | Full Text | PDF(187KB) | CrossRef | PubMed
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