10 Ultrasound-Guided PFC Essentials

Ultrasound: The most powerful diagnostic tool available to SOF Medics […]. It should be a top procedural skill goal for all SOF providers to become subject matter experts in point-of-care ultrasonography.

I’ve been thinking about this post for a while…  searching for the right format. And then it finally hit me! Why on earth would I re-invent the wheel, if I can channel this message through the paths you are quite familiar with!? Especially after Doug Powell gifted me such a brilliant introduction in a previous post!

The PFC Working Group has already laid the foundation and set the framework in their position paper on the PFC capabilities. All I have to do is show you how POCUS (point-of-care ultrasound) can support and improve them all. It shouldn’t be hard, as “sky is the limit” when it comes to the wealth of information that can be obtained from an ultrasound screen. It’s like having the NVGs or other visual aids at night! I’m sure you can handle your business without them, but why on earth would you waste time if able to achieve your goals in a more efficient, accurate and safe way?  Smarter not harder, right?

Not that POCUS is any kind of novelty in the Special Operations Medicine. It’s been around for quite a while. SOLCUS banner black with patchThe SOLCUS concept is already well-supported by the existing literature. For a number of reasons we are still in the window of knowledge translation, and that is why you may have a justified perception of insufficient training and utilization. Nevertheless, don’t try to convince yourself that you don’t need it or it’s too hard to learn… Thousands of people who are quite successful at point-of-care ultrasonography, wouldn’t have lasted an hour at any SOF training or selection program… Let alone providing medical care under fire… You’ve been pretty ‘darn’ good at both.

So… Even Carl could do itHaving settled the training and ability issue, let’s see how that would work in practice! How about a hypothetical SOLCUS-guided PFC scenario… Let me tell you: once you get a hang of it, and it’s going to happen really fast, you will never want to practice medicine without ultrasound! Why would you do the minimum if you can always aim for the best?

TALE OF A RUSTY NAIL

SOLCUS-GUIDED PFC SCENARIO

Just a little technicality: The numbers in the text correspond with the PFC capabilities as listed the following table:

PFC capabilitiesYour team is on a week-long mission in the middle of Noland. While searching through a building, one of your guys falls through a hole in the floor. You dash to check him out.

Your weapons guy has fallen all the way through the floor.  A large rusty nail pinned through his lateral calf. You complete the assessment, and proceed to get that nail out. Thankfully it didn’t injure any vital structures, and Carl’s leg is neurovascular intact. Wound care, antibiotics – his tetanus is up-to-date – you hope for the best.

Being a tough guy as he is, Carl insists that he is perfectly fine… But just to be safe, you decide to grab the ultrasound machine from a nearby TRUCK and perform an e-FAST exam (6). Thankfully, there is no pericardial, pleural nor peritoneal free fluid. Looking for a pneumothorax (PTX) is the last thing on your mental checklist. You are quite relieved to find none! Placing a chest tube is the easy part… Dealing with the aftermath would be quite cumbersome in your current position. 

The following morning Carl wakes up with a red and swollen leg. Your physical exam suggests cellulitis, but you know better than that! With extensive cellulitis you have about 50% chance of getting it right on just the clinical assessment. Rather than tossing a coin, you put the ultrasound probe on the leg, and sure enough you find an abscess (6). What’s more – you notice intense reverberation artifact coming from the center of the abscess cavity. Aha! There must be a foreign body hiding in there. 

As high-speed as you are, you know that regional anesthesia under ultrasound guidance takes less time, results in fewer complications and has a higher chance of success. You go for a sono-guided popliteal nerve block (5). You drain lots of purulent material and a rusty piece of nail. After the I&D you rescan the area to make sure you got it all (8).

Now, the problem is that Carl doesn’t look so well… You decide to start IV fluids, antibiotics and analgesia. After 3 failed attempts, you finally get the line started under ultrasound guidance (2,7). A quick IO would have been an option, but certainly less optimal! Especially if you think long-term management… In most cases the goal is to remove the IO needle within 3-4 hours. But if you insist on starting that way – ultrasound can save you a lot of trouble by confirming the intraosseous placement (2,7). No matter what they told you, those IOs happen to end up in a bunch of undesired places… (Check out the “Feedback to the Field” resources on the SOMA website to read about some awful IO fiascos).

You are finally ready for a telemedicine consult. Doc was able to review the images you sent. He surely agrees with your actions, and compliments your SOLCUS skills (9). However, he cannot promise you a timely evac.

Carl seems to be resting, but when you start trending his vitals, you know things just aren’t getting any better. He is becoming more tachycardiac, and his BP is slowly going down. He is also febrile. You take the ultrasound machine to look at the heart, lungs and the IVC (1,2,3,6). You see a hyper-dynamic heart with clear lungs and relatively flat IVC… You integrate it with the clinical picture of febrile illness and soft-tissue infection… Crap… He is septic

You make it back to the HOUSE. After yet another cell phone chat with your doc, you start pushing more IV fluids… You get another ultrasound-guided peripheral IV (2,7). They are working on that evac, but still no definitive time… Hours later, as you hit the 6th liter, Carl’s SBP barely holds 95 mmHg, and he is becoming tachypneic… His lungs sound very junky, so you decide to repeat your heart-lung-IVC scan (1,2,3,6). His IVC is full, his lungs are wet and his systolic function has decreased…  Septic cardiomyopathy?

With this picture you have no choice but to control his airway and put him on a vent. The junior medic is begging you to let him tube the patient, so you place the ultrasound probe on Carl’s neck in order to supervise your junior’s actions. First you identify the cricothyroid membrane, just in case you needed a surgical airway. Then you watch the screen to see the tube pass into the trachea (1,2,4,6) at first attempt! Your capnography is malfunctioning, and you know how reliable clinical exam is for ETT confirmation… You don’t have an x-ray, but you can clearly see bilateral lung sliding on ultrasound (3, 6). This way you know that junior didn’t go into the right main-stem. You place the probe over the stomach (7) just to see a large fluid-filled gastric bubble… “We are lucky he didn’t aspirate”… You quickly pass the OG tube and decompress the stomach. At once you realize Carl didn’t urinate in quite a few hours… Foley, Foley… Oh great – no bags… You can’t just put a Foley with no bag attached to it… You’ll have to do repetitive catheterizationsUltrasound will help you assess his bladder volume (1,7) at regular intervals. That’s how you’re going to know when to empty Carl’s bladder, so you can follow his UOP.

You arrange for a video-conference with your doc, and you make the point of showing him Carl’s decreased systolic function on ultrasound in real-time (1,6,9). Given it’s a negative prognostic factor, it does the trick of speeding-up evacuation.

As they load him, someone bumps the ETT and it looks like it might have moved. You make sure the tube is still tied in place. It’s way too loud to auscultate for breath sounds, so you grab the probe instead, and document bilateral lung sliding as evidence of bilateral ventilation (1,3,4,10).

Carl makes a full recovery!

*   *   *

I hope you get the picture how multifunctional and versatile ultrasound is. It’s your force multiplier when it comes to prolonged field care!

Thanks to ultrasound you can build a life-saving bridge from the state of thinking that you recognize the problem, to knowing and being sure about the issue at hand. In the most critical circumstances it helps you maximize safety, efficiency and diagnostic accuracy, while decreasing mortality and morbidity of your patients.

While for now, an ultrasound machine is mostly out there in your TRUCK, or even at the HOUSE, soon enough in can be in your pocket. As the technology advances, and we move from portable to pocket-size devices, it has the potential to become a standard item in your RUCK arsenal.

Do you really want to practice sono-less PFC?

Questions? Comments? Concerns?

Here or: solcus.education@gmail.com

6 thoughts on “10 Ultrasound-Guided PFC Essentials

  1. The patient should have been MEDEVAC’d early in the scenario. This should have been the goal of the medic. The picture that you paint as US as the be-all imaging technique in the hands of the field medic distorts reality. An honest discussion would mention problems with sensitivity, specificity, NPV and PPV, especially in the hands of providers that do not do this often. Then there are the problems and complications that can arise when medic performs a procedure, which he performs at low volume, based on a false positive reading. At Role 2 in Afghanistan, I watched general surgeons with multiple deployments struggle with equivocable abdominal FAST results when trying to make decisions about when to operate. This reeks of the “cool new toy”.

    The literature linked far from settles the question. Some are single case reports. Some are extrapolated from civilian paramedics who presumably do this daily. Some even shows the opposite of what you imply here. For example, this article is linked as evidence in PUB MED

    “Difficulties encountered by physicians in interpreting focused echocardiography using a pocket ultrasound machine in prehospital emergencies.”

    You should be much more cautious in asserting that US use with each individual US exam (cardiac, lung, etc), as you describe in this scenario, can demonstrably improve outcomes in Spec Ops medicine before advocating for its use in this way.

    1. Thank you very much for the comments which have been thoroughly read and considered.

      Please let me start by reinforcing the goal of this post. We aimed at illustrating the potential of point-of-care ultrasound in relation to the PFC capabilities. As clearly stated in the text, it was a hypothetical scenario.

      It cannot go unnoticed that SOF medicine is moving back to the concept of prolonged field care, defined by NATO as:

      Field medical care, applied beyond ‘doctrinal planning time-lines’ by an NSOCM (NATO Special Operations Combat Medic), in order to decrease patient mortality and morbidity. Utilizes limited resources, and is sustained until the patient arrives at the next appropriate level of care.

      While we are heading back to the roots, we must ensure that we are moving ahead at the same time. I couldn’t possibly explain it more eloquently than MSG Harold R. Montgomery in the most recent issue of JSOM:

      I believe the next generation is truly the most important and the most challenged. These are the new SOF medics who are taking up and will take up the challenge in the coming years. You have two challenges. The first challenge is to retain and propagate everything that has been learned over the past decade. Do not let our brothers’ blood be wasted. Stand firm against the remaining naysayers and push for the right kind of training and equipment for the SOF medic. The second challenge is that you will do this in a very different environment. Your environment is global and in the far reaches with long-range evacuation routes and limited external medical support. It will be back to the traditional SOF roots. You must be prepared to manage patients in the prolonged field care setting and on your own. It is not a new concept but stretches through the lineage of all the SOF units and missions. However, you must integrate our newer concepts with that lineage and come up with something better. […]

      On behalf of my generation, I ask that you remember where it all came from and the history of arguing, debating, pondering, and bleeding that made the changes that you can now take for granted. Be self-critical and always evaluate yourself and your team as to how you can improve.

      I believe that being self-critical is one of the most important things about SOF. We are always striving to improve our capability to execute the mission. Never rest on your laurels. Look to the next mission and emerging requirements and fix the problem before it can become a fiasco.”

      Point-of-care ultrasound is one of the most positively disruptive innovations that hit medicine in a long time, and it certainly belongs in the hands of a highly capable and trained SOF medic. Especially if we expect them to care for their patients over an extended period of time. While early evacuation and tele-medical consult would certainly remain the optimal solution, those might not be an option! What if there is NO plane standing by, waiting for a call, or NO medical personnel on board to help the lone medic…

      Imagine you are the patient… Would you rather they treat your tamponade blindly or under ultrasound guidance? Would you prefer to have a large bore chest tube for presumed hemo/pneumothorax if an ultrasound could rule out free fluid in your pleural cavity and/or a pneumothorax? Would you like to burden your team with an evacuation due to suspected testicular torsion if all you had was sonographically confirmed orchitis with highly INCREASED vascular flow?

      And YES, those are conditions that a SOF medic is expected to manage, among 500 other critical tasks

      Now, that we must do a better job in assisting those highly capable and bright individuals with ultrasound training and skill retention is YET another story… Ultrasound machines are already in their hands, with more on the way…

      1. When you lead off a post with a comment like:

        “A medic without an ultrasound is like a sniper without a scope”

        your post is already chock full of inappropriate hyperbole. This hubris is one of the things that makes dealing with SOF medicine so maddening for those who care about evidenced-based, outcome-driven decision making.

        The USSOCOM TTP’s have level 1 evidence for exactly one intervention: tourniquet use at point of injury. Everything else falls well below that threshold and most of it has no evidence or extrapolated evidence at best. For you to litter your post with capitals, italics and boldface completely discredits your reply as a serious discussion.

        You quote MSG Montgomery:

        “Do not let our brothers’ blood be wasted. Stand firm against the remaining naysayers and push for the right kind of training and equipment for the SOF medic.”

        Let me re-phrase this:

        “Do not let our brothers’ blood be wasted. Stand firm against the fools who minimize the importance of the oldest saying in medicine: ‘first do no harm.'”

        Every decision in medicine weighs risk versus benefit. The more experience one has, the better their assessment of risk/benefit becomes. My seminal moment in theater in this regard was the 10 year girl who was effectively euthanized due to a decision by a SOF medic to perform a surgical crich. Crich-ing a kid makes a well-trained surgeon pucker. Maybe that medic placed it correctly, maybe he didn’t. But between him, the flight medics, the ambulance crew, it was dislodged and wound up in her esophagus. She would have at least had a fighting chance had he simply rolled her on her side in the recovery position with some O2. Why did this happen? Because the SOF medic lacked the knowledge to properly assess risk versus benefit in an extreme situation. My experience is not isolated. Someone should survey anesthesia provider’s with Iraq and Afghanistan deployments to see what their experiences with surgical crich in the field. Very similar.

        New tools do not make up for this deficit. If anything they run the risk of further eroding it as basic skills are de-emphasized. Meanwhile the medic thumps his chest saying “I’ve been trained!!!!”

        Now we have crich kits for medics in spite of no assessment of NNT versus NNH over a decade of war, whole blood transfusion kits at the point-of-injury with guidance like “A for A, O for everyone else,” anti-venom in the load-outs, and ultrasound to make everything better.

        The endless justifications for this always go back to something like:

        “While early evacuation and tele-medical consult would certainly remain the optimal solution, those might not be an option!”

        I’m sorry but I have personally observed fancy tools and arrogance get in the way of early evacuation and consult. Please stop this line of argument and get scientific!!!

        So…

        “Imagine you are the patient… Would you rather have an ex-fix erroneously placed on your non-fractured femur with subsequent high risk of devastating osteomyelitis that was diagnosed incorrectly by a medic with ultrasound OR would you rather not have had that done because someone pointed out the risk of a procedure with false positive rate of 1 in 10 by SOF medics per the literature linked at the top of articles like this?”

    2. As the consulting physician, at what point would you have recommended evacuation? Would the MOI prompt the recommendation to the ground force commander and TSOC? Early in the scenario the patient fell on a nail and has some local pain. Would that be enough to abort the mission? Having the ultrasound to detect the formation of an abscess could help gain additional information to make the case. The majority of medics probably wouldn’t have called until the fever and decreasing blood pressure. It’s something we have to work on. Medics in general have a problem with calling early because of a lack of trust with the guy on the other end of the Sat phone who may not understand constraints in resources or deficiency in a certain skill. There is also an element of hubris and bravado that we have to overcome. It’s getting better as we demonstrate the volume of consults hospital physicians make as well as strengthening relationships and networks with competent our Docs.
      The picture painted seemed to be one to showcase the possibility of ultrasound use in a deployed setting, just another tool, not the be-all and end-all. US machines have been sitting in some of our units for 5+ years now, better to learn some basic techniques than to ignore its existence. Some docs and medics like it and train with it and some don’t. SOCM medics are now getting some of the basics during the course so both familiarity and desire to add it to the load out will only increase.
      Sustaining all of our skills continues to be a problem. Sites like this with SOCM-specific references can help guide the medic in practice when docs and PAs are unavailable to help. Right now guys are just finding whatever random YouTube video that comes up without any references or background. Due to its non-invasive nature it’s something than can easily be practiced in the team room prior to a hospital rotation or deployment.

  2. Thanks for the thoughtful comments and sorry for my delay in responding. In considering new technology, there are multiple issues at play.

    Taken in a vacuum, this post seems to advocate for the “next best thing” in medicine without reflection to its training and application, when, in fact, the ultrasound has been part of the US SOF toolkit (Army at least) for 10+ years, and has more recently been covered universally in initial training. The fielding to Special Forces Groups is going to expand even further this coming year.

    As a unit surgeon (medical director in civilian terms) for the past 10 years, I have struggled with the same observations as Anonymous with the application of any new tactics, techniques or procedures in medicine. The reality is, however, that we put our medics in impossible situations and expect them to perform in situations that would make most hospital-based providers cringe. Fair? Probably not. Reality? Yes. This is where the PFC WG is working to mitigate risk and provide the best training and education aides to tackle these situations.

    Rest assured, Anonymous, that there are, in actuality, very few medics carrying US into the field presently. There are many reasons why it has not presently gained acceptance, and most medics are mature providers that understand their own present limitations. The purpose of this post is to present a scenario to hopefully demonstrate the many applications for US in the hands of a trained provider. It is absolutely recognized as a diagnostic adjunct and we do not advocate this as the primary diagnostic device.

    In the end, optimistically, I would say that fully trained and fielded, only about 25% of the mature medic force would carry this technology forward, and only then in the correct operational context (at the HOUSE, or during prolonged TRUCK evacs).

    In regards to the comments of evidence-based practice: pre-hospital medicine suffers from lack of data and we all must acknowledge and understand this fact. In the face of no data, the WG seeks to present best evidence and expert recommendations for exactly those situations where there is no guidance presently. It is our responsibility to continuous evaluate and re-evaluate recommendations in the face of new data: both published and anecdotal.

    Only through thoughtful debate and continuous dialogue will we be able to tackle these issues. Thank you again for everyone’s comments in the interest of providing the best information to those with the difficult task of providing care to the best patients in difficult situations.

    Sean

  3. Thank you Anonymous for kicking off the discussion. Help me understand the actual focus of your objections. Is it that SOF medics shouldn’t use ultrasound or that ultrasound is too new of a tool to medicine?

    You mention a few times that ultrasound is a shiny new tool or fancy tool and that the medic should use their experience to make better decisions and to consult early.

    You also mention an ER doc struggling to perform a FAST and the unfortunate bad outcome crich-ing the kid. Help me fully understand your objections.

    Ultrasound is only a tool, like the x-ray, iStat or the BP cuff. Properly trained it its use, it has the potential to answer a question you should form in the evaluation of the patient. The benefit of ultrasound is that it can answer many more questions than most of the other tools the medic may have at the time. The current machines most of the SOF medics have access to are not small enough to carry for POI use. They can be staged in the “truck” or “house” for use as needed. Smaller machines are out there and are getting better all the time so at some point they will be used at POI more consistently.

    There is always a balance in how far SOF medicine should push the boundaries. We (I) will not wait for something to be validated ten ways to Sunday before I push it forward. If it works and it helps the medic answer questions and make better decisions then it should be trained and utilized. Otherwise, we would only have the tourniquet in our toolbox using your argument.

    As Sean mentioned, ultrasound is not new or shiny for the SOF medic. I say they are more than capable in its use and well within their scope of practice. Lack of training and bad outcomes are always going to be a part of SOF medicine and all medicine in general. I remember my first two-weeks as a medic with 100% success at IV’s.

    For anyone that has not experienced a bad or catastrophic outcome after a mistake or even doing everything perfect, welcome to medicine. Like Mantis said from “Secrets of the Furious Five – Wait for it…”

    The article proposed a list of 10 Ultrasound-Guided PFC Essentials. Let’s discuss the list for their benefits and not whether it should be utilized. The decision has been made by the SOF medics that ultrasound is a tool they want to use. As Paul states, the shortfall is in the available time and incorporation of ultrasound into PFC scenario training. We should focus on correcting that deficiency and basing future PFC training on the 10 essentials outlined here.

    Thanks ~ Bill

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