California Department Puts Ultrasound to the Test

This article appeared in the EMS World special supplement Combating the Hidden Dangers of Shock in Trauma, developed by Cambridge Consulting Group and sponsored by North American Rescue, LifeFlow by 410 Medical, and QinFlow. Download the supplement here. 

Point-of-care ultrasound (POCUS) is widely used in emergency medicine to assess critical injuries in acute trauma patients quickly and accurately. Ultrasonography is routinely utilized in EDs, for example, to detect life-threatening “hidden” trauma such as pneumothorax or occult blood in the abdomen.

Despite acute trauma (including unintentional and violence-related injuries) being among the top 10 causes of death for all age groups in the United States,¹ POCUS has yet to be readily accepted and widely utilized in the prehospital setting.

In an effort to provide our community with quicker and more accurate diagnostic assessments for trauma patients, the Redlands Fire Department (RFD) in California has collaborated with Arrowhead Regional Medical Center and Butterfly Network to determine the need for and benefits of using portable handheld ultrasound to better detect critical life-threatening traumatic injuries.

With EMS being the first health care providers to encounter patients, adding portable handheld ultrasound to paramedics’ toolbox can only be beneficial. But like any innovative procedure or equipment, there are barriers to overcome when introducing POCUS into the prehospital setting. Roadblocks include the cost of equipment, training logistics, quality assurance and improvement, and the retention of skills among paramedics. 

Prehospital trauma management aims to prevent further injury, initiate resuscitation, and provide safe and timely transport of injured patients.² The handheld ultrasound device used, the Butterfly iQ+, is the size of an electric shaver and can be instantly attached to a cell phone or tablet to conduct a focused abdominal sonography for trauma (FAST) exam for occult blood identification or lung window sliding for a pneumothorax.

The Butterfly iQ+ puts ultrasound on a chip to create the world’s first handheld whole-body imager. By fusing semiconductors, artificial intelligence, and cloud technology, it’s now possible to use ultrasound in the field with a cell phone or iPad for less than $2500 per device and a department membership fee.

Benefits of Prehospital Ultrasound

Ultrasound is a safe, noninvasive procedure that can be performed in real time to assess anatomic and physiologic abnormalities. The process takes just a few minutes and can be conducted while en route to the hospital or during other patient management. 

Prehospital FAST exams have been shown to improve overall diagnostic accuracy, which assists in proper patient disposition to the most appropriate care facility.³ 

A handheld ultrasound device such as Butterfly iQ+ can allow first responders to quickly identify a pneumothorax, which can be rapidly treated with needle decompression.⁴ In addition, the device can aid in the early detection of occult blood in the abdomen.⁵ Once that’s identified first responders can notify the trauma center, which then, in turn, can prepare its trauma team and operating room for the incoming patient. This early notification and treatment help enable transport to the appropriate facility within the “golden hour.”

Ultrasound Implementation

The Redlands Fire Department consists of 4 stations with 41 paramedics and serves a 36-square-mile area with a residential population of 71,000. The department runs approximately 11,300 responses a year, with 8500 (75%) classified as EMS incidents. The jurisdiction is surrounded by 2 major freeways and a canyon road. 

Approximately 15% of EMS incidents managed by RFD are caused by some sort of injury or trauma. With such a high percentage of trauma-related calls, trialing a tool that has the potential to both quickly and accurately detect hidden trauma took little convincing.

Over a week in January 2022, RFD’s paramedics were trained by Arrowhead Regional Medical Center physicians on 4 views using the portable handheld ultrasound device. In addition to FAST exams and lung sliding, the paramedics were trained in identifying cardiac standstill by utilizing the parasternal and subxiphoid views used to support decisions in terminating resuscitation.

To train so many paramedics in a short period of time, each training day had morning and afternoon sessions. Each session consisted of didactic lectures, sonography review, hands-on examinations, proctored scanning sessions, and review sessions. The training was conducted to support current clinical practice and complement current EMS regional protocols. 

After the didactic lecture and sonography review, much of the course focused on hands-on training with paramedics using each other as patients. Multiple exams were performed by each student under direct physician supervision.

Since our initial training, refresher courses have been ongoing in conjunction with the department’s monthly training, allowing our personnel to refine their skills while identifying any gaps in their technique. 

In addition, researchers have been completing ride-alongs with RFD crews carrying the devices on each shift to provide additional instruction and real-time feedback. 

The ultimate goal of the ultrasound trial is to determine the efficacy and efficiency of the device in the field to identify critical life-threatening conditions and retention of paramedic skill in its use. 

First-Month Case Studies

In the first month of implementation, RFD crews used the device in the field 6 times. 

Case No. 1—A patient in their early 20s was found after a long-distance fall. The patient was unconscious with a palpable pulse upon EMS arrival but shortly thereafter lost the pulse. High-performance CPR was conducted on scene, obtaining return of spontaneous circulation. Due to the blunt-force trauma from the long-distance fall, providers conducted a FAST exam and lung sliding exam while the patient was being prepped for transport. There was no delay in patient care due to utilizing ultrasound. The EMS crew found a positive FAST exam and reported their finding to the receiving facility. Upon arrival the patient coded again in the ED and was revived. The patient was then taken to the operating room, where they expired.

Case No. 2—A patient in their late teens was involved in a single-vehicle traffic collision with major damage. The patient was seen driving at a high rate of speed and appeared to hit a light pole before rolling the vehicle into a retaining wall. The patient was partially ejected out the passenger side of the vehicle, combative, with a smell of alcohol and intermittent vomiting. Abrasions were noted to their extremities and face. The patient was also tachycardic and hypertensive. Due to the blunt-force trauma and chief complaint of altered level of consciousness, the EMS crew conducted a FAST exam and lung sliding exam while the patient was being prepared for transport. There was no delay in patient care, no significant findings were identified, and the patient was transported to a Level 1 trauma center, where they were treated for minor injuries and discharged home.

Case No. 3—A patient in their early 30s was riding a motorcycle at night and struck a midsize sedan in an intersection, causing the patient to be thrown off the motorcycle and over the car, landing approximately 20 feet away. The patient was wearing a helmet but had obvious injuries that included deformity to the right side of the chest wall with tenderness on palpation, midshaft femur instability and crepitus, and an open fracture to the left arm. Responders splinted all extremity injuries on scene and placed the patient in a c-collar for distracting injuries. They provided pain management and performed a FAST exam and lung window exam. The ultrasound showed possible right-side pneumothorax and no free fluid in the abdomen. The patient denied difficulty breathing and exhibited no further indications of pneumothorax, so prehospital chest decompression was not performed. The patient was transported to a Level 1 trauma center, where they underwent repair of their open left radial fracture, open left ulnar fracture, and right femoral fracture. The patient was noted by the trauma team to have a trace right pneumothorax that required no emergency treatment. 

Case No. 4—A patient in their 70s was last seen by home care providers approximately 2 hrs prior to their call for assistance. The patient was found pulseless and apneic by responders with no bystander CPR initiated. The patient was found to be in asystole with notable rigor and lividity; therefore, no resuscitation was attempted. Subxiphoid and pericardial ultrasound views were utilized to determine cardiac standstill for assistance in determination of death. 

Case No. 5—A patient in their 40s was found in cardiac arrest in their bedroom. Per family members the patient had been experiencing bloody stools intermittently for several weeks. The family reported the patient became altered but refused to seek care and went to lie down. The patient was found by the family to have copious amounts of blood coming from their mouth and rectum. EMS crews found the patient to be pulseless and apneic in asystole. They initiated CPR and conducted a FAST exam that confirmed occult blood in the hepatorenal recess (ie, Morison’s pouch). After approximately 20 mins of CPR and ALS procedures, there was no change in patient status, so the patient was pronounced dead, and ultrasound was conducted and recorded to confirm cardiac standstill.

Case No. 6—A patient in their 60s was found by family members to be in cardiac arrest. The patient received bystander CPR for approximately 5 mins prior to EMS arrival. Upon EMS arrival the patient was found to be pulseless and apneic in asystole. After approximately 20 mins of high-performance CPR and ALS procedures, there was no change in their status. The patient was pronounced dead, and ultrasound was conducted and recorded to confirm cardiac standstill.

Quality Improvement

An imperative portion of our ultrasound trial is quality assurance and improvement, which is being conducted by the department’s EMS coordinator and researchers from Arrowhead Regional Medical Center.

Paramedics are asked to record and upload images and videos from the device to the Butterfly cloud, as well as document procedures in the electronic patient care report and submit surveys to the researchers. The researchers review the surveys for patient information and exam indications and compare them to the images and videos uploaded. The EMS coordinator reviews documentation and the cloud images and videos and provides feedback.

Conclusion

Although it’s still early in the trial, we can safely say no delays in patient care have occurred due to the utilization of ultrasound in the field. Ultrasound is proving to be useful in the prehospital assessment and determination of critical life-threatening injuries. As more agencies join the trial and more patients are enlisted, we will be able to determine the necessity and benefit of prehospital ultrasound use in our community.  

See More: The Butterfly iQ+ in Action

• Lung scan: https://youtu.be/eHipSFr6zN4
• FAST exam: https://youtu.be/xLCHZBG8nv0
• Butterfly iQ+: https://youtu.be/E1rJ623_z64

Video: Anatomy of Abdominal Bleeding

To illustrate how much damage can result from hidden injuries in the abdomen and how much blood can be lost before abdominal distention can be seen, the Centre for Emergency Health Sciences created a video so you can appreciate the need to identify, locate, and stabilize these potentially deadly injuries early.

This video gives you a true appreciation of blood and fluid that can accumulate in a patient before distention is noted and exhibit how prehospital ultrasound technology can alert you to this hidden hemorrhaging. 

References

1. Centers for Disease Control and Prevention. 10 Leading Causes of Death, United States 2020, Both Sexes, All Ages, All Races. WISQARS Leading Causes of Death Visualization Tool. Accessed April 2, 2022. https://wisqars.cdc.gov/data/lcd/home 

2. Lucas B, Hempel D, Otto R, et al. Prehospital FAST reduces time to admission and operative treatment: A prospective, randomized, multicenter trial. Eur J Trauma Emerg Surg. Published October 18, 2021. doi: 10.1007/s00068-021-01806-w  

3. Lyon M, Walton P, Bloch A, Shiver SA. 321: Out-of-hospital critical care providers’ retention of ultrasound skills for diagnosis of pneumothoraces: A nine-month follow-up [abstract]. Ann Emerg Med. 2009; 54(3): S100–S101. doi: https://doi.org/10.1016/j.annemergmed.2009.06.352 

4. O’Dochartaigh D, Douma M. Prehospital ultrasound of the abdomen and thorax changes trauma patient management: A systematic review. Injury. 2015; 46(11): 2093–102. doi: 10.1016/j.injury.2015.07.007.

5. Rotondo MF, Cribari C, Smith RS, eds. Resources for Optimal Care of the Injured Patient. American College of Surgeons Committee on Trauma. Accessed April 2, 2022. www.facs.org/-/media/files/quality-programs/trauma/vrc-resources/resources-for-optimal-care.ashx

Carly Crews, RN, EMT, is EMS coordinator for the Redlands Fire Department in San Bernardino County, California. Reach her at cmcrews@confire.org.