Mike Mallin is a legend in emergency ultrasound but, by day, he’s a regular guy and community ED doc. In this episode, Mike and Rob talk about
- making the change from an academic to community medicine job
- working in a place that sparks joy
- working locum tenens
- soft tissue ultrasound looking for abscess
- placing peripheral IV catheters under ultrasound guidacne
- how they approach night shifts (both single and stacks of shifts)
- patient handoffs
Soft tissue ultrasound
This is one of Mike Mallin’s favorite exams, because no matter how good he thinks he is at guessing how much or if any pus is underneath the skin, he’s often surprised when looking with ultrasound. A landmark study by Tayal in 2006 found that the introduction of soft tissue ultrasound into an ED evaluation for a skin and soft tissue infection changed management 56% of the time. Some patients who docs thought needed drainage didn’t and some that docs did not think needed drainage did.
Pearls when looking for an abscess
Compress with the probe: Pus can look a lot like surrounding tissue – especially nasty, thick MRSA pus. Sometimes the only way to see the pus pocket is to compress. What you’re looking for is the swirl sign (sometimes called the ‘squish sign’)
Use Color Doppler. Make sure that dark pocket of fluid you’re about to incise isn’t a AV fistula, or a random artery or vein. An 11 blade in a vascular structure is considered bad form.
Look for Air: While looking at the infection, beware of air bubbles in the skin, they- along with fluid tracking on the fascial planes, can tip you off to gas forming bacteria. While that doesn’t always mean necrotizing fasciitis, it should get your attention. Unless there is already a hole in the skin for air to get in, these patients probably need a surgeon’s hands on them.
Soft tissue air. Ultrasound from Joseph Minardi
Another example of necrotizing fasciitis on US from the EDE blog
Rob’s Patient Handoff Macro
This is a [ ] year old [ ] who presented to the emergency department with a chief complaint of [ ]. Patient care transferred from Dr. [ ] at [ ]. Presenting symptoms: [ ] Workup to this point: [ ] Pending studies: [ ] Plan at time of sign out: [ ] Study results: [ ] Patient reassessment: [ ] Plan: [ ]