1. Knobology and Criteria Jamie Jenkins MD Regional Ultrasound Director FHS St Josephs Medical Center Ultrasound : Zonare

2. Only 21% of EM physicians personally perform bedside ultrasound Standard of Care: Central lines No lawsuits for misreads as of 2007 3 lawsuits for failure to use 2 with AAA 1 with rule out ectopic Credentialing Can we hide behind it or with out it? Medical Legal Aspect

3. Core Applications of Ultrasound

4. Knobology How to use the machine

5. Knobology: The Basics

6. Changing probes Press the transducer key and then use the soft keys to select which transducer you need Please do not change the Transducer plug-ins on the side of the machine.

7. Exam Type

8. New Patient: Training Scans At the Ultrasound machine Click ‘New patient’ button upper left of key board Last name: Training First name: EDUS Do not fill out MR number Operator: Your name Press exit On first page, press space bar and type in pt name and MR number

9. New Patient: Complete Scans to be Uploaded to Patients Record  Enter an order in EPIC (Ultrasound ED Bedside)  At the Ultrasound machine Click ‘New patient’ button upper left of key board  Use the cursor to select the worklist button on the screen.

10. New Patient: Complete Scans to be Uploaded to Patients Record  Select patients name from list  The screen will self populate  Fill in your name under operator  Press exit and start scanning  Press end exam at the completion of your study

11. Documentation:.procdoc Please use.procdoc for documentation. Due to the new workflow this is required as it allows the loop with Cerner, Radnet, EPIC and PACS to close. Select the blue link that says Ultrasound ED Bedside.

12. Documentation: worksheet Once you click on the link. The worksheet below will appear. You do not have to fill out the entire thing, just scroll to the comments section and type in “See Note”.

13. Documentation: NOTE Please use the.EDUS smartphrases for documentation of your findings. The smartphrases can be copied from me Jamie Jenkins

14. If you manually enter info instead of using worklist If you manually enter the patient information including the MR number please follow the guidelines below No leading zeros No dashes No FIN numbers Ex: MR number is 001-234-567 Enter 1234567 You still need to enter an order after you finish the scan It is preferred that you use the worklist

15. Credentialing 50 scans to remain credentialed in all areas of ultrasound over 2 years CME is required as well This lecture Scanning shifts with me Ultrasound courses/lectures at conferences

16. Key Points Enter an Order prior to performing bedside ultrasounds (even for central lines) Document with.procdoc and.edus smartphrases Please email me if you have any questions: jamiegoodis@gmail.com

17. OB/ IUP OB/ Pregnancy Scan OB mode: Calculations Transabdominal views of the uterus transverse and horizontal Fetal Heart Tones (m-mode) Fetal dates >12weeks BPD <12weeks crown rump length -BPD (Inner to outer walls of the skull) Clips of bilateral adenexa (even if obvious IUP)

18. Misconception: A very low B-HCG rules out ectopic pregnancy Truth: 40% of ectopic pregnancies will present with a B-hcg less than 1000 mIU/ml 20% will present with a B-hcg less than 500 mIU/ml Pts who present with a B-hcg less than 1000 mIU/ml have a higher risk of ectopic pregnancy Keep in mind with ectopics all you may see is an empty uterus and free fluid in the pelvis. Early Pregnancy Ultrasound

19. Transabdominal Ultrasound:

20. Gallbladder Transverse and horizontal clips through the gallbladder Measurement of the anterior wall of the gallbladder (2-3 mm) Measurement of the CBD (4-8mm) Look for: Stones Wall thickness Pericholeycystic fluid Sonomurphys CBD dilitation

21. Gallbladder Common Bile Duct

22. Indications: Signs and symptoms of Choleycystitis Most sensitive signs: Stones and Sono Murphys sign Very specific signs: Wall thickness, pericholeycystic fluid Gallbladder Literature

23. FAST Clips of RUQ LUQ Suprapubic Cardiac Depth Pericardial vs Pleural effusion Parasternal long if no SX view

24. Aorta Transverse View epigastric and infra-renal Measure the outer to outer wall of the Aorta Nl <3cm longitudinal views of the aorta in the epigastric region Bifurcation of the iliacs

25. Questions?????? Please email me with any and all questions Jamiegoodis@gmail.com