Cool stuff coming in 2015!

I gotta give a shout out to the #FOAMed world.  The last year and a half has been really stimulating, learning from and exchanging with an amazing cohort of peers, all striving towards self-improvement and saving a few extra lives. I’m also really thankful for all those who take a few minutes of their busy days to read or listen to some of the stuff I spew out, and truly appreciate comments and discussion.

Undeniably #FOAMed has made me a better doc, both from the standpoint of learning and inspiration, which is really the fuel behind continuing education. I’ve been involved in organizing events, and in fact, doing so, and the interaction with both the faculty and the participants has been, in and of itself, of immense worth in terms of motivation and a feeling of kinship to a like-minded group, which I think is very important to practicing physicians.

As a consequence of some of these #FOAMed introductions, some good things are in the planning stages for 2015.

Winter: check out BEEM january 26-28 out in Vancouver BC – I can’t make that but really wish I could.

Spring: Two really interesting events in collaboration with l’ASMIQ (Association des Specialistes en Medicine Interne du Quebec – Quebec internists), one being a half day on Shock & Resus (may 30th), and a full day on Lung Ultrasound (may 29th) featuring the grandfather of it all, guru Dr. Daniel Lichtenstein, the one who invented it (well…discovered it, technically). Both take place in Montreal. (Technically this is for ASMIQ members but if anyone is interested, let me know and I’ll see what I can do!)

Of course, CCUS 2015 takes place may 1-3 in Montreal. Can’t miss that. Register at

Summer? I’m not running anything, but definitely going to SMACC Chicago. Just go. ‘Nuff said.

Fall: Ken Milne (@TheSGEM) and I will be planning a really cool day combining a critical appraisal workshop and a review of acute care highlights, taking place in Montreal in the fall. Ken will teach us how to learn while being skeptical, and participants should leave with an important skill as well as a headful of practical knowledge. We don’t have a title for this yet but I’ll be sure to let you know! In the meantime be sure to check out Ken’s awesome stuff at He keeps it real.



I’ve also been asked to organize an Ultrasound Simulation Workshop (we are doing an EchoSchockSim in CCUS 2015), which may also happen towards the end of the year.


conferences 2015

Ok, so that was just a bit of an update on what’s up in the next year. Hope to meet some of you at these events, do come and say hi!




A Witnessed Arrest: Advanced Bedside Ultrasound. #FOAMed, #FOAMcc, #FOAMus

So I was taking over the ICU in the evening, and as I walked in I hear that an arrest had happened and she was now being wheeled out of the ICU to radiology for a CT head and CT angio. So I didn’t get to do a bedside exam.

The story was that an 84 year old woman who had been admitted for atrial arrhythmia had been noted to have different blood pressure in the upper extremities, and the concerned family had urged to hospitalist to seek additional opinions. At the very moment when she was being examined by but the daytime ICU doc and a cardiologist, she suddenly deteriorated. They were actually in the process of bedside ultrasound, which had been normal aside from a small pericardial effusion, when she became unresponsive, seemed to have some lateralizing signs, became bradycardia and arrested. They got ROSC with an epic within a couple of minutes.

The feeling was that, having been started on one of those NOACs (Eliquis), she had bled and arrested by neurocardiac axis. Definitely reasonable, but given the BP discrepancy, ruling out aortic dissection was also a must.

So here is the scan:

A quick glance reveals an ascending aortic aneurysm with what appears to be a dissection and a visible flap. The CT of the head was normal.  A closer look seems to reveal that the dissection extends into the brachiocephalic trunk.  My colleague discussed with the radiologist who repeatedly told him it was a type A but wouldn’t say anything more (don’t ask…). Just as a reminder, here is the current classification:

aortic dissection class

So in discussion with the family, there was obviously concern about the possible stroke (an early normal CT obviously does not rule out an ischemic infarct) and given that a palpable pulse does not exclude dissection, bedside ultrasound was the next step (also because the radiologist had not clearly pronounced himself on the scan – in all fairness he may have just done a preliminary reading – so here is what we see, with the carotid being in the lower right area of the flow box, and part of the jugular in the left upper.

As a comparison, here is the left side (normal – but inverted – jugular rt and carotid lt).

Clearly, most of the right carotid lumen is actually false lumen of the dissection, with only a small crescentic lumen between 3 and 6 o’clock. Not good.

Here are the basic cardiac views:


parasternal long axis


We can see a small pericardial effusion which looks textured – likely blood, and essentially normal function.  Now here is a right-sided parasternal view, showing the dissected aneurysm, including the dissected intimal flap:

Now this isn’t a routine view, and honestly I did it after having seen the scan where one can see that the aneurysm abuts the chest wall, which would make it ultrasoundable, and i can’t really say I would have done it without that knowledge. But now I would, if a similar case would present itself. Very insensitive but quite specific.

So I thought this was an interesting case to show, as a rapidly developing clinical picture, and from the point of view of bedside ultrasound, it displays the usefulness of carotid imaging and alternate views – and how simple it is to do.  Unfortunately at her age and given state she was not deemed a surgical candidate and passed away the next day.


thanks for reading!

…to sharpen up your resuscitation and ultrasound skills, don’t forget to come to CCUS 2015, may 1-3 in Montreal, Canada!  Register at and for more details,