Canadian Society of Internal Medicine does Lung Ultrasound!



Happy to be hosting a satellite event for the CSIM Annual meeting taking place in Montreal.  As an internist, I’ve been long wanting to see my colleagues working on the wards integrate bedside ultrasound into their practice. After all, as an ICU guy, i try to catch the patients spiralling down. However, bedside ultrasound in the care of hospitalized patients should actually have a greater impact! Wait, I hope I’m not promoting myself out of a job here… Oh well it is for the patients’ benefit.

But it’s true, preventing deterioration is best done well…prior to the deterioration.

Anyhow, looks like we’re gonna have a pretty good day, focused on lung ultrasound:




The faculty – besides me – is excellent: Andre Denault and Georges Desjardins are pros at doing and teaching, and workshop instructors Ian Ajmo and Philippe St-Arnaud, intensivist colleagues from my shop’s team, are great too.

I’m hoping that the echo-naive participants leave fully convinced that practicing acute care without ultrasound is essentially unethical, given today’s accessibility to the technology.  I hope they can see that it out-does the most educated guesses we can muster, most of the time. Because that is what we do when held to the limitations of physical exam, even if DeGowin, Bates and Shapira were doing the physical exams themselves…





Bedside ultrasound for Hospitalists: A Must! #Hospitalist, #FOAMed, #FOAMus

Hi, so here is a quick little overview on why anyone taking care of hospitalized patients unequivocally need to use bedside ultrasound in a daily, integrated fashion, even if they don’t realize it yet.

It isn’t just for the flashy spot diagnoses in the ICU or the ER, but really for daily rounds, assessing common cardiac, respiratory, renal, gastrointestinal and even neurological syndromes.

Love to hear from any hospitalists or medical consultants out there about their use of bedside ultrasound!



The Clinical Revolution of Bedside Ultrasound: Not Bloodless! #FOAMed, #FOAMus, #FOAMcc

Thanks to @icerman_ex’s sharp eye, just finished reading @EMNerd’s awesome post on bedside ultrasound (   I think it casts the right light on bedside ultrasound, and as usual in spectacular prose that is the only #FOAM I know that discusses science so artfully.

There are a couple of things I’d like to add, for those who may be interested.  And, as a disclaimer, I am heavily, heavily biased towards the widespread use of bedside ultrasound. It is a revolution in medicine, undoubtedly the biggest one of the last decades, but, as with any revolution, blood will be shed, and it’s only when the dust settles that our science will be better.

First of all, everyone should understand that due to bedside ultrasound coming into its own in the era of evidence-based medicine, it is being asked to jump through hoops like no other tool has been. Try looking for a randomized trial on the use of the stethoscope… So it is important to keep this in mind as the fine tuning takes place, rather than try to blindly adopt it or toss it out with every new study that comes out.

As Rory points out, the issue isn’t one of accuracy per se, rather than the clinical interpretation of that accuracy – that is, the clinician being able to tune out the noise, just like one would parts of the history or physical that are irrelevant or misleading. The failure to do so will lead to unnecessary interventions or testing.

Another point is that the second generation of bedside sonographers are not inherently the same as the first, who took up the probes to answer clinical questions and created the protocols and algorithms – as always, much kudos to Daniel Lichtenstein, “le premier des pioneers” – whereas the second generation will be a very mixed bag, many of which will carry bedside ultrasound and push it farther, but also many others who will apply what they have learnt without necessarily the same framework.  If you look at the history of medical developments, initial wonders often have subsequent setbacks, until training and practice are fine tuned – take the history of laparoscopic surgery, for instance.

The key point in all this is that proper clinical integration is necessary, and that trainees have to be well mentored by those who do use the tool in a daily fashion, and finally – as always – some good studies in a number of clinical scenarios, so as not to have (only) a pixelated view of the patient.






Jon-Emile says…

Wonderful post:

You know my position on inspiratory IVC collapse []

My problem with the Kenji trial is that is certainly does not [and cannot] tell us if seeing IVC collapse means that a patient will augment their cardiac output in response to a fluid bolus. What their trial tells us is that using less fluids and more pressors in shocked patients probably improves outcomes … but i think few of us doubt that currently [especially in light of the PROCESS trial last spring]. Instead [and i say this facetiously of course] they could have used a random number generator that was weighted to giving less fluids and more pressors instead of bedside ultrasound … and they probably would have received similar results.

It is hard for me to imagine a physiological scenario whereby a patient has a fixed and dilated IVC on ultrasound with respiration [spontaneous, triggered, or passive] but could still be fluid responsive. So when I see a fixed, dilated IVC, I feel fairly confident that fluids should stop [again this does not tell me about the patient’s volume status, as a patient could have a very plump IVC and be volume deplete].

But this physiology is not new and was published by Magder in the early 90s [invariant right atrial pressures with respiration predicted fluid non-responsiveness very well] and also by Pinsky in the early 90s when he found that in post surgical patients that right atrial distending pressure is dissociated from right ventricular end-diastolic volume. Which means that when you see right heart congestion, you have probably already reached cor pulmonale.

The true challenge is IVC collapse … it is affected by many conflicting variables [as you know]; there is probably a good portion of patients who have IVC collapse [especially those on PEEP, triggering the ventilator] who are actually fluid non-responders, yet we push them closer and closer to cor pulmonale needlessly … so until someone finds a better non-invasive physiological solution …

as EM Nerd, so aptly puts it …

“In medicine we frequently propagate half-truths and unsubstantiated certainties.”

Thanks for the post space,


Excellent points!




Pericardiocentesis for tamponade w/bedside ultrasound: Procedure Video. #FOAMed, #FOAMcc, #FOAMus

So this case was interesting on a couple of levels.

A 76 year old woman presented to the ER with a complaint of abdominal discomfort and was admitted with a diagnosis of pneumonia and lower abdominal cellulitis. She had a history of diabetes, obesity and remote oral cancer which had been treated 6 yrs ago.  The next morning, while still in the ER awaiting a ward bed, she had a hypotensive episode, and fortunately the ER doc on shift grabbed an ultrasound probe and took a look, calling me a few minutes later with a diagnosis of tamponade. She was absolutely correct. I saw and echo’d her shortly after:

The first two clips show the IVC, which is distended with minimal variation. This should prompt the bedside sonographer to anticipate downstream pathology (except for iatrogenic volume overload and renal failure…).

The subsequent clips show subxiphoid views (and one clip of the associated left pleural effusion) showing a significant pericardial effusion and difficult to distinguish cardiac chambers.

Clinically, she was dyspneic, uncomfortable, HR 115, BP 130’s systolic (in ER in 80’s then got some fluid). Her heart sounds were not particularly quiet, and her JVP was difficult to assess due to obesity.

Here is the drainage video:

Her abdominal pain resolved very rapidly, her breathing improved and vitals stabilized.

Pathology is still pending, but bloody effusions commonly include malignancy, tuberculosis, but also simple viral paricarditis.

So I think this is a great case for the argument of integrating ultrasound into physical examination rather than as an ancillary test.  Because she didn’t present with a predominant hypotensive or respiratory component, the diagnosis wasn’t seriously entertaine, and obesity, body habitus and pleural effusion undoubtedly made physicians overlook the cardiomegaly. However, in my opinion and that of most bedside sonographers, abdominal pain warrants an abdominal us exam, and the distended IVC would have prompted at least a quick cardiac assessment, and the effusion would have been noted immediately.

In my CC/IM practice, hardly anyone escapes the probe, as cardiopulmonary and abdominal status is hardly ever irrelevant to me…