Publications by authors named "Keith S Boniface"

28 Publications

  • Page 1 of 1

Utilization of Automated Keyword Search to Identify E-Scooter Injuries in the Emergency Department.

Cureus 2021 Nov 13;13(11):e19539. Epub 2021 Nov 13.

Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

Background and objective Accurate identification and categorization of injuries from medical records can be challenging, yet it is important for injury epidemiology and prevention efforts. Coding systems such as the International Classification of Diseases (ICD) have well-known limitations. Utilizing computer-based techniques such as natural language processing (NLP) can help augment the identification and categorization of diseases in electronic health records. We used a Python program to search the text to identify cases of scooter injuries that presented to our emergency department (ED). Materials and methods This retrospective chart review was conducted between March 2017 and June 2019 in a single, urban academic ED with approximately 80,000 annual visits. The physician documentation was stored as combined PDF files by date. A Python program was developed to search the text from 186,987 encounters to find the string "scoot" and to extract the 100 characters before and after the phrase to facilitate a manual review of this subset of charts. Results A total of 890 charts were identified using the Python program, of which 235 (26.4%) were confirmed as e-scooter cases. Patients had an average age of 36 years and 53% were male. In 81.7% of cases, the patients reported a fall from the scooter and only 1.7% reported wearing a helmet during the event. The most commonly injured body areas were the upper extremity (57.9%), head (42.1%), and lower extremity (36.2%). The most frequently consulted specialists were orthopedic and trauma surgeons with 28% of cases requiring a consult. In our population, 9.4% of patients required admission to the hospital. Conclusions The number of results and data returned by the Python program was easy to manage and made it easier to identify charts for abstraction. The charts obtained allowed us to understand the nature and demographics of e-scooter injuries in our ED. E-scooters continue to be a popular mode of transportation, and understanding injury patterns related to them may inform and guide opportunities for policy and prevention.
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http://dx.doi.org/10.7759/cureus.19539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8667961PMC
November 2021

Point-of-Care Ultrasound in the Diagnosis of an Incarcerated Inguinal Hernia.

Cureus 2021 Jul 9;13(7):e16281. Epub 2021 Jul 9.

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA.

Emergency physicians can use point-of-care ultrasound to diagnose inguinal hernias as well as their potential complications, including small bowel obstruction, incarceration, and even strangulation. We provide an overview of the sonographic appearance of inguinal hernias, as well as the diagnostic criteria of serious complications. In this case report, point-of-care ultrasound findings included a non-reducible inguinal hernia associated with significant bowel dilation in multiple loops without signs of intestinal ischemia or necrosis.
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http://dx.doi.org/10.7759/cureus.16281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349524PMC
July 2021

Images in Primary Care Medicine: Point-of-Care Ultrasound in Gout.

Cureus 2021 May 18;13(5):e15096. Epub 2021 May 18.

Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

Gout is the most common crystal arthropathy and is frequently diagnosed and managed by primary care physicians. Point-of-care ultrasound (POCUS) is a valuable tool to aid in the diagnosis of gout via the identification of the double contour sign, aggregates of crystals, tophi, and erosions. In addition, POCUS can aid in the management of gout by recognizing early signs of gout, monitoring the effectiveness of urate-lowering therapy, and guiding aspiration and corticosteroid injection.
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http://dx.doi.org/10.7759/cureus.15096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211301PMC
May 2021

Learner-centered Survey of Point-of-care Ultrasound Training, Competence, and Implementation Barriers in Emergency Medicine Training Programs in India.

AEM Educ Train 2020 Oct 27;4(4):387-394. Epub 2019 Dec 27.

Department of Emergency Medicine The George Washington University Washington DC.

Background: Point-of-care ultrasound (POCUS) is important to the practice of emergency medicine (EM), but requires training to achieve competence. The purpose of this study was to describe the current state of POCUS practice and perceived barriers to the implementation in EM training programs in India.

Methods: A cross-sectional survey consisting of 28 questions was administered to 378 faculty and residents in postgraduate EM training programs across India.

Results: Data were collected from 159 physicians from 16 institutions; 76% of them were EM residents, with a response rate of 42%. Respondents overwhelmingly reported high interest (91%) in learning POCUS topics. Respondents identified highest levels of comfort with the performance and interpretation of trauma ultrasound (US) and echocardiography. Conversely, there was a scarce interest and low levels of competence in performing obstetric US, which may be a result of the practice of triaging these complaints to obstetricians and gynecologists. Lack of US equipment and dedicated training were the highest rated barriers by a significant margin, which 56% of respondents ranked as "very important."

Conclusions: While significant interest in POCUS exists among the Indian EM physicians, comfort and competence were limited to trauma and echocardiography applications. Expansion of and comfort with POCUS use in these settings may be sought through improvement of access to US equipment and a dedicated US curriculum.
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http://dx.doi.org/10.1002/aet2.10423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592833PMC
October 2020

Optic Nerve Sheath Diameter Measured by Point-of-Care Ultrasound and MRI.

J Neuroimaging 2020 11 8;30(6):793-799. Epub 2020 Sep 8.

Department of Radiology, The George Washington University Medical Center, Washington, DC.

Background And Purpose: Ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) and optic nerve diameter (OND) is a method frequently used to screen for an increased intracranial pressure. The aim of this study was to assess the accuracy of US measurements of ONSD and OND, when compared to magnetic resonance imaging (MRI) measurements as the criterion standard.

Methods: In this prospective, single-institution study, orbital US was performed for those patients requiring an emergent brain MRI. ONSD and OND of both eyes were measured in the axial and coronal planes in straight gaze by US. ONSD and OND from brain and orbital MRI were measured by two neuroradiologists. Correlation and agreement between readings were assessed using Pearson's correlations.

Results: Eighty-two patients met inclusion criteria. The mean axial and coronal ONSD in the MRI examinations was 5.6 and 5.7 mm at 3-5.9 mm behind the globe, respectively. The mean ONSD from the US measurements was 6.22 and 5.52 mm in the axial and coronal planes, respectively. The mean OND in US examinations was 4.31 mm (axial) and 3.68 mm (coronal). Axial versus coronal measurements of ONSD had a modest correlation in US assessment with an r of .385 (P < .001) but there were no correlations between any of the US and MRI measurements.

Conclusions: In measuring ONSD and OND, US measurements showed a modest correlation between axial and coronal measurements, but no concordance was found between US and MRI in our setting.
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http://dx.doi.org/10.1111/jon.12764DOI Listing
November 2020

A cruise ship emergency medical evacuation triggered by handheld ultrasound findings and directed by tele-ultrasound.

Int Marit Health 2020 ;71(1):42-45

The George Washington University, 2120 L Street NW, Suite 450, 20037 Washington, DC, United States.

Cruise ships travel far from shoreside medical care and present a unique austere medical environment. For the cruise ship physician, decisions regarding emergency medical evacuation can be challenging. In the event that a passenger or crew member becomes seriously ill or is injured, the use of point-of-care ultrasound may assist in clarifying the diagnosis and stratifying the risk of a delayed care, and at times expedite an emergent medical evacuation. In this report we present the first case reported in the literaturę of an emergency medical evacuation from a cruise ship triggered by handheld ultrasound. A point-of-care ultrasound performed by a trained cruise ship physician, reviewed by a remote telemedical consultant with experience in point-of-care ultrasound, identified an ectopic pregnancy with intraabdominal free fluid in a young female patient with abdominal pain and expedited emergent helicopter evacuation from a cruise ship to a shoreside facility, where she immediately underwent successful surgery. The case highlights a medical evacuation that was accurately triggered by utilising a handheld ultrasound and successfully directed via a tele-ultrasound consultation. American College of Emergency Physicians (ACEP) health care guidelines for cruise ship medical facilities should be updated to include guidelines for point-of-care ultrasound, including training and telemedical support.
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http://dx.doi.org/10.5603/IMH.2020.0010DOI Listing
December 2020

Development of a nomogram to predict small bowel obstruction using point-of-care ultrasound in the emergency department.

Am J Emerg Med 2020 11 16;38(11):2356-2360. Epub 2019 Dec 16.

Department of Pharmacy, Kaiser Permanente Colorado Region, Aurora, CO & Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, UT, United States of America.

Objective: Early diagnostic prediction in patients with small bowel obstruction (SBO) can improve time to definitive management and disposition in the emergency department. We sought to develop a nomogram to leverage point-of-care ultrasound (POCUS) and maximize accuracy of prediction of SBO diagnosis.

Methods: Using data from a prospective cohort of 125 patients with suspected SBO who were evaluated with POCUS in the ED, we developed a nomogram integrating age, gender, comorbidities, prior abdominal surgery, physician's pre-test probability, and POCUS findings to determine post-test risk of SBO. The primary outcome was to develop a nomogram to allow calculating output probabilities for predictive models using POCUS findings. The discriminative ability of the nomogram was tested using a C-statistics, calibration plots, and receiver operating characteristic curves.

Results: The derivation cohort included 125 patients with a median age of 54 years who underwent POCUS for a suspected SBO. One-fourth of the patients (25.6% [32/125]) had SBO. Using a retrospective stepwise selection of clinically important variables with the POCUS results, the final nomogram incorporated four relevant factors for the prediction of SBO: small bowel diameter (odds ratio [OR] per 1 mm increase, 1.10; 95% CI, 1.03-1.17; P = 0.001), positive free intraperitoneal fluid between bowel loops (OR, 8.19; 95% CI, 2.62-25.62; P < 0.001), clinician's moderate (OR, 5.94; 95% CI, 0.83-42.57; P = 0.08) or high pretest probability (OR, 11.26; 95% CI, 1.44-88.25; P = 0.02), and patient age (OR per 1 year increase, 1.03; 95% CI, 1.00 to1.07; P = 0.08).The discriminative ability and calibration of the nomogram revealed good predictive ability as indicated by the C-statistic of 0.89 for the SBO diagnosis.

Conclusion: A unique nomogram incorporating patient age, physician pretest probability of SBO, and POCUS measurements of small bowel diameter and the presence of free intraperitoneal fluid between bowel loops was developed to accurately predict the diagnosis of SBO in the emergency department. The nomogram should be externally validated in a novel cohort of patients at risk for SBO to better assess predictability and generalizability.
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http://dx.doi.org/10.1016/j.ajem.2019.12.010DOI Listing
November 2020

Diagnostic Accuracy and Time-Saving Effects of Point-of-Care Ultrasonography in Patients With Small Bowel Obstruction: A Prospective Study.

Ann Emerg Med 2020 02 23;75(2):246-256. Epub 2019 Jul 23.

The George Washington University Medical Center, Washington, DC; Massachusetts General Hospital-Harvard Medical School, Boston, MA. Electronic address:

Study Objective: We evaluate the accuracy of point-of-care ultrasonography compared with computed tomographic (CT) scan and assess the potential time-saving effect of point-of-care ultrasonography in diagnosing small bowel obstruction.

Methods: This was a prospective observational study of a convenience sample of patients with suspected small bowel obstruction in an academic emergency department (ED). Physician sonographers were blinded to clinical data, laboratory results, and CT scan findings. Point-of-care ultrasonographic findings of small bowel obstruction was the primary outcome, defined as bowel-loop diameter greater than or equal to 25 mm with abnormal peristalsis. Maximum bowel dilatation, visible peristalsis, interluminal free fluid, and bowel wall thickness were evaluated. Time to completion of imaging results was abstracted from the medical records for each imaging modality.

Results: The study included 125 patients (median age 54.0 years [interquartile range 43 to 63 years]; 46% men), of whom 32 (25.6%) had small bowel obstruction, and 9 (7.2%) underwent surgery for it. Overall, the sensitivity of point-of-care ultrasonography for small bowel obstruction was 87.5% (95% confidence interval 71.0% to 96.5%), and specificity was 75.3% (95% confidence interval 65.2% to 83.6%). The area under the receiver operating characteristic curve to accurately predict small bowel obstruction was 0.74 (95% confidence interval 0.66 to 0.82). Results were similar across evaluated subgroups, including physician training level. The average time to obtain a CT scan report was 3 hours, 42 minutes; obtaining an abdominal radiograph took 1 hour, 38 minutes; and the mean elapsed time to complete point-of-care ultrasonography was 11 minutes.

Conclusion: In ED patients with suspected small bowel obstruction, point-of-care ultrasonography has a reasonably high accuracy in diagnosing small bowel obstruction compared with CT scan, and may substantially decrease the time to diagnosis.
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http://dx.doi.org/10.1016/j.annemergmed.2019.05.031DOI Listing
February 2020

Direct Observation Assessment of Ultrasound Competency Using a Mobile Standardized Direct Observation Tool Application With Comparison to Asynchronous Quality Assurance Evaluation.

AEM Educ Train 2019 Apr 19;3(2):172-178. Epub 2019 Feb 19.

Department of Emergency Medicine The George Washington University Washington DC.

Objectives: Competency assessment is a key component of point-of-care ultrasound (POCUS) training. The purpose of this study was to design a smartphone-based standardized direct observation tool (SDOT) and to compare a faculty-observed competency assessment at the bedside with a blinded reference standard assessment in the quality assurance (QA) review of ultrasound images.

Methods: In this prospective, observational study, an SDOT was created using SurveyMonkey containing specific scoring and evaluation items based on the Council of Emergency Medicine Residency-Academy of Emergency Ultrasound: Consensus Document for the Emergency Ultrasound Milestone Project. Ultrasound faculty used the mobile phone-based data collection tool as an SDOT at the bedside when students, residents, and fellows were performing one of eight core POCUS examinations. Data recorded included demographic data, examination-specific data, and overall quality measures (on a scale of 1-5, with 3 and above being defined as adequate for clinical decision making), as well as interpretation and clinical knowledge. The POCUS examination itself was recorded and uploaded to QPath, a HIPAA-compliant ultrasound archive. Each examination was later reviewed by another faculty blinded to the result of the bedside evaluation. The agreement of examinations scored adequate (3 and above) in the two evaluation methods was the primary outcome.

Results: A total of 163 direct observation evaluations were collected from 23 EM residents (93 SDOTs [57%]), 14 students (51 SDOTs [31%]), and four fellows (19 SDOTs [12%]). The trainees were evaluated on completing cardiac (54 [33%]), focused assessment with sonography for trauma (34 [21%]), biliary (25 [15%]), aorta (18 [11%]), renal (12 [7%]), pelvis (eight [5%]), deep vein thrombosis (seven [4%]), and lung scan (5 [3%]). Overall, the number of observed agreements between bedside and QA assessments was 81 (87.1% of the observations) for evaluating the quality of images (scores 1 and 2 vs. scores 3, 4, and 5). The strength of agreement is considered to be "fair" (κ = 0.251 and 95% confidence interval [CI] = 0.02-0.48). Further agreement assessment demonstrated a fair agreement for images taken by residents and students and a "perfect" agreement in images taken by fellows. Overall, a "moderate" inter-rater agreement was found in 79.1% for the accuracy of interpretation of POCUS scan (e.g., true positive, false negative) during QA and bedside evaluation (κ = 0.48, 95% CI = 0.34-0.63). Faculty at the bedside and QA assessment reached a moderate agreement on interpretations noted by residents and students and a "good" agreement on fellows' scans.

Conclusion: Using a bedside SDOT through a mobile SurveyMonkey platform facilitates assessment of competency in emergency ultrasound learners and correlates well with traditional competency evaluation by asynchronous weekly image review QA.
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http://dx.doi.org/10.1002/aet2.10324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457355PMC
April 2019

The Utility and Survivorship of Peripheral Intravenous Catheters Inserted in the Emergency Department.

Ann Emerg Med 2019 09 27;74(3):381-390. Epub 2019 Mar 27.

Health Policy and Management and Emergency Medicine, George Washington University, Washington, DC.

Study Objective: We compare the use and survivorship rate of peripheral intravenous catheters placed in the emergency department (ED) by insertion method.

Methods: We analyzed a prospective cohort of ED patients who received a peripheral intravenous catheter in the ED by ultrasonographically guided or landmark insertion. Research assistants recorded the uses of the ED-inserted catheters during the ED visit and hospitalization. Among subjects admitted, research assistants tracked catheter survivorship for 72 hours or hospital discharge, whichever came first. Research assistants documented reason for catheter removal and whether it was replaced during hospitalization. Premature removal was defined as catheters that were replaced because of mechanical failure, complication, or discomfort. We used multivariate binomial regression to estimate the relative risk of insertion method on premature removal and a Kaplan-Meier curve to compare survivorship duration by insertion method.

Results: A cohort of 1,174 patients with a mean age of 45 years and 63% female predominance was analyzed. Catheter use was 73% and 78% in the ED and hospital for the administration of fluids, medications, or contrast agents (and 96% if blood drawn for testing was included). Peripheral intravenous use did not differ significantly in the ED or hospital by insertion method. For 330 patients who were admitted, 132 of 182 patients (73%) in the ultrasonographically guided group and 117 of 148 (79%) in the landmark group had 72-hour catheter survival. Premature removal was not significantly more likely to occur if the catheter was inserted by the ultrasonographically guided method compared with the landmark one (relative risk 1.26; 95% confidence interval 0.88 to 1.80).

Conclusion: ED-inserted peripheral intravenous catheters were frequently used in the ED and hospital. Peripheral intravenous use and hospital survivorship of ED-inserted peripheral intravenous catheters were similar by insertion method.
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http://dx.doi.org/10.1016/j.annemergmed.2019.02.003DOI Listing
September 2019

Assessment of Point-of-Care Ultrasound Training for Clinical Educators in Malawi, Tanzania and Uganda.

Ultrasound Med Biol 2019 06 21;45(6):1351-1357. Epub 2019 Mar 21.

Department of Emergency Medicine, George Washington University Medical Center, Washington, DC, USA.

Integrating point-of-care ultrasound (POCUS) to enhance diagnostic availability in resource-limited regions in Africa has become a main initiative for global health services in recent years. In this article, we present lessons learned from introducing POCUS as part of the Global Health Service Partnership (GHSP), a collaboration started in 2012 between the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Peace Corps and Seed Global Health to provide health care work force education and training in resource-limited countries. A cross-sectional survey of GHSP clinical educators trained to use POCUS and provided with hand-held ultrasound during their 1-y deployment during the period 2013-2017. The survey consisted of 35 questions on the adequacy of the training program and how useful POCUS was to their overall clinical and educational mission. Clinical educators engaged in a series of ultrasound educational initiatives including pre-departure training, bedside training in the host institutions, online educational modules, educational feedback on transmitted images and training of local counterparts. In this study 63 GHSP clinical educators who participated in the POCUS trainings were identified, and 49 were included at the study (78% response rate). They were assigned to academic institutions in Tanzania (n = 24), Malawi (n = 21) and Uganda (n = 18). More than 75% reported use of POCUS in clinical diagnoses and 50% in determining treatment, and 18% reported procedural application of ultrasound in their practice. The top indications for POCUS were cardiac exams, second- and third-trimester obstetric exams, lung and pleura, liver and spleen and gynecology/first-trimester obstetrics. The largest perceived barriers were lack of ultrasound knowledge by the clinical educators, lack of time, equipment security, difficulty accessing the Internet and equipment problems. We concluded that our multiphase POCUS training program has increased the utility, acceptability and usage of POCUS in resource-limited settings.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2019.01.019DOI Listing
June 2019

The Global Health Service Partnership's point-of-care ultrasound initiatives in Malawi, Tanzania and Uganda.

Am J Emerg Med 2019 04 27;37(4):777-779. Epub 2018 Aug 27.

Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston MA; and The George Washington University Medical Center, Washington DC, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2018.08.065DOI Listing
April 2019

Ultrasound-guided intravenous access in adults using SonoStik, a novel encapsulated sterile guidewire: A prospective cohort trial.

J Vasc Access 2018 Sep 12;19(5):441-445. Epub 2018 Mar 12.

1 Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC, USA.

Purpose: We evaluated the performance of an encapsulated guidewire designed for single-handed use with ultrasound-guided vascular access (SonoStik) with Seldinger technique, as compared with conventional intravenous catheters placed under ultrasound guidance in healthy subjects.

Methods: This is a prospective cohort trial in healthy subjects in which each subject served as his/her own control by having a SonoStik ultrasound intravenous cannulation placed in one arm and a conventionally placed, standard ultrasound intravenous cannulation placed in the other arm. The basilic vein was used because it is a non-visible and non-palpable vein. Emergency department technicians with extensive experience in ultrasound-guided intravenous access performed the procedures. The first-attempt success rate of intravenous-guided intravenous by using the SonoStik was compared to the standard ultrasound intravenous cannulation in adult healthy subjects. The secondary outcomes including time of procedure, technicians' and subjects' satisfaction, and complications were compared in both arms of the study.

Results: A total of 24 volunteers with a mean age of 22.7 years were enrolled. Four emergency department technicians with extensive prior experience with ultrasound-guided intravenous access but with no prior experience using the SonoStik device performed the procedures. The first-attempt success was 83.3% with the use of SonoStik ultrasound intravenous cannulation compared to 95.8% with the standard ultrasound intravenous cannulation. There was a mean of 1.14 insertions per each successful placement in the SonoStik group compared to 1.04 insertions by using the standard catheters (mean differences = -0.1; 95% confidence interval = -0.6 to 0.4). There were no complications in either SonoStik or the standard ultrasound intravenous cannulation group. The mean time of insertion using SonoStik was slightly longer compared to standard ultrasound intravenous cannulation (143.3 vs 109.7 s).

Conclusion: This study demonstrated that emergency department technicians skilled in ultrasound-guided intravenous access could successfully place SonoStik 83.3% of the time in vessels that were unable to be palpated or visualized. Compared to standard ultrasound intravenous cannulation, the odds ratio of successful cannulation with SonoStik was 0.91 (95% confidence interval = 0.04-17.5). In all cases, the time required to successfully insert SonoStik was less than 4 min from tourniquet application to catheter advancement to hub, with a mean time of less than 2.5 min.
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http://dx.doi.org/10.1177/1129729818758228DOI Listing
September 2018

Point-of-care ultrasound leads to diagnostic shifts in patients with undifferentiated hypotension.

Am J Emerg Med 2017 Dec 26;35(12):1984.e3-1984.e7. Epub 2017 Aug 26.

Department of Radiology, George Washington University Medical Center, United States.

Objective: To assess the impact of an ultrasound hypotension protocol in identifying life-threatening diagnoses that were missed in the initial evaluation of patients with hypotension and shock.

Methods: A subset of cases from a previously published prospective study of hypotensive patients who presented at the Emergency Department in a single, academic tertiary care hospital is described. An ultrasound-trained emergency physician performed an ultrasound on each patient using a standardized hypotension protocol. In each case, the differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. This is a case series of patients with missed diagnoses in whom ultrasound led to a dramatic shift in diagnosis and management by detecting life threatening pathologies.

Results: Following a published prospective study of the effect on an ultrasound protocol in 118 hypotensive patients, we identified a series of cases that ultrasound protocol unexpectedly determined serious life threatening diagnoses such as Takotsubo cardiomyopathy, pulmonary embolism, pericardial effusion with tamponade physiology, abdominal aortic aneurysm and perforated viscus resulting in proper diagnoses and management. These hypotensive patients had completely unsuspected but critical diagnoses explaining their hypotension, who in every case had their management altered to target the newly identified life-threatening condition.

Conclusions: A hypotension protocol is an optimal use of ultrasound that exemplifies "right time, right place", and impacts decision-making at the bedside. In cases with undifferentiated hypotension, ultrasound is often the most readily available option to ensure that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential.
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http://dx.doi.org/10.1016/j.ajem.2017.08.054DOI Listing
December 2017

Sonographic localization of a retained urethral foreign body in an elderly patient.

J Clin Ultrasound 2018 May 27;46(4):296-298. Epub 2017 Jun 27.

Section of Emergency Sonography, Department of Emergency Medicine, George Washington University Medical Center, 2120 L Street NW, Suite 450, Washington, DC, 20037.

A retained urethral foreign body is an uncommon presentation in the Emergency Department. The diagnosis and treatment of retained urethral foreign bodies are determined by their size, location, shape, and mobility and often require specialty consultation and operative intervention. In this case of a 74-year-old man with a self-inserted, retained urethral foreign body, we present the utility of a bedside ultrasound to detect the depth, size, and distance from the meatus of the object to guide the approach to extraction of the object at the bedside in the Emergency Department. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:296-298, 2018.
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http://dx.doi.org/10.1002/jcu.22515DOI Listing
May 2018

Ultrasound and Perforated Viscus; Dirty Fluid, Dirty Shadows, and Peritoneal Enhancement.

Emerg (Tehran) 2016 ;4(2):101-5

Department of Emergency Medicine, George Washington University Medical Center, Washington DC, USA.

Early detection of free air in the peritoneal cavity is vital in diagnosis of life-threatening emergencies, and can play a significant role in expediting treatment. We present a series of cases in which bedside ultrasound (US) in the emergency department accurately identified evidence of free intra-peritoneal air and echogenic (dirty) free fluid consistent with a surgical final diagnosis of a perforated hollow viscus. In all patients with suspected perforated viscus, clinicians were able to accurately identify the signs of pneumoperitoneum including enhanced peritoneal stripe sign (EPSS), peritoneal stripe reverberations, and focal air collections associated with dirty shadowing or distal multiple reflections as ring down artifacts. In all cases, hollow viscus perforation was confirmed surgically. It seems that, performing US in patients with suspected perforated viscus can accurately identify presence of intra-peritoneal echogenic or "dirty" free fluid as well as evidence of free air, and may expedite patient management.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893760PMC
June 2016

Bedside Ultrasound Reduces Diagnostic Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension.

Crit Care Med 2015 Dec;43(12):2562-9

1Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC. 2Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA. 3Department of Critical Care Medicine and Anesthesiology, The George Washington University Medical Center, Washington DC. 4Department of Emergency Medicine, Shiekh Khalifa Medical City, Abu Dhabi, United Arab Emirates.

Objectives: Utilization of ultrasound in the evaluation of patients with undifferentiated hypotension has been proposed in several protocols. We sought to assess the impact of an ultrasound hypotension protocol on physicians' diagnostic certainty, diagnostic ability, and treatment and resource utilization.

Design: Prospective observational study.

Setting: Emergency department in a single, academic tertiary care hospital.

Subjects: A convenience sample of patients with a systolic blood pressure less than 90 mm Hg after an initial fluid resuscitation, who lacked an obvious source of hypotension.

Interventions: An ultrasound-trained physician performed an ultrasound on each patient using a standardized hypotension protocol. Differential diagnosis and management plan was solicited from the treating physician immediately before and after the ultrasound. Blinded chart review was conducted for management and diagnosis during the emergency department and inpatient hospital stay.

Measurements And Main Results: The primary endpoints were the identification of an accurate cause for hypotension and change in physicians' diagnostic uncertainty. The secondary endpoints were changes in treatment plan, use of resources, and changes in disposition after performing the ultrasound. One hundred eighteen patients with a mean age of 62 years were enrolled. There was a significant 27.7% decrease in the mean aggregate complexity of diagnostic uncertainty before and after the ultrasound hypotension protocol (1.85-1.34; -0.51 [95% CI, -0.41 to -0.62]) as well as a significant increase in the absolute proportion of patients with a definitive diagnosis from 0.8% to 12.7%. Overall, the leading diagnosis after the ultrasound hypotension protocol demonstrated excellent concordance with the blinded consensus final diagnosis (Cohen k = 0.80). Twenty-nine patients (24.6%) had a significant change in the use of IV fluids, vasoactive agents, or blood products. There were also significant changes in major diagnostic imaging (30.5%), consultation (13.6%), and emergency department disposition (11.9%).

Conclusions: Clinical management involving the early use of ultrasound in patients with hypotension accurately guides diagnosis, significantly reduces physicians' diagnostic uncertainty, and substantially changes management and resource utilization in the emergency department.
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http://dx.doi.org/10.1097/CCM.0000000000001285DOI Listing
December 2015

Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial.

Ann Emerg Med 2016 07 23;68(1):10-8. Epub 2015 Oct 23.

Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

Study Objective: Randomized controlled trials report inconsistent findings when comparing the initial success rate of peripheral intravenous cannulation using landmark versus ultrasonography for patients with difficult venous access. We sought to determine which method is superior for patients with varying levels of intravenous access difficulty.

Methods: We conducted a 2-group, parallel, randomized, controlled trial and randomly allocated 1,189 adult emergency department (ED) patients to landmark or ultrasonography, stratified by difficulty of access and operator. ED technicians performed the peripheral intravenous cannulations. Before randomization, technicians classified subjects as difficult, moderately difficult, or easy access according to visible or palpable veins and perception of difficulty with a landmark approach. If the first attempt failed, we randomized subjects a second time. We compared the initial and second-attempt success rates by procedural approach and difficulty of intravenous access, using a generalized linear mixed regression model, adjusted for operator.

Results: The 33 participating technicians enrolled a median of 26 subjects (interquartile range 9 to 55). The initial success rate was 81% but varied significantly by technique and difficulty of access. The initial success rate by ultrasonography was higher than landmark for patients with difficult access (48.0 more successes per 100 tries; 95% confidence interval [CI] 35.6 to 60.3) or moderately difficult access (10. 2 more successes per 100 tries; 95% CI 1.7 to 18.7). Among patients with easy access, landmark yielded a higher success rate (10.6 more successes per 100 tries; 95% CI 5.8 to 15.4). The pattern of second-attempt success rates was similar.

Conclusion: Ultrasonographic peripheral intravenous cannulation is advantageous among patients with difficult or moderately difficult intravenous access but is disadvantageous among patients anticipated to have easy access.
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http://dx.doi.org/10.1016/j.annemergmed.2015.09.009DOI Listing
July 2016

Trauma-Induced Bilateral Ectopia Lentis Diagnosed with Point-of-Care Ultrasound.

J Emerg Med 2015 Jun 19;48(6):e135-7. Epub 2015 Mar 19.

George Washington University Medical Center, Washington, DC.

Background: Ocular trauma and acute loss of vision are high-yield patient presentations that may benefit from the use of bedside ultrasound to aid in the diagnosis of a variety of vision-threatening problems.

Case Report: We present a case of bilateral lens dislocation in which the diagnosis of lens dislocation was missed on initial computed tomography of the orbits but detected on bedside ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point-of-care ultrasound can rapidly identify ocular pathology and expedite specialist consultation, and if necessary, transfer to a specialty center for further management.
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http://dx.doi.org/10.1016/j.jemermed.2015.01.004DOI Listing
June 2015

Ultrasound credentialing in North American emergency department systems with ultrasound fellowships: a cross-sectional survey.

Emerg Med J 2015 Oct 22;32(10):804-8. Epub 2015 Jan 22.

Department of Emergency Medicine, George Washington University, Washington DC, USA.

Objective: To describe the credentialing systems of North American emergency department systems (EDS) with emergency ultrasound (EUS) fellowship programmes.

Methods: This is a prospective, cross-sectional, survey-based study of North American EUS fellowships using a 62-item, pilot-tested, web-based survey instrument assessing credentialing and training systems. The American College of Emergency Physicians (ACEP) distributed the surveys using SNAP survey (Snap Surveys Ltd, Portsmouth, New Hampshire, USA).

Results: Over 6 months, 75 eligible programmes were surveyed, 55 responded (73% response rate); 1 declined to participate leaving 54 participating programmes. Less than 20% of EDS credential nurses, physician assistants, nurse practitioners and students in EUS. Respondent EDS reported having an average of 4.2 ± 3.3 ultrasound faculty members (faculty identifying their career focus as EUS). The median number of annual point-of-care ultrasounds reported was 5000 (IQR 3000-8000). 30 EDS (56%) credential each examination individually and 48 EDS (89%) use ACEP credentialing criteria. 61% of fellowship leadership believe their credentialing system is either satisfactory or very satisfactory (Cronbach's coefficient α=0.84).

Conclusions: The data show heterogeneity among North American EDS with EUS fellowship programmes with regard to credentialing systems despite published guidelines from the ACEP and Canadian Emergency Ultrasound Society.
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http://dx.doi.org/10.1136/emermed-2014-204112DOI Listing
October 2015

Intensive care ultrasound: IV. Abdominal ultrasound in critical care.

Ann Am Thorac Soc 2013 Dec;10(6):713-24

1 Department of Emergency Medicine, George Washington University Medical Center, Washington, DC.

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http://dx.doi.org/10.1513/AnnalsATS.201309-324OTDOI Listing
December 2013

Ultrasound-guided arthrocentesis of the elbow: a posterior approach.

J Emerg Med 2013 Nov 26;45(5):698-701. Epub 2013 Aug 26.

George Washington University Medical Center, Washington, DC.

Background: Identification of fluid in the elbow joint by physical examination alone can be challenging. Ultrasound can assist in the diagnosis of elbow effusion, and guide aspiration of the effusion.

Objectives: We illustrate the anatomy and ultrasound guidance technique of a posterior approach to elbow arthrocentesis using examples of normal and pathologic elbow joint ultrasound images.

Discussion: The posterior distal humerus at the level of the olecranon fossa provides an excellent acoustic window into the joint space. This location also provides a safe path for the performance of ultrasound-guided arthrocentesis.

Conclusion: Ultrasound-guided arthrocentesis of the elbow from a posterior approach is a helpful technique to guide the aspiration of the painful swollen elbow.
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http://dx.doi.org/10.1016/j.jemermed.2013.04.053DOI Listing
November 2013

Horizontal subxiphoid landmark optimizes probe placement during the Focused Assessment with Sonography for Trauma ultrasound exam.

Eur J Emerg Med 2012 Oct;19(5):333-7

Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC 20037, USA.

Objective: To introduce an external landmark for optimizing probe placement during Focused Assessment with Sonography for Trauma (FAST) exam.

Methods: This prospective study was conducted in two phases. First, the students and emergency medicine residents were trained in FAST exam utilizing the horizontal subxiphoid (HS) landmark. The landmark consists of the crossing points of a horizontal line extending from the xiphoid process to the right midaxillary line (H point) and left posterior axillary line (S point). Second, the trained students and residents performed FAST among Emergency Departments patients at two teaching hospitals. The primary outcome was a target organ acquisition score for each view, derived from the number of target organs visualized on an initial probe placement. Secondary endpoints included: time required to obtain the requisite images, and the impact of patient characteristics on landmark prediction rate.

Results: Forty-eight providers performed 477 exams. The collective prediction rate of the HS landmark was 86.6% for both H and S points upon first attempt without further probe adjustments. Operators visualized all required target structures at the first probe placement site in 430 out of 477 (90.1%) cases at the right upper quadrant, and in 392 out of 474 (82.7%) cases at the left upper quadrant without further probe adjustments. Limited probe adjustment (<2 cm from the initial landmark site) improved the success rate up to 95.6 and 90% to the right upper quadrant and left upper quadrant, respectively. As BMI increased, precision score decreased and image acquisition time increased.

Conclusion: The HS line is an external landmark that may optimize probe placement and facilitates teaching and performance of FAST examination.
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http://dx.doi.org/10.1097/MEJ.0b013e32834ddb82DOI Listing
October 2012

Emergency medicine Joint Fellowship Curriculum.

J Emerg Med 2012 Aug 25;43(2):351-5. Epub 2011 Sep 25.

Department of Emergency Medicine, The George Washington University, Medical Faculty Associates, Washington, DC 20037, USA.

Background: The authors describe a Joint Fellowship Curriculum instituted for emergency medicine fellows in diverse fellowships. The curriculum is based on commonalities established among the varying fellowships offered within their Department of Emergency Medicine. Fellowships included in the curriculum development include Disaster/Emergency Medical Services, International Emergency Medicine, Health Policy, Ultrasonography, and Medical Toxicology.

Objectives: The focus of this educational activity is to promote the development of the fellow into an expert within their field of specialization.

Discussion: Recognizing that topics such as scholarly activities, career development, clinical practice of medicine, business of medicine, and personal development are universally applicable to a variety of emergency medicine fellowships, the curriculum attempts to provide uniform instruction. The quality and applicability of this instruction was assessed and found to have been very well received by the participating fellows.

Conclusion: The authors encourage academic emergency medicine departments with a number of fellowship training opportunities to consider providing such a uniform curriculum of instruction as well.
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http://dx.doi.org/10.1016/j.jemermed.2011.05.068DOI Listing
August 2012

Tele-ultrasound and paramedics: real-time remote physician guidance of the Focused Assessment With Sonography for Trauma examination.

Am J Emerg Med 2011 Jun 13;29(5):477-81. Epub 2010 Apr 13.

Department of Emergency Medicine, George Washington University Medical Center, Washington, DC 20037, USA.

Objectives: The aim of this study was to examine the capability of ultrasound-naïve paramedics to obtain interpretable Focused Assessment With Sonography for Trauma (FAST) images under the remote direction of emergency physicians (EPs).

Methods: Paramedics without experience using ultrasound participated in a 20-minute lecture covering orientation to the ultrasound machine and the FAST examination. The paramedics subsequently performed FAST examinations on a model patient, whereas the EP remained in another room, out of visual contact. The EP communicated with the paramedic via radio, viewing video from the ultrasound machine on a monitor and directing the probe movements to obtain the views of the FAST examination. We examined the success rate, time to complete the examinations, and adequacy of images from the paramedics' first FAST examination.

Results: Fifty-one paramedics performed their first FAST examinations and were able to successfully complete 100% of the views of the FAST. The median time from probe placement to examination completion was 262 seconds (interquartile range, 206-343 seconds). The median time to complete right upper quadrant (RUQ) versus left upper quadrant (LUQ) views was 39 and 50 seconds, respectively. The time to complete the LUQ scan took significantly longer than the RUQ (P < .01). Paramedics completed cardiac and pelvic view in a median time of 42 and 25 seconds, respectively.

Conclusions: The study demonstrated that paramedics with no prior ultrasound experience could obtain FAST images under remote guidance from experienced EPs in less than 5 minutes. Given rapidly evolving data transmission technology, this has applicability in battlefield, remote, and rural prehospital settings.
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http://dx.doi.org/10.1016/j.ajem.2009.12.001DOI Listing
June 2011

Acute subretinal hemorrhage and exudative age-related macular degeneration: the role of bedside ocular ultrasound in ED diagnosis and management.

Am J Emerg Med 2009 Mar;27(3):369.e5-369.e7

Department of Emergency Medicine, George Washington University Medical Center, Washington, DC 20037, USA.

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http://dx.doi.org/10.1016/j.ajem.2008.07.011DOI Listing
March 2009

Are one or two dangerous? Sulfonylurea exposure in toddlers.

J Emerg Med 2005 Apr;28(3):305-310

Department of Emergency Medicine, George Washington University Hospital, Washington, DC.

Sulfonylurea-based oral hypoglycemics are in widespread use in the adult population, increasing the potential for unintentional exposure in children. This article examines the risk of toxicity in children under 6 years of age who ingest one to two tablets of a sulfonylurea. We review the literature on sulfonylurea toxicity, including cases reported to the American Association of Poison Control Centers (AAPCC). The ingestion of one to two sulfonylurea tablets by a small child can lead to profound hypoglycemia with severe sequelae if untreated. As a result, all potential sulfonylurea ingestions by young children should be evaluated by a physician. A capillary glucose level must be rapidly determined at presentation and should then be repeated at regular intervals for up to 8 hours. A longer observation period is recommended for the extended release preparation of glipizide. Asymptomatic children who do not develop hypoglycemia within the recommended observation period may be safely discharged home. All children who exhibit clear symptoms of hypoglycemia or glucose levels < 60 mg/dL should be admitted for supplemental glucose (oral or intravenous), with careful observation of clinical condition and monitoring of serum glucose levels. In cases refractory to intravenous glucose, therapy with octreotide or diazoxide may be beneficial.
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http://dx.doi.org/10.1016/j.jemermed.2004.09.012DOI Listing
April 2005
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