VGH CTU - Procedures and POCUS

On the ward, look for supplies in the ward supply rooms or in the CTU Procedure room (hallway behind T10C – code 2+4 and then 3). Lidocaine is an order in Cerner (5mL ampoules, get two) – remember to order this ahead of time and notify the nurse so you can have this at the bedside when you are ready to begin your procedure.

In the ED, supplies will be located at the supply station in Zone A beside the trauma bays. Sometimes you will find items in the trauma bays as well. Lidocaine can be found in the minor procedures/suture cart.

Consent forms are found on FormFast. Put in orders for fluid analysis prior to the procedure so the RN can get labels and send samples off to lab promptly. Note that despite good evidence for direct inoculation of culture bottles, lab has asked us to use the orange-top containers and will refuse your culture bottle! 

• “LAB – Synovial (Joint) Fluid Testing”
• “LAB – Pleural (Chest) Fluid Testing”
• “LAB – Peritoneal (Ascites, Abdominal, Paracentesis) Fluid Testing”
• “CSF (Adult) Studies for Encephalitis / Meningitis”

Procedure protocols and videos for your reference:
1. Thoracentesis (NEJM video)
2. Paracentesis (NEJM video)
3. Lumbar puncture 
4. Knee arthrocentesis*
5. Internal jugular central venous catheter* (NEJM video)

Other resources courtesy of Dr. Nathan Chan 
1. Narrated procedure tutorials
2. Written notes and checklists

Tutorials: Learn POCUS/Scanning tutorials https://ubcimpocus.com

Opportunities in sharpening your POCUS skills is an exciting part of CTU at VGH! A number of CTU attendings are formally POCUS trained and passionate about teaching and promoting use of ultrasound on the ward. VGH also has a POCUS team that can be consulted for bedside ultrasound assessments (volume assessments, effusions, etc) and can help with ultrasound-guided procedures (thoracentesis, paracentesis, lumbar puncture, joint arthrocentesis, central access). 

POCUS Service
0900-1600 Monday to Friday, no weekends. Consult requests via the POCUS Phone. 

Where are the ultrasound units?

• The QPath-enabled ultrasound units are on T10C, T10H, T14G
• Other ultrasound units can be found in the ICU and Emergency for use in those areas.

What is QPath?

• QPath is a POCUS image archiving system which allows you to upload your POCUS images to an online database accessed with your VCH credentials. This allows you to keep records of your exams, as well as the opportunity to submit your scans to POCUS staff for review (formative only, not part of any assessment). Access at vchpocus.qpath.cloud. If you’re having access issues or did not set up an account, speak with Dr. Wiskar or Dr. Arishenkoff.

What are the rules?

• Respect the equipment (clean with Caviwipes after use, leave where you found it connected to power supply and ready for the next operator)
• Understand the limitations of bedside ultrasound. Exam findings by competent POCUS operators can be a very useful adjunct to the clinical assessment, but findings should be interpreted in the clinical context and should not be used in isolation to direct management.

What kind of situations should make me think about doing a POCUS exam?

• Persistent hypoxia or rising creatinine while diuresing… is this really decompensated heart failure?
• New or worsening hypotension NYD
• New or worsening dyspnea/hypoxia NYD
• Does the patient with cellulitis have an abscess?
• Does the patient with arthralgia/arthritis have an effusion?
• In any willing patient to practice your scanning technique and review normal findings

POCUS is a skill that requires novices to reach a critical mass of scans in order to develop a baseline of competence and start to use POCUS as an adjunct to the physical exam. If you scan frequently, you will get better. If you don’t scan, you will be rusty. Very worthwhile skill – ultrasound technicians have gone home when your overnight call shift starts!