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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Saturday, July 2, 2016

Ultrasound may seem intimidating at first, but it is not a procedure out of your reach. Those of you still feeling shy about it should just play with it to increase your comfort level. It's OK to be early for a shift or to stay late figuring out the machine. Try using ultrasound on patients who will allow it and scribes who don't say no. It can't hurt, and it will make you a better and more knowledgeable provider.

We all know an "official" ultrasound is needed to confirm a suspected DVT, but what if you just need to know right away? Picture this: You are starting an overnight shift and are already 10 patients deep. Your 55-year-old patient with leg pain and unilateral leg swelling is waiting for an ultrasound, and it's going to be awhile. Your plan is to do some basic labs and obtain the official ultrasound to rule out a DVT. The patient has a few risk factors for DVT and a story to match. Why not test your bedside skills and see what you can see?

Bedside ultrasound for DVT is a great way to plan your night and your patient's future. You begin to ask yourself if you need to transfer this patient, probably let him go home, or admit him to the hospital. It's nice to know where your ducks are, so throwing the ultrasound on patients to make a decision from the get-go is imperative. Then you can order that official test. Why can't you do it, too? The good news is you can, and here is how.

The Procedure
Bedside ultrasound with linear probe to detect DVT in lower extremity
Collection of data, formal ultrasound, and admit/discharge plan

​The Pause
We want to draw your attention directly to our video. If you have been following our series on ultrasound, all you need to do is watch this and like magic, you have your answer. You can read the first four part of this ultrasound series on our website. (See box.)

Watch Dr. Amie Wood demonstrate using ultrasound for detecting DVT.

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Clinical Pearls and EBP
The best way to detect proximal lower extremity DVTs in the emergency department is to use a "modified 2-point compression technique that focuses on the highest probability areas, decreases the study time to less than 5 minutes, and provides similar sensitivity and specificity." (Acad Emerg Med 2000;7[2]:120.)

A "negative compression ultrasound study may safely delay the need for anticoagulation therapy" if a patient has a clinically suspected DVT. (BMJ 1998;316[7124]:17) Not only does bedside-provider ultrasound help determine the diagnosis and plan, the 2-point DVT compression examination has been "assessed in multiple randomized controlled studies and is well accepted when used properly with pretest probability assessments" (JAMA 2008;300(14):1653.) It's imperative you try it and expedite the care of your patient who need it most.

​Tip of the Week
Amie Woods, MD, a clinical ultrasound expert, has some tips if you decide to dabble in the artistry we call ultrasound. Dr. Woods suggests using the bedside ultrasound test to help make clinical decisions. Usually, following the common femoral vein to the mid thigh will give you the results you need. This can be a reasonable tool to diagnosis DVT if you can confirm the compressibility. It's important to note that this does not rule out superficial DVT. All superficial DVTs have the ability to form a true DVT and need formal outpatient follow-up or a repeat study. But this means it's possible for you to send patients home on high-dose aspirin therapy and schedule a repeat exam with a vascular surgeon. Formal studies are never a bad idea, but your steady hand can help predict the long-term outcome.

Suggested Reading

  • Crisp JG, Lovato LM, Jang TB. Compression Ultrasonography of the Lower Extremity with Portable Vascular Ultrasonography Can Accurately Detect Deep Venous Thrombosis in the Emergency Department. Ann Emerg Med 2010;56(6):601.
  • Frazee BW, Snoey ER, et al. Negative Emergency Department Compression Ultrasound Reliably Excludes Proximal Deep Vein Thrombosis. (Abstract 102.) Acad Emerg Med 1998;5(5):406.
  • Nunn KP, Thompson PK. Towards Evidence-Based Emergency Medicine: Best Bets from the Manchester Royal Infirmary. Using the Ultrasound Compression Test for Deep Vein Thrombosis Will Not Precipitate a Thromboembolic Event. Emerg Med J 2007;24(7):494.

Read the first four parts of this series:
Part 1: We Had You at Ultrasound
Part 2: Foreign Body Removal
Part 3: Eye Think It's the Retina
Part 4: Ultrasound-Guided IV Line Placement

Wednesday, June 22, 2016


A young woman came in after a FOOSH injury complaining of difficulty moving a painful shoulder. The Y view was difficult to obtain, but the AP view is below. What three radiographic signs help make the diagnosis?

LTB-June 1.jpg 

The signs include:

  • The light bulb sign is when the humeral head is rotated internally so it looks more like a lightbulb than a club.
  • The rim sign where there is an increased distance (more than 6 mm) between the arc of the glenoid and the arc of the humeral head. The distance is much closer at the top of the glenoid than the bottom in this image.
  • There is an angle in Moloney's arch. There should be a smooth scapulohumeral arch. Peaks in the glenohumeral location should raise suspicion of a posterior shoulder dislocation. The equivalent of Moloney's arch in the hip is Shenton line.

This is a posterior dislocation. These account for only two to four percent of shoulder dislocations, and they can look remarkably normal in general location, which means as many as 50 percent have been reported to be missed on initial radiographs. A good Y view can be exceedingly helpful in making the diagnosis.

Request an axillary view or a CT if a Y view is difficult. Bedside ultrasound is likely the quickest way to confirm the diagnosis for those skilled at musculoskeletal point-of-care scanning.

LTB-June 2.jpg 

A diagnostic Y view was eventually obtained. The shoulder was put back using a traction-counter traction technique under conscious sedation.

​Tips to Remember:

  • Careful inspection of the AP shoulder film can increase suspicion for a posterior shoulder dislocation.
  • Other imaging modalities are available to confirm the diagnosis.



Wednesday, June 8, 2016


This Father's Day, Emergency Medicine News would like to recognize a true leader in emergency medicine. James R. Roberts, MD, a distinguished professor and emergency physician, is one of the founding fathers of the specialty. Since 1972he directly assisted in building the profession, paving the way for thousands of individuals who now call the ED their home.

Dr. Roberts was one of the first emergency physicians in the country, and he has taught tens of thousands of students over the years including physicians, fellows, residents, nurse practitioners, physician assistants, and nurses. His expertise is recognized worldwide, and his procedure textbook, Clinical Procedures in Emergency Medicine, is a staple in every ED, not to mention the global reach of his EMN column. (http://emn.online/INFOCUS-JR.) Dr. Roberts' clinical work in the ED and his toxicology expertise have helped saved the lives of thousands of sick children and adults.

This video is a small collection of images highlighting some of his work in emergency medicine​. Many of these photos were captured during my first clinical rotation alongside Dr. Roberts and his team at Mercy Hospital of Philadelphia, where he was chairman for more than 20 years. It would be impossible to compile a video of all the photos he took of patients and procedures over the past decades, but these are some of the most memorable.

Not only has Dr. Roberts groomed students and new practitioners, he has also taught many, including me, the art of the profession. It's not often you find his kind of intelligence anywhere, but when you do, it is rarely in his modest form. He manages to effortlessly balance his great intellect with a great sense of humor and wit that makes practicing emergency medicine rewarding, interesting, and fun.

I am truly lucky to call him Dad. He taught me everything from my ABCs in grade school to the ABCs of ED patients. He is a truly unique and dedicated soul, but he is, above all else, a caring person. Not only is he highly educated, he practices with feeling, intuition, common sense, and passion. His modest mentorship and enthusiasm for emergency medicine is contagious, in a good way.

This fall during the American College of Emergency Physicians Scientific Assembly in Las Vegas, Dr. Roberts will receive the award for Outstanding Contribution in Education. In nominating him for that award, Anthony S. Mazzeo, MD, wrote, "He has educated physicians worldwide on the nuances of all aspects of EM, from the mundane to the exotic, all with the charisma and erudite vocabulary that is undeniably 'trademark Roberts'. … Dr. Roberts remains a humble, modest, dedicated, and hard-working educator who would clearly never seek the recognition of this award. However, those of us who have worked with Jim and learned from Jim over the years feel this recognition is undeniably warranted."

Happy Father's Day to all the fathers of emergency medicine, and Happy Father's Day to my Dad, James R. Roberts, MD.

Thursday, June 2, 2016

It's time to be fearless and embrace the true utility — and maybe implement a new policy in your ED — of ultrasound-guided intravenous (IV) line insertion.

ultrasound machine.jpg 

Many physicians, NPs, and PAs already know how to place US-guided IVs, but we can help teach those who don't. Provider teaching can be in the form of real-time IV placement or a short 60-minute procedural training course open to all those who are interested. You can even use our procedural videos to help get you started! (http://emn.online/Mar16PP.)


We all know our difficult patient population includes prior IV drug abusers, obese patients, patients with chronic illnesses, and hypovolemia. Let's make the procedure less painful for them! No one is asking for our nurses to place central lines or diagnose a DVT using US, but basic understanding of US technology is not difficult and can be beneficial for the patient. A delay in establishing vascular access can result in a delay in the administration of a fluids and medications.

Patients frequently experience delays in diagnosis and initiation of treatment. Multiple attempts at attaining vascular access also result in frustration and a loss of productivity by the treating team. (Clin Pediatr [Phila] 2009;48[9]:895.) (Rauch, Dowd, Eldridge, Mace, & Schears, 2009). Nurses and technicians are more likely to establish a well-placed, working IV site once they can identify the veins and arteries on the screen. This could help speed up treatment for a patient who needs an 18 g needle for a CT scan to rule out a PE or a septic patient who needs resuscitation.


The Approach
n Ultrasound-guided intravenous line placement
n Using sterile approach

scan 2.jpg 

The Pause
Make sure this particular procedure is already approved for immediate use. The emergency medicine technicians (EMTs) can use the US machine to insert IV lines in most hospitals, but in other institutions, RNs are allowed to do this without an order. And still, some facilities allow only a physician or midlevel to run the procedure.


The Approach
n Inform patient of need for intravenous line.
n Alert nurse and EMT team or place order for IV line.
n Nursing or EMT team attempt standard IV insertion. A US-guided approach should be activated if IV placement cannot be obtained within two attempts. NOTE: Consider creating a standing order or policy for department to allow nurses to complete this activity on their own without waiting.
n Regardless of who is initiating line placement, obtain the following items: appropriate-sized catheter (18 g is suggested), chlorhexidine prep pad, tourniquet, IV line set up or start kit with NS flush, sterile towel, and marking pen. Also obtain the US machine with linear probe, sterile US gel packets, US probe sterile plastic cover, sterile gloves, and any other equipment (i.e., culture bottles or lab testing tubes).
n Obtain written or verbal consent for the procedure.
n Prepare for US-guided IV placement. First, use the linear probe to examine the arm without a tourniquet. Attempt to locate deep and superficial veins for IV cannulation. Consider deep brachial veins and move the probe slightly higher up the bicep to look for deeper veins.
n NOTE: Remember that arteries will be pulsating and veins will not. If you turn on the color indicator, arteries will also appear red and veins will appear blue.
n Continue to look for veins by pressing down on the probe. Veins should be easily compressible. Add the tourniquet. Continue your search.
n Once you have located the vein you wish to cannulate, use the marking pen to mark the site. Note the depth on the US machine so you know how far to advance your needle.
n This is where it gets a little tricky. If you are confident that you can stick the vein without continuous US guidance, you can clean and prep the site and then insert the needle. At this point, you will be finished with the procedure.

If you are unsure, then you need to take this a few steps farther:
n Clean the site with chlorhexidine.
n Add sterile gel to the site on the arm you plan to cannulate.
n Set up a sterile towel on side table, and drop your sterile needle onto it. You will use the towel later to wipe off any extra gel. It's good to be prepared.
n Don sterile gloves.
n Ask an assistant to open the US probe-cover packet. Grab it and ask the assistant to squeeze gel inside the sleeve of the US probe cover. Do not break sterility.
n Have your assistant place the linear probe into the sleeve as you expand it over the full length of the probe and cord. Do not break sterility.
n Place the sterile-covered probe onto the site you already examined.
n Relocate the vein using your landmarks and markings.
n Use the US-guided technique to watch your needle enter the skin and cannulate the appropriate vein.
n Complete IV setup once the vein has been properly cannulated and the outline setup has been connected.
n Clean off the arm with the towel to remove any extra gel or blood.
n Complete the procedure by securing the IV line, drawing labs or cultures (if indicated), and flush the line with NS. NOTE: We often suggest that providers draw a 10 mL syringe of blood during initial placement, which can be placed in your sterile field prior to starting the procedure.

​Major Cautions
n If your patient is a frequent flyer and you know a line will be tough, try to use the US technique immediately, before completing two blind sticks.
n Do not forget to remove the tourniquet when the procedure is complete.
n Do not break your sterile field. You are cannulating a deep vein, and the potential for artery cannulation is possible.
n Immediately remove the IV catheter, and add pressure to any site where arterial cannulation was inappropriately completed.
n Consider US of the upper extremity to rule out DVT if a patient returns to the ED with arm pain after a deep vein cannulation and signs of DVT.

​Tip of the Week
Feel free to ask your administration if you can create a policy for US-guided IV placement and explain why it is beneficial for patient care (pain control, expedited testing etc.) and nursing autonomy. Consider offering to teach a 60-minute lab on US-guided IV insertion.

​Educational Considerations
Using ultrasound for IV access requires training, and the literature is mixed. Physician training is incorporated into residency training with up to 16 hours of didactic and more than 100 ultrasound scans. It is suggested that "nursing and technician staff members train with at least one hour didactic with additional hands on training." (J Emerg Med 2006;31[4]:407.)

The Emergency Nurses Association's policy supports US-guided IV placement by physicians, nurses, and techs in the appropriate setting. Read more about it at http://bit.ly/1iy4taJ.

​Click here to watch a video of ultrasound-guided intravenous line insertion, and read the first three parts of this series:
Part 1: We Had You at Ultrasound
Part 2: Foreign Body Removal
Part 3: Eye Think It's the Retina

Watch this month's video​.

PP photo.JPG

Monday, May 2, 2016

Part 3 in a Series

The Problem: Unilateral, painless vision changes and floaters

Ocular ultrasound is a short and sweet procedure that could change your practice and greatly benefit your patients. It can actually be used to diagnose retinal detachment, which in the past required a referral to an ophthalmologist and often led to delayed therapy. Noninvasive and simple ultrasound techniques can be used on any patient of any age presenting with visual changes. The differential for visual changes with or without complete vision loss or blurry vision encompasses a daunting list. This is for you especially if retinal detachment is on your differential.

First, let's review the anatomy. Visual messages are sent from the retina through the optic nerve to the brain. Patients experience painless, unilateral vision loss, which may be permanent if for some reason the retina becomes detached, moves, or is pulled away from its normal position. Other problems, such as retinal tears or breaks, can cause brief vision loss and can lead to future complete detachment. ("Facts about Retinal Detachment," NIH, National Eye Institute; http://1.usa.gov/21P46bg.) Patients will complain of unilateral vision changes without other symptoms aside from blurry or cobweb vision or floaters (photopsia). Some say they even see black, which can be the last fatal phase of retinal detachment.

Ocular structures. Photo courtesy of CreativeCommons.com

Things you can see with ocular ultrasound:

  • Retinal detachment
  • Posterior vitreous detachment (PVD)
  • Vitreous hemorrhage
  • Lens dislocation
  • Choroid detachment
  • Intraocular foreign body
  • Globe rupture
  • Orbital fractures
  • Central retinal artery and central retinal vein occlusions​

The Possibilities: History taking

Ask your patient the following questions before performing your ultrasound-guided exam:

  • Are you nearsighted?
  • Have you had painless vision loss?
  • Have you had a prior retinal detachment?
  • Is there a family history of retinal detachment?
  • Have you had cataract surgery? Recent eye trauma?
  • Did it seem like a dark curtain came over your eye?
  • Do you have a history of uveitis, degenerative myopia, or other eye complications?
  • And most importantly, have you experienced an increase in the number of floaters, cobweb-like vision, or cloudy/flashy vision in one eye in the past few weeks or months?

If your patient said yes to any of these questions, it's time to break out the ultrasound machine and be prepared to look directly at the retina. Remember, a retinal detachment may occur at any age, although it is more common in those over 40 and Caucasian males. (http://1.usa.gov/21P46bg.)

The Procedure: Ocular ultrasound

  • Ultrasound-guided identification of retinal detachment using the linear probe
  • Identification of structures: Anterior (lens, cornea, iris, ciliary bodies) and posterior chambers (vitreous, retina, optic nerve sheath diameter [ONSD], optic disc)
  • Identification of normal retina vs. detachment
  • Prompt and appropriate follow-up with retinal specialist if defect found
  • Measurement of ONSD if concerned about elevated intracranial pressure

The Approach

  • Complete an excellent history and fundoscopic exam.
  • Obtain an ultrasound machine.
  • Put your patient in a supine position.
  • Engage linear probe (7.5 MHz or greater). Set the machine in B-mode and activate the "ocular" preset.
  • Place a clear Tegaderm over the patient's affected eye after he closes it. This will prevent the lubricating gel from getting into his eye. It also does not pull off eyebrows or eyelashes. Tell the patient this prior to application, and that it prevents any foreign bodies from entering the eye or causing eye irritation.
  • Smooth out any air bubbles in the Tegaderm.
  • Add lubricating gel over the Tegaderm.
  • Darken the lights in the room.
  • Be prepared to use the probe in the transverse plane. The indicator should be pointing toward the patient's ear (i.e., you are looking at the left eye, the probe is held in the transverse or horizontal position with the indicator pointing toward the left ear).
  • Gently place the linear probe over the Tegaderm and adjust your depth to see the entire globe: the anterior and posterior chambers and ONSD. Identify all structures.
  • Locate the retina and determine if detachment has occurred. You will see a white line flopping around and waving gingerly at you on the screen. It looks almost like a streamer.
  • Pull off the Tegraderm to reveal a dry, non-irritated eye and complete appropriate follow-up. Immediately call for assistance if there is a detachment, and refer to ophthalmology.
  • Note: If you wish to measure the ONSD, it should be <5 mm. The provider should be concerned about elevated intraocular pressure if it is >5 mm. Studies have shown these two ailments have a direct clinical correlation. Start in the transverse plane when you measure. Measure the width of the optic nerve sheath 3 mm posterior to the retina and then "rotate the transducer clockwise to measure the ONSD in the sagittal plane, perpendicular to your first measurement. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
  • Compare both eyes.
  • Limit your examination of the eye(s) with the ultrasound and adhere to ALARA principle (as low as reasonably achievable).

Click here to watch a video of ocular ultrasound.
Special thanks to Amie Woods, MD, an emergency physician at INOVA Fairfax Hospital and an assistant clinical professor at George Washington University, for her help in making this video.


This procedure may initially sound difficult and above your level of expertise, but once you see a retinal detachment on ultrasound, you will never forget it. Discovering a retinal detachment is as simple as turning on the machine, using your linear probe on the affected eye, and examining the globe and its structures.

The retina itself is usually a flat white thickened line, which lies securely among the tissues at the back of the eye. A normal globe itself will appear dark (the vitreous), and the retina will appear white.

A significant detachment will show the white retinal tissue flopping and waving around in the black area, close to its normal resting place. Sometimes, you may be able to identify PVDs or hemorrhages. PVDs are usually thinner and smoother than retinal detachments and are more mobile. Retinal detachments should also not extend to the ciliary bodies because of their anatomy while PVDs usually do. A retinal detachment should also not extend over the optic sheath. Retinal detachments will be thicker, white (hyperechoic) membrane-like structures with multiple folds and move with ocular movements. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)

Retinal detachment as seen on ultrasound ocular exam. Photo courtesy of Dr. Amie Woods, Inova Fairfax Hospital


Keep in mind, your patient may still have a retinal artery occlusion (RAO) or spasms even if the retina appears normal. These patients may present with similar complaints of vision loss or changes caused by clots or blocked retinal arteries. The retina is starved of oxygen and nutrients and essentially dies and causes these symptoms. RAO may occur in patients who are symptomatic and without retinal detachment or who have a history of atherosclerosis. Final exam tip: You may see macular edema on your fundoscopic exam if you suspect RAO. RAOs can be treated with lasers, blood thinners, and treatments used for atherosclerosis.

Our retinal partners use a freezing treatment called cryopexy to fix the retina with lasers. They basically fuse it back in place. The majority of retinal detachments are treated successfully if identified quickly by the emergency department provider. Remember, the retina is at high risk for complications and requires an ophthalmologist's care.



  • Don't push too hard on the probe. You won't need to apply much pressure at all if you use enough gel.
  • Use the bridge of the patient's nose or his forehead to stabilize your hand.
  • Use a dark room.
  • Keep it clean. Use the Tegaderm approach.
  • Obtain a fundoscopic exam prior to the ultrasound exam.
  • Test the visual acuity.
  • Use the "freeze" button on the machine to hold your image on the screen so you can complete the identification and measurements of the globe's structures. This allows you to look longer and closer without leaving the probe directly on the patient's eye. It also allows you to measure the ONSD accurately.
  • If you suspect ruptured globe and see that while doing your exam, stop and call the specialist immediately. Refrain from using tense pressure on the orbit.
    o Warm lube? No way, this is not a fetus! Chilling the lube actually allows you to complete a better exam because it causes increased viscosity and "allows the gel to stack easily." (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)
  • Retinal detachment and PVD are difficult to distinguish, but patients may be more likely to say they see floaters as opposed to having vision loss if suffering from PVD.

Procedural Pause Overachievers

If you really want to impress your ophthalmology colleagues, you can also measure the blood flow to the retinal artery based on a very simple equation related to the diameter measurements and blood flow seen on the ultrasound exam. If you want to know more about this, check out this great Austrian study by Droner, et al. (Curr Eye Res 2002;25[6]:341; http://bit.ly/25snrDM.)​

BONUS VIDEO: Watch Dr. Amie Woods' TEDx talk, "This is What's Making Me a Better Doctor," for her experience with ultrasound and a patient with a life-threatening condition: http://bit.ly/1VucDAx.


About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner for Johns Hopkins Medicine at the Sibley Memorial Hospital in Washington, DC, an adjunct faculty associate and clinical instructor of nursing at the Malek School of Health Professions, Marymount University in Arlington, VA, and is Dr. Roberts’ daughter.

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