Enjoy the next Thomas Jefferson Point-of-Care Ultrasound Educator of the Month Series! This post is brought to you by Kelly Goodsell, MD Clinical Instructor & Ultrasound Fellow at Thomas Jefferson University Hospital in Philadelphia, PA.
Dr. Elzen is a Consultant Physician in Anesthesia and Critical Care Medicine at the Karolinska University Hospital in Stockholm, Sweden. She is a point-of-care ultrasound (POCUS) educator in the Karolinska Institute. Together with the Anesthesia and Critical Care Ultrasound Group at Karolinska she runs a basic and an advanced hemodynamic monitoring course and trains students and residents of all levels.
Dr. Elzen joined the Jefferson POCUS Division remotely as part of our educator of the month lecture series to share her experiences using point-of-care transesophageal echocardiography (POC TEE) in the resuscitation of trauma patients.
Dr. Elzen began by introducing us to Karolinska University Hospital and some of the unique aspects of the medical system in Sweden. Karolinska is a Level 1 trauma center with 1.5 million visits to the hospital annually. The hospital receives 1800 trauma patients annually. 300 of those are pediatrics trauma patients. At any one time, there are 3 trauma teams, 1 neurosurgery team, and 1 CT surgery team in the hospital and ready to perform patient care. Dr. Elzen described a hybrid set-up with trauma bays physically connected to CT, interventional radiology and ED operating rooms. Trauma resuscitations are run by interdisciplinary teams including Surgery, Anesthesia and Critical Care. Radiologists may also participate in trauma resuscitations by performing the FAST exam – a concept that seems foreign to us in the States. She also notes that the use of TEE for hemodynamic monitoring in the ICU is ubiquitous at Karolinska Hospital, and that many residents in anesthesia and critical care receive training in TEE. Despite the commonplace use for hemodynamic monitoring, POC TEE for trauma/resuscitations was not routinely done. She also notes that in her hospital system Emergency Physicians currently have little access to, or training in, TEE.
Dr. Elzen went on to explain how she became excited about the potential for POC TEE and presented the case of a patient with undifferentiated hypotension after a boating injury. In the operating room, the patient had a radiologist performed FAST examination which showed intraperitoneal free fluid but was negative for free pericardial fluid. The patient then went into PEA arrest. A TEE examination was performed and demonstrated a large thrombosed pericardial effusion with resulting tamponade physiology. An emergent thoracotomy was performed, and the patient was resuscitated. Here the use of TEE during trauma arrest dramatically changed the focus of the surgical team and ultimately led to a positive outcome for this patient. Dr. Elzen spoke of how this case offered an opportunity to open interprofessional dialogue about the benefits of POC TEE.
Since then Dr. Elzen has worked to reduce barriers to use of POC TEE in her institution. This has included in-department training, simulation, and quick reference tools outlining a simplified 4 view protocol for the emergency or critical care setting. She notes this simplified POCUS algorithm, credited to anesthesia colleague Dr. Johan L Nordström, translates well from the known transthoracic views and has helped facilitate a comfortable transition for new users. Her message to us – TEE can be simple and can have tremendous impact on patient care at the bedside. We thank Dr. Elzen for sharing with us her insight and her passion for ultrasound!
Dr. Elzen and @jeff_sono seek research partners in #POCUS and #TEE.