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Hi Matt,
I am making sure that this thread is working.
Your question: Is there anyway you could provide me with details on the nurse training that was provided for cannulation? Were there any medico-legal issues you had to navigate in terms of sonographers actually being able to needle in Victoria?"
The training is fairly informal. We do a short session on cannulation theory, and practising with a phantom, and then do some supervised cannulations, and then get assessed. For ultrasound guided cannulation it is also a short session with one of the radiologist. It is not very involved, and no medico-legal issues, and in fact radiographers can do an ultrasound guided cannulation short course. We are happy for you to ring us at RMH if you want any more information.
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Hi Matt, it was probably myself talking about cannulation . Some Sonographers can cannulate at RMH , and have done a short course with the nursing educators, then a few supervised cannulations before they are signed off to do it themselves . This is very easy . We usually have our nurses do it though, as this gives us time to chat to the radiologist and prepare the contrast . Let us know if you have any more Ceus queries .
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Thank you for your question.
There are many reasons why a formal ultrasound may be requested in cases of suspected FDIU.
National, and many international guidelines on management of stillbirth state that evaluation following a stillbirth include fetal autopsy, gross and histologic exam of the placenta, umbilical cord and membranes, and genetic studies. A formal scan could assist with confirming FDIU on a high resolution machine, identifying location of placenta, fetal position (which can help the Ob/Gyns plan delivery), identifying gross features such as oligohydramnios/polyhydramnios/skeletal or any other anomalies in the fetus/placenta that may not be identified at bedside ultrasound, as this can help guide further investigations. It may also help identify other causes, such as IUGR. The thought of an autopsy can be very distressing to parents, so not all parents are willing to go through the autopsy, hence maximizing info through ultrasound may be helpful for future management.
There have a rare number of instances (particularly in cases where imaging was difficult eg. obesity, or where TV scanning was not performed), where fetal heart motion was missed or vice versa. Clinicians sending these referrals may want to eliminate any trace of doubt and share the burden of responsibility. Additionally, it is often requested by the patient and their partner to also be in no doubt about the findings.
As discussed in the below article point of care ultrasound 'should not be considered a substitute for formal diagnostic ultrasound'. Point of care ultrasound in obstetrics: https://onlinelibrary.wiley.com/doi/pdfdirect/10.1002/ajum.12133
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Thank you for your question.
There are numerous useful resources available online:
https://onlinelibrary.wiley.com/doi/full/10.1002/jum.16129
We do not currently have a protocol for endometriosis, however some practices use a checklist, which may include looking for endometriosis markers on a transvaginal examination, (if clinically indicated) which includes:
Adenomyosis, endometriomas, question mark sign (fixed uterine anteversion and/or retroflexion), site specific tenderness, ovarian mobility, fixed/kissing ovaries(fixed together), fallopian tube distortion, the sliding sign(rectum glides freely over cervix), posterior cul-de-sac obliteration and deep infiltrating endometriosis nodules in anterior and posterior compartments.
The ASA is currently investigating hands-on training options.
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have found these 2 articles that may assist the enquirer in regards to differentiating punctate calciifcations versus colloid ring down artifact. Modern equipment does minimise artifacts in some settings, but my advice would be for us to direct this sonographer to their specific manufacturer in order to modify their specific equipment settings. Hope this helps - Marilyn
https://www.sonographers.org/secureassets/872673aa-102e-ee11-9122-0050568796d8/kjr-24-22-thyroid.pdf
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Hello Gayle
The cardaic SIG has had a hard think about your issues and drafted this reply to you. Please not, this is NOT legal advice not work related advice. This is a group of sonographers putting our collective thoughts down to support a fellow cardiac scanner.
Best wishes
Anthony Wald
SIG Cardiac chair
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Hey Jared, a completely valid question. It's always hard when a radiologist contradicts what your line thinking has always been.
The other members of the SIG group who contributed to this answer and myself broadly agree with you in the sense that raised velocities in the coeliac axis during full expiration can be associated with MALS.
One of our SIG members documents if there is significant PSV difference between inspiration and expiration in the Coeliac artery even if the PSV is slightly under 350cm/s, as getting the correct Doppler angle in the Coeliac axis can sometimes be difficult.
This is an extract from the Journal of medial ultrasound that backs that point up a bit that they suggested we steer your way. The study isn't the most recent but the principal still stands - Median Arcuate Ligament Syndrome 2003
''The median arcuate ligament is found at the T12-L1 level and bridges the crura of the diaphragm just anterior to the aorta. In patients with the median arcuate ligament syndrome, the celiac artery is compressed by the median arcuate ligament with expiration. With inspiration, the celiac artery descends in the abdominal cavity, resulting in a more vertical orientation of the celiac artery, which often relieves the compression. With the patient in the erect position, the celiac artery descends farther in the abdominal cavity, resulting in an even more vertical orientation of the celiac artery and relief of compression by the ligament''
Below is another extract from a much more recent publication which details some other nuances to be aware of that another member thought might be useful
Pellerito, John S., and Joseph F. Polak. Introduction to Vascular Ultrasonography. Seventh edition. Philadelphia, Pennsylvania: Elsevier, 2020. Print. Revxin Chapter 26 p 547-581
A potential pitfall for celiac artery stenosis is the median arcuate ligament (MAL) syndrome. The MAL is a fibrous band that extends from the diaphragmatic crura on either side of the aortic hiatus. The MAL usually passes just superior to the celiac artery. In some people, however, the MAL passes along the anterior margin of the celiac artery and may cause celiac artery compression during expiration. During the examination, the examiner may observe a characteristic change in the appearance of the celiac artery during different phases of the respiratory cycle. On expiration, the celiac artery assumes a hook-like appearance because of compression of the vessel by the ligament, and on inspiration, the artery takes a neutral, non-compressed course. With pulsed Doppler, mechanical compression of the celiac artery by the MAL is detected as increased PSV during expiration. On inspiration, a normal PSV is observed. Therefore inspiratory and expiratory velocity measurements should be obtained whenever MAL syndrome is suspected. Chronic compression of the celiac artery by the MAL may produce a fixed stenosis of the celiac artery with an elevated PSV that persists during inspiration.
This member (like myself) doesn't use a particular PSV but looks for the hook appearance in expiration, and a change in velocity. If a change with inspiration/expiration can't be produced you can also get them to stand which lower the mesentery and relieve the compression.
General consensus is that the radiologist has it backwards :)
Majority of credit for this answer goes to Dan Rae and Donna Oomens.
Hope this helps.
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Sorry it's taken a while to get back to you.
The answer is a bit multi-faceted. In regards to forearm fistulae you are completely right, retrograde radial artery flow beyond the anastomosis is perfectly normal in instances where the palmer arch is intact, and depending on where you read this retrograde distal radial flow can make up to 25% of the overall volume flow. Some papers even suggest that in some fistulas the retrograde flow alone is actually sufficient to provide effective dialysis.
Being that you mostly see upper arm AVFs you are likely exposed to a higher proportion of patients with distal ischemia due to a higher prevalence of this symptom in this variety of AVF. This is because brachial artery anastomoses tend to be larger which create lower vascular resistance, that pull more blood through the fistula and away from the hand, which is a problem that’s compounded by the fact that this is the only inflow artery to the forearm, as opposed to a RCAVF where only one of three arteries to the hand is affected.
We also need to discuss the differentiation between steal and steal syndrome. Most BCAVF will demonstrate physical steal whether that’s a bit of bi-directional flow in the brachial artery beyond the anastomosis or a retrograde radial/ulnar artery. This can be totally asymptomatic but becomes steal syndrome when symptoms of ischemia are present which is, like you say, a purely clinical diagnosis.
These symptoms can often be worse during HD which for sonographers obviously isn’t great because we can’t scan them during this period to see if there is any haemodynamic change. In answer to your actual question though - the only useful information we can provide via ultrasound is the status of the fistula (functional? Volume flow? Stenoses?),forearm arteries (all patent?) and the palmer arch (intact?).
Hope this helps
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Hi Lauren,
We had a good chat about your question in our SIG meeting last night. It's a great question and we aim to get back to you with a full answer with reference papers by the end of next week.
Thanks for posting and feel free to ask any other vascular related questions.
Matt
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Thank you for your question.
2023 Guidelines confirm that, " As a sole finding, sonographically detected polycystic ovaries are not sufficient to make the diagnosis of PCOS, although they may represent a mild form of ovarian hyperandrogenism and insulin resistance."
As per available guidelines and position papers, Combined Oral Contraceptives (CoCs) are recommended as the first-line treatment in adult women with PCOS in order to regulate menses and/or improve features of hyperandrogenism. Alternatives to COCs include cyclic progestin therapy, continuous progestin therapy (progestin-only pills), or a progestin-releasing intrauterine device(IUD).
As per the 2018 International Evidence- based Guidelines from Monash: https://www.monash.edu/medicine/sphpm/mchri/pcos/guideline: “Reliable assessment of biochemical hyperandrogenism is not possible in women on hormonal contraception, due to effects on sex hormone-binding globulin and altered gonadotrophin-dependent androgen production. Where assessment of biochemical hyperandrogenism is important in women on hormonal contraception, drug withdrawal is recommended for three months or longer before measurement, and contraception management with a non-hormonal alternative is needed during this time.”
In view of the available evidence, we can conclude that PCOS assessment cannot be performed when the patient is on any form of contraception.
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Thank you for your question.
This is the most current ASA guideline for intimate examinations: https://www.sonographers.org/publicassets/cf41bf67-4f90-ec11-9107-0050568796d8/UPDATE---PUB_0602_GUIDELINE-Intimate-examinations-Consent-and-Chaperones-Jan22.pdf
Additionally, ASUM do not list this as a contraindication either: https://www.asum.com.au/files/public/SoP/curver/Obs-Gynae/Gynaecological-GL-2020.pdf
Patients should be above 18 as a legal informed consent must be obtained. But there is no specific requirement to exclude those who are not sexually active.
As always, Sonographers should adhere to their department protocols.
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I am right handed scanner but have taught myself to scan left handed for cardiac scans and a variety of MSK scanning . Definitely possible with allowing time for adjustments . My experience as a physio suggests long term relief requires a good physio with progression of exercises to strengthen wrist extensors, this take 3-6 mths in the chronic cases so persistance needed. If pain is inhibiting exercises and scanning then cortisone injection can help in the short term and PRP injections (into the tear) may also help if early treatment not helping
Are you properly managed through WorkCover with, useful input from the treating doctor, physio etc, and workplace management, through a return-to-work coordinator.
Wages are covered by insurance while under WorkCover care so it is a good idea to have the sonographer at work helping with other tasks. (Are desk duties an option?)
Another possible option while in recovery mode is to be rostered as a trainer for students, supervising and overseeing their actions, without actually scanning. That way the injured sonographer remains engaged with the workplace, and maintains a sense of worth and value, and students get a real boost to their training. I have used this option in the past with very good results.
Hope this helps
Let us know if issues are ongoing
Peter Esselbach
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Thank you for your question.
Uterine length is measured from fundus to the external os of the cervix. Uterine width is the maximum transverse diameter. Uterine height is the maximum AP diameter.
Uterine volume will vary between nulliparous and parous states. A normal range would be approximately 100-150ml, again depending on patient history.
Attached is an article that may provide additional information.
http://www.ijmse.com/uploads/1/4/0/3/14032141/ijmse_2016_volume_3_issue_3_page_305-309.pdf
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Thank you for your question.
Ultrasound is often the first and usually the only imaging modality used to evaluate placental abruption, but an index of suspicion should be maintained for the diagnosis since ultrasound is relatively insensitive for the diagnosis. This is partly because a retroplacental hematoma may be identified only in 2-25% of all abruptions.
The echogenicity of hematomas depends upon their age. Acute hematomas imaged at the time of symptoms tend to be hyperechoic or isoechoic compared to the adjacent placenta. As the hematoma is commonly isoechoic to the placenta, it may be mistaken for focal thickening of the placenta.
Common locations are subchorionic (between the placenta and the membranes), retroplacental (between the placenta and the myometrium), and preplacental (between the placenta and the amniotic fluid). Retroplacental hematomas have a variable appearance; they can appear solid, complex, and hypo-, hyper-, or isoechoic compared with the placenta. If hypoechoic, then it is most probably resolving and therefore not acute. A retroplacental hematoma is more likely to be seen with more extensive placental separation and in patients who go on to have adverse maternal and perinatal outcome but its absence does not exclude the possibility of abruption, including a severe abruption, because blood may not collect and remain behind the placenta. Other findings suggestive of abruption include a subchorionic collection of fluid (even remote from the placental attachment site), echogenic debris in the amniotic fluid, or a thickened placenta; especially if it shimmers with maternal movement ("Jello" sign), placental thickening to over 5.5cm and separation of placental edges. However the main aspect to remember is that ultrasound may not always detect placental abruption so in an emergency it is best to manage based on clinical findings.
References for added info:
"Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences" from Up To Date
TropI, Levine D. Hemorrhage during pregnancy: sonography and MR imaging. AJR Am J Roentgenol 2001; 176:607.
Shinde GR, Vaswani BP, Patange RP, et al. Diagnostic Performance of Ultrasonography for Detection of Abruption and Its Clinical Correlation and Maternal and Foetal Outcome. J Clin Diagn Res 2016; 10:QC04.
Qiu Y, Wu L, Xiao Y, Zhang X. Clinical analysis and classification of placental abruption. J Maternal Fetal Neonatal Med 2021; 34:2952
Yeo L, Ananth CV, Vintzileos AM. Placental abruption, Lippincott, Williams &Wilkins, Hagerstown, Maryland 2003.
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Thank you for your question. We've attached two articles that review cesarean section scar measurements in the third trimester for you. We found these quite informative.
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.13902https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/uog.15786
Disclaimer: by using this service you recognise that the information provided is general in nature; it does not constitute professional advice. Any views expressed are those of individual(s) and may not reflect ASA’s views. The ASA does not endorse any product or service identified. You use any information provided at your sole risk and the ASA is not responsible for any errors or for any consequences arising from that use.
Certificate of Capacity is issued by the nominated treating doctor (NTD) once the person has reported the problem to management and a WorkCover insurance claim has been raised.
You should report incapacity to your management?
ASA has no advise on examples of Certificate of Capacity as such. Light duties are prescribed once the person has sought medical advice and reported through the proper channels.
A hand therapist may help via a thumb brace for support. Cortisone injection also may be of benefit if synovitis is present in the thumb joints. Best to seek advice from a GP or physio.