Single Operator Sterile Sheathing of an Ultrasound Probe for an Ultrasound Guided Procedure

Originally published 2011-Mar-07

During the care of critically ill patients either in the Emergency Department or other settings can involve the placement of Central Venous Catheters.  The literature supports the use of Ultrasound Guidance to prevent mechanical complications and increase success rates.  However, in addition to mechanical complications the patients can be at risk for delayed complications such as central line associated blood stream infections, CLABSI, or line infections.

One method to reduce this is the use of full barrier sterile precautions.  This includes placing the ultrasound probe in a sterile sheath to allow real-time guidance and maintaining the sterile field.  Many sterile sheaths are not designed for a single operator placement in the way they are folded and packaged.  This has lead to frustration, loss of sterility, infamous gel accident stories, and a reliance on an assistant.  However, there is a method to sheath the probe and maintain the sterile field as a single operator.

The procedure can be broken down into the following steps:

1. Place the probe upright in the holder
2. Place adequate nonsterile gel on the probe surface
3. Engage full barrier sterile precautions for the operator
4. Open the sterile sheath and place on non-dominant hand
5. Invert the sheath onto the dominant hand
6. Grasp the top of the probe
7. Unfurl the sheath onto the probe and cord
8. Secure the sheath in place and smooth out air bubbles
9. Place sterile gel on the sheath to allow imaging and procedural guidance

This was also published Academic Emergency Medicine in the Dynamic Emergency Medicine Section with an accompanying manuscript.  Trotter M, Nomura JT, Sierzenski PR. Acad Emer 2010;17:e153.

Tips and Tricks for Placement Confirmation of IJ Central Lines

Originally Published 2011-Jan-20

This is a short blurb that my colleagues and I wrote for the ACEP US Section Newsletter, January 2011 edition.

American College of Emergency Physicians Emergency Ultrasound Section Newsletter
Tips and Tricks Section January 2011

Christiana Care Health System Emergency Medicine Ultrasound Fellowship Program
DT Cook MD, JT Mink MD, JT Powell MD, PR Sierzenski MD RDMS, and JT Nomura MD RDMS

Placement of a central line is a common procedure in the resuscitation of critically ill patients in the Emergency Department. Real-time ultrasound guidance can reduce mechanical complications associated with central venous cannulation. This includes decreasing arterial puncture and increasing the rate of first pass success.

One complication of central venous catheter placement that may be detected by ultrasound guidance of vessel cannulation is misdirection of the catheter. We have all had internal jugular (IJ) catheters that travel into the subclavian or flip in a retrograde direction. We can employ ultrasound to gauge direction of the needle, location of the bevel and direction of the guidewire J-Tip.

When cannulating the IJ you can evaluate the placement of the guidewire to ensure it is placed correctly. The first step is to make certain that the wire has been placed in the IJ without puncture of the posterior wall. As described in several publications visualization of the wire should occur in a transverse and sagittal plane to ensure its location of prior to dilation.

You can then angle the transducer and trace the IJ and wire to the brachiocephalic vein (Figure 1). Depending on the maximal depth and frequency of your probe you may or may not be able to visualize the superior vena cava. The next step is to evaluate the ipsilateral subclavian vein to ensure the wire is not directed laterally (Figure 2). You have now ensured that the wire is at least directed to the ipsilateral brachiocephalic.

If you prep widely enough you can also repeat this on the contralateral side to ensure that you have not directed the wire to the contralateral subclavian or IJ.

Figure 1: View of the wire in the brachiocephalic vein. This probe does not have a low enough frequency and maximal depth to adequately view the superior vena cava in this patient. The probe is placed lateral and posterior to the clavicular head of the sternocleidomastoid muscle and directed toward the contralateral nipple.

Figure 2: The subclavian artery and vein are visualized without wire present in the subclavian vein. The probe is placed superior the clavicle and lateral to the clavicular head of the sternocleidomastoid muscle.

What does Takeokun mean?

Originally published: 2011-Jan-11

Dr. Chris Nickson (@precordialthump) from Life in the Fast Lane asked me to explain the name and logo for my blog.  I figured that if Chris was wondering then others might be too.

First the name Takeokun.com for the blog.  My middle name is Takeo which is where that comes from.  I grew up in Hawaii where there are a lot of Japanese-Americans where it is common to have a Japanese middle name.  My last name, Nomura, is a common Japanese name and I didn’t want lots of people ending up at the financial company of the same name.

“Kun” is a Japanese honorific attached to the end of a name, usually for males.  There are several honorifics that can be used after a name from the more common “san” to the more formal respectful “sama”.  Several friends during my college years did refer to me at Takeokun with a sense of familiarity and friendship.   Quite a bit to say it is my middle name.

The story behind the logo is a little more involved.  I figured for a branding on the web I needed to get a logo for my website.  I went to Kitamura Kazuaki who works under the name Horitomo.  He was an apprentice to Horiyoshi III of Yokohama, a world famous Japanese tattoo artist.  Tomo-san is a specialist in the tebori form of Japansese tattoo, or traditional hand tattooing.  He is an extraordinary artist in his chosen medium.

The logo is a stylized water pattern that is common in Japanese tattooing.  The water pattern highlights waves which is a reference to the waves involved in Ultrasound, my primary area of specialization and interest in Emergency Medicine.  Also water adapts to its surroundings just like Emergency Medicine specialists.

Hope this satisfies the curiosity surrounding the name and logo for this blog. 

How Timed Tweets Can Distract From Your Message

Originally Posted on 2010-Sept-18 (An old post but with events in the news as they are it still remains relevant, unfortunately.)

There are several software options for people to use to interact with Twitter and manage their posts.  Some of the more popular interfaces allow you to create Tweets and have time flagged for a delayed or a timed post.  While this is beneficial to prevent bursts of Tweets that can dilute the impact of the individual Tweets it can also have unintended consequences.

Recently there was a shooting at the Johns Hopkins campus that made national news.  There was a rash of erroneous information that was sent out over the net.  To the credit of the Hospital system they did utilize their Twitter stream, @JohnsHopkins, to distribute information for the public and the Johns Hopkins community.

However, they also had some timed tweets that were sent out during the incident and distracted from the messages about the tragedy.  There was even some outcry from followers.

@JohnsHopkins did respond that this was due to timed Tweets that were continuing to fire as they were placed prior to the incident.

Judging by the time stamps there were several Tweets that “escaped” during the ongoing events that were of national interest.  This dilution of the impact of the tragedy Tweets could have been avoided by canceling the timed Tweets and focusing the message on the ongoing events.

The first thing to be done would have been to eliminate the timed Tweets once the shooting occurred and the decision was made to use Twitter to distribute information.  However, there could have been a problem depending on the software that was used to create the timed Tweets.

I suspect that timed Tweets were stopped once they realized what was going on as there is a long gap in the timeline.  Once again this is a new area that organizations are moving into and processes and methods need to be refined.  Errors like this can serve to modify how we all use Twitter and other Social Media venues, but only if we pay attention and learn from them.  I am sure @JohnsHopkins has learned this valuable lessons, as have I.