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Re: All for US and US for all

Dear Editor,

Atkinson et al.[1] in their paper highlighted how catheterisation of central venous system for vascular access is an essential skill for emergency physicians. Clinician inexperience has been identified as being associated with a higher number of complications.[2]

Mansfield did not find that ultrasound usage in his study group, patients requiring chemotherapy, was beneficial. Miller[3] however showed that ultrasound usage resulted in a shorter time from skin puncture to blood flash, a significant reduction in the number of attempts required to secure access and reduction in time to line placement. All laudable goals in an emergency department environment where time is a precious commodity.

Miller achieved these results with a short intense 1 hour training session for both residents and faculty. As the number of such procedures performed by an individual emergency physician in the UK or Ireland are likely to be low skill maintenance has rightly been higlighted as being important. Atkinson suggests that teaching the technique to other staff may help in this regard.

Rosenberg[4] identified that ‘video game aptitude appears to predict the level of laparoscopic skill in the novice surgeon’. Hand eye coordination or visual-spatial skills are also required for the technique of ultrasound guided vascular access. Could it be possible that there is some benefit to being a member of the ‘playstation generation’ with respect to development of visual-spatial skills compelementary to medical practice?

One other method of skill retention could be to utilise ultrasound for difficult peripheral access intermittently to maintain familiarity with kit, machine and the visual spatial skills required. Abboud[5] suggests that the general application of ultrasound guidance for venous access in the ED has reached a critical mass and the recent focus on patient safety and clinical outcomes has lead to increased attention being given to use of ultrasound in the emergency department. Even at a cost of £15,000 per ED and the requirements for ongoing training and certification it would appear as if the time of ultrasound has come for the emergency physician

References

1. Atkinson P, Boyle A, Robinson S, Campbell-Hewson G. Should ultrasound guidance be used for central venous catheterisation in the emergency department? Emerg Med J 2005;22(3):158-64.

2. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331(26): 1735-8.

3. Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 2002;9(8):800-5.

4. Rosenberg BH, Landsittel D, Averch TD. Can video games be used to predict or improve laparoscopic skills? J Endourol 2005;19(3):372-6.