<p begin="00:00:07.318" end="00:00:09.711" style="s2">- [Voiceover] A curved, or<br />phased array transducer,</p>
<p begin="00:00:09.711" end="00:00:11.431" style="s2">with a pelvis exam type,</p>
<p begin="00:00:11.431" end="00:00:14.568" style="s2">is used to perform the<br />pelvis ultrasound exam.</p>
<p begin="00:00:14.568" end="00:00:16.987" style="s2">A full bladder is used<br />as an acoustic window</p>
<p begin="00:00:16.987" end="00:00:18.989" style="s2">to view the pelvic organs.</p>
<p begin="00:00:18.989" end="00:00:22.579" style="s2">The pelvis is evaluated in two plains.</p>
<p begin="00:00:22.579" end="00:00:25.534" style="s2">Place the transducer<br />in a long axis position</p>
<p begin="00:00:25.534" end="00:00:28.254" style="s2">with the orientation marker<br />to the patient's head,</p>
<p begin="00:00:28.254" end="00:00:31.254" style="s2">at the level of the symphysis pubis.</p>
<p begin="00:00:32.384" end="00:00:36.384" style="s2">Angle the transducer<br />inferiorly into the pelvis.</p>
<p begin="00:00:38.036" end="00:00:40.705" style="s2">The bladder appears in the<br />near-field of the image,</p>
<p begin="00:00:40.705" end="00:00:43.616" style="s2">as a hypoechoic triangular structure.</p>
<p begin="00:00:43.616" end="00:00:45.800" style="s2">The uterus is gray in appearance</p>
<p begin="00:00:45.800" end="00:00:48.233" style="s2">and located either directly posterior</p>
<p begin="00:00:48.233" end="00:00:50.087" style="s2">or superior to the bladder.</p>
<p begin="00:00:50.087" end="00:00:52.139" style="s2">The endometrial stripe will appear as</p>
<p begin="00:00:52.139" end="00:00:55.945" style="s2">a bright echogenic line from<br />the fundus to the cervix.</p>
<p begin="00:00:55.945" end="00:00:58.877" style="s2">The uterus does not always<br />lay directly in the midline</p>
<p begin="00:00:58.877" end="00:01:02.209" style="s2">so it may be necessary to<br />slightly rotate the transducer</p>
<p begin="00:01:02.209" end="00:01:04.732" style="s2">to view the entire length of the uterus.</p>
<p begin="00:01:04.732" end="00:01:07.015" style="s2">Sweep the transducer from side to side</p>
<p begin="00:01:07.015" end="00:01:09.219" style="s2">to see the entire uterus.</p>
<p begin="00:01:09.219" end="00:01:12.192" style="s2">The ovaries may be seen<br />by sweeping the transducer</p>
<p begin="00:01:12.192" end="00:01:14.615" style="s2">to the lateral aspects of the pelvis.</p>
<p begin="00:01:14.615" end="00:01:18.536" style="s2">They are almond-shaped and<br />slightly hypoechoic structures.</p>
<p begin="00:01:18.536" end="00:01:20.605" style="s2">Follicles may appear as multiple</p>
<p begin="00:01:20.605" end="00:01:24.688" style="s2">hypoechoic, cystic structures<br />within the ovaries.</p>
<p begin="00:01:27.166" end="00:01:29.314" style="s2">Some follicles may be quite prominent,</p>
<p begin="00:01:29.314" end="00:01:31.981" style="s2">depending upon the luteal stage.</p>
<p begin="00:01:34.855" end="00:01:37.375" style="s2">To obtain a transverse view of the uterus,</p>
<p begin="00:01:37.375" end="00:01:39.869" style="s2">rotate the transducer 90 degrees,</p>
<p begin="00:01:39.869" end="00:01:42.788" style="s2">so the orientation marker<br />is to the patient's right.</p>
<p begin="00:01:42.788" end="00:01:46.581" style="s2">The bladder appears more<br />rectangular in shape in this view.</p>
<p begin="00:01:46.581" end="00:01:48.775" style="s2">Sweep the transducer superiorly</p>
<p begin="00:01:48.775" end="00:01:51.181" style="s2">from the level of the cervix to the fundus</p>
<p begin="00:01:51.181" end="00:01:53.284" style="s2">to see the entire uterus.</p>
<p begin="00:01:53.284" end="00:01:56.324" style="s2">The ovaries will be seen on<br />either side of the uterus</p>
<p begin="00:01:56.324" end="00:01:57.941" style="s2">and can vary in location,</p>
<p begin="00:01:57.941" end="00:02:01.024" style="s2">from a superior to inferior position.</p>

<p begin="00:00:01.116" end="00:00:04.033">(soft piano music)</p>
<p begin="00:00:08.347" end="00:00:10.000">- Heart failure's an enormous problem for</p>
<p begin="00:00:10.000" end="00:00:12.833">medicine and hospitals in general.</p>
<p begin="00:00:14.988" end="00:00:16.508">But especially the emergency department,</p>
<p begin="00:00:16.508" end="00:00:18.063">because we're the first stop for people</p>
<p begin="00:00:18.063" end="00:00:19.730">who are in distress.</p>
<p begin="00:00:22.023" end="00:00:24.733">- CMS is decreasing reimbursement.</p>
<p begin="00:00:24.733" end="00:00:26.155">It's really important for the hospital and</p>
<p begin="00:00:26.155" end="00:00:28.601">institution to streamline<br />that so that we're</p>
<p begin="00:00:28.601" end="00:00:32.184">not readmitting, or<br />we're gonna lose money.</p>
<p begin="00:00:33.760" end="00:00:35.627" tts:origin="0% 0%">- And if you lose money<br />on one of your biggest</p>
<p begin="00:00:35.627" end="00:00:38.284" tts:origin="0% 0%">admissions to the<br />hospital, you're going to</p>
<p begin="00:00:38.284" end="00:00:41.523">have a hard time staying<br />open as a hospital.</p>
<p begin="00:00:41.523" end="00:00:44.727">- So, from a quality of life to a resource</p>
<p begin="00:00:44.727" end="00:00:47.644">expenditure, there's great impacts.</p>
<p begin="00:00:52.562" end="00:00:53.918">(soft guitar music)</p>
<p begin="00:00:53.918" end="00:00:56.573">- I created the idea<br />of a multi-disciplinary</p>
<p begin="00:00:56.573" end="00:01:00.033">heart failure clinic whereby the physician</p>
<p begin="00:01:00.033" end="00:01:03.305">could team up with the other<br />healthcare professionals</p>
<p begin="00:01:03.305" end="00:01:04.824">and try and troubleshoot a lot of problems</p>
<p begin="00:01:04.824" end="00:01:06.241">at the same time.</p>
<p begin="00:01:07.782" end="00:01:10.593">So an emergency room<br />physician in a remote facility</p>
<p begin="00:01:10.593" end="00:01:13.082">has a patient present with<br />a shortness of breath.</p>
<p begin="00:01:13.082" end="00:01:16.069">He pulls up our acute<br />heart failure order set.</p>
<p begin="00:01:16.069" end="00:01:18.822">He follows the directions, looking at</p>
<p begin="00:01:18.822" end="00:01:21.543">impedance cardiography,<br />looking at cardiac index,</p>
<p begin="00:01:21.543" end="00:01:24.124">cardiac output, vascular resistance,</p>
<p begin="00:01:24.124" end="00:01:26.782">stroke volume that gives him an immediate</p>
<p begin="00:01:26.782" end="00:01:29.682">gratification in terms of<br />what he's dealing with.</p>
<p begin="00:01:29.682" end="00:01:32.042">Is this pulmonary, is this cardiac,</p>
<p begin="00:01:32.042" end="00:01:34.380">is this fluid overload,<br />and he therefore has</p>
<p begin="00:01:34.380" end="00:01:37.081">both a diagnostic toolkit<br />as well as a treatment</p>
<p begin="00:01:37.081" end="00:01:40.164">toolkit in which to initiate therapy.</p>
<p begin="00:01:41.498" end="00:01:43.842">Whilst heart failure<br />remains still somewhat of</p>
<p begin="00:01:43.842" end="00:01:46.693">a bedside diagnosis, the BioZ machine was</p>
<p begin="00:01:46.693" end="00:01:50.278">just a very quick, instantaneous way to be</p>
<p begin="00:01:50.278" end="00:01:54.361">able to get that information<br />to hand immediately.</p>
<p begin="00:01:55.444" end="00:01:59.128" tts:origin="0% 0%">- It's very non-invasive,<br />it has no pain involved,</p>
<p begin="00:01:59.128" end="00:02:01.461" tts:origin="0% 0%">it's very simple, very fast.</p>
<p begin="00:02:05.179" end="00:02:08.706">- So the patient is either hypotensive or</p>
<p begin="00:02:08.706" end="00:02:10.761">suddenly short of breath,<br />within five minutes</p>
<p begin="00:02:10.761" end="00:02:12.293">I can respond, react, and</p>
<p begin="00:02:12.293" end="00:02:14.790">instigate new treatment strategies.</p>
<p begin="00:02:14.790" end="00:02:16.457">That is very useful.</p>
<p begin="00:02:17.924" end="00:02:20.284">- We use it in our outpatient<br />clinics all the time,</p>
<p begin="00:02:20.284" end="00:02:21.995">and we use it in the hospital as well.</p>
<p begin="00:02:21.995" end="00:02:24.206">- In a nutshell, the<br />ICG devices are helping</p>
<p begin="00:02:24.206" end="00:02:26.934">diagnostically, they're<br />helping in the early,</p>
<p begin="00:02:26.934" end="00:02:29.223">immediate therapeutic intervention.</p>
<p begin="00:02:29.223" end="00:02:32.462">- It gives you a feeling that<br />you're not just guessing,</p>
<p begin="00:02:32.462" end="00:02:35.042">you're using scientific<br />knowledge to help you</p>
<p begin="00:02:35.042" end="00:02:37.591">make a decision on how<br />this treatment should be</p>
<p begin="00:02:37.591" end="00:02:38.831">used in this patient.</p>
<p begin="00:02:38.831" end="00:02:42.293">- And one of the attractions<br />of impedance cardiography is</p>
<p begin="00:02:42.293" end="00:02:44.617">that it parallels the<br />information that we get from</p>
<p begin="00:02:44.617" end="00:02:45.960">a right heart cath.</p>
<p begin="00:02:45.960" end="00:02:48.305">- And so when we got<br />this tool, we recognized</p>
<p begin="00:02:48.305" end="00:02:49.983">very quickly that we<br />weren't gonna have to put</p>
<p begin="00:02:49.983" end="00:02:52.966">people through all this<br />invasive technology.</p>
<p begin="00:02:52.966" end="00:02:55.177">- The number of right<br />heart caths we do now</p>
<p begin="00:02:55.177" end="00:02:58.844">has been reduced by something like 90%.</p>
<p begin="00:03:02.886" end="00:03:06.510">- Five years ago, everybody<br />with heart failure got admitted.</p>
<p begin="00:03:06.510" end="00:03:10.232">Now, we can help quantify a<br />little bit more accurately</p>
<p begin="00:03:10.232" end="00:03:12.015">how bad their heart failure is.</p>
<p begin="00:03:12.015" end="00:03:13.618">- [Nurse] And it became very clear that</p>
<p begin="00:03:13.618" end="00:03:15.120">we could usually send the patient home</p>
<p begin="00:03:15.120" end="00:03:19.029">within 24 to 36 hours,<br />and patients love that.</p>
<p begin="00:03:19.029" end="00:03:21.982">- So that in itself, and decreasing our</p>
<p begin="00:03:21.982" end="00:03:24.988">readmission rates has benefited<br />the hospital in a great way.</p>
<p begin="00:03:24.988" end="00:03:26.948">- The big picture is to keep<br />them out of the hospital,</p>
<p begin="00:03:26.948" end="00:03:29.422">keep their standard of<br />living high quality.</p>
<p begin="00:03:29.422" end="00:03:32.261">- At St. John's, we've just got the lowest</p>
<p begin="00:03:32.261" end="00:03:36.428">30 day readmission rate out<br />of 127 hospitals in Illinois.</p>
<p begin="00:03:38.968" end="00:03:41.966">- With Dr. Jennison and<br />with our heart failure team,</p>
<p begin="00:03:41.966" end="00:03:45.988">it is amazing to see what one person with</p>
<p begin="00:03:45.988" end="00:03:50.077">a burning passion can do, and how somebody</p>
<p begin="00:03:50.077" end="00:03:54.282">who is part of a private<br />group can influence</p>
<p begin="00:03:54.282" end="00:03:57.685">the care of an entire<br />community of physicians</p>
<p begin="00:03:57.685" end="00:04:00.014">by setting up a team of folks that are</p>
<p begin="00:04:00.014" end="00:04:03.030">hospital-based, not physician based.</p>
<p begin="00:04:03.030" end="00:04:05.652">- It's affected our<br />reputation in a great way.</p>
<p begin="00:04:05.652" end="00:04:09.015">It's basically shown us<br />that we can strive to</p>
<p begin="00:04:09.015" end="00:04:11.257">be one of the best programs in the nation.</p>
<p begin="00:04:11.257" end="00:04:14.257">(soft guitar music)</p>

<p begin="00:00:01.324" end="00:00:04.324">(slow gentle music)</p>
<p begin="00:00:05.277" end="00:00:07.724">- [Voiceover] This is<br />our work environment.</p>
<p begin="00:00:07.724" end="00:00:10.792">In the back of an<br />ambulance, which is limited.</p>
<p begin="00:00:10.792" end="00:00:13.792">(slow gentle music)</p>
<p begin="00:00:16.256" end="00:00:17.842">What we do isn't in the ER.</p>
<p begin="00:00:17.842" end="00:00:19.357">It's not in a</p>
<p begin="00:00:19.357" end="00:00:20.678">nice clean environment.</p>
<p begin="00:00:20.678" end="00:00:21.761">Sometimes we're in the field,</p>
<p begin="00:00:21.761" end="00:00:22.808">sometimes we're in mud,</p>
<p begin="00:00:22.808" end="00:00:24.801">sometimes we're just out.</p>
<p begin="00:00:24.801" end="00:00:26.213">We bounce down the road.</p>
<p begin="00:00:26.213" end="00:00:27.565">We're never still.</p>
<p begin="00:00:27.565" end="00:00:29.017">The first idea of</p>
<p begin="00:00:29.017" end="00:00:30.926">ultrasound in EMS</p>
<p begin="00:00:30.926" end="00:00:33.518">was brought to me by Jason Bowman.</p>
<p begin="00:00:33.518" end="00:00:34.859">- Most EMS systems that use ultrasound</p>
<p begin="00:00:34.859" end="00:00:36.522">they save it for trauma.</p>
<p begin="00:00:36.522" end="00:00:39.522">(slow gentle music)</p>
<p begin="00:00:40.658" end="00:00:42.852">For the city Keller we<br />don't run much trauma.</p>
<p begin="00:00:42.852" end="00:00:44.519">We talked about the medical uses of it</p>
<p begin="00:00:44.519" end="00:00:46.103">and how we can add in all the extra things</p>
<p begin="00:00:46.103" end="00:00:47.383">that they do in the ER.</p>
<p begin="00:00:47.383" end="00:00:49.261">It's not commonly done in EMS.</p>
<p begin="00:00:49.261" end="00:00:51.322">The most valuable one<br />we've been using it for</p>
<p begin="00:00:51.322" end="00:00:53.000">is cardiac examinations.</p>
<p begin="00:00:53.000" end="00:00:54.779">For our hypotensive patients.</p>
<p begin="00:00:54.779" end="00:00:56.912">Because before we just knew,<br />okay, they're in shock.</p>
<p begin="00:00:56.912" end="00:00:58.279">And we could look at a few small things</p>
<p begin="00:00:58.279" end="00:01:00.143">to try to tell what was going on.</p>
<p begin="00:01:00.143" end="00:01:01.675">But with ultrasound we could tell</p>
<p begin="00:01:01.675" end="00:01:02.844">this is cardiogenic shock.</p>
<p begin="00:01:02.844" end="00:01:03.809">This is septic shock.</p>
<p begin="00:01:03.809" end="00:01:05.385">This is hypovolemia.</p>
<p begin="00:01:05.385" end="00:01:07.254">We can tell exactly what's going on.</p>
<p begin="00:01:07.254" end="00:01:08.453">There's no wasting time.</p>
<p begin="00:01:08.453" end="00:01:10.749">- We've used it to check for new thoraxes.</p>
<p begin="00:01:10.749" end="00:01:13.126">We've used it to check for triple As.</p>
<p begin="00:01:13.126" end="00:01:14.922">One of the better things,<br />I think, that I've used</p>
<p begin="00:01:14.922" end="00:01:16.546">it for is starting IVs.</p>
<p begin="00:01:16.546" end="00:01:18.546">We had a patient who was</p>
<p begin="00:01:19.595" end="00:01:21.687">like we say, if somebody's doing very bad</p>
<p begin="00:01:21.687" end="00:01:22.927">they're circling the drain.</p>
<p begin="00:01:22.927" end="00:01:25.742">A lot of things have to happen very fast.</p>
<p begin="00:01:25.742" end="00:01:27.841">Access for medications to be given</p>
<p begin="00:01:27.841" end="00:01:29.368">is one of our priorities.</p>
<p begin="00:01:29.368" end="00:01:31.554">So, on this patient there were no visible</p>
<p begin="00:01:31.554" end="00:01:33.899">vessels to be able to start an IV on.</p>
<p begin="00:01:33.899" end="00:01:35.969">I grabbed the ultrasound<br />machine and told one</p>
<p begin="00:01:35.969" end="00:01:38.357">of our other paramedics to grab the drill.</p>
<p begin="00:01:38.357" end="00:01:41.428">And we'll see who gets one of them faster.</p>
<p begin="00:01:41.428" end="00:01:43.648">We would much rather<br />have an intravenous line</p>
<p begin="00:01:43.648" end="00:01:46.101">than an intraoceous line in the bone</p>
<p begin="00:01:46.101" end="00:01:47.657">because they run better, they're easier</p>
<p begin="00:01:47.657" end="00:01:49.006">to push strokes through.</p>
<p begin="00:01:49.006" end="00:01:50.437">And they just work better.</p>
<p begin="00:01:50.437" end="00:01:52.713">I actually ended up beating him</p>
<p begin="00:01:52.713" end="00:01:54.367">in getting that IV</p>
<p begin="00:01:54.367" end="00:01:57.191">and being able to give treatment<br />to that patient faster.</p>
<p begin="00:01:57.191" end="00:01:58.727">Which was</p>
<p begin="00:01:58.727" end="00:02:00.576">very impressive to me.</p>
<p begin="00:02:00.576" end="00:02:03.258">I believe that this is the next thing</p>
<p begin="00:02:03.258" end="00:02:05.411">that will help us to do our job better.</p>
<p begin="00:02:05.411" end="00:02:06.926">- We've already pretty<br />well mandated it where</p>
<p begin="00:02:06.926" end="00:02:09.458">you have to have it available<br />in the emergency room.</p>
<p begin="00:02:09.458" end="00:02:11.582">I think it should be the<br />same in the ambulance.</p>
<p begin="00:02:11.582" end="00:02:13.745">- You make a difference<br />in one patient's life,</p>
<p begin="00:02:13.745" end="00:02:15.552">and one patient's outcome</p>
<p begin="00:02:15.552" end="00:02:17.371">and it's worth all the work.</p>
<p begin="00:02:17.371" end="00:02:21.538">That's what sold me, and that<br />should sell anybody else.</p>