<p begin="00:00:02.788" end="00:00:05.595" style="s2">- If my wife or one of my children</p>
<p begin="00:00:05.595" end="00:00:09.516" style="s2">needed a central line, I<br />would ask two questions.</p>
<p begin="00:00:09.516" end="00:00:11.620" style="s2">I would need to know the experience</p>
<p begin="00:00:11.620" end="00:00:14.177" style="s2">of the individual who's placing the line</p>
<p begin="00:00:14.177" end="00:00:17.513" style="s2">and whether or not he or<br />she is using ultrasound.</p>
<p begin="00:00:17.513" end="00:00:19.625" style="s2">And if they're not using ultrasound,</p>
<p begin="00:00:19.625" end="00:00:21.958" style="s2">I would find another doctor.</p>
<p begin="00:00:22.939" end="00:00:25.522" style="s2">(lively music)</p>
<p begin="00:00:41.010" end="00:00:43.991" style="s2">- [Man] When I came to<br />Houston and Memorial Hermann,</p>
<p begin="00:00:43.991" end="00:00:45.277" style="s2">I became aware that ultrasound</p>
<p begin="00:00:45.277" end="00:00:48.228" style="s2">wasn't being used for<br />central line insertion.</p>
<p begin="00:00:48.228" end="00:00:49.821" style="s2">Either in our hospitals</p>
<p begin="00:00:49.821" end="00:00:53.281" style="s2">or in the general medical community.</p>
<p begin="00:00:53.281" end="00:00:55.134" style="s2">- It is just like driving blindly</p>
<p begin="00:00:55.134" end="00:00:58.462" style="s2">on the road versus driving<br />with your total vision, right?</p>
<p begin="00:00:58.462" end="00:01:00.722" style="s2">It gives you total confidence</p>
<p begin="00:01:00.722" end="00:01:04.333" style="s2">and certainty about what you're doing.</p>
<p begin="00:01:04.333" end="00:01:05.598" style="s2">And what is happening with the patient</p>
<p begin="00:01:05.598" end="00:01:07.521" style="s2">which is the most important thing.</p>
<p begin="00:01:07.521" end="00:01:09.455" style="s2">- I presented the results</p>
<p begin="00:01:09.455" end="00:01:11.670" style="s2">of the use of ultrasound at Cedar Sinai</p>
<p begin="00:01:11.670" end="00:01:13.577" style="s2">and also results in the literature</p>
<p begin="00:01:13.577" end="00:01:15.320" style="s2">from around the world.</p>
<p begin="00:01:15.320" end="00:01:17.162" style="s2">Showing that the injuries</p>
<p begin="00:01:17.162" end="00:01:19.957" style="s2">from central line insertion can be reduced</p>
<p begin="00:01:19.957" end="00:01:22.941" style="s2">if not eliminated with<br />ultrasound guidance.</p>
<p begin="00:01:22.941" end="00:01:25.744" style="s2">- You cannot achieve the kind of numbers</p>
<p begin="00:01:25.744" end="00:01:27.577" style="s2">that have been achieved nation wide</p>
<p begin="00:01:27.577" end="00:01:29.271" style="s2">without using ultrasound.</p>
<p begin="00:01:29.271" end="00:01:30.580" style="s2">But in our way we say</p>
<p begin="00:01:30.580" end="00:01:33.177" style="s2">central lines should not<br />cause pneumothoraces.</p>
<p begin="00:01:33.177" end="00:01:36.806" style="s2">It should be a rarity rather<br />than the acceptability.</p>
<p begin="00:01:36.806" end="00:01:38.929" style="s2">And that's where we're<br />doing in this hospital.</p>
<p begin="00:01:38.929" end="00:01:41.135" style="s2">Trying to show that you<br />can do a lot of lines</p>
<p begin="00:01:41.135" end="00:01:43.260" style="s2">without doing pneumothorax.</p>
<p begin="00:01:43.260" end="00:01:45.435" style="s2">And we have been able to do so so far.</p>
<p begin="00:01:45.435" end="00:01:48.750" style="s2">- In fact, for two of our hospitals,</p>
<p begin="00:01:48.750" end="00:01:52.142" style="s2">they've reported over a year's worth</p>
<p begin="00:01:52.142" end="00:01:55.024" style="s2">of practice in the hospital</p>
<p begin="00:01:55.024" end="00:01:59.191" style="s2">without the occurrence of a<br />single iatrogenic pneumothorax.</p>
<p begin="00:02:00.444" end="00:02:02.559" style="s2">- These are considered<br />never events certainly</p>
<p begin="00:02:02.559" end="00:02:06.815" style="s2">by Medicare and probably<br />will be never events</p>
<p begin="00:02:06.815" end="00:02:08.710" style="s2">by insurance companies.</p>
<p begin="00:02:08.710" end="00:02:10.593" style="s2">And probably will be never events</p>
<p begin="00:02:10.593" end="00:02:12.178" style="s2">from the legal system.</p>
<p begin="00:02:12.178" end="00:02:14.056" style="s2">So that's really three good reasons</p>
<p begin="00:02:14.056" end="00:02:16.219" style="s2">other than intellectually wanting</p>
<p begin="00:02:16.219" end="00:02:18.196" style="s2">to do the right thing.</p>
<p begin="00:02:18.196" end="00:02:20.839" style="s2">- We've actually created a new award</p>
<p begin="00:02:20.839" end="00:02:24.498" style="s2">for hospitals that are achieving zero</p>
<p begin="00:02:24.498" end="00:02:28.081" style="s2">iatrogenic pneumothoraces<br />for a whole year.</p>
<p begin="00:02:29.708" end="00:02:32.266" style="s2">We're goin' for zero.</p>
<p begin="00:02:32.266" end="00:02:33.340" style="s2">This amazing?</p>
<p begin="00:02:33.340" end="00:02:36.000" style="s2">And actually, I didn't even mention it</p>
<p begin="00:02:36.000" end="00:02:38.561" style="s2">but we, our emergency departments.</p>
<p begin="00:02:38.561" end="00:02:42.440" style="s2">We have nine of 'em,<br />busy, we saw over 400,000</p>
<p begin="00:02:42.440" end="00:02:43.746" style="s2">visits last year.</p>
<p begin="00:02:43.746" end="00:02:45.579" style="s2">They placed a lot of central lines.</p>
<p begin="00:02:45.579" end="00:02:49.075" style="s2">They use ultrasound and it is amazing</p>
<p begin="00:02:49.075" end="00:02:52.158" style="s2">but we had no iatrogenic pnuumothorax</p>
<p begin="00:02:53.096" end="00:02:55.179" style="s2">for the whole year.</p>
<p begin="00:02:55.179" end="00:02:57.210" style="s2">(lively music)</p>
<p begin="00:02:57.210" end="00:02:58.517" style="s2">We're talkin' about emergencies.</p>
<p begin="00:02:58.517" end="00:03:00.255" style="s2">We're talkin' about level one trauma.</p>
<p begin="00:03:00.255" end="00:03:02.052" style="s2">I mean this is pretty amazing.</p>
<p begin="00:03:02.052" end="00:03:04.635" style="s2">(lively music)</p>
<p begin="00:03:06.715" end="00:03:08.490" style="s2">- A few weeks back I have a patient</p>
<p begin="00:03:08.490" end="00:03:11.573" style="s2">in the ICU, almost 350 or 380 pounds.</p>
<p begin="00:03:14.641" end="00:03:16.476" style="s2">Blood pressure was in 60s.</p>
<p begin="00:03:16.476" end="00:03:19.125" style="s2">Neck was barely visible.</p>
<p begin="00:03:19.125" end="00:03:20.944" style="s2">Groin we can not access.</p>
<p begin="00:03:20.944" end="00:03:23.481" style="s2">And we got the ultrasound.</p>
<p begin="00:03:23.481" end="00:03:25.304" style="s2">Was able to look at thigh jay</p>
<p begin="00:03:25.304" end="00:03:27.115" style="s2">and we put the line in.</p>
<p begin="00:03:27.115" end="00:03:28.954" style="s2">And that was the best thing</p>
<p begin="00:03:28.954" end="00:03:32.148" style="s2">because it was made out of night almost</p>
<p begin="00:03:32.148" end="00:03:34.051" style="s2">and we need a line.</p>
<p begin="00:03:34.051" end="00:03:35.218" style="s2">And we got it.</p>
<p begin="00:03:36.222" end="00:03:37.341" style="s2">Patient did very well</p>
<p begin="00:03:37.341" end="00:03:39.425" style="s2">and eventually she got out of ICU.</p>

<p begin="00:00:13.668" end="00:00:15.823" style="s2">- Ultrasound guided<br />central lines are rapidly</p>
<p begin="00:00:15.823" end="00:00:17.657" style="s2">becoming standard to care.</p>
<p begin="00:00:17.657" end="00:00:20.913" style="s2">Ultrasound allows us to do<br />this procedure much safer</p>
<p begin="00:00:20.913" end="00:00:24.081" style="s2">than a standard blind landmark approach.</p>
<p begin="00:00:24.081" end="00:00:26.511" style="s2">In this segment I'm gonna take<br />you through how we can map</p>
<p begin="00:00:26.511" end="00:00:30.342" style="s2">the jugular vein for the<br />procedure of an intrajugular line</p>
<p begin="00:00:30.342" end="00:00:32.040" style="s2">using the central approach.</p>
<p begin="00:00:32.040" end="00:00:34.869" style="s2">So let me show you how to<br />position our ultrasound.</p>
<p begin="00:00:34.869" end="00:00:36.887" style="s2">We have our model here, lying down.</p>
<p begin="00:00:36.887" end="00:00:38.698" style="s2">I normally would be at the head of the bed</p>
<p begin="00:00:38.698" end="00:00:40.833" style="s2">and if you look at his neck,</p>
<p begin="00:00:40.833" end="00:00:42.460" style="s2">you can actually see the two heads</p>
<p begin="00:00:42.460" end="00:00:43.867" style="s2">of his general cleidomastoid.</p>
<p begin="00:00:43.867" end="00:00:45.749" style="s2">We see a sternal head<br />and the clavicular head</p>
<p begin="00:00:45.749" end="00:00:47.764" style="s2">that usually form a triangle.</p>
<p begin="00:00:47.764" end="00:00:50.306" style="s2">Normally in a blind landmark approach,</p>
<p begin="00:00:50.306" end="00:00:53.528" style="s2">our needle would be going<br />to the apex of the triangle.</p>
<p begin="00:00:53.528" end="00:00:56.940" style="s2">We're now gonna use ultrasound<br />to localize the vein.</p>
<p begin="00:00:56.940" end="00:00:58.583" style="s2">We're gonna now find the vein</p>
<p begin="00:00:58.583" end="00:01:01.330" style="s2">and make the needle<br />insertion so much safer.</p>
<p begin="00:01:01.330" end="00:01:02.994" style="s2">We're gonna go ahead and choose our system</p>
<p begin="00:01:02.994" end="00:01:05.670" style="s2">which is gonna be placed just<br />to the right of the patient.</p>
<p begin="00:01:05.670" end="00:01:08.670" style="s2">We're gonna use a linear transducer.</p>
<p begin="00:01:09.561" end="00:01:12.822" style="s2">We're gonna go ahead and<br />set up our examination type.</p>
<p begin="00:01:12.822" end="00:01:17.125" style="s2">I'm gonna hit exam, I'm<br />gonna click on venous,</p>
<p begin="00:01:17.125" end="00:01:21.144" style="s2">select, and we're gonna be<br />ready to start scanning.</p>
<p begin="00:01:21.144" end="00:01:24.217" style="s2">We're going to also use<br />a little trick to put</p>
<p begin="00:01:24.217" end="00:01:27.835" style="s2">the transducer marker actually<br />to the patient's left.</p>
<p begin="00:01:27.835" end="00:01:30.752" style="s2">The reason I do this is to<br />maintain the orientation</p>
<p begin="00:01:30.752" end="00:01:33.422" style="s2">from the head of the bed<br />so the vein and the artery</p>
<p begin="00:01:33.422" end="00:01:35.958" style="s2">are in the normal anatomic positions,</p>
<p begin="00:01:35.958" end="00:01:38.643" style="s2">so it's not to create more<br />confusion when you're using</p>
<p begin="00:01:38.643" end="00:01:42.415" style="s2">ultrasound for guidance of a procedure.</p>
<p begin="00:01:42.415" end="00:01:43.871" style="s2">I'm gonna go ahead and<br />put a little bit of gel</p>
<p begin="00:01:43.871" end="00:01:45.454" style="s2">on this transducer.</p>
<p begin="00:01:48.630" end="00:01:51.972" style="s2">And now let's take a look at<br />his neck in the normal place</p>
<p begin="00:01:51.972" end="00:01:56.349" style="s2">that we would normally<br />have put our needle.</p>
<p begin="00:01:56.349" end="00:01:58.053" style="s2">So if we're looking at<br />the screen, in the center</p>
<p begin="00:01:58.053" end="00:02:02.581" style="s2">of the screen is a very<br />large anechoic structure.</p>
<p begin="00:02:02.581" end="00:02:06.185" style="s2">And you can see that it easily collapses.</p>
<p begin="00:02:06.185" end="00:02:08.427" style="s2">This is the jugular vein.</p>
<p begin="00:02:08.427" end="00:02:10.260" style="s2">Just adjacent to this,</p>
<p begin="00:02:11.485" end="00:02:15.567" style="s2">to the left of the screen and<br />below the vein is the artery.</p>
<p begin="00:02:15.567" end="00:02:19.247" style="s2">That is what we want to avoid<br />and just a little bit more</p>
<p begin="00:02:19.247" end="00:02:21.536" style="s2">to the left of that is the thyroid.</p>
<p begin="00:02:21.536" end="00:02:25.703" style="s2">So the ultrasound allows<br />us to easily find the vein.</p>
<p begin="00:02:26.623" end="00:02:29.415" style="s2">We can track it along its entire course.</p>
<p begin="00:02:29.415" end="00:02:31.942" style="s2">First thing we can identify,<br />is the vein patent?</p>
<p begin="00:02:31.942" end="00:02:34.981" style="s2">You might have a patient who<br />has had a previous cannulation</p>
<p begin="00:02:34.981" end="00:02:38.304" style="s2">and the vein itself may<br />not be a good candidate.</p>
<p begin="00:02:38.304" end="00:02:40.621" style="s2">The second thing, once<br />we've identified the vein,</p>
<p begin="00:02:40.621" end="00:02:43.785" style="s2">we can map the skin and<br />actually put marks on the skin,</p>
<p begin="00:02:43.785" end="00:02:47.505" style="s2">and we can also look at the<br />side of the ultrasound image</p>
<p begin="00:02:47.505" end="00:02:49.552" style="s2">to see how deep the vein is.</p>
<p begin="00:02:49.552" end="00:02:53.515" style="s2">And in this case it's<br />about one centimeter deep.</p>
<p begin="00:02:53.515" end="00:02:55.187" style="s2">I'm gonna show you how to use ultrasound</p>
<p begin="00:02:55.187" end="00:02:58.339" style="s2">to actually guide your needle<br />into the intrajugular vein.</p>
<p begin="00:02:58.339" end="00:03:01.252" style="s2">As you can see we have<br />a Blue Phantom here.</p>
<p begin="00:03:01.252" end="00:03:03.453" style="s2">We're gonna be able to<br />take a look at the vein,</p>
<p begin="00:03:03.453" end="00:03:04.737" style="s2">first with ultrasound,</p>
<p begin="00:03:04.737" end="00:03:07.503" style="s2">and then I'm gonna use<br />the ultrasound transducer</p>
<p begin="00:03:07.503" end="00:03:10.405" style="s2">to actually guide my<br />needle toward the vein.</p>
<p begin="00:03:10.405" end="00:03:14.624" style="s2">I'm gonna go ahead and<br />place a little bit of gel</p>
<p begin="00:03:14.624" end="00:03:18.791" style="s2">onto the neck where I expect<br />the jugular vein to lie.</p>
<p begin="00:03:19.763" end="00:03:21.812" style="s2">And then I'm gonna use my transducer</p>
<p begin="00:03:21.812" end="00:03:23.645" style="s2">to identify this vein.</p>
<p begin="00:03:25.271" end="00:03:28.545" style="s2">And you can see on this image,</p>
<p begin="00:03:28.545" end="00:03:33.247" style="s2">we can see what is supposed to<br />be a vein here in the center.</p>
<p begin="00:03:33.247" end="00:03:36.421" style="s2">And it's compressible; it's<br />about a centimeter deep or so.</p>
<p begin="00:03:36.421" end="00:03:39.795" style="s2">So I can use ultrasound guidance.</p>
<p begin="00:03:39.795" end="00:03:42.840" style="s2">I can now place this needle into the vein.</p>
<p begin="00:03:42.840" end="00:03:46.305" style="s2">Normally this whole setup will<br />be under sterile procedure,</p>
<p begin="00:03:46.305" end="00:03:48.767" style="s2">the transducer will be<br />covered with a sterile sheet,</p>
<p begin="00:03:48.767" end="00:03:52.508" style="s2">I'll be in full sterile<br />prep, and the needle</p>
<p begin="00:03:52.508" end="00:03:55.322" style="s2">and the rest of the equipment<br />all will be sterile.</p>
<p begin="00:03:55.322" end="00:03:57.163" style="s2">But for the purposes of this demonstration</p>
<p begin="00:03:57.163" end="00:03:59.364" style="s2">I think you'll recognize<br />how I'm placing the needle</p>
<p begin="00:03:59.364" end="00:04:01.621" style="s2">and how we're cannulating the vein.</p>
<p begin="00:04:01.621" end="00:04:04.274" style="s2">So I put the target in<br />the center of the image,</p>
<p begin="00:04:04.274" end="00:04:06.916" style="s2">so this would be the<br />jugular vein in the center</p>
<p begin="00:04:06.916" end="00:04:08.774" style="s2">and we know that the jugular vein's about</p>
<p begin="00:04:08.774" end="00:04:11.129" style="s2">a centimeter and a half deep in this case.</p>
<p begin="00:04:11.129" end="00:04:13.311" style="s2">I'm now gonna show you how<br />you can actually follow</p>
<p begin="00:04:13.311" end="00:04:17.032" style="s2">the needle tip as you slowly<br />march toward the vein.</p>
<p begin="00:04:17.032" end="00:04:20.501" style="s2">I have the jugular vein<br />centered in the image,</p>
<p begin="00:04:20.501" end="00:04:24.021" style="s2">I can see it's compressible,<br />we're sure it's the vein.</p>
<p begin="00:04:24.021" end="00:04:27.104" style="s2">Now I take my needle and<br />put it right adjacent</p>
<p begin="00:04:27.104" end="00:04:29.789" style="s2">to the transducer in the mid part</p>
<p begin="00:04:29.789" end="00:04:32.488" style="s2">and we can see the needle tip,</p>
<p begin="00:04:32.488" end="00:04:34.322" style="s2">and I'm gonna slowly advance,</p>
<p begin="00:04:34.322" end="00:04:37.361" style="s2">but while I'm advancing<br />I'm angling the transducer</p>
<p begin="00:04:37.361" end="00:04:40.366" style="s2">away from the needle and<br />toward the needle tip</p>
<p begin="00:04:40.366" end="00:04:44.388" style="s2">so I always have the needle<br />tip in the field of view.</p>
<p begin="00:04:44.388" end="00:04:46.658" style="s2">And when I do that I can always keep track</p>
<p begin="00:04:46.658" end="00:04:50.825" style="s2">of how far I've gone, and<br />then I do this nice and slow.</p>
<p begin="00:04:56.646" end="00:05:01.387" style="s2">And you can see I'm getting<br />closer to the vein now.</p>
<p begin="00:05:01.387" end="00:05:03.619" style="s2">And I've actually hit the vein.</p>
<p begin="00:05:03.619" end="00:05:07.786" style="s2">And if you can get a close<br />look here, you can actually see</p>
<p begin="00:05:09.171" end="00:05:12.083" style="s2">a little bit of blue liquid here,</p>
<p begin="00:05:12.083" end="00:05:16.250" style="s2">which demonstrates that<br />I've actually hit the vein.</p>