Ultrasound Skills Development
Training Reps and Game-Time Experience
I love this time of year when college football is closing in and all the hype about ‘what could be’ is at a peak. Last minute decisions are being made to determine who key starters are going to be and who will get the precious remaining ‘training reps’ with the first team offense or defense that are so critical to getting timing down and recognizing and working through mistakes in a real ‘Game-Time’ atmosphere.
It was at a workshop that I was teaching last year in Chicago that got me to thinking about this analogy as it relates to putting into clinical practice new ultrasound techniques. A very insightful anesthesiologist at the workshop asked me a very good question. He indicated his desire to incorporate the new ultrasound techniques we had been covering but was concerned with what would almost certainly be a relatively ‘not so slick’ performance (in terms of technique and even in communicating with his assistant in front of the patient). After working with he and his group, I have no doubts that he can safely and effectively accomplish his goal, but I can appreciate and understand the additional stress he was describing that comes with trying a new technique in a real ‘Game-Time’ experience. The stress of working on something new at a workshop in nothing like the stress one experiences trying to do the same in front of a real patient. That is, getting comfortable to a low stress environment will only take you so far. At the same time, how can you improve your skill in a real clinical scenario without hurting the patient (or taking all day) without actually getting in that atmosphere? I would like to take this time discuss this issue and hopefully offer some helpful solutions to this dilemma.
Certainly, there is nothing that beats having an expert or ‘coach’ with you at your facility that has just gotten you oriented and prepared and will stand with you as you perform the new technique several times in a row then offer advice afterward. Let’s assume this isn’t an everyday option for everyone and talk about how you can still get in some valuable training reps in a ‘Game Time’ experience to boost your confidence and advance your technique while you work out some of the kinks in your routine.
The first and easiest way to develop comfort with your routine and general ultrasound technique is to find ‘additional’ opportunities to scan real patients in the holding room (or wherever your blocks and procedures are typically performed). When I say ‘additional’, I mean[nonmember]…
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[ismember]simply extra times to scan a patient that may not be, strictly speaking, absolutely necessary or part of your usual routine. This might include scanning a patient’s neck prior to doing a central line for someone who does not use ultrasound to perform a central line. This may certainly give you valuable information related to the procedure at hand, and it may afford you the opportunity to recognize the orientation of the brachial plexus with a very thorough examination of the neck. As well, whether or not you would ever consider utilizing ultrasound to help with a difficult IV or arterial line insertion, it is reasonable (and extremely helpful in difficult situations) to scan a patient’s wrist or armbefore performing these procedures. Again, it may give you some helpful insight regarding their vascular anatomy, but it will give you an opportunity to recognize structures and more successfully handle the probe. You might find a number of times when an ultrasound scan might be an adjunct to your usual clinical decision-making.
The next opportunity to develop your skills as you look to integrate ultrasound into your nerve block routine is to simply scan with ultrasound to practice your technique and to recognize the sonoanatomy, then put down the probe and perform the nerve block as you normally do. Utilizing ultrasound usually means entering from new places at new angles and trusting your ultrasound skills more, and you do not want to make that leap before you are ready. Remember, you never want to be doing ‘sort of both’ techniques. After you perform the nerve block with nerve-stimulation as you normally would, look again with the probe to have another chance to scan and to see how the local anesthetic has spread. If this ‘pre-scan’ convinces you that you are ready to convert to an ultrasound technique and approach because the anatomy is very obvious to you, this may be the opportunity you have really needed. Either way, you got to scan and get training reps in a ‘Game Time’ experience, but you had no pressure to alter your technique.
Lastly, you may consider scanning patients that might possibly (or will very likely) benefit from a nerve block prior to surgery to see if they appear to be a candidate for a nerve block should the need arise in the PACU. If it is a nerve block that you cannot or would not do without ultrasound, and you discover prior to surgery that their body habitus is prohibitive, you may alter your anesthetic plan accordingly since you know you are unlikely to see what you wanted at the end of the case. As well, if you see the anatomy very well this time, you can alter your anesthetic plan with the anticipation that you will be able to perform the nerve block at the end of the case. I have stated the additional advantage that you have here on several occasions. That is, Rescue Blocks are dramatic to the patient and the PACU staff if you do it well, but the patient is very appreciative still even if you do a suboptimal job because they will have benefited (at least to some degree) from your attempt.
These opportunities can help you move forward in your probe handling, structure recognition, comfort in a new situation, communication with your staff and organizing some of the small stuff that you encounter as you incorporate ultrasound into your routine. As well, they are real clinical experiences, but they do not commit you to performing ultrasound techniques until you are ready.[/ismember]