This document discusses turning up the gain on pre-hospital ultrasound use. It proposes two studies: 1) A 1000 patient randomized trial of pre-hospital ultrasound use for major presentations to evaluate costs and benefits. Paramedics would perform ultrasounds and transmit scans/videos via satellite for remote advice. 2) A 1000 patient study validating pre-hospital ultrasound's accuracy in detecting limb fractures compared to radiography. The document outlines challenges including potential confounding factors and the need for broad patient-focused outcomes. It advocates training paramedics to perform focused scans that could impact treatment and inform remote specialists.

1. TURNING UP THE GAIN
IN PRE-HOSPITAL
ULTRASOUND
Luke Regan - @lukearegan

2. Remotely supported prehospital
ultrasound for pre-hospital emergencies
Centre for Rural Health, University of Aberdeen
P Wilson, L Eadie, L Regan, P Sherriff

4. SMACCForce
DISCLAIMER
This brief presentation on pre-
hospital care research in the
North of Scotland contains
maps, entirely unnecessary
holiday snaps of my family

5. CONFLICT OF INTEREST

12. *Scottish
paramedic
removes
renal
calculus pre-
hospitally
following
ultrasound
diagnosis

18. 12 months of
EMRS primary
jobs

23. 325
Deaths
206
Deaths

24. ? MOTIVATION OF RESEARCH ?

32. The obvious precedent /
analogy
• 50% of all patients receiving ECG tele-
advice from a CCU nurse resulting in
pre-hospital thrombolysis prior to arrival
at Inverness hospital had journey times
to hospital greater than 30 mins.
• The relative benefit of stopping,
performing ECG, transmitting and
awaiting advice has now been
established.

33. Meanwhile in the rest of the world……
• Very apparent practice creep
• Ultrasounds appearing at the roadside in
increasing numbers of pre-hospital
services
• Remains an evidence poor area
• Small scale trials likely to swing academic
opinion in either direction on little or no
scientific basis

34. WHAT ARE THE BIG QUESTIONS in PH-
POCUS?
- does it make a difference
- which scans make a difference
- does it take too long
- who should do it
- how long does it take to acquire
competency
- should it only be done en route or in
the trapped patient, ie never when it
prolongs scene time

36. WHAT ARE THE BIG QUESTIONS in PH-
POCUS?
- does it make a difference - YES
- which scans make a difference – BIG
ONES
- does it take too long - NO
- who should do it – THE PERSON WITH
THE Pt
- we don’t get radiologists to teach
POCUS to bedside clinicians, why
should in hospital clinicians teach pre-

37. SO….the big plan
Evaluate the costs and
benefits of ambulance to
hospital satellite comms
and ultrasound scanning
• 2 studies:
– A 1000 patient randomised
controlled trial of POCUS for
major presentations
– A 1000 patient validation study
about the accuracy of detection
of limb fractures with PoCUS in

38. Satellite transmission of major
presentations trial
• 5 SAS Highland ambulances equipped with
ultrasound machines, satellite
communications technology, webcams
• Patients randomised: machine either switched
on or not
• Video precis of patient story and scan
performed with fixed time limit of possible
scanning/sending process
• Ultrasounds, video and remote advice
received via satellite communications system
• Patient follow-up after 6 months with QoL

39. Fracture diagnosis trial
• Can ultrasound used by paramedics at
scene have diagnostic equivalence to
radiography for long bone fractures?
• Paramedics to record a clinical
judgement based on ultrasound scans
• Scans to be recorded and expert opinion
given
• Clinical judgements and expert opinion to
be compared with X-rays

40. 5 stations

41. Pre-hospital research:
land of the endless
confounders
• Hawthorn effect on paramedic and
receiving consultant as neither blinded to
subject arm
• Pre-hospital US may just trigger
increased likelihood of US in resus with
associated benefits
• Main benefit may just come from video
precis of patient with good handover
rather than the subsequent ultrasound

42. Pre-hospital research:
land of the endless
confounders• Hence the decision to do a 1000
patient study with 5 separate
ambulance stations/teams involved
and to aim for broad but patient-
focussed endpoints of EQ5D and
mortality
• This is a real world, real service
study. If you were reviewing an
ultrasound, you want to know about
the patient

48. Processes
InvolvedTraining of ambulance personnel,
communications, firewall access
(CRH/NHSH/SAS)
• Recruitment and awareness sessions,
• Ultrasound introduction days,
• Practice with protocols and road-testing of
processes,
• Design of video training packages and aide-
memoires for vehicles
• Image review practice sessions for receiving

55. 1 - IF YOU WANT PEOPLE TO FUND YOUR
HYDROGEN POWERED ROCKET SHIP,
FIRST DEMONSTRATE YOU CAN WORK A
BBQ

57. 2 - IF YOU ARE CONVINCED
THAT ONLY ONE TYPE OF
PERSON CAN LEARN A
CERTAIN SKILL, YOU ARE
LIKELY ARROGANT, LAZY OR
INSANE… and with technical
skills like ultrasound, you are
unlikely to be correct

59. 3- EVERYONE WANTS A MAGIC
TECHNO BOX
THAT INSTANTLY GIVES A CLEAR
DIAGNOSIS

60. “DIG THREE GRAVES UP THERE.”
“I’LL EXPLAIN IT TO YOU LATER.”

61. The End