From C. Ted Lord, MD, Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland Maine on POCUS
I am a pediatric anesthesiologist with a substantial adult anesthesia practice as well. I completed fellowship in 2012 and had an early enthusiasm for the possibilities of POCUS. It has been fascinating to watch as various specialties both nationally and, for me, locally raced ahead of anesthesiology in the use of diagnostic ultrasound, establishing residencies and ultrasound fellowships with diagnostic elements, and publishing. An additional fellowship, akin Emergency Medicine ultrasound fellowship or Anesthesiology regional fellowship would appears not to be the solution for the vast majority of us. However, keeping those of us in long in practice current and able to teach our increasingly POCUS-savvy residents is an unanswered challenge coexisting with the need to have those leaving pediatric anesthesia fellowships now ready to incorporate these skills immediately.
I completed the ASA Diagnostic POCUS program last year and the entire time was thinking “How can we create a pediatric specific program for POCUS?” Upper airway ultrasound and gastric ultrasound for foreign bodies are a few POCUS applications I find useful in pediatrics in ways seldom applicable to my adult practice. The fundamentals of image acquisition for lung, cardiac, and abdominal POCUS is similar across adult and pediatric practice but the pathologies in question are not.
For those newly fellowship trained and with demonstrable POCUS case numbers, would a pediatric-specific process via SPA allow a pediatric POCUS certificate? How about for those of us in practice long enough that we received no POCUS training in residency or fellowship? The SPA program could be a supplemental pediatric “icing” to the adult ASA program “cake” or might stand alone if workshop/POCUS course/local mentorship was able to establish the fundamentals.
Something that could prime the POCUS pump from many institutions would be to collect, review, and publish/disseminate curricula, guidelines for institutional POCUS privileging, and templates for complaint study reporting. The SPA POCUS Special Interest Group is an existing base of experience and potential on these topics.
From Nancy Glass MD on pregnancy testing
Thank you for today's PAAD: I've been against the blanket policy of pre-op pregnancy tests ever since we began doing them at Texas Children’s Hospital. Many of our international patients and parents were offended by this program.
To the risks already identified in the paper, I would add one more: in the current apocalyptic political environment--outing an adolescent's pregnancy and documenting the test result in the medical record could put her and her family in danger. Several states want to monitor pregnancies and "make sure" women cannot travel to terminate an unwanted pregnancy.
I am horrified by the possibility that we could become instruments of the state and accessories to taking away patient and parent decision-making
From Dr. Jamie Peyton Boston Children’s Hospital
Great PAAD today (as usual). As someone who has just started wearing hearing aids myself at the age of 49 I thought it was an interesting topic to highlight. The initial issue for me was covid associated tinnitus, which I assumed would go away, having started five days into my first bout with the virus just after I lost my sense of taste. Having been annoyed by it and ignoring it for a couple of years and, more importantly, annoying my wife for a similar amount of time by telling her to stop mumbling and speaking too quickly with her Brooklyn accent, I got myself checked out. Sure enough, I had some high-frequency hearing loss alongside the tinnitus, so I trialed some hearing aids. There is a plethora of options, including ones that sit deep in the ear canal and need to be placed by an audiologist every six weeks but are invisible to others but they have the disadvantage of completely blocking sound from entering the ear naturally, so everything is heard through the device. Other ‘invisible’ ones require battery changes every 3 days, which seemed a huge environmental price to pay for vanity, so I went for a more traditional set of hearing aids which are rechargeable and surprisingly discrete. Interestingly, part of the process of being fitted for the hearing aids involved a session on the psychological aspects of wearing them and the stigma associated with ‘outing’ yourself as hearing impaired. I skipped this session as I was not at all concerned about it (as my wife put it, ‘Why should you start caring about what you look like or what other people think about you now?’ – which may reveal some different psychological issues!), but in conversation with the audiology team, it became evident that many people are. So, I thought I’d send in a response and do my bit to try to reduce the stigma that others may feel about wearing hearing aids. They help at work, particularly in the noisy OR environment and have also prevented my wife from strangling me, although she does still mumble, and I haven’t managed to refine that accent yet.
From Audra Webber MD
The topic of preoperative pregnancy testing is one that is near and dear to my heart, and I have argued for years that to require it against a patient's wishes (or at all) in order to proceed with a surgery someone has received insurance approval for, taken time off of school or work for (or the parents have in the case of minor patients) flies in the face of patient autonomy, and our ASA guidelines. In addition I have witnessed firsthand in multiple centers the lack of informed consent when obtaining a urine sample for a pregnancy test, especially for minor patients. That the patient has no idea a pregnancy test is being performed or that the results will become part of their medical record flies in the face of informed consent.
Imagine this scenario - Hypothetically a young teen (<15) trauma patient might come through the ED after a car accident with multiple injuries requiring surgical treatment, and in the array of labs run in the trauma bay a pregnancy test is performed and was positive. You might know this because you were directly involved in this patient's care. Or, you might know this because it was gossip the ambulatory surgery center 2 days later heard from another medical professional. Was the test even necessary? She would have proceeded to the OR regardless. And now, unbeknownst to the patient herself, she is a topic of conversation.
What is the solution? I believe pre-operative pregnancy testing should be OFFERED to the patient pre-operatively - with full informed consent and no obligation. Even better, prior to DOS the preoperative phone call (from surgeon or anesthesia office) should include this informed consent and state the patient may prefer to take a home pregnancy test the day prior if they do not want the results being part of their medical record.
I wholeheartedly agree with Jackson et al's suggestions. I am actually giving a POINT/COUNTERPOINT on this topic at ASA this October titled:
"Preoperative pregnancy testing for elective surgery - necessity, consent and confidentiality in a post Roe world"
In it, I am arguing preoperative pregnancy testing should be OPT IN and my counterpart is arguing it should be OPT OUT.