Category: General

Basics techniques needed to evaluate the Appendix!

Posted on by Gail Crawford

Typical indicators for an appendicitis are:

• Pain extending from umbilicus into the RIF (McBurney’s point)
• Loss of appetite +/- Fever
• +/- Nausea and vomiting
• Rebound tenderness
• Increased white cell count (WCC)

Atypical indicators:

• Pain localised to RIF
• Diarrhoea (Prolonged)
• Frequency of urination

Other signs can include:
• Rovsing’s Sign – Deep pressure in the LIF will cause pain in the RIF
• Psoas Sign – Inflamed appendix can put pressure on the psoas muscle. The patient flexes right hip for pain
relief.
• Obturator Sign – inflamed appendix which comes into contact with obturator internus can cause spasm when
flexing and internally rotating the hip.
(https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543)

Diagnosis can be made through:
• Patient History
• Clinical Examination
• WCC
• Ultrasound and +/- CT scan/MRI

HOW DO WE DIAGNOSE AN APPENDICITIS ON ULTRASOUND? KEY ELEMENTS.

Identify the appendix (Blind ended tube arising from the caecum)
Be aware that the appendix can sit in various positions. Using a clock face:

1 O’clock – Pre-ileal (Anterior to terminal ileum)
2 O’clock – Post-ileal (Posterior to terminal ileum)
5 O’clock – Pelvic (Over pelvic brim)
6 O’clock – Sub-caecal (Inferior to the caecum)
11 O’clock – Retro-caecal (Behind the caecum). Most common position.
https://teachmeanatomy.info/abdomen/gitract/appendix

Understand the layers that make up the bowel wall!


Sourced from https://commons.wikimedia.org/wiki/File:Mucosa.jpg

Use a HIGH frequency linear probe, with an empty patient bladder.
Start scanning high in the abdomen over the ascending colon, and put increasing probe pressure (Graded compression) on when scanning inferiorly. This moves air from the bowel and improves visualisation.

  • Identify the caecum (characterised by large calibre, typically filled with gas/faecal material (hyperechoic), haustral folds – lobulated appearance, and very slow peristatic movement).
  • Identify the iliocaecal valve (Valve between small and large intestine)/terminal ileum  – Small bowel, narrow calibre, valvulae conniventes (smooth wall), visible peristalsis, fluid can be seen moving through.
  • Appendix

DIRECT SIGNS SEEN ON ULTRASOUND
• Non compressible blind ended tube (Appendix)
• Measuring > 7 mm in diameter
• Wall thickness > 3mm
• Appendicolith
• Target sign (Axial Position)
• Colour doppler – Hyperaemia (Ensure scale setting accordingly).
• Potentially avascular if necrotic.

INDIRECT SIGNS SEEN ON ULTRASOUND
• Free fluid (Around appendix and in POD)
• Hyperechoic mesenteric fat
• Enlarged lymph nodes

References:
• Carroll D & Jacob K et al (2019) “Appendicitis” sourced May 2019
https://radiopaedia.org/articles/appendicitis
• Mostbeck G et al (2016) “How to diagnose an acute appendicitis: Ultrasound first” sourced May 2019
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805616/
• Löfvenberg F and Salo M (2016) “Ultrasound for Appendicitis: Performance and Integration with Clinical
Parameters” sourced May 2019 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5156797/
• Puylaert JB (1986) Acute Appendicitis: US evaluation using graded compression sourced May 2019
https://pubs.rsna.org/doi/10.1148/radiology.158.2.2934762
• https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543)
• https://teachmeanatomy.info/abdomen/gi-tract/appendix/
• https://commons.wikimedia.org/wiki/File:Mucosa.jpg

Are Sonographers looking after themselves??

Posted on by Gail Crawford

Written by Gail Crawford (Director/Tutor Sonographer at Integrated Ultrasound Education)

Recently Integrated Ultrasound Education (IUE) in conjunction with Angie Bain – director and wellbeing practitioner at ‘Survive to Thrive’ ran a “Counselling for Sonographers” session.

Angie is a fantastic, highly motivated and engaging presenter.

While most of you, like myself, have been to basic education sessions about counselling, and delivery of bad news; and studied the basic foundations at a  university level;  what really sparked my interest from Angie’s Talk and something that I really hadn’t considered at all was:

“Are sonographers looking after THEMSELVES……. mentally” ??????

I don’t really think this is something that I have ever really thought about in my role as a sonographer.

We are busy concentrating on our occupational health and safety, ergonomics; muscular pain and injury, which are all extremely important in our role as a Sonographer and definitely as a tutor; I talk to students on day one of training about the importance of ergonomics and its role in our profession.

As sonographers we can spend 20 – 30 min or even up to an hour with a patient.  Often, they confide in us, whether it is about their upcoming day, the tough time they are having in their lives with children not performing at school, having to move house, etc.  Often these conversations are intense/draining on the brain.  We are often involved in delivery of “Bad news”; a failed pregnancy or worse the demise of a third trimester pregnancy.  These circumstances never get any easier.  I have been scanning for 20 years and I can still outline the severely traumatising news I have had to give.  This can impact on us as Sonographers both mentally and physically.

Often after encountering these patients we are then required to continue with our normal days list.  Missing lunch, trying to keep on time.   When your list run’s late you can encounter more problems, like making silly mistakes, or patients being hostile/annoyed that you are running late.  You the sonographer has to manage these expectations, along with doing the best job possible

.

https://quotesgram.com/img/ultrasound-technician-quotes/3780469  – Love this quote…. so true!!

Have you ever really stopped and thought about yourself – SELFCARE ?

Angie provided us with a useful set of insights into how we can be mindful of our own mental health and wellbeing.

  • Have you debriefed about a situation with a colleague ? Does your practice have a policy regarding such stress/mental health scenarios? There are other help lines available such as Beyond Blue, Headsup and Lifeline.
  • Have you considered meditation ?
  • Have you considered that maybe your exhaustion at the end of the day is mental not physical and that getting your body moving with a leisure activity maybe helpful.
  • Love this point – Mums who are trying to juggle work/children – loose some mum guilt and give yourself some time for you (This really resonates with me a proud, but often overworked mum of two beautiful girls).

I love working as a sonographer and tutor sonographer.  It is such an amazing, challenging, rewording career, but until now I have never really considered the full enormity of what we offer.  Yes we are highly specialised practitioners, but along with offering the practical component of our occupation comes an inherent level of communication, counselling or involvement in delivery bad news.

Sonographers you are amazing and be kind to yourselves!!!

COVID-19 – “The Sonographers Dilemma”

Posted on by Gail Crawford

COVID-19 – “The Sonographers Dilemma”

This is a personal account of my feelings, thoughts and learnings as a Sonographer/Tutor Sonographer in a Private Practice setting in Australia!

Are your anxiety levels running high?  Mine are!

I’m worried about my elderly Grandparents (90 and 92), my parents, and all of those friends and family in the community who have weaker immunity.

How is this Corona Virus Pandemic going to play out in your region?

How do we as Sonographers help contain the spread, and keep ourselves safe when we are UNABLE to  maintain “Social distancing”.  As Sonographers our patients are close, and we are often in the room with them for 20-30 minutes at a time.

Currently in Australia where I am based, confirmed numbers are relatively low.  But anxiety levels are excessive.  My question especially as a Sonographer in a Private Practice setting, is how do we keep ourselves safe/limit our exposure, to the active virus?  How do we ensure that we don’t contribute to the spread? To our patients and our loved ones?

Currently we are following the Australian Government Department of Health Guidelines (https://www.health.gov.au/)

  • People who have been overseas in the past 14 days are required to self-isolate and will not be examined (can postpone appointment)
  • People who have come into contact with a confirmed case of COVID-19 are also required to self-isolate for 14 days and will not be examined (can postpone appointment)
  • People who have a fever are also asked to re-schedule their appointment.

But what about those people who may have contracted the virus via community transmission (unknowingly) and are asymptomatic.  These are the people we sonographers my encounter.

I watched the ISUOG webinar on the 17/03/2020  and want to share “ my personal key learnings” from the speakers.  The entire webinar can be found at:

Prof Francesco Castelli (Italy), accentuated how quickly the virus spreads, and that it is highly infectious amongst health workers.   He also said that often first testing of the virus can provide a False negative reading…. So be cautious.  If clinical symptoms fit, then treat as COVID-19 as precaution.  He also said that once testing positive, it may take up to 3 weeks for a patient to be non-infectious (not be contagious).

Dr Jill Lee Cheng Sim (Singapore), discuss how the Singaporean health care system had learnt from the SARS outbreak in 2009, where 25% of health care workers were infected.  To date on 1% of health care workers have been infected with the COVID-19 virus.

This is attributed to:

  • Protective equipment and good infection control training.
  • General preventative measures and PPE use.

Also remember to support colleagues, be aware of Mental and social health.

Prof Liona Poon (HK) stated that they wear a mask at all times whilst at work and that even at lunch personal hygiene etiquette (Social Distancing) should be maintained.  This is how health care workers in Wuhan enabled the disease unknowingly.  The appropriate masks have been stated as N2/N95.  That staff in Hong Kong also change their clothes and shower prior to coming home.  Preventing any spread via clothing.

A guide to the correct use of the N2/N95 mask can be found at this site:

https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/diseases-infection/infection-prevention/transmission-precautions/p2n95-mask

I have started implementing my learnings from Tuesdays nights Webinar immediately.  Here is a photo of me with my new fashion accessory  “N2 mask” (Getting use to the feeling on my face)….. trying not to hyperventilate😊

I am continuing with all my usual behaviours also.  Gloving for all patients, cleaning the room and probes thoroughly between patients.

Changed my clothes prior to leaving work and showered as soon as I got home!

We all need to stick together at these tough times.  Stay safe.

Please feel free to touch base with questions/discussion😊

Gail

Director/Tutor Sonographer/Sonographer (Integrated Ultrasound Education)

Email: gail@iuc.consulting.com.au