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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5784_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •How to Use this Book
- •Contents
- •Contributors
- •Objectives
- •US Management
- •Ultrasound Management Goals
- •Quality Improvement
- •Clinical Protocols
- •Information Management
- •Ultrasound Strategy
- •Situational Awareness
- •Creating a US Network with Key System Personnel
- •Timing
- •New Frontiers
- •Pitfalls
- •References
- •Objectives
- •Introduction
- •Leadership
- •Ultrasound Equipment
- •US Training
- •Who Else Is Using Ultrasound?
- •The Ultrasound Director Job
- •Extramural Involvement
- •Compensation
- •System Wide POC US Director
- •Medico-Legal Issues
- •Defensive Planning
- •Key Recommendation
- •Relevant Literature
- •References
- •Objectives
- •Introduction
- •Job Search
- •Peak Value
- •Contract Considerations
- •Negotiation
- •Discussion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •The Presentation
- •Programming
- •Capture Your Data
- •Synergy
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Pre-course Materials
- •Ultrasound Courses
- •Course Setting
- •Supplemental Education
- •Determining Competency
- •Pitfalls
- •Key Recommendations
- •References
- •Learning Objectives
- •Introduction
- •Deliberate Practice
- •Educational Goals
- •Blended Learning
- •Web-Based Instruction
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Main Ideas
- •Curriculum Development
- •General Needs Assessment
- •Targeted Needs Assessment
- •Basic Competencies
- •Advanced Competencies
- •Educational Strategies
- •Implementation
- •Ultrasound Champion
- •Funding Considerations
- •Discussion
- •Pitfalls
- •Key Recommendations
- •Medical School Year 2
- •Medical School Year 3
- •Medical School Year 4
- •References
- •Objectives
- •Introduction
- •Curriculum
- •Faculty
- •Equipment
- •Competency Assessment
- •Other Residency Experiences
- •EUS Fellowship Guidelines/Core Content
- •Education Skills
- •Quality Assurance
- •Leadership
- •Equipment
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Networking
- •Coding/Billing/Reimbursement
- •Budget/Economics
- •Credentialing/Privileges
- •Point-of-Care Ultrasound Program Accreditation
- •Problem Solving
- •Politics/Institutional POC US/Negotiation Skills
- •Discussion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Initial Education
- •Trainee-Based Pathway
- •Practice-Based Pathway
- •Experiential Component
- •Credentialing
- •Supervision
- •Independently Practicing APPs
- •Non-independently Practicing APPs
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Simulator Considerations
- •Commercially Available Simulators
- •Partial-Task Trainers: Phantoms
- •Anatomic Simulator: Live Model
- •Anatomic Simulator: Phantom
- •Anatomic Simulator: Computer-Based
- •Discussion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Machine Selection
- •Compact Cart-Based Ultrasound Machines
- •Hand-Carried Ultrasound Machines
- •Pocket-Carried Ultrasound Machines
- •Pole or Arm Mounted US Machines
- •Probe Selection
- •Equipment Purchase Considerations
- •Service
- •Image Quality
- •Machine Companies
- •Summary
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •US Machine Cleaning
- •Preventive Maintenance
- •Basic Toolkit
- •VCRs/CD Recorders
- •Broken Control Surface Buttons
- •Ultrasound Cart Wheel Assemblies
- •Wiring Check
- •Customizing
- •Essential Supplies
- •Power Cords
- •Small Parts Transducer Holder
- •US Carts Are Not Sacrosanct!
- •Color Code Your Transducers
- •US Cart Supplies
- •Industrial Velcro
- •Label Maker
- •Midline Markers
- •Artwork
- •Anthropomorphize Your Fleet
- •Signage
- •Ultrasound Supply Storage Cabinets
- •Poster Printer
- •Service Options
- •Original Equipment Manufacturer
- •Biomed Engineering
- •Equipment Insurance
- •Multi-Vendor Service Providers
- •Breakdowns
- •Longevity
- •Pitfalls
- •Key Recommendations
- •Objectives
- •Introduction
- •Machine Accessories
- •Barcode Reader
- •USB Accessories
- •Probe Accessories
- •Endocavitary Probe Covers
- •Sterile Probe Covers
- •Ultrasound Gel
- •Ultrasound Gel Warmers
- •Procedural Guidance Accessories
- •Echogenic Needles
- •Control Syringes
- •Needle Guides
- •Peripheral Intravenous Catheters
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Bioeffects
- •System Power
- •Thermal Index
- •Thermal Bioeffects
- •Mechanical Index
- •Nonthermal Bioeffects
- •Prudent Use
- •Ultrasound Safety Education
- •Infection Control
- •Noncritical Devices (Noninvasive Probes)
- •Semi-Critical Devices
- •Critical Devices
- •Other Ultrasound Machine Elements
- •Summary
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Terminology
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Infrastructure
- •Middleware
- •Data Entry
- •Report Generation
- •Image Review/Quality Improvement
- •Education/Credentialing
- •Order Entry/Billing
- •Middleware Vendors
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Media Acquisition Options
- •Internal Image Acquisition
- •External Image Acquisition
- •Image Format
- •Internet Cloud Storage
- •Video Editing Software
- •Ultrasound Education Creation
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Departmental Aspects
- •Interdepartmental Aspects
- •National Organizational Aspects
- •The Contrarian’s Viewpoint
- •Accreditation
- •Future Considerations
- •Conclusion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Key Terms
- •Historical Background
- •Obtaining Point-of-Care Ultrasound Privileges (Step-by-Step)
- •You Were Denied Privileging, Now What?
- •Pitfalls
- •Key Points
- •References
- •Objectives
- •Introduction
- •What Is Accreditation?
- •Other Ultrasound Imaging Accreditation Organizations
- •Pitfalls
- •Key Recommendation
- •References
- •Objectives
- •Introduction
- •CPT Coding
- •Global vs. Professional vs. Technical
- •Facility Setting
- •Professional Component
- •Technical Component
- •Medicare Patients: Hospital Outpatient Prospective Payment System
- •Medicare Patients: Inpatient Versus Outpatient
- •RVUs
- •Machine Purchase
- •Hand-Held Ultrasound Devices
- •Limited vs. Complete Ultrasound
- •Diagnostic vs. Procedural Codes
- •Add-on Codes
- •Nonphysicians Performing Ultrasounds
- •RN/Medics Performing Ultrasound-Guided Procedures
- •Licensed Independent Practitioners
- •Insurance Payment Policies
- •Technical Billing
- •Core Emergency Ultrasound CPT Codes
- •Diagnostic POC US
- •Trauma Ultrasound 93308, 76705, 76604
- •Female Pelvic Ultrasound: Pregnant 76815, 76817; Nonpregnant 76857, 76830
- •Abdominal Aortic Aneurysm (AAA), Urinary Tract 76775, Screening AAA 76706, Bladder 76857
- •Cardiac 93308
- •Biliary, Bowel, Hemoperitoneum, Appendix 76705
- •Abdominal Ultrasound LCDs: L31572, L34572
- •Deep Venous Thrombosis (DVT) 93971
- •Soft Tissue/Musculoskeletal
- •Thoracic Ultrasound 76604
- •Ocular Ultrasound 76512
- •Ultrasound-Guided Procedures
- •Advanced Emergency Ultrasound Codes
- •Outpatient vs. Inpatient
- •Government ABCs
- •Medicare
- •MACs
- •Medical Necessity/ICD
- •Payment Edits
- •Multiple Procedure Payment Reduction (MPPR)
- •Billing Optimization
- •Conclusion
- •Exhibit 1
- •Emergency Ultrasound Coding Guide 2017
- •References
- •Objectives
- •Introduction
- •Ultrasound Management in Global Medicine: Key Concepts
- •Equipment
- •Maintenance
- •Program Implementation
- •Education Strategies
- •Politics: Funding, Billing, Infrastructure
- •Discussion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Pediatric Abdominal Complaints
- •Pre-urethral (Bladder Size) Catheterization
- •Head Trauma
- •Musculoskeletal Complaints
- •FAST
- •Soft Tissue Infections
- •Pneumonia
- •Venous Access
- •Equipment
- •Managing Anxiety/Pain
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Ultrasound During Triage
- •Incorporating Ultrasound into Disaster Planning
- •Equipment
- •Conclusion
- •Key Recommendations
- •Objectives
- •Introduction
- •Trauma Evaluation
- •Cardiac Arrest
- •Telemedicine
- •Limitations
- •Conclusion
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Commitment
- •Soliciting Department Chair/Director Support
- •Safety
- •Cost
- •Ultrasound Director Support
- •Following Guidelines
- •Conclusion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Applications
- •Education
- •Medical Knowledge
- •Pathways
- •Skills Acquisition
- •Program Infrastructure
- •Program Director
- •Research Protocol Implementation
- •Equipment
- •Data Management
- •Quality Assurance
- •Conclusion
- •Pitfalls
- •Key Recommendations
- •References
- •Objectives
- •Introduction
- •Needs Assessment
- •Practical Considerations
- •Pitfalls
- •Key Recommendations
- •References
- •ACEP US Guidelines
- •ACEP Emergency US Imaging Criteria Compendium

13 Ultrasound Equipment Maintenance
191
ultrasound coupling agents have been touted to be equally effective and less messy;
in the future, we may be using small amounts of a residue-free ultrasound coupling
liquid applied with a cloth just prior to scanning.
US Machine Cleaning
(See Chap. 15 – Safety and Infection Control for probe cleaning)
Preventive Maintenance
This is somewhat machine dependent but may include any or all of the following:
Basic Toolkit
Invest in a basic multipurpose toolkit that includes slotted and Phillips screwdrivers, and
an adjustable wrench so you can tighten up some of the common trouble spots on your
carts. Many ultrasound machines will use Torx type screws, so a folding Torx wrench
may come in handy. Common cart trouble spots include cart housing screws, power
cord attachment sites, and wheel assemblies. Having a few basic tools available will
allow you to attend to some of these machine specic problems yourself (Fig.13.21).
Fig. 13.21 It is helpful to
have a basic equipment
repair toolkit for some of
the cart items that you will
periodically want to adjust
or tighten up yourself.
Many carts use a Torx
based system

192
A. Dewitz
Cleaning theTrack Ball
You can learn how to do it yourself or have it done during semiannual preventive
maintenance visits. Why bother? The internal trackball mechanism gets coated with
US gel over time impairing its function. A track pad or touch screen panel avoids
this problem altogether (Fig.13.22).
Fig. 13.22 Trackballs need periodic cleaning to remove ultrasound gel that can impede smooth
trackball function

13 Ultrasound Equipment Maintenance
193
Filter andFan Care
The ED is a VERY dusty place. Many ultrasound units have dedicated power supplies with cooling fans and lters to keep the electronics from overheating. Ideally
these lters should be cleaned every few months. Waiting for a biannual or annual
preventive maintenance visit is often inadequate and the lters may be clogged up
by then. The lters need to be removed, washed with soap and water, then dried and
replaced. If you don’t clean them, the fans will no longer function efciently, and
your electronics can overheat, give you error messages or crash your equipment
software. Any piece of equipment in your clinical care setting that has an onboard
cooling fan running will inevitably vacuum up lots of ever-present dust. This is yet
another reason why we should not leave our ultrasound machines running when not
in use (Fig.13.23).
Fig. 13.23 The ER is a
very dusty place. Onboard
lters should be cleaned
every several months to
avoid overheated
electronics. Once a year
cleaning is inadequate

194
Fig. 13.24 A VCR head
cleaner will help maintain
good quality video images
if you are still using this
type of image storage
medium
A. Dewitz
VCRs/CD Recorders
Not a lot of people are still recording ultrasound images with videotape, but if you
still use this medium for image review, your VCR’s image quality can be improved
by using a $5–$10 tape head cleaner every few months (Fig.13.24). Digital image
capture devices like CD recorders simply need a periodic cleaning of the control
surfaces and a periodic check of their plugs and connectors.
Tighten theLoose Stuff
Problem spots are machine specic. Your biomedical engineering folks or your
equipment repair tech can point out what gets attended to on a routine preventive
maintenance visit. Power cord holders on some older machines need monthly attention to keep them from loosening and falling off due to the heavy forces placed on
them.
Broken Control Surface Buttons
Older machines often have plastic buttons that dry out and crack after having been
T-Sprayed a few thousand times; TGC control buttons seem to be the rst to break
down. You can order a bag of replacement buttons and knobs from your ultrasound
equipment vendor and with a bag of replacements handy you can address these
small annoyances yourself (Fig.13.25).

13 Ultrasound Equipment Maintenance
Fig. 13.25 Buy a bag of new buttons for your older machines so you can replace them when they
break
195
Ultrasound Cart Wheel Assemblies
The plastic wheel housings on some ultrasound carts are poorly designed for the
rigors of clinical use and will predictably loosen and fall off. This is mostly a cosmetic issue. The plastic housing simply hides the fact that the wheels get mightily
gunked up over time, usually with a combination of dried blood, EKG electrode
stickies, foam IV securing devices, tape of various sorts, and unbelievable amounts
of hair! (Fig.13.26). When your cart starts to shimmy or be noticeably difcult to
roll around, it is time to give the wheels some attention. Ultrasound cart wheel
assemblies need periodic cleaning and oiling, removal of the many adherent adhesive items with a solvent like Goo Gone or Goof Off, and the occasional haircut
(forceps and scissors work best, high and tight!). The foot controlled wheel locking
switches get very dirty over time but can be easily cleaned with any general-purpose
spray cleaner and a bristle brush or old toothbrush. Seriously unglamorous stuff
(Fig.13.27).

196
A. Dewitz
Fig. 13.26 Cart wheel woes that you will inevitably need to address: cracked housings, glued on
EKG electrodes, dressing materials, foam IV securing devices, and more hair than you can imagine
Fig. 13.27 Cart wheel cleaning: soak and brush off the foot pedals, forceps and scissors for the
haircuts. Wear gloves!

13 Ultrasound Equipment Maintenance
197
Fig. 13.28 Power cord plug end woes: bent pins, a cracked housing, exposed wires: all bad, time
for replacement
Wiring Check
Power cord plug ends take lots of abuse. The machines get plugged in and out many
times a day, 365days a year, and occasionally the cord will take an extra whack
when people move the ultrasound machine having forgotten that it is still plugged
in. When the plug pins get bent, if the plug end housing is cracked and has wires
peeking through anywhere, or if the power cord has nicks in it from being run over
a few too many times it is time for repair or replacement (Fig.13.28). It can be help-
ful to have a backup power cord on hand. If you just need to replace a bent plug pin
that you can no longer straighten, you can have your hospital electrician install a
new hospital grade plug end (Fig. 13.29). Periodically you should also visually
inspect the power cord for nicks and defects in the housing.

198
Fig. 13.29 The famed
“Hospital Grade” plug
A. Dewitz
Ideally, a well-designed machine should have all important wiring hidden and
protected within the cart or housing. This is rare with older machines in particular.
Important but exposed wiring can get disconnected. Velcro cable ties (1/2×6in.,
purchased at any hardware store) can be used to help neaten up this clutter and can
help keep your equipment wiring tidy and out of harm’s way.
Customizing
Customizing your new ultrasound equipment to suit your specic practice needs is
an essential and fun part of the process of getting your machine ready for use in your
clinical setting. Even after many years in the business and many (14!) machine purchases later, I have yet to see an ultrasound machine that didn’t benet from customization and modications to make it more user friendly and better suited to our
ED practice setting. All our ultrasound machines start out their lives in the Ultrasound
Section “Chop Shop” (our Ultrasound Section ofce) before they get launched into
the ED.If you buy several machines at a time you can do them up in bulk.
Essential Supplies
So what are the essentials? You’re going to need some 4″×2″ industrial Velcro
strips, ¾″ Velcro sticky-back tape, ¾″×8″ Velcro cable ties, plastic cable ties, metal
extension springs or Kevlar/polycarbonate retractable key fobs, coiled plastic key
rings and clips, and some metal key rings (Fig.13.30).

13 Ultrasound Equipment Maintenance
Fig. 13.30 Essential customizing supplies for new machines include: industrial and regular Velcro
sticky-back tape, Velcro cable ties, plastic cable ties, piano wire extension springs, coiled key,
metal key rings, and robust key fobs
199
Transducers andTransducer Cords
Implementing a system to protect your transducers and transducer cords will be
your number one customizing task. Surprisingly little attention has been paid to this
issue by ultrasound vendors, likely due to the fact that historically, ultrasound carts
were mostly parked in one location and the patient was brought to that location for
imaging. Most older ultrasound machines were very poorly designed for high
mobility applications. Newer point-of-care machines and carts are much better
designed in terms of footprint, wheel assemblies and simplied keyboards, but they
are still mostly lacking in good transducer cord management solutions. At 4000 to
over 10,000 dollars each times three to four transducers on each machine, you have
a big incentive to protect these most essential and pricy parts of your ultrasound
eet. If your transducer cords are not properly secured it is almost guaranteed that
you will at some point in time nd a transducer cord snugly wrapped around one of
your ultrasound cart’s caster wheels (Fig.13.31). While this will predictably cause
you severe agita and might even bring the occasional tear to an ultrasound director’s
eye, it is an entirely avoidable event.
Transducer trauma can be likened to neuro trauma. For the transducer head, the
closed head injury model applies. You drop it, your crystals get damaged, and things

200
Fig. 13.31 A transducer
cord wrapped around a cart
caster wheel; guaranteed
agitation
A. Dewitz
are never quite the same thereafter. User education on proper transducer care is the
best preventive medicine to keep this type of trauma from occurring. Users should
be taught from the outset that the transducer is very expensive, somewhat fragile,
and should always be protected. There should be zero tolerance for laying the probe
on a stretcher, a tray table, or on top of the ultrasound machine. “In your hand, in the
cup holder, or on your VISA” is a useful mantra for inculcating good transducer
care behaviors.
For the transducer cord, the spinal cord injury model applies. An unsecured
transducer cord will drape onto the oor, and will at some point inevitably get run
over and caught in the cart’s wheel assembly. As a result, the cord housing may be
violated, some essential wiring may have been severed, and the transducer rendered
less than optimal, possibly useless. For this issue there is a simple x: don’t let the
cord ever hit the oor.
Transducer and transducer cord protection can take on many forms. Years ago I
had our hospital welder build a stainless steel cage for cord storage on a “mobile”
285lb machine that was probably originally designed to just sit it one location and
not be moved around a lot. (But what a good workout we got every shift!) The idea
of a transducer cord bungee system began many years ago when Dr. Anthony Dean
sent me pictures demonstrating how he used a bicycle cable, some coiled key rings
and carabiners to improvise a system to keep his transducer cords from draping
onto the oor, getting run over and traumatized (Fig.13.32). I used the coiled key
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