Author: Gail Crawford

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 – What should we expect if we contract the virus?

Posted on by Gail Crawford

COVID 19 – What should we expect if we contract the virus?

My take on this question to date is expect the unexpected!!!

Written by Gail Crawford (Director and Tutor Sonographer – Integrated Ultrasound Education)

 

As like many of you, I have been trying to keep abreast of the signs and symptoms of COVID 19 or the “corona virus”.  To date those predominantly advertised and marketed to the world by the World Health Organisation (WHO), and leaders in the medical field are:

  • “Fever, dry cough, and tiredness”

Serious symptoms include:

  • Difficulty breathing/shortness of breath, Chest pain, and/or loss of speech/movement.

With a lesser emphasis on:

  • Nasal Congestion, headache, conjunctivitis, sore throat, diarrhea, loss of taste or smell and skin rash/discoloration.

They are stating that 80% of people will recover from the virus without hospital treatment and that predominantly the elderly and people with underlying medical conditions such as heart and lung problems, diabetes, high blood pressure and cancer are the people at most risk of serious complications.

A friend of mine, a health worker who would like to remain anonymous was recently diagnosed with Covid 19.  For the purpose of this blog post we will call her “Anne”.

From contact tracing it appears Anne acquired the virus at work.  But not necessarily from direct contact with a person/patient. It is assumed that she may have contracted it from a hard surface item such as paper, pen, desk etc (We now know that the virus can remain active of hard surfaces for up to 72 hours and porous surfaces such as paper for up to 24 hours) (Neeltje van Doremalen, et al – Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1).

I thought this would be a prime opportunity to ask a little more about her own personal experiences of the virus, and her fellow colleagues.  Their symptoms and how they have felt both mentally and physically.

This is an outline of Anne’s Journey……

Anne had been working long hours up to her initial diagnosis.  She is generally well, with mild asthma and has been post-menopausal for 3 years.

Day 1. – symptoms began to appear, so presumably contagious prior to this – “Sneezing” with normal temperature (36.5 degrees).

Day 2 – Sore throat, “Runny nose” and normal temperature (37.2 degrees).  Normal temperature can range from 36.1 degrees up to 37.2 degrees.

Day 3 – Sore throat, “Runny nose”, cough, fatigue and only “Very mild temperature (37.5 degrees) – Low grade fever”. 

It was at this stage that a test for Covid 19 was arranged.

Day 4 – Sore throat, “Runny nose”, “severe fatigue/lethargy”, diarrhoea, cough and only “Very mild temperature”.

Day 5 – Cough, extreme headache, diarrhoea, sore throat has eased, “Normal temperature” and “severe lethargy”.  Results are POSITIVE FOR COVID 19.

 

That evening was REALLY DIFFICULT, Anne experienced shortness of breath and an unfounded “Anxiety”.   She also said that many of her colleagues experience this atypical anxiousness.  Enough to prevent her from wanting to fall asleep.  We can already appreciate that the Covid 19 pandemic is posing a significant physiological threat, and has altered everyone’s daily lives significantly, however there is research now stating that we need to also review the  “neuropsychiatric symptoms” caused by the disease, such as seizures, confusion and general “haziness”.

Day 5 – Her colleague also tested positive, but through this entire ordeal has only experienced mild hot flushes (Raised temperature).  NO other symptoms.

Day 6, 7 & 8 – “Runny nose”, “Normal temperature”, Cough, diarrhoea, headache, “sever lethargy” and loss of taste and smell (anosmia).

Anne said that many of her colleagues had sever sinus pain early on and had lost their taste and smell.  However, it was not till day 6 that it occurred for her.  It appears for these colleagues it is taking a long period of time for them to regain their taste and smell (> 5 weeks).

During this entire time, she has been home quarantined, visited by a variety of emergency services including Fire brigade, Police, SES, Defence force to ensure she is abiding by quarantine laws.  She has also been in regular contact with her assigned medical practitioner, who has been exceptional.  Providing medical support in a physical and mental capacity. This has really helped in her “fight” against this virus.

Day 9 – Another day from “Hell” – Cough now productive, taste improved, diarrhoea stopped (Via medication), “Crazy heavy post-menopausal bleed” and ongoing lethargy.  What has caused this bleed?   This is a very atypical symptom seen in the literature; however, it appears that some of Anne’s colleagues have also experience similar symptoms.  This bleed went on for 6 days.

The literature demonstrates a link between estrogen (Female hormones) and the virus, stating that estrogen could/can help in the fight against the virus and boost immunity.  Thus potentially those with decreased estrogen levels could potentially be at greater risk of more sever Covid 19 symptoms (Such as Anne being menopausal).  Interestingly one of the many trials being set up to minimise symptoms of the  virus is whether female hormones, HRT or the pill could assist in the “fight”, especially for men.

So what caused Anne’s bleed?

There is developing literature outlining blood clothing disorders occurring in Covid positive patients, this is being supported by autopsies on these patients. It is being demonstrated that the Covid 19 virus may cause “atypical blood clotting”, which can result in “COVID Toes” linked to lower limb blood clots, pulmonary embolism and clots leading to stokes.

But on writing this blog post I can not located any up to date research papers on “Covid positive patients and post-menopausal bleeding PMP”, maybe it is a result of the virus causing an inflammatory response with the endometrium (Endometrial atrophy).   Either way this needs to be investigated to exclude any other underlying causes.

“My take home message in regards to this symptom  is that we may potentially see more patients over the coming months and years who may have been infected with the virus, presenting for pelvic ultrasound looking for causes of PMP bleeding”.

Day 10 – Productive cough, taste completely returned, “ongoing bleeding”, ongoing lethargy.

Day 11 – Now treated with Antibiotics for productive cough (preventing any change of pneumonia), ongoing lethargy.

Let’s fast forward to;

Day 29 – “Ongoing severe lethargy”, “cough eased, but still transient”.  Chest cleared.

Now a COVID 19 Survivor testing negative to the virus!!!!

So from all of this what are my takings?

What is my advise…..?

Until a vaccine is developed it is a real possibility that at some stage, we will all get the virus.    There is a large and varied range of symptoms, not just the “Typical” symptoms that have been documented to date in the literature.  Please be vigalent and  “Expect the Unexpected”.

Please feel free to contact me with any feedback or suggestions:

Email: (gail@iuc.consulting)

 

References: