Policies for the Internal Medicine Ultrasound

As you likely realize, our program’s purchase of two ultrasound machines is a considerable expense. Thus, diligent adherence to these policies is necessary to ensure that we are caring for these machines and most importantly not losing them or lending them out to non-medicine services.

Accounting for and Protecting the Machine

  • Where will the machines be stored?
    • In the CCD: Room 10-475 (HONC workroom)
    • In Mitchell: Room TC-519A (copy room near 5NW)
  • Who keeps track of the machines?
    • Each resident that checks out the machine is responsible for its safe return. However, we want to ensure that we are performing a q24hour double-check to account for both machines.
    • In the CCD: The MROC is responsible for checking that the ultrasound is present in CCD room 10-475 (HONC workroom) at the start of his/her shift. The MROC should initial the sheet to verify that he or she has completed this task.
    • In Mitchell: The dayfloat for the on-call GENS team is responsible for performing this check. Again, this resident should initial the sheet to verify that the ultrasound was present for that morning.
    • If a machine is missing:
      • Please contact the last person to have checked out the machine.
      • Then attempt to locate the machine in its last location.
      • If these steps fail, please notify the CROC (pager 2762).
    • How do I check out the machine?
      • There is a check-out sheet in each ultrasound storage area. Please write your name, pager number, time of check-out, and expected location of use for the machine.
      • Machines are secured to the wall in each of these rooms using a lock with a 4-digit passcode.
      • We expect that the machine will be checked out for a specific use or procedure. You should return the machine promptly after that specific use.
      • You are not to check out the machine for hours at a time.
        • Example: Cardiology NF resident cannot check out the machine for the duration of his/her shift. S/he should return the machine after each individual volume assessment.
      • When you return the machine, please lock it to the wall with the provided lock. Spin the passcode to a random number so that it cannot be unlocked without the code.
    • Can I share the password with my students or non-medicine residents?
      • No, we ask that a medicine resident accompany the machine for any use on the floors.
    • Where can I get supplies for the ultrasound?
      • Ultrasound gel will be kept with each machine. We expect that disinfectant wipes will come from routine floor stock.
      • If the ultrasound gel tubes are all empty, additional stock will be kept in the chiefs’ office in Mitchell and in the designated cabinet in CCD 10-475.


Clinical Use of the Ultrasound

  • Can I use the ultrasound for bedside diagnosis?
    • We are equipping you with these machines and an ultrasound curriculum. Our goal is to give you an additional tool for bedside diagnosis and acute medical decision-making.
    • Even though certain ultrasound techniques can confer a high sensitivity and specificity in experienced hands, you should still order a gold-standard test or follow routine clinical practice.
      • Example: You screen a patient with a high pretest probability for DVT overnight on GENS call and find no ultrasound evidence of DVT. Your patient still has a swollen, erythematous leg on rounds. You should still order venous ultrasonography with expert interpretation.
    • Be careful how you document your ultrasound findings and your rationale for using the ultrasound in your notes, particularly if you are using the ultrasound to change management. An example is found below. Consider making a .dotphrase as well.
      • Example: Your patient with CHF, dyspnea, and hypotension has an unclear volume status on bedside examination. You ultrasound the IVC and see it is only 1.3 cm in diameter and collapses with each inspiratory effort. You decide to give one liter of normal saline. You document the findings in your note with wording like,

Preliminary resident-performed bedside ultrasound revealed IVC measuring 1.3 cm with significant collapse. These findings suggest volume depletion in agreement with the patient’s history, physical examination, and labs. Thus, we are treating the patient for presumed hypovolemia.

  • Can I use the ultrasound for bedside procedures?
    • However, you must continue to follow policies for procedures in the hospital including following these rules:
      • Do not perform any procedures that you are not competent to perform.
      • Always consult Procedure Service first if the procedure will happen during daytime hours. Our ultrasound machine is not meant as a way around the Procedure Service. You must continue to call them for all procedures on the floor and in the ICU.
      • The ultrasound may be used for emergent procedures. As has always been the case, document your rationale for performing the procedure, consent for the patient, etc.
    • The availability of the ultrasound should not affect the nurses’ practice of obtaining IV access. RN’s should still ask a resource RN, a charge RN, and/or an ICU RN before asking the MD to place an ultrasound-guided IV.