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What to do when you break your arm?

16 May

We are two lovely (according to our supervisor) EM-residents from Medical Centre Haaglanden, The Hague and Erasmus MC, Rotterdam, working at the Sint Franciscus Hospital, Rotterdam for a month to increase our ultrasound skills. We expected to perform e-FAST and cardiac ultrasound a lot, but instead our supervisor sent us several times to all those broken bones. The first time I performed an ultrasound, I put up my glasses, but couldn’t see anything except a white line, but my supervisor told me ‘bone is blinding’, so that’s okay!

The following days, we saw a great number of patients with broken bones. Inhabitants in this area are not so steady (not to mention the amount of patients with drug abuse) and fall quite easily apparently, which was great for our ultrasound exposure. Therefore we will show you some beautiful ones (not patients but ultrasound images) below.

Case 1: What will happen when a 7 year old decide to fall from her bike and there is no ultrasound addict available, because he is performing PSA at her with propofol. Fig 1en 2.


Fig 1


Fig 2

An incomplete reposition at the emergency room, followed by reposition at the operating room next morning was the unfortunate result in this case.


Pols# en echo

18 Jan

Geachte collega’s,

Een videolezing van Gael Smits, SEH arts KNMG Eindhoven, over echogeleid reponeren van polsfracturen.

Groet, Laura

Ultrasound is not time-consuming!

27 Jun

In the Netherlands, the majority of Emergency Physicians unfortunately do not use ultrasound frequently at this moment. One of the arguments I often hear is: “I don’t have the time to perform ultrasound at my busy Emergency Department (ED), because there are to many patients to take care of”. Hopefully my case will prove otherwise.

A few months ago, this 40 year old guy from Poland came to our ED. Our secretary called the triage nurse to inform ‘this man doesn’t look good’, maybe you can pick him up. As the nurse went to call for this patient, he indeed didn’t look well and that was not because the use of alcohol. He looked pale and diaphoretic all over, but didn’t speak a word English, German or Dutch. As they walked to a empty room, the nurse shouted for my help as they always do. While I was doing nothing except drinking coffee at my busy ED, she said: Please come over immediately ‘this man doesn’t look good’. I carefully watched the nurse (and the patient as well) and followed them into the room with my ultrasoundmachine, because this man was indeed looking awful. As she put the man on the monitor to get his vital signs, it was my time to shout. I ordered for ECG and regular bloodtest, because he might have STEMI. While I was preparing my device I noticed the man holds his both hands on his belly. Instead of performing an cardiac exam first, I choose to do abdomen (see fig 1 and 2). I diagnosed free fluid in his belly before the needle (for bloodtest) was actually in this specific patient. Later on, we found out that he was using brufen for a week because of backpain and the CT-scan revealed an hole in his stomach, so he went for surgery and did well afterwards.

fig 1 echo

fig 2 echo

I’ll guarantee, everything I just wrote down was for real (except the nurse was checking me out obviously).

I hope this case will stimulate you all to perform ultrasound more rapid and more often in future! Those of you, interested in learning ultrasound, you can always contact me for a four week ultrasound rotation at Sint Franciscus Gasthuis in Rotterdam. Although we are fullly booked until april 2015.


All the best,

Arthur Rosendaal


Emergency ultrasound case of the month….2014 !! Rest of the case and diagnosis

10 Jan

The ultrasound showed a right kidney with a little bit of hydronefrosis, mild at most, but the “money shot” was in the pelvis ..
A large cystic mass with anechoic to hyperechogenic content, some concrement-like structures were also seen within.

Right kidney                                       Left kidney

Casus EM dutch jan 2014 re nierCasus EM dutchjan 2014 li nier

Pelvic view

Casus EMdutch jan 2014 + uitleg
The patient was sent to gynaecology where a transvaginal ultrasound was done …. with similar findings.

On basis of the findings of  the ultrasound(s) she was brought to the OR. Where the gynaecologist found the large cyst (9 – 6 – 5 cm) which had facilitated a torsion of the right ovary. Luckily the ovary could be spared.

The pathology report showed : Cyst with skin, bone, cartilage and braintissue..  conclusion : mature teratoma

Final diagnosis : Large mature teratoma with torsion of the right ovary (and little bit of  hydronefrosis of  the right kidney)

A few pearls can be taken from this case in my humble opion:

-Be sceptic of other people’s diagnosis when a patient is handed over to your care, don’t let it narrow your frame of thinking

-Emergency ultrasound can guide your management in the right direction within seconds.Without it you might lose valuable time (and in this case an ovary)

-Always scan the pelvis/bladder after doing  renal ultrasound, don’t be satisfied with hydronefrosis, check if you can identify the cause downstream. (also always take a look at the aorta by the way, AAA /iliacal aneurysm can also be a cause of hydronefrosis and mimic renal colic)

– Torsion of the ovary can be a tricky diagnosis, pelvic exam not always helpful.

Love to hear your comments on this case …. Check EMdutch in a month or so for the next emergency ultrasound case !!

Emergency ultrasound case of the month……2014 !!

6 Jan

From Vincent Rietveld, SEH-arts/ Emergency physician at the Westfriesgasthuis Hoorn, @vindoctwit:

Happy new year to all !! Hope you got through december without an ultrasound case of the month on EM Dutch ;-).

Here’s one to start of 2014 , I  picked this one up on one of my shifts at the Westfriesgasthuis in Hoorn. To me it illustrates beautifully why emergency ultrasound can be so helpful in providing better care for your patients and should be a core competency for all (dutch) emergency physicians!  Read for yourself and see what you think ..

A 23 year old female, with no relevant past medical history, came to the ED the day before I saw her, with sudden onset right sided flank pain radiating to the lower adbomen and groin.

It was noted that during physical exam she experienced colik-like pain, her right lower quadrant was mildly tender on palpation and pelvic exam was not painful. No fever and labs were normal.

Preliminary diagnosis stated in the chart: ureter stone  or maybe even an appendicitis. She was told to come in the next day to be re-evaluated.
The next day she first was seen by the surgical resident who, thinking ureterstone, asked us to do an ultrasound for hydronefrosis. The EM-resident ( @HoekAmber ), who did an elective ultrasound rotation with us,  eagerly jumped at the ultrasound- opportunity that was presented to her. ” Ok”  I said to her ” Go ahead set up the machine and get started I’ll see you in two minutes”. One minute later she called me: “Vincent.. you might want to take a look at this …!!”

When I saw the patient , despite plenty of opiates,  she was still in a lot of pain which was now continuous and non-coliky and mostly in the right lower quandrant.

Her abdomen was still mildy tender on palpation in the right lower quadrant. Still no fever. No labs or urine yet  (all normal later on, HCG also neg)

Heeeeeeerrrrre’s ………….. the ultrasound  !!:

Right kidney

Casus EM dutch jan 2014 re nier

Left kidney

Casus EM dutchjan 2014 li nier

Pelvic views

casus EMdutch jan 2014

casus EMdutch jan 2014 2

Still thinking ureter stone ??

For diagnosis and rest of the case … click here