VOTW: Biceps Tendinitis

Hi all,

This week’s VOTW is brought to you by Dr. Evans!

A 56 year old male presented with dull left shoulder pain for two days. He denied any trauma, swelling, erythema to the area or fevers. He did endorse repetitive lifting motions at work. The exam was unremarkable except for some pain w/ ROM of the shoulder. A POCUS showed…

In Clip 1, the long head of the biceps tendon is seen in the bicipital groove (between the greater and lesser tuberosity) in its short-axis surrounded by a rim of hypoechoic fluid. 

Clip 2 shows the biceps tendon in its long-axis, again surrounded by a small amount of hypoechoic fluid. This is consistent with biceps tendinitis. The tendon itself appears intact without tears. The patient was discharged with NSAIDs and ortho follow up.

POCUS Shoulder Exam

We have all had patients presenting with non-traumatic shoulder pain. They get their therapeutic x-ray and you tell them to try NSAIDs and follow up with ortho.

While the POCUS shoulder exam may not be life-saving, it has the potential to quickly provide the diagnosis for a range of pathologies. Finding the answer to the patient's pain may might result in a more satisfied patient 😊. The hard part is learning and remembering this multi-step exam.

Evaluting the long head of the biceps tendon is Step 1 and is the easiest part of the shoulder exam (in my opinion), so we’ll go over that today! Stay tuned for future VOTWs for the rest of the shoulder exam.

Technique

• Have patient sitting in chair or side of the bed (see below)

• Use a linear high-frequency probe

• Have the patient flex elbow at 90 degrees with palm facing up and arm adducted

• Place the probe horizontally along the bicipital groove (proximal humerus) and find the echogenic long head of biceps tendon in transverse

• Rotate the probe 90 degrees to see the tendon in its long axis

• Look for disruptions in the tendon, fluid around tendon, or subluxation (tendon not in bicipital groove)

Image 1. Positioning for evaluating the biceps tendon

Artifact Corner

Tendons exhibit an artifact called anisotropy. This means the appearance of tendons can be different depending on the angle of insonation (the angle of the beam onto the object). It will look hyperechoic at one angle and hypoechoic at another angle. Don’t mistake this for a tendon tear or fluid. Fluid or tendons will not change in appearance with different angles of insonation.

So next time you have a patient with shoulder pain, take a quick look at the biceps tendon, you might find the answer right away!

Happy Scanning,

Your Sono Team

Crowding and Boarding

ED Boarding and Crowding

Crowding is defined as "the need for services exceeds an ED's capacity to provide these services." Many things contribute to crowding including more patients with lack of access to other forms of care, inefficient ED processes, inadequate staffing, or short supply of inpatient beds. 

Crowding is a problem as it has been linked with worse patient care. One study conducted showed that crowded EDs are associated with longer door to needle times in STEMI patients by 23 minutes. Another study showed similar results with respect to stroke patients getting CT imaging. Another study showed similar results with respect to sepsis measures (longer time to fluids and antibiotics). 

Many EDs use the Input-throughput-output model to identify areas that can be improved in an effort to reduce crowding. Input is dictated by the patients. While measures like improved outpatient access, freestanding EDs, and more urgent cares can influence this, ultimately the ED itself has minimal control over these factors. 

The next part of this model is throughput, which is defined as all the activities that happen during the ED visit for a patient. This includes triage, registration, labs, imaging, specialist access, charting, social work. This is largely dictated by staffing and processes. This is the most modifiable by the ED. Certain models can influence this - split flow models that are designed to quickly see and disposition patients with less emergent presentations. Appropriate staffing levels makes crowding easier to navigate. Improved charting models can also decrease the amount of time a patient is in the ED.

The final influencing factor is output which is determined by whether the patient is admitted, discharged, or transfered. Split flow models can help with faster dicharges. Having hospital bed managers efficiently move admitted patients can also help. 

Ultimately if the hospital is full from an inpatient bed perspective, there will be more patients boarding in the ED. Boarding is considered to be the biggest contributor to ED crowding. Boarding is defined by the Joint Commission as the "practice of holding patients in the emergency department after the decision to admit or transfer has been made." Recommendations state that this should not be longer than 4 hours. Boarding patients often require 

Boarding patients can pose a problem as they often require resources and attention of nursing staff - timed medications, timed lab draws, timed neuro checks, respiratory support, titration of drips. There is also the issue of the patient being admitted to an inpatient team that is not persistently available like the ED physicians. Coordinating care can become challenging, and all these factors can lead to worse patient outcomes. 

•Crowding and boarding. Crowding and Boarding EMRA. (n.d.). https://www.emra.org/books/advocacy-handbook-2019/crowding-and-boarding

•Savioli G, Ceresa IF, Gri N, Bavestrello Piccini G, Longhitano Y, Zanza C, Piccioni A, Esposito C, Ricevuti G, Bressan MA. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J Pers Med. 2022 Feb 14;12(2):279. doi: 10.3390/jpm12020279. PMID: 35207769; PMCID: PMC8877301.