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SACH Ultrasound

Courses

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Dr Stellan Batsman Dr Jari Havela Caj Skoglund

Visited Blairgowrie, Brechin, Pitkerro; Stonehaven & Forfar Leith & Edinburgh If this is Tuesday…

Norrbotten visitors tour Tayside. - January 2010

Tromso 2010 – Preparatory Visit for Life Long Learning Programme application

SACH Centre for Ultrasound, AECC

Courses

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Commissioned by Scottish Association of Community Hospitals. Run in Skottland For GPs/Midwives

Dr Hamish D. Greig

GP Out of Hours, Angus.

Formerly a GP Principal in Brechin, 22yrs

Prev Chair of The Scottish Association of

Community Hospitals (SACH)

Organiser of SACH Ultrasound Courses

Who am I?

General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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Vad heter ni?- Dr Hamish D. Greig

•  For yke? - GP Out of Hours, Angus.

•  Varifran?- Jag kommer fran Brechin, Skottland.

•  Praktikant du US,

•  Sa roligt att ses igen!

Talar du Engelska?

General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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Vad heter ni?- Dr Hamish D. Greig

•  For yke? –Natt lakare, Angus.

•  Varifran?- Jag kommer fran Brechin, Skottland.

•  Praktikant du US, “lillebror” du Dr Budgie Hussain

•  Sa roligt att ses igen!

Talar du Engelska?

General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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Vad jag ska talar 1. I am a clinician not a Sonographer -Lakare 2. I use ultrasound as a tool- immediate 3. I am aware I am a Praktikant –we must all realise our limitations 4. Javisst, I can talk for Scotland –I am here both days – come and talk to me! 5. My presentations contain more information than we can cover but it will be available to you.

•  Tack for inviting me/SACH. • Dr Pervez Hussain “Budgie” is the real hero

GP Ultrasound in rural practice, Scotland Vilhelmina 2013

Geography of Brechin

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GP Ultrasound in rural practice, Scotland Vilhelmina 2013

Geography of Brechin

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NW area of

Brechin

Practice

General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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Sweden or Scotland?

General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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Links

•  Screening data

•  Clinical cases

•  Ultrasound Courses

•  Aberdeenshire

•  Community Health Partnership aspects

•  Course Programme Scans

Principles •  Adds to Clinical skills •  Follow RCGP/RCR

Guidelines 1993; 2010 •  Awareness of

limitations •  Aim –improved

diagnoses and referrals

Opportunities • Early pregnancy • Pregnancy viability - accepted practice • General Abdominal – esp GB and kidneys • Pelvic Ultrasound • Prostate/bladder • Aneurysms –screen/FU

SACH Ultrasound

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SACH /Univ Bournemouth ULTRASOUND COURSE

SACH Ultrasound Courses •  Theoretical & Practical course

with support for supervised practice to obtain Univ Bournemouth Certificate. RCGP/RCR Guidelines

•  3-4:1 Delegates:tutor per station •  In cahoots with Dr Budgie

Hussain & team, •  Centre for Ultrasound, University

of Bournemouth.

CHIC

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SACH /Univ Bournemouth ULTRASOUND COURSE

Aims To improve access for patients to

diagnostic tests within the community

To reduce unnecessary travel / a Sustainability agenda

To support Remote & rural practice esp intermediate care and community hospitals

Model for other subjects/use of Telemedicine

CHIC

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! Introductory Course ! Log book –Abdomen,

Pelvis & Obstetrics ! Case studies " Accreditation •  CPD/mentoring " Post grad Certificate " US Diploma

•  NHS Education in Scotland Support

•  Prof Gillian Needham FRCR

•  University of Bournemouth AECC

•  Dr P Budgie Hussain and Dr David Kay FRCR

SACH Ultrasound

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GP US Scotland •  Dr Joan Noble MRCGP

FRCP •  Dr R Liddell Dip US •  18 yrs experience •  1-2 sessions per week •  Referrals from partners

and specialists

•  Advantages •  Waiting time <2 weeks •  Immediate if required •  Enables quicker diagnosis and

more accurate treatment •  Referrals more accurate with

scan prints & report - often OP not required

•  Accepted Direct for surgery •  So Patients & Surgeons happy!

SACH Ultrasound

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Vilhelmina April 13 13-11-09

Evaluation Ultrasound Course Carnoustie 2011

“Very useful and appropriate course - structured with lectures fitting into the practical process; a lot of practical training.” GP

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Vilhelmina April 13 13-11-09

Evaluation Ultrasound Course Carnoustie 2011

What did you think? Was the course? Excellent V.Good Good Adequate Poor?

Appropriate for your - Personal needs? 100%

Appropriate for your - Service needs? 88% 12%

Was the quality of presentations? 100% Was the quality of the workshops? 100% Was the format of the course? 100% The Quality of the venue? 100% The Scope to network? 88% 12%

Overall educational experience? 100%

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SACH Vilhelmina April 2013

Vilhelmina April 13 13-11-09

Nairn Integrated Primary Care centre and Community Hospital

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GP US Scotland Audit •  Of 49 cases Scanned •  Referrals saved

14 AN + 2 EPU 3 Gynae + 3 urology 14 Raigmore Scans

•  ~ 72% that would otherwise have gone elsewhere

•  Aortic Aneurysm Screen •  Male 65-75 yrs (600) •  555 attended 92.5% •  Full CVS Diab screen •  AAA – 27 = 5% •  6 operations + 21 F Up •  41 incr BP + 2 new Diab

SACH Ultrasound

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GP US Arran Scotland •  Aortic Aneurysm

Screen •  Each year 65th

Birthday = 90 / yr •  3 AAA all small •  Further 4 ops in 5yrs

after the project

Criteria for referral •  > 4.5 cm require review

by specialist with result •  Or accelerated progress

•  National Screening Program + Arran

Receptionists scanning!

SACH Ultrasound

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GP US Scotland •  Early Pregnancy Loss

Working Group •  “GPs can provide a

service”. •  For example One year

in Nairn •  22 pat 5 Rh-ve

Results •  14 Vag bleeding •  + 8 Routine Scans •  20 GP Scan +

•  8 Evac RPOC •  2 Nat Resolution

•  45% Sole care GP •  3 ongoing Pregnancies •  7 Natural Resolution

SACH Ultrasound

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GP US Scotland •  Early Pregnancy Loss •  Advantages of GP

Scan •  Familiar Staff & Place •  Continuity of Care •  Partner present almost

all the time

•  No bad news in AN Clinic •  Immediacy of Scan and

result –counselling •  Rescan by same person if

required. •  More Appropriate use of

Specialist resources

SACH Ultrasound

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Case 1 – (Natt yrke) 19yr old female 12hrs hypogastric pain Para 0+1 1st trimestre Bleeding ++ which has

settled. ?Early abortion ?Missed

abortion

On exam. •  Uterus Just Palpable •  Lower abdomen

slightly tender, general, not localised pain

•  Urinalysis HCG + ve Blood +

SACH Ultrasound

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Case 1 19yr old female 12hrs hypogastric pain Para 0+1 Seen x1 already - now

00.30 am Anxiety, no transport,

supportive partner.

Uterus with amorphous mass RPOC

SACH Ultrasound

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Case 2 phone call 21yr old female 12hrs hypogastric pain Para 0+1 Seen x1 already

– during evening HCG +

Urinalysis Neg so given Dihydrocodeine

Observe & Review SOS

SACH Ultrasound

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Case 2 (attend Community hospital)

21yr old female Rural patient Glenclova 13hrs hypogastric pain Para 0+1 BO 5 days ago Seen x 1 already…. Has

brought Mother and bag

On exam. •  Uterus Just Palpable •  Lower abdomen tender •  Bowel palpable – BS++ •  ?Constipation ?Early

abortion

SACH Ultrasound

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Case 2 21yr old female 14hrs hypogastric pain Para 0+1 Worried ++ Seen x 1 already - now

01.30 am Previously advised

admission might be required

SACH Ultrasound

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Case 3 42yr old female 12/52 1-2 hrs bleeding/<period Para 2+ 0 Lower Abd ache Urinalysis Blood + Counselled - Conservative

management.

SACH Ultrasound

Unfortunately, sometimes you do not find what you want. – blighted ovum. Sac 8/52

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Case 4 30yr man Restless Pain RUQ & R

loin to R Groin Haematuria ?dilated calyces

SACH Ultrasound

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SACH Ultrasound

Case 4 30yr man Pain RUQ & R loin

Haematuria Dilated

calyces –obstructed kidney 2ry to Calculus

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SACH /Univ Bournemouth ULTRASOUND

COURSE. Resources eg Centre for Ultrasound http://www.cusultrasound.co.uk/contact-and-

location.aspx

BMUS Video Library http://www.bmus.org/about-ultrasound/au-

videocase.asp

http://www.ultrasoundcases.info/ http://www.cetl.org.uk/learning/tutorials.html

CHIC

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10  Hospitals  within  1  CHP  that  work  as  a  network  providing  complementary  services  to  the  local  area  

Guiding  Principle:-­‐  “Care  should  be  delivered  

locally  whenever  it  is  safe  and  feasible  to  do  so”  

Some  local  residents  may  expect  it!    13-11-09 Vilhelmina April 13 35

Community Hospitals in rural practice, Scotland Hemavan April 2009

Aberdeenshire Community Hospitals –”Shire”  

Challenges for Aberdeenshire CHP •  Local Change

–  Intermediate Care Audits x 2 –  25% of patients in Acute bed could be cared for in an

alternative setting –  40% shift in Outpatient activity from 2ry to 1ry Care –  Changing routes of admission - Emergency Care Centre –  Assessing the impact of changes in Acute Sector bed

configuration and usage –  Our own ambitious plans to develop the capacity of primary

and community care services

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Community Hospitals in rural practice, Scotland Vilhelmina April 2013 prev Hemavan

•  Endoscopy – Upper & lower GI endoscopy - 4 centres •  Ultrasound Scans – Accredited GP Service – General & Gynae /

obstetrics - an extension of clinical skills – Course provided locally by CHP, SACH & accredited provider with NES & Grampian HB support. ~2000 scans done in the last year

•  Cardiac assessment – Exercise Treadmill + Echo +/- Holter monitor Cardiomemo

•  Chemotherapy – oral Chemo clinics for Bowel CA

•  A&E – 11 units all linked via Telelink to Aberdeen A&E - Network

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Community Hospitals in rural practice, Scotland Hemavan April 2009

Aberdeenshire Community Hospitals –”Shire”

•  Endoscopy – Upper & lower GI endoscopy - 4 centres

•  Ultrasound Scans – Accredited GP Service – General & Gynae / obstetrics - an extension of clinical skills – Course provided locally by Community Health Partnership, SACH & accredited provider with NHS Education for Scotland & Grampian HB support. ~2000 scans done in the last year

•  Cardiac assessment – Exercise Treadmill + Echo +/- Holter monitor Cardiomemo; Risk Stratification for surgery

•  Chemotherapy – oral Chemo clinics for Bowel CA

•  A&E – 11 units all linked via Telelink to Aberdeen A&E - Network

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Community Hospitals in rural practice, Scotland Hemavan April 2009

Aberdeenshire Community Hospitals –”Shire”

Fraserburgh Banff

Huntly

Insch

Inverurie

Aboyne

Banchory

Stonehaven

Turriff Peterhead

Key:-­‐   Dermatology Minor Surgery Orthopaedics Modernised Elderly Care Services      Diabetes INR Testing ENT Psychogeriatrics

     Endoscopy Ultrasound Cardiac Assessment

Ellon

Westhill Portlethen

Alford

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Shire simulation 2007

Aberdeen

SACH /Univ Bournemouth ULTRASOUND

COURSE.���CHIC

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Aberdeenshire “The Shire” Ultrasound Endoscopy - Upper GI & Σoscopy (Screening

for Colon CA) Cardiology -Stratification of CHD patients

Exercise ECG/Echocardiogram Minor Surgery Dermatology Orthopaedics ..etc…

SACH /Univ Bournemouth ULTRASOUND

COURSE.���CHIC

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Case spread:- General Abdominal work Obstetrics –not anomaly screening Gynaecology (+/- Transvaginal app.) Urinary Tract Investigation Musculoskeletal problems Deep Venous Thrombosis in conjunction

with other tests Thyroid problems Guidance eg Insertion of lines/ LP/Taps

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SACH /Univ Bournemouth ULTRASOUND

COURSE.���•  Aberdeenshire CHP - GPWSI Ultrasound Service

•  2009/10 Audit of GPwSI Scans Onward Referred To Secondary Care.

Total Scans 2266 from 11 GPWSI (of 14) Onward referrals 381 =16% Now 2013 7%

But these are not a true reflection of the service as this includes all scans referred elsewhere.

CHIC

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Vilhelmina April 13 13-11-09

Chart 1: Aberdeenshire GPSI Ultrasound Scanning Activity 2010/11

Source: Health Intelligence (CHP Monitoring Proforma) 43

Aberdeenshire CHP - GPWSI Ultrasound Service���2009/10 Audit of GPwSI Scans ���Onward Referred To Secondary Care. CHIC

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Reason for Onward Referral

No. Scans Referred

Comments

Second opinion 63 Includes patients with complex history / known abnormalities/prev surgery; GPSI request for rescan; ongoing symptoms; Follow up after previous secondary care scans/appointment.

Type of Scan not done by individual GPwSI

TV/Pelvic -105

TV 36; Pelvic 69

Testicular - 13

Liver related 90 Cancer/poss cancer 28

Gynae/?Pregnancy/IVF 24

Kidney 10 Muscular/MSK 6 Other/Misc 42 Requested by Patient/ At GP request/?Mass/? Haematoma/? Abscess/ Child/

Aortic Aneurysm/ Spleen/ Complex cyst/ Bowel/referral to Urology/?hernia/ patient in wheelchair. incl scan not done in Community - 1 x DVT 1 x thyroid

381 44

Aberdeenshire CHP - GPWSI Ultrasound Service���2009/10 Audit of GPwSI Scans ���Onward Referred To Secondary Care. CHIC

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SACH /Univ Bournemouth ULTRASOUND

COURSE.���Resources amongst others

BMUS Video Library http://www.bmus.org/about-ultrasound/au-

videocase.asp

http://www.ultrasoundcases.info/

http://www.cetl.org.uk/learning/tutorials.html

CHIC

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SACH Vilhelmina April 2013

Vilhelmina 2013 13-11-09

Adamson Memorial Hospital, Cupar, Fife

P Zanre Photo

SACH /Univ Bournemouth ULTRASOUND

COURSE.���SACH /NES courses •  3 day course Theoretical + Practical

–”Hands on” Diagnostic US •  Log book + Accreditation •  45 GPs + 4 A&E/urology + 12

midwives •  40 + Accreditations 2006-9 •  ****Star NHS Grampian •  Tayside & Nairn GPwSi •  Skye & Arran

CHIC

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Vilhelmina April 13 13-11-09

Chart 3: Aberdeenshire Minor Surgery Attendances (Percentage), 2004-2010

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Vilhelmina April 13 13-11-09

Chart 7: Aberdeenshire Community Cardiology Activity, 2011/12

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Det var allt! Tack myket

General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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General Practitioner Ultrasound in rural practice, Scotland Vilhelmina April 2013

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