So are we starting on time, quarter of? Just turned over. All right, so my name is Dr. Paul Mayo. I've been informed that I'm from Northwell Health on Long Island. And you'll do some other introductions, will you, Scott? You're on such a roll, though. All right, so should I go a little further? Yeah, the reason that Scott and I are sitting between these two younger individuals is they have been fighting about things. They come from the same institution, university, but they're in opposing hospitals. They have violent disagreement on a regular basis. And it was decided to settle these disagreements in a fair fight. And that's why we're here. Gentlemen, you have to stay apart, because they're going to become angry soon enough. And can you tell us the rules of engagement here briefly? What are they going to be doing? Absolutely. So we've got, I'm Scott Millington. I'm from Ottawa, Canada. It's nice to meet you all. Thanks for coming. We'd like to keep the session relatively fast-moving and informal. So our debaters will be nimble. We'll ask the audience to be nimble. And if you'd like to say something and weigh in on the debate, we welcome that. So just present yourself quickly to the mic. But you'll have to move quickly before we move on to the next topic. We're going to try and cover five or six topics today in debate format between our two friendly debaters here. And we will introduce the topic. There will be a two-minute pro, a two-minute con, the opportunity for our fighters to rebut each other if they so choose. And then we'll leave a few minutes for comments. Perhaps Dr. Mayo and I will weigh in. But better yet, we'd love to hear the audience weigh in, support one of our fighters, or present perhaps a third voice. And we can chat about it for a few minutes. And then we'll move on to the next topic. Does that sound good for everyone? And we have strict time limits. Exactly at the two-minute mark, we're going to bring out that proverbial, what is it, a cane that they use in the old music halls. We put the cane, and we yank the person off the stage. I thought you were doing a trap door. Yeah, trap door, OK? Yeah, so should we get started? Yeah, absolutely. So I've lost the topics of the debate here already. Actually, I know the first one. So the first one, I suppose, comes with a trigger warning, certainly going to trigger me. And we're going to talk a little bit about the role of ultrasound. We're here for a POCUS debate session, of course. And we'd like to talk a little bit about the role for the inferior vena cava. So ultrasound, inferior vena cava, I see people. It's wonderful. People are sighing and shaking their heads already. I wonder if they're pro or con. So we'll talk about the utility of this tool in its various forms. And the pro side will be taken by Ibrahim. And we'll go for two minutes. And then we'll have Yonatan with his con point of view. I think just an important thing, Ibrahim decided that we should do this a little bit differently. And so you're not going to be seeing slides with any evidence there. Instead, we put countless hours into playing with mid-journey to create some AI graphics to try to convey our points while we duke it out up here. Gentlemen, or gentlemen, start your engine. The timer is on. Hello, everyone. Thanks for coming. So the first topic is going to be the IVC and ultrasound in the IVC and how helpful that is in the intensive care unit. The way I look at the IVC is that, just like anything in life, when you pose a question to technology or ask it to do something, you have to ask that technology to do the right thing, meaning that we hear a lot of things about the IVC and fluid responsiveness or volume tolerance and whatnot. And sometimes it may not answer that question appropriately, just like a car can't really fly. But it does a good job taking you from point A to point B on the floor, on the terrain. And the way I look at the IVC is that, just like anything with point-of-care ultrasound, it helps me understand the patient's physiology a little bit better. So when trying to estimate CVP, it may not be perfect, mainly in patients who are spontaneously breathing, but looking at the IVC in a serial fashion in a single patient where I understand the patient's physiology, I know how much peep I have them on, I know how the right ventricle looks like, I know how the LV looks like. In that patient, changes in that IVC may help me sometimes understand that patient's physiology a little bit better. I'll give a quick example. If I have a patient who was on a ventilator, sedated, with no significant respiratory effort, and I see that their inferior vena cava went from being plethoric to now significantly collapsible, and I don't have a history of significant hypovolemia or bleeding, then at that point I start thinking, hmm, am I looking at a patient that their venous tone is actually, now they're going into vasodilatory state and could potentially be early sepsis, for example. 10 seconds. And essentially, that's one of the uses I like to utilize the IVC in, and obviously in your patients with cardiogenic shock or any form of cardiac failure, in time or not, it can still be very helpful. Yoni, you're up next. Move quickly. Is two minutes gonna be enough? That's hard. Probably not. All right, so Yoni, go for it. No worthwhile task is supposed to be easy. So I have here a nice graphic of a wizard looking into a crystal ball, getting all the answers that we need to manage our critically ill patients, and this is how many of us that were early adopters of coronary care ultrasound felt when we were following some of the early IVC data. We had really nice receiver-operator curves, we had our 12% variation, and we patted ourselves on the back when we made what we thought were really good medical decisions. But over the past five-plus years, the house of cards has fallen, and now we've realized that those that are practicing their fluid tolerance or fluid responsiveness based on the IVC size and respiratory variation are really gambling. And so we now have nice data, I think of Antoine Villers-Baron out of France showing that our ROC curves are more of a coin toss and not particularly helpful. So Ibrahim at his institution has a lot of time on his hands, and so therefore he doesn't mind doing an extra test that doesn't really give him useful information but occupies that time. At University Hospital in Newark where things are really, really busy, I choose to be a little bit more wise with applying the probe and find that the IVC doesn't help me at all. That was fast, all right. So we then open up some time for commentary. Let's allow a rebuttal if either of our fighters chooses to. So thank you, Yoni, for highlighting how not busy we are in New Brunswick. Even though I agree with Yoni regarding the IVC and volume responsiveness, I still think that understanding your patient's physiology just by looking at serial measurement can still be helpful, even though that requires time. But in New Brunswick, we're actually very fast in patient care, so that creates a lot of free time on our hands to do extra stuff. So I will concede that following something over time can be helpful. So if the patient comes in and the IVC is non-existent or virtual, as we like to say, and over time it starts to become dilated and plump, that does tell you something. Do we have any commentary from the audience? Any questions? Because if not, I will be the peacemaker. Yes, sir. Hello, my name is Michael. I'm from Thomas Jefferson University Hospital in Philadelphia. I have a question. It's not directly the IVC, but there's been a couple of studies about using the IJ, like focused assessment of the IJ to get a number for your right atrial pressure. Does that change your view of using either of those things in conjunction or independently? So I have not integrated IJ variation into things. You can certainly try to garner a little bit of information about volume status, but obviously regurgitant jets and other things will get in the way of that. There's also some data on using the carotid as well for figuring this out, and it just hasn't been repeated in large studies. And I think the biggest lesson I've taken away from IVC is the studies that caused us to change our practice. When you look at them, we're quite small in numbers, and the more recent ones are larger and just can't reproduce that data. So if I can comment, if you're using the right atrial, the examination of the IJ to calculate right atrial pressure, there's some information about that. Dr. Schmidt, were you involved with a study with that? Yes, I believe so. However, I'll challenge you. Why would you be interested in the right atrial pressure at all, because I think there's definitive, absolute evidence that CVP does not predict volume responsiveness. Point, period. I agree with that point, but it isn't the only value of knowing the right atrial pressure. It gives you information about pump function, and I would agree with Shelly Magder that says we've ignored the right atrial pressure, perhaps, for too long. But I agree completely in terms of volume prediction. It's not useful. All right. Scott, do you have some comment you want to add on these folks here, the argument? No, I think both sides were well stated. The use of IVC, either size or respiratory variation, makes me nervous for the reasons that were mentioned, and I would just add the further technical difficulties with measuring it, right? So I think we assume that we're gonna generate a number of millimeters that is accurate, and I think that that's a bit of wishful thinking. So I think you're measuring it inaccurately. Just to highlight one of the things that I see all the time is that when somebody breathes, they shift the IVC over laterally a bit, and then instead of measuring, you were measuring a mid-cut, let's pretend, and now you're measuring a little bit off-center, and so it looks smaller. There's a whole series of technical limitations that would make me nervous about any accurate type of measurement, so... So the truth lies in between, because if Yoni had read the article by Antoine Viveron in 2018, as I recall, he would have noticed that there was strong evidence that we should use a gray zone approach, that there is no absolute cut-off value for IVC measurement that predicts volume responsiveness. Rather, the present French recommendation is ignore resipophasic variation for the reasons that Scott just told us. It's a translational artifact issue. But rather, if the IVC at end exhalation, if they're on a ventilator, is less than one centimeter, they are volume responsive. If it's greater than 2.5, they are not. In between, as they say there, ça c'est le gray zone, je ne sais pas. We have to do something else to figure it out, including clinical judgment. What's that, right? So if you're uncertain, you can be sure that your patient is likely to fall into that gray zone, and I think that I will concede- That's the problem, indeterminate. I will concede that the IVC is a test that is useful in extremes, but I'm really hoping for a test that helps me out when I'm genuinely uncertain, and my feeling is that most of the time, that's not the IVC. Next in line, what's the next debate? No other comments from the audience? Okay, wonderful. Well, we have not solved that one, and let's move on to our next one. The next topic of debate is gonna revolve around a philosophy, and we wanna ask whether POCUS, whether your ultrasound probe is more like a stethoscope, or is it more like a CT scanner? So this revolves around issues of archiving and perhaps billing. So is an ultrasound image that you capture something secret, like I heard an S3? No, you're not allowed to hear it. You must just trust that I did, and it's not recorded anywhere. Or is it more like a CT scan, where those images live forever, and then they can be audited after the fact? So is ultrasound a stethoscope or a CT scanner? I believe taking the pro is Yoni. Yoni, I'm starting the clock. Ready? Go. It's fun using mid-journey for this. So when we practice medicine in a training institution, the fellow or resident goes in, examines a patient, and then the attending goes in and verifies that examination. So the idea that we're gonna be acquiring images and making medical decisions and having no way to do quality assurance and quality control and therefore have accountability should be unconscionable for us. The practice of what's called hit-and-run ultrasound or ghost ultrasound really shouldn't be tolerated by anybody. So at my institution, we order our ultrasound studies. We pull it up on the machine. We perform it. We save the images. The fellow hits end on the machine. The images then go into a system where they do a quick report. They sign the report. It's immediately available to everybody to see their report and the images. And then the attending will sign the report and make any changes that are necessary. And so we have the ability to clearly see if the fellows are acquiring good images. And we can extrapolate fellows to attending to anybody, whether they're acquiring the images correctly and then not just acquisition being important, but are they interpreting it correctly? And I can't tell you, I can't count the number of times that I have really great fellows, but when they're first starting out, the things that they think they saw are very different. We've had many things that were missed that we would only know were missed because we have a quality assurance program. The other side to this is that if you're not doing it in a way that hospital administration sees, then you're not doing it at all. And when you're asking for equipment, when you're asking for that second or third ultrasound machine and that other probe, they just see the expense of everything. They don't see the value. And so while you don't get paid a lot of money for billing, it does add up. Five seconds. And making it worthwhile. All right, a powerful argument. The counter, go for it. So it's gonna be hard to counter that argument because I'm trying to get similar software at my institution. But the way I look at it, so just like Yoni earlier mentioned, they are really short on time up in Newark. And imagine you are a physician, you have to perform an ultrasound test, and you have to go scan the patient's barcode, create a new exam, save every image, make sure it's retrospective or prospective, make sure all the settings on your ultrasound machine are okay, put end, put that into a report, and then finish that exam, go type in that report in the EMR so you can eventually bill for it. That takes up a lot of time. Maybe some time people can use to scan the IVC. And essentially, it could, you know, we know in medicine the more hurdles or kind of like tasks you put on someone to perform a test or a task, for example, it's gonna decrease compliance, and that could be a downside. Another downside for it is that it puts an extra cost on the healthcare system, even though all of us, we wanna bill and increase our RVUs and reach our RVU targets. But at the end of the day, we look at it as a significant cost, and these softwares can go anywhere from 15K a year per department to some companies quoting 150K for like a healthcare system or a hospital, so it's extremely expensive. And that money could be put somewhere else while still ensuring that individuals are performing, you know, and learning and doing appropriate ultrasound exams at the bedside. I don't know how it was back in the day, but in maybe 15, 20 years ago, or even in the early 1990s when they started doing POCUS in France and whatnot, they didn't have these, you know, softwares, and they were still able to do a pretty good job and start this whole, you know, point-of-care ultrasound and advanced echo. Okay, well within time limit. Okay, do we have a rebuttal? One minute, go ahead. So I would just say the point about the time that it takes is valid, and I know Scott will have some comment here. Our system does require the fellow to first go and order it, and there are probably about eight mouse clicks more than anybody wants to do to get it into the system, into the ultrasound. And then after the ultrasound's done, they have to then go back to a computer. The reports are not cumbersome. It's clicking checkboxes, really. You can make your own templates, and then we have a short interpretation. But I believe, Scott, you've now bypassed some of this, and you do your reports within the machine. Is that correct? Yeah, there is the possibility of doing, the workflow's getting better and better. So it is possible to perform the scan on the machine, and then the reporting software can be integrated. So you actually don't have to leave the machine and go to a separate standalone computer to hop on whatever archiving software you use. So it's getting better, and I do think the point about every step of complexity that you add is gonna interfere with compliance. It's gonna interfere with compliance of the workflow for archiving. But also, I do worry that if you do make ultrasound a nuisance, then maybe it will occasionally discourage somebody from doing an ultrasound. And that's sort of the last thing I think anyone, any of us on this stage would like to see. I should have said this up front, but of course you'll forgive us that sometimes we did need a pro and a con. So some of our debaters maybe are playing devil's advocate here, so don't hold their views necessarily completely against them. And so far it's been a pretty friendly debate. Does anybody from the audience wanna weigh in on this billing, archiving, CT scan versus stethoscope argument? Ibrahim is allowed to respond. Oh, of course. Would you like to respond first? No, okay. Yeah, it's a well-stated argument. Well, we got so friendly there. I was gonna ask from a community standpoint. Yeah. I'll go ahead. From a community standpoint, I mean, one of the things that I think about is how you grab your stethoscope, I go room to room to room. And other than just a quick wipe down with the alcohol at the time, I can keep moving. And when I do wanna use an ultrasound, I think the bar has been raised because it's go get the machine, go get the patient data entered. It does not directly link to any of my EMRs that I've used in a number of years. And so there's printing, making sure it gets into the chart, gets taped into the chart. Then separately, it is a big deal. And I actually really do wonder if, well, I completely agree with what Yoni's saying. Sorry. In terms of the training component, the quality assurance. I also think part of this is a volume issue. And that if rather than doing this once a day, I was grabbing this pocket probe and putting it on somebody, every single patient every day because it was that easy and it took 30 seconds rather than five minutes each time. I think we did actually improve our skillset. And especially if we're thinking of it from a POCUS, I'm not looking to be an excellent sonographer on everything day one, but moving, I mean, it's how, frankly, how I learned plural ultrasound years ago is you just stick it on every patient and you see it and you're learning it and you're reading articles that you guys are publishing and your skillset is going up. And I just wonder that we've created a big barrier to adoption. I think it's a fair point. I think barriers are everyone's enemy here. We want to see the barriers come down. Absolutely. In the old days, what we used to do, and I think it was a fair compromise, was that we would perform the study. We had no means of saving the images or formally reporting them, but we would make sure that in our daily progress notes, we had a clear section that said, I performed a point-of-care ultrasound. These were my findings and how it influenced the management of the patient. And so I'm agreeable to that compromise, although I think a world where we can easily archive is better. So we're in back, a question, a comment. Just a comment. I also work in community medicine. I've been at a couple, the last two places have both tried to or initiate billing for ultrasound. I like to look at it as kind of like part of your physical exam. So some of us use it. Other people don't use it. But a lot of times when you work with colleagues that don't use ultrasound, oftentimes they come to the same conclusions. I wouldn't say that the care is that much different, even though there's certain parts where ultrasound obviously benefits you. But there's always this discussion about billing for it. And as you said, we're trying to pay for the machinery and things like that. But if an IR physician or a radiologist told you that we need more CAT scans or more IR procedures because we have to pay for our instruments, I think all of us would cringe a little bit. So I think we have to watch out for doing things and billing for things just to pay for what we wanna do as far as our physical exams. So I would say to that, nobody's performing ultrasounds that are not clinically indicated. And the amount of money that you're getting paid for your interpretation isn't gonna be a driver for most clinicians. So really it's just getting credit for what you're already doing. I was trained by Dr. Mayo and I was doing point-of-care ultrasounds for eight plus years before I even had the ability to document, store, and bill for it. And I was always doing it then and the practice hasn't changed now. Yeah, no, I didn't mean that. I meant, so in a lot of places it's hard to get access as far as HIPAA and everything else to put it on the PICS or the PACS system so it's available to everyone or to document it. Sure. But I guess my thing is we should avoid saying that we shouldn't do ultrasound just because we can't make it available for everyone. Because in a community center, that's harder to get than a larger academic center. The other thing also to consider is, while the ideal would be for it to go into EHR, it's not that difficult to at least get it to go into a PAX or to save it on a machine and archive it on a hard drive. So at least it's there, and there can be something done. And I tell my fellows, because sometimes they feel like they don't have that minute to order the test, and I say, like, OK, if you truly don't, you can still hit the Save button each time you're getting an image, and then you'll know when you did it. And so at least the next day, we can look at what you saw and make sure that we're doing right by our patients. So in a training program, it's essential for assessment of quality, teaching purposes, conference purposes to archive. But we have to be honest, in community practice, in general practice, non-teaching practice, the only reason we archive is because the United States CMS system requires us to do that to bill. Otherwise, if you really think about it, when was the last time an active clinician went back to check their images to compare it to something? This is a dynamic, active scanning that we're doing. So I query whether archiving, unless it's for teaching purposes, has any merit whatsoever, and it's forced on us because of this ridiculous RVU system we live in. So archiving, reporting, I like the Canadian approach. What's an RVU? Oh, yeah. What's an RVU? Which is, I did it. I write the result, and I don't need an image because no one's going to look at it except the biller, the CMS person. So any other comments? Are we pretty much on time here? I think we're doing great. Yeah, we're doing pretty well. I mean, these archiving questions are luckily getting easier with time as technology marches forward. Hopefully, we're no longer in the trenches here of the wars between ICU and cardiology and radiology over turf, and archiving and proof of quality insurance, there was a role for it in that era, right, where you were defending yourself and justifying the safe things that you did. Hopefully, we're all moving through that now, and we've passed it, and so we don't need to use that line of argument. Okay. What's up next? What's up next is a bit of Canadian content. We're going to talk a little bit about Vexus protocols for venous congestion and just their overall utility in the critically ill patients. All right. This will be interesting. Go for it. So Vexus, for those of you who are not familiar with it, is a scoring system that an intensivist or a physician at the bedside or provider at the bedside can perform ultrasound of organ systems such as liver and kidney, and mainly hepatic vein and renal vessels, and essentially extrapolate how congested these organs are. The reason why I like the idea of Vexus is quite often when we are caring for patients, mainly in the intensive care unit, we do hit a patient that kind of looks like the Michelin man, and this is a patient that has significant congestion and organ congestion. And why I like Vexus is because it's finally opening the provider's eyes at looking at venous congestion as a parameter to kind of like quantify. We're no longer just thinking about cardiac output. We're no longer just thinking about mean arterial pressure. We're thinking about also venous congestion and starting to modify our approach to the patient to optimize organ perfusion, microcirculation, and organ perfusion pressures. There is still no prospective data that shows, hey, if you use Vexus, you're going to save more patients. But I would argue in the intensive care unit, if you can tell me how many interventions that we do that were studied consistently over the past 25 years that show every single time you look at them, a mortality benefit will just be doing 6 mL per kg of predicted body weight and early antibiotics. So I like it because it helps the physician and the provider look at the patient's physiology, venous congestion, and start thinking about perfusion pressure and microcirculation. Five seconds. OK. Awesome. Nice. Yoni? Ready to go? I'm ready. All right. So, you know, my opponent here, my nemesis, just stated a couple sentences ago that there's no prospective evidence to support the use of Vexus. And I think that's an important thing for all of you to hear, and I'm going to repeat it again, don't worry. But to back up a little bit, the concept of venous congestion is nothing new. Guyton described it, and you all read it back in medical school. And the individual components of Vexus have been reported fairly extensively, and even in the cardiology literature, and haven't really been widely used in clinical practice. And I think the Vexus score is a really nice concept of taking some things that are a little separate but interrelated and putting them together to try to do good. But if you look at the only paper really out there that the authors cite as their evidence for use of Vexus, it was in cardiac surgery patients, pre and post. It was a post hoc analysis. And they excluded all of the patients that I care for. They couldn't be critically ill. They couldn't have acute kidney injury. They couldn't have cirrhosis. They couldn't have chronic kidney disease. So the problem with the Vexus score, when you read the paper and see what they cite in terms of odds ratios of a higher Vexus being associated with worse outcomes, is it's just not the patients that medical intensivists are caring for. So there are studies that are in process looking at this in a rigorous fashion. I'm looking forward to them. But just like the COVID pandemic and the crazy practices with anticoagulation, it wasn't until we had large multicenter randomized trials that we knew that we were doing something either harmful or beneficial for our patients. The other thing to think about, too, is none of these measurements are particularly simple. So portal vein pulsatility, renal Doppler, these are not easy. And interpretation being accurate is a big concern of mine as well. OK. A rebuttal, sir? So I'm just going to say, we're going to talk about this subject, me and Ione, in a couple years, hopefully when the studies start to roll out. I do agree we don't have any prospective studies. But I'll make the argument that do we have any prospective studies that shows if you look at the LVOT VTI in patients and change management based off of that in a randomized fashion in a large scale, how often does that impact mortality, even though majority of us who do advanced echo at the bedside almost routinely use that measurement? I failed to describe my image. You're all probably wondering what was going on in my head. This young man is fending off all the ladies because there were a lot of exclusion criteria in the Vexus paper. So that's what's going on. It took about eight iterations with the mid-journey to get this. Is there any strong defender of the Vexus or the venous congestion measurements in the audience that wants to leap up and take up the sword against this naysayer Ione? Scott, what's your opinion? Well, I mean, maybe we can relate this back to the first debate topic. I mean, some of us are old enough to remember surviving sepsis guidelines, resuscitating people to a CVP of at least 12, I think it was. And that always struck me as kind of funny, right? Because your CVP is supposed to be zero. And if I make your CVP 12 and I make your IVC fat, then we're going to actually impair venous return to the right side of the heart, aren't we? So that seems like we're doing a bad thing. So I like this because it kind of flips the dynamic on its head. And it says to us that let's decongest our patients. Let's make the IVC small. Let's get the CVP down towards the normal range. Let's improve venous return to the right side of the heart. Let's reduce pressure in the post-capillary region and improve organ perfusion. And I really like that. And so if we get from rinse to spin faster, right, from filling people up with fluids to diuresing them, if we can get to that a day earlier, then I would hypothesize that that's going to be good for our patients and their kidneys, frankly. So that's what I like about it. So if then I could be a referee. We have on my left side, not so young but still young attending, who I have been working with for eight long years since he was a second year medical student. And he's been torturing me because he is a meticulous, demanding, requiring, evidence-based medicine type of guy. He wants everything done correctly. On the other hand, to paraphrase the great Martin Tobin, in the absence of evidence at the bedside in the ICU where we lack it, he would propose that the best approach is sound physiological reasoning. And that's what Scott is suggesting. Yoni, what do you think? I think the physiology makes sense. I agree with Scott that it's exciting and we need to flip the paradigm. But I don't want to start changing practice until we study it. And this is the thing. It's not a difficult thing to study. And again, going back to the pandemic and anticoagulation, all we need is a bunch of hospitals to come together, a couple of months worth of data, and we can answer all of this. So the fact that we're years down the road and aren't there yet is just a problem on our ends. If there's no further comment, should we move to the next debate? Topic number four. So we're going to talk a little bit about a procedure here. So let's do a central line. And my favorite central line is the subclavian central line. And so the question arises, should you use real-time ultrasound guidance to insert a subclavian or should you do it by the old-timey landmark technique? Go for it. Awesome. So I'm a huge fan of the subclavian site for central line placement. The issue that I see is that a lot of the trainees now don't know how to do that line or put that line in. And the main reason is because of concerns of causing complications such as arterial puncture, a pneumothorax, a hemothorax. And the way I look at performing procedures in 2023, imagine if you're a surgeon and you're blind and would you like your surgeon to be blind when they're operating on you? Probably not. So we have ultrasounds now and we can easily look and identify the subclavian vein, subclavian artery under ultrasound and cannulate these veins. And also while you're looking, you look to see if there's any thrombosis or any major anatomical issues in the vein itself. And that has been studied, even though it's small studies, a single center. And it shows that if the individual utilizes ultrasound to cannulate the subclavian vein, less pneumothorax, less arterial puncture, and a similar success rate with a higher success rate with a similar number of punctures. So in 2023, I think utilizing the ultrasound in a longitudinal kind of plane will help you see your needle as it's going through the vein. And you'll see the plural line right underneath the subclavian vein. And if you're visualizing your needle going through, you'll be able to avoid any complications such as a pneumothorax or a hemothorax. You finished early. Go ahead, Yoni. So I like using ultrasound for pretty much everything. It's fun. It's interesting. But some things are just straightforward. And we all know that IJ central lines, ultrasound is mandatory. Anatomy can be variable in terms of vessel placement. But the location of the subclavian is really quite steadfast. And so the idea that we have to take a very safe procedure with a very high success rate and a low complication rate and add a device to it doesn't hold water in my book. Here we've got a physician walking through a complicated maze, but there's a straight path right through it. So why do we have to go side to side to get to our final product? It reminds me of some hospitalist colleagues of mine that sent me a paper to review. It was a paper on ultrasound-guided lumbar puncture. And in this paper, it was a position statement. The language was such that if it was published, it would make everybody feel obligated to use an ultrasound to perform an LP, which seemed crazy to me because LP is a simple, safe procedure. And ultrasound can help you sometimes, but it's certainly not necessary. Now I will concede to my colleague that it's very hard to ignore the ultrasound. So what I actually do in practice here, because I still love doing it at Landmark, is I just look at it with the ultrasound to make sure it's there. And then after my needle and guide wire, and I check it before I dial it. So I incorporate it a little bit, but it's such a beautiful, straightforward Landmark technique. I don't want to give it up. All right, I see some positive head shakes in the back when Yoni was speaking. So if anybody wants to step forward to disagree or agree, is there some comment here? OK, Scott, you're a acolyte of the subclavian approach. Up in Canada, are you a ultrasound guy or a old school guy? Yeah, I do tend to use ultrasound. I teach the residents and the fellows the technique, and there's a number of my colleagues who then forbid them from using it. And honestly, I think that those things are not incongruent with each other, because I do think that there's a learning curve here. If you stumble upon somebody doing this technique under ultrasound guidance, you do kind of wonder whether they're trying to commit murder, because the needle is going in at such a steep angle, right? And so you need to have perfect depth control. And so whether a first year resident can achieve that milestone, my colleagues are skeptical, and so am I. So perhaps this is a procedure for fellows and attending physicians who've got 50 or 100 or more ultrasound guided lines under their belts and that really good depth control. So I think that's a fair compromise. I'm very annoyed always when you put the subclavian in and it goes down the other arm or up the neck. So there actually is a wire check. You can actually clean all four spots, and then you can check to make sure the wire's in the right place before you dilate and put the line in, and that avoids that really frustrating situation. Sir, step forward. Yeah, I was just going to say, I think everyone should know how to do the anatomical, because occasionally you don't have the, obviously, the ultrasound there. But I find that you can, with the ultrasound ones, the patients are actually fairly comfortable. So you don't have to keep them as still and maybe sedate them potentially if they're more awake. It just seems like a more comfortable line than the anatomical. So I will say that one of the ways I used to rationalize the need for landmark is if you don't have an ultrasound available. And that doesn't really hold with IJ central line or whatnot. And so I look at my intraosseous catheter as my go-to thing if I need something quick and fast. But yes, it's a much more difficult. It's not just, I don't know who in the audience hasn't done an ultrasound guided subclavian, but it's magnitudes more technical than an ultrasound IJ. And so it really takes somebody with significant experience to be able to do it reliably. Once learned, great. I think that the gentleman's comment was well taken though. If you work in a trauma ICU and you have a lot of C-spine collars on, it's really nice when the line goes in a bit more laterally, right? More comfortable for the patient. You don't have the collar, the sweaty collar sitting on the line. And so I think that's a nice advantage too, but we're getting into niche arguments here. So I thought it curious that, did I hear you say that the least experienced person should not use it, but the most experienced, you named a number of 100, should use it. There's some lack of logic in that statement, Scott. We'll take that up afterwards though. I think though that to support that, the first study about subclavian with ultrasound was out of Greece a good 10 years ago in critical care medicine. And they commented, they showed reduced complication rate, but they said it was a hard technique to master. So keep that in mind if you dare take it up. Okay. Are we up next? We are astonishingly on time here. Yeah, of course we are. I'm extremely impressed. All right. So our fifth topic now is, I mean, near and dear to everyone's heart. We're wondering whether my ICU, whether your ICU should purchase a transesophageal echocardiogram probe. Yes. All right. Well, let's move on to the next topic then. No, pardon me. Now, we're going to have the pro side of the debate first. Yes, this is yes. My hospital should buy a TEE probe. Ibrahim, I was surprised that you agreed to take the con side here. I'm looking forward to the magic that you're going to work. What we have here is a gentleman looking at a brick wall, which is how I often feel when I take my echo probe and I put it trans-thoracically on a patient with hyperinflated lungs, a BMI of 52, subcutaneous emphysema, and then dressings all over the place. And I had hair before that patient came, and then it all fell out as I stressed out trying to figure out what kind of management was needed here. So the idea that I'm just going to stand there and continue looking at a brick wall wondering what's on the other side is crazy. And we have a tool. It's a transesophageal probe. And so we're not advocating for doing a TEE on every patient. But if I can't see what I need to trans-thoracically, then that's what it's for. You pop it in. You get some beautiful views. It is safe. Okay? The safety profile is phenomenal. It's not hard to learn. You can practice on a simulator. I was trained with Dr. Mayo. I did, I don't know how many hours of simulator work. Three hours. Three hours on a simulator. 15 full studies at the end. Had the entire 13-view exam memorized and then went to a patient and started acquiring images. You don't have to acquire the 13-view one. Our emergency colleagues like a 4-view exam. But it is a really, really valuable technique. The only strong arguments against it would be, and I say strong in quotation marks, would be cost. It's a more expensive probe. You're looking at, in the $30,000 range, although I think some companies are lowering them into the high teens, low 20s now. And then whether or not your cardiology colleagues are able to handle the fact that you have a probe. But most of them don't want to do the TEE on this patient anyway. This is the one when you call them and ask, and they look for an excuse, because it's a sick patient. It's not going to be easy, and they don't really understand how it's going to be useful. I let him go another 12 seconds over for obvious reasons. Yes? Go for it. OK. Awesome. So the way I look at TEE probes in the ICU is that we should start by taking baby steps. So most ICUs in North America, I think, initially should work on excelling their skills in trans-thoracic echoes, because most of your patients are not going to be intubated. You're not going to be doing conscious sedation to do a TEE in the ICU most of the time. So you should really be really, really, really, really good at 2D trans-thoracic echo and some of the Doppler measurements before even thinking of purchasing a TEE probe. And when you want to go ahead and buy that TEE probe, you're going to first realize that it costs a lot of money. And then hospital administrators are going to give you a hard time. Then you're going to need to get credentialed. Then you're going to need to play well with your cardiology colleagues. And then cleaning that TEE probe is going to be a big issue. And the Joint Commission, I don't know if you have it up in Canada, but when they come, it's like a really, really bad thing. They look at TEE probes in the ICU, and the first question is, do you have that checklist? Are you cleaning them appropriately? Are you storing them in the appropriate spot? So even though I believe that in the future, almost all ICUs should have a TEE probe, especially if you're in a tertiary care center, you have ECMO capability, and you see a lot of complex patients. But right now at this moment, I think we should put all those resources that we have and focus on 2D echo first, and excelling in 2D echo trans-thoracically before we venture into the TEE world. All right. So I hope we- Who was the person? That's not shame, anyway. It was Scott. Yeah. So anyway, thank you for attending. And maybe next year we'll try it again. Yeah. Thanks, everyone. It was a real pleasure. And hopefully you all enjoyed it. Thank you to our brave debaters, most of all. Yes. Thank you.

ultrasound guidance

landmark technique

subclavian central line

complications

success rate

Vexus protocols

venous congestion

transesophageal echocardiogram