Which Equipment for the BLUE-Protocol? (And for Whole-Body Critical Ultrasound). 1 – The Unit

Abstract

If we attributed the paternity of the ultrasound revolution to the laptop machines, the merit of the physicians who developed critical ultrasound at the bedside before the advent of these technologies (using smaller equipment, superior in many respects) would not be considered.

With its use of complicated machines (even laptops) with complicated techniques and nonsuitable probes, ultrasound remains a complicated discipline. The use of pocket machines will not make critical ultrasound simpler. Their small size does not eliminate the main steps (or difficulty): probe handling, image acquisition, and image interpretation. Hypermodern machines, which destroy real time (instant response) and artifacts, can harm lung ultrasound.

The essential thing with laptop technology is to note the width and not the height of the unit. This is because obstacles are lateral, not above. Remember that the unit always remains on its cart (an excellent accessory, by the way). We need narrow units, not laptops.

Appendix 1: The PUMA, Our Answer to the Traditional Laptops

An ultrasound unit has three dimensions: depth, width, and height. The width is critical for rapidly reaching the bedside, which is why we do not favor large laptops (50–70 cm). The height must be considered using the cart, allowing one to work comfortably at human level. A laptop machine is a few centimeters in height but the space below (up to 100,000 cc) is empty space. The PUMA exploits every cubic centimeter available. Since 1982 (ADR-4000) and 1992 (Hitachi-405), we have fully exploited this space for inserting all useful equipment, to the point that our cart can be considered a Polyvalent Ultrasound and Management Apparatus (PUMA). We just developed the 4th dimension: imagination.

The PUMA is our answer to the current laptop market. The PUMA is not an ultrasound unit. It includes an ultrasound unit.

The PUMA exploits each floor (Fig. 2.6). Basic life-support equipment at the lobby (25-cm high), extreme emergency procedural equipment at the first floor (for treating tension pneumothorax, pericardial tamponade, immediate central venous cannulation, etc.) (10 cm), some refresher textbooks on the second floor, of help to the youngest users (5 cm), etc., at the imagination of the user. On the fourth floor, you find an ultrasound machine, 27-cm high, with the keyboard at the perfect ergonomic height for clinical use. On the top of the PUMA, you have a top. This top bothers nobody and is highly useful, since this is the area where are fixed the (unique) probe, the contact product, and the disinfectant. They are fixed using adapted holes within polystyrene that we built ourselves, allowing these items not to fall when the cart is moved (Fig. 2.6, and see details in Fig. 4.3). This avoids the loss of time: time for picking objects up from the dirty ground, time for disinfecting them, or, if not, time for managing patients with the nosocomial infections that may occur as a result. This is not high tech, this is just a bit of imagination. The PUMA: another face of holistic ultrasound.

Fig. 2.6

The PUMA concept. This figure shows that ultrasound is only a part of patient management. The concept of the PUMA (Polyvalent Ultrasound and Management Apparatus) allows major procedures in the critically ill. It does not yet make coffee (which may be considered, to relax the team once the patient is promptly stabilized), but inserting a coffee machine at the highest level would be technically possible. This wink just indicates that the height is not a limiting factor. In other words, laptop machines are not a major key for developing critical ultrasound in our hospitals. Note, at the upper floor, how the three tools are solidly fixed, preventing any fall (see diving view in Fig. 3 of Chap. 4)