Monthly Archives: December 2019

POCUS: A Holiday in the Sun

Posted on by
1

Getting started with point-of-care ultrasound (POCUS) is like taking a vacation in Bali, Bermuda, or the Bahamas.  Let’s say you’ve landed in an exotic destination and plan to rent a car to explore the island. After collecting your keys, what’s next? Jump in the vehicle and peel off to the beach? Of course not – you’ll take a minute to consider the controls of your car, where you’re going, and how you’ll get there. POCUS is no different from a dream island visit.

Mackenzie headshot 2

In an unfamiliar vehicle, it’s normal to become acquainted with the controls. You want to know how to turn on the car’s lights and wipers and position the mirrors and windows appropriately. There’s a direct analog in performing a POCUS study. The operator has to select the correct transducer and examination preset before getting started. If it’s a machine you’re not familiar with, you need to take a moment to locate essential controls such as depth and gain. Even if the machine is familiar, you need to optimize those settings to ensure you can obtain quality images, just as you would with the mirrors in your car.

It’s also second-hand nature to adjust a car for comfort. The seats and steering wheel need to be positioned so you have a comfortable trip, and the climate settings arranged for passenger comfort. For a successful POCUS scan, the same steps should happen. Both the operator and the patient should be comfortable and positioned correctly. That means adjusting the bed, lowering the side rails, and placing the patient and machine where you can obtain adequate images while ensuring no one has to be a contortionist.

Taking a car on the road on unfamiliar roads can be stressful, and more so if you’re not used to driving on the left. If driving on the opposite side of the road is unfamiliar, it’s smart to visualize how you will be oriented on the road and during turns before heading out on the road. Successful POCUS users have the same habit: they understand where the indicator marker is on both the screen and the transducer before acquiring images. Failing to do so leads to confusion and a breakdown of pattern recognition, just as driving on the left might.

With the car and orientation controls sorted, you’re still not going to fire up the engine yet. Most travelers take a moment to figure out where they’re headed, with a GPS or map. The sonologist needs to take the same step, remembering the focused question they’re trying to answer with the POCUS study, and what they need to see to be satisfied. While you might be happy to ramble aimlessly in a car, POCUS scans should stay focused.

Of course, this assumes that renting a car is the best way to get around the island. Maybe you’d be better served by a taxi, bus, or boat. Or maybe after seeing the rental vehicle, you decide the car can’t accommodate your plans. In the same vein, not all clinical questions can be answered with POCUS. An alternative imaging modality or comprehensive ultrasound may be the test you need, and it’s OK to change your mind and decide you need something else after you perform the scan.

POCUS is rewarding and helps both clinicians and patients, but isn’t always easy. Think of POCUS like the start of a vacation, and you may find your studies are easier, and a bit closer to a holiday in the sun.

 

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

Connect_digital_graphics_E-NEWSLETTER

David Mackenzie, MDCM, is an emergency physician at Maine Medical Center, in Portland, Maine. Follow Dr Mackenzie on Twitter @mackendc.

The Expanding Scope and Diagnostic Capabilities of Vascular Ultrasound

Posted on by
1

Peripheral Vascular Disease (PVD) in the United States affects approximately 8 million to 12 million patients a year; some experts in the field believe this number may be underestimated. The disease is associated with significant cardiovascular morbidity and mortality, with a high rate of fatal and non-fatal cardiovascular events, such as myocardial infarction, stroke, renal failure, limb amputations, abdominal aortic aneurysms, pulmonary embolus, and progressive ischemic end-organ dysfunction. The reduction in quality of life from global vasculopathy in many patients can thus be significant.

George Berdejo

George Berdejo, BA, RVT, FSVU

Prompt and accurate diagnosis of these disease processes is of utmost importance and high-quality vascular ultrasound plays an essential role. In fact, vascular ultrasound and the role of the vascular ultrasound professional has evolved and expanded rapidly and is at the core of modern vascular disease care in the United States and is emerging around the world.

Vascular ultrasound can be seen at the intersection of imaging, physiology, physiopathology, interventional medicine, and surgery and is utilized widely by healthcare providers from many specialties, including but not limited to vascular technologists and other subspecialty sonographers, vascular surgeons, vascular interventional radiologists, vascular medicine physicians, cardiologists, radiologists, and other vascular specialists with an interest in vascular disease.

At the core of any thriving vascular surgery practice is high-quality vascular ultrasound imaging. Duplex vascular ultrasound (DU) is used to evaluate all of the major vascular beds outside of the heart. The use of duplex ultrasonography for the study of vascular disease is firmly established but is also rapidly expanding. Thanks to continued improvements in the performance of ultrasound devices, vascular ultrasound can be used to perform a greater range of assessments in a noninvasive manner in some cases excluding the need for more invasive, expensive, contrast-based imaging modalities.

The recent proliferation of “less and minimally invasive” endovascular options currently available and offered to patients with various vascular disease processes has mandated better, less invasive, preferably noninvasive methods, to diagnose the disease that is being treated. Advances in technology have increased the diagnostic capabilities of vascular ultrasound and its role not only in diagnosis but also in planning and performing interventions and in patient follow-up and surveillance after intervention. Indeed, vascular ultrasound has become the standard “go-to” diagnostic imaging technique prior to most vascular interventions and has certainly emerged as the imaging technique of choice for following patients after most vascular interventions.

Endograft Evaluation. Duplex vascular ultrasound has emerged as the standard of care for surveillance after endovascular repair of abdominal aortic aneurysms. A major complication of this procedure is endoleak (persistent or recurrent flow within and pressurization of the residual aneurysm sac). This results in persistent risk of aneurysm rupture and potential death. Ultrasound assessment allows imaging and Doppler interrogation of deep structures and low-flow detection capabilities needed in patients with low-volume/low-velocity endoleak. Duplex vascular ultrasound, in good hands, has supplanted computed tomographic angiography as the primary surveillance technique in these patients. In addition, DU allows for the ability to resolve the deep structures of the abdomen to measure aneurysm sac size.

Hemodialysis Access Mapping and Surveillance. Higher frequency, better resolution, smaller footprint transducers that are currently available provide the high-resolution images that are needed to assess the veins and arteries of the upper extremity in order to plan the optimal access sites and also to provide the surveillance often needed postoperatively in order to maximize the life of the access and the quality of life for the dialysis patient.

Lower Extremity Vein Reflux Testing. Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. An estimated 40 percent of people in the United States have CVI. The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. Duplex ultrasound is integral in the evaluation, treatment and follow-up of these patients. Absent the appropriate equipment, the initial duplex reflux scan is among the most physically challenging, labor-intensive scans performed in vascular ultrasound. These exams account for 20%–25% of all the ultrasound scans performed in our practice.

Lower Extremity Arterial Mapping. Our philosophy regarding the practical evaluation of patients with known peripheral arterial disease who require intervention includes the use of duplex ultrasound as the primary first-line imaging modality precluding the use of more expensive, invasive, and nephrotoxic diagnostic arteriography in most patients.

Vascular ultrasound is now being used by increasing numbers of specialists who are employing both traditional and newer cutting-edge methods and techniques to improve patient care and management and who are dedicated to the delivery of quality care to their patients.

The future is bright for both vascular ultrasound and the vascular sonography professional!

 

Do you have any tips for performing vascular ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

 

 

George Berdejo, BA, RVT, FSVU, is Director of Vascular Ultrasound Outpatient Services at White Plains Hospital in White Plains, New York. He is the Chair of the AVIDsymposium (www.AVIDsymposium.org) and is the current Chair of the Cardiovascular Community of the AIUM.

Novice to Competence to Understanding Our Role as POCUS Educators

Posted on by
1

Nights at the VA medical ICU could get lonely sometimes. When the hubbub of the day had drawn down and the critical care fellows had gone home, the work in the ICUs slowed.Headshot_kevin piro

I figured that I would make use of the time that had seemingly stopped. I grabbed the ultrasound and went to scan and chat with a friendly gentleman whom I had admitted the previous night. It became readily apparent that I was still a struggling learner at this point in my training. There was something that looked like cardiac motion, but not resembling anything like the diagrams and videos I had looked at on my own. It was an uncomfortable place to be.

I imagine that is where a lot of people get frustrated and stop, especially when they don’t have someone to encourage and nurture their continued practice. I had a different luxury. Just a few weeks prior, I had received an inquiry about participating in a new general medicine POCUS fellowship at Oregon Health & Science University, and I was instantly sold on its potential. Here was a chance to carve out a new path and to invest in a skill that offered me a skillset that could improve my patient care. And I knew that I would have the benefit of POCUS experts literally holding my hand as I learned the skill. What a luxury!

So, I kept scanning in the ICU prior to my fellowship. You know what I found? Patients are much more forgiving than we might imagine them to be. Most understand that hospitals are frequently places of learning and like to be engaged in the process and, as I stumbled through my next few exams, I was reminded of my Dad’s words of encouragement, “the only difference between you and an expert is that they have done it once or twice.” So I kept at it. I was terrible the next times too. But, it got easier and I felt less intimated with each scan I performed. By the time I hit fellowship, I was already moving in the right direction.

When I started my POCUS fellowship, I was fortunate to work with all sorts of supportive colleagues that allowed me to continue to grow. Where I had struggled to build a foundation on my own, colleagues collected from internists, sonographers, and EM physicians provided me with the scaffolding. They provided me with lessons. “Remember, air is the enemy of ultrasound” and “ultrasound does not give you permission to turn your brain off. It is a problem-solving tool.” They entertained clinical application questions. They gave back when I leaned in. These colleagues were an amazing support network and would help me construct the mosaic that I teach from now.

A few months into the fellowship, I could complete a competent exam comfortably. It came together one day for me when I completed a Cardiovascular Limited Ultrasound Exam (CLUE) on a pleasantly demented older man, who had shortness of breath likely representing heart failure. As I looked at his lungs, taking stock of the bilateral B-lines and pleural effusions that confirmed his diagnosis, I discussed and showed the findings with his daughter.

“This makes so much sense now!” she remarked. The lightbulb went on for her as I democratized her father’s clinical information. The lightbulb came on for me too as I had a sense of satisfaction of both feeling confident in my diagnosis, but also being better able to teach and engage a family in their medical care. My transformation from novice to competency was mostly complete.

Now, a little more than 2 years removed from my fellowship, I have a little more perspective on the road from novice to competency, not only from my personal experience but also from my opportunity to network with an amazing group of enthusiastic (IM) POCUS educators.

These educators are largely trained by their own curiosity, their attendance at POCUS CME courses, or by latching onto experts from peripheral medical departments. In essence, these educators are pulling themselves up by their own bootstraps in a time when there is a distinct scarcity of POCUS educators within Internal Medicine, which can leave the supposed “all-knowledgeable” physician in an uncomfortable place of vulnerability. They have shared the angst that POCUS is a particularly challenging skill to learn due to its humbling nature – we may not know how badly we were hearing murmurs as medical students, but I bet most learners can guess by looking at a picture how poorly they are doing when they are scanning. It was a feeling I shared back in the ICU as a resident, but our experiences diverged when I had mentors who invested in me learning this valuable skill.

But, these physicians who learned POCUS independently are now at the next, even harder, part. As new leaders, we must reach behind us and pull up the trainees, whether that be by creating the next POCUS fellowship, starting or improving a residency POCUS program, or simply training your fellow colleague. We are tasked with making new learners feel supported and encouraged, and to make this technology accessible in fields where POCUS is not the standard of care. We need to foster these learners’ growth so that they can arrive at their own lightbulb moment and so they keep scanning on the ICUs in the effort to improve the care they deliver.

 

What was your defining moment in your decision to go into ultrasound? Have you had a unique learning experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

Connect_digital_graphics_E-NEWSLETTER

 

Kevin M. Piro, MD, participated in and helped build a point-of-care ultrasound fellowship at Oregon Health & Science University (OHSU), becoming only the second general medicine-focused ultrasound fellowship in the nation. Dr Piro is now a hospitalist at OHSU.