Category Archives: Emergency Medicine

When Data Isn’t Enough!

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“I’m looking for volunteers, not hostages.”
            — Mike Tomlin (Head Coach of the Pittsburgh Steelers Football Team)

I enjoy quotes that help keep things in perspective (even though I’m more an ice hockey fan than an American football fan), and I could have used coach’s advice after my Emergency Ultrasound Fellowship concluded in 2002. I believed, then, that every Emergency Physician would find the allure of ultrasound’s rapid, portable diagnosis irresistible and abruptly begin using it. A string of successful research and equally enthused editors would publish article after article and ease the path to acceptance of “emergency medicine ultrasound” or “point-of-care ultrasound” (POCUS).

As if data would impose ultrasound adoption.

The hard pivot did not come as quickly as I hoped. As an example, my early work examined how ultrasound improved the safety of central venous cannulation. The fields of Anesthesia and Interventional Radiology learned this years before Emergency Medicine, and it seemed natural that, once adopted, finding a vein with ultrasound anywhere would prove too irresistible for the Emergency Physician to pass up.

I soon discovered that trainees embraced ultrasound (they knew no alternative) but more experienced providers passed on it, stubbornly reverting to what they found more comfortable. They rationalized that learning something new disrupted their workflow. Besides, their cases rarely had complications.

Make no mistake, youth alone would not resolve the disrupted workflow dilemma. A few years later, motivated by the work of Peter Pronovost in intensive care units and championed by Atul Gawande’s Checklist Manifesto, my research team attempted to incorporate ultrasound-guided central line checklists in the Emergency Department to decrease central line-associated bloodstream infections. After presentations at journal club and grand rounds, we measured checklist adherence at exactly zero! I distinctly remember trainees’ wry joy in seeing my face as the paper with the printed checklist was ceremoniously discarded, the central line expertly inserted under ultrasound, and the patient stabilized. The academic journals and even the lay press had done their part disseminating the new information but implementation of a checklist…that was a new challenge unto itself.

Examining what changes behavior in healthcare feels like psychoanalysis. Lesson one is we’re not rational beings moved by published data. The AIUM promotes guidelines, education, and training, and offers a stage to persuade and model the benefits of ultrasound-assisted medicine. But is this enough?

The growing field of Implementation Science suggests there’s more to do. A salient theory pertinent to changing behavior in health care is known as the COM-B system. Capability, Opportunity, and Motivation are essential conditions that underpin Behavior. In our checklist example, we possessed the capability and opportunity but the motivation was so low it sank adoption. Behavior didn’t change. Data was not enough.

Our team, led by Dr. Enyo Ablordeppey, took a different approach to adopting new ultrasound techniques, which we presented at AIUM 2022 in San Diego. Before we imposed confirming central line placement solely by ultrasound, precluding the chest x-ray and saving radiation exposure, we worked backward from COM-B to create a framework of interventions. We gathered the group of end-users and began by listening to them. Out of these sessions, we developed seven strategies:

  1. Training
  2. Supervision
  3. Feedback
  4. Organizational buy-in
  5. Decision support
  6. Planned adaptation (ie, prizes for, and promotion of, early adopters)
  7. Algorithm development

Our program to De-Implement Routine Chest Radiographs after Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol is called DRAUP. It’s a mouthful and a mound of work but, 6 months into it, we increased ultrasound adoption and decreased chest x-ray utilization by 50% with identical complication rates to conventional behavior. For comparison, 10 years later, we still don’t utilize the central line insertion checklists!

At the root of it, implementing innovative ultrasound requires addressing an interplay of environmental, cognitive, sensory, and emotional processes. All ultrasound users have experienced the implementation challenge when an innovation seems blithely disregarded despite impact. Procedural guidance, nerve blocks, spectral Doppler diagnostics (all topics expertly covered in San Diego at AIUM 2022) lack traction despite concluding slides with imperceptible font sizes to document volumes of references!

Why isn’t the evidence enough? Perhaps we’ve taken the wrong approach? Perhaps we need to uncover barriers from our non-ultrasound using hostages and promote facilitators from our ultrasound volunteers! What’s worked at your shop?

A headshot of Dr. Daniel Theodoro, MD, MSCI.

Dr. Daniel Theodoro, MD, MSCI, is the Division Director of Washington University’s Emergency Medicine Ultrasound Program. In 2002, he completed the first Emergency Medicine Ultrasound Fellowship at North Shore University Hospital in Manhasset, New York. His team’s current projects include how to de-implement dogmatic chest x-rays after ultrasound-driven central line placement confirmation, how well COVID lung findings prognosticate future oxygen requirements, and how TEE can inform CPR quality. Tweet him @TeddyDanielz!

Interested in learning more about POCUS? Check out the following posts from the Scan:

Ultrasound Education in the Post-COVID Era

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In his book, The Innovator’s Dilemma, Clayton Christensen discusses the idea of disruptive technology. This market force that challenges industry norms can create new opportunities but also requires traditional market fixtures to adapt in order to maintain effectiveness.

Point-of-care Ultrasound (POCUS) has emerged as a disruptive technology in medical imaging. It relies heavily on education, both for new learners and also for those continuing to advance their knowledge base as skilled sonologists. As ultrasound technology improves and the scope of POCUS expands, two important facets of ultrasound education are collaboration and innovation. 

Ultrasound has traditionally been confined to specific rooms within the house of medicine. However, POCUS has grown to include a variety of specialties. Emergency medicine, critical care, hospital medicine, outpatient clinics, and even surgical specialties have all benefitted from “Ultrasound First” and the diagnostic specificity of ultrasound. But just as every disruptive technology creates challenges for traditional users, the democratization of ultrasound has required new users and traditional imaging specialties to rethink the imaging paradigm. 

Since each specialty (traditional or new adopter) comes to the table with a unique skillset and expertise, we benefit from collaboration. In the same way that a rising tide lifts all boats, cross-departmental collaboration allows for a broader understanding of the interplay between a patient’s anatomy, physiology, and ultrasound findings. 

In our institution, we have sought to use ultrasound as a tool to build bridges between departments. We have brought sonologists from various specialties together to teach anatomy with ultrasound. We have brought our ED residents to the MICU to scan patients with known pathology and MICU fellows to the ED. We have conducted cross-departmental ED/Radiology case conferences discussing the use of bedside ultrasound and traditional imaging. In each of these examples, we have sought ways to build collaborative relationships with other departments and benefit from each other’s particular perspective and experience. 

Ultrasound proficiency requires a firm foundation of both didactic knowledge and psychomotor skill. There is a significant interdependency between the classroom and the bedside. By restricting access to both spheres, COVID-19 has interrupted our normal way of living and educating and created a number of challenges to continuing ultrasound education. But, like a silver lining behind every dark cloud, the distance that COVID has created physically has drawn us together in unique ways. Distancing, occupancy limits, and virtual interactions have required us to reimagine ways of reaching learners. 

A large part of our continuing ultrasound education is a regular ultrasound lecture series. Virtual education has allowed for more flexibility with attendance. Individuals who traditionally could not attend an in-person lecture due to time or geographical constraints can now participate. We previously included learners from various departments within our institution. However, with virtual lectures, we have included students, residents, fellows, and faculty from other institutions throughout our greater region.

In addition to increasing the participant base, virtual education has allowed us to tap into a broader faculty base. The traditional model of medical education relies on in-person lectures and didactic education. Virtual education opens opportunities to include regional, national, and international experts. Prior to COVID, a visiting lecturer would have to take time away from their personal practice and travel to a particular place. Now, a speaker can attend via Zoom or other platforms. This has allowed us to invite outside experts to our educational forum. And for faculty looking to build an educational portfolio and progress through the academic ranks, virtual education allows for junior faculty to gain experience as visiting lecturers. 

As we emerge from the COVID era, I personally look forward to losing the masks, gathering together again, and seeing the word “virtual” used less ubiquitously in the English lexicon. But our imperative as ultrasound educators is to learn from the ways that COVID has changed our existing models for education and has caused us to adapt to new teaching methods. We should embrace the disruptive technologies of the past year and find ways to blend the advantages of cross-departmental, in-person learning with cross-institutional virtual education. To the extent that we are successful in this endeavor, we will find increased cohesion as a community, improved educational opportunities for our learners, and, ultimately, improved outcomes for our patients. 

Matthew Tabbut, MD, FACEP, is Director of Emergency Ultrasound at MetroHealth Medical Center in Cleveland, Ohio.

Interested in learning more about POCUS? Check out the following posts from the Scan:

The Personal Touch: The importance of human interactions in ultrasound

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As I write this, the novel coronavirus COVID-19 is spreading across the globe, inciting fear and anxiety. Aside from frequent hand-washing and other routine precautions, many leaders, officials, and bloggers are advocating for limiting person-to-person contact. This has resulted in cancelation of many professional society meetings, sporting events, and social gatherings, and has stimulated new conversations regarding working from home and virtual meetings. Although these suggestions have many clear benefits (such as the decreased burden of commuting; limiting the spread of infection), there are additional reports describing the impact loss of face-to-face interactions may have on job satisfaction, workflow efficiency, and quality.Fetzer-David-14-2

The current practice of medicine, more than ever, relies on a team approach. No one individual has the time, knowledge, or experience to tackle all aspects of an individual’s care. No one is an island. Unlike many television shows that highlight a single physician performing everything from brain surgery to infectious disease testing, the reality is that we each rely on countless other members of the healthcare team. That practice of medical imaging, ultrasound, in particular, is no different. Whether we work in a radiology, cardiology or vascular, or obstetrical/gynecology practice, the team, and more importantly the relationship between team members, is paramount to an effective and impactful practice.

As a radiologist in a busy academic center, I rely on and value my personal relationship with my team of 50+ sonographers. These relationships have been facilitated by day-to-day, face-to-face interactions, allowing me to get to know the person behind the ultrasound images. These interactions foster an environment of trust. For my most experienced sonographers, my implicit trust ultimately leads to fast, efficient and precise exam interpretations, while for sonographers I rarely work with, my index of suspicion regarding a finding is naturally heightened, impacting my confidence in my diagnosis and thus affecting my interpretation, and ultimately how my report drives patient care.

The trust goes both ways: a strong relationship also fosters honest communication whereby sonographers can come to me with questions or concerns regarding exam appropriateness, adjustments to imaging protocols, and the relevance of a specific imaging finding. The direct interaction provides an opportunity for sonographers, new and experienced, to be provided immediate direct feedback regarding their study—they can learn from me, and often I from them, making us all that much better at the end of the workday.

In addition to trust, open communication allows for users of ultrasound to take advantage of one of the key differentiating features of ultrasound compared to other modalities: the dynamic, real-time nature of image acquisition. Protocol variations can be discussed on-the-fly. Preliminary findings can be shared with the interpreter, and additional images can be obtained immediately, without having to rely on call-backs, inaccurate reports, and reliance of follow up imaging (often by other modalities). This ultimately enhances patient care and decreases healthcare costs. In our practice, we have the ability to add contrast-enhanced ultrasound for an incidental finding, allowing us to make definitive diagnoses immediately, without having to recommend a CT or MRI—this would not be possible if it were not for a personalized checkout process.

We continue to hear about changes in ultrasound workflow across the country: sonographers and physicians, small groups and large, academic and private practices have all considered or have already implemented changes that minimize the communication between sonographer and study interpreter. This places more responsibility on the sonographer to function independently, and minimizes or even eliminates the opportunities for quality control and education. Sonographer notes and worksheets, and electronic QA systems, are poor substitutes for the often more nuanced human interaction. In my experience, these personal encounters enhance job satisfaction, and the lack of it risks stagnating learning and personal drive. There have been many sonographers that have left local practices to join our medical center specifically to take advantage of the sonographer-radiologist interaction we continue to nurture.

Some elements driving these transformations are difficult to change: growing numbers of patients; increasing reliance on medical imaging; medical group consolidation; etc. Many changes to sonographer workflow have been fueled by a focus on efficiency (decreasing scan time, improving modality turn-around times, etc.). Unfortunately, these changes have been made with little regard to how limiting team member communication impacts examination quality, job satisfaction, and patient outcomes; for those of you in a position to address workflow changes, consider these factors. For sonographers yearning for this relationship, do not be afraid to reach out to your colleagues and supervising physicians—ask questions, be curious, and engage with them. Nearly everyone appreciates a human interaction, and even the toughest personality can be cracked with a smile and some persistence. In the end, it is the human interactions and the open and honest communication that not only make us better healthcare providers but happier and healthier human beings.

 

David Fetzer, MD, is an assistant professor in the Abdominal Imaging Division, as well as is the Medical Director of Ultrasound in the Department of Radiology at the UT Southwestern Medical Center.

 

Interested in reading more about communication? Check out the following posts from the Scan:

Clinical Tests Worldwide

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“A pregnancy test and a dip urine,” Dr. St. Louis responded. “Wow!” I replied in surprise. Having completed a fellowship in global health, I had learned that testing was severely limited in resource-limited settings, particularly outside of normal business hours. This was still impressive. We had just been discussing how things were going with his new job at Princess Alice Hospital and what tests were available overnight in his workplace that is located in the eastern mountains of Grenada. During weekday daytime hours, imaging is limited to plain film x-ray. Occasionally, there is an ultrasound technician also available. If desperate, the technicians can be called in from home. All other tests: blood, urine, CSF, must be batched and sent by car via a winding, serpiginous road over a mountain to the capital. If they’re lucky, you may get the test result in about 6 hours; however, most take up to 12 hours. Most advanced imaging, CT and MRI, are only available in the private sector.

I first met Dr. Daniel St. Louis just a few weeks after beginning the Masters of Emergency Medicine program offered by the University of Guyana and started with the help of Emergency Medicine faculty and Vanderbilt University. With other emergency medicine colleagues, I had spent a lot of time helping him learn to perform, interpret, and apply point-of-care ultrasound studies during his training in the Accident and Emergency Department at Georgetown Public Hospital before he returned to his native island in the south Caribbean. Dr. St. Louis immediately saw the benefit of ultrasound during his training and requested every piece of material possible to be able to master sonography.

The care that Daniel and his colleagues provide with limited testing is really impressive. But of all tests that Dr. St. Louis could be equipped with while caring for a sick patient on an overnight shift, ultrasound is uniquely valuable. Bedside ultrasound doesn’t require a technician, it is reusable, it is versatile, it provides rapid diagnosis of many critical illnesses, and it provides the diagnosis to actionable diseases where lives hang in the balance of the minutes and hours ultrasound saves. There are more significant tests: a microscope and Giemsa stain in a malaria endemic zone or rapid HIV testing at the national public health level. But when I was standing in front of a child in shock from shrapnel wounds outside Mosul, Iraq, an ultrasound probe is what I want most.

As bedside ultrasound machines continue to become more portable and more affordable, the significance of bedside ultrasound will continue to grow. This is true in a large academic tertiary medical center, in regional access hospitals in Grenada, and in critical access health posts in the most remote regions of the globe. AIUM and its members are uniquely positioned to aid in providing equipment and, more importantly, providing education and techniques to help improve the quality of bedside ultrasound as one of the most important clinical tests worldwide. Will we be up for the challenge?

If you work in a resource-limited setting, how is ultrasound most useful for you? How have you seen ultrasound incorporated into medical care in other nations? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jordan Rupp, MD, RDMS, is an Assistant Professor of Emergency Medicine at Vanderbilt University Medical Center and the Director for Global Sounds:  Ultrasound Development Project.  Read more about Global Sounds at www.globalsoundsproject.org or continue the conversation on Twitter:  @globalsounds_us.

Ultrasound Made Me the Doctor I Wanted to Be

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I didn’t come into medicine knowing much about what doctors really did. I also didn’t graduate my emergency medicine residency really believing point-of-care ultrasound (POCUS) was all that useful. Maybe it’s just a fad, I remember thinking.Minardi, Joseph J.

There were two things I did come to enjoy about medicine: making interesting diagnoses and intervening in ways that helped patients. Those were the victories and they were always more satisfying when I got to do them as independently as possible. It was great to diagnose appendicitis with a CT scan, but I had to share at least some of the credit with the radiologist.

I remember sometimes being frustrated with the fragmentation of care in American medicine. Send the patient to another facility with these services, order this imaging study by this specialist, consult this specialist for this procedure, and so on.

A few cases early in my career really brought to light these frustrations.

One was a young woman who didn’t speak English who presented to our community hospital who appeared to have abdominal pain. It took hours after getting approval to call in a sonographer, consulting with the radiologist, and eventually calling in the gynecologist from home to take her to the operating room for her ruptured ectopic pregnancy. Hours went by while her condition worsened and I felt helpless, being uncertain about her diagnosis and relying on fragmented, incomplete information from others to make management decisions. Luckily, her youth allowed her to escape unscathed, but I was frustrated with what I didn’t know and couldn’t provide for her: a rapid, accurate diagnosis and quick definitive action.

In another case, a young boy was transferred to our tertiary care center for possible septic hip arthritis and waited nearly 24 hours to undergo more ED imaging, subspecialty consultation, then wait for the availability of the pediatric interventional radiologist to perform X-ray guided hip aspiration with procedural sedation. I remember again feeling helpless and seeing the hopelessness in the eyes of his parents after seeing so many doctors, spending so many hours far from home just waiting on someone to tell them what was wrong with their son and what was going to be done to help him.

After I was asked to lead POCUS education for our residency program and began to embrace it as a clinical tool, I encountered similar cases, but now with much more satisfying experiences for me as a physician, and hopefully, presumably for my patients. Now, I routinely hear stories from my residents and colleagues that go something like Hey Joe, check out this ectopic case, ED to OR in 20 minutes with bedside ultrasound. We have had cases of suspected hip arthritis where we were able to provide a diagnosis and care plan from the ED in 2–3 hours by performing bedside US-guided hip arthrocentesis. These and numerous other cases where diagnoses are made in minutes independently by the treating clinician have convinced me that POCUS can help improve healthcare. My colleagues and I have performed diagnostic and therapeutic procedures that we never would have considered attempting before we could competently use POCUS, allowing us to provide immediate care right where and when the patients needed it.

The “passing fad” of POCUS has allowed me to make medicine and being a doctor more into what I wanted it to be: seeing patients, giving them a diagnosis, decreasing the anxiety over uncertainty, and providing relief for their suffering. I trained and practiced without the advantages of ultrasound and I have seen the positive impact it can have not only on patients but also on the health care system and my job satisfaction as well. The advantages of more immediate, efficient diagnoses, better availability of advanced procedures can all be provided in a less fragmented, more cost-effective manner when treating clinicians are armed with and properly trained to use POCUS. There’s no way I would ever go back.

If you learned how to use ultrasound after you completed your original medical education, how did it affect your career? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Joseph J. Minardi, MD, is Chief of Emergency and Clinical Ultrasound, and Associate Professor of Emergency Medicine and Medical Education at the West Virginia University School of Medicine.

The Future of Point-of-Care Ultrasound in Pediatric Emergency Medicine

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Pediatrics entices practitioners with its focus on treating illness in the youngest patients, for long-term outcomes of future growth and development. When I reflect on my own journey through Pediatrics and Pediatric Emergency Medicine, helping patients in real-time through providing the best quality care given limited information, drew me to Pediatric Emergency Medicine.

Lianne Profile FinalPediatric Emergency Medicine (PEM) focuses on providing acute care to patients from the newest newborns to teenagers. With this breadth of ages comes differing pathology, physiology, and of course differences in relative and absolute size. Integration of point-of-care ultrasound (POCUS) into PEM practice offers the clinician an added tool to provide the best possible care. Children are ideal patients for POCUS scanning as they often have slimmer body habitus, fewer comorbidities, and there is increasing interest in limiting ionizing radiation amongst all patients, especially the very young.

POCUS offers direct visualization for procedures such as endotracheal tube airway confirmation, central-line insertion, and intravenous and intraosseous access. Utilizing this clinical adjunct allows for accuracy in nerve block administration, reducing the volume used of local anesthetic and decreasing the need for systemic sedation. Visualizing fractures following reduction and assessing joints and soft tissue infections prior to decision of incision and drainage or aspiration can all be achieved using POCUS.

Because our patients vary in size, optimizing planning prior to starting procedures can help to maximize success. Risk in pediatric procedures is heightened due to variable sizing, risking too-deep insertion of needles and endotracheal tubes. Direct visualization helps to support the provider in making safe choices.

Beyond procedures, POCUS allows PEM providers to optimize resuscitation, through real-time monitoring of volume status, cardiac function, and pulmonary edema. Reassessment throughout resuscitation adds additional information to vital signs and end-organ markers as patients are treated.

As machines become increasingly accurate at more portable sizes, and as cloud storage is increasingly popular among organizations, the future of POCUS offers providers along the care-continuum the opportunity to share information and images. My hope for the future of acute POCUS would be to have pre-hospital POCUS, emergency POCUS, consultative radiology imaging, and follow-up POCUS imaging in community clinics on an integrated system allowing for shared images and progressive monitoring for long-standing conditions.

The future of POCUS is bright as innovation and technology disruption move ultrasound outside of the walls of the hospital, placing transducers in the hands of those at the bedside from the helicopter to the remote health clinic. For countries such as Canada, increased portability means increasing access for those populations most at risk of health inequity, those living in the far North and remote regions of my country, who have limited access to urban care. POCUS with added portability and technological integration can help improve access, and shared decision making between urban centers and remote regions with patient safety and privacy as a priority.

I’m excited to see where POCUS integration moves in the course of the rest of my medical career, as I look forward to being an advocate for access and clinical education in addition to being an expert that maintains clinical accountability, safety, and privacy. The promotion of these critical pillars will help determine the success of the POCUS-empowered clinical experience.

Do you use point-of-care ultrasound in pediatric practice? If so, how has it helped you? Is there another medical field you think should use ultrasound more? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Lianne McLean, MB BCh, BAO, FRCPC, is Assistant Professor at the University of Toronto; and Staff Physician and Chair of the Council of Informatics & Technology in the Division of Emergency Medicine at the Hospital for Sick Children in Toronto, Canada.

Storing Blood as a Dry Powder

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Did you know that blood can only be stored for up to 6 weeks when refrigerated? Because synthetic blood is not available in the clinic, blood supplies must be continually replenished from healthy donors. Even if there is a surge in blood donations at one point in time, 6 weeks later there could be shortages if continued donations do not meet the current demand. Blood can be frozen for a decade or more but significant challenges in processing blood for frozen storage limit this option to specific situations such as for rare blood types or military use. The freezing process currently utilizes high concentrations of glycerol to protect red blood cells during frozen storage but this compound must be removed prior to transfusion, and the de-glycerolization process is very sensitive and time-consuming. Therefore, most hospitals and medical centers utilize refrigeration for blood storage.

What if, instead of refrigerating or freezing blood, there was a method to freeze-dry blood for long-term storage as a dry powder, similar to the process used for astronaut food? This could enable long-term blood storage at room temperature, and when the blood is needed for transfusion the cells could be quickly reconstituted simply by adding sterile water. Not only would this offer another option for long-term storage, it would be particularly useful in situations where refrigeration or freezing is not available, such as in some remote medical centers or for the military in far-forward settings. In addition, this method could enable stockpiles of strategic blood reserves in order to maintain an adequate blood supply during disasters such as hurricanes, which disrupt blood donations.

Blood cells dried

Electron microscopy image of red blood cells after drying/rehydration following ultrasound-mediated loading with preservative compounds.

The idea of turning blood into a dry powder and then rehydrating it for transfusion may sound like science fiction, but could it become a reality? Can nature provide clues to help us solve this problem? There are many cases in history where significant scientific breakthroughs were achieved by studying nature. For example, the Wright brothers studied the characteristics of birds’ wings during flight to discover an effective design for airplane wings. Also, Alessandro Volta invented the battery after carefully studying the electric organ in torpedo fish. In the context of cell preservation, it has been found that some organisms can survive complete desiccation for long periods of time. For example, tardigrades and brine shrimp (“water bears” and “sea monkeys”) can be dried out and remain in a state that approaches “suspended animation” for decades, but when they are rehydrated they return to normal physiological function and can even reproduce. This led us to ask the question, if these complex multicellular animals can survive desiccation, why not individual red blood cells? Scientists have found that these organisms produce protective compounds, including certain sugars and proteins, which prevent damage to their membranes during drying and rehydration.

Unfortunately, human cells do not have the transporters in their membranes that enable internalization of the protective compounds found in organisms that can survive desiccation. Therefore, an active loading method is required. We realized that the process of ultrasound-mediated drug delivery via sonoporation could potentially be applied to solve this problem and enable delivery of protective compounds into human red blood cells. In the past, most ultrasound research has either ignored red blood cells or attempted to minimize sonoporation in these cells. But what if we could intentionally sonoporate red blood cells outside of the body in order to actively load them with protective compounds so that they could be stored as a dry powder at room temperature until needed for transfusion?

Our initial efforts to load red blood cells with protective compounds for storage as a dry powder have been promising. We prepared solutions containing red blood cells, preservative compounds, and microbubbles followed by treatment with B-mode ultrasound for ~60 seconds. After ultrasound treatment, the cells were freeze-dried and stored as a dried powder at room temperature (21–23 °C) for 6 weeks or longer. Cells were rehydrated with water and we measured up to 30% recovery of viable red blood cells. In addition, we performed electron microscopy imaging of the rehydrated red blood cells and observed evidence of normal biconcave-discoid shape. Our next steps involve testing the rehydrated cells in an animal model of acute hemorrhage in order to assess the function and safety of the red blood cells in vivo after dry storage at room temperature.

Research studies are currently ongoing and much more work remains to be done before clinical translation is possible, but if it is successful this approach could have a significant impact on blood supply, particularly in locations where refrigeration and freezing are not available. In addition, this approach could potentially enable dry storage of other cell products. As I consider the possibilities of this approach, I wonder if there are other things that we can learn from nature that could also transform medical practice.

Have you learned something else from nature that has been incorporated into your medical practice? Do you have any ideas that could potentially transform medical practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jonathan Kopechek is an Assistant Professor of Bioengineering at the University of Louisville. His Twitter handle is @ProfKope.

The Expeditious Evolution of Emergency Ultrasound Fellowships

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RJG Photo 2

Access to the internet was dial up through AOL, Bill Clinton was President, and ultrasound machines were big, clunky, and new to the emergency department. It was 1999 and I was in Long Island as a resident. As a resident, I saw the ultrasound machine lurking around the emergency department, but very few faculty seemed to know how to use it. A search of fellowships in emergency ultrasound found a single listed fellowship in Chicago, so I organized a rotation to see what ultrasound was all about.

Emergency ultrasound fellowships in the early 2000s were disconnected, isolated, and in many ways under the radar. As the ultrasound interest group president in SAEM (soon to become the Academy of Emergency Ultrasound) I heard firsthand how difficult it was for fellows to find ultrasound fellowships and how difficult it was for fellowship directors to find applicants. Partnered with Pat Hunt, we started EUSFellowships.com as a platform for fellows and programs to meet. Ultrasound became more mainstream as ACEP, SAEM, and CORD fought to have ultrasound integrated into residency training and general emergency medicine.

Eventually EUSFellowships.com evolved into the Society of Clinical Ultrasound Fellowships as a more robust organization focused on advanced training for bedside ultrasound. The first couple of emergency ultrasound fellowships started around 1997. Within 5 years there were 12 fellowships, and within 10 years there were 27. Today there are over 100 emergency ultrasound fellowships graduating more than 70 fellows each year. There are more ultrasound fellows graduating each year than in toxicology and EMS combined.

Emergency ultrasound fellows today join a large vibrant group of specialists across the United States and the world. Physicians use ultrasound to diagnose, monitor, and guide procedures everywhere from the African savannah to the neighborhoods in New York City. The initial meetings in the 1990s involved small groups getting together to discuss cutting-edge research and new applications. Now ultrasound meetings in emergency medicine involve hundreds of people discussing topics such as board certification or ultrasound program management. Research has evolved from single “we can do it too” projects to multi-center collaboratives. The change in ultrasound over the last 20 years is mind blowing.

When I interview medical students now, I ask them why they went into medicine. What do they want to achieve? One of the best answers I hear is that they want to make a difference in medicine and improve care for all patients. I feel that I have been lucky enough to witness the birth of a new subspecialty that will improve how patients are cared for in the future.

What was your initial experience with ultrasound education? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Romolo Gaspari, MSc, MD, PhD, FACEP, is the Executive Vice Chairman of the Department of Emergency Medicine at UMASS Memorial Medical Center. He has also served as the president of a number of Emergency Ultrasound Societies including what is now the Academy of Emergency Ultrasound and the Society of Clinical Ultrasound Fellowships.

Flying Samaritans, the Seed to Pediatric Point-of-Care Ultrasound

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There are some experiences in life that seem to have a tremendous impact on the person you become, and the career path you decide to take. When I started working with the Flying Samaritans in medical school, little did I know that it would change the trajectory of my career.

Kids from El Testerazo Mexico

The kids I fell in love with in El Testerazo, holding the pictures I had taken and shared with them. They came by even if they weren’t sick. Of note, they are now in their 20s with families of their own.

Since the UC Irvine School of Medicine was so close to the USA-Mexico border, the UC Irvine Flying Samaritans chapter was actually a driving chapter. Each month we drove down to El Testerazo, Mexico, to give medical care and medications to an underserved community. I immediately fell in love with the community and the children of El Testerazo, Mexico. They would all laugh at my then broken high school-level Spanish but would appreciate my trying. There was also something about the group of undergraduates (who ran the clinic), medical students, residents, and attending physicians who volunteered their time there that brought back the humanity to medicine. The experience was challenging and rewarding at the same time—to work with limited resources, but to become a trusted member of their community was priceless. Each time I went to the “Flying Sams” clinic, I remembered why I went into medicine in the first place.

During my time with the “Flying Sams,” I worked with a then Emergency Medicine resident, Chris Fox. When he told me he was going to Chicago to do a 1-year Emergency Ultrasound fellowship, I thought he was crazy.

Old ultrasound machine

The ancient beast of an ultrasound machine that we had in the “Flying Sams” clinic.

Not only was he leaving sunny Southern California, but he was going to spend a year looking at ultrasounds? When I looked at ultrasounds, I could barely make out structures; images looked like the old tube TVs from the 1980s. When Fox returned, he said, “Steph, the next big thing will be pediatric ultrasound.” Again, I thought he was crazy. But slowly, by seeing how ultrasound impacted the management of our patients in El Testerazo, I realized the brilliance in this craziness. Chris Fox’s enthusiasm and “sonoevangelism” was infectious. I think nearly everyone in the “Flying Sams” ended up eventually doing an ultrasound fellowship. Even though the ultrasound machine in the clinic was old, and images were of limited quality, we were still able to impact the medical care of this community that became near and dear to my heart.

And so it began…my passion for emergency ultrasound (now referred to as point-of-care ultrasound) and for Global Health. My initial goal was to become good at performing ultrasounds. As I quickly realized, I was one of the only people who had experience in pediatric point-of-care ultrasound. I felt a tremendous responsibility to become as knowledgeable and skilled as possible if I were going to teach others this powerful tool. After 4 years of undergraduate education, 4 years of medical school, 3 years of a Pediatrics residency, and 3 years of a Pediatric Emergency Medicine fellowship, I decided to do an additional 1-year fellowship in Emergency Ultrasound. With medical school loans looming and so many years without a “real job,” I was reluctant to do this. This California girl moved from sunny Southern California to Manhattan to embark on a 1-year Emergency Ultrasound fellowship. This was a move far outside of my comfort zone for so many reasons. And that was one of the reasons why it ended up being one of the best decisions I’ve ever made. It has been a privilege to be a part of this growing community… to take better care of the most vulnerable of patients… and to give this tool to other doctors around the world. I certainly would have never had these experiences or opportunities if it weren’t for the “Flying Sams” and Chris Fox; to both, I am forever grateful.

 Are you involved in global medical education? If so, what led to your decision to go into the field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie J. Doniger, MD, RDMS, FAAP, FACEP is the Editor of the first pediatric point-of-care ultrasound textbook “Pediatric Emergency and Critical Care Ultrasound,” and is currently practicing Pediatric Emergency Medicine and Point-of-Care Ultrasound in New York. She has additional training in Tropical Medicine and is in charge of Pediatric POCUS education for WINFOCUS Latinamerica.

Interest in Interest Groups

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Ultrasound in medical education is a powerful idea whose time has come. With its value in the clinical setting being increasingly recognized, leaders of a point-of-care ultrasound (POCUS) movement are making a strong case for introducing ultrasound early in medical training. Not only is it a useful educational tool to illustrate living anatomy and physiology, but it is also an important clinical skill- guiding procedure, improving diagnostic accuracy, and facilitating radiation-free disease monitoring. As the list of POCUS applications grows exponentially across specialties, I believe that to maximize the potential impact, it is vital to introduce this skillset early during the pleuripotent stem cell phase of a young doctor’s career.

Wagner

Looking around, there are signs this movement is here to stay. Ten years after the first medical schools began integrating ultrasound into the curriculum, an AAMC report of US and Canadian schools stated that at least 101 offered some form of ultrasound education, with the majority including it into the first 2 years of the curriculum. If one visits the AIUM medical education portal (http://meded.aium.org/home), 77 medical schools list a faculty contact person involved with ultrasound curriculum development and integration.

It should be noted that the depth of content varies from school to school, as not all institutions value ultrasound to the same degree. Recommendations on core clinical ultrasound milestones for medical students have been published and results from a forthcoming international consensus conference will help improve standardization, though there will likely be much variability until it is required by LCME or included on board exams.

It is during this time of transition that the importance of ultrasound interest groups (USIGs) cannot be understated. USIGs provide a wider degree of flexibility often not possible within a formal curriculum, quickly adapting for changes not only for meeting times and group sizes but also topics and teaching strategies. Indeed, for schools without a formal ultrasound curriculum, it is often how one gets started. For ultrasound faculty, USIGs provide fertile ground for experimenting with new teaching ideas and cultivating both student and faculty enthusiasm for POCUS at one’s institution. For senior students, USIGs can provide opportunities to participate in research projects, serve as near-peer instructors, and participate at regional and international meetings. The spread of local, student-run Ultrafest symposiums is a testament to the power ultrasound has to draw people in and the impact students can have beyond their own institution. The AIUM National USIG (http://www.nationalusig.com/) provides a nice resource for further collaboration while student competitions like AIUM’s Sonoslam or SUSME’s Ultrasound World Cup showcase ultrasound talent and teamwork in an anti-burnout, fun environment. I have no doubt that some of these exceptionally motivated students will become future leaders in the field, as some already have (http://www.sonomojo.org/).

While many of these students will pursue and jumpstart their careers in Emergency and Critical Care Medicine, students from varying backgrounds and interests are needed in USIGs. The frontier of Primary Care ultrasound is wide open and may become crucial as we see more emphasis on population medicine and cost containment as opposed to fee-for-service models. With the exception of in the ER, the utilization of pediatric ultrasound has been surprisingly lagging and more POCUS champions are certainly needed here. In addition, the early exposure to POCUS can increase comfort with ultrasound and help drive novel developments by future specialists. Some lesser-known potential examples include advancing work already underway: gastric ultrasound for aspiration risk by anesthesiologists, sinusitis and tonsillar abscess drainage for ENTs, diagnosing and setting fractures for orthopedists, noninvasively measuring intracranial pressure by ophthalmologists and neurologists, and detecting melanoma metastasis by dermatologists. Until it is more widespread, a skillset in POCUS can be a helpful way to distinguish oneself in an application process and provides an excellent academic niche. After medical school, some USIG students will go on to form ultrasound interest groups in their specialty organizations, going beyond carving out a special area of interest for themselves and helping to advance the field and shape future policies.

Similar to other enriching things like viewing art and discussing philosophy, I believe all students should be exposed to ultrasound and given the opportunity to learn this skill. While I feel strongly that ultrasound should be a mandatory component of an undergraduate curriculum, I also recognize that not all will enjoy and excel in it, and many will settle for nothing more than the bare minimum. However, I believe the USIGs help us to motivate and empower those few individuals with the passion and grit to really help propel this movement forward and show the world what is possible. This is truly an exciting time. I hope you will join us.

Ultrafest

Are you a member of an ultrasound interest group? Has it improved your skill set? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Michael Wagner, MD, FACP, RDMS, is an Assistant Professor of Medicine at the University of South Carolina School of Medicine in Columbia. There he serves as the Director of Internal Medicine Ultrasound Education for the residency program, Assistant Director of Physical Diagnosis for the undergraduate curriculum, and faculty advisor to the student ultrasound interest group. You can view his 2017 talk for the USCSOM USIG here (https://youtu.be/FfO7SXRwjLY) and an AIUM webinar with Janice Boughton on a pocket ultrasound physical exam here (https://www.youtube.com/watch?v=ywuIeoEfG1I).