Tag Archives: POCUS

Growing a POCUS Program in a Large Academic Institution: a guide and some lessons learned

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Point-of-care ultrasound (POCUS) has quickly become an area of interest within medical education. As of 2020, a total of 57% of medical schools have incorporated POCUS training within their curricula.1 Integration of ultrasound into undergraduate medical education (UME) has been shown to help students learn anatomy, physiology, and pathology in a more effective and dynamic way.2

Indiana University School of Medicine (IUSM), which has more than 1400 medical students spread across 9 campuses throughout the state, began the process of implementing a longitudinal UME POCUS curriculum in 2018. Their journey is outlined below—for a more detailed review, see Russell et al.2

Step 1:  Create a POCUS committee.  A POCUS committee was created to identify and coordinate with key stakeholders throughout the institution. This committee was composed of a program manager, student representatives, and faculty from the departments of radiology and emergency medicine. Under the direction of the Executive Associate Dean for Educational Affairs, the committee worked with the regional deans, course directors, key educators, and sponsors to identify space within the existing curriculum for POCUS.
Lesson learned: Engagement at multiple levels was key to the simultaneous integration of the curriculum across all campuses and ensuring an equitable learning experience for all.

Step 2. Consider physical space and POCUS equipment. With many learners and multiple sites, the decision was made to use handheld ultrasound devices. While imaging parameters from these devices may be suboptimal at times, decreased cost and increased portability compared to cart-based ultrasound systems proved advantageous. A check-out system was created to allow learners to easily borrow the devices for self-driven education.
Lesson learned: Handheld devices allowed for easy to stand-up educational sessions, smaller educational groups, more hands-on time, and overall greater program flexibility.

Step 3. Instructional material and modules. Because of limited classroom time, the didactic portion of the curriculum was delivered asynchronously. The curriculum was divided into a series of 16 modules designed to complement and augment the existing medical school curriculum (Figure 1). The POCUS modules paralleled the curriculum as it advanced from basic science to bedside care (Figure 2). Modules were divided into diagnostic, procedural, and symptom-based categories.
Lesson learned: Take advantage of online, self-paced learning modules. Completing modules prior to hands-on instruction minimized classroom time and maximized scanning opportunity.

Figure 1. The 16 learning modules, included in the IUSM POCUS program, divided categorically (originally published in Ultrasound J2).
Figure 2. An approach to structuring a curriculum and progressively building upon concepts throughout the UME curriculum.

Step 4. Phased implementation. POCUS was initially integrated into anatomy and targeted clerkships. These areas were ideal starting points as they had existing POCUS champions and already had some POCUS elements (obstetrics, emergency medicine, etc).
Lesson learned: Identify and leverage existing POCUS opportunities, then expand.

Step 5. Development of an ultrasound learning website. A POCUS website was created using an institutional learning management system (LMS) where all relevant information was stored. This also allowed for easy and rapid dissemination of course materials such as modules, lab facilitator guides, equipment check-out procedures, open lab times, and consent forms.
Lesson learned: Keep critical information centralized for quick access and easy updates.

Step 6. Interprofessional collaboration. Having an adequate number of proctors was a barrier to implementing the hands-on elements of the curriculum. The team increased its number of available instructors by using a train-the-trainer approach for non-POCUS-trained faculty.3  The pool of available instructors expanded to include senior sonography students, senior medical students who had previously completed an elective in POCUS, residents (emergency medicine, family medicine, and radiology), ultrasound fellows, as well as POCUS-trained faculty.
Lesson learned: Interdepartmental and interprofessional collaboration multiplies your efforts and reduces the workload.

Step 7. Continue to build upon the foundation. The team recently launched a combined graduate medical education POCUS curriculum that started with 3 targeted residency programs and will soon include more than 10 residency and fellowship programs for the upcoming academic year. The experience gained and the connections made in building the UME curriculum have made this effort within the graduate medical education (GME) realm equally successful.
Lesson learned: The success of the UME program was dependent upon effective collaboration, support from executive leadership, and strong student interest in learning POCUS.

References:

  1. Russell FM, Zakeri B, Herbert A, et al. The state of point-of-care ultrasound training in undergraduate medical education: findings from a national survey. Acad Med 2021 Nov 16. doi: 10.1097/ACM.0000000000004512.
  1. Russell FM, Herbert A, Ferre RM, et al. Development and implementation of a point of care ultrasound curriculum at a multi-site institution. Ultrasound J 2021; 13:9. doi: 10.1186/s13089-021-00214-w.
  1. Russell FM, Herbert A, Zakeri B, et al. Training the trainer: faculty from across multiple specialties show improved confidence, knowledge and skill in point of care ultrasound after a short intervention. Cureus 2020; 12:e11821.

Daniela Lobo, MD, FAAFP, is an Assistant Professor of Family Medicine and POCUS Fellow at Indiana University School of Medicine.
Josh Kaine, MD, is an Emergency Medicine POCUS Fellow at Indiana University School of Medicine and future ultrasound faculty at IUSM.

We invite you to comment below or on Twitter (@IUEM_ultrasound) and share with us what challenges or successes you’ve faced while trying to implement a POCUS curriculum at your institutions, residencies, student clerkships, or electives.

End-of-Residency Perspective on Early Ultrasound Education

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I remember clearly the first day I ever held an ultrasound probe. It was my second week of medical school, I knew next to nothing about medicine, and my faculty member turns to me and enthusiastically says “oh look, you have a few thyroid cysts.” I, of course, immediately thought a few things. First, how many are there, how big are they, what do I need to do, could it be cancer, and why is the faculty member so nonchalant about this.

The next thing I thought was “what is a thyroid”.

After the initial and very clearly unnecessary panic was over, I thought to myself that it was very interesting we were scanning things before we were taught about them in class. Throughout my training, I have come to realize how lucky I was to get such early exposure to ultrasound training and teaching. At Eastern Virginia Medical School, ultrasound was integrated into all aspects of the curriculum. This started in anatomy lab, continued into our second-year courses in pathology, and was a crucial part of 3rd year rotations where each rotation had several portable ultrasounds for students to use to scan. In the Family Medicine clerkship, we were tasked with scanning multiple people for AAA, and on surgery, we had to get 5 images of cholelithiasis. By the 4th year, faculty were using ultrasound to do procedural training and students were in the trauma bay performing FAST exams for the team. Although I thought this was the norm, I quickly found out on the interview trail that this experience separated me from a lot of my peers.

A selfie of a very young David sent to his clerkship director as proof he did his scans for the rotation.

In residency, we had a point-of-care or POCUS-centered curriculum. Although we all got the same instruction, I felt like my previous experience, and most of all my comfort with the probe, made me into the “ultrasound guy” of my program. While the immense clinical utility is not lost on any of my peers, the amount of time it takes to become comfortable just did not fit into the time constraints of residency.

While I do not think ultrasound can be filed under “you can’t teach an old dog new tricks,” I do strongly believe that integrating it into medical education early on is crucial for the future of medicine. Based on my conversations with colleagues at different schools and institutions, often, ultrasound training is saved for residents and fellows, and it really shouldn’t be. Although, this surely is based on several factors including class size, cost, requirement for specialization (eg, prenatal ultrasound for OB/GYN, MSK ultrasound for Sports Medicine and Orthopedics), and availability of sufficient machines.

One of the most frustrating things for me is the train of thought that imaging is ruining the art of the physical exam. While yes, many people will get a CT of their abdomen and pelvis in the ED, the dynamic and live view that ultrasound provides is invaluable in learning about anatomy. Multiple studies, including one that I have worked on, have shown that a longitudinal and integrated ultrasound curriculum improves procedural and physical exam skills. Many of these studies show that the biggest effect is when it is started early in training.

After being the confused MS1 who was freaking out about his thyroid cysts (which since have gone away by the way), and being slightly frustrated at the time that more work and learning was on my plate, it’s abundantly clear to me now that this is the direction that medical education needs to go. Every first-year medical student at every institution should have their hands on probes throughout their first year, especially while learning anatomy. My challenge to medical school leadership is to find a way to incorporate or expand on ultrasound in their curriculum. At first, your students will not be confident, and they will feel like they don’t know what they are doing, but it CAN and it WILL help in the long run. It certainly did for me.

David Neuberger, MD, is currently a 3rd year Family Medicine Resident at Emory University in Atlanta, GA. He will be pursuing a Primary Care Sports Medicine fellowship at the University of Louisville this upcoming year and has a special interest in ultrasound and ultrasound education.

How I Brought Point-of-Care Ultrasound (POCUS) to My Family Medicine Department

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As I demonstrate a handheld ultrasound (US) machine to the eager medical students in our clinical simulation laboratory today, I am struck by a vivid recollection of my own first time seeing a handheld US machine. I was a 4th year medical student on an away rotation at a rural hospital in my home country of Peru. A visiting foreign obstetrician produced an amazing small machine, detecting fetal malposition when unsatisfied with palpation with Leopold’s maneuvers alone.

My fascination with the clinical utility of bedside US began that day and has continued through my move to US postgraduate training in family medicine, a geriatric medicine fellowship, academic faculty roles, the completion of an accredited POCUS fellowship, and right through to my current passion for growing POCUS use within family medicine practice.

I have learned so much along the way, have been helped by so many mentors and colleagues, that I write today to share my POCUS journey in the hopes that my story may be useful to others.

In 2018, I joined the department of Family Medicine at the University of Michigan in Ann Arbor (AAFP). The AAFP had recently released its novel POCUS curriculum guidelines for family medicine physicians, and the department was in search of a champion to lead the development of a POCUS program for our department. I was fortunate to be chosen for this role and over the intervening 3 years have had the privilege of working with several wonderful, enthusiastic colleagues across our department, our institution, and on a national scale through the AAFP’s POCUS interest group.

Early on in my role as POCUS champion, I realized that to be successful with this project, I was going to need a lot of help from a lot of people! My first stop (along a long journey) was to ask my department chair for time and resources. He readily obliged, providing me with the protected time to do an established accredited POCUS fellowship (which luckily was available through our emergency medicine department) and important administrative resources, which were also vital as we developed our program.

During my yearlong fellowship, I worked hard to become a clinical sonographer, educator, academic leader, and administrator in US. These newly acquired skills have been invaluable since assuming the role of Clinical US director for my department. There have been many challenges and administrative headaches—who knew that selecting and purchasing ultrasound machines could be so complicated?!?—but countless successes.

In terms of successes, we have defined minimum credentialing requirements for POCUS use, defined pathways for faculty interested in training in POCUS, and obtained hospital privileges for the same from our department. We have developed billing for our clinical POCUS use in ambulatory care as well as electronic health record order sets and templates for easy documentation. With regard to the POCUS curriculum that we initially set out to create, we now have a formal POCUS curriculum for family medicine residents as well as an intensive US track for residents interested in a more in-depth POCUS educational experience. Additionally, I am so excited that we will be welcoming our first Advanced Primary Care US fellow for a one-year fellowship this July.

It has not always been easy, but I have been so fortunate with wonderful supportive departmental leadership and fantastic emergency medicine colleagues who are always eager to help with advice on regulatory or administrative requirements. Developing the POCUS program for our department has taken a lot more time than I initially anticipated, and at times, the process has proved tedious. There certainly have been times when I have doubted if it has been worth the time and effort and doubted that colleagues share my vision for the potential POCUS offers for improving our patient care in family medicine or whether they see it as a burden, yet another thing to learn. However, the excitement I felt the first time I saw the handheld US those (many!) years ago in Peru, is reflected in the excitement I see in the faces of the medical students here in the clinical simulation lab today. This shared enthusiasm and passion for POCUS tells me that in the end, it truly will have been worth it.

An US track resident in training.
An US track resident performing US as part of training.

Juana Nicoll Capizzano, MD, is a Clinical Assistant Professor and Clinical US Director of Family Medicine at Michigan University.

Interested in learning more about developing ultrasound education? Check out the following posts from the Scan:

Getting Sonography Students Hands-on Experience

Ultrasound Education in the Post-COVID Era

Sink or Swim? Modifying POCUS Medical Education Curriculum During Coronavirus Pandemic

Teaching Point-of-Care Ultrasound

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:

Point-of-Care Ultrasound for Internal Medicine: Don’t Forget the Basics

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As specialists in General Internal Medicine, we are excited to see the benefits of incorporating point-of-care ultrasound (POCUS) when assessing medical patients with complex, multi-system disorders. For example, in a patient with heart failure with reduced ejection fraction and chronic obstructive pulmonary disease (COPD) who presents with dyspnea and is found to have diffuse wheezing on auscultation, a number of possible diagnoses exist. Using basic POCUS techniques, findings of asymmetric B-lines, focal pleural irregularity, cardiac findings that seem unchanged from baseline, and a small, collapsible inferior vena cava, increase our suspicion that an infectious precipitant exacerbating the patient’s COPD is the presumptive diagnosis, rather than a primary cardiac cause.

When applied appropriately, POCUS provides real-time data previously not readily available at the bedside. This data can narrow the differential diagnosis [1] and guide intervention. Such benefits of using POCUS to assess medical patients are increasingly known [2–4].  Although new and advanced applications often predominate in the spotlight, basic applications can add a significant amount of information to assist in the care of our patients [5]. The important role that POCUS can play in evaluating medical patients has recently been recognized by the American College of Physicians and Society of Hospital Medicine [6, 7].

As medical educators, we are equally excited about how POCUS can revolutionize bedside teaching—we have seen this tool provide learners with the opportunity to inspect and then confirm the exact location and height of the jugular vein, see then feel a pulsatile liver secondary to severe tricuspid regurgitation, and percuss then visualize a sonographic Castell’s sign [8]. These “aha” moments when our learners see these maneuvers brought to life are incredibly rewarding. However, the excitement that POCUS brings sometimes needs to be balanced by caution.

Despite POCUS being relatively easy to learn, there are multiple pitfalls. The need to apply minimal criteria when acquiring and interpreting images cannot be understated. Just as important as (if not more important than) correctly identifying a positive finding is the ability to recognize when a scan does not meet minimal criteria. Communicating and teaching these limitations to new POCUS users is of paramount importance. Beyond image acquisition and interpretation, achieving competence in clinical integration requires time, repetitive practice, and feedback. As POCUS educators, we frequently see learners flock to advanced applications, such as advanced hemodynamics and detailed cardiac valvular assessments, without necessarily first mastering the basics. Our experience has been that the yield for many of these advanced applications is not high, but the cognitive load in learning them—especially before mastering the basics—is. 

Our approach to using and teaching POCUS is to ensure that we ourselves maintain an appropriate amount of curiosity and humility. We continue to spend time tweaking image acquisition techniques and increasing our understanding of the appropriate uses and limitations of POCUS. This includes expanding our knowledge of the many reasons for false positives and negatives, ensuring our ability to recognize technically limited studies, and maintaining a commitment to finding, applying, and developing the evidence-base to support the use of POCUS for internal medicine. Balancing the tension between experimenting with advanced applications and mastering basic POCUS is sometimes challenging. The steep learning curve of basic POCUS can fool many into thinking mastery has been achieved when there are additional pitfalls to learn.

While we do not wish to dampen learner enthusiasm for high-level applications, we believe there are ways to build learner enthusiasm around basic POCUS. First, we ensure that learners are challenged with cases where clinical integration is complex and nuanced. Emphasis on patient safety and outcomes can help emphasize the need to master basic applications. Second, as educators, we should model a commitment to lifelong learning. Regularly identifying then closing learning gaps can help avoid the illusion that POCUS mastery has been achieved, when in actuality, even basic POCUS applications need to be continually refined and thoughtfully integrated in each unique clinical scenario. This, in addition to encouraging higher-level learners to take a deep dive into high-level applications to appreciate the challenges of these advanced scans, can help maintain while also balancing the excitement of integrating POCUS into the care of complex medical patients. 

REFERENCES

  1. Buhumaid RE, et al. Integrating point-of-care ultrasound in the ED evaluation of patients presenting with chest pain and shortness of breath. Am J Emerg Med 2019; 37(2):298–303.
  2. Filopei J, et al. Impact of pocket ultrasound use by internal medicine housestaff in the diagnosis of dyspnea. J Hosp Med 2014; 9(9):594–597.
  3. Razi R, et al. Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. J Am Soc Echocardiogr 2011; 24(12): 1319–1324.
  4. Mozzini C, et al. Lung ultrasound in internal medicine efficiently drives the management of patients with heart failure and speeds up the discharge time. Intern Emerg Med 2018; 13(1):27–33.
  5. Zanobetti M, et al. Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest 2017; 151(6): 1295–1301.
  6. Soni NJ, et al. Point-of-Care ultrasound for hospitalists: A position statement of the Society of Hospital Medicine. J Hosp Med 2019; 14: E1–E6.
  7. Qaseem A, et al. Appropriate use of point-of-care ultrasonography in patients with acute dyspnea in emergency department or inpatient settings: A clinical guideline from the American College of Physicians [published online ahead of print April 27, 2021]. Ann Intern Med. doi: 10.7326/M20-7844.
  8. Cessford T, et al. Comparing physical examination with sonographic versions of the same examination techniques for splenomegaly. J Ultrasound Med 2018; 37(7): 1621–1629.

Janeve Desy, MD, MEHP, RDMS, and Michael H. Walsh, MD, work in the Department of Medicine at the University of Calgary; Irene W. Y. Ma, MD, PhD, RDMS, RDCS, works in the Department of Medicine and Department of Community Health Sciences at the University of Calgary.

Want to learn more about POCUS for General Internal Medicine? Check out the following resources from the American Institute of Ultrasound in Medicine (AIUM):

POCUS in Primary Care: Advice for Incorporating Ultrasound into the Clinic

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The utility of point-of-care ultrasound (POCUS) is readily apparent in a busy Emergency Department (ED) or Intensive Care Unit. Now, as healthcare in the U.S. changes and decentralizes, widespread POCUS in primary care is poised to show its value to medical systems in a way that will eclipse its impressive origins in hospitals. However, there are many reasons primary care ultrasound hasn’t taken off…yet. Among them is that effectively incorporating POCUS into a clinic can be hard work with many upfront challenges. The following is some advice on overcoming these challenges, focusing on 3 areas.

  1. Determine your desired scope of practice and manage expectations
  2. Get really good at POCUS
  3. Optimize your clinic POCUS workflow

1. Determine your desired scope of practice and manage expectations

Learning to use ultrasound is very similar to learning a musical instrument—you don’t jump in with Chopin, you start off by playing Chopsticks or practicing chords. When determining their intended POCUS scope of practice, outpatient clinicians need to consider that the things they are most interested in doing right away might be some of the more technically demanding or challenging things to learn. Here are some good examples of common outpatient POCUS goals and more appropriate starting points for beginners:

Body RegionAspirational POCUS ApplicationAppropriate POCUS Starting Point
AbdominalGallstones, Cirrhosis, AppendicitisAscites
CardiacLVH, Pulmonary HypertensionPericardial Effusion
PulmonaryPneumoniaPleural Effusions and Pulmonary Edema
MusculoskeletalRotator Cuff TearsKnee Effusion

Furthermore, even if you appropriately start small and easy, chances are you will at some point perceive that you are terrible. This is normal and experienced by many POCUS experts when they first started. Keep at it, and ensure you have a marathoner’s mindset; remember it’s no quick sprint and requires a stepwise approach. You can learn more about a specific approach to teaching and a framework for growing a POCUS skillset for generalists (PEARLS) by watching the AIUM webinar, “PEARLS: A Physical Exam with Pocket Sized Ultrasound for Routine Use,” here: https://youtu.be/ywuIeoEfG1I

2. Get really good at POCUS

Easy as that, right? Unfortunately, learning POCUS in the clinic is HARDER than learning POCUS in the hospital setting. The time constraints are just as bad as in the ED and, generally, the pathology is much less frequent and more subtle when present. Obtaining cardiac windows in the patient who can’t get out of their wheelchair or rollator let alone climb up to the exam table is not an uncommon circumstance. So how do you get really good under these circumstances? Three key interconnected principles dominate the philosophy we try to instill in our learners as part of our training:

  • Scan Routinely
  • Practice Deliberately
  • Track Your Experience (Build Your Portfolio)

Scan Routinely is probably the most controversial of these, and for me, also the most important. The routine performance of “educational” scans during residency, fellowship, or other training period is the bedrock for successful training and is generally accepted in the POCUS community. This allows one to practice deliberately and pursue a path towards mastery.

The number 1 biggest mistake I see in the early plateaued POCUS learner is they are only performing scans if they feel it is clinically indicated or they have a specific clinical question they expect POCUS to help them answer. If you are not routinely using POCUS you will likely not achieve or maintain the experience where your POCUS skillset will be clinically useful to you.

My threshold for incorporating ultrasound into my evaluation of patients is probably much lower than other POCUS users, and my experience has been that this has helped me tremendously. This experience has supported the perspective that POCUS should be viewed as a vital clinical skill to be perpetually maintained and improved upon, not a separate and distinct diagnostic test to be brought out only when patients fit into narrow predefined boxes.

Finally, even if you do not incorporate images into the EMR or bill for your exams (and there are many reasons why you should not do this early on), you should routinely save your images and build a portfolio. Committing your interpretations to a log, on paper or electronically, allows you to attain vital feedback through your longitudinal experience and patient follow-up. It also allows you to more easily seek expert mentorship, teach others, and can serve as inspiration if your motivation or progress seems to drop off.

3. Optimize your clinic POCUS workflow

Like many aspects of clinic, part of optimizing your POCUS workflow involves training your staff. In many ways, it helps to treat the POCUS device like the clinic EKG machine. If you know you will likely include POCUS because of the chief complaint (eg, dyspnea, flank pain, or lower extremity swelling) have staff put the patient in the most suitable room and ensure they are properly undressed/draped in advance. Train staff to be comfortable handling the device, cleaning it, and setting it up in the room with patient information entered in (if applicable). If you unexpectedly determine POCUS is needed during an encounter but setup is suboptimal, see another patient while the patient and room are prepared. Also, consider restructuring how you examine patients. Often time constraints do not permit the traditional order of history -> traditional examination -> ultrasound examination, and you will be more efficient by incorporating ultrasound sooner and blending history and pertinent traditional exam maneuvers along the way.

Finally, when first starting off, when incorporating routine scanning into your workflow, keep a narrow focus and a set time limit (<5 minutes). Don’t be shy about using an alarm on your phone to keep yourself honest. You may need to focus on obtaining a single high-quality view, and then add additional views as you’re able while still staying under time. Taking 20 minutes to perform POCUS in the middle of a packed clinic is another common mistake that can torpedo a workday and create negative associations that increase reluctance to practice and utilize POCUS.

Once you obtain some basic skills at POCUS and have a good clinic workflow, you’ll quickly get a few early saves and successes that enhance your dedication and propel you forward. Before long, you will wonder how you ever did without it!

Mike Wagner is looking to the camera while semi recumbent on a patient bed. He is holding an ultrasound transducer in his right hand and his pants leg has been pulled up to bare his knee.
Mike Wagner, MD, FACP, FAIUM, during a remote/virtual teaching session.

Mike Wagner, MD, FACP, FAIUM, is an Associate Professor of Medicine at the University of South Carolina School of Medicine in Greenville.

Want to learn more from Mike Wagner? Check out these resources from the American Institute of Ultrasound in Medicine:

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:

Sink or Swim? Modifying POCUS Medical Education Curriculum During the Coronavirus Pandemic

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Modifying a point-of-care ultrasound (POCUS) medical education curriculum initially designed for 4-year matriculation into a 3-year experience is undoubtedly challenging. This 1-year shortening, combined with the added constraints of mandated social distancing guidelines of the coronavirus pandemic, caused us to search for concrete answers to these new directives that would lead us to either sink or swim in this new ocean of learning.

Claude Bernard, a 19th-century French physiologist, remarked that “it is what we think we know already that often prevents us from learning.” This educational concept was true with our efforts to modify a successful ultrasound in medical education curriculum and transform it into a case-based learning approach for a condensed 18-month pre-clerkship ultrasound curriculum.

How we had conducted ultrasound labs previously would have to be revisited, revised, and revamped to transform the curriculum successfully.

Planning began to modify the ultrasound curriculum for the 18-month pre-clerkship experience approximately 2 years before the pandemic was even on the horizon. In-person meetings were held with fellow faculty to discuss and debate the patient-centered learning course’s mission and goals and where the ultrasound curriculum would be housed. Our discussions took place with ease, and ideas for collaboration easily flowed. Plans were made for in-person, hands-on scanning where students scanned each other, volunteers, or standardized patients, without giving any thought to the physical contact.

There was no thought to the exam rooms’ square footage or how students would enter and exit the ultrasound center. Live introductory lectures at the onset of each lab were planned for 25–30 students to introduce the case and review the scanning techniques and logistics for each lab session. The planning included no discussion of online learning or simulated scanning for students from a remote location. Ultrasound instruction would proceed into the new curriculum with a slight modification to how ultrasound content had been previously delivered.

Then, while finalizing our plans for a start date of August 2020, all in-person instruction was suspended for our institution. It was mid-March, and we had a nearly solidified sketch of the ultrasound lab logistics and learning methods for the inaugural class of the 3-year medical school and the 18-month pre-clerkship curriculum.

Nevertheless, that suddenly changed, and the uncertainty of instructing anyone in-person to do any part of the curriculum was up for discussion. The faculty was mandated to work from home away from the ultrasound center with its hand-held systems, full-size ultrasound machines, and simulation capabilities. Student interactions were reduced to phone calls, emails, and video interactions within online course offerings as each student cohort was scattered throughout the 159 counties of our state.

Learning to conduct curriculum meetings through online platforms filled our days. Trying to accomplish fully online ultrasound electives with a plethora of students and revamp the new ultrasound curriculum within the changing coronavirus guidelines stayed on our minds as we struggled through the spring and early summer.

Nevertheless, we made it!

When the inaugural class of the new pre-clerkship curriculum began, we laid out a plan to keep students, staff, and faculty safe through the 3W’s: wearing a mask, watching physical distance, and hand washing.

Facilities management personnel had surveyed our ultrasound exam rooms and learning spaces and posted how many students could be in each room. Hand sanitation stations and masks were made available for students as they entered the ultrasound center. Signage and arrows were erected to direct students in and out of the ultrasound center in a one-way fashion. An online meeting platform was set up in each exam room for students to hear live instruction before beginning the lab. Instructors utilized a laser point at each room’s door to direct student scanning and maintain social distancing. Students used hand-held ultrasound equipment with image transfer capabilities to obtain images needed to complete their online case-based ultrasound assignments. Although these safety measures were not visualized in our early curriculum planning meetings, the ultrasound curriculum was successfully delivered!

While we did not meet the goal of remote hands-on ultrasound instruction for all ultrasound labs during the pandemic, we learned to conduct in-person ultrasound scanning labs safely and effectively within a new accelerated medical school curriculum. The constraints and trials of a global pandemic did not preclude us from putting aside what we already knew and navigating a new course into the future!

Headshot photograph of the post author, Rebecca J. Etheridge. She is shown in front of a gray background wearing a blue suit jacket and has shoulder-length red-brown hair.

Rebecca J. Etheridge, EdD, RDMS, is an assistant professor at the Medical College of Georgia at Augusta University.

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

The Role of Musculoskeletal Ultrasound in Sports Injuries

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Approximately 20% of the U.S. population engaged in sports or exercise on a daily basis from 2010–2019.1 As expected, exercise and sports-related injuries are common, not only in the elite athlete but also in the general population. These injuries frequently lead to sport participation absence (SPA) and often, contact with the health care system. Although history and physical examination are the primary tools of diagnosis, musculoskeletal ultrasound (MSK US) has become the “stethoscope” for evaluation of sports medicine patients.

Even though MSK US has been widely used in Canada and Europe for years, the dramatic utilization increase in the United States has only occurred over the last two decades.2, 3 Between 2003 and 2015, there was a 347% increase in total MSK US volume within the Medicare population.3 The growth in subspecialties such as physical medicine and rehabilitation, rheumatology, and sports medicine has outpaced the growth in radiology. This Point-of-Care Ultrasound (POCUS) by clinicians may help facilitate diagnosis, expedite treatment planning, and reduce patient wait time and number of visits by offering one-stop clinics. 

Cristy Nicole French, MD
Cristy Nicole French, MD

POCUS can be quite useful to evaluate sports injuries. Propelled by advances in technology, the advent of compact, portable, and more affordable ultrasound machines may facilitate prompt diagnosis of sports injuries on the field and in the training room. The real-time nature of ultrasound provides the opportunity to interact with the athlete and correlate symptoms with sonographic findings. Patients enjoy this opportunity to “share their story” and often provide critical information to the diagnostic puzzle. They also appreciate the immediate findings the physician may be able to provide at the time of imaging. In fact, most patients actually prefer ultrasound to MRI.4 Other unique advantages of MSK US for sports imaging are the ability to easily assess the contralateral side as a control and the capability for dynamic imaging. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies.4 Sports clinicians often encounter a treatment gap for a substantial percentage of young, active patients with a strong desire to return to activity, yet for whom conservative measures have failed and surgery is not indicated. Fueled by media coverage of the treatment of high-profile professional athletes, the field of orthobiologics has exploded in recent years. Ultrasound can provide target localization during administration of a wide array of injectable agents (prolotherapy, autologous whole blood, and platelet-rich plasma) in addition to image-guided peritendinous corticosteroid injections, tendon needling or fenestration, and even percutaneous ultrasonic tenotomy (Tenex).

With the development of high-frequency transducers, MSK US has equal diagnostic accuracy to magnetic resonance imaging (MRI) for evaluation of many superficial tendon and ligament abnormalities. In the current era of cost containment, the utilization of MSK US as an alternative to other more expensive imaging modalities may represent an effective way to save healthcare dollars.5, 6 However, many issues related to accuracy, observer variability, and high-quality training need to be considered, aside from pure economics, to ensure that MSK US is ethically and adequately performed in the best interest of patient care.

As any of us who have picked up a transducer know, some of the most significant disadvantages of ultrasound are the relatively long learning curve and inherent operator dependence. These challenges are compounded in MSK US by the complex anatomy, pathology, and terminology not often included in general ultrasound education programs. Dedicated training and standardized technique can minimize these limitations. Many subspecialty residency and fellowship programs have recognized the necessity of standardized, high-quality training and have strategically designed curricula to become proficient in the core competencies of MSK US.

In recent years, quantitative ultrasound methods, such as shear-wave elastography (SWE) and contrast-enhanced ultrasound, have emerged as an adjunct tool to standard B-mode imaging in the evaluation of various structures throughout the body. In particular, SWE has seen an exponential increase in the number of musculoskeletal applications. Shear-wave elastography can assess tissue stiffness by applying a mechanical stress that generates shear waves, which then travel through the tissue at a speed proportional to its stiffness. By quantifying mechanical and elastic tissue properties, SWE may provide important information about pre-clinical injuries in musculoskeletal tissues as well as tissue healing after injury. Although SWE is FDA-approved on most ultrasound platforms, its use for clinical imaging in musculoskeletal ultrasound has lagged behind research due to lack of standardization in study protocols, techniques, and outcomes measures. Nonetheless, SWE has a promising role in the future of ultrasonography in sports medicine and may help practitioners to better estimate injury severity and individualize the retraining plan for the injured athlete.

References

  1. Hauret KG, Bedno S, Loringer K, Kao TC, Mallon T, Jones BH. Epidemiology of Exercise- and Sports-Related Injuries in a Population of Young, Physically Active Adults: A Survey of Military Servicemembers. Am J Sports Med. Nov 2015;43(11):2645-53. doi:10.1177/0363546515601990
  2. Sharpe RE, Nazarian LN, Parker L, Rao VM, Levin DC. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. J Am Coll Radiol. Feb 2012;9(2):141-6. doi:10.1016/j.jacr.2011.09.008
  3. Kanesa-Thasan RM, Nazarian LN, Parker L, Rao VM, Levin DC. Comparative Trends in Utilization of MRI and Ultrasound to Evaluate Nonspine Joint Disease 2003 to 2015. J Am Coll Radiol. Mar 2018;15(3 Pt A):402-407. doi:10.1016/j.jacr.2017.10.015
  4. Nazarian LN. The top 10 reasons musculoskeletal sonography is an important complementary or alternative technique to MRI. AJR Am J Roentgenol. Jun 2008;190(6):1621-6. doi:10.2214/ajr.07.3385
  5. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: medicare use, costs, and potential for cost substitution. J Am Coll Radiol. Mar 2008;5(3):182-8. doi:10.1016/j.jacr.2007.07.016
  6. Bureau NJ, Ziegler D. Economics of Musculoskeletal Ultrasound. Curr Radiol Rep. 2016;4:44. doi:10.1007/s40134-016-0169-5

Dr. Cristy French (Twitter: @cristy_french) is an Associate Professor in the Division of Musculoskeletal Radiology at Penn State Health Milton S. Hershey Medical Center. She is the Director of Musculoskeletal Ultrasound as well as the Musculoskeletal Fellowship Director.

Point-of-Care Ultrasound for Pregnant Patients?

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Point-of-care ultrasound, or POCUS, has become fully incorporated into almost every aspect of clinical care over the past 5 years. COVID-19 has further solidified the use of POCUS for the evaluation of dyspnea and cough given its portability. But what about the use of POCUS for a woman during pregnancy?

Ultrasound has been consistently employed to evaluate the fetus in all 3 trimesters. There is another patient, though; the mother! Rising maternal morbidity and mortality secondary to cardiovascular disease requires the obstetrical care provider to employ point-of-care clinical assessment that targets the maternal cardiovascular system.  This is the problem and the solution may be “getting a CLUE” by implementing cardiac limited ultrasound evaluation (CLUE) at the bedside as suggested by Kimura et al.

In contrast to fetal imaging, which utilizes higher frequency transabdominal and transvaginal ultrasound probes, penetration of the chest wall requires a lower frequency probe (2–4 mHz). Ideally, a low frequency probe that is compatible with most commonly used obstetrical equipment would facilitate ease of utilization. The CLUE protocol employs the following views: parasternal long axis view, lung anteroapex view, lung posterolateral base view, subcostal view, and right sub-xyphoid view. These views allow the clinician to evaluate the patient for pathophysiologic findings including the presence of pleural or pericardial effusion; abnormal contractility, chamber enlargement, and valvular dysfunction. Assessment of the size and collapsibility of the inferior vena cava can be a noninvasive marker of right-sided filling pressures to evaluate volume status in an oliguric patient with preeclampsia.

I propose that CLUE be extrapolated from the non-pregnant patient population for applicability in the pregnant patient population. This may be particularly relevant in certain scenarios including: triage of pregnant women with cardiac symptoms in an outpatient or in-patient setting as an adjunct to the physical exam; and labor and delivery units with lack, or limited immediate availability, of formal echocardiography. While anecdotal case experience suggest utility, formal studies designed to compare CLUE in pregnancy to the gold standard of transthoracic echocardiography will confirm the feasibility of CLUE in this unique population. Even though obstetricians are trained to perform obstetrical and gynecologic ultrasound, and are well versed with the existing ultrasound equipment on their units, additional training may be required. In addition to obstetrical care providers, other clinicians, such as emergency room and internal medicine providers, may also perform CLUE to assess the maternal cardiopulmonary system.

Limitations of point-of-care cardiac examination of the heart include both patient characteristics and technique. Large body mass size and enlarged breast tissue common in pregnancy can lead to imaging acquisition challenges. Off-axis imaging technique can lead to false positive or false negative diagnoses. Patient positioning should be optimized and shifted to left lateral tilt to accommodate aortocaval compression.

CLUE demonstrates potential as an innovative diagnostic point-of-care technique that can be adapted to maternal use. Timely future clinical studies that compare CLUE with formal echocardiography during pregnancy will further clarify its feasibility and full utility in the clinical arena as a tool to combat rising maternal morbidity in the new millennium.

  1. Kimura BJ, Shaw DJ, Amundson SA, Phan JN, Blanchard DG, DeMaria AN. Cardiac Limited Ultrasound Examination Techniques to Augment the Bedside Cardiac Physical Examination. J Ultrasound Med. 2015;34:1683–1690.

Carolyn M. Zelop, MD, is a Director of Perinatal Ultrasound and Research at The Valley Hospital, Ridgewood, New Jersey; a Clinical Professor of Ob/ Gyn at NYU School of Medicine; and she is a senior member of the AIUM and the ACOG rep to women’s imaging for ACR.

Interested in learning more about ultrasound and pregnancy? Check out the following posts from the Scan: