Who Has Time to Scan?

Posted on June 20, 2017 by aium1952

When I arrived to my shift in the Emergency Department one Thursday, there were 5 unassessed patients on my side with more than 25 in the waiting room, some waiting for hours to be seen. Anyone who works in a busy practice knows the pressure to expeditiously evaluate these patients, and point-of-care ultrasound (POCUS) may be the last thing on your mind.

However, when used properly, POCUS is a time saver. It can lead us to the diagnosis faster, allow for next-step downstream testing, and alert our colleagues in other specialties early that we might need them soon, perhaps even occasionally saving lives.

The excuses to not do an ultrasound are many. How do I fit it into my busy practice? The question is: truly how do I not?

Have the equipment easily accessible.

Searching for an ultrasound machine can be extremely frustrating and a disincentive to using it. No one likes to walk around and search every patient room before you even start to scan.

Because of this, every area should have their designated machine with a home base that is clearly marked and known to everybody. There are additional smart ways to ease this process. We are using a Real Time Location System with RFID technology where equipment is easily located on a tracking board. Other institutions can page an assistant through their EMR to set up the ultrasound in the patient room. Though more cost-intensive, some have chosen to have a wall-mounted machine in every room.

Location board

Bring the machine with you.

Don’t be lazy. There are many patient complaints such as shortness of breath, flank or upper abdominal pain, first trimester bleeding, or eye problems where I am likely going to do an ultrasound study. In these cases, I will bring the machine into the room when first meeting the patient, rather than excuse myself to get it later. Through this, the traditional fragmentation of patient evaluation—ordering a test and waiting for the results—becomes streamlined and sometimes provides the definitive answer immediately.

Rethink your work-flow.

It does not help to bring the ultrasound system with you if you first need to place an EMR order. Although institution-specific, some have found ways to break up the traditional work-flow (order > worklist > scan), allowing evaluation of patients right away. This requires a discussion with your IT department and administrator but can enable you to rapidly use ultrasound at the bedside.
Also get in the habit of doing an exam the same way every time and maybe set up your machine with predefined labels. You will be surprised how much more efficient you will be and how the quality of your scans will improve with repetition.

Have learners leave the machine in the room.

Our more senior trainees are very versed with ultrasound and usually can get high-quality images without much hands-on direction. If you have learners at different stages, I highly recommend having them leave the ultrasound machine in the room after completing an exam. You can then review their study right in the room and obtain more views as needed. This avoids setting up the equipment again just for a few additional images.

Keep equipment on the machine.

Having commonly-used supplies on the machine can reduce frustration of going in and out of the room. The most common ultrasound-guided procedure at our facility is IV access. For this reason, we stock the special catheters as well as sterile gel packets on the machine.

Recall the last time you weren’t lazy, rolled the ultrasound machine into the room with you and found the ileocolonic intussusception and asked the pediatric radiologist to stay late to do the air contrast enema, or the surgeon to take the patient to the OR with a ruptured abdominal aortic aneurysm (AAA)? Perhaps it was as simple as knowing it was acute cholecystitis and not ordering the contrast CT scan, sparing the young person contrast and radiation. If I can do it on a busy night, so can you.

Do you have other tips on how to fit ultrasound into your busy practice? How has ultrasound made your job easier? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Tobias Kummer, MD, RDMS, FACEP, is Director of Emergency Ultrasound in the Department of Emergency Medicine at Mayo Clinic in Rochester, MN.

Ultrasound in Medical Education: How Far We’ve Come

Posted on February 14, 2017 by aium1952

Point of care ultrasound was an obscure elective during my medical school years, a poorly-attended vacation elective to fill the free time between the match and the first day of residency. At the time, the 2 Emergency Medicine attendings directing the course volunteered an expertise, which endured widespread disregard; their craft persisted, unappreciated by the department and hospital. These faculty had a unique passion, a vision of a paradigm shift in medicine that would save more lives, make better decisions, and improve overall care.

I was initially skeptical of that vision. When they expressed excitement over our new, $50,000 Micromaxx (considered a bargain at the time), it sounded to me like the typical exorbitant medical expense with marginal benefit, peddled by savvy sales r morrow_image1 eps. Then we caught our first tamponade in cardiac arrest during a pulse check and I was hooked: POCUS didn’t belong as one of those obscure hobbies limited to the especially nerdy, but was a vital diagnostic and procedural tool, to be learned and disseminated. I went through residency clearly enamored with the technology. To my dismay, early in my internship, we lost our ultrasound director. It was then that I found mentors in podcasts and through the Free and Open Access Medical Education (FOAMed) community.

By my final year of residency, nurses and attendings were calling on me to pause my work in my assigned pod to travel to theirs to help with US-guided procedures. Having identified the need, I started teaching residents and nurses US-guided procedures. The barriers to education were high-quality simulation phantoms, machine access, and educational time. Time we could volunteer, and for machines we begged and borrowed, but for phantoms, we hit a wall. I searched for answers in the young community of FOAMed but found few workable alternatives to the hundred-to-thousand-dollar commercial phantoms. It was at this impasse that I found inspiration from Mythbusters’ use of ballistics gel. I experimented with ballistics gel to create my own phantom and found it morrow_dsf8521 to be an effective and practical alternative to the commercial phantoms. I was approached by several companies aiming to turn this into a money-making opportunity, but I felt this information needed to be shared. This skill was too critical to keep it locked up behind a patent. Instead, with the whole-hearted spirit of FOAMed, I published guides and answered questions and gave cooking classes.

I’ve continued to follow the vision of bringing bedside ultrasound to widespread use, from residency to fellowship, and now into my role as Emergency Ultrasound Director and Director of Ultrasound Education at the University of South Carolina School of Medicine Greenville. The future is bright: the FOAMed community is large and growing; US technology is being integrated into earlier stages of medical education; and pocket machines are bringing US in closer reach of the busy clinician. Ultrasound is moving into the hands of clinicians at the bedside and becoming an extension of our physical exam, and there is a growing literature base to support this trend. Someday ultrasound will take its rightful place next to the stethoscope, and my job as an “ultrasound director” will seem as foreign a concept as “director of auscultation.” The complementary forces of FOAMed and formal medical education will bring us to this future of safer procedures and greater diagnostic accuracy, and I am excited to be a part of it.

How have you seen ultrasound medical education change? What are your favorite FOAMed resources? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dustin Stephen Morrow, MD, RDMS, is Ultrasound Director at Greenville Health System Emergency Medicine, as well as Director of Ultrasound Education at University of South Carolina School of Medicine Greenville. He can be found on Twitter: @pocusmaverick.

Obsessed With Ultrasound

Posted on November 8, 2016 by aium14750

1. Tell us how and why you became interested in ultrasound?
During my Emergency Medicine at Mayo Clinic, I gained exposure to point-of-care ultrasound (POCUS) for procedural guidance. I was immediately drawn to the hands-on and technical aspects of using ultrasound, and began advancing my use for diagnostic shih purposes. After a few cases of diagnosing acute pathology at the bedside (AAA, free fluid, and DVT to name a few), I was hooked! Following residency, I decided to expand my ultrasound training and pursued an Emergency Ultrasound Fellowship at Yale, while also working toward obtaining my Registered Diagnostic Medical Sonographer (RDMS) certification. Ever since I’ve adopted a liberal use of POCUS in my clinical practice, I can say without a doubt that it’s made me a better Emergency Physician, and I can’t imagine practicing without it!

2. Talk about your role as Program Director of the Emergency Ultrasound Fellowship Program at The Scarborough Hospital in Toronto.
I’m thrilled to be able to bring the skills that I’ve learned during my own EUS Fellowship training to the Emergency Medicine community in Toronto! Our team built the Fellowship Program from the ground up, and our Department went all in with the purchase of 4 additional new ultrasound machines and QPath software for archiving. I’m truly proud of what we’ve accomplished. It certainly helps that I have an extremely supportive Department Chair and 2 amazing fellows this year!

3. What prompted the writing of your book Ultrasound for the Win!?
When trying to learn more about ultrasound myself during residency, I found that there was a void in high-yield POCUS books geared toward Emergency Physicians. I found that the few textbooks that were available, while informative, could be quite dense and intimidating to read. So I decided to develop a book that I, myself, and I believe most Emergency Physicians, would appreciate — a case-based interactive and easy-to-read format that’s clinically relevant to our daily practice. It’s a book that a medical student or resident interested in POCUS can easily read and reference during an Emergency Medicine rotation.

4. What’s one thing you learned about yourself through the writing/editing process?
It’s made me realize just how obsessed I am with ultrasound! Writing and putting together the book was hard work, but also enjoyable and extremely satisfying! Seeing these real cases compiled one after another really highlights the potentially life-saving role of POCUS in medicine, and the profound difference it can make in improving patient care and outcomes.

5. What advice would you offer medical students when it comes to ultrasound?
Scan many and scan often—it’s simple; the more you practice POCUS, the better you will be at it! Also, don’t be afraid to take initiative in your own education—while some attendings may not be comfortable enough with POCUS to teach it to you, don’t let that be a deterrent to your own learning. There’s a plethora of resources available online, including Matt & Mike’s Ultrasound Podcast and Academic Life in Emergency Medicine that you can reference!

How did you become interested in ultrasound? What are your go-to resources? What book would you like to see written? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Jeffrey Shih, MD, RDMS, is an Emergency Physician and author of the book Ultrasound for the Win! Emergency Medicine Cases. He is Program Director of the Emergency Ultrasound Fellowship Program at The Scarborough Hospital in Toronto, Canada, and Lecturer in the Faculty of Medicine at the University of Toronto. He can be reached at jeffrey.shih@utoronto.ca and on Twitter: @jshihmd

How to Obtain Focused Cardiac Ultrasound Images

Posted on August 2, 2016 by aium14750

My first exposure to handheld ultrasound was as a first-year medical student. I was assigned to a cardiology clinic with an attending that pioneered handheld ultrasound examinations. Watching him move from patient to patient and use ultrasound to simultaneously diagnose and teach inspired me to learn how to use ultrasound and incorporate it into my practice.

Parasternal long axis demonstrating a dilated left ventricle.

As a budding cardiologist, examining and triaging patients with handheld ultrasound is a part of my daily work. Although handheld ultrasound and the stethoscope differ vastly in their technology, at the bedside, both are limited by the user’s interpretation of the examination findings. I have found when using handheld ultrasound, as with the stethoscope, perhaps the most important tool is “between the ears.”

The “Introduction to Focused Cardiac Ultrasound” set of lectures provide an overview to focused cardiac ultrasound views and a guide to obtain them. The main goal is to develop an understanding of the scope of focused cardiac ultrasound and to “get the heart on the screen” when scanning. The first lecture focuses on the parasternal long axis and subcostal views of the heart. In practice these views will often be the most helpful and accessible. The second lecture reviews the parasternal and subcostal views and introduces the apical views of the heart. Each lecture includes sample diagnoses.

My rationale for reviewing all the basic views of the heart is to provide a broad survey of all the windows and probe orientations. When a formal cardiac echo is ordered, these are the views and windows obtained by the sonographer. In practice with handheld ultrasound, one or two of these views can be utilized to answer the question at hand. Based on patient positioning and body habitus, however, certain windows may provide a better view of the heart.

My hope in sharing all the views in the second lecture is to not overwhelm the learner but rather provide a strong foundation in understanding the anatomical relationships of the ventricles and atria in the body and see how one window builds off the next. The views in this lecture are directly applicable to structured bedside ultrasound examinations, such as the “CLUE examination.”

At our home institution, we utilize these lectures in a continuously rolling small-group lecture series for our medical students and house staff. The cardiology fellow leads the lecture and the hands-on scanning portion, rotating every third week on the step-down cardiology unit. Overall the feedback has been positive with many of the trainees spreading the skills to other rotations. We are happy to share this resource and welcome feedback.

What resources are invaluable to you? What tools do you use to continually learn? Where do you find the information you need? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Colin Phillips, MD, is Fellow, Division of Cardiovascular Disease at Beth Israel Deaconess Medical Center.

A Word of Encouragement

Posted on May 10, 2016 by aium14750

One excellent online teaching tool for emergency ultrasound states that “scientists have been fascinated by the mechanism of acoustics, echoes and sound waves for many

Attendees get hands-on experience at AIUM’s Wake Forest

centuries.”

I am not one of those scientists.

Frankly, I don’t like physics. I find it challenging to understand things I can’t see. Take gravity, for example. I know and can tell quite distinctly that it exists. The scar on my shin following a childhood attempt at flight is a faithful reminder of its existence. It still remains hard for me to understand the intricacies of this force because of its invisibility. To me, this is similar to a lot of physics concepts.

It’s therefore hilarious that I was somehow drawn to ultrasound. It must have been the enticement of being able to see more, although the ability to “see” is granted by what is unseen—ultrasound waves. The joke was definitely on me.

So how did I get here?

My journey with point-of-care ultrasound (POCUS) started with a remark by a friend of mine. At the time, she was an emergency medicine resident and she told me about a trauma patient that she had performed a “FAST” on. Close to completing 3 years of Pediatric residency, I had never heard of such a thing. I remained intrigued with the idea of quick decision-making scans performed by the provider actively involved in the patient care. Who wouldn’t want this given the chance? The challenge of course lies in acquiring the knowledge.

Things now got interesting.

During my Pediatric Emergency Medicine (PEM) fellowship, I sought to learn more about POCUS. My initiation was not spectacular to say the least. The words of my instructors bounced off the surface of my brain with very little being absorbed. This would have been OK if I were an ultrasound machine. It wasn’t very good when trying to learn how to obtain and interpret ultrasound images however.

By the second and third lesson, I was convinced that I would never learn ultrasound. But as in the majority of love stories, persistence paid off.

Gradually my images changed from what resembled a 1970s television screen after midnight to recognizable structures. By the end of my PEM fellowship, I had acquired a few rudimentary skills. I took an opportunity to pursue an Emergency ultrasound fellowship immediately after my PEM fellowship and the dread of my early ultrasound learning days came upon me again. So many applications, so little understanding.

One day as I scanned a patient, “Eureka!” I finally understood the parasternal long axis. There was hope for me yet.

How did I finally get here?

Persistence – The old adage holds true. If at first you don’t succeed, try, try again.When the words or explanation didn’t make sense, I would try a video (YouTube has some great videos). I would get models of structures to understand the anatomy and relate to them to my scans. I would seek out others to explain concepts in different ways to help my understanding.
Memorization – This provided a foundation and served as the means to the end. When using POCUS, there is a lot to remember and you have to put in the necessary study time.

Finally, I was able to understand what was going on and what the picture was telling or NOT telling me. I also learned not to beat myself up for not understanding everything. That is what colleagues, mentors, online resources, and practice are for.

I now understand a lot of POCUS–more than I ever imagined or thought possible. I didn’t let my dislike of physics or the challenge of image recognition stop me. I figured if others could learn this, I should at least give it a decent shot. And that’s what I ask of those I teach or anyone interested in learning.

What would you tell someone starting to learn ultrasound? What aspect was most difficult for you? How did you overcome it? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Atim Uya, MD, is the Point of Care Ultrasound Director, Division of Emergency Medicine, Department of Pediatrics, University of California, San Diego/Rady Children’s Hospital, San Diego, California.

Pediatric Emergency Ultrasound: We’ve Come a Long Way, Baby

Posted on April 26, 2016 by aium14750

My first rotation as a pediatric emergency medicine (PEM) fellow was on the adult trauma service. It was 2006 and in West Philadelphia there was no shortage of patients with gun shot wounds, stabbings, and motor vehicle crashes. The trauma surgeons were hard on the surgery trainees, and generally nice to the PEM fellows. We weren’t training to be surgeons on the front line after all. One attending, however, was indiscriminate in his wrath and unbiased in his intent to humiliate.

dreamstime_xs_59669332 A few days into the rotation, during a trauma alert, he chose me: “Jennifer, the FAST, do the FAST!” I was completely puzzled and looked at him blankly. This, of course, made him angrier. “Do the FAST exam!”

Unable to admit at the time that I had never heard of the FAST exam, I remained silent. Seeking to avoid any fear, shame, or humiliation that would certainly accompany future traumas, I immediately read everything I could about it, and the surgery fellows taught me at the bedside.

I returned to the children’s hospital wanting to learn more about ultrasound. Unfortunately, at the time, no one in PEM knew much about it. In fact, none of my colleagues or mentors had any experience with it. I sought guidance from my general emergency medicine colleagues next door who welcomed me and trained me as one of their own.

In time, I proposed a research study in the pediatric emergency department: point-of-care ultrasound for pediatric soft tissue infections. At the time, the radiology faculty weren’t keen on this. They were unaware of non-radiologists using ultrasound and didn’t understand why emergency physicians would need to use it. It was a slippery slope, they argued, and might result in indiscriminate and “unregulated” usage. We compromised–I could use ultrasound in the emergency department solely for research purposes. The machine, literally under lock and key, was off limits to anyone but those involved in the study.

As I found out, my experience was not unique. Many of my PEM colleagues around the country faced similar obstacles from specialists outside of the emergency department. Point-of-care ultrasound at that time was simply not the standard of care.

Nearly a decade later, I practice in a very different climate. Point-of-care ultrasound is a mainstay in my patient care practice; and I now have the support (and collaboration) of my radiology colleagues and others outside of emergency medicine.

More broadly, PEM ultrasound is a recognized subspecialty. Notably:

There are approximately 10 dedicated 1-year fellowships in pediatric point-of-care ultrasound.
Pediatric point-of-care ultrasound is part of the American Board of Pediatrics core content for pediatric emergency medicine fellowship training, and has been incorporated into the PEM subspecialty board examination.
Landmark publications include the American Academy of Pediatrics Policy Statement and Technical Report for PEM point-of-care ultrasound.
There is a PEM ultrasound international organization (www.p2network.com).
AIUM invited me to write this blog.

We certainly have come a long way.

Do you have a similar ultrasound story? What other areas have come a long way when it comes to ultrasound? What areas are poised to be next? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jennifer R. Marin, MD, MSc, is Director of Emergency Ultrasound in the Division of Pediatric Emergency Medicine as well as Quality Director, Point-of-Care Ultrasound at Children’s Hospital of Pittsburgh of UPMC.

Simulators Role in Ultrasound Training

Posted on October 6, 2015 by aium14750

I believe the future of health care will involve the expanded use of diagnostic ultrasound, which will be accomplished through the use of an enhanced version of today’s handheld ultrasound scanner. I envision this “sono-scope” to be a wireless, lightweight, handheld imaging device with a long battery life and high-quality image capture that will expand the capabilities of the stethoscope.

The compact, portable ultrasound pedersen_image scanners began entering the medical imaging marketplace around year 2000. Since then the market has grown dramatically, and the portable scanners have bifurcated into two broad groups: (i) The pocket-sized or handheld scanners (HHUS) and (ii) the larger, full-featured point-of-care ultrasound systems (POCUS).

These devices provide doctors with an extension of their senses and augment existing tools. But to be truly transformational, users need to receive ultrasound training from the beginning of their medical career, which will allow them quickly to “rule in” and “rule out” possible diagnoses and lead to earlier treatment decisions and/or more relevant further tests.

I maintain that the main barrier for making the HHUS (and POCUS) every clinician’s examination tool of choice, is not the technology, but rather the lack of opportunity to acquire and develop the needed scanning skills.

Thus, finding training strategies that enable the integration of ultrasound into medical schools is an essential step in overcoming this barrier. If the next generation of doctors had ultrasound for diagnosis and guided procedures as a vital part of their training, they would quickly develop a natural comfort with this tool and, with time, increasing sophistication. A parallel can be drawn regarding the attitude toward acquiring computer skills. As recent as 40 years ago, the operation of computers was thought to be limited to a select, carefully trained group of specialists. Today, nearly everyone is able to operate computers at some level.

Effective training in medical ultrasound requires both clinical knowledge (understanding of anatomy, physiology, and pathology) and scanning skills (psycho-motor skills, which are the integration of motion and the mental processes of recognizing anatomic structures in 3D from the 2D images). While both clinical knowledge and scanning skills are essential, the former is often emphasized at the expense of the latter because clinical knowledge can be delivered cost effectively and in flexible formats through online courses (including MOOCs), self-study, and in traditional classroom courses. Scanning skills, on the other hand, are acquired through hands-on experience, by examining patients, preferably both healthy and with symptoms, under the guidance of an experienced sonographer. Here, the medical educational enterprise does not currently have the capacity to meet this training need. There are too few scanners available for learners to use. There are too few patients or human subjects in general available for scanning. Last but not least, there are too few qualified instructors who can guide the learning.

There exists a potentially effective approach to overcoming this limitation in delivering scanning skills training: The use of ultrasound training simulators. Simulation provides a controlled and safe practice environment to promote learning. The efficacy of the simulator-based training is well-established. For example, human errors related to airline accidents have decreased in large part due to flight simulator training. Likewise, high-fidelity medical simulations have been shown to be educationally effective, as evidenced by the strong correlation between surgical simulator training and improved outcomes. Several studies have demonstrated the learning value of simulator-based training in diagnostic ultrasound.

Just as HHUS and POCUS have proliferated over the last 15 years, so have ultrasound simulator products. Some training simulators cover multiple clinical specialties, while others are designed for a specific application. Typically, the learner scans a physical manikin with a realistic-looking sham transducer, which produces an image on the display corresponding to the position and orientation of the sham transducer on the manikin, along with an anatomy display of the location of the image plane through the body.

An important component of the simulator design is the degree to which the simulator provides structured learning with guidance, interaction, and assessment. While all simulators include educational modules, only a few offer self-paced learning and competence verification. All in all, today’s ultrasound simulators are sophisticated devices that are capable of meeting training needs on basic and even intermediate levels. However, because the purchase price is sufficiently high (from $10K to more than $100K) sonography programs and simulation centers at larger hospitals are typically the only facilities able to acquire this technology.

When the medical community is ready to embrace ultrasound as an imaging modality of first choice for doctors from all specialties, I am convinced that technological innovation will lead to affordable, yet customizable and realistic training simulators. In particular, what is needed are portable and lightweight simulators that run on ordinary, modern PC/laptops, making personal ownership of a simulator possible as well as allowing medical schools to purchase such simulators in large quantities. For individualized training, it is essential that the simulator be task-based and able to verify the acquired skills level. To deliver the best realism, the image material should preferably be acquired directly from human subjects, and to provide the optimal development and assessment of psychomotor skills, the scanning practice on the simulator should resemble actual patient scanning as closely as possible. Such low-cost training simulators can lay the groundwork for building up such ultrasound skills both among practicing specialists and students enrolled in medical schools.

Have you/do you use simulators in your ultrasound training? What are the advantages or disadvantages? What would make simulation training better? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Peder C. Pedersen is Professor of Electrical and Computer Engineering at Worcester Polytechnic Institute.

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