Ultrasound in the Diagnosis and Management of Chronic Obstructive Pulmonary Disease

Posted on November 14, 2023 by aium1952

Chronic Obstructive Pulmonary Disease (COPD) is a prevalent and debilitating respiratory condition that affects millions of people worldwide. While traditional diagnostic methods like spirometry and imaging techniques such as CT scans have played a vital role in managing this disease, ultrasound is emerging as a powerful tool in both diagnosis and treatment.

The Basics of COPD

COPD is a progressive lung disease characterized by the restriction of airflow due to chronic bronchitis and emphysema. The primary symptoms include breathlessness, coughing, and excessive mucus production. It is typically associated with a history of smoking, but environmental factors also play a role. Diagnosing and monitoring the progression of COPD is crucial for effective management.

The Role of Ultrasound in Diagnosis

Sonographic Assessment of Lung Morphology: Ultrasound imaging offers a noninvasive and radiation-free approach to assess lung morphology. Studies published in the Journal of Ultrasound in Medicine have demonstrated the effectiveness of ultrasound in evaluating lung parenchyma,¹ pleura,¹ and diaphragm.² By examining these elements, clinicians can identify changes in the lung structure and rule out other conditions that might mimic COPD symptoms.

Evaluation of Diaphragm Function: COPD often affects diaphragm function, resulting in respiratory muscle weakness. Ultrasound allows for real-time assessment of diaphragm movement, enabling clinicians to detect early signs of diaphragmatic dysfunction.² This information is valuable in selecting the appropriate treatment strategy for each patient.

Ultrasound-Guided Thoracentesis

In some cases, COPD patients develop pleural effusion, a condition characterized by an abnormal buildup of fluid in the pleural cavity. Ultrasound can be used to guide thoracentesis, a procedure in which this excess fluid is drained. A Journal of Ultrasound in Medicine report has highlighted the accuracy and safety of ultrasound guidance during this procedure, minimizing complications and improving patient outcomes.³

Monitoring Disease Progression

Ultrasound is not limited to the initial diagnosis but also plays a crucial role in monitoring COPD progression. Repeat ultrasound examinations can help evaluate changes in lung structure, assess diaphragm function, and track the effectiveness of ongoing treatments. Regular ultrasound monitoring can lead to more tailored and effective care plans for COPD patients.

Point-of-Care Ultrasound in COPD

Point-of-care ultrasound (POCUS) is a valuable tool for quickly assessing COPD exacerbations in emergency situations. It allows healthcare providers to rapidly evaluate lung abnormalities, pneumothorax, and pleural effusion, guiding immediate treatment decisions.⁴

Future Implications

As technology continues to advance, ultrasound is likely to play an even more prominent role in the diagnosis and management of COPD. Developments in portable and handheld ultrasound devices are making it easier for clinicians to perform ultrasound examinations at the bedside, providing real-time information to aid in decision-making.

Conclusion

The use of ultrasound in the diagnosis and management of COPD is a promising and evolving field. It offers a noninvasive, safe, and cost-effective means of assessing lung morphology, diaphragm function, and pleural effusion. With continued research and technological advancements, ultrasound is likely to become an indispensable tool in the fight against this chronic respiratory disease, helping patients receive more accurate diagnoses and tailored treatment plans.

References:

1. Martelius L, Heldt H, Lauerma K. B-lines on pediatric lung sonography: comparison with computed tomography. J Ultrasound Med 2016; 35:153–157. doi: 10.7863/ultra.15.01092.

2. Xu JH, Wu ZZ, Tao FY, et al. Ultrasound shear wave elastography for evaluation of diaphragm stiffness in patients with stable COPD: A pilot trial. J Ultrasound Med 2021; 40:2655–2663. doi: 10.1002/jum.15655.

3. Lane AB, Petteys S, Ginn M, Nations JA. Clinical importance of echogenic swirling pleural effusions. J Ultrasound Med 2016; 35:843–847. doi: 10.7863/ultra.15.05009.

4. Copcuoglu Z, Oruc OA. Diagnostic accuracy of optic nerve sheath diameter measured with ocular ultrasonography in acute attack of chronic obstructive pulmonary disease. J Ultrasound Med 2023; 42:989–995. doi: 10.1002/jum.16106.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Interested in learning more about lung ultrasound? Check out the following articles from the American Institute of Ultrasound in Medicine’s (AIUM’s) Journal of Ultrasound in Medicine (JUM). After logging into the AIUM, members of AIUM can access them for free. Join the AIUM today!

Threading the Needle at UltraCon

Posted on February 28, 2023 by aium1952

Ultrasound has many advantages when used for interventional procedures such as improved visualization of the anatomy in relation to the needle tip. But acquiring the skills to perform ultrasound‐guided procedures takes time and practice.

And that is why the AIUM has devoted a full-day symposium called “Threading the Needle” to this topic on March 27, 2023, at UltraCon. The symposium provides a comprehensive overview of ultrasound-guided procedures, including:

Instrumentation
The needles and associated instrumentation commonly used in ultrasound-guided procedures will be shared. Important features and variations in equipment will be introduced for all specialties.

Teaching Tools
How do you teach others at your institution to perform procedures? The facilitator will provide an overview of best practices with specific examples.

Skills Station
Needle guidance principles will be taught for clinical applications such as IV access, target practice, and more utilizing hands-on models and cutting-edge technologies.

Safety
What are the important safety considerations when performing ultrasound-guided procedures?

Threading the Needle is just one of eight in-depth symposia featured at UltraCon 2023. Check out the Full Schedule to get a sneak peek at everything you could learn.

Another helpful resource about these procedures is the AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures.

Therese Copper, BS, RDMS, is the Director of Accreditation, and Mark Macoit is the Marketing Manager at the American Institute of Ultrasound in Medicine (AIUM).

Ultrasound Education in United States Medical Schools

Posted on January 24, 2023 by aium1952

Although nearly every medical specialty uses ultrasound, medical schools are inconsistently integrating ultrasound education into their curriculum. According to a 2019 study (by Nicholas et al) of United States Accredited Medical Schools (USAMS),¹ although integration of ultrasound into curricula has increased since a prior study in 2014 (by Bahner et al),² ultrasound instruction is still inconsistent.

In the fall of 2019, researchers contacted 200 allopathic and osteopathic USAMS for the Nicholas study.¹ Of those schools, 168 (84%) responded and, of those, 122 (72.6%) indicated they have an ultrasound curriculum.

Of the medical schools that responded, 46 (23%) indicated they did not have ultrasound curriculum.¹

Although this study did not look into why they did or did not have the curriculum, some barriers clearly still remain to incorporating it, such as those mentioned in a 2016 study by Dinh et al³: lack of funding, lack of trained faculty, and lack of curricular space.

According to the Nicholas study, it seems as though some of the schools (42) work around the lack-of-funding barrier by having volunteers as faculty. Only 35 (20.8% of those who responded) compensate their faculty and, of those, 22 (13.1%) are compensated monetarily.¹And when schools can’t afford their own ultrasound machines, some have found other means, such as borrowing hospital ultrasound equipment.³ Other means of helping to distribute the cost of starting up a program include gradually adding classes, using near-peer teaching, and self-directed asynchronous learning using online resources and simulators.³

As medical students who have learned about ultrasound have reported that it improves their understanding of anatomy and physical examination skills, and more specialties adopt this technology, students need to learn about it before they need to use it in clinical practice.¹

Although more schools keep adding ultrasound to their curricula, it is not yet nationwide, and many who have succeeded had to struggle to make it happen. It is imperative that USAMS receive the funding and support they need to train medical students in the safe and effective use of ultrasound.

References

Nicholas E, Ly AA, Prince AM, et al. The current status of ultrasound education in United States medical schools. J Ultrasound Med 2021; 40:2459–2465. https://doi.org/10.1002/jum.14333.
Bahner D, Goldman E, Way D, Royall NA, Liu YT. The state of ultrasound education in U.S. medical schools: results of a national survey. Acad Med 2014; 89:1681–1686.
Dinh VA, Fu JY, Lu S, Chiem A, Fox JC, Blaivas M. Integration of ultrasound in medical education at United States medical schools: A National Survey of Directors’ experiences. J Ultrasound Med 2016; 35:413–419. https://doi.org/10.7863/ultra.15.05073.
Tarique U, Tang B, Singh M, Kulasegaram KM, Ailon J. Ultrasound curricula in undergraduate medical education: a scoping review. J Ultrasound Med 2018; 37:69–82. https://doi.org/10.1002/jum.14333.

Cynthia Owens, BA, is the Publications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

What if Ultraportable Ultrasound Devices Were the Future of Healthcare in Africa?

Posted on October 18, 2022 by aium1952

The improvement and miniaturization of ultrasound devices is a result of the need to make ultrasound devices quickly accessible regardless of location. The right diagnosis at the right time in the right place can take you a step ahead in this race for point-of-care diagnosis.

Developed countries have experienced very significant direct and indirect impacts on the quality of care for patients in acute care and those who are hospitalized. However, if in these countries, ultrasound has made it possible to bypass certain additional examinations (standard radiography, CT, MRI, etc) for certain precise indications despite the latter being nevertheless available, it can be deduced logically that under certain conditions, point-of-care ultrasound (POCUS) would have an even greater impact in settings where other modalities are simply not available.

Indeed, developing countries and areas with limited resources often have in common a lack of diagnostic imaging means: old, non-mobile X-ray machines with little or no function at all and you’ll rarely find CT or MRI, and when you do, it is inefficient except in concentrated, large cities.

Add to this an extremely limited electricity supply, which significantly reduces the effectiveness of the existing means even further. It directly results in the impossibility of full-time operation due to power cuts, and indirectly through breakdowns and the gradual deterioration of the equipment related to variations in electrical voltage.

These various problems make Africa extremely fertile ground for the use of clinical ultrasound (POCUS) with exactly the same benefits as those obtained in other better-developed regions, but better still the absence of other means of diagnosis, which could lead clinical ultrasound to become the “gold standard” for clinical diagnosis in African.

The problem, however, is the availability of the devices, especially the type of device. Indeed, the devices currently present in Africa are either static or relatively portable (more than 10kg), which poses a real problem of mobility for an imaging modality that could otherwise be performed at the patient’s bedside.

Ultraportable devices with their small size, their resistance, their autonomy, and their low energy requirement could be a valuable diagnostic aid in Africa. However, there remains the problem of their availability (most manufacturers limit their network to developed countries) and their cost (due to the low purchasing power of practitioners in developing countries), the very idea of obtaining one at its actual cost is completely illusory.

What if the manufacturers of ultraportables developed strategies to support doctors who want to equip themselves and the educated societies with POCUS, set up conventional classroom-based training courses and E-learning free or at a reduced price for all doctors wishing to learn?

Yannick Ndefo, MD, is a general practitioner in Cameroon and a POCUS ambassador for POCUS Certification Academy.

Interested in learning more about ultrasound in global health? Check out these posts from the Scan:

I Lost My Stethoscope…on Purpose

Posted on July 12, 2022 by aium1952

In July of 2016, my medical school gave me my first, only, and likely, last stethoscope. Since its adoption by clinicians, it has become so iconic to the physician identity. I wanted to hear murmurs and rales—and sometimes prank my classmates and yell into the diaphragm. Since the start of my clinical rotations, it has been my constant companion, tucked away in my bag until I drape it behind my neck at the start of shift. I felt naked without it. Not in my bag? Might as well show up to work without my scrub top. But here I am, almost 3 years into residency: it’s somewhere at the bottom of my bag…I think.

Throughout the years, emergency clinicians have continued to adapt and evolve in parallel to the rapidly expanding medical device industry, such as portable ultrasounds. The term “portable”, when describing ultrasounds, has evolved beyond most of our wildest imaginations. The once bulky, immobile machines that were only seen in the “ultrasound suite or room” are now stowed away in backpacks and physicians’ back pockets. The ubiquitous nature of ultrasound has encouraged even physicians that did not train with it to adapt and learn to utilize it for almost any chief complaint.

I posit the adoption of point-of-care ultrasound (POCUS) as part of the routine physical exam in the emergency department. Except in the case of an asthmatic assessment for wheezing, confirmation of breath sounds after rapid sequence induction (RSI), or in a patient with penetrating chest trauma, the stethoscope has become obsolete.

Transthoracic echocardiograms are often the most interesting studies due to the dynamic nature of the exam and the potential for performing various advanced studies. Everyone gets excited seeing a pericardial effusion and making a determination if the patient has early signs of tamponade or the visualization of a transvenous pacemaker wire’s capturing. However, I am arguing for the complete replacement of the stethoscope with point-of-care ultrasound. So, unless you believe in the existence of an I/VI systolic murmur in the patient’s upper left sternal border, you’re probably already convinced of its utility for the cardiac exam. So, let’s talk lungs.

A 32-year-old male presented after a mountain bike accident complaining of shoulder and back pain since he had fallen onto the dirt mound after overestimating a jump. He had been diverted from the trauma bay and moved to the back of the department after having been triaged with an Emergency Severity Index (ESI) of 3. I entered the room and introduced myself. He was tachypneic but easily spoke in full sentences. I placed him on the monitor and found this otherwise healthy, active, and fit male was hypoxic to 90% on room air.

Pneumothorax, right? I just needed to prove it. I set his nasal cannula to 5 liters and continued my physical exam. Breath sounds were normal, trachea was midline, no paradoxical chest wall movement or obvious deformities. On repeat vitals the patient was normotensive, but the pulse oximetry was dipping from 96%, then 94%, then holding at 90%. The nurse immediately called the x-ray technician, however, they were busy with various other trauma patients. My attending brought an ultrasound to the bedside, which revealed no lung sliding on his left. Clearly, he needed a tube thoracostomy performed. Using POCUS, we expedited treatment; the kit was brought to bedside, and by the time the technician had arrived, I had already consented the patient, prepped for the procedure, and anesthetized the site. The tube was placed successfully, and vitals immediately improved. Ultimately, the patient was weaned to 2 liters of oxygen via nasal cannula and admitted to the hospital.

Fast forward to the fall. It was the middle of my second year, and COVID-19 was rearing its head again. But physicians were wiser this time: we ought not to rush to intubate, lest the patient never come off the ventilator. It was mid-afternoon, and the ED staff was pushing through their post-prandial drowsiness. A 64-year-old male with a history of hypertension and medication noncompliance was rushed to the resuscitation bay in respiratory distress. He was in extremis, fluctuating between 80–85%. We put on a non-rebreather and cranked up the oxygen. Using an Egyptian translator, he responded in 2- to 3-word sentences: he reported a recent COVID-19 exposure in his family in Egypt just before returning to the United States and reported the only symptom of shortness of breath.

We listened to his lung fields. We all had differing opinions as to what we were hearing. I reported rales, another reported rhonchi, and the first year medical student said, “[The lungs] sound really bad.” I could not appreciate jugular vein distention (JVD) due to body habitus. He had no lower extremity edema. Blood gas demonstrated no acid-base imbalance. COVID screening was pending. The X-ray technician was on the way. The respiratory technician had put him on a bilevel positive airway pressure machine (BiPAP), but he continued to deteriorate, though more slowly. I was pushed to set up for intubation. But I asked to mix a bag of nitroglycerin first while I took the time to perform an ultrasound. While others argued this was COVID pneumonia, I thought it was due to his hypertension or sympathetic crashing acute pulmonary edema (SCAPE). If I intubate, he codes.

The first blood pressure was taken while I looked at his lungs. B-lines everywhere, systolic greater than 230 and diastolic in the low 100s. While giving myself a pat on the back, I asked the nurse to go ahead and hang the nitroglycerin while keeping him on BiPAP. He stabilized, then headed upstairs to the ICU.

Still not convinced? One more case. A woman in her 70s with a history of congestive heart failure and paroxysmal atrial fibrillation presented complaining of shortness of breath. She had been taking her medications, including her diuretic, as prescribed. She was hypoxic in the mid-80s. After improving her saturations with a nasal cannula, I looked at her monitor and confirmed with an electrocardiogram (EKG): she was also in atrial fibrillation with rapid ventricular response (RVR) in the 130s. She insisted it was due to her fast heart rate. She had been adamant the last time this happened, she was simply given a medication to slow her heart, which caused complete resolution of her symptoms.

Next best step? Is it merely rate control then? Is tachycardia the etiology or symptom? I heard rales bilaterally, measured JVD to the angle of her mandible, and noted 3+ pitting edema to her legs. Ultrasound demonstrated a severely depressed ejection fraction with any pericardial effusion. Her inferior vena cava was plethoric. She had diffuse B lines bilaterally with small pleural effusions. The temptation is simply to rate control. Yet, in taking a step back to further assess, I chose, rather, to drop her preload with noninvasive positive pressure ventilation (NIPPV) and IV diuretics.

In multiple cases, the utilization of POCUS has proven an invaluable tool. I believe it is a vital skill. The emergency physician ought to become comfortable with this tool so readily at our disposal. The next time you feel the need to listen for the difference between rhonchi and rales, pick up a probe to settle the argument.

Author, Aaron Alindogan, MD, is a second year resident at the Department of Emergency Medicine at UT Health San Antonio. Editor, Ryan Joseph, DO, DTM&H, is an assistant professor of emergency medicine at UT Health San Antonio.

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

Posted on June 28, 2022 by aium1952

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 J*²).

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:

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.

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.

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

Posted on May 31, 2022 by aium1952

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 4^th 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 3^rd 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

Posted on April 19, 2022 by aium1952

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 4^th 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 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!

Posted on April 5, 2022 by aium1952

“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:

Training
Supervision
Feedback
Organizational buy-in
Decision support
Planned adaptation (ie, prizes for, and promotion of, early adopters)
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?

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:

Let’s Democratize Ultrasound, and Save Lives

Posted on February 22, 2022 by aium1952

The health systems of most underdeveloped countries have one thing in common: the total absence of health insurance. The entire cost of illness is borne by the patient and their family. If we add to this problem low and uncertain incomes, the result is patients who often do not have enough money to pay for their health care. In the best cases, we have patients who will be content to pay only for the minimum and essential care since they cannot afford more. This very often leads to insufficient care.

Patient spending in a hospital is generally based on 2 components:

Expenses related to diagnosis: Complementary biological and imaging tests
Expenses related to care: Medications and care

The impact of poverty and the indigence of the patients will weigh as much on one component as on the other. The patients will only agree to undergo an examination if they are convinced that it will bring vital information. Similarly, among the prescribed drugs and treatments, they will spend only on what seems to them vital in the immediate future or essential to save a life in the short term. The direct consequence is an increase in morbidity and mortality, and an increase in costs per relapse and re-hospitalization, frustration, etc.

There is, therefore, a major problem in the practice of medicine in poor areas:

How do we convince the patient it is worth their money?
How do we make them realize the degree of urgency and dangerousness of the pathology?

It is recognized worldwide that an image is worth a thousand words and images are what ultrasound offers us.

The whole world is learning a little more every day to appreciate the diagnostic and therapeutic value of ultrasound, but one of the most impactful elements that can be achieved with ultrasound is communication, the transmission of information.

The disease is no longer just abstract. We can show it to the patient, we can see his eyes fill with gratitude when he finally manages to see what is hurting him, what has caused him so much worry. We go from the abstract to the concrete.

If this is already a plus in developed societies where the patient wants to satisfy his curiosity, get information, and understand, in underdeveloped countries a new aspect emerges. The patient can see what he is going to spend his money on, why he will pay for transport from a village to the city to see a specialist or carry out an expensive examination, why he will accept that a needle is inserted into his body, why his stomach will be opened.

Ultrasound can literally boost compliance with treatment and it seems to be magic that the benefits of ultrasound are the same regardless of the environment.

To illustrate my remarks, I present to you a 50-year-old patient, with high blood sugar levels for 3 years, which was not monitored because she believed that she could control this with plants and bark. On examination, we found a painful epigastric mass in the left hypochondrium, which was mobile with respiration. The ultrasound found a voluminous left renal abscess. Thanks to the ultrasound image, and the comparison of the two kidneys, I was able to convince the patient to travel to the city, to pay for an abdominal CT-Scan (the price of which represents her wage over 4 months) and to undergo ultrasound-guided percutaneous drainage (Figure 1).

Figure 1. Left, Ultrasound image of the left renal abscess and a normal right kidney.

Figure 1. Right, CT scan of the left renal abscess and the normal right kidney.

The benefits of communication with ultrasound are even greater when it comes to point-of-care ultrasound (POCUS). You are the examining doctor, you tell the patient what you suspect, you scan their body to answer the questions you have asked, and when you have the answer, it is a moment of bonding and complicity between you and the patient that only those who use POCUS can understand. BEAUTIFUL!!!

Any doctor practicing in rural areas, remote areas, or poor areas should learn to do POCUS. With online learning, everything is accessible now. Free or inexpensive online courses and scholarships for developing world doctors should be strongly encouraged. Ultrasound societies must look into offering such content. Universities should as well because the future of health will develop with POCUS.

If we want to help poor countries progress, knowledge sharing must be at the center of the priorities. We need to take into account inequalities that result in health personnel who most need POCUS are also those who are not able to afford training whether online or face-to-face. It is necessary to ensure that there are elite developing-world doctors who have mastered POCUS, and who will be able to teach it to others and thus participate in the popularization of ultrasound.

Let’s democratize ultrasound, and save lives.