Therapy Dogs

What could be cuter and more beneficial to patients than a team of six Golden Retriever therapy dogs showing kids how to undergo procedures?

Jessie having echocardiogram-1

Therapy dog, Jessie, undergoes an echocardiogram while being comforted by ‘Mom’, who is holding her paw.

At Southampton Children’s Hospital in the UK, the therapy dogs help the pediatric patients overcome their anxiety and fear by providing support ranging from general meet-and-greet style Animal Assisted Activity visits to Animal Assisted Therapy. The therapy dogs assist in physiotherapy, speech and occupational therapy, phlebotomy services and injections, radiology investigations, and by supporting children in the anaesthetic room.

leo on mri scanner

Leo demonstrating laying down in an MRI scanner.

One of the reasons therapy dogs are so helpful is that they are nonjudgmental and take the healthcare environment in stride. They don’t cajole or persuade, and I am sure that is why the children sometimes trust them more than the people who are with them. Every parent and medical staff member is trying to get the procedure done, which is why using the dogs as a bridge between the healthcare team and the child is so very useful. As a volunteer, it has been a privilege to be able to develop this service for the hospital.

I am delighted to say that we have images and videos that enable us to assist the medical staff even when we are not there! The library of pictures and videos that the staff can show the children when they are anxious includes such things as:

  • A short film, ‘Leo goes to X-ray,’ showing therapy dog, Leo, going to the X-ray department and explaining how easy it is to have a radiology investigation, whether it is a plain film X-ray or CT/MRI scan.  (https://www.youtube.com/watch?v=Vb8kIU4y9H4)
  • A video of a therapy dog heading down to theatre after admission procedure and showing what the route to theatre looks like as well as showing the anaesthetic room.
  • As well as many adorable and helpful photos.
archie investigations collage

Archie demonstrating, from top left, a thermometer to the arm, stethoscope to the chest, SATS testing, and pulse oximitry on a paw.

You can see more in this report on yahoo! news.

 

 

Have you ever worked with therapy dogs? If so, what was your experience like? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Lyndsey Uglow is the Lead Animal Assisted Intervention Handler at Southampton Children’s Hospital Therapy Dogs.

A Model Citizen

“Lie down on your back, your elbow is about to get a lot of gel on it,” said the proctor during our most recent AIUM headquarter course. As staff, we often have to step in and assist at meetings in ways we had not planned. This moment was not any different, but we do it because we want to understand and enhance the attendee experience. Turns out I have a “beautiful” elbow and yes, some of you beginners are pressing too hard.

Parreco scan

Sonographer Haylea Weiss scanning Jamie Parreco’s ankle.

As I had my second joint scanned, I thought, what a cool experience; my body is going to help advance the safe and effective use of ultrasound. I found myself offering to volunteer any chance I could, having my elbow, ankle/foot, and shoulder scanned in the end. I listened, watched, and learned as attendees explored.

So why am I telling you this? As a program/meeting planner, it was valuable for me to see things from a model’s perspective:Parreco ankle scan

  • You really should wear comfortable clothes.
  • Gel really will get all over you.
  • Talking to the attendee can help them learn.

 

Here at the AIUM, we offer great opportunities for models to get involved at our annual meeting and courses, but for those of you who have not gotten on one of those exam beds as a model in a while, I encourage you to do so. Everyone learns on that bed; ultrasound grows on that bed; your future sonographers and physicians need you on that bed.

We have a unique opportunity to provide true hands-on experience in our field and I encourage you to support that in any way you can. Who knows, you may learn a thing or two about your body as well. #snappinganklevictim

 

Have you ever been a model for a hands-on ultrasound course? Share your experience below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Jamie Parreco is Director of the Events and Continuing Education Services department at the AIUM in Laurel, Maryland.

Pioneering Ultrasound Units

If you think your ultrasound machine is out-dated, imagine if you still had to use these from as long ago as the 1940s. 

1940s

Ultrasonic Locator
Dr G. D. Ludwig, a pioneer in medical ultrasound, concentrated on the use of ultrasound to detect gallstones and other foreign bodies embedded in tissues. During his service at the Naval Medical Medical Research Institute in Bethesda, Maryland, Dr Ludwig developed this approach that is similar to the detection of flaws in metal. This is A-mode in its operation and was Dr Ludwig’s first ultrasonic scanning equipment.

Locator

 

1950s

Ultrasonic Cardioscope
Designed and built by the University of Colorado Experimental Unit, the Cardioscope was intended for cardiac work.

Ultrasonic Cardioscope

 

1960s

Sperry Reflectoscope Pulser / Receive Unit 10N
This is an example of the first instrument to use an electronic interval counter to make axial length measurements of the eye. Individual gates for the anterior segment, lens, and vitreous compartment provided accurate measurement at 10 and 15 MHz of the axial length of the eye. This concept was the forerunner of all optical axis measurements of the eye, which are required for calculation of the appropriate intraocular lens implant power after cataract extraction. This instrument, which includes A-mode and M-mode, was developed by Dr D. Jackson Coleman and Dr Benson Carlin at the Department of Ophthalmology, Columbia Presbyterian Medical Center.

Sperry Reflectoscope Pulser

 

Sonoray Model No. 12 Ultrasonic Animal Tester (Branson Instruments, Inc.)
This is an intensity-modulated B-mode unit designed exclusively for animal evaluations. The instrument is housed in a rugged aluminum case with a detachable cover that contains the cables and transducer during transportation. The movable transducer holder on a fixed-curve guide was a forerunner of mechanical B-scan ultrasonic equipment.

Sonoray Animal Tester

 

Smith-Kline Fetal Doptone
In 1966, pharmaceutical manufacturer Smith Kline and French Laboratories of Philadelphia built and marketed a Doppler instrument called the Doptone, which was used to detect and monitor fetal blood flow and the heart rate. This instrument used the continuous wave Doppler prototype that was developed at the University of Washington. 

Smith Kline Fetal Doptone

 

Smith-Kline Ekoline 20
Working in collaboration with Branson Instruments of Stamford, Connecticut, Smith-Kline introduced the Ekoline 20, an A-mode and B-mode instrument for echoencephalography, in 1963. When B-mode was converted to M-mode in 1965, the Ekoline 20 became the dominant instrument for echocardiography as well as was the first instrument available for many start-up clinical diagnostic ultrasound laboratories. The A-mode was used in ophthalmology and neurology to determine brain midlines.

Ekoline 20

 

University of Colorado Experimental System
Developed by Douglas Howry and his team at the University of Colorado Medical Center, this compound immersion scanner included a large water-filled tank. The transducer moved back and forth along a 4-inch path while the carriage on which the transducer was mounted moved in a circle around the tank, producing secondary motion necessary for compound scanning. 

Compound immersion scannerCompound immersion scanner tub

 

1970s

Cromemco Z-2 Computer System (Bioengineering at the University of Washington)
This color-Doppler prototype, introduced in 1977, was the computer used for early color Doppler experiments. Z2 “microcomputers” were used for a variety of data acquisition and analysis applications, including planning combat missions for the United States Air Force and modeling braking profiles for the San Francisco Bay Area Rapid Transit (BART) system during actual operation.

Cromemco Z-2 Computer System

 

ADR-Model 2130
ADR of Tempe, Arizona, began delivering ultrasound components to major equipment manufacturers in 1973. Linear array real-time scanners, which began to be manufactured in the mid-1970s, provided greater resolution and more applications. Grayscale, with at least 10 shades of gray, allowed closely related soft tissues to be better differentiated. This 2-dimensional (2D) imaging machine was widely used in obstetrics and other internal medicine applications. It was marketed as an electronic linear array, which was faster and more repeatable without the need for a water bath as the transducer was placed right on the skin.

ADR Model 2130

 

Sonometrics Systems Inc, NY BR-400V
The first commercially available ophthalmic B-scanner, this system provided both linear and sector B-scans of the eye. The patient was examined in a water bath created around the eye by use of a sterile plastic ophthalmic drape with a central opening. Both A-scan and B-scan evaluations were possible with manual alignment of the transducer in the water bath. The instrument was developed at the Department of Ophthalmology, Columbia Presbyterian Medical Center by Dr D. Jackson Coleman, working with Frederic L. Lizzi and Louis Katz at the Riverside Research Institute.

Sonometrics Systems Inc, NY BR-400V

 

Unirad GZD Model 849
Unirad’s static B-scanner, allowing black-and-white anatomic imaging, was used with a scan arm and had similar controls as those used today, including processing, attenuation compensation, and gain.

Unirad GZD Model 849

 

1980s

American Flight Echocardiograph
This American Flight Echocardiograph (AFE) is a 43-pound off-the-shelf version of an ATL 400 medical ultrasonic imaging system, which was then modified for space shuttle compatibility by engineers at the Johnson Space Center to study the adaptations of the cardiovascular system in weightlessness. Its first journey to space was on the space shuttle Discovery in 1985 and its last on the Endeavour in 1992. The AFE generated a 2D cross-sectional image of the heart and other soft tissues and displayed it in video format at 30 frames per second. Below, Dr Fred Kremkau explains more about it.

 

To check out even more old ultrasound machines, visit the American Institute of Ultrasound in Medicine’s (AIUM’s) An Exhibit of Historical Ultrasound Equipment.

 

How old is the ultrasound machine you use now? What older ultrasound equipment have you used? Did it spark your desire to work with ultrasound? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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The AIUM is a multi-disciplinary network of nearly 10,000 professionals who are committed to advancing the safe and effective use of ultrasound in medicine.

Are You Sonogenic?

Most of us who do ultrasound commonly use the disclaimer that “the study is suboptimal because of the patient’s body habitus” (we stay away from the word “limited” because this word has specific billing implications). This phrase conveys to the referring physician that we are not getting the pictures we hope to get because of something we can’t control, namely the patient’s size. No matter how we tweak the transducer frequency, adjust the time-gain compensation curve, or simply press harder we cannot achieve optimal image quality.Lev

Sometimes, however, we are either pleasantly or unpleasantly surprised. A thin individual may have soft tissues that are difficult to penetrate, leading to an image of suboptimal quality.

Conversely, a patient with high body mass index may turn out to be a breeze to scan. Clearly, there is something more than simply patient size that is at work here. After all, echoes on ultrasound are created at interfaces between tissues that differ in acoustic impedance. A larger patient with relatively homogenous subcutaneous tissues (fewer interfaces) may reflect and scatter the beam less than a patient whose tissues are composed of a more varied mixture of fat, fibrosis, and/or edema (more interfaces).

When people consistently look great in photographs, we call them “photogenic”. The implication of this word is that somehow the camera loves the subject so much that their still image “overachieves” compared to the expected output. When you think about it, that may be a subtle insult, but it is usually used as a compliment. Conversely, a person we find attractive may, for reasons that are unclear, not be at their best in photographs.

In light of the above, I would like to coin a new word, “sonogenic”. A sonogenic person is one who transmits sound so well that their ultrasound images consistently exceed expectations. A patient that frustrates us because their images are of lower quality than expected would be characterized as “non-sonogenic”.

Using this word can potentially facilitate communication. The sonographer could say to the reading physician: “Sorry for these images; the patient wasn’t sonogenic”. The physician’s reports can become shorter: “The study is suboptimal because of patient’s body habitus” becomes “the patient is not sonogenic”. The noun form would be “sonogenicity” (yes, “photogenicity is a word”). A simple grading system may even become part of the ultrasound report, i.e., sonogenicity is above average, average, or below average.

In conclusion, I hereby propose that the word “sonogenic” be added to the formal ultrasound lexicon. What do you think?

 

Would you use the term sonogenic? Do you have any other suggested new terms that could better describe an aspect of an ultrasound examination? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Levon N. Nazarian, MD, FAIUM, FACR, is Professor and Vice Chairman for Education in the Department of Radiology at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.

The Place of POCUS in Prevention of Physician Burnout

Doctors’ jobs, in the hospital or clinic, have been getting more demanding and less rewarding in the last several years. Well-meaning changes including the rise of electronic medical records and attempts to improve how we do our jobs through quality measures have made us sad and tired and supply none of the joy that we can get from a satisfied patient or a diagnostic puzzle cleverly solved. We may find ourselves aging, with multiplying frown lines and receding hairlines, sitting at our computers finishing our documentation, while our families have vacations and parties without us. Although we make enough money, strangely, it doesn’t buy happiness.

When we are tired and sad; we lack the creativity to make job changes. Fear eclipses courage.

IMG_9919Sometimes we do stupid things involving alcohol or indiscretions, or buying something expensive on credit… family members give us “that look.”

We feel inadequate.

We get grumpy and stop doing that extra little bit to connect with the patient or unravel the mysterious illness. The precious little job satisfactions of working well with our team or taking our patients’ point of view become rarer.

We are burning out. There’s that telltale smell of smoke as our soul shrivels and our dreams fry.

What do we need? Probably a vacation, maybe even a stint working in global medicine, to change our perspective. Counseling and confiding in friends can help. If we keep doing the same job, perhaps we need a scribe to take care of the paperwork. Also learning a new skill could make us wake up and love medicine again. Enter point-of-care ultrasound.

I don’t want to trivialize the pain of burnout. It can be devastating, making us depressed, ending marriages, wrecking careers and friendship, collapsing us inward, and sometimes leading to suicide. Somehow we need to jump off of that horrific course and better sooner than later. I got close to burning out early in my career and ever since that time I’ve done everything I can to stay in love with my job. For me, learning to do point-of-care ultrasound enriched my practice and, along with a major career adjustment, kept me from getting all charred and crispy.

Doing point-of-care ultrasound, for a physician who is already skilled in practice but has no ultrasound experience, can be life-altering. As I matured in my practice, some of my physical exam skills improved but others atrophied for lack of use and because I knew that I couldn’t trust them. A fluid wave doesn’t predict ascites. Dullness in the base of the lung doesn’t lead me to suspect a pleural effusion. Splenomegaly, if not massive, is so hard to detect in my super-adequately nourished patients. Learning basic point-of-care ultrasound brought me back to paying good attention to my patients’ bodies. And they were fascinated and appreciated the extra care. I also was able to more quickly solve their medical mysteries and shorten previously prolonged evaluations. Seeing patients got more fun.

Burnout is an awful feeling and is preventable. It happens when we get ourselves into situations that are not sustainable and don’t feed our souls. We physicians have vast options and we need to recognize when we are trying to do a job that is wrong for us. And before we quit the profession entirely, we need to try learning something that makes it fun again. Point-of-care ultrasound, for instance.

 

How do you avoid burnout? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Janice Boughton MD, FACP, RDMS, is an internist  Moscow, Idaho. She practices hospital medicine and rural primary care as well as teaching point of care ultrasound techniques in the US and Africa. She also writes about healthcare economics in her blog (www.whyisamericanhealthcaresoexpensive.blogspot.com.)

Dr. Boughton graduated from the Johns Hopkins School of Medicine in 1986 and completed residency training at the Johns Hopkins Hospital and the University of Washington. She started doing bedside ultrasound in 2011.

Prolong Your Sonography Career

How many of you entered into the career of a diagnostic medical sonographer with the intent of eventually retiring and living comfortably after 20+ years? Me too! The reality is very few of us make it to 10 years, let alone 20 in this field. Without giving you copious amounts of statistics and a personal sob story that I am sure most of you can relate to, the fact is we are all incredibly prone to injury. After just 6 years of scanning, I have shoulder, back, elbow, and wrist pain daily. After sending out my own personal survey, I was able to verify that almost 100% of you can relate to this discomfort.

For the past 5 years, I have been a huge fitness advocate devoting my time to bettering myself and those looking to live a healthier lifestyle. Just a few weeks ago it clicked; why not incorporate my love for fitness into my love for sonography?! I took on the challenge by recording some of my upper body, specifically shoulder workouts that I had been doing lately in the gym. With increased BMIs, shorter scan durations, and increased patient loads, we need to take care of ourselves first and foremost. I feel incorporating physical training and stretching would prolong our careers and our quality of life.

Some of you are probably wondering how you can incorporate working out after a busy day, but when you make small changes daily, you do get stronger. Strength, in turn, makes scanning easier and ultimately decreases your pain. My arms are twice the size they were when I started scanning 6 years ago. Through yoga, stretching, and these upper body workouts my body now has a way of protecting my joints that are most susceptible to injury.

Can you believe the solution to our injuries has been to find a new career!!? I did not go to college for 4 years and work my butt off to just “find a new career.” Let’s work together on improving our own personal health and let’s start with these shoulder strength exercises.

I challenge you to find 3 days a week to do the following exercises seen in the linked video and listed below:

  • Resistance band warm-ups
  • Bicep and hammer curls
  • Pulley lateral raise
  • Bent over lateral raise
  • Barbell upright rows
  • Machine shoulder press

**Start with 10 repetitions and 2 sets of each exercise and increase those numbers each week.

I absolutely love posting my fitness journey, including great workouts that will have you thanking me later. You can find me on Instagram: @_sonographer_squats_ or by email: shaunadittl@gmail.com. Below, I posted my shoulder workout that will help you through the list I mentioned above, as well as the link to my survey.

Survey:

https://www.surveymonkey.com/r/fitbysonographersquats

 

Interesting Survey Results:

Gebelle_Figure 1

 

Gebelle_Figure 2

 

Gebelle_Figure 3

Shoulder Workout Video:

 

 

 

Do you do any strength training to prevent injuries? What exercises would you recommend? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.
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Shauna Gebelle, BS, RDMS, RDCS, RVT, is a Perinatal Sonographer in San Diego, California.

Menstrual Pain: Is it Adenomyosis?

Frequently, during daily ultrasound consultations, female patients complain about certain symptoms during their menstrual period, whereas other women go through their monthly cycle without experiencing pain and might feel just a little discomfort associated with their period.Ticci

For those women who do suffer from various common menstrual disorders that can cause stress, pelvic ultrasound is commonly used to investigate any underlying medical problems in menstrual abnormalities.

For example, before speaking with her physician, Brianna didn’t know which symptoms were normal and which were not, since she always thought that a cycle that’s “regular” for her may be abnormal for someone else. She was just chilling at a regular doctor’s checkup when the physician advised her about a vaginal ultrasound after she told him about her symptoms during her menstrual period.

Brianna had never experienced a transvaginal ultrasound before and she thought that it was a little weird and awkward, although some of her friends had told her a while back that the procedure was not painful.

Brianna was referred to my office for the ultrasound exam. She complained about a persistent pelvic pain during her period and about heavy bleeding.

Ultrasound findings:

  • enlarged globular uterus with different densities within the myometrium
  • pockets of fluid within the muscle of the uterus (myometrial cysts)
  • linear acoustic shadowing without the presence of fibroids and echogenic linear striations, like stripes

That’s adenomyosis and it’s very common. And she’s probably never heard of it.

 

 

 

Adenomyosis

Adenomyosis is a common benign gynecologic disorder and its etiology and association with infertility are still unclear. It is a benign disorder previously associated with multiparity but recently, an association with infertility has emerged.

Adenomyosis can be asymptomatic or present with menorrhagia, dysmenorrhea, and metrorrhagia.

Other symptoms may be painful intercourse and/or persistent bladder pressure. These symptoms usually occur in patients aged 35 to 50, and the condition may affect 65% of women.

The patient looked at me while I tried to quell her fears, trying to explain that it is just an unusual thickening of the uterine wall, caused by glandular tissue being pushed into the muscle.

“It’s cancer?” That’s the first question.

“No, it’s not cancer.” I try to explain: it’s something I saw on the ultrasound called adenomyosis and it’s not going to turn into cancer.

The patient probably had never heard that word before and she’s asking how to spell it so she could go home and Google it.

“Is that a bad thing?” That’s the next question.

I answer, “no, it just doesn’t sound like a good thing. ”

 

Adenomyosis and Endometriosis

Brianna is actually very worried at this point. She’s heard the word “Endometriosis” before because some of her female friends have had it and they thought that, perhaps, that was the cause of their fertility problem.

That’s the next question.

“Is adenomyiosis similar to endometriosis?”

I try to explain that endometriosis happens when endometrial cells are outside the uterus. Adenomyosis is when these cells grow into the uterine wall.

This is my answer and I’m trying to reassure my patient that the two syndromes are quite different. Endometriosis is much more severe. Because Brianna remembers that her friends had pregnancy problems, she’s now scared to death.

Pregnancy and fertility, that’s the great issue.

 

Pregnancy and fertility

“Is it possible to get pregnant with Adenomyosis?”

“Don’t be too concerned, Madam” is my answer.

Evidence that links adenomyosis to fertility is limited to case reports and small case series. But there is a significant association between pelvic endometriosis and adenomyosis (54% to 90% of cases), and it is well known that endometriosis causes infertility. For this reason, findings of infertility were due to endometriosis rather than adenomyosis.

At this point in the conversation, I really think that it is very important to calm the patient.

“In most women, it’s not going to have a medical impact. Sometimes, doctors don’t even tell their findings because it’s not really clinically significant,” I say to her.

 

Treatment

Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, including a high risk of miscarriage and obstetric complications.

The therapeutic choice depends on the woman’s age, reproductive status, and clinical symptoms. However, so far, few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed, and no drugs labeled for adenomyosis are currently available. Nonetheless, the disease is increasingly diagnosed in young women with reproductive desire, and conservative treatments should be preferred.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. An antiproliferative effect of progestins suggests their use for treating adenomyosis by reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to induce regression of adenomyosis by relieving pain and reducing bleeding.

There is evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

 

 Let’s go back to our office

After this long talk, Brianna realized she didn’t need to freak out.

One thing she really couldn’t understand is why she’d never heard the name of this condition.

She was also kind of upset because she spent her teenage years suffering so much from pelvic pain during periods and now that she’s ready to have a family and give birth, a doctor tells her about an annoying medical condition, gives her all this news that explains all her symptoms, which may cause fertility problems and she’d never heard of it before!

Any suggestions for getting the word out about adenomyosis?

 

Do you have any suggestions for getting the word out about adenomyosis? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Pietro Ticci, MD, is originally from Florence, Italy, and has been a medical doctor in the Florence Area (Tuscany) since 1995. Currently, he is an Ultrasound Physician at his private medical facilities in the Florence Area.