The Democratization of Point-of-Care Ultrasound

The subtle sound of a distant explosion rang out. We barely flinched, numb to the sound that was a near-daily occurrence at our remote outpost in war-torn Afghanistan in 2005. Minutes later, a fast-approaching Humvee suggested that this time, something was amiss. The sight of a bloodied soldier draped over the vehicle’s hood provided confirmation.

CPT Jonathan Monti, left, and Lt. Col. Robert Craig, in the army physical training shirt, treat a trauma casualty at Forward Operating Base Ripley in 20005.

As we scrambled to prepare our dusty, sparsely equipped treatment tent, casualties poured through the door. A young Afghan man, triaged as minimally injured, lay in front of me, peppered from head to toe with small shrapnel wounds. His wounds were indeed benign-appearing, as his triage category suggested, but penetrating wounds can be deceptive. I struggled to gauge whether his lack of responsiveness to my questions was due to our language barrier, or something more sinister like blunt or penetrating head trauma. His primary survey was otherwise unremarkable…nosignificant external hemorrhage, airway intact without labored breathing. His blood pressure was borderline low, not an uncommon finding in the thin/healthy. 

I dusted off the nearby SonoSite 180, now widely considered to be the first portable ultrasound device of its kind. Most of its knobs were still foreign to me, and my inexperienced eyes struggled to interpret the grainy images. His belly and lungs appeared unremarkable, but scanning through his subxiphoid region, the black stripe encircling his heart jumped out at me, inconsistent with my already-anchoring bias of a traumatic brain injury, but consistent with the images I had only seen in Ma and Mateer’s landmark text.

I quickly called the surgeon, whose experience with the device barely surpassed my own. After a quick look at both the machine and text, he commanded his team to prep the operating suite, an equally dusty, adjacent tent. Minutes later, the surgeon’s skillful incision of the patient’s pericardium evacuated the now-tamponading bloody effusion, revealing the tiny piece of shrapnel embedded within the patient’s right ventricular wall and saving the patient’s life.

On that day, the humbling and lifesaving power of point-of-care ultrasound (POCUS) was revealed to me. As a junior clinician with limited trauma experience, I had no formal ultrasound training, mentorship, or experience. Yet this machine, when coupled with only a book, and the desire to learn, allowed me the opportunity to overcome the shortcomings of my physical exam skills, my resource constraints, and my cognitive bias, and the mistriage of another, to ensure a patient received the timely and definitive care he deserved. In the decade or so since, I have been fortunate to serve my patients while under the tutelage of several POCUS experts whose altruistic and thoughtful mentorship allowed me the opportunity to cultivate my passion for this powerful tool, while also imparting the nuances and limitations of POCUS, frequently leading me back to a common question:

How can we best harness the full power of POCUS?”

There is a rapidly growing body of evidence that suggests that clinicians of various skill levels can effectively employ focused POCUS applications with minimal training. Though not without risk, POCUS is no different from other clinical skills; performed with variable competency regardless of profession, specialty, or scope of practice. Some will evoke the mantra of “a fool with a tool is still a fool,” which may certainly be true, but it is unfair to assume that foolhardiness is necessarily bound by profession, experience, or even breadth/depth of training.  

The notion that POCUS can/should only be monolithically employed by a limited number of broadly/extensively trained physicians may be yet another example of the monoculture of thought that continues to plague our healthcare system. Certainly, any diagnostic testing should be performed thoughtfully; but do we limit who can use the stethoscope, or order a CBC, based upon title or his/her knowledge of Bayesian principles, Fagan’s nomogram, or pre/post-test probabilities and test-characteristics? Do all successful clinicians adhere to these principles with each and every test they order? Are there other factors to consider when ordering diagnostic testing, particularly in the resource-constrained areas where POCUS can have the greatest impact?

Until POCUS is adaptably and appropriately employed by all those who provide care, regardless of practice setting and scope, its full benefit and potential, especially to those living in medically underserved areas, cannot be realized. Some will inevitably oppose this concept, citing concerns with expertise, patient safety, documentation, reimbursement, etc. Ironically, it is these same arguments that emergency physicians faced 2 decades ago before successfully overcoming significant resistance to fully integrate POCUS into emergency medicine practice.

POCUS leaders are uniquely poised to best mitigate the risks associated with POCUS use through the provision of expanded training opportunities that are well-crafted, appropriately focused, and variably commensurate with clinicians’ skills, cognition, practice setting, and scope. Some of our most innovative POCUS educators are already doing so, whether by incorporating POCUS into the physical exam, or training nurses to perform diagnostic ultrasound, or training medics to employ ultrasound in austere locations. The rise of artificial intelligence/machine learning is already reducing the training burden traditionally associated with POCUS.

POCUS is a rare technological tool; one that is portable, versatile, and liked by both patients and clinicians alike. It can expedite diagnosis and care, improve the accuracy of our physical exam, and help us overcome our own anchoring bias while reducing the risk of procedural error, healthcare cost, and iatrogenic radiation exposure. Though it may not impact a majority of patients, for those it does, that impact is often significant. But the most uniquely promising characteristic of POCUS that we should all embrace is its ability to bring better-informed clinicians of any ilk, back to the bedside where they belong, wherever those in need of care may be.


Do you believe the democratization of point-of-care ultrasound can enhance patient care? Share with us your thoughts or your efforts to do so: comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Dedicated to the memory of CPT Jeremy A. Chandler, 1st BN, 3rd Special Forces Group, whose life was lost while bravely serving his country on that fateful day, August11th, 2005, in Tarin Kowt, Afghanistan.
https://www.greenberetfoundation.org/memorial/jeremy-a-chandler/

Jonathan Monti, PA-C, RDMS, is an Associate Professor of Emergency Medicine PA Studies at Baylor University and president of the Society of Point-of-Care Ultrasound (SPOCUS). He is currently conducting research on the unconventional employment of ultrasound in the U.S. Armed Forces as an employee of the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Teaching Point-of-Care Ultrasound

Ultrasonography (US) is now used in some fashion by most specialties, and in graduate medical education, performing a US examination is now a routine expectation in the fields of emergency medicine, surgical critical care, diagnostic radiology, pulmonology, and gynecology. The American Medical Association has confirmed that physician‐performed US is within the scope of practice of appropriately trained physicians and recommend that training and education standards be developed by individual medical specialties.

In light of its clinical and education utility, it is reasonable to expect that US would be taught during medical school. Some national and international bodies, including the AIUM, have proposed curricula for medical students. While its level of use is variable, several schools have described integrated US into undergraduate medical education. Several studies have shown that students are able to and want to learn point-of-care US (POCUS) in medical school. Let’s review some tips for engaging medical students while teaching POCUS.

1. Hands-on time

Allow the medical student to have hands on the probe as much as possible. Limit lecture time to only that which must be done in lecture format. Make sure group learning time is done in small groups with maximal time for each student to use the probe. Give them time to work through different positions and views to help identify windows and quality images. Use your verbal commands to direct them instead of taking the probe. If you are going to take the probe, put your hand over theirs.

2. Engage the student

Find a use for ultrasound that is relevant to the student’s specialty of choice. Most specialties now have some use for ultrasound. IF you cannot identify a use for ultrasound in the specialty of choice, consider teaching general skills like US-guided IV insertion. Describe how US was or would have been useful during residency.

3. Make it fun

Use simulation liberally. Consider having a game or competition (see Sono-games, SonoSlam, or other similar competitions for potential ideas). Multiple homemade procedural models have been described and are inexpensive. Medical students, in general, love practicing procedures and are mostly competitive by nature. There are several ways for the more experienced student to improve their US skills in a fun manner. Some ideas include identifying inanimate objects blindly that are immersed in water, a competition like fastest FAST exam, or making a procedural simulation competition.

4. Short and sweet

Keep sessions engaging by spreading practice out over time. Again, keep lectures as brief and need-to-know as possible. Most medical students will only need a brief physics review and do not, for example, need to know the Nyquist limit. They need to know how to answer focused questions with ultrasound. Students will lose interest if doing the same exam over many hours. Consider spreading sessions, especially image review sessions, out to 1 hour or less over several days. Intersperse different types of ultrasound (e.g., abdominal, cardiac, pulmonary, vascular) within the same session to keep students engaged.

5. Start early

Expose students to US early on in medical school. Consider adding it to anatomy or physiology classes while students are still in their pre-clinical years. If you do not have the swing to add a formal session to preclinical years, consider having voluntary “anatomy review” sessions using US. Try to get enough interest to start an interest group for students that is student-run. This will allow them to take some of the responsibility for scheduling and promoting events and you can focus on what you do best, teaching US.

Ultrasonography is coming to medical education and will continue to grow in use. While students going into specialties like radiology and emergency medicine may instantly be engaged in US teaching, consider ways to engage other students. There is a role for US in nearly every specialty.

Sonographers can and should play a key role in teaching medical students techniques for US. Sonographers perform these exams every day for many years. They have tricks for obtaining quality images and many sonographers are also quite good at interpreting exams, as well.

Embrace medical students and engage them with your passion for ultrasound. Show them how it will be helpful to them in the future. Take an active role in medical student education and watch the use of ultrasonography in medical practice continue to grow.



Do you have suggestions for teaching POCUS to medical students? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Joshua J Davis, MD, is an Emergency Medicine Resident at Penn State Milton S. Hershey Medical Center.

Why Teach Ultrasound?

Sonosorority on ultrasound teaching rounds: (left to right) Michelle Nasal, Grace Rodriguez, Jessica Everett, Erin Wendell, and Tatiana Thema, with Creagh T. Boulger, MD.

Early in my career, I recall my choice to pursue my academicniche in ultrasound and more specifically ultrasound education being questioned. “Why would you do that?” “How are you going to get promoted?” “This is just a fad!”. For a moment I paused wondering if I should heed this advice. Was I making a mistake? I am happy I did not dwell on that moment because I would not be where I am, I would not have gotten promoted, I would not have touched so many learners, met so many amazing people, and helped so many patients.

One of my first patients as a doctor illustrates why I teach ultrasound. I was a brand-new doctor maybe 10 days under my belt. I walked in the room of my patient. They were in clear discomfort, I was nervous. I pushed on their abdomen. Unsure, I walked out to my supervisors and said: “I think I have an acute abdomen in bed 10.” We paged surgery and were ordering other imaging when my now-mentor, Dave Bahner, suggested we do a FAST exam. This was before the ultrasound invasion in medical school and my only exposure to ultrasound was limited and in OB and the trauma bay. He immediately noted significant free fluid and presumed rupture of a neobladder. The patient went promptly to the OR. This opened my eyes and sparked the passion for ultrasound that has fueled my career. I could use this machine to look inside and help patients on the outside.

So why teach ultrasound and who should you teach?

I teach ultrasound because…

It enables me to bring 2-dimensional anatomy to life. One of my greatest joys is showing a new medical student, undergrad, or high school student their own heart beating right in front of them and see the awe in their eyes.

It makes complicated concepts simple. I recall the challenge in medical school of the preclinical years 1 and 2. Understanding systole, diastole, cardiac valves, and flow. On paper, these are complicated and merely rote memorization. Watching these events occur on ultrasound in real time and how they are altered by simple maneuvers such as Valsalva or squatting truly aids in full understanding of the concepts.

Ultrasound is always relevant. One of my favorite courses to teach is ‘The Approach to Undifferentiated Shock’. This is attended by all fourth-year medical students. By the fourth year in medical school, many students are distracted by interviews and matching and have already chosen their respective fields. I love this course because as a teacher, I get one last chance to show them the light, or rather sound, and how it could help them if they encounter a patient in shock. I ask each of them their field of choice and if they see ultrasound having a role in their career. Many will nod affirmatively to appease me but by the end of the course, they are asking if we can teach them more ultrasound before they graduate. Ultrasound helps me connect and let them know how we use ultrasound to understand the causes of shock and how to manage these patients. This ability to break down silos and demonstrate how useful it can be across many specialties that care for patients is one of my favorite aspects of teaching bedside ultrasound.

Innovation

Ultrasound is such an exciting new tool and developed into a new field. New probes, technology, and applications are always evolving and changing how we use it to care for patients.

Ultrasound education is equally as exciting and dynamic. Because of challenges such as limited curricular time and tight budgets we have gotten creative to teach ultrasound. Ultrasound education has led the way with new concepts such as remote instruction, flipped classroom, near-peer training, learning through modeling, and gaming.

Mentorship

I have been fortunate to be blessed with amazing mentors who have given me amazing opportunities. The ultrasound community is small and welcoming, as well as young, fresh, and innovative. One of the greatest joys of teaching ultrasound has been the relationships I have made. I have found wonderful mentors but also been able to be a mentor. To watch my students turn into fellowship directors, division heads, and national speakers has been one of the greatest rewards. I have seen that hard work, loving what you do, and helping others learn ultrasound is a winning strategy for me and possibly you too.

Clinical Excellence

I make myself endlessly available to my learners and that offer does not end at graduation. More so than any award I have ever gotten, the greatest accomplishments of my career are the notes, emails, and texts saying thank you: ultrasound saved my patient last night. Those clinical wins where a patient benefits from a bedside ultrasound make every late night of lecture prep worth it.

So, why teach ultrasound? Ultrasound is the future of medicine and medical education. Get involved!

Why do you teach ultrasound? What do you value most about teaching the next generation of ultrasound users? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Creagh Boulger, MD, RDMS, FACEP, is Assistant Professor, Assistant Director of Ultrasound, and Assistant Fellowship Director of Emergency Ultrasound at Ohio State University Wexner Medical Center.

Richard G. Barr, MD, the Journal of Ultrasound in Medicine’s New Editor-in-Chief

The American Institute of Ultrasound in Medicine (AIUM) is proud to announce that Richard G. Barr, MD, PhD, FAIUM, FSRU, FACR, is the new editor-in-chief of the Journal of Ultrasound in Medicine (JUM). Dr Barr’s tenure as editor-in-chief officially began January 1, 2019.

Barr

Congratulations on your new role as JUM editor‑in‑chief, Dr Barr.

A regular contributor to, and reviewer for, the JUM, Dr Barr has a diverse background that is well suited for the journal’s continued growth. He is a board-certified radiologist and PhD chemist who currently serves as assistant chairman of the Department of Radiology at Northside Medical Center and as president of Radiology Consultants Inc. In addition, Dr Barr is a professor of radiology at Northeastern Ohio Medical University.

Dr Barr has already instituted some changes to the journal to help with the increased submission rate: he has increased the number of deputy editors from 3 to 5. Dr Barr has selected Michael Blaivas, MD, FAIUM, and Andrej Lyshchik, MD, PhD, to join Flemming Forsberg, PhD, FAIUM, Wesley Lee, MD, FAIUM, and Mark Lockhart, MD, FAIUM, as his deputy editors. Dr Barr has also stated that at present, the JUM will be accepting the same number of articles, but they are discussing the possibility of online-only articles as the number of submissions continues to increase.

An additional change coming to the JUM is that invitations will be sent to experts inviting them to write and submit articles reviewing topics of interest for JUM readers. The topics may be in areas of controversy or reviewing how to image an organ, etc.

Dr Barr is a fellow of the AIUM, Society of Radiologists in Ultrasound, and American College of Radiology, and his interests include breast imaging, contrast-enhanced ultrasound, and elastography. He has published more than 100 scientific articles and has given more than 300 talks around the world. He received a 2017 Radiological Society of North America Honored Educator Award and Aunt Minnie named him a semifinalist for the most influential radiology researcher in 2017.

“I look forward to serving as editor-in-chief for the JUM,” said Barr. “My predecessors have done an excellent job creating an international journal for all ultrasound subspecialties. I hope to continue this great work while increasing the readership and quality of the content.”

Do you want to know more about the JUM? Visit the Journal of Ultrasound in Medicine online, and if you have any comments, add them below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Richard G. Barr, MD, PhD, FAIUM, FSRU, FACR, is the assistant chairman of the Department of Radiology at Northside Medical Center, and president of Radiology Consultants Inc, both in Ohio. In addition, Dr Barr is a professor of radiology at Northeastern Ohio Medical University.

Training and Integrating Sonographers via Dedicated Preceptors

Hiring new staff members is risky business. Despite all the resources invested in identifying and evaluating qualified candidates, there’s no guarantee they’ll be a good long-term fit for the department. As new staff members begin to settle into a new job, there are a variety of reasons why they might ultimately leave the position. Many of these reasons can be traced back to deficiencies in orientation and training programs. With this in mind, it is of the utmost importance to invest appropriately in the onboarding process. A successful onboarding and training program provides benefits to the candidate and the organization.IMG_2125

My experience with these processes comes primarily from my current position as the Ultrasound Educator at St. David’s North Austin Medical Center in Austin, Texas. A huge portion of our sonographers are hired and contracted to maternal-fetal medicine (MFM) clinics around the Austin area; working for Austin Maternal-Fetal Medicine. Expectations for these sonographers are high. They perform all ultrasound examinations common to maternal-fetal medicine practice, including fetal echocardiography and diagnostic 3D/4D techniques. The scarcity of qualified candidates means that we often hire candidates from out of state, and integration to the department and community are among our primary concerns; having a structured training program helps with that.

New employees spend their first 2 days on the job attending facility orientation. Their third day of work is their first day in the MFM department. They’ll meet with leaders and physicians, and tour all relevant areas. In addition, I spend some time with them reviewing the training process and setting expectations. At this time, we pair them with a Sonographer Preceptor. The preceptor/trainee assignment is, of course, subject to change, but we try to limit this as part of the goal is to provide some stability and consistency during the training period.

The standard training period is 3 months in duration, although, we have extended training in some cases up to 6 months. This period may look different for various candidates based on their prior experience level. However, there are several characteristics that remain fixed:

1. One-on-one work with a preceptor

The Sonographer Preceptor is expected to directly observe while offering real-time feedback, every part of the trainees workday. This level of intensity may only be reduced after consultation with the Ultrasound Educator.

2. Weekly preceptor feedback report

This weekly report is filled out by the Preceptor and reviewed with the trainee. They review things that are working well and also plan which tasks need additional focus for the following week.

3. Image review with the Ultrasound Educator

On a weekly or biweekly basis, the trainee will meet with the Ultrasound Educator to review the Preceptor feedback report and review a selection of examinations from the prior week.

4. Didactic and written material for review

Each candidate is supplied with protocols, American Institute of Ultrasound in Medicine (AIUM) guidelines, review articles, and some pre-recorded lectures that cover essential quality standards and approaches for the department.

This high-touch training period helps to ensure that we have a strong understanding of the progress being achieved and can quickly adjust if we do not see steady growth.

Many people will recognize that it takes years to develop strong, comprehensive skills, in the performance of MFM ultrasound examinations. So what can we expect to accomplish in only 3 to 6 months? Upon completion of the training period, the sonographer should be able to:

  1. Complete normal fetal anatomic surveys, fetal echocardiograms, and other examinations in non-obese patients, demonstrating an understanding of proper technique, measurements, and optimization.
  2. Exercise professional discernment by getting help when their own efforts do not produce the answers or quality they expect.

These two goals may initially appear to be overly simplistic, but they work together beautifully in the transition out of the training period and into independent performance. Completion of normal (relatively easy) examinations proves that they understand the target. They understand what normal looks like and the essential techniques involved. The second point is key as it gives department leadership the confidence to allow them to work independently, because we know that they understand what good enough is, and we know that they have the resources they need in order to help them when they cannot meet expectations on their own. This is an important skill that never expires. This is relevant for sonographers, physicians, and other health care practitioners throughout their careers. Knowing when you’ve hit your limit and when to seek additional counsel is key to providing the best care to our patients (regardless of one’s particular level of expertise).

These two benchmarks, along with ongoing quality assurance efforts, help give us confidence in our team even as they continue to grow their individual skills and proficiencies over the coming years.

A note on Preceptor selection

Key to the success of this process is the selection of Sonographer Preceptors. These team members fill two distinct (individually important) roles: technical trainer and social integrator. With that in mind, selection of the individuals who fill this role is very important. Social characteristics we look for are warmth, kindness, extraversion, and the tendency to be inclusive. Technical expertise is evaluated based on history, quality assurance, physician feedback, and ability to evaluate and explain abnormal cases.

Full-time training in a one-on-one environment for 3 months or more at a time can be emotionally and mentally exhausting (even if rewarding). With this in mind, we try to maintain several Preceptors on our team so that these sonographers are able to work independently for extended periods between training new employees.

The social and integrative aspects of our Preceptor Program are not formally defined, yet the benefits are clearly evident. We see that our new employees make strong connections with their preceptors and other team members, frequently having lunch together and engaging in other extracurricular activities during time off.

It is important to point out that preceptors should typically be individual team members—not leads, supervisors, or managers. These formal leaders have other administrative duties that will inevitably get in the way of the one-on-one, full-time training involved in a preceptorship. Of course, leads, supervisors, and educators, may set aside time for some training of new hires, and this is certainly beneficial. For example, in our departments, I frequently set aside time to work with new hires or existing employees on specific skills such as 3D/4D, fetal echocardiography, or abnormal cases. Sonographers enjoy these sessions and benefit from them, but that does not replace the benefit of having a dedicated preceptor.

People don’t stay in jobs where they feel disconnected from the culture and community. This training program, with assigned preceptors, helps to meet the human need for connection in addition to building and verifying technical skills that are necessary for success.

For additional reading:
https://www.forbes.com/sites/forbeshumanresourcescouncil/2017/09/21/seven-ways-to-integrate-new-hires-and-make-them-feel-welcome-from-the-first-day/#1282eff640f6
https://www.thebalancecareers.com/employee-orientation-keeping-new-employees-on-board-1919035
https://trainingindustry.com/blog/performance-management/dont-ignore-training-when-onboarding-new-employees/

Does your practice have a mentor program for sonographers? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Connect

Will Lindsley, RDMS (FE, OBGYN, AB), RVT, is an Ultrasound Educator in Maternal-Fetal Medicine and Fetal Echocardiography in Austin, TX.

Ultrasound at the Zoo

Zoo medicine is quite the paradox. In one way, zoo veterinarians are specialists in that what we do daily; it is very unique and specialized and there are few licensed veterinarians that are employed as full-time clinicians in zoological parks. On the contrary, zoo veterinarians are also the ultimate general practitioners as our patients include everything from invertebrates to great apes and elephants (and all life forms in-between)… and for this wide variety of patients, we attempt to be their pediatrician, surgeon, dermatologist, cardiologist, radiologist, etc. I am fortunate to be the Senior Staff Veterinarian at the Louisville Zoo in Louisville, Kentucky.

In terms of imaging modalities, most zoo hospitals are equipped with plain radiography (film or digital) and have some ultrasound capabilities. A few of the larger zoos in the country have computed tomography (CT) in their on-site hospitals. In Louisville, when one of our patients requires advanced imaging, we make arrangements with local facilities with CT or MRI capabilities.

For ultrasound imaging, we have a portable Sonosite M-Turbo unit with both a curvilinear, 5-2 MHz transducer for primarily transabdominal imaging, and a linear array, 10-5 MHz transducer for primarily transrectal imaging. In addition, we have several donated large rolling Phillips Sonos units with an assortment of probes for both echocardiography and transabdominal imaging. One remains in the Zoo’s Animal Health Center and others are stored and used in animal areas for pregnancy diagnosis, echocardiograms on awake gorillas (through the mesh barrier), or just training/conditioning animals for awake ultrasound exams.

Zoo animals may present unique challenges when ultrasound imaging transcutaneously. In the case of fish and amphibians, imaging through a water bath (without even touching the patient!) can be very effective and noninvasive. The rough scaly skin of some reptiles makes a warm water bath similarly effective as a conductive medium for imaging snakes and lizards. Birds are not often examined via ultrasound because of the extensive respiratory (air sac) system they possess that interferes with the sound waves. For mammals, different species present different challenges. Many mammal species are thickly furred necessitating clipping of hair to establish good contact between the transducer and the skin. For transabdominal imaging, some species are very gassy (hippos, gorillas), which may complicate diagnostic imaging. Large or dangerous mammals that are examined awake via training need to be conditioned to present the body part of interest (chest, abdomen) at the barrier mesh and trust their trainer/keeper to allow contact with the probe. Often the greatest hurdle is habituating the animal to the ultrasound gel! When performing transabdominal imaging in our pregnant African elephant cow, rather than go through gallons of ultrasound gel smeared on her flank to fill in all the cracks and crevices in her thick skin, we run water from a hose just above wherever the transducer is placed.

DSC_4176

As general practitioners, zoo veterinarians have variable amounts of training in ultrasonography. We strive to do the best we can and are constantly learning, but the high variability in our daily tasks makes becoming an expert in ultrasound very difficult. So “it takes a village,” and we will regularly utilize specialists in our community to assist us in providing the best medical care for our patients. If I have a zebra or related species that requires a reproductive ultrasound exam, we will reach out to a local equine veterinarian that can apply their expertise in horses to a related species. Great apes have a high incidence of heart disease so whenever a gorilla or orangutan is anesthetized for an exam, part of the comprehensive care they receive is an echocardiogram by a human sonographer. Female great apes may get attention from our volunteer gynecologic sonographer as part of a reproductive evaluation. If the ultrasound exam is on a sea lion, wolf, or bear, I may contact a veterinary radiologist or veterinary internist competent in ultrasonography to assist.

In summary, ultrasonography represents a valuable, noninvasive, diagnostic tool for the zoo veterinarian.

Have you ever performed an ultrasound examination at a zoo? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Zoli Gyimesi, DVM, is the Senior Veterinarian at the Louisville Zoo in Louisville, Kentucky.

Evidence-Based Sonology: Changing the Practice of POCUS

Let’s say you are working in a busy emergency department. You get a call that a patient is being brought in by ambulance in cardiac arrest. You quickly assemble your team, assign roles, and discuss the plan—just in time for the patient to arrive. A paramedic performs one-arm compressions on an elderly man, pale yellow–his mouth stented open with a laryngeal mask airway. Your swarm of providers descends upon the patient, performing their jobs simultaneously in perfect concert. Airway, ventilations, rhythm checks, epinephrine: everything is running smoothly, but the patient is in pulseless electrical activity. During a rhythm check, someone looks at the heart with ultrasound. You glance at the screen and see a blurry subcostal cardiac view. You can barely make out the pericardium, but you see a weak contraction of the ventricles; there’s still no pulse. Compressions are quickly resumed. You consider all of the information – what are the chances this patient will survive? Should we keep going? Should I place a transesophageal probe? Wait, do I even have one of those?! Is ultrasound enough evidence to determine if further efforts are futile? Amidst your thoughts you hear a loud and eager call out: “I got a pulse!”. The team buzzes again – blood pressure, electrocardiogram, labs, vasopressors, cooling. You wonder, “Why did I even do that ultrasound? Is there any evidence it helps?”.

The difficulty encountered in this scenario is one that occurs countless times across the world’s hospitals each day. Point-of-care ultrasound (POCUS) has exploded off the shelves over the past decade. It has been borrowed from the hands of sonographers and cardiologists and made available to anyone who can afford a machine (training course optional). Overall, this has been a remarkably positive movement. Safer procedures, faster diagnoses, and sometimes a replacement for more potentially harmful imaging modalities. However, it is not without dangers. Those who use it aren’t always looking for the evidence for POCUS, as if it is somehow outside of the requirement for evidence. Others might not use this modality when it is indicated, ignoring the evidence that supports the use of POCUS. Both practices are unsafe. This is a big problem…but it’s one we can fix with the concept of evidence-based sonology.

Practicing based on the best available evidence has been a cornerstone of medicine since its advent; however, only more recently has it seen a visible resurgence. Now that it is in vogue there are physicians who are evidence-based medicine (EBM) specialists, there are EBM blogs and EBM courses. We teach our learners EBM principles and practices. So why has POCUS almost eluded this trend? Why would the evidence for POCUS not be examined with the same perspicacity as resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency department, for example? I have some theories. In the early days, POCUS was practiced by a few champions with a dream who understood how POCUS could revolutionize practice. However, ultrasound equipment was not yet widely available. This limited initial studies to case reports and case series on new uses, touting primarily theoretical benefits to patients. As anyone who has used ultrasound knows, this tool holds a powerful allure by allowing its user to magically look into the body and directly visualize physiology and pathology. It is easy to imagine that after a while you build up a confidence; when you see something it must really be there. In a sense, the rapid outbreak of ultrasound use and the ever-expanding list of applications outran the available evidence basis.

A review of a subset of ultrasound-related abstracts showed that there is now increasing research, although most of it would be classified as quasi-experimental, which may not be enough to inform practice.1 But the times, they are a’ changin’. Now ultrasound is ubiquitous, at least at most academic centers, in emergency departments, ICUs, and other places that care for the acutely ill. Therefore, the body of literature is growing, and now we just have to pay attention to it. Enter evidence-based sonology (EBS).

Your first question is probably – sonology? What’s that? Did he just misspell sonography? No. Sonology is a term that implies an expertise in the entire spectrum of POCUS. Not only the acquisition (the “-graphy”) of the images, but additionally the indications for performing it, the interpretation, and the subsequent appropriate medical decision making.2 This is important because the evidence for this modality could fall apart at any one of these levels, so practitioners must be attuned to the hurdles of each step. Your second question probably is, isn’t this just EBM? Of course! But it is something that we could improve, and therefore we need to rebrand this practice to continue teaching it as a concept to anyone that uses POCUS. There are several reasons why this is important. As POCUS becomes more integrated into medical practice, it is important that we are all on the same page. Research helps us understand the benefits and limits of this tool for each application. It helps us to know the best time to use the tool, how accurate it is when we use it, how it affects patients when we use it, and potential harms associated with it.EBS Graphic

So where do we go from here? There are 3 main ways you can practice EBS:

  1. Know the evidence
  2. Model the evidence
  3. Make the evidence (AKA perform research)

As far as knowing the evidence, this is nothing new for anyone practicing in a medical field. You know how to get a hold of journals. These days it’s easier than ever. You can even use social media, podcasts, and blogs to further distill the information for you. Just make sure you read the original evidence yourself and develop your own decisions about how it will change your practice. Secondly, you have to actually implement what you learn. Obviously, not all research articles are practice-changing, but many will at least add something to your understanding of POCUS in clinical practice. For example, in the aforementioned case of cardiac arrest, recent literature could have informed many steps of using POCUS. Cardiac activity on ultrasound has an odds ratio of 3.6 for survival to admission.3 Patient’s in PEA with cardiac activity on POCUS might benefit from continuous adrenergics instead of standard ACLS.4 Furthermore, an understanding that there is the risk of misdiagnosis of cardiac standstill and the risk of delaying chest compressions, might make you pay closer attention to these details during use of POCUS.5,6 Practicing with this evidence is not only the safest practice, but for those at teaching institutions, it can help create a newer generation of EBS followers. Lastly, make the evidence. Do the research. If you have a question, go find the answer. Collaboration is easier now that ultrasound is more widespread, as is evidenced by more multi-center trials.7-9 Talk about research ideas at national meetings and consider research groups for important questions.

There is now a greater evidence basis for POCUS than ever before. No longer are we restricted to a few case reports and our own intuition. We have randomized controlled trials; we have meta-analyses; we have real patient-centered outcomes. Know the evidence, model the evidence, and make the evidence. These are simple practices that we need to support for the sake of our patients. Now it’s up to you. Will you start practicing EBS? Think of creative ways to begin promoting this concept today.

References:

  1. Prats MI, Bahner DP, Panchal AR, et al. Documenting the growth of ultrasound research in emergency medicine through a bibliometric analysis of accepted academic conference abstracts. [published online ahead of print April 15, 2018]. J Ultrasound Med. doi.org/10.1002/jum.14634.
  2. Bahner DP, Hughes D, Royall NA. I-AIM: a novel model for teaching and performing focused sonography. J Ultrasound Med. 2012; 31:295–300.
  3. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33–39.
  4. Gaspari R, Weekes A, Adhikari S, et al. A retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A REASON Study. Resuscitation. 2017; 120:103–107.
  5. Huis In ‘t Veld MA, Allison MG, Bostick DS, et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017; 119:95–98.
  6. Hu K, Gupta N, Teran F, Saul T, Nelson BP, Andrus P. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2018; 71:193–198.
  7. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014; 371:1100–1110.
  8. Atkinson PR, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med. 2018; 72:478–489.
  9. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33–39.

Do you already practice evidence-based sonology? If not, will you start?  Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Michael Prats, MD, is currently Assistant Ultrasound Director and Director of Ultrasound Research in the Department of Emergency Medicine at the Ohio State University Wexner Medical Center. He is the founder of the Ultrasound G.E.L. Podcast that reviews recent articles in point of care ultrasound. Follow him on Twitter by his handle @PratsEM or visit ultrasoundgel.org.