The Personal Touch: The importance of human interactions in ultrasound

As I write this, the novel coronavirus COVID-19 is spreading across the globe, inciting fear and anxiety. Aside from frequent hand-washing and other routine precautions, many leaders, officials, and bloggers are advocating for limiting person-to-person contact. This has resulted in cancelation of many professional society meetings, sporting events, and social gatherings, and has stimulated new conversations regarding working from home and virtual meetings. Although these suggestions have many clear benefits (such as the decreased burden of commuting; limiting the spread of infection), there are additional reports describing the impact loss of face-to-face interactions may have on job satisfaction, workflow efficiency, and quality.Fetzer-David-14-2

The current practice of medicine, more than ever, relies on a team approach. No one individual has the time, knowledge, or experience to tackle all aspects of an individual’s care. No one is an island. Unlike many television shows that highlight a single physician performing everything from brain surgery to infectious disease testing, the reality is that we each rely on countless other members of the healthcare team. That practice of medical imaging, ultrasound, in particular, is no different. Whether we work in a radiology, cardiology or vascular, or obstetrical/gynecology practice, the team, and more importantly the relationship between team members, is paramount to an effective and impactful practice.

As a radiologist in a busy academic center, I rely on and value my personal relationship with my team of 50+ sonographers. These relationships have been facilitated by day-to-day, face-to-face interactions, allowing me to get to know the person behind the ultrasound images. These interactions foster an environment of trust. For my most experienced sonographers, my implicit trust ultimately leads to fast, efficient and precise exam interpretations, while for sonographers I rarely work with, my index of suspicion regarding a finding is naturally heightened, impacting my confidence in my diagnosis and thus affecting my interpretation, and ultimately how my report drives patient care.

The trust goes both ways: a strong relationship also fosters honest communication whereby sonographers can come to me with questions or concerns regarding exam appropriateness, adjustments to imaging protocols, and the relevance of a specific imaging finding. The direct interaction provides an opportunity for sonographers, new and experienced, to be provided immediate direct feedback regarding their study—they can learn from me, and often I from them, making us all that much better at the end of the workday.

In addition to trust, open communication allows for users of ultrasound to take advantage of one of the key differentiating features of ultrasound compared to other modalities: the dynamic, real-time nature of image acquisition. Protocol variations can be discussed on-the-fly. Preliminary findings can be shared with the interpreter, and additional images can be obtained immediately, without having to rely on call-backs, inaccurate reports, and reliance of follow up imaging (often by other modalities). This ultimately enhances patient care and decreases healthcare costs. In our practice, we have the ability to add contrast-enhanced ultrasound for an incidental finding, allowing us to make definitive diagnoses immediately, without having to recommend a CT or MRI—this would not be possible if it were not for a personalized checkout process.

We continue to hear about changes in ultrasound workflow across the country: sonographers and physicians, small groups and large, academic and private practices have all considered or have already implemented changes that minimize the communication between sonographer and study interpreter. This places more responsibility on the sonographer to function independently, and minimizes or even eliminates the opportunities for quality control and education. Sonographer notes and worksheets, and electronic QA systems, are poor substitutes for the often more nuanced human interaction. In my experience, these personal encounters enhance job satisfaction, and the lack of it risks stagnating learning and personal drive. There have been many sonographers that have left local practices to join our medical center specifically to take advantage of the sonographer-radiologist interaction we continue to nurture.

Some elements driving these transformations are difficult to change: growing numbers of patients; increasing reliance on medical imaging; medical group consolidation; etc. Many changes to sonographer workflow have been fueled by a focus on efficiency (decreasing scan time, improving modality turn-around times, etc.). Unfortunately, these changes have been made with little regard to how limiting team member communication impacts examination quality, job satisfaction, and patient outcomes; for those of you in a position to address workflow changes, consider these factors. For sonographers yearning for this relationship, do not be afraid to reach out to your colleagues and supervising physicians—ask questions, be curious, and engage with them. Nearly everyone appreciates a human interaction, and even the toughest personality can be cracked with a smile and some persistence. In the end, it is the human interactions and the open and honest communication that not only make us better healthcare providers but happier and healthier human beings.

 

David Fetzer, MD, is an assistant professor in the Abdominal Imaging Division, as well as is the Medical Director of Ultrasound in the Department of Radiology at the UT Southwestern Medical Center.

 

Interested in reading more about communication? Check out the following posts from the Scan:

The Excitement of New Ultrasound Technologies and Their Effects on Imaging-Guided Interventions

Recent advancements in ultrasound technologies have generated excitement in the field of ultrasound-guided intervention. For me, an interventional radiologist, these developments create new potential to perform needed procedures and a complementary approach to addressing our patients’ complex medical conditions. Further, benefits from these technologies include enabling us to achieve better patient outcomes, improve patient satisfaction, gain operational efficiencies, and improve stake holder’s satisfaction.azar_nami

The new technologies to which I’m referring are ultrasound contrast and ultrasound fusion. Ultrasound fusion is an element of artificial intelligence that combines the anatomic details of cross-sectional imaging like CT scan, PET scan, and MRI with the power of real-time ultrasound and is gaining more acceptance and popularity in medicine. Similar to a car’s GPS, ultrasound fusion helps a user find something. The powerful tool enables the operator to find lesions, which normally are difficult or even impossible to find on standard ultrasound. Needle navigation in the form of virtual tracking is a bonus that identifies needle location even when it is obscured by air or bone. It’s also a great teaching tool for inexperienced physicians who are interested in interventional radiology.

Ultrasound contrast is also emerging as a powerful tool in the field of interventional radiology. It enables the operator to better visualize a lesion and characterize the lesion and surrounding tissue. Now, we also can perform an ultrasound contrast sinogram to assess any cavity or catheter location, which opens new horizons in the field of ultrasound intervention, mainly in pediatric intervention.

An additional benefit for ultrasound contrast that it can be given without worrying about renal injury. This is very valuable when it comes to avoiding the toxic effect of iodinated contrast, especially in renal transplant intervention. Also, its very sensitivity to assess bleeding when compared with that of Doppler ultrasound. This technology allows us to discharge our patients home earlier after procedures when the contrast study is negative.

This is a very exciting time in the field of interventional radiology (IR). So many procedures that we could not perform using real-time ultrasound in the past now can be safely done with only ultrasound. Our patients appreciate how convenient it is. The procedures are done quickly, without the need to move the patient from their bed onto a stiff CT scan table. The lack of ionizing radiation in IR is also an attractive concept to the patient (mainly pediatric and/or pregnant), the clinician, and our IR staff.

Our institution is very supportive of utilizing advanced ultrasound technologies, as ultrasound allows us to gain operational efficiencies and is a more cost-effective alternative to CT-guided procedures. Operational efficiencies are gained by doing interventional cases portably with ultrasound, thus allowing the interventional CT suite to be utilized for diagnostic exams, which bring additional revenue to the institution. The ordering clinicians are also cognizant of radiation dose reduction, so providing an alternative to CT-guided procedures appeals to them.

Even though the implementation of contrast-enhanced ultrasound and fusion has been slower in the United States when compared with our colleagues abroad, it has brought a lot of excitement to my colleagues and me in interventional radiology. Like any new technology, the more we use, the more we appreciate its value. I predict they will become the new norm in daily practice. These advancements will continue to evolve and be an essential part of medicine.

 

Interested in reading more about contrast ultrasound? Check out the following posts from the Scan:

 

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Nami Azar, MD, MBA, is an Associate Professor of Radiology in the Department of Radiology at University Hospitals of Cleveland Medical Center in Ohio.

Ultrasound in Central Vein Assessment – The Importance of Knowing

Thorough vascular assessment prior to any intravascular device insertion is of paramount importance – for both clinician and patient. It guides the clinician to evaluate the current state of vessel health, determining suitability of the veins, and to follow a pre-determined pathway that will lead to the best decision for the patient. The assessment phase alone in vascular access procedures highlights a number of important underlying anatomical structures, as there are frequently variances amongst many patient groups and it provides a platform to perform a thorough assessment of the vascular structures to evaluate vessel health, viability, size, and patency, including the location of other important and best-avoided anatomical structures – prior to performing any procedures. The success in complication-reduction alone drives the importance of patient safety and improved patient- and device-related outcomes, not to mention patient satisfaction and comfort.

Its use for assisting the proceduralist are many:

  • pre-procedural ultrasound assessment of the vascular anatomy provides a rational choice of the venous access most likely to be associated with an optimal clinical outcome;
  • real-time, ultrasound-guided puncture and cannulation of the vein reduces the risk of failure and/or damage to the surrounding structures;
  • ultrasound scan after the venipuncture allows an early/immediate detection of puncture-related complications such as pneumothorax or local hematoma;
  • ultrasound-based tip navigation verifies the proper direction of the guidewire and/or the catheter during its progression into the vasculature;
  • transthoracic echocardiography allows proper ultrasound-based tip location;
  • ultrasound is also useful for detection of late complications such as catheter-related venous thrombosis, tip migration, or fibroblastic sleeve.

A simple yet systematic approach to vessel assessment is the RaCeVA (Rapid Central Vein Assessment), a process manifested as a quick and highly effective process for performing vessel assessment in a compelling and methodical approach. It allows a systematic approach to exclude venous abnormalities such as thrombosis, stenosis, external compression, and anatomical variations of size and shapes; it also allows a full anatomic evaluation for optimum site selection and the best insertion approach for the patient. It also has many advantages: it takes only 30–40 seconds for each side, it is easy to teach, easy to learn, and it is a useful guide for a rational choice of the central vein to be accessed, in terms of patient safety and cost-effectiveness, since it helps the operator to choose the most favorable puncture site and the optimal insertion site, with an overall improvement of the clinical outcomes and patient satisfaction.

RaCeVA - table

The RaCeVA Steps

Important considerations include the following:

  1. size of the vein (internal diameter/caliber)
  2. depth of the vein (depth of target vessel from skin surface)
  3. respiratory variations (influence of respiratory cycle on vein diameter)
  4. compression by artery (influence of arterial pulsation on vein diameter)
  5. proximity to non-venous structures that must not be damaged (pleura, nerve, artery)
  6. exit site location – convenience/appropriateness in terms for best care and maintenance
Image 1

Overview of RaCeVA steps highlighting ultrasound transducer scanning points – courtesy of the author.

Utilization of the RaCeVA protocol throughout both pre- and post- device insertion stages offers multiple advantages: “before” (to define the anatomy and the best target vessel), “during” (with real-time techniques of ultrasound-guided venipuncture: short-axis in-plane, short-axis out-of-plane, long-axis in-plane), and “after” cannulation (to detect or rule out complications such as pneumothorax, malpositions, local hematoma).

 

As a tool, RaCeVA is designed (a) to teach the different ultrasound-guided approaches to the central veins, (b) to help the operator to scan systematically all possible venous options, and (c) to guide the operator in choosing the most appropriate vein to be accessed, on a rational and well-informed basis. Optimal training is mandatory, through formal programs and hands-on sessions that imply using vascular simulation phantoms – the latter being especially important for practitioners to perform repeated ultrasound-guided vascular cannulations without posing serious risks for patients and ultimately successfully transferring this practice to patients.

 

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Timothy R. Spencer, RN, DipAppSc, BHSc, ICCert, APRN, VA-BC™, is Director of Global Vascular Access, LLC, in Scottsdale, Arizona.

 

The Best of the Scan, 5 Years in the Making

The Scan has been a home for all things ultrasound, from accreditation to zoos, since its debut 5 years ago, on February 6, 2015.MISC_SCAN_5_YR_ANN_DIGITAL_ASSETS_FB

In its first 5 years, the Scan has seen exponential growth, in large part due to the hard work of our 110 writers, who have volunteered their time to provide the 134 posts that are available on this anniversary. And it all began with Why Not Start? by Peter Magnuson, the AIUM’s Director of Communications and Member Services, who spearheaded the blog’s development.

In honor of this 5th Anniversary, here are some of your favorites:

Top 5 Most Viewed Posts

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1. Ultrasound Can Catch What NIPT Misses
by Simcha Yagel
(August 4, 2015)

Sonographer Stretches2. Sonographer Stretches for an ‘A’ Game
by Doug Wuebben and Mark Roozen
(January 31, 2017)

Keepsake3. The Issue with Keepsake Ultrasounds
by Peter Magnuson
(April 30, 2015)

Hip Flexor Stretch4. 3 Stretches All Sonographers Should Do
by Doug Wuebben and Mark Roozen
(January 19, 2016)

Anton5. From Sonographer to Ultrasound Practitioner: My Career Journey
by Tracy Anton
(October 23, 2018)

The Fastest Growing Posts
That Are Not Already in the Top 5

And we have plenty more great posts, such as:

To Treat or Not to Treat – That is the Question!

What if your newborn has a patent ductus arteriosus?

Some might ask, what is a ductus arteriosus?

During fetal development, a patent ductus arteriosus (PDA, see Figure) is important for diverting well-oxygenated blood returning from the placenta past the fluid-filled lungs and directly into the systemic circulation in order to perfuse organs.

Blood Flow with Patent Ductus Arteriousus

A patent ductus arteriosus allows for diverting aortic blood to flow into the lungs and thus pressurize the pulmonary circulation as well as allow for deoxygenated blood to enter into the aortic arch if the flow is reversed. Very low birth weight infants are prone to this condition and choice of appropriate treatment is in question. Image provided by Blausen.com.(4)

In full-term newborns, the PDA closes within two days of birth by means of vasoconstriction and anatomic remodeling.(1) Or it doesn’t. In 65% of premature infants born at 30 weeks’ gestation or less, the PDA fails to close within the first 7 days.(2, 3) Therefore, the pulmonary and systemic circulations remain connected. Consequently, blood is shunted away from the general systemic circulation to the lungs and can lead to severe flow-related problems such as central nervous system ischemia and hemorrhage, necrotizing enterocolitis, and renal failure. Such a Patent Ductus Arteriosus (PDA) leads to the ultimate question of to treat or not to treat? The two schools of thought in neonatology are watchful waiting, treating with nonsteroidal anti-inflammatory drugs (NSAID) or an invasive procedure to close the ductus.

Possible concerns are multifactorial. Intervention risks side effects from medications and procedural complications. Watchful waiting risks diminished blood and oxygen supply to the brain and abdominal organs. Quantifying blood flow and oxygen supply in these fragile humans is nearly impossible, especially since most of them are actually very low birth weight babies (VLBW, i.e. <1,500 grams). They are tiny.

In rare cases, clinicians use MRI to image and quantify PDA and carotid flow. That, however, requires specialized facilities in which the neonates can remain in their protective incubators while being in the magnet.

Imagine you could use ultrasound to assess not only the PDA but also the blood flow to the brain and the abdomen. Ultrasound is the ideal modality as it is non-ionizing, can be used at the bedside and is already a part of neonatal care. Yet, assessing blood flow quantitatively using 2D pulsed-wave ultrasound has been a challenge in and of itself. It not only requires user-selected angle correction as well as lumen diameter measurements but also neglects flow outside of the 2D image plane. Others may use simple velocity measurements or surrogate markers, but those do not represent flow.

A possible solution has been proposed by our group at the University of Michigan (UM). It is using 3D ultrasound to employ Gauss’ Theorem to quantify flow. While high-frequency ultrasound is excellent for VLBW babies, imaging a 1-mm diameter PDA lumen may still be a challenge. The UM team has previously shown the benefits of 3D color flow for quantification of blood flow. We hypothesize that even a PDA lumen could be assessed accurately, despite its challenging diameter. In addition, if successful, clinicians should be able to measure flow in the PDA within 6 seconds after obtaining a cross-sectional color flow image of the PDA with minimal to no user dependence. This presupposes a 2D matrix array capable of recording 5 color flow volumes per second.

In an American Society of Echocardiography (ASE) and AIUM co-sponsored investigation (E21 and EER funding), we will assess the effects of PDAs before and after treatment. Baseline blood flow for cardiac output, total brain blood flow, blood flow to the small intestines, and renal blood flow will be determined in full-term healthy neonates. An inter- and intraoperator variability study will be employed to warrant scientific rigor and target an end-organ flow estimation with <10% variation for test-retest and <10% between operators. Blood flow measurements in VLBW cohorts scheduled for intervention will yield estimates before and after intervention and thus provide insight in the predictive value for this method.

The ultimate goal is that 3D ultrasound will help caregivers to determine if adequate flow to end organs exists and if intervention is required. Furthermore, stable and unstable VLBW cohorts can possibly be differentiated by their flow to end organs and through the PDA. Thus, answering the question of whether to treat or not to treat.

Principle Investigators: Oliver D. Kripfgans, Ph.D. and Jonathan M. Rubin, M.D., Ph.D.
Co-Investigators: Gary Weiner, M.D. and Marjorie C. Treadwell, M.D.

References:

  1. Deshpande P, Baczynski M, McNamara PJ, Jain A. Patent ductus arteriosus: The physiology of transition. Semin Fetal Neonatal Med 2018;23(4):225–231. doi: 10.1016/j.siny.2018.05.001
  2. Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol 2012;36(2):123–129. doi: 10.1053/j.semperi.2011.09.022
  3. Egbe A, Uppu S, Stroustrup A, Lee S, Ho D, Srivastava S. Incidences and sociodemographics of specific congenital heart diseases in the United States of America: an evaluation of hospital discharge diagnoses. Pediatr Cardiol 2014;35(6):975–982. doi: 10.1007/s00246-014-0884-8
  4. Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

 

Oliver D. Kripfgans, PhD, FAIUM, is a Research Associate Professor in the Department of Radiology at the University of Michigan. Jonathan Rubin, MD, PhD, FAIUM, is a Professor Emeritus in the Department of Radiology at the University of Michigan.

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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A Major Boon for Physical Therapy

As a second-year physical therapy (PT) student, I was first introduced to ultrasound for musculoskeletal conditions in 2009.

I was immediately intrigued.Headshot

I continued to dabble in musculoskeletal ultrasound (MSKUS) for a couple of years but never really with a focus on becoming good or great at the skill, more on the emphasis of becoming more knowledgeable and comfortable with human anatomy (ie, looking at muscle pennate structure, fibrillar patterns of tendons and ligaments, and identifying what they were).

Then, in 2011, I sought out a mentor for MSK ultrasound whom I had known since PT school, Wayne Smith, who is also a physical therapist with 40 years of experience. Wayne has been doing MSKUS since 2000 and in 2011 was working at Andrews Institute with Josh Hackel in the physical therapy department.

Soon after starting the training, Wayne and I collaborated with my PT clinic owner to help create a physical medicine model combining physiatry with physical therapy; MSKUS was a large piece of this model.

We quickly realized how powerful MSKUS had become and that it had turned into a gatekeeper and point-of-care diagnostic tool. MSK ultrasound is a great adjunct to evaluating a patient at time zero and in the hands of qualified physical therapists with requisite training. MSKUS allowed the clinic to execute and expedite patient plan of care by immediately cutting out unnecessary imaging studies (MRI mainly), streamlining physical therapy plans, aiding the physician with percutaneous-ultrasound-guided needle procedures, and/or immediate referral for surgical consult or advanced imaging if needed.

At this time, the RMSK exam was not on my radar so the training was piecemeal; I made the most out of my time to train with Wayne every 6 weeks while practicing and reading Jon Jacobsen’s Fundamentals of Musculoskeletal Ultrasound book.

In 2014, I took on a part-time trial with an orthopedic surgeon performing MSKUS in his office as well as physical therapy services consisting of evaluation, therapeutic exercise, and home exercise prescription. This business model became very successful and super-charged my learning in MSK ultrasound because I was now able to get feedback not only with other imaging studies, such as MRI, but I was then able to synergize findings in surgery that were based on the MSKUS imaging studies (ie, bursal sided rotator cuff tear vs intrasubstance). This feedback was very valuable and accelerated my learning curve. This orthopedic clinic is now an AIUM-accredited diagnostic center in MSK ultrasound within the state of Arizona.

In the medical model or in a stand-alone outpatient physical therapy practice, incorporating orthopedic physical therapy evaluation, MSK ultrasound evaluation combined with exercise prescription is a very powerful visit for the patient. It cuts out unnecessary imaging, saving the patient money and additional timely medical visits as well as expediting the patient’s plan of care. I’ve since incorporated this business model to many other physician offices in the greater Phoenix area.

Incorporating MSKUS into physical therapy has been a major boon for the profession and for the medical community in general.

My workweek now consists 100% of performing MSKUS scans, teaching at A.T. Still University (Mesa), starting up an online MSKUS training program, and mentoring physical therapists, athletic trainers, general sonographers, and radiology technicians in the field of musculoskeletal ultrasound in their preparation to take the RMSK or RMSKS certification exam.

Interested in reading more about how ultrasound can change physical therapy? Check out Carrie Pagliano’s post, Real-time Ultrasound in Physical Therapy.

Colin Thomas Rigney, PT, DPT, OCS, RMSK, is the Director of MSK Ultrasound for Physicians United as well as a member of both the Residential and Post-Professional Doctor of Physical Therapy Degree Faculty at A.T. Still University in Mesa, Arizona, teaching courses on Radiology and Imaging for Physical Therapy students.

 

Have you incorporated musculoskeletal ultrasound in your physical therapy practice? What benefits have you experienced? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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POCUS: A Holiday in the Sun

Getting started with point-of-care ultrasound (POCUS) is like taking a vacation in Bali, Bermuda, or the Bahamas.  Let’s say you’ve landed in an exotic destination and plan to rent a car to explore the island. After collecting your keys, what’s next? Jump in the vehicle and peel off to the beach? Of course not – you’ll take a minute to consider the controls of your car, where you’re going, and how you’ll get there. POCUS is no different from a dream island visit.

Mackenzie headshot 2

In an unfamiliar vehicle, it’s normal to become acquainted with the controls. You want to know how to turn on the car’s lights and wipers and position the mirrors and windows appropriately. There’s a direct analog in performing a POCUS study. The operator has to select the correct transducer and examination preset before getting started. If it’s a machine you’re not familiar with, you need to take a moment to locate essential controls such as depth and gain. Even if the machine is familiar, you need to optimize those settings to ensure you can obtain quality images, just as you would with the mirrors in your car.

It’s also second-hand nature to adjust a car for comfort. The seats and steering wheel need to be positioned so you have a comfortable trip, and the climate settings arranged for passenger comfort. For a successful POCUS scan, the same steps should happen. Both the operator and the patient should be comfortable and positioned correctly. That means adjusting the bed, lowering the side rails, and placing the patient and machine where you can obtain adequate images while ensuring no one has to be a contortionist.

Taking a car on the road on unfamiliar roads can be stressful, and more so if you’re not used to driving on the left. If driving on the opposite side of the road is unfamiliar, it’s smart to visualize how you will be oriented on the road and during turns before heading out on the road. Successful POCUS users have the same habit: they understand where the indicator marker is on both the screen and the transducer before acquiring images. Failing to do so leads to confusion and a breakdown of pattern recognition, just as driving on the left might.

With the car and orientation controls sorted, you’re still not going to fire up the engine yet. Most travelers take a moment to figure out where they’re headed, with a GPS or map. The sonologist needs to take the same step, remembering the focused question they’re trying to answer with the POCUS study, and what they need to see to be satisfied. While you might be happy to ramble aimlessly in a car, POCUS scans should stay focused.

Of course, this assumes that renting a car is the best way to get around the island. Maybe you’d be better served by a taxi, bus, or boat. Or maybe after seeing the rental vehicle, you decide the car can’t accommodate your plans. In the same vein, not all clinical questions can be answered with POCUS. An alternative imaging modality or comprehensive ultrasound may be the test you need, and it’s OK to change your mind and decide you need something else after you perform the scan.

POCUS is rewarding and helps both clinicians and patients, but isn’t always easy. Think of POCUS like the start of a vacation, and you may find your studies are easier, and a bit closer to a holiday in the sun.

 

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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David Mackenzie, MDCM, is an emergency physician at Maine Medical Center, in Portland, Maine. Follow Dr Mackenzie on Twitter @mackendc.