Novice to Competence to Understanding Our Role as POCUS Educators

Nights at the VA medical ICU could get lonely sometimes. When the hubbub of the day had drawn down and the critical care fellows had gone home, the work in the ICUs slowed.Headshot_kevin piro

I figured that I would make use of the time that had seemingly stopped. I grabbed the ultrasound and went to scan and chat with a friendly gentleman whom I had admitted the previous night. It became readily apparent that I was still a struggling learner at this point in my training. There was something that looked like cardiac motion, but not resembling anything like the diagrams and videos I had looked at on my own. It was an uncomfortable place to be.

I imagine that is where a lot of people get frustrated and stop, especially when they don’t have someone to encourage and nurture their continued practice. I had a different luxury. Just a few weeks prior, I had received an inquiry about participating in a new general medicine POCUS fellowship at Oregon Health & Science University, and I was instantly sold on its potential. Here was a chance to carve out a new path and to invest in a skill that offered me a skillset that could improve my patient care. And I knew that I would have the benefit of POCUS experts literally holding my hand as I learned the skill. What a luxury!

So, I kept scanning in the ICU prior to my fellowship. You know what I found? Patients are much more forgiving than we might imagine them to be. Most understand that hospitals are frequently places of learning and like to be engaged in the process and, as I stumbled through my next few exams, I was reminded of my Dad’s words of encouragement, “the only difference between you and an expert is that they have done it once or twice.” So I kept at it. I was terrible the next times too. But, it got easier and I felt less intimated with each scan I performed. By the time I hit fellowship, I was already moving in the right direction.

When I started my POCUS fellowship, I was fortunate to work with all sorts of supportive colleagues that allowed me to continue to grow. Where I had struggled to build a foundation on my own, colleagues collected from internists, sonographers, and EM physicians provided me with the scaffolding. They provided me with lessons. “Remember, air is the enemy of ultrasound” and “ultrasound does not give you permission to turn your brain off. It is a problem-solving tool.” They entertained clinical application questions. They gave back when I leaned in. These colleagues were an amazing support network and would help me construct the mosaic that I teach from now.

A few months into the fellowship, I could complete a competent exam comfortably. It came together one day for me when I completed a Cardiovascular Limited Ultrasound Exam (CLUE) on a pleasantly demented older man, who had shortness of breath likely representing heart failure. As I looked at his lungs, taking stock of the bilateral B-lines and pleural effusions that confirmed his diagnosis, I discussed and showed the findings with his daughter.

“This makes so much sense now!” she remarked. The lightbulb went on for her as I democratized her father’s clinical information. The lightbulb came on for me too as I had a sense of satisfaction of both feeling confident in my diagnosis, but also being better able to teach and engage a family in their medical care. My transformation from novice to competency was mostly complete.

Now, a little more than 2 years removed from my fellowship, I have a little more perspective on the road from novice to competency, not only from my personal experience but also from my opportunity to network with an amazing group of enthusiastic (IM) POCUS educators.

These educators are largely trained by their own curiosity, their attendance at POCUS CME courses, or by latching onto experts from peripheral medical departments. In essence, these educators are pulling themselves up by their own bootstraps in a time when there is a distinct scarcity of POCUS educators within Internal Medicine, which can leave the supposed “all-knowledgeable” physician in an uncomfortable place of vulnerability. They have shared the angst that POCUS is a particularly challenging skill to learn due to its humbling nature – we may not know how badly we were hearing murmurs as medical students, but I bet most learners can guess by looking at a picture how poorly they are doing when they are scanning. It was a feeling I shared back in the ICU as a resident, but our experiences diverged when I had mentors who invested in me learning this valuable skill.

But, these physicians who learned POCUS independently are now at the next, even harder, part. As new leaders, we must reach behind us and pull up the trainees, whether that be by creating the next POCUS fellowship, starting or improving a residency POCUS program, or simply training your fellow colleague. We are tasked with making new learners feel supported and encouraged, and to make this technology accessible in fields where POCUS is not the standard of care. We need to foster these learners’ growth so that they can arrive at their own lightbulb moment and so they keep scanning on the ICUs in the effort to improve the care they deliver.

 

What was your defining moment in your decision to go into ultrasound? Have you had a unique learning experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Kevin M. Piro, MD, participated in and helped build a point-of-care ultrasound fellowship at Oregon Health & Science University (OHSU), becoming only the second general medicine-focused ultrasound fellowship in the nation. Dr Piro is now a hospitalist at OHSU.

Who Owns POCUS?

The debate over point-of-care ultrasound (POCUS) governance was rekindled recently when the Canadian Association of Radiologists published a POCUS position statement. The statement rankled some prominent POCUS leaders who hotly debated the statement’s merit via Twitter. This is a debate certainly worth having, but it is hardly a new one. Some likened it to the “turf battles” that emergency physicians successfully overcame well over a decade ago. To be clear, there is a governance problem, largely the result of technology/machine availability outpacing the development of POCUS training, credentialing, and employment guidelines and standards. Referring to the POCUS realm as the “wild, wild west” as Zwank and colleagues did, is somewhat apropos. But to develop the best solutions, we must first define the problem.empty conference room

The problem – “who”…or “how”? The statement seems to frame the problem around who is best qualified to govern POCUS. Most would agree that radiologists are imaging experts with the most training in interpreting ultrasound. But if using Bahner’s popular I-AIM framework, the image interpretation that most radiologists practice is only one aspect of POCUS. POCUS is a separate entity from consultative ultrasound. Clinician-performed at the point of care, POCUS has different goals, primary of which is to answer focused questions that guide and expedite proper definitive care. Its versatility allows it to be employed well outside of the domain of traditional diagnostic ultrasound, enhancing the safety of bedside procedures, improving the physical exam, and directing further testing & timely care. But when did you last see a radiologist at the bedside of a patient outside of the interventional radiology (IR) suite…one willing to personally “clinically correlate” the image findings rather than just include the phrase in their report?

Rhetorical questions aside, if we lived in a perfect and resource-rich world, we might all be able to dedicate a full year to the performance of ultrasound, or even better, radiologists would come to the bedside to perform the exam within minutes of the order. But we don’t. Fortunately, there’s already quite a bit of data suggesting that the requisite training for non-radiologists to safely employ POCUS isn’t as extensive as some might have us think. Additionally, the American Medical Association’s resolution (AMA HR. 802) long ago recommended that training and education standards for the employment of ultrasound be developed by each physician’s respective specialty society, effectively recognizing the importance of self-governance of this modality. I would argue that the problem, therefore, centers less around the “who” and more around the “how” of governance.

Practical solutions – Interprofessional collaboration is key: The desire to ensure patient safety is the common ground here. We all want to ensure POCUS is safely employed, but how do we best do so? Training and utilization standards can ensure this, but overly restrictive standards can create unnecessary barriers that limit POCUS employment and prevent patients from reaping the demonstrated benefits of POCUS. The radiology specialty undoubtedly has a wealth of valuable expertise to contribute to this debate. Their well-established and validated training and imaging standards could well-serve as a framework upon which POCUS standards could be built and certainly makes them deserving of a seat at the table. But given how and where POCUS is employed, surely the clinicians doing so deserve a seat also. To suggest that “non-imagers” are incapable of developing rigorous, evidence-based training and utilization standards that allow for the safe employment of POCUS simply isn’t fair, nor is it well-substantiated, if we’re using emergency physicians as an example.

Furthermore, unilaterally developed statements such as this are what drive us to remain in our respective silos and can hinder the progress still required in this realm. The solution is a collaborative one, considerate and respectful of the diagnostic ultrasound knowledge and experience of imaging experts, the setting in which POCUS is employed, and the variety of ways clinicians can capably employ it to enhance patient care at the bedside. This collaborative concept isn’t mine, nor is it new, thankfully (more thoughtful discourse on the topic can be found here and here). It’s time that we recognize and leverage the talent that each discipline can offer toward the safe, effective employment of POCUS. It’s time to embrace interdisciplinary and interprofessional collaboration.

The inherent value of POCUS lies in its ability to transcend clinical specialties, settings, and practice scopes. It is distinctly different from consultative ultrasound and therefore shouldn’t be bound by standards created long before POCUS existed. It is a valuable, patient-centered adjunct that demands new standards that are 1) considerate of both its versatility and the multitude of settings in which it can be employed, 2) considerate of the experience of those who have previously employed US, and 3) created by all those actively employing it to enhance the care they directly provide at the bedside. But rest assured, ultrasound no longer belongs only to radiologists, or any one specialty/profession for that matter, and that’s a good thing.

 

Have you integrated a collaboratively developed approach to POCUS training and/or utilization?  Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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Jonathan Monti, DSc, PA-C, RDMS, is an Associate Professor of the US Army / Baylor EMPA Residency Program at Madigan Army Medical Center and President of the Society of Point-of-Care Ultrasound (SPOCUS). He is actively engaged in research that assesses POCUS training and its unconventional employment by a myriad of users.

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.