Dating Pearls

Assisted reproductive technology (ART) dating trumps all other sonographic dating. If the dating is off with ART, think about asking if the embryo was put in the uterus at 5 days, and not zero days, as that is how it is often calculated. This can be important if the embryo is larger than expected, as ART pregnancies have an increased incidence of Beckwith Weidman Syndrome, which is an overgrowth syndrome. If the embryo is smaller than expected, then the embryo should be followed more closely for possible congenital or chromosomal anomalies.

If the pregnancy is not ART, dating should be based on the 2014 ACOG/AIUM Committee Recommendations (Methods for Estimating the Due Date. Committee Opinion No, 700. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129:e150–154).

Measurement of the embryo or fetus in the first trimester is the most accurate method to determine gestational age. In the first trimester, the 2014 Recommendations state that if the pregnancy is less than 8 weeks 6 days, the embryo should be within 5 days of LMP (last menstrual period) and otherwise should be re-dated using ultrasound dates of the crown rump length. One mistake often made at this time is to include the gestational sac size in dating; the crown rump length is more accurate than the sac size and thus it should not be averaged into the estimated gestational age.

Crown rump length growth curves have been updated by Pexsters et al (Ultrasound Obstet Gynecol 2010; 35:650–655) using 4387 exams, whereas Hadlocks curves (Hadlock et al Radiology 1992; 182:501–505) were only based on 416 exams. These have some significant discrepancies in the 5–7 weeks gestational age range so we recommend using the Pexsters curves.

Crown Lump Length

From 9 weeks to 16 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 7 days and be re-dated if greater than “7-day” discrepancy.

From 16 weeks to 21 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 10 days and be re-dated if greater than “10-day” discrepancy.

From 22 weeks to 27 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 14 days and be re-dated if greater than “14-day” discrepancy.

From 28 weeks and beyond, the 2014 Recommendations suggest that the dating should be within 21 days and be re-dated if greater than “21-day” discrepancy.

We should not re-date a pregnancy in the second or third trimester if there are good ultrasound dates in the first trimester. If the patient gives “excellent dates” based on history (eg keeping a temperature chart, knowing date of conception based on specific dates of being with partner) and there is a greater than expected discrepancy of dates, then a follow-up sonogram should be recommended in 2–4 weeks, depending on the time of gestation (4 weeks in the second trimester and 2 weeks in the third trimester) so that appropriate growth can be assessed.

Serial growth is important in assessing dating. A fetus that grows 4 weeks in a 4-week period is likely dated appropriately. When the fetus grows more than 4 weeks in a 4-week period then accelerated growth should be reported, suggesting either an LGA (large for gestational age) or macrosomic fetus. History of prior pregnancies can be particularly helpful in these cases. Placement of the calipers at the outer edge of the subcutaneous tissue is particularly important in these cases. We often require 3 measurements, which are averaged to assess LGA/macrosomic fetuses.

When fetuses grow less than 4 weeks in a 4-week period then SGA (small for gestational age) or IUGR (intrauterine growth restriction) are suspected. Additional studies for well-being should be performed, such as umbilical artery Doppler, middle cerebral artery Doppler, maximum vertical pocket of amniotic fluid, biophysical profile, cerebroplacental ratio (CPR), or antenatal testing.

 

Do you have any tips on sonographic dating? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dolores H. Pretorius, MD, is a Professor of Radiology at University of California, San Diego, and Director of Imaging at UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

Andrew D. Hull, MD, is a Professor of Clinical Reproductive Medicine at University of California, San Diego, and Director of UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

WFUMB 2017 Taipei

We recently had the opportunity to travel to Taipei for the 16th World Federation for Ultrasound in Medicine and Biology (WFUMB) Congress. Given that it was our first international conference and our first time traveling to Asia, we knew we had an exciting opportunity in attending this conference, but there was some apprehension and concerns about logistics and what to expect with international travel. The conference planning committee, however, really put in hard work to plan a wonderful conference and execute the conference without many hitches. The conference staff members were unbelievable— they were always happy to help, ensured that everyone knew where to go, communicated with conference guests professionally, ensured excellent delivery of talks, and even assisted in tours of the countryside. Every detail was attended to by the planning committee. Our apprehensions about the conference and a foreign land evaporated the first day, as we were fascinated by the beauty of the city and the hospitality of the citizens.

Dr Yusef Sayeed and Dr Kate Sully

 

Yusef:

Last Spring I was approached by AIUM to present a lecture at WFUMB. I had served in leadership roles within AIUM and presented sessions at the national conferences already, so I was happy to be able to serve in this role. I presented a few talks that covered topics from regional blockade for acute trauma to interventional guidance with a focus on regenerative medicine techniques. I thought that these would be good additions to an ultrasound conference because this is a relatively new approach to treating musculoskeletal pain and injury.

As an interventional pain physician with primary specialty training in occupational medicine, that evaluates and treats work injury with interventional techniques, I was astounded to see the level of training and use of ultrasound for the evaluation and treatment of musculoskeletal disorders. Our international counterparts are doing much to advance the field in both diagnosis and treatment, which was apparent at the expansive range of presentations and posters at the conference. As the evidence continues to mount for the utility of ultrasound in the point-of-care model for musculoskeletal injuries in the United States, it has already been well established by our international counterparts. I am really looking forward to returning to WFUMB in the future and would encourage colleagues to attend this wonderful conference!

 

Kate:

Attending the WFUMB conference was really a remarkable experience. It allowed me, for the first time, to learn how medicine, and ultrasound in particular, is approached in another part of the world. But not just one other part of the world. In fact, 49 countries were represented at the conference, allowing me to connect and learn from colleagues I would never have met otherwise.

The conference lecture series was robust, with several different tracks tailored to multiple different specialties. As an interventional physiatrist, I use ultrasound to evaluate and treat musculoskeletal pathology. Each year at AIUM’s conference, there are several MSK lectures, some of which I have presented myself. At the WFUMB conference, the MSK lectures covered many topics, offered hands-on workshops, and included well thought-out research. I’ve long recognized that ultrasound is a fantastic tool in medicine and its utility in our country is expanding. I was happy to learn, however, that there is also outreach to integrate ultrasound in struggling nations as well and that WFUMB may be an excellent institute to facilitate that outreach. It’s notable to recognize that ultrasound can be such a valuable tool in different settings with very different financial means. In the closing ceremonies, I was humbled to receive the “Young Investigator Award” for research that I had presented that week, “Work-Related Repetitive Use Injuries in Ultrasound Fellows,” but I was especially grateful for a fantastic educational and cultural experience during my first international conference.

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How have you seen ultrasound incorporated into medical care in other nations? If you have attended any conferences that required international travel, what was your experience? Comment below or let us know on Twitter: @AIUM_Ultrasound.

 

Yusef Sayeed, MD, MPH, MEng, CPH, DABPM, is an interventional pain and occupational medicine specialist at the Battle Creek VA in Michigan.

Kate Sully, MD, DABPMR, is an interventional pain and physical medicine and rehabilitation specialist at the Battle Creek VA in Michigan.

Do You Allow Patients to Video?

An expecting new mother comes into your practice for a routine ultrasound exam. During the exam she pulls out her cell phone to capture a few photos and maybe a short video. What do you do?

As cell phone use has become ubiquitous, the AIUM has been receiving more and more calls and messages asking about cell phone use policies during obstetric exams. Practices are searching for guidance on how to set such a policy and what should be included.

To get a sense of how practices are dealing with this issue, last month, the AIUM sent a short survey to 1,652 individuals in 1,138 AIUM OB-accredited practices. Nearly 22% of recipients completed the survey.

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Allow patients to record exams?

According to the results, 88% said their practice does not allow videotaping during OB exams. However, only 51% said their practice has a written policy that supports this.

Why Have a Policy?
Those practices that forbid or restrict videotaping do so for a number of reasons. Some of the most commonly cited reasons include:

policy

Written policy in place?

  • It is distracting. Several respondents mentioned that having people videotaping is very distracting to the sonographers and physicians who are trying to conduct a medical examination. To help these individuals focus on medical care, videotaping is not allowed.
  • Legality. In order to protect the patient’s medical information and staff identity, practices do not allow videotaping.
  • Findings. When a sonographer or physician begins an examination, they do not know what they might find. To avoid the widespread sharing of unread studies or potentially personal information or decisions, practices ask that patients keep their phones off.

Enforcement
While nearly half of AIUM-accredited practices stated they do not have a written policy, there are several ways in which patients are told or asked to refrain from videotaping. Those methods include:

  • Information in new patient packages
  • Signs posted throughout the practice: waiting rooms, exam rooms, on the ultrasound machines
  • Verbal statements from sonographers and physicians

Even using these methods, survey respondents acknowledge that enforcement is difficult because people still pull out their phones and hit record. Some practices do empower their employees by allowing them to stop the exam should a visitor not comply with the videotaping rules.

When Is It OK?
Of those practices that allow videotaping, most have rules about when and how it is allowed.

  • Some practices allow short videos showing certain anatomy.
  • Others state that patients can’t videotape staff or require that staff stay silent when patients are videotaping.
  • In some practices, the sonographers and physicians use their discretion to control when and for how long videotaping can occur.
  • Others allow unlimited videotaping after the diagnostic portion of the exam.
  • Some practices will allow FaceTime (non-permanent) video during the exam but prohibit permanent videotaping.
  • And still others are completely open and allow the entire exam to be videotaped.

Even among those practices that forbid videotaping, some may be allowed. The typical exceptions are for deployed parents or foreign parents of a surrogate. Many practices mentioned that they try to avoid the videotaping issue altogether by stating their policy and then following that by telling the patient they will supply some pictures or short video clips.

What can you do?
If your practice is looking to set a policy or even seeking resources to support your policy, here are some items that might help.

  • Legal Counsel—If you are concerned about the legal aspect of allowing videotaping, or you are looking to set an official policy, seek legal advice and counsel.
  • AIUM’s Keepsake Imaging Official Statement—This resource may help you in framing your policy, and it serves as a great document to share with patients.
  • HIPAA—Several practices mentioned HIPAA compliance in their policies or statements as a reason for not allowing the use of videotaping during exams.
  • Consent Law—In setting your policy, you may have support through your state’s consent laws.

In most cases, obstetric patients are not videotaping with ill intent. But as physicians and sonographers, there are legitimate and medical reasons to consider whether your practice should institute a policy on the use of videotaping equipment. While it can be a challenge to balance legal liability, best practice guidelines, and customer service, working with your staff, your legal counsel, and your customers, you can create a policy that works for all.

Back to Academia

“How long have you been practicing?! And you went back to do an ultrasound fellowship? That’s amazing! I could never do that.” This was pretty much how the conversation went when people found out about my ultrasound background. You see, after my residency training, I practiced for 2 years as a Locum Tenens physician, then an additional 5 years in a community emergency department (ED), before going back for an ultrasound (US) fellowship. Sure, it is an unconventional path, but I believe if you want it badly enough, you can do it, too.

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Kristine S. Robinson, MD

To me, the biggest challenge was the salary cut. Many US fellows make somewhere around $50–70,000 annually. For most of us working in a community ED, that is a fourth or a fifth of what we could typically earn in a year. It all depends on your situation: Do you have kids? Car payments? Other significant bills? Is your mortgage reasonable? Do you have an emergency fund to fall back on? Does your spouse make a decent living? I recommend creating a realistic monthly budget. Be honest with yourself and decide what you can and cannot live without: cable with all the trimmings, the monthly wine and beer clubs, frequent international travel, the latest trend in fashion, the newest must-have gadget, and weekly trips to your favorite restaurants. If money is still tight, check to see if there is an option to moonlight.

The second challenge was going back to student mode. The assigned readings, coursework, podcasts, and post-chapter exams were time-consuming, but not daunting. Although, in the beginning, physics was giving me a bit of heartburn. I think the major adjustment I encountered was interacting with attending physicians and US faculty who were younger than me. There was also the research requirement, which most community-based emergency physicians (EPs) happily abandoned. As for the mandatory clinical hours (scanning and ED shifts), many full-time EPs would experience a reduction of 2–3 shifts per month. However, as a fellow, you have additional labor-intensive responsibilities, which include research, helping with the US quality assurance process, weekly US conferences, medical student US labs, EM resident US lectures and labs, US teaching shifts, and so forth.

Another challenge I grappled with was work-related musculoskeletal complaints from repetitive motion. In addition to our US teaching load, we were expected to perform about 4 to 6 9-hour scanning shifts a month, averaging about 22 to 28 scans a shift. Perhaps it was my age, but after a full day of scanning, I often had mild to moderate wrist, hip, and back pains. To be frank, I did not exactly practice good US ergonomic techniques, which in general is not often taught in EM US fellowship programs. Luckily, these were minor complaints and never progressed to anything serious.

With these challenges, you might wonder if it was all worth it. I absolutely believe so. In fact, I have often said that it was the best career decision that I had made so far. Before I even finished my fellowship, I was presented with 3 lucrative job offers. I instantly became a more competitive and coveted applicant. I had carved a niche for myself, and I knew that I would be vital to any ED I join. With my US experience, I improved my diagnostic and procedural skills. Not to mention, US made my shifts more fun. Lastly, if you are still not convinced, most US fellowships are only a year long, and time goes by fast.

 

Have you returned to school to gain more training in ultrasound? What was your experience? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Kristine S. Robinson is an Assistant Professor and Ultrasound faculty at West Virginia University (WVU) Department of Emergency Medicine in Morgantown, WV. She finished her Emergency Medicine residency at Geisinger Medical Center in Danville, PA, in 2008. Afterward, she worked for 2 years as a Locum Tenens physician and 5 years in a community hospital before returning to WVU to complete an Ultrasound fellowship in 2016.

Focused Ultrasound and the Blood-Brain Barrier

When does a barrier protect and when does it hinder? This question is central to the challenge of delivering therapeutics to the brain. For many neuropathologies, the answer is clear: there is a critical need for strategies that can allow clinicians to effectively deliver drugs to the brain. We believe focused ultrasound (FUS) has the potential to be a powerful tool in this quest.

Part of this challenge lies in the unique nature of the blood vessels in the brain. The cells that line these vessels are tightly linked together, creating a complex obstacle—called the blood-brain barrier (BBB)—that prevents the vast majority of drugs from entering the brain from the bloodstream. Throughout the years, several strategies of bypassing the BBB have been used, with limited success and many adverse effects. These range from directly inserting a needle into the brain for injections, to the administration of hyperosmotic solutions, which create gaps between cells in the BBB throughout a large volume.

In 1956, Bakay et al successfully ablated brain tumors using high-intensity FUS. In doing so, he observed that the permeability of the BBB was enhanced in the periphery of the ablated tissue. While this was exciting news for BBB enthusiasts, the necessity of damaging tissue in the process of opening the BBB was clearly unacceptable. Several decades later, this approach was successfully modified by administering microbubbles, an ultrasound contrast agent, before sonicating (Hynynen et al 2001). This made it possible to use much lower power levels to produce the desired increase in BBB permeability, thereby avoiding brain damage. By adjusting where the ultrasound energy is focused, specific brain regions can be targeted. For a few hours after treatment, drugs can be administered intravenously, bypass the BBB, and enter the neural tissue in the targeted areas.

Over the past 16 years, many preclinical studies have used FUS to increase the permeability of the BBB, delivering a wide range of therapeutic agents to the brain, from chemotherapeutics and viruses, to antibodies and stem cells. Efficacy has been demonstrated in models of Alzheimer’s disease, Parkinson’s, brain tumors, and others. Moreover, the safety of using FUS to increase BBB permeability has been tested in every commonly used laboratory animal.

The flexibility of FUS as a tool for treating neuropathologies may go beyond the delivery of drugs to the brain. Recently, FUS was shown to reduce the amount of β-amyloid plaques and improve memory deficits in the brains of transgenic mice (Burgess et al 2014, Leinenga and Gotz 2015, Jordao et al 2013).

The success of these preclinical trials has led to the initiation of 3 human trials. Two of these trials are testing the safety of increasing the permeability of the BBB in brain tumors for chemotherapy delivery, and the third is evaluating the safety and initial effectiveness of FUS in patients with early stage Alzheimer’s disease. The rapid movement towards clinical testing has been accompanied by impressive technological advancements in the equipment used to focus ultrasound through the human skull. Arrays of thousands of ultrasound transducers can be controlled to produce sound waves that travel through bone and brain, and arrive at precisely the same time in the targeted location. The sound produced by vibrating microbubbles can be detected and used to ensure the treatment is progressing as planned.

If the barrier to drug delivery to the brain can be bridged by FUS, the development of effective treatment strategies for a wide range of neuropathologies will expand. Given the clear need for such treatments and the flexibility of FUS, the recent push toward clinical testing is encouraging. The coming years will be critical in demonstrating the safety of the technique and spreading awareness. Success in these regards will go a long way in establishing FUS as an impactful tool in the fight against inflictions of the central nervous system.

 

If you deliver drugs to the brain, how do you do so? Have you found a way to permeate the blood-brain barrier using ultrasound? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Charissa Poon and Dallan McMahon are PhD students at the Institute of Biomaterials & Biomedical Engineering, University of Toronto, and the department of Medical Biophysics, University of Toronto, respectively.

Kullervo Hynynen, PhD, is professor at the department of Medical Biophysics and the Institute of Biomaterials & Biomedical Engineering, University of Toronto, and a senior scientist at Sunnybrook Research Institute in Toronto, Canada.

How Portable Ultrasound Got Me a Bottle of Wine

Well, Tuesday morning clinic was busy as usual. Hypertension, diabetes, depression, “it-hurts-here”s where troubling all my patients. My desk was across the hall from a colleague who had just seen a retired internist gentleman, 80 years old, reporting muscle weakness in his hips, fatigue, bitemporal headaches and some odd jaw symptoms when he ate. Don (I called him that, mostly because that was his name.) was investing some quality phone time trying to arrange a temporal artery biopsy as this method for diagnosis seemed so reasonable to him and to his internist patient. I listened in on his conversation, always ready to help, invited or not.

“Don, you know, if we pull our portable ultrasound machine, look at his temporal arteries and he has bilateral halo signs, the specificity approaches 100% for temporal arteritis and you can avoid biopsy all together in 38% of patients.”  I provided him a few convincing articles. He was not quite sure as he had never heard of this before.

Halo

Both internists were game, the doctor and the patient. Portable US in the exam room showed bilateral halos around the temporal arteries. I showed them the finding. Both raised their metaphorical eyebrows.

Patient: “I practiced internal medicine for almost 50 years and I have never seen anything like this. That is pretty impressive.”

Don: “Let’s get a sed rate today… See what that shows. Start some steroids and we’ll follow-up next Tuesday.” (For those not in-the-know, sed is erythrocyte sedimentation rate.)

On Friday, after 3 days of steroids, he was starting to feel like his old self again. Headaches were resolving. Fatigue was much better. By Tuesday, with his visit to the clinic, he was ecstatic over his progress. Don reported that he kept remarking on that young man with his portable US machine (That was me.) and how that US would’ve changed his practice had he had one back then.

On Thursday, the patient wanted to show his appreciation to both Don and I by bringing in 2 bottles of red wine, 1 for him and 1 for me.

I had read about the utility of portable ultrasonography, oh, 12-15 years ago for the first time. I had drunk the cool-aid of portable ultrasonography. At our medical school, we provide 27 hours of didactics and hands-on training for our medical students in their first 2 years. Our internal medicine residents get formal didactics on echo, abdomen, vascular, as well as MSK, small parts, and many other US applications. We have provided CME for over 700 physicians in our 3- and 4-day courses. I have been convinced that we need to reach out and teach all who will listen that portable ultrasonography can fundamentally change the way we practice medicine in certain settings.

So portable ultrasound changed this patient’s experience; quicker diagnosis and quicker recovery of health. He was grateful and expressed his gratitude with the fruit of the vine.

So portable ultrasound changed my colleague’s thoughts on its utility based on one clinical exposure. Don asked me many times to use my machine for other patients of his.

So what did I get from this profound, thought-provoking intersection of patient doctor and too? Personal gratification of helping? An underscoring of my belief that portable ultrasonography is important?

I got a nice bottle of wine!

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Do you know of an instance in internal medicine in which ultrasound resulted in a quicker diagnosis? Have you incorporated ultrasound into your internal medicine practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Apostolos P. Dallas, MD, FACP, CHCP, is Assistant Professor of Medicine at Virginia Tech Carilion School of Medicine, Director of CME at Carilion Clinic, and Associate Program Director of the Internal Medicine Residency program at the Virginia Tech Carilion School of Medicine.

The Rolling Sonograms

“Hold still and keep your eye shut tight,” I instructed, as I lathered my probe with gel and placed it carefully on my model’s left eye. Having just narrowly escaped the brink of elimination, we were riding a wave of momentum. The trophy was so close we could taste it, but the final round of SonoSlam 2017 was a real-time scan-off on model patients, and our opponents had already proven their skill. Having a live audience didn’t make imaging a pupillary reflex or calculating ejection fraction any easier, and we were feeling the heat.

The day began with scans on rotating stations testing basic knowledge and technique for various organ systems. We struggled with the hepatobiliary station (turns out most teams did over the course of the day; guess we all need more practice) and the physics/knowledge station (I still don’t know how Fourier functions are used to convert sinusoidal data to Cartesian data to produce an image). Still, we put in a strong showing, and at halftime, of 27 teams, 2 of the 3 Ohio State teams placed in the top 5.

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Round 2 was trickier but more entertaining than round 1, with stations designed to test our technique and creativity. Among the highlights: identifying an image acquired by a teammate via ultrasound charades, guiding a blindfolded teammate to acquire the correct scan using nothing but verbal cues, and acquiring a biopsy sample under ultrasound guidance. These were difficult, but despite a few groans of frustration, we enjoyed ourselves as we raced through the stations. We felt so good about our performance that we even let ourselves think ahead, speculating whether we would face our teammates in the final. That changed quickly, however, with the announcement of the finalists: we had made the final, but placed third, and were the only OSU team left.

The first challenge of the finals was Dr. Boulger’s favorite ultrasound game, the peel-and-reveal. Tiles filling the screen are removed one by one until someone correctly guesses the image underneath, with more points awarded the more tiles remained. Any hesitation or uncertainty meant more points for the competition, and only the top 2 teams would survive till the second round. Watching the other teams grab an early lead, we sweated bullets as we clawed our way back, only to fall behind again with a premature guess. It was neck-and-neck till the very end, when a gutsy call of McConnell’s sign from Sam edged us into second place. We collapsed back into our chairs in relief, and our attendings, watching from the back, let out their collective breath, probably.

For the final challenge, each team sent a representative to scan on live models behind a closed curtain, with their screens displayed for the audience to see. Each team member had to scan twice, and the audience would vote on the better image by way of cheers and applause. They were also allowed to give advice to the scanners, which meant the auditorium soon became a pandemonium of shouted instructions. Objectives included cardiac output and bladder calculations, MSK ultrasound, and ocular imaging. This time we took the early lead thanks to Charles’ affinity for shoulder scans, but quickly ran into setbacks as well (hard to measure bladder volume when the patient had just peed). We managed to keep up our momentum, however, and after 6 nerve-wracking rounds, we edged our opponents 4-2, clinching the SonoSlam championship for Ohio State for the second time.

Looking back on the day’s events, I am proud of our team’s accomplishments but also impressed with the competition. We have great mentors and almost a decade of ultrasound experience between the 3 of us, but some of the other teams were no less strong, and frankly we were very fortunate to take home the title. To me, this means a bright future for ultrasound education, as medical students across the country are learning valuable skills that will put them in good stead for residency and beyond. More importantly, it means that next year’s teams will have to step up their game, as Ohio State must now defend its title as 2-time SonoSlam champion. No pressure, guys.

 

Have you participated in SomoSlam? If so, tell us about your experience. Comment below or let us know on Twitter: @AIUM_Ultrasound.

The 2017 SonoSlam champions, The Rolling Sonograms, was composed of Samatha King, Charles McCombs, and Jeffrey Yu. Samantha King is a fourth year medical student from the Ohio State University College of Medicine planning to pursue a career in emergency medicine. Charles McCombs is a third year medical student at the Ohio State University College of Medicine and hopes to end up in pediatrics and/or emergency medicine. Jeffrey Yu is an anesthesiology PGY-1 at the Ohio State University Wexner Medical Center.