Interest in Interest Groups

Ultrasound in medical education is a powerful idea whose time has come. With its value in the clinical setting being increasingly recognized, leaders of a point-of-care ultrasound (POCUS) movement are making a strong case for introducing ultrasound early in medical training. Not only is it a useful educational tool to illustrate living anatomy and physiology, but it is also an important clinical skill- guiding procedure, improving diagnostic accuracy, and facilitating radiation-free disease monitoring. As the list of POCUS applications grows exponentially across specialties, I believe that to maximize the potential impact, it is vital to introduce this skillset early during the pleuripotent stem cell phase of a young doctor’s career.

Wagner

Looking around, there are signs this movement is here to stay. Ten years after the first medical schools began integrating ultrasound into the curriculum, an AAMC report of US and Canadian schools stated that at least 101 offered some form of ultrasound education, with the majority including it into the first 2 years of the curriculum. If one visits the AIUM medical education portal (http://meded.aium.org/home), 77 medical schools list a faculty contact person involved with ultrasound curriculum development and integration.

It should be noted that the depth of content varies from school to school, as not all institutions value ultrasound to the same degree. Recommendations on core clinical ultrasound milestones for medical students have been published and results from a forthcoming international consensus conference will help improve standardization, though there will likely be much variability until it is required by LCME or included on board exams.

It is during this time of transition that the importance of ultrasound interest groups (USIGs) cannot be understated. USIGs provide a wider degree of flexibility often not possible within a formal curriculum, quickly adapting for changes not only for meeting times and group sizes but also topics and teaching strategies. Indeed, for schools without a formal ultrasound curriculum, it is often how one gets started. For ultrasound faculty, USIGs provide fertile ground for experimenting with new teaching ideas and cultivating both student and faculty enthusiasm for POCUS at one’s institution. For senior students, USIGs can provide opportunities to participate in research projects, serve as near-peer instructors, and participate at regional and international meetings. The spread of local, student-run Ultrafest symposiums is a testament to the power ultrasound has to draw people in and the impact students can have beyond their own institution. The AIUM National USIG (http://www.nationalusig.com/) provides a nice resource for further collaboration while student competitions like AIUM’s Sonoslam or SUSME’s Ultrasound World Cup showcase ultrasound talent and teamwork in an anti-burnout, fun environment. I have no doubt that some of these exceptionally motivated students will become future leaders in the field, as some already have (http://www.sonomojo.org/).

While many of these students will pursue and jumpstart their careers in Emergency and Critical Care Medicine, students from varying backgrounds and interests are needed in USIGs. The frontier of Primary Care ultrasound is wide open and may become crucial as we see more emphasis on population medicine and cost containment as opposed to fee-for-service models. With the exception of in the ER, the utilization of pediatric ultrasound has been surprisingly lagging and more POCUS champions are certainly needed here. In addition, the early exposure to POCUS can increase comfort with ultrasound and help drive novel developments by future specialists. Some lesser-known potential examples include advancing work already underway: gastric ultrasound for aspiration risk by anesthesiologists, sinusitis and tonsillar abscess drainage for ENTs, diagnosing and setting fractures for orthopedists, noninvasively measuring intracranial pressure by ophthalmologists and neurologists, and detecting melanoma metastasis by dermatologists. Until it is more widespread, a skillset in POCUS can be a helpful way to distinguish oneself in an application process and provides an excellent academic niche. After medical school, some USIG students will go on to form ultrasound interest groups in their specialty organizations, going beyond carving out a special area of interest for themselves and helping to advance the field and shape future policies.

Similar to other enriching things like viewing art and discussing philosophy, I believe all students should be exposed to ultrasound and given the opportunity to learn this skill. While I feel strongly that ultrasound should be a mandatory component of an undergraduate curriculum, I also recognize that not all will enjoy and excel in it, and many will settle for nothing more than the bare minimum. However, I believe the USIGs help us to motivate and empower those few individuals with the passion and grit to really help propel this movement forward and show the world what is possible. This is truly an exciting time. I hope you will join us.

Ultrafest

Are you a member of an ultrasound interest group? Has it improved your skill set? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Michael Wagner, MD, FACP, RDMS, is an Assistant Professor of Medicine at the University of South Carolina School of Medicine in Columbia. There he serves as the Director of Internal Medicine Ultrasound Education for the residency program, Assistant Director of Physical Diagnosis for the undergraduate curriculum, and faculty advisor to the student ultrasound interest group. You can view his 2017 talk for the USCSOM USIG here (https://youtu.be/FfO7SXRwjLY) and an AIUM webinar with Janice Boughton on a pocket ultrasound physical exam here (https://www.youtube.com/watch?v=ywuIeoEfG1I).

Patient Zero

My rock, my reminder, my inspiration, my failure

Soucy

Case 1
It was fall 2009 and early in my second year of residency. Having spent multiple months off service, I was excited to get back into the swing of emergency care in “critical” bay. The patient was a 44-year-old male presenting with syncope. Admittedly, he was an alcoholic who was an on-the-wagon, off-the-wagon type. His trip to the ED found him off the wagon for several weeks, deeply depressed, and outwardly self-neglected.

His story was not unfamiliar to the ED; lots of alcohol without eating or drinking much else and lots of time on the couch. Today, he got up to get something from the fridge but found himself at the bottom of a set of stairs. A housemate was kind enough to call EMS when it took more than a few minutes for him to wake up. He didn’t remember much and complained of a headache, some rib pain, and significant fatigue getting around the house recently.

It was early morning so I had a bit more time than usual to chitchat. He wore a Minnesota Twins jersey. Though I was from the northeast, I told him how I was a big Kirby Puckett fan growing up, which segued into discussion about their current season, game soon-to-be in progress, and the Vikings acquisition of Farve. “Who would have thought,” he said; “No kidding,” I reaffirmed. Our conversation was natural, comfortable, and enjoyable. Before I left the room, I recognized his oxygen saturation at 91% and blood pressure had dropped to systolics in the 90s but recovered into the low 100s.

All the usual suspects were considered but we thought his low saturations (sats) were most likely due to his smoking history and low blood pressure due to dehydration. Fluids and albuterol went in, labs came back, and time ticked by. Acute renal insufficiency, hyponatremia, hypomagnesemia, and normal chest x-ray without any improvement in vitals despite our interventions. Radiology called and said they could do the CT of the head but chest with contrast would have to wait until after fluids and a creatinine recheck. Critical bay became busy and his clock continued to tick.

I was surprised by how quickly my body reacted to the “code blue in CT” called out overhead. I didn’t know why I knew it was him, but I did. As my body turned the corner to CT, my mind was unprepared to absorb what I saw. His head and neck had turned a deep unnatural blue. He was confused and was asking for help. In between explaining that his heart had briefly stopped and quickly moving him from the scanner, a wide-eyed radiology resident appeared in the doorway, “saddle PE” (pulmonary embolism).

We rolled quickly. Sats and blood pressure were down, heart rate was up—mine included. I assured him everything was going to be okay and he believed me. “Wake me up when the Twins score doc,” he said with a smile. Intubation was smooth as lytics were mobilized.

With cardiothoracic surgery at the bedside, his tachycardia devolved into PEA (pulseless electrical activity). I ran the code while thoracics prepped ECMO (extracorporeal membrane oxygenation). Both groins were inaccessible and I was told we would do an ED thoracotomy. “Ready,” the surgeon said. “Yes,” I said confidently, not knowing what would happen next. The clamshell and cannulation were smoother and quicker than I could have imagined. The machine worked, but his body didn’t.

I still critique my conversation with his mother. It was my first time breaking bad news alone. I was inexperienced and unpolished, but honest and raw. We cried together. I wish I could have been better for him and for his mother.

Case 2
Several months and various rotations passed, including ED ultrasound, which I took a liking to. I again found myself in “critical” working with one of my favorite attendings. EMS patch was for a 78-year-old female being brought in from her rehab facility hypotensive, hypoxic, tachypnic, and ill appearing. The report did not disappoint. The patient was postoperative day 5 from a transabdominal hysterectomy for leiomyomas. The patient was doing well until the day before presentation when she felt fatigued and feverish and then in the morning when she felt shortness of breath and extreme fatigue, which had progressed. She looked like she might die any second.

My attending listened to the reports, watched my exam, and performed his own. “So, what do you think?” I hesitated. Literally any organ system or combination of systems could be failing. A trip down the wrong diagnostic or therapeutic pathway could lead to delay, decompensation, and death. I was relieved when he told me to prepare for a central line so we could start pressors and antibiotics for her septic shock. It was clear to me that she was dying and I did not know the etiology, but my veteran attending did.

The patient was sterilely prepped and ultrasound placed on the neck. The internal jugular (IJ) was plump, very plump, the plumpest IJ I had ever seen. “Cake,” I thought. Simultaneously it then dawned on me that physiologically this wonderfully plump IJ did not make sense in septic shock. I consulted my attending and given the patients worsening cardiovascular collapse despite fluid resuscitation, we proceeded.

As I secured the sutures, I ran through the types of shock, differential for each, and ways I could figure it out at the bedside. Antibiotics started and I pulled up to the bedside with the ultrasound. I was suspicious for an obstructive process; however, due to the patient’s postoperative status I performed the FAST (focused assessment with sonography for trauma) exam. “Negative belly,” I thought to myself as I quickly moved to the patients left chest. The focused cardiac exam quickly aligned all the puzzle pieces. I personally had never seen acute right ventricular strain at the bedside but the septal D-ing of her hyperdynamic heart on parasternal short and apical 4 was irrefutable.

My attending agreed and we changed our trajectory. Instead of MICU (Medical Intensive Care Unit) admission, antibiotics, fluids, and pressors, ultrasound indicated the patient needed something different. Given her recent extensive operation, an emergent CT was performed showing saddle embolus. In coordination with OB/GYN and critical care, the patient received thrombolytics. 2 weeks later, I was there when she walked out of the hospital with her children and grandchildren.

The Lesson
I could not reconcile the 2 poignantly different outcomes. Both were getting pulmonary embolism workup and I ordered all the right emergent testing. So, how could an elderly patient with every comorbidity in the throws of dying live while a middle aged otherwise fairly healthy patient who cracked a joke minutes before he arrested not? Ultrasound (and thrombolytics) of course!

Point-of-care ultrasound (POCUS) is an incredible diagnostic tool that is transforming clinical practice and medical school education. Numerous studies have shown it to be a critical component of directed resuscitation in the emergency and ICU departments’ critically ill population. In various disease processes, its use has been shown to decrease procedural complications, improve mortality, and decrease time to safe disposition. All technology is not created equal; ultrasound is unique. Instead of pulling me away from the patient, POCUS allows me to stay at the bedside gathering important information; improving my efficiency, addressing concerns, and talking with loved ones. Undoubtedly the extra time communicating and caring for the patient has improved my job satisfaction and is one of the reasons patients like it. But, there is an often overlooked significance to POCUS’s story, which has caused ripples to be felt for generations.

I believe the soul of POCUS rests firmly in what makes our profession exceptional; our willingness to self-evaluate, improve, and innovate for those we serve. POCUS stands as an early example of disruptive innovation, which has transformed the way we think about our job as clinicians. At the time of its introduction in the 70s and 80s this type of “out-of-the-box” thinking did not conform to the traditional framework. Its existence challenged many long-held beliefs and medicine’s titanic momentum perpetuated throughout generations. These innovators took the road less traveled and persevered in the face of adversity. Their gift has enabled countless others to save lives and improve patient care around the world as well as demonstrate our profession’s ability to adapt in rapidly changing times.

My path to ultrasound resulted from those emotions that remained unresolved and the process unfinished after medicine left its first mark. Feelings of inadequacy loomed, challenging my perception of the limitations of medicine and my own abilities. Painful at the time, I like to think that generations of physicians have constructively, therapeutically, applied this driving force to be better than they were the day before in whatever field their passions lie. Ultrasound is my tool, my promise to him, to her, to myself to be my best and help others be theirs.

What struggles have you overcome in your career? And how has ultrasound helped you overcome them? How do you think POCUS will change in the future? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Zachary Soucy, DO, FAAEM, is Assistant Professor of Emergency Medicine, Director of Emergency Ultrasound, and Co-Director of the Emergency Ultrasound Fellowship at Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, in Lebanon, New Hampshire.

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.

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.