Training Beyond Discipline – Developing Devotion in Ultrasound

Mathews Benji KA point-of-care ultrasound (POCUS) revolution is unfolding before our eyes, forever changing the way we interact with patients. It started with a revolution in specialties such as emergency medicine and critical care, and now it has entered into my sphere with internal medicine and hospital medicine. I see this whenever I’m on clinical service. A 3rd year medical student talks about diffuse B-lines as we stop antibiotics and start diuretics on a patient with pulmonary edema; a 3rd year resident asks to look at a patient’s kidney with ultrasound as we manage undifferentiated acute kidney injury; nursing staff curiously looking on as a patient is shown their weak heart as goals of care are discussed.

At the same time, we in internal medicine and hospital medicine are living in a medical world filled with many challenges towards implementation of POCUS. Though there are many devices in the emergency rooms and some in the critical care wards, there are not many in the inpatient wards nor in the clinics. Though numerous workshops and courses abound in POCUS, many attendees do not continue to use this skillset after training. Those that received initial training find it too challenging to discipline themselves to continue to scan.

It is that latter sentiment that caught my attention this last year. The concept of discipline and viewing POCUS through its lens. A quote by Luciano Pavarotti comes to mind,

“People think I’m disciplined. It is not discipline. It is devotion. There is a great difference.”

I’ve often heard the sentiments:

“It is so hard to learn POCUS, how do you find the time for it on a busy clinical service to get images?”

“I find it hard to set aside time during my non-clinical work days as other work and life piles up.”

I’m not sure about you, but the word discipline does not often carry an inspirational tone to it. There is a sense of drudgery, lack of passion surrounding the word. As an ultrasound director, that is the farthest from what I want my learners to experience with POCUS.

When I looked up the word discipline in the Oxford Dictionary there it was as well:

dis·ci·pline
noun
1.
the practice of training people to obey rules or a code of behavior, using punishment to correct disobedience.
“a lack of proper parental and school discipline”

2.
a branch of knowledge, typically one studied in higher education.
“sociology is a fairly new discipline”

Is it #1 that we were aiming for? Or at the very least, is that what people are sensing? Hopefully, we’re not using punishment to correct disobedience. The Pavorotti quote struck a chord in me. As a contrast to discipline, we have devotion.

The word “devotion” is defined by Oxford Dictionary as follows:

de·vo·tion
noun
1.  love, loyalty, or enthusiasm for a person, activity, or cause.
“Eleanor’s devotion to her husband”
synonyms: loyalty, faithfulness, fidelity, constancy, commitment, adherence, allegiance, dedication; More

•  religious worship or observance.
“the order’s aim was to live a life of devotion”
synonyms: devoutness, piety, religiousness, spirituality, godliness, holiness, sanctity
“a life of devotion”

•  prayers or religious observances.
plural noun: devotions
synonyms: religious worship, worship, religious observance

Devotion does have some concepts borne from religion or worship but that doesn’t make it an irrelevant word for the POCUS learner or teacher. The first definition of love, loyalty, or enthusiasm captures the essence of what most of us are hoping POCUS to be for our learners. As my good friend and POCUS enthusiast, Dr. Gordy Johnson, from Portland, Oregon, says, we need to remember “our first kiss.” What was the moment that grasped us with POCUS?

Don’t get me wrong, I’m not completely opposed to the word discipline, but it move beyond that if we’re going to develop fully devoted clinicians in the realm of bedside ultrasound. Those that are equipped with the cognitive elements know when POCUS should be used, why it should be used, how to acquire images, and then how to clinically integrate it.

This post was originally intended as a follow-up of the AIUM webinar on the Comprehensive Hospitalist Assessment & Mentorship with Portfolios (CHAMP) Ultrasound Program with hopes to continue the conversation surrounding what makes for an effective training program. The program involved online modules, an in-person course with assessments, portfolio development, refresher training, and final assessments. The key lesson we have learned is that longitudinal training with deliberate practice of POCUS skills with individualized performance feedback is critical for skill acquisition. However, the intangible pieces of how people continued to scan was developing an enthusiasm and love surrounding ultrasound by seeing its impact in the marketplace. As they were continuing to scan, their patients, their students, the many nursing staff were partnering in a stronger way with this diagnostic powerhouse in their hands.

With all this, I cannot help but be optimistic when I see the commitment of many in the POCUS movement already. I would urge all of us to evaluate how we develop devotion in ultrasound, how to tap into the dynamism of the POCUS movement coming up the pipeline with our medical students and residents. They have the potential to disrupt inertia and be an impactful force to integrate POCUS more into internal medicine and hospital medicine.

 

If you are an ultrasound educator, how do you inspire devotion? What are some of your best practices surrounding training in POCUS? Which do you think is most important: dedication or devotion? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Benji K. Mathews, MD, FACP, SFHM, is the Ultrasound Director of the Department of Hospital Medicine at HealthPartners in St. Paul, Minnesota.

Vascular Access for Fiona

Life as a vascular access nurse can be very challenging and diverse in a pediatric hospital. A typical day is fast-paced and includes neonatal, pediatric, and adult patients. Veins may be small, tortuous and often found in unusual locations, eg an extremity or scalp vein. For many patients, imaging tools such as ultrasound are essential for successful placement of IVs, midline catheters, and PICCs. The Vascular Access Team sees patients in both the inpatient and outpatient settings. While many of our procedures are routine, a phone call in February 2017 forever changed the way we view our specialty of vascular access.

The caller on the phone was Amy from the Cincinnati Zoo Marketing Department. She described an urgent clinical situation with Fiona, a 3-week-old premature hippo who was dehydrated and needed IV access. The Zoo staff was desperate as Fiona was not taking any bottles and her IVs were only lasting 8–12 hours. Amy had previous experience with the Vascular Access Team when her daughter had surgery at our institution. She referred to our team as the “Vein Whisperer.” Amy wanted to know if we would be able to use the same tools we used on her daughter to gain IV access with Fiona.pic 8

Fiona was already a star in the eyes of the Cincinnati community. Fiona was born on January 24, 2017, the first premature hippo on record to survive. Fiona was small, around 30 pounds, and was being cared for by a specialized team of experts at the Zoo. Her day-to-day progress was being reported on social media and the local news.

My answer to Amy was, “Of course we can help Fiona!” In my mind, I was thinking of all the things we would need to bring to the Zoo. Supplies included an ultrasound machine, probe cover, ultrasound gel, skin antisepsis, varying sizes and lengths of IV and midline catheters, dressings, etc. I kept thinking…this is a premature hippo, what will we need to insert and maintain the catheter? I asked my colleague Blake to accompany me to the Zoo. Blake is an experienced vascular access nurse and is always up for a challenge! We gathered all our supplies and began our journey to the Zoo.

We arrived in the Hippo Cove area of the Cincinnati Zoo. We met two of the veterinarians who updated us on her condition. Fiona was dehydrated, on oxygen, and extremely weak. They described her condition as critical. We put on special scrubs and removed our shoes. As we were led into the small room where Fiona was, the room temperature was very warm as an effort to maintain Fiona’s body temperature. Fiona was on the floor, laying on a blanket.

Fiona was surrounded by 2–3 Hippo team specialists. Amid their worried looks, they quickly reviewed Fiona’s history, IV access issues, and her inability to take a bottle. Fiona was receiving nutrition through an intermittent naso-gastric tube.

Time was of the essence; we began setting up the 2D ultrasound machine and the necessary supplies. Initially, I scanned her head to assess for any scalp veins, there were no visible veins identified. Blake began scanning her hind leg; she was able to locate a viable vein, about 0.2 cm below the skin. The vein easily compressed and had a straight pathway. Based on her assessment and fluid requirements, we decided to use a 3Fr 8cm midline catheter.

The vein was accessed under ultrasound guidance, using a transverse approach. The midline catheter initially threaded with ease but we were unable to advance it fully. Fluids were connected to the catheter but it only lasted 20 minutes before leaking. The midline catheter was discontinued. Another vein was visualized under ultrasound guidance on the hind leg; the midline catheter was trimmed to 7 cm and threaded with ease. The midline catheter flushed and aspirated with ease.

pic1

 

Due to Fiona’s occasional activity of standing up, we really wanted a secure catheter. The midline catheter was sutured to her skin and a dressing was applied. We discussed the care and maintenance with the veterinary staff, and the decision was made to infuse continuous fluids through her midline catheter to maintain patency.

Over the next 2 days, Fiona gradually began to regain her strength. She began slowly taking her bottles and standing up. Fiona received 5 liters of fluids over 6 days through her midline catheter. The catheter was discontinued on day 6.

Fast forward and now Fiona has celebrated her 1st birthday. She did so with the Hippo team that provided the delicate care that she needed. The Vascular Access Team is so proud to have been part of her care. On that cold February day, we were able to use our 20+ years of experience and knowledge to provide the right catheter under imaging to provide her with the lifesaving fluids she needed.

 

Have you preformed ultrasound in an unusual situation? Tell us your story by commenting below or letting us know on Twitter: @AIUM_Ultrasound.

Darcy Doellman MSN, RN, CRNI, VA-BC, is Clinical Manager of the Vascular Access Team at Cincinnati Children’s Hospital.

 

Flying Samaritans, the Seed to Pediatric Point-of-Care Ultrasound

There are some experiences in life that seem to have a tremendous impact on the person you become, and the career path you decide to take. When I started working with the Flying Samaritans in medical school, little did I know that it would change the trajectory of my career.

Kids from El Testerazo Mexico

The kids I fell in love with in El Testerazo, holding the pictures I had taken and shared with them. They came by even if they weren’t sick. Of note, they are now in their 20s with families of their own.

Since the UC Irvine School of Medicine was so close to the USA-Mexico border, the UC Irvine Flying Samaritans chapter was actually a driving chapter. Each month we drove down to El Testerazo, Mexico, to give medical care and medications to an underserved community. I immediately fell in love with the community and the children of El Testerazo, Mexico. They would all laugh at my then broken high school-level Spanish, but would appreciate my trying. There was also something about the group of undergraduates (who ran the clinic), medical students, residents, and attending physicians who volunteered their time there that brought back the humanity to medicine. The experience was challenging and rewarding at the same time—to work with limited resources, but to become a trusted member of their community was priceless. Each time I went to the “Flying Sams” clinic, I remembered why I went into medicine in the first place.

During my time with the “Flying Sams,” I worked with a then Emergency Medicine resident, Chris Fox. When he told me he was going to Chicago to do a 1-year Emergency Ultrasound fellowship, I thought he was crazy.

Old ultrasound machine

The ancient beast of an ultrasound machine that we had in the “Flying Sams” clinic.

Not only was he leaving sunny Southern California, but he was going to spend a year looking at ultrasounds? When I looked at ultrasounds, I could barely make out structures; images looked like the old tube TV’s from the 1980s. When Fox returned, he said, “Steph, the next big thing will be pediatric ultrasound.” Again, I thought he was crazy. But slowly, by seeing how ultrasound impacted the management of our patients in El Testerazo, I realized the brilliance in this craziness. Chris Fox’s enthusiasm and “sonoevangelism” was infectious. I think nearly everyone in the “Flying Sams” ended up eventually doing an ultrasound fellowship. Even though the ultrasound machine in the clinic was old, and images were of limited quality, we were still able to impact the medical care of this community that became near and dear to my heart.

And so it began…my passion for emergency ultrasound (now referred to as point-of-care ultrasound) and for Global Health. My initial goal was to become good at performing ultrasounds. As I quickly realized, I was one of the only people who had experience in pediatric point-of-care ultrasound. I felt a tremendous responsibility to become as knowledgeable and skilled as possible, if I were going to teach others this powerful tool. After 4 years of undergraduate education, 4 years of medical school, 3 years of a Pediatrics residency, and 3 years of a Pediatric Emergency Medicine fellowship, I decided to do an additional 1-year fellowship in Emergency Ultrasound. With medical school loans looming and so many years without a “real job,” I was reluctant to do this. This California girl moved from sunny Southern California, to Manhattan to embark on a 1-year Emergency Ultrasound fellowship. This was a move far outside of my comfort zone for so many reasons. And that was one of the reasons why it ended up being one of the best decisions I’ve ever made. It has been a privilege to be a part of this growing community… to take better care of the most vulnerable of patients… and to give this tool to other doctors around the world. I certainly would have never had these experiences or opportunities if it weren’t for the “Flying Sams” and Chris Fox; to both I am forever grateful.

 

 Are you involved in global medical education? If so, what led to your decision to go into the field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie J. Doniger, MD, RDMS, FAAP, FACEP is the Editor of the first pediatric point-of-care ultrasound textbook “Pediatric Emergency and Critical Care Ultrasound,” and is currently practicing Pediatric Emergency Medicine and Point-of-Care Ultrasound in New York. She has additional training in Tropical Medicine and is in charge of Pediatric POCUS education for WINFOCUS Latinamerica.

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.

Who Has Time to Scan?

image001When I arrived to my shift in the Emergency Department one Thursday, there were 5 unassessed patients on my side with more than 25 in the waiting room, some waiting for hours to be seen. Anyone who works in a busy practice knows the pressure to expeditiously evaluate these patients, and point-of-care ultrasound (POCUS) may be the last thing on your mind.

However, when used properly, POCUS is a time saver. It can lead us to the diagnosis faster, allow for next-step downstream testing, and alert our colleagues in other specialties early that we might need them soon, perhaps even occasionally saving lives.

The excuses to not do an ultrasound are many. How do I fit it into my busy practice? The question is: truly how do I not?

  1. Have the equipment easily accessible.

Searching for an ultrasound machine can be extremely frustrating and a disincentive to using it. No one likes to walk around and search every patient room before you even start to scan.

Because of this, every area should have their designated machine with a home base that is clearly marked and known to everybody. There are additional smart ways to ease this process. We are using a Real Time Location System with RFID technology where equipment is easily located on a tracking board. Other institutions can page an assistant through their EMR to set up the ultrasound in the patient room. Though more cost-intensive, some have chosen to have a wall-mounted machine in every room.

Location board

  1. Bring the machine with you.

Don’t be lazy. There are many patient complaints such as shortness of breath, flank or upper abdominal pain, first trimester bleeding, or eye problems where I am likely going to do an ultrasound study. In these cases, I will bring the machine into the room when first meeting the patient, rather than excuse myself to get it later. Through this, the traditional fragmentation of patient evaluation—ordering a test and waiting for the results—becomes streamlined and sometimes provides the definitive answer immediately.

  1. Rethink your work-flow.

It does not help to bring the ultrasound system with you, if you first need to place an EMR order. Although institution-specific, some have found ways to break up the traditional work-flow (order > worklist > scan), allowing evaluation of patients right away. This requires a discussion with your IT department and administrator but can enable you to rapidly use ultrasound at the bedside.
Also get in the habit of doing an exam the same way every time and maybe set up your machine with predefined labels. You will be surprised how much more efficient you will be and how the quality of your scans will improve with repetition.

  1. Have learners leave the machine in the room.

Our more senior trainees are very versed with ultrasound and usually can get high-quality images without much hands-on direction. If you have learners at different stages, I highly recommend to have them leave the ultrasound machine in the room after completing an exam. You can then review their study right in the room and obtain more views as needed. This avoids setting up the equipment again just for a few additional images.

  1. Keep equipment on the machine.

Having commonly-used supplies on the machine can reduce frustration of going in and out of the room. The most common ultrasound-guided procedure at our facility is IV access. For this reason, we stock the special catheters as well as sterile gel packets on the machine.image003

Recall the last time you weren’t lazy, rolled the ultrasound machine into the room with you and found the ileocolonic intussusception and asked the pediatric radiologist to stay late to do the air contrast enema, or the surgeon to take the patient to the OR with a ruptured abdominal aortic aneurysm (AAA)? Perhaps it was as simple as knowing it was acute cholecystitis and not ordering the contrast CT scan, sparing the young person contrast and radiation. If I can do it on a busy night, so can you.

Do you have other tips how to fit ultrasound into your busy practice? How has ultrasound made your job easier? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Tobias Kummer, MD, RDMS, FACEP, is Director of Emergency Ultrasound in the Department of Emergency Medicine at Mayo Clinic in Rochester, MN.

Ultrasound in Medical Education: How Far We’ve Come

Point of care ultrasound was an obscure elective during my medical school years, a poorly-attended vacation elective to fill the free time between the match and the first day of residency. At the time, the 2 Emergency Medicine attendings directing the course volunteered an expertise, which endured widespread disregard; their craft persisted, unappreciated by the department and hospital. These faculty had a unique passion, a vision of a paradigm shift in medicine that would save more lives, make better decisions, and improve overall care.

I was initially skeptical of that vision. When they expressed excitement over our new, $50,000 Micromaxx (considered a bargain at the time), it sounded to me like the typical exorbitant medical expense with marginal benefit, peddled by savvy sales rmorrow_image1eps. Then we caught our first tamponade in cardiac arrest during a pulse check and I was hooked: POCUS didn’t belong as one of those obscure hobbies limited to the especially nerdy, but was a vital diagnostic and procedural tool, to be learned and disseminated. I went through residency clearly enamored with the technology. To my dismay, early in my internship, we lost our ultrasound director. It was then that I found mentors in podcasts and through the Free and Open Access Medical Education (FOAMed) community.

By my final year of residency, nurses and attendings were calling on me to pause my work in my assigned pod to travel to theirs to help with US-guided procedures. Having identified the need, I started teaching residents and nurses US-guided procedures. The barriers to education were high-quality simulation phantoms, machine access, and educational time. Time we could volunteer, and for machines we begged and borrowed, but for phantoms, we hit a wall. I searched for answers in the young community of FOAMed but found few workable alternatives to the hundred-to-thousand-dollar commercial phantoms. It was at this impasse that I found inspiration from Mythbusters’ use of ballistics gel. I experimented with ballistics gel to create my own phantom and found it morrow_dsf8521to be an effective and practical alternative to the commercial phantoms. I was approached by several companies aiming to turn this into a money-making opportunity, but I felt this information needed to be shared. This skill was too critical to keep it locked up behind a patent. Instead, with the whole-hearted spirit of FOAMed, I published guides and answered questions and gave cooking classes.

I’ve continued to follow the vision of bringing bedside ultrasound to widespread use, from residency to fellowship, and now into my role as Emergency Ultrasound Director and Director of Ultrasound Education at the University of South Carolina School of Medicine Greenville. The future is bright: the FOAMed community is large and growing; US technology is being integrated into earlier stages of medical education; and pocket machines are bringing US in closer reach of the busy clinician. Ultrasound is moving into the hands of clinicians at the bedside and becoming an extension of our physical exam, and there is a growing literature base to support this trend. Someday ultrasound will take its rightful place next to the stethoscope, and my job as an “ultrasound director” will seem as foreign a concept as “director of auscultation.” The complementary forces of FOAMed and formal medical education will bring us to this future of safer procedures and greater diagnostic accuracy, and I am excited to be a part of it.

How have you seen ultrasound medical education change? What are your favorite FOAMed resources? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dustin Stephen Morrow, MD, RDMS, is Ultrasound Director at Greenville Health System Emergency Medicine, as well as Director of Ultrasound Education at University of South Carolina School of Medicine Greenville. He can be found on Twitter: @pocusmaverick.