POCUS: My Path to Be an Effective Global Citizen

Bus 22 from Stanford to Pacific Free Clinic (PFC) – 1.5 hours. Bus 22 and 25 from PFC to Santa Clara Valley Medical Center – 1 hour. Bus 70 from PFC to Foothill Family Community Clinic – 30 minutes. Bus 70 and 26 from PFC to Community Health Partnership – 30 minutes. Without a car, I managed the PFC and networked with community clinics and hospitals by bus. These bus rides provided me with a glimpse of one barrier disadvantaged patients endure in order to access the healthcare system. If my weekly navigation of San Jose’s health care system has been one long bus ride, so too has my medical training–a long seamless journey of exploring three vital components of medicine: community service to the underserved, translational/epidemiologic research, and internal medicine.

As stated in the opening of my personal statement for residency application (above) community service was one of my main motivations to go into internal medicine. Yet, despite 7 years of volunteering and managing 3 free clinics in 3 cities, I became focused on developing clinical skills and establishing an academic career instead. I pushed community service aside during my residency training and beyond until my trip to Gros-Morne, Haiti, where I, together with Atria Connect (https://www.atriaconnect.org), taught point-of-care ultrasound (POCUS).

Through Atria Connect, 14 other physicians from around the world and I trained 12 Haitian physicians at Hospital Alma Mater, where there were no echocardiograms, CT imaging, or MRI. There were 2 diagnostic imaging modalities available: a nonfunctional x-ray machine and an ancient ultrasound machine with just a transvaginal probe. For 3 months, we rotated weekly to provide hands-on training in a longitudinal POCUS curriculum that combined flipped classroom learning with online modules, onsite hands-on teaching (Picture 1), and remote hands-on training via a tele-ultrasound platform. At the end of the curriculum, the 2 youngest Haitian physicians then spearheaded a longitudinal training program for the remaining clinical staff within the hospital.

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Picture 1. Left to Right: Dr. Bruno Exame (Haiti), Dr. Ricardo Henri (Haiti), Dr. Jesper Danielson (Sweden), Dr. Michel Hugues (Haiti). Dr. Hugues, the Chief Medical Officer of Hospital Alma Mater, is shown performing focused cardiac ultrasound under the guidance of Dr. Danielson and Dr. Henri. Dr. Exame was evaluating the quality of the ultrasound image.

Similar to many global health efforts with POCUS, the 15 trainers, including myself, and the Haitian physicians experienced an evolution in clinical care. It ranged from expedited diagnoses of tuberculosis through the FASH protocol (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3554543/) to an unexpected evaluation of left heart failure possibly due to thiamine deficiency, to immediate trauma triages of patients from motor vehicle accidents in a town where traffic laws do not exist. With POCUS, Haitians have access to diagnostic medicine that would otherwise be denied in rural Haiti, where it would take a 4-hour bus/motorcycle ride on unpaved road to obtain. The evolution went beyond clinical management and access to basic health care, however.

Besides transforming medicine in resource-low settings, POCUS rekindled my initial drive to go into internal medicine: community service for the underserved. It empowers me to serve more effectively by training providers with an innovative technology of sustainable impact. With a tele-ultrasound platform and WhatsApp, POCUS draws me closer to the underserved in remote places, thus expanding community service on to a global scale, onsite and offsite.

More importantly, POCUS loops me back to community service at the local level, the original start of my journey to internal medicine. Similar to the Haitians in Gros-Morne, the disadvantaged in the United States face obstacles in which an additional trip to basic diagnostic radiology or cardiology, other than limited outpatient medicine encounters, proves to be difficult. An expedited evaluation with POCUS for simple clinical questions can maximize diagnostic capability and further advance clinical care as a way of improving access in this vulnerable population.

One instance in which I had a missed opportunity was during my residency in expediting care for my favorite clinic patient at an urban health clinic. She, unfortunately, suffered from multi-organ manifestations of sarcoidosis. One day, she presented with an acute onset of dyspnea and chest pain without hypoxia. Her examination was not significant for volume overload, pneumonia, or reactive airway disease. Her breath sound was mildly reduced on the right side. A chest X-ray was ordered. However, due to transportation cost and her inability to take off additional time from work, she did not obtain a chest X-ray until 3 days later. Her chest X-ray showed a spontaneous pneumothorax of 8 cm in size due to structural lung changes from her sarcoidosis. She was immediately sent to the emergency room for pigtail placement. Had I learned lung ultrasound, an immediate diagnosis would have been made and her care would be further advanced at minimal cost. While POCUS benefits all patients, POCUS magnifies the impact for the underserved by overcoming socioeconomic barriers.

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Picture 2. Left to Right: Dr. Michel Hugues (Haiti), Dr. Bruno Exame (Haiti), Dr. Jesper Danielson (Sweden), Dr. Gigi Liu (United States), Dr. Ricardo Henri (Haiti), and Dr. Josue Bouloute (Haiti) on the last day of the 4-month POCUS training.

My life-changing trip to Gros-Morne, Haiti (Picture 2), expanded my global awareness and revived my sense of social responsibility through community service locally, regionally, nationally, and internationally. This is the essence of global citizenship (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726429/?report=reader; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6076566/?report=reader). Instead of just providing much-needed medical care to the underserved, POCUS empowers providers to be a more effective global citizen by expediting diagnosis and care efficiently and cost-effectively. It has been a privilege to be trained as a physician and be taught by amazing mentors with life-saving POCUS skills. As a global citizen, I vow to train health care workers on POCUS on multiple geographic levels as part of my social mission to improve access and care for the disadvantaged, even if this requires a very long bus ride…

 

How has POCUS changed your practice? What do you do to be a global citizen? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Dr. Gigi Liu, MD, MSc, FACP, is a hospitalist and proceduralist at Johns Hopkins Hospital who leads the POCUS curriculum for Osler Internal Medicine Residency program and Johns Hopkins Bayview Internal Medicine Residency program.

 

 

 

 

 

POCUS in Pediatrics

Do you work in a children’s hospital? Do you perform POCUS? Do you ever wonder if other divisions in your hospital are using POCUS as well?

Point-of-care ultrasound (POCUS) is growing quickly across all medical specialties, including pediatrics. Within pediatrics, POCUS is being utilized in the emergency department, intensive care unit, operating room, clinic as well as on the inpatient floor. While the scope of practice may differ across sub-specialties, the issues pertaining to education, training, credentialing, equipment procurement, and workflow solutions are universal.A Abo

At Children’s National Medical Center (CNMC) in Washington, DC, we have established a hospital-wide oversight committee for POCUS, which is a multi-disciplinary effort throughout the institution. Our aim is to standardize the use of POCUS across the hospital with respect to
1) education/training/credentialing,
2) documentation/image archival, and
3) maximizing the financial benefit.

Education, Training, and Credentialing

Each division who uses POCUS should have a champion who is responsible for the education and training of both trainees and faculty within the division. Many faculty in pediatrics, and pediatric sub-specialties, were not trained in POCUS as part of their residencies and fellowships; therefore, the opportunity to learn POCUS as a faculty member is incredibly important. Once competent in POCUS, faculty should have the ability to become credentialed in POCUS. A hospital-wide POCUS initiative can promote POCUS education across divisions through collaboration. Divisions can share POCUS curriculums with one another in addition to sharing resources. For example, divisions can bring their resources together and host a hospital-wide POCUS course. Furthermore, at CNMC, we recently received a grant to establish an ultrasound simulation program, which will be incorporated into our hospital-wide simulation program.

Documentation and Image Archival

Divisions that are using point-of-care ultrasound for medical decision making or procedural guidance should be documenting their findings in the medical record and archiving the appropriate images. In an ideal world, the ultrasound images would be accessible in the medical record, along with the documentation. The ability to view the POCUS images, by all clinicians providing care, improves the flow of knowledge among clinicians and in turn, improves patient care. From a workflow standpoint, the ability to archive the images in a centralized location, with the ability to connect the images to the electronic medical record, may be better accomplished as a hospital-wide initiative.

Maximizing the Financial Benefit

Collaboration among the divisions using point-of-care ultrasound can have a financial impact as well. For instance, when purchasing ultrasound equipment, the cost per machine is lowered when purchased in bulk. Furthermore, once the infrastructure is in place with respect to credentialing as well as the ability to document and store ultrasound images, clinicians may have the ability to bill for their services.

In order to accomplish the aforementioned aims, it is crucial to have hospital-wide support. To that end, we have strong partnerships with other clinical divisions, such as Radiology and Cardiology, who share their ultrasound expertise with the POCUS community. Furthermore, we have established relationships with other groups as well, such as information technology, purchasing, legal, biomed, and credentialing.

Are you interested in doing something similar at your institution? Wondering where to start? One suggestion is to send out a survey to all the division chiefs to better understand if POCUS is currently being used (or will be used in the future) in their respective divisions. Be sure to ask if the division has a POCUS champion. From there, plan a meeting with all the champions and start a discussion on how to improve POCUS at your institution. For a resource, check out the following reference.

Strony R, Marin JR, Bailitz J, et al. Systemwide clinical ultrasound program development: an expert consensus model. West J Emerg Med. 2018; 19:649–653.

 

Do you work in a children’s hospital? Do you perform POCUS? Do you ever wonder if other divisions in your hospital are using POCUS as well? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Alyssa Abo, MD, FAAP, FACEP, is Director of Clinical Ultrasound in Emergency Medicine, and Chair of the Hospital Oversight Committee for Point-of-Care Ultrasound at Children’s National Medical Center in Washington, DC, as well as Associate Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences in Washington, DC.

Artificial Intelligence and Point-of-Care Ultrasound

One of the greatest ongoing challenges of POCUS (point-of-care ultrasound) is educating existing physicians, residents, students and others. There are not even enough teachers to teach everyone who wants to learn. Clinicians would like to get the results from POCUS performed on their patients but have difficulty investing the effort required to learn, practice, and then become credentialed. Further complicating things for some is the dreaded self-doubting period, which could last months or years, where providers worry they may make a mistake and be ridiculed for it, or worse.Blaivas

One potential answer is thought to be artificial intelligence (AI); kind of like it seems to be for everything in medicine today. What good is AI in POCUS anyway? What if the education required was simply to find the correct spot on the body to apply the probe? Then the algorithm would do the rest and it would be more accurate than the best POCUS masters. Not only would training be truly minimized, maybe to minutes, but the examination would be shortened as well. A few sweeps through organs, whether it is the liver and gallbladder or the heart, may be enough for the AI algorithm to do its thing. This would mean all those busy clinicians really would get a great return on their time investment. If the algorithm is that accurate and expert, providers will not be questioned easily when they document an AI US finding.

AI is an inescapable topic of sensational news stories and movies alike. AI is simply a machine approximation of human-like intelligence in task performance. The type most associated with image interpretation is deep learning. How does it work? Programmers develop software architectures roughly resembling levels of neurons in the cerebral cortex, with multiple connections. The levels of neurons have specific functions and transmit messages to neurons in the next row via mathematical functions. They are also capable of sending messages in reverse as feedback. Such a deep network is often termed a convolutional neural network (CNN; or some variant on the name). It can learn to interpret images, whether CXR, head CT, or ultrasound, by scanning each image one tiny part at a time, then pooling all of the neuronal-like reactions to those tiny parts and coming up with an answer. Give it enough training data and such a CNN can become very accurate.

Well, imagine a CNN algorithm plugged into your favorite POCUS machine. The CNN is trained on the liver and gallbladder; it has seen millions of example images, both normal and abnormal. It can recognize liver anatomy and point it out for you, the same for every detail around the gallbladder and biliary tree. It’s great at identifying pathology and can make measurements in the correct spots for the wall, common bile duct (CBD), and more. Once again, who really cares? I spent 2 decades scanning the gallbladder, performing research studies, and publishing on it. Well, while it may not have been an issue for me, not everyone invests their free time like that. Yet, many would like to be able to put a probe on the abdomen, have the ultrasound machine tell them where to move it, point out pathology, and come up with a likely diagnosis. Did I mention it could happen in real time, at the patient’s bedside, while you are casually speaking to them? How useful would this be? It could substitute for years of training, maybe even over 2 decades worth. There are other subtle benefits too. Although some studies seem to show that CNN CT algorithms seem to catch so much pathology radiologists can miss, the individual CNN may not be as good at finding something a rare expert might pick up, at least for now. But the CNN never gets tired. It never gets hit with a massive wave of scans to read late at night or overwhelmed with clinicians calling to discuss imaging studies. Thus, even experts can benefit from such algorithms as an aid.

Not happy with the image quality due to patient body habitus or another factor? It turns out another algorithm can actually artificially improve the image clarity and quality, and do so accurately without introducing false data. This has not been introduced into clinical use of POCUS but is likely to be just around the corner. The key is to make sure nothing is invented by the algorithm that is not actually there.

Imagine incredible ultrasound expertise from a short exam that required minimal training to perform. This scenario will come, but not this year or the next. As some speakers and authors have noted, AI coupled with POCUS is a big step toward the fabled and elusive “tricorder” first depicted in the 1960s Star Trek television series. An incredible hand-held device (that does not even require body contact), which diagnoses maladies in a few short sweeps over the patient. The eventual outcome of approaching such a device is greatly increased speed, efficiency, confidence, and accuracy of patient assessment and diagnosis. The benefit of significantly decreased skill/training requirements will also pose some challenges for the workforce, but these are likely to appear gradually and may be hardly noted.

What about combining other data feeds along with the ultrasound images? AI algorithms are great at interpreting EKG tracings and even cardiac and lung auscultation. Studies analyzing digital auscultation signals using deep learning systems are able to diagnose many more abnormalities than humans are. The result could be synergistic and add redundancy in diagnosis, such as for abnormal lung or heart sounds during ultrasound evaluation. Maybe other signals could be incorporated also.

These algorithms just need data, lots of data, and that is the conundrum for people seeking to develop AI apps. What do you think about companies getting de-identified image data without provider and patient awareness? Do you think it would help you to have a smart machine that analyzed the images and made calculations within seconds? What about incorporating other diagnostic signals such as digital auscultation, EKG tracings, or maybe some other signal?

 

 

Share your thoughts on AI in ultrasound: comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Michael Blaivas, MD, MBA, FACEP, FAIUM, is an Affiliate Professor of Medicine in the Department of Medicine at the University of South Carolina, School of Medicine. He works in the Department of Emergency Medicine at St. Francis Hospital in Columbus, Georgia.

The Democratization of Point-of-Care Ultrasound

The subtle sound of a distant explosion rang out. We barely flinched, numb to the sound that was a near-daily occurrence at our remote outpost in war-torn Afghanistan in 2005. Minutes later, a fast-approaching Humvee suggested that this time, something was amiss. The sight of a bloodied soldier draped over the vehicle’s hood provided confirmation.

CPT Jonathan Monti, left, and Lt. Col. Robert Craig, in the army physical training shirt, treat a trauma casualty at Forward Operating Base Ripley in 20005.

As we scrambled to prepare our dusty, sparsely equipped treatment tent, casualties poured through the door. A young Afghan man, triaged as minimally injured, lay in front of me, peppered from head to toe with small shrapnel wounds. His wounds were indeed benign-appearing, as his triage category suggested, but penetrating wounds can be deceptive. I struggled to gauge whether his lack of responsiveness to my questions was due to our language barrier, or something more sinister like blunt or penetrating head trauma. His primary survey was otherwise unremarkable…nosignificant external hemorrhage, airway intact without labored breathing. His blood pressure was borderline low, not an uncommon finding in the thin/healthy. 

I dusted off the nearby SonoSite 180, now widely considered to be the first portable ultrasound device of its kind. Most of its knobs were still foreign to me, and my inexperienced eyes struggled to interpret the grainy images. His belly and lungs appeared unremarkable, but scanning through his subxiphoid region, the black stripe encircling his heart jumped out at me, inconsistent with my already-anchoring bias of a traumatic brain injury, but consistent with the images I had only seen in Ma and Mateer’s landmark text.

I quickly called the surgeon, whose experience with the device barely surpassed my own. After a quick look at both the machine and text, he commanded his team to prep the operating suite, an equally dusty, adjacent tent. Minutes later, the surgeon’s skillful incision of the patient’s pericardium evacuated the now-tamponading bloody effusion, revealing the tiny piece of shrapnel embedded within the patient’s right ventricular wall and saving the patient’s life.

On that day, the humbling and lifesaving power of point-of-care ultrasound (POCUS) was revealed to me. As a junior clinician with limited trauma experience, I had no formal ultrasound training, mentorship, or experience. Yet this machine, when coupled with only a book, and the desire to learn, allowed me the opportunity to overcome the shortcomings of my physical exam skills, my resource constraints, and my cognitive bias, and the mistriage of another, to ensure a patient received the timely and definitive care he deserved. In the decade or so since, I have been fortunate to serve my patients while under the tutelage of several POCUS experts whose altruistic and thoughtful mentorship allowed me the opportunity to cultivate my passion for this powerful tool, while also imparting the nuances and limitations of POCUS, frequently leading me back to a common question:

How can we best harness the full power of POCUS?”

There is a rapidly growing body of evidence that suggests that clinicians of various skill levels can effectively employ focused POCUS applications with minimal training. Though not without risk, POCUS is no different from other clinical skills; performed with variable competency regardless of profession, specialty, or scope of practice. Some will evoke the mantra of “a fool with a tool is still a fool,” which may certainly be true, but it is unfair to assume that foolhardiness is necessarily bound by profession, experience, or even breadth/depth of training.  

The notion that POCUS can/should only be monolithically employed by a limited number of broadly/extensively trained physicians may be yet another example of the monoculture of thought that continues to plague our healthcare system. Certainly, any diagnostic testing should be performed thoughtfully; but do we limit who can use the stethoscope, or order a CBC, based upon title or his/her knowledge of Bayesian principles, Fagan’s nomogram, or pre/post-test probabilities and test-characteristics? Do all successful clinicians adhere to these principles with each and every test they order? Are there other factors to consider when ordering diagnostic testing, particularly in the resource-constrained areas where POCUS can have the greatest impact?

Until POCUS is adaptably and appropriately employed by all those who provide care, regardless of practice setting and scope, its full benefit and potential, especially to those living in medically underserved areas, cannot be realized. Some will inevitably oppose this concept, citing concerns with expertise, patient safety, documentation, reimbursement, etc. Ironically, it is these same arguments that emergency physicians faced 2 decades ago before successfully overcoming significant resistance to fully integrate POCUS into emergency medicine practice.

POCUS leaders are uniquely poised to best mitigate the risks associated with POCUS use through the provision of expanded training opportunities that are well-crafted, appropriately focused, and variably commensurate with clinicians’ skills, cognition, practice setting, and scope. Some of our most innovative POCUS educators are already doing so, whether by incorporating POCUS into the physical exam, or training nurses to perform diagnostic ultrasound, or training medics to employ ultrasound in austere locations. The rise of artificial intelligence/machine learning is already reducing the training burden traditionally associated with POCUS.

POCUS is a rare technological tool; one that is portable, versatile, and liked by both patients and clinicians alike. It can expedite diagnosis and care, improve the accuracy of our physical exam, and help us overcome our own anchoring bias while reducing the risk of procedural error, healthcare cost, and iatrogenic radiation exposure. Though it may not impact a majority of patients, for those it does, that impact is often significant. But the most uniquely promising characteristic of POCUS that we should all embrace is its ability to bring better-informed clinicians of any ilk, back to the bedside where they belong, wherever those in need of care may be.


Do you believe the democratization of point-of-care ultrasound can enhance patient care? Share with us your thoughts or your efforts to do so: comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Dedicated to the memory of CPT Jeremy A. Chandler, 1st BN, 3rd Special Forces Group, whose life was lost while bravely serving his country on that fateful day, August11th, 2005, in Tarin Kowt, Afghanistan.
https://www.greenberetfoundation.org/memorial/jeremy-a-chandler/

Jonathan Monti, PA-C, RDMS, is an Associate Professor of Emergency Medicine PA Studies at Baylor University and president of the Society of Point-of-Care Ultrasound (SPOCUS). He is currently conducting research on the unconventional employment of ultrasound in the U.S. Armed Forces as an employee of the Henry M. Jackson Foundation for the Advancement of Military Medicine.

Teaching Point-of-Care Ultrasound

Ultrasonography (US) is now used in some fashion by most specialties, and in graduate medical education, performing a US examination is now a routine expectation in the fields of emergency medicine, surgical critical care, diagnostic radiology, pulmonology, and gynecology. The American Medical Association has confirmed that physician‐performed US is within the scope of practice of appropriately trained physicians and recommend that training and education standards be developed by individual medical specialties.

In light of its clinical and education utility, it is reasonable to expect that US would be taught during medical school. Some national and international bodies, including the AIUM, have proposed curricula for medical students. While its level of use is variable, several schools have described integrated US into undergraduate medical education. Several studies have shown that students are able to and want to learn point-of-care US (POCUS) in medical school. Let’s review some tips for engaging medical students while teaching POCUS.

1. Hands-on time

Allow the medical student to have hands on the probe as much as possible. Limit lecture time to only that which must be done in lecture format. Make sure group learning time is done in small groups with maximal time for each student to use the probe. Give them time to work through different positions and views to help identify windows and quality images. Use your verbal commands to direct them instead of taking the probe. If you are going to take the probe, put your hand over theirs.

2. Engage the student

Find a use for ultrasound that is relevant to the student’s specialty of choice. Most specialties now have some use for ultrasound. IF you cannot identify a use for ultrasound in the specialty of choice, consider teaching general skills like US-guided IV insertion. Describe how US was or would have been useful during residency.

3. Make it fun

Use simulation liberally. Consider having a game or competition (see Sono-games, SonoSlam, or other similar competitions for potential ideas). Multiple homemade procedural models have been described and are inexpensive. Medical students, in general, love practicing procedures and are mostly competitive by nature. There are several ways for the more experienced student to improve their US skills in a fun manner. Some ideas include identifying inanimate objects blindly that are immersed in water, a competition like fastest FAST exam, or making a procedural simulation competition.

4. Short and sweet

Keep sessions engaging by spreading practice out over time. Again, keep lectures as brief and need-to-know as possible. Most medical students will only need a brief physics review and do not, for example, need to know the Nyquist limit. They need to know how to answer focused questions with ultrasound. Students will lose interest if doing the same exam over many hours. Consider spreading sessions, especially image review sessions, out to 1 hour or less over several days. Intersperse different types of ultrasound (e.g., abdominal, cardiac, pulmonary, vascular) within the same session to keep students engaged.

5. Start early

Expose students to US early on in medical school. Consider adding it to anatomy or physiology classes while students are still in their pre-clinical years. If you do not have the swing to add a formal session to preclinical years, consider having voluntary “anatomy review” sessions using US. Try to get enough interest to start an interest group for students that is student-run. This will allow them to take some of the responsibility for scheduling and promoting events and you can focus on what you do best, teaching US.

Ultrasonography is coming to medical education and will continue to grow in use. While students going into specialties like radiology and emergency medicine may instantly be engaged in US teaching, consider ways to engage other students. There is a role for US in nearly every specialty.

Sonographers can and should play a key role in teaching medical students techniques for US. Sonographers perform these exams every day for many years. They have tricks for obtaining quality images and many sonographers are also quite good at interpreting exams, as well.

Embrace medical students and engage them with your passion for ultrasound. Show them how it will be helpful to them in the future. Take an active role in medical student education and watch the use of ultrasonography in medical practice continue to grow.



Do you have suggestions for teaching POCUS to medical students? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Joshua J Davis, MD, is an Emergency Medicine Resident at Penn State Milton S. Hershey Medical Center.

Ultrasound at the Zoo

Zoo medicine is quite the paradox. In one way, zoo veterinarians are specialists in that what we do daily; it is very unique and specialized and there are few licensed veterinarians that are employed as full-time clinicians in zoological parks. On the contrary, zoo veterinarians are also the ultimate general practitioners as our patients include everything from invertebrates to great apes and elephants (and all life forms in-between)… and for this wide variety of patients, we attempt to be their pediatrician, surgeon, dermatologist, cardiologist, radiologist, etc. I am fortunate to be the Senior Staff Veterinarian at the Louisville Zoo in Louisville, Kentucky.

In terms of imaging modalities, most zoo hospitals are equipped with plain radiography (film or digital) and have some ultrasound capabilities. A few of the larger zoos in the country have computed tomography (CT) in their on-site hospitals. In Louisville, when one of our patients requires advanced imaging, we make arrangements with local facilities with CT or MRI capabilities.

For ultrasound imaging, we have a portable Sonosite M-Turbo unit with both a curvilinear, 5-2 MHz transducer for primarily transabdominal imaging, and a linear array, 10-5 MHz transducer for primarily transrectal imaging. In addition, we have several donated large rolling Phillips Sonos units with an assortment of probes for both echocardiography and transabdominal imaging. One remains in the Zoo’s Animal Health Center and others are stored and used in animal areas for pregnancy diagnosis, echocardiograms on awake gorillas (through the mesh barrier), or just training/conditioning animals for awake ultrasound exams.

Zoo animals may present unique challenges when ultrasound imaging transcutaneously. In the case of fish and amphibians, imaging through a water bath (without even touching the patient!) can be very effective and noninvasive. The rough scaly skin of some reptiles makes a warm water bath similarly effective as a conductive medium for imaging snakes and lizards. Birds are not often examined via ultrasound because of the extensive respiratory (air sac) system they possess that interferes with the sound waves. For mammals, different species present different challenges. Many mammal species are thickly furred necessitating clipping of hair to establish good contact between the transducer and the skin. For transabdominal imaging, some species are very gassy (hippos, gorillas), which may complicate diagnostic imaging. Large or dangerous mammals that are examined awake via training need to be conditioned to present the body part of interest (chest, abdomen) at the barrier mesh and trust their trainer/keeper to allow contact with the probe. Often the greatest hurdle is habituating the animal to the ultrasound gel! When performing transabdominal imaging in our pregnant African elephant cow, rather than go through gallons of ultrasound gel smeared on her flank to fill in all the cracks and crevices in her thick skin, we run water from a hose just above wherever the transducer is placed.

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As general practitioners, zoo veterinarians have variable amounts of training in ultrasonography. We strive to do the best we can and are constantly learning, but the high variability in our daily tasks makes becoming an expert in ultrasound very difficult. So “it takes a village,” and we will regularly utilize specialists in our community to assist us in providing the best medical care for our patients. If I have a zebra or related species that requires a reproductive ultrasound exam, we will reach out to a local equine veterinarian that can apply their expertise in horses to a related species. Great apes have a high incidence of heart disease so whenever a gorilla or orangutan is anesthetized for an exam, part of the comprehensive care they receive is an echocardiogram by a human sonographer. Female great apes may get attention from our volunteer gynecologic sonographer as part of a reproductive evaluation. If the ultrasound exam is on a sea lion, wolf, or bear, I may contact a veterinary radiologist or veterinary internist competent in ultrasonography to assist.

In summary, ultrasonography represents a valuable, noninvasive, diagnostic tool for the zoo veterinarian.

Have you ever performed an ultrasound examination at a zoo? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Zoli Gyimesi, DVM, is the Senior Veterinarian at the Louisville Zoo in Louisville, Kentucky.

Evidence-Based Sonology: Changing the Practice of POCUS

Let’s say you are working in a busy emergency department. You get a call that a patient is being brought in by ambulance in cardiac arrest. You quickly assemble your team, assign roles, and discuss the plan—just in time for the patient to arrive. A paramedic performs one-arm compressions on an elderly man, pale yellow–his mouth stented open with a laryngeal mask airway. Your swarm of providers descends upon the patient, performing their jobs simultaneously in perfect concert. Airway, ventilations, rhythm checks, epinephrine: everything is running smoothly, but the patient is in pulseless electrical activity. During a rhythm check, someone looks at the heart with ultrasound. You glance at the screen and see a blurry subcostal cardiac view. You can barely make out the pericardium, but you see a weak contraction of the ventricles; there’s still no pulse. Compressions are quickly resumed. You consider all of the information – what are the chances this patient will survive? Should we keep going? Should I place a transesophageal probe? Wait, do I even have one of those?! Is ultrasound enough evidence to determine if further efforts are futile? Amidst your thoughts you hear a loud and eager call out: “I got a pulse!”. The team buzzes again – blood pressure, electrocardiogram, labs, vasopressors, cooling. You wonder, “Why did I even do that ultrasound? Is there any evidence it helps?”.

The difficulty encountered in this scenario is one that occurs countless times across the world’s hospitals each day. Point-of-care ultrasound (POCUS) has exploded off the shelves over the past decade. It has been borrowed from the hands of sonographers and cardiologists and made available to anyone who can afford a machine (training course optional). Overall, this has been a remarkably positive movement. Safer procedures, faster diagnoses, and sometimes a replacement for more potentially harmful imaging modalities. However, it is not without dangers. Those who use it aren’t always looking for the evidence for POCUS, as if it is somehow outside of the requirement for evidence. Others might not use this modality when it is indicated, ignoring the evidence that supports the use of POCUS. Both practices are unsafe. This is a big problem…but it’s one we can fix with the concept of evidence-based sonology.

Practicing based on the best available evidence has been a cornerstone of medicine since its advent; however, only more recently has it seen a visible resurgence. Now that it is in vogue there are physicians who are evidence-based medicine (EBM) specialists, there are EBM blogs and EBM courses. We teach our learners EBM principles and practices. So why has POCUS almost eluded this trend? Why would the evidence for POCUS not be examined with the same perspicacity as resuscitative endovascular balloon occlusion of the aorta (REBOA) in the emergency department, for example? I have some theories. In the early days, POCUS was practiced by a few champions with a dream who understood how POCUS could revolutionize practice. However, ultrasound equipment was not yet widely available. This limited initial studies to case reports and case series on new uses, touting primarily theoretical benefits to patients. As anyone who has used ultrasound knows, this tool holds a powerful allure by allowing its user to magically look into the body and directly visualize physiology and pathology. It is easy to imagine that after a while you build up a confidence; when you see something it must really be there. In a sense, the rapid outbreak of ultrasound use and the ever-expanding list of applications outran the available evidence basis.

A review of a subset of ultrasound-related abstracts showed that there is now increasing research, although most of it would be classified as quasi-experimental, which may not be enough to inform practice.1 But the times, they are a’ changin’. Now ultrasound is ubiquitous, at least at most academic centers, in emergency departments, ICUs, and other places that care for the acutely ill. Therefore, the body of literature is growing, and now we just have to pay attention to it. Enter evidence-based sonology (EBS).

Your first question is probably – sonology? What’s that? Did he just misspell sonography? No. Sonology is a term that implies an expertise in the entire spectrum of POCUS. Not only the acquisition (the “-graphy”) of the images, but additionally the indications for performing it, the interpretation, and the subsequent appropriate medical decision making.2 This is important because the evidence for this modality could fall apart at any one of these levels, so practitioners must be attuned to the hurdles of each step. Your second question probably is, isn’t this just EBM? Of course! But it is something that we could improve, and therefore we need to rebrand this practice to continue teaching it as a concept to anyone that uses POCUS. There are several reasons why this is important. As POCUS becomes more integrated into medical practice, it is important that we are all on the same page. Research helps us understand the benefits and limits of this tool for each application. It helps us to know the best time to use the tool, how accurate it is when we use it, how it affects patients when we use it, and potential harms associated with it.EBS Graphic

So where do we go from here? There are 3 main ways you can practice EBS:

  1. Know the evidence
  2. Model the evidence
  3. Make the evidence (AKA perform research)

As far as knowing the evidence, this is nothing new for anyone practicing in a medical field. You know how to get a hold of journals. These days it’s easier than ever. You can even use social media, podcasts, and blogs to further distill the information for you. Just make sure you read the original evidence yourself and develop your own decisions about how it will change your practice. Secondly, you have to actually implement what you learn. Obviously, not all research articles are practice-changing, but many will at least add something to your understanding of POCUS in clinical practice. For example, in the aforementioned case of cardiac arrest, recent literature could have informed many steps of using POCUS. Cardiac activity on ultrasound has an odds ratio of 3.6 for survival to admission.3 Patient’s in PEA with cardiac activity on POCUS might benefit from continuous adrenergics instead of standard ACLS.4 Furthermore, an understanding that there is the risk of misdiagnosis of cardiac standstill and the risk of delaying chest compressions, might make you pay closer attention to these details during use of POCUS.5,6 Practicing with this evidence is not only the safest practice, but for those at teaching institutions, it can help create a newer generation of EBS followers. Lastly, make the evidence. Do the research. If you have a question, go find the answer. Collaboration is easier now that ultrasound is more widespread, as is evidenced by more multi-center trials.7-9 Talk about research ideas at national meetings and consider research groups for important questions.

There is now a greater evidence basis for POCUS than ever before. No longer are we restricted to a few case reports and our own intuition. We have randomized controlled trials; we have meta-analyses; we have real patient-centered outcomes. Know the evidence, model the evidence, and make the evidence. These are simple practices that we need to support for the sake of our patients. Now it’s up to you. Will you start practicing EBS? Think of creative ways to begin promoting this concept today.

References:

  1. Prats MI, Bahner DP, Panchal AR, et al. Documenting the growth of ultrasound research in emergency medicine through a bibliometric analysis of accepted academic conference abstracts. [published online ahead of print April 15, 2018]. J Ultrasound Med. doi.org/10.1002/jum.14634.
  2. Bahner DP, Hughes D, Royall NA. I-AIM: a novel model for teaching and performing focused sonography. J Ultrasound Med. 2012; 31:295–300.
  3. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33–39.
  4. Gaspari R, Weekes A, Adhikari S, et al. A retrospective study of pulseless electrical activity, bedside ultrasound identifies interventions during resuscitation associated with improved survival to hospital admission. A REASON Study. Resuscitation. 2017; 120:103–107.
  5. Huis In ‘t Veld MA, Allison MG, Bostick DS, et al. Ultrasound use during cardiopulmonary resuscitation is associated with delays in chest compressions. Resuscitation. 2017; 119:95–98.
  6. Hu K, Gupta N, Teran F, Saul T, Nelson BP, Andrus P. Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med. 2018; 71:193–198.
  7. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014; 371:1100–1110.
  8. Atkinson PR, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators. Ann Emerg Med. 2018; 72:478–489.
  9. Gaspari R, Weekes A, Adhikari S, et al. Emergency department point-of-care ultrasound in out-of-hospital and in-ED cardiac arrest. Resuscitation. 2016; 109:33–39.

Do you already practice evidence-based sonology? If not, will you start?  Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

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Michael Prats, MD, is currently Assistant Ultrasound Director and Director of Ultrasound Research in the Department of Emergency Medicine at the Ohio State University Wexner Medical Center. He is the founder of the Ultrasound G.E.L. Podcast that reviews recent articles in point of care ultrasound. Follow him on Twitter by his handle @PratsEM or visit ultrasoundgel.org.