Novice to Competence to Understanding Our Role as POCUS Educators

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

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

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

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

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

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

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

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

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

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

 

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

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

Who Owns POCUS?

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

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

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

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

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

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

 

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

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

Therapy Dogs

What could be cuter and more beneficial to patients than a team of six Golden Retriever therapy dogs showing kids how to undergo procedures?

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Therapy dog, Jessie, undergoes an echocardiogram while being comforted by ‘Mom’, who is holding her paw.

At Southampton Children’s Hospital in the UK, the therapy dogs help the pediatric patients overcome their anxiety and fear by providing support ranging from general meet-and-greet style Animal Assisted Activity visits to Animal Assisted Therapy. The therapy dogs assist in physiotherapy, speech and occupational therapy, phlebotomy services and injections, radiology investigations, and by supporting children in the anaesthetic room.

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Leo demonstrating laying down in an MRI scanner.

One of the reasons therapy dogs are so helpful is that they are nonjudgmental and take the healthcare environment in stride. They don’t cajole or persuade, and I am sure that is why the children sometimes trust them more than the people who are with them. Every parent and medical staff member is trying to get the procedure done, which is why using the dogs as a bridge between the healthcare team and the child is so very useful. As a volunteer, it has been a privilege to be able to develop this service for the hospital.

I am delighted to say that we have images and videos that enable us to assist the medical staff even when we are not there! The library of pictures and videos that the staff can show the children when they are anxious includes such things as:

  • A short film, ‘Leo goes to X-ray,’ showing therapy dog, Leo, going to the X-ray department and explaining how easy it is to have a radiology investigation, whether it is a plain film X-ray or CT/MRI scan.  (https://www.youtube.com/watch?v=Vb8kIU4y9H4)
  • A video of a therapy dog heading down to theatre after admission procedure and showing what the route to theatre looks like as well as showing the anaesthetic room.
  • As well as many adorable and helpful photos.
archie investigations collage

Archie demonstrating, from top left, a thermometer to the arm, stethoscope to the chest, SATS testing, and pulse oximitry on a paw.

You can see more in this report on yahoo! news.

 

 

Have you ever worked with therapy dogs? If so, what was your experience like? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Lyndsey Uglow is the Lead Animal Assisted Intervention Handler at Southampton Children’s Hospital Therapy Dogs.

The Place of POCUS in Prevention of Physician Burnout

Doctors’ jobs, in the hospital or clinic, have been getting more demanding and less rewarding in the last several years. Well-meaning changes including the rise of electronic medical records and attempts to improve how we do our jobs through quality measures have made us sad and tired and supply none of the joy that we can get from a satisfied patient or a diagnostic puzzle cleverly solved. We may find ourselves aging, with multiplying frown lines and receding hairlines, sitting at our computers finishing our documentation, while our families have vacations and parties without us. Although we make enough money, strangely, it doesn’t buy happiness.

When we are tired and sad; we lack the creativity to make job changes. Fear eclipses courage.

IMG_9919Sometimes we do stupid things involving alcohol or indiscretions, or buying something expensive on credit… family members give us “that look.”

We feel inadequate.

We get grumpy and stop doing that extra little bit to connect with the patient or unravel the mysterious illness. The precious little job satisfactions of working well with our team or taking our patients’ point of view become rarer.

We are burning out. There’s that telltale smell of smoke as our soul shrivels and our dreams fry.

What do we need? Probably a vacation, maybe even a stint working in global medicine, to change our perspective. Counseling and confiding in friends can help. If we keep doing the same job, perhaps we need a scribe to take care of the paperwork. Also learning a new skill could make us wake up and love medicine again. Enter point-of-care ultrasound.

I don’t want to trivialize the pain of burnout. It can be devastating, making us depressed, ending marriages, wrecking careers and friendship, collapsing us inward, and sometimes leading to suicide. Somehow we need to jump off of that horrific course and better sooner than later. I got close to burning out early in my career and ever since that time I’ve done everything I can to stay in love with my job. For me, learning to do point-of-care ultrasound enriched my practice and, along with a major career adjustment, kept me from getting all charred and crispy.

Doing point-of-care ultrasound, for a physician who is already skilled in practice but has no ultrasound experience, can be life-altering. As I matured in my practice, some of my physical exam skills improved but others atrophied for lack of use and because I knew that I couldn’t trust them. A fluid wave doesn’t predict ascites. Dullness in the base of the lung doesn’t lead me to suspect a pleural effusion. Splenomegaly, if not massive, is so hard to detect in my super-adequately nourished patients. Learning basic point-of-care ultrasound brought me back to paying good attention to my patients’ bodies. And they were fascinated and appreciated the extra care. I also was able to more quickly solve their medical mysteries and shorten previously prolonged evaluations. Seeing patients got more fun.

Burnout is an awful feeling and is preventable. It happens when we get ourselves into situations that are not sustainable and don’t feed our souls. We physicians have vast options and we need to recognize when we are trying to do a job that is wrong for us. And before we quit the profession entirely, we need to try learning something that makes it fun again. Point-of-care ultrasound, for instance.

 

How do you avoid burnout? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Janice Boughton MD, FACP, RDMS, is an internist  Moscow, Idaho. She practices hospital medicine and rural primary care as well as teaching point of care ultrasound techniques in the US and Africa. She also writes about healthcare economics in her blog (www.whyisamericanhealthcaresoexpensive.blogspot.com.)

Dr. Boughton graduated from the Johns Hopkins School of Medicine in 1986 and completed residency training at the Johns Hopkins Hospital and the University of Washington. She started doing bedside ultrasound in 2011.

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.