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.

Why SonoStuff.com?

Three reasons:

As a co-director of technology enabled active learning (TEAL) at the UC Davis school of medicine I incorporate important technologies into the medical curriculum, which has primarily been point of care ultrasound (POCUS). Ultrasound is an incredible medical education tool and curriculum integration tool. It can be used to teach, reinforce, and expand lessons in anatomy, physiology, pathology, physical exam, and the list goes on.

I knew there was a better way to teach medical students thaschick_photo_1n standing in front of the classroom and giving a lecture. Student’s need to learn hands-on, spatial reasoning, and critical thinking skills to become excellent physicians. Teaching clinically relevant topics with ultrasound in small groups with individualized instruction
is the best strategy. I needed to flip the classroom.

I started by creating online lectures for an introduction to ultrasound lecture, thoracic anatomy, and abdominal anatomy:

Introduction to Ultrasound, POCUS

FAST Focused Assessment of Sonography in Trauma Part 1

FAST Focused Assessment of Sonography in Trauma Part 2

Aorta Exam AAA POCUS

Introduction in Cardiac Ultrasound POCUS

Topics quickly grew in scope and depth. I initially housed my lectures on YouTube and emailed them out to students before the ultrasound laboratory sessions. However, I wanted a platform that allowed for improved organization and showcasing. I needed a single oschick_photo_2nline resource they could go to to find those materials I was making specific to their medical curriculum.

https://www.youtube.com/channel/UCOhSjAZJnKpo8pP7ypvKDsw

Around the same time, during a weekly ultrasound quality assurance session in my emergency department I realized we were reviewing hundreds of scans each month and the reviewers were the only ones benefiting educationally from the process. Many cases were unique and important for education and patient care.

We began providing more feedback to our emergency sonographers and I decided I could use the same software I was using to develop material for the school of schick_photo_3medicine to highlight the most significant contributions to POCUS in our department every week. I quickly realized I needed a resource to house all these videos, one that anyone in my department could refer to when needed. The most efficient and creative method was to start a blog. I was discussing the project and possible names for the blog with colleagues and Dr. Sarah Medeiros said, “sounds like it’s a bunch of ultrasound stuff”. https://sonostuff.com was born.

I owe a great deal to free and open access to medical education or FOAMed. I was hungry for more POCUS education in residency and the ultrasoundpodcast.com came to the rescue. I became a local expert as a resident and even traveled to Tanzania to teach POCUS.

schick_photo_4I primarily began www.SonoStuff.com to organize and share with my department of emergency medicine and school of medicine, but it grew into a contribution to the growing body of amazing education resources that is FOAMed. I now use it as a resource in my global development work along with the many other FOAMed resources.

The work we all do in FOAMed, including AIUM’s the Scan, are an incredible and necessary resource. I have read the textbooks and attended the lectures, but I would not be where I am without FOAMed. I know all or most of those contributing to FOAMed do it out of love for education and patient care, without reimbursement or time off. Thank you to the many high-quality contributors and I am proud to play a small part in the FOAMed movement.schick_photo_5

Michael Schick, DO, MA, is Assistant Professor of Emergency Medicine at UC Davis Medical Center and Co-Director of Technology Enabled Active Learning, UC Davis School of Medicine. He is creator of www.sonostuff.com and can be reached on Twitter: ultrasoundstuff.

Obsessed With Ultrasound

1. Tell us how and why you became interested in ultrasound?
During my Emergency Medicine at Mayo Clinic, I gained exposure to point-of-care ultrasound (POCUS) for procedural guidance. I was immediately drawn to the hands-on and technical aspects of using ultrasound, and began advancing my use for diagnostic shihpurposes. After a few cases of diagnosing acute pathology at the bedside (AAA, free fluid, and DVT to name a few), I was hooked! Following residency, I decided to expand my ultrasound training and pursued an Emergency Ultrasound Fellowship at Yale, while also working toward obtaining my Registered Diagnostic Medical Sonographer (RDMS) certification. Ever since I’ve adopted a liberal use of POCUS in my clinical practice, I can say without a doubt that it’s made me a better Emergency Physician, and I can’t imagine practicing without it!

2. Talk about your role as Program Director of the Emergency Ultrasound Fellowship Program at The Scarborough Hospital in Toronto.
I’m thrilled to be able to bring the skills that I’ve learned during my own EUS Fellowship training to the Emergency Medicine community in Toronto! Our team built the Fellowship Program from the ground up, and our Department went all in with the purchase of 4 additional new ultrasound machines and QPath software for archiving. I’m truly proud of what we’ve accomplished. It certainly helps that I have an extremely supportive Department Chair and 2 amazing fellows this year!

3. What prompted the writing of your book Ultrasound for the Win!?
When trying to learn more about ultrasound myself during residency, I found that there was a void in high-yield POCUS books geared toward Emergency Physicians. I found that the few textbooks that were available, while informative, could be quite dense and intimidating to read. So I decided to develop a book that I, myself, and I believe most Emergency Physicians, would appreciate — a case-based interactive and easy-to-read format that’s clinically relevant to our daily practice. It’s a book that a medical student or resident interested in POCUS can easily read and reference during an Emergency Medicine rotation.

4. What’s one thing you learned about yourself through the writing/editing process?
It’s made me realize just how obsessed I am with ultrasound! Writing and putting together the book was hard work, but also enjoyable and extremely satisfying! Seeing these real cases compiled one after another really highlights the potentially life-saving role of POCUS in medicine, and the profound difference it can make in improving patient care and outcomes.

5. What advice would you offer medical students when it comes to ultrasound?
Scan many and scan often—it’s simple; the more you practice POCUS, the better you will be at it! Also, don’t be afraid to take initiative in your own education—while some attendings may not be comfortable enough with POCUS to teach it to you, don’t let that be a deterrent to your own learning. There’s a plethora of resources available online, including Matt & Mike’s Ultrasound Podcast and Academic Life in Emergency Medicine that you can reference!

How did you become interested in ultrasound? What are your go-to resources? What book would you like to see written? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Jeffrey Shih, MD, RDMS, is an Emergency Physician and author of the book Ultrasound for the Win! Emergency Medicine Cases. He is Program Director of the Emergency Ultrasound Fellowship Program at The Scarborough Hospital in Toronto, Canada, and Lecturer in the Faculty of Medicine at the University of Toronto. He can be reached at jeffrey.shih@utoronto.ca and on Twitter: @jshihmd

My Chilean Experience

Earlier this year, I had the opportunity to travel to Chile to present at the 18th Congress of Medical Technology meeting in Santiago. It was an amazing experience that I will never forget! The total travel time was about 14 hours, which began in Orlando with a flight delay and an emergency change to an earlier flight that had one seat left and was just about to
close its doors!Chile

Sonographers, as well as other allied health professionals, begin their education in the Colegio de Tecnologos Medicos (College of Medical Technologies); and the Capitulo de Ecografia (Sonography Chapter) is an arm of the College.  It is estimated that there are about 300 sonographers in the country of Chile. I was invited to speak at the meeting of the congress and the preconference, which was the inaugural meeting of the Sonography Chapter.

The evening before the preconference, I was invited to meet with a group of sonographers at a reception to discuss professional issues, certification, and education. The reception was hosted by the President of the College of Medical Technologies, Veronica Rosales, and the President of the Sonography Chapter and AIUM member, Mario Gonzalez Quiroz. At the reception, I was introduced to Fernando Lopez, known as the first sonographer in Chile with about 30 years of experience. I found the sonographers of Chile to be very welcoming and gracious, as well as curious about the role of sonographers in the U.S. They are also eager for educational opportunities to expand their knowledge and expertise.

I gave a total of 6 lectures during the 2 meetings on a variety of topics, including point-of-care, acute abdomen, obstetrical pathology, and pediatric sonography. Oh…did I mention that I don’t speak Spanish? I had synchronous translation of my lectures, and then I was able to enjoy other lectures that were then translated into English for me. As I was developing my lectures, I learned that with asynchronous translation, presentations should be shorter and you need to speak slowly. For me, that meant I had to reduce my typical image-heavy 100-120 slide presentation down to 70-80 slides. Luckily that worked within the time I was given.

This was my first time having lectures translated, my first international lectures, and my first time in Chile (actually my first time in South America)…lots of firsts! It was a true honor to present at this meeting and to meet the sonographers of Chile. I feel like I have made lifelong friendships, expanded my professional family, and experienced the beauty of a new country.

Have you given talks to an international audience? What was your experience? How can U.S.-based physicians and sonographers support their counterparts in other countries? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Charlotte Henningsen, MS, RT(R), RDMS, RVT, is the Chair & Professor of the Sonography Department at Adventist University of Health Sciences and the Director of the Center for Advanced Ultrasound Education. She currently serves as the AIUM 2nd Vice President.

FOAMed Made Me A Better Lecturer

My glossy, relentless smile slowly began to sag. My enthusiasm waned. I asked myself, “Why are you even here?

Although that was the first time I actually asked the question, truth be told, it had been germinating in my brain for the past few months.FullSizeRender

It was during one particularly bland and unprepared lecture in my first year of medical school when I found it nearly impossible to read the deluge of text on the PowerPoint slide and listen to the speaker. Not only was I quickly losing interest, but the speaker appeared to be caught off guard by the content of his own slides.  The phrase “Why did I put that in this slide?” was uttered over and over again. Unfortunately, my despair was not limited to this one professor or this one lecture. In fact, getting a good lecture was more outlier than standard.

It was at that moment I decided to stop attending lectures. I figured since the speakers gave me access to their slides and all they were doing in class was reading the slides, I could stay at home and do just as well. As validation for this theory, my grades improved.

Shortly after graduating medical school, I was asked to give my first lecture as an intern. What did I do? I created a PowerPoint with bullets. That lecture went over about as well as those medical school lectures did: horribly.

While the content was acceptable, the presentation wasn’t engaging, and worst of all, it was boring. I found myself perpetuating the cycle and becoming a part of the problem rather than a solution.

For my next lecture, instead of focusing on the required content, I focused on my audience. Luckily I had a group of mentors who had grappled with this so I began to study not only the content of their lectures but also how they lectured.

Soon after, I discovered podcasts and the #FOAMed (Free Open Access Medical Education) movement. Inexplicably, I found I could watch an entire 20-minute talk online without checking my phone. For someone with the attention span of a small bird, this was no small feat.

I tried to emulate what I had been learning and observing for my next talk, and when I gave my next lecture to the residents, I found they were spending less time on their phones and computers and more time engaged in my lecture. After that experience, I immediately asked for more opportunities to lecture because I knew the only way to improve was to do more of them. While the residency was very accommodating, they were only able to give me a lecture every couple of months, and I needed more.

Since I couldn’t give lectures to our residents as frequently as I desired, I thought maybe I could practice on my computer. Initially, I figured I could record a few lectures and put them on YouTube. But the more I thought about it, the more I wasn’t sure this is how I wanted to distribute my content. I always got distracted when I went on YouTube. I would start looking for ultrasound videos and then somehow end up watching an hour of compilations of cats falling asleep and rollerbladers falling.

That’s when I thought about creating a website. I wanted a place where I could upload all of my lectures in an easy-to-navigate format, with minimal distractions. I remember reading somewhere that the average student attention span was approximately 10 minutes, so decided I was going to try and make my videos 5 minutes long to increase the likelihood that people would actually watch the whole video. That’s where 5-minute sono was born.

Eventually I purchased a USB microphone and paid for good screen capture software and began recording. Initially I wanted to focus on purely instructional videos without any mention of the evidence or current literature. This made it much easier to keep my content as short as possible, with the long-term plan to create a podcast where I could talk about literature as much as I wanted. Setting up a website to look good and work seamlessly is very difficult. Thankfully the ultrasound director where I went to residency is kind of a genius on that front. There have definitely been a few hiccups along the way, but overall the experience of been pretty amazing. This has taken a tremendous amount of work, but viewership has been steadily increasing, which is encouraging.  I still have a large amount of instructional 5-minute sono videos to create, but decided to start introducing more literature reviews in the form of a blog and podcasts. Soon I’ll begin my faculty position at the University of Tennessee in Chattanooga, Tennessee, Department of Emergency Medicine, and anticipate I’ll be able to lecture to the residents to my heart’s content. But that won’t stop me from continuing the steady stream of ultrasound instructional videos and supporting the FOAMed movement.

How do you make your talks more engaging? What are your favorite FOAMed resources? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jacob Avila, MD, is Co-fellowship and Ultrasound Director, Clinical Assistant Professor at the University of Tennessee in Chattanooga, Tennessee. To check out some of his FOAMed material, visit 5 Min Sono.

How to Obtain Focused Cardiac Ultrasound Images

My first exposure to handheld ultrasound was as a first-year medical student. I was assigned to a cardiology clinic with an attending that pioneered handheld ultrasound examinations. Watching him move from patient to patient and use ultrasound to simultaneously diagnose and teach inspired me to learn how to use ultrasound and incorporate it into my practice.

cardiac_pic2

Parasternal long axis demonstrating a dilated left ventricle.

As a budding cardiologist, examining and triaging patients with handheld ultrasound is a part of my daily work. Although handheld ultrasound and the stethoscope differ vastly in their technology, at the bedside, both are limited by the user’s interpretation of the examination findings. I have found when using handheld ultrasound, as with the stethoscope, perhaps the most important tool is “between the ears.”

The “Introduction to Focused Cardiac Ultrasound” set of lectures provide an overview to focused cardiac ultrasound views and a guide to obtain them. The main goal is to develop an understanding of the scope of focused cardiac ultrasound and to “get the heart on the screen” when scanning. The first lecture focuses on the parasternal long axis and subcostal views of the heart. In practice these views will often be the most helpful and accessible. The second lecture reviews the parasternal and subcostal views and introduces the apical views of the heart. Each lecture includes sample diagnoses.

My rationale for reviewing all the basic views of the heart is to provide a broad survey of all the windows and probe orientations. When a formal cardiac echo is ordered, these are the views and windows obtained by the sonographer. In practice with handheld ultrasound, one or two of these views can be utilized to answer the question at hand. Based on patient positioning and body habitus, however, certain windows may provide a better view of the heart.

My hope in sharing all the views in the second lecture is to not overwhelm the learner but rather provide a strong foundation in understanding the anatomical relationships of the ventricles and atria in the body and see how one window builds off the next. The views in this lecture are directly applicable to structured bedside ultrasound examinations, such as the “CLUE examination.”

At our home institution, we utilize these lectures in a continuously rolling small-group lecture series for our medical students and house staff. The cardiology fellow leads the lecture and the hands-on scanning portion, rotating every third week on the step-down cardiology unit. Overall the feedback has been positive with many of the trainees spreading the skills to other rotations. We are happy to share this resource and welcome feedback.

What resources are invaluable to you? What tools do you use to continually learn? Where do you find the information you need? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Colin Phillips, MD, is Fellow, Division of Cardiovascular Disease at Beth Israel Deaconess Medical Center.