A Personal Vignette From the ’60s and ’70s

In the mid to late 1960s, neurologic sonography at the Neurological Institute at Columbia Presbyterian Medical Center was being performed by Lewis B. Grossman, MD, and Georgina Wodraska within the Neuroradiology section. I had developed a friendship with Dr Grossman in part due to a similarity in our family medical histories of early demise due to coronary artery disease. We had discussed this one evening and the following morning Dr Grossman did not show up for work and had died of a heart attack.

Two other life-changing events happened later that day. First, Georgina Wodraska informed me that I was to be the new head of Neurologic Sonography, much to my astonishment and with significant doubt as my exposure to sonography was extremely limited and I had significant doubt regarding its capabilities beyond that of detecting midline displacements of the brain. Second, that afternoon I started on a physical activity regimen that progressed over time from walking to long distance running (and now in my 80s back to walking).

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Dr Tenner and his daughter, Sallye,
wrapped in mylar while waiting out a flash storm
in a Utah canyon alcove in May 2017.
Sallye, ARDMSRVT, is a sonographer at
Bay Pines Veterans Health Center in St. Petersburg, Florida.

In the mid to late ’60s, the neuroradiologists’ armamentarium consisted of an x-ray tube for radiographs and a needle. The needle was placed directly into an artery (carotid, vertebral, brachial) or into the subarachnoid space to perform arteriography or pneumoencephalography, respectively. To better understand the source of brain echo reflections, ultrasound using a 1.5-MHz transducer using the thin squamosa of the temporal bone as a window was done while vigorously flushing the carotid needle with a bolus of normal saline, which caused an amplification of the echo reflections within the intracerebral arterial vasculature. We also realized that lesions within the brain that were within the field of view of insonation may also be seen. Although the acoustic impedance of normal brain tissue and brain tumors have little difference ex vivo, there are significant differences in vivo due to 1) the basic angioarchitecture of the tumor, which is distended in vivo and collapsed ex vivo, and 2) surrounding brain edema and areas of liquefaction necrosis and cyst formation within the tumor. Hydrocephalus, arterio-venous malformations, giant aneurysms, intra and extra axial tumors, and some congenital malformations were also detectable.

A mode neurosonography is heavily operator-dependent and required an in-depth knowledge of neuroanatomy and neuropathology. Training a sonographer required a dedicated teacher and a highly motivated and dedicated student.

In 1971 I headed the section of Neuroradiology at SUNY Downstate Medical Center where a sonography school was formed and we were able to attract a student, Larry Waldroup, who had a keen interest in neurosonography. He subsequently took a position with Barry Goldberg, MD, and had a most productive and distinguished career.

Our experience with neurosonography resulted in the publication of a textbook “Diagnostic Ultrasound in Neurology” in 1975. This was also the time that computer tomography was becoming widely available. Needless to say, the timing of the publication and the introduction of computed tomography, a mainstay of diagnostic radiology, did not bode well for the sales of the textbook. Although, the Preface of the textbook states “in recent years there has been striking progress in the scope and pace of ultrasonic examinations and methodology,” which is still true today. Ultrasound of the brain has now also found a mainstay nitch in neonatal, intraoperative neurosonography, and transcranial Doppler.

Do you have any stories to tell of the evolution of ultrasound? Who are your mentors? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dr Michael Tenner is a Professor of Radiology and Neurosurgery and Professor and Director of Neuroradiology at New York Medical College in Valhalla, New York.

Excellence in Education

It is an honor to receive the 2017 Peter H. Arger, MD, Excellence in Medical Student Education Award. I am fortunate to know Dr. Arger and recognize his remarkable achievements in education, accreditation, and leadership in ultrasound. It’s my great privilege to work with different students, whether they are medical students, residents, fellows, sonography students, vascular technology students, or physicians of different medical specialties. I have had many great teachers and mentors toJohn_Pellerito learn from. Some of my favorite teachers like Barry Goldberg, Ken Taylor, Chris Merritt, and Peter Arger have the gift to communicate complex ideas and make them simple and easy to understand. Teachers at that level inspire me to be the best I can be.

I know there are many educators who understand that feeling when a student “gets it.” The anatomy and physiology that they’ve been studying comes to life. When the ultrasound unit is no longer a confusing mess of dials and buttons and becomes a window into the human body. When they realize that in their hands, ultrasound can make a difference in patient care.

I am lucky to work with a team of physicians and sonographers who enjoy teaching our medical students. We meet to devise new ways to integrate ultrasound into our longitudinal 4-year ultrasound program. One of the techniques we use to engage our students is to integrate games into our classes. Our SONICS (SONographic Integration of Clinical skills and Structure) faculty has enjoyed putting together ultrasound games for our students. We find that gaming increases their excitement and takes advantage of their competitive edge. One of our latest creations, the Hunger Games (J Ultrasound Med 2017; 36:361–365), has proven very successful.

During this class, we ask one member of each student team to fast prior to a scan of the gallbladder and mesenteric arteries. Following a breakfast of a bagel and cream cheese, the students are rescanned to assess for changes in gallbladder size and mesenteric blood flow. All scanning is performed by the students with faculty guidance. One team is deemed the “winner” and awards are given. The session combines both anatomic and physiologic principles to learn about gastrointestinal and vascular function and incorporate Doppler techniques. This activity provides the foundation for a powerful integration of Doppler ultrasound into medical education.

What are some of the ways that you have engaged your students with fun and interactive ultrasound programs? Do you have any stories from your own education to share? Comment below or let us know on Twitter: @AIUM_Ultrasound.

John S. Pellerito, MD, is professor of Radiology at Hofstra Northwell School of Medicine and Vice Chairman of Radiology at Northwell Health.

Ultrasound in the Age of Telehealth, Telemonitoring, Telemedicine, Robots, and Kimonos

Today, there is online access to almost everything; groceries, a video chat with your grandmother across the globe, step-by-step instructions on how to fix your lawnmower, and a virtual doctor to help with pain in your abdomen. The healthcare applications of the internet have exploded in recent years with digital health and telemedicine assuming one of the highest growth areas for start-up entrepreneurs. The expansion of telehealth resources (IT infrastructure/capabilities) has allowed telemedicine to extend to isolated, inaccessible, remote spaces (maybe even your living room). And telehealth has gone beyond just a video chat with incorporation of sensing technologies including cameras, digital stethoscopes, and ultrasound.
Kat and Scott

Ultrasound imaging in austere locations is not just about access to an ultrasound system; it requires both the ultrasound operator, and the interpreter, to have specific knowledge, competency, and ultimately accountability about the quality of the examination, and the diagnosis it helps to provide. Our NASA-sponsored research team has shown that novice ultrasound operators can acquire diagnostic quality ultrasound images after a short training period with remote tele-ultrasound guidance in a space medicine environment. The astronaut operators were able to perform terrestrial standard abdominal, cardiovascular, and musculoskeletal ultrasound examinations with modest remote guidance oversight; zero gravity specific exams of the eyes, spine, and sinus were also completed. Importantly, the astronaut crewmembers quickly became more autonomous during their 6-month mission in space and were able to self-direct image acquisition.

But a major challenge with tele-ultrasound is operator training. William R. Buras, Sr, Director, Life Sciences at Tietronix Software Inc, and his team are making an augmented reality user interface for ultrasound scanning using a wearable heads-up display with imbedded guidance to improve ultrasound competency. This innovative Houston team is being funded by a NASA grant.

Unfortunately, when it gets to real-world practicality, neither the ultrasound machine nor the examination is intuitive. A team in Canada led by Dr Andy Kirkpatrick are working on a sustainable ultrasound solution using both remote ultrasound system operation and telemonitoring. They investigated the ability of non-trained firefighters to perform ultrasound in Edmonton being guided from Calgary. “We found that by using just-in-time–training with motivated firefighters, the remote examiner guiding the firefighters was 97% correct in determining the presence of a simulated hemo-peritoneum. Ironically, while this trial design also attempted to examine the utility of remote ultrasound knobology control, the firefighters were so good at the task that the remote knobology control became less of a relevant problem” said Dr Kirkpatrick.

To reduce the challenges of novice ultrasound operators, at team in France, led by Dr Phillipe Arbelle, linked a robot-coupled ultrasound device with a remote operator. The distant clinician can move the ultrasound probe with a joystick to acquire the ultrasound images. His concept has been implemented in a French ultrasound device, SonoScanner, that the European Space Agency will begin investigating on the International Space Station.

Similar work in robotic ultrasound is being done in Australia, where a team is building a robotic ultrasound machine that can perform abdominal ultrasound.

Have you seen the guy in a kimono buying a car? Online resourcing is indeed pants-optional. But if you plan on telemonitoring be suitably dressed.

Alien

What other areas have come a long way when it comes to ultrasound? What areas are poised to be next? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Kathleen M Rosendahl-Garcia, BS, RDMS, RVT, RDCS, is a NASA contractor working for KBRWyle and is a senior scientist and clinical sonographer in the Space Medicine division working under the Human Health and Performance Contract. Scott Dulchavsky, MD, PhD, is the Roy D. McClure Chairman of Surgery and Surgeon-in-Chief at Henry Ford Hospital in Detroit, and Professor of Surgery, Molecular Biology and Genetics at the Wayne State University School of Medicine. He is also a principal investigator for NASA and heads a project teaching astronauts how to use medical ultrasound in space.

A Future Career Path for the MSK Sonographer

The sonographic community has the opportunity to take advantage of recent orthopedic surgeons’ interest in diagnostic ultrasound. Although much of the interest was prompted by the usefulness of guided injections, sonographers need to fully appreciate and understand the value of the information derived from an ultrasound study, which will ultimately lead the surgeon to better surgical decisions and better patient outcomes. Once you are a part of the orthopedic diagnostic team, you will be able to function as a specialist Physician Assistant member, adding a new dimension to the orthopedic practice and demonstrating the incredible value of diagnostic soft tissue imaging.

I am a Board-Certified Orthopedic Surgeon, with subspecialty in shoulder orthopedics including arthroscopy and open surgery. I incorporated diagnostic shoulder/MSK ultrasound as part of my office practice 20 years ago especially for evaluation of patients presenting with protracted shoulder pain (in addition to the traditional history and physical exam, and occasional MRI).

I have valued diagnostic shoulder imaging in my practice and determined that all Orthopedic Surgeons should be using ultrasound imaging as part of their usual diagnostic evaluation of patients (especially patients presenting with protracted painful shoulder problems affecting function). In addition, an ultrasound exam with normal findings may be more important than an ultrasound exam that finds some pathology.

I have concluded that the real-time ultrasound examination with comparison to the contralateral side available to the orthopedic surgeon, in most cases, is more valuable than the information obtained from the MRI (especially regarding soft tissue pathology, present or absent).

For example, compare the MRI detail of the supraspinatus with the ultrasound motion clip of the supraspinatus moving under the acromion (see the still MR image below and, at bottom of the page, the 1st video, which is the active ultrasound clip of the supraspinatus). MRI is accomplished with arms immobilized at one’s side, and does not benefit from the study being compared to the contralateral side. However, it produces a nice clear image. The ultrasound image in long axis can be a still image or a motion clip viewing the supraspinatus or infraspinatus moving under the acromion and the reaction causing impingement syndrome, spurs along the anterior lateral border of the acromion, dynamic sub acromial bursitis, or a rotator cuff tear, which may be attritional and similarly present on viewing the asymptomatic shoulder.

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The Math

The following statistics help to identify the future vital need for the sonographer to become part of the team working with the surgeon in an orthopedic office practice (Orthopaedic Surgeon Quick Facts, www.aaos.org; 10 Interesting Statistics and Facts About Orthopedic Practice, www.beckersspine.com; Am J Orthop 2016;45(2):66-67; 20 Things to Know About Orthopedics, www.beckershospitalreview.com).

There are approximately 28,000 (2012) orthopedic surgeons in the US, 75% of whom are in private practice, and many are in group practices of 2 or more. The general orthopedic surgeon sees an average of 70-90 patients per week, of which an estimated 12% or more have shoulder problems. This equates to 10 orthopedic shoulder evaluations per week for 1 solo general orthopedic practice, and 20 for a 2-man group (in the same office). Ten to 20 patients (minimum) per week would then benefit from ultrasound imaging information, assisting the surgeon in making a surgical decision.

The following image identifies how important the cross axis image is, as well as describes the degree of rotator cuff injury and approximates the relative number of rotator cuff muscle tendon units that have been rendered dysfunctional.

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Left, Close to the infraspinatus/supraspinatus interval and insertion site, many fibers are in harm’s way for tendon/fibril tearing. Center, The area for careful X-axis grid examination, looking for possible partial undersurface tearing, fibers losing their connection/attachment to the footplate. Right, Example of an X-axis grid examination of this full-thickness tendon tear, which should be accompanied by an x-axis measurement of the width/base of the triangular tear. Real time examination can help to identify the quality of the tissue, which may require repair. Usually, orthopedic surgeons pay more attention to the MRI reading and the coronal views (ultrasound long axis view). (See the 2nd video clip below for real-time imaging of the X-axis rotator cuff tear.) The X-axis view/measurement is the more important image. The wider the tear, the more tendon fibrils are affected and the more dysfunction to the rotator cuff area involved.

This need for diagnostic shoulder ultrasound information could be sufficient and important enough to support an entire career for an MSK sonographer. All the other valuable areas of MSK expertise that come with the MSK sonographer would be an extra bonus to the orthopedic office practice: helping with other ultrasound examinations, diagnosis, and surgical decisions.

Video clip 3 below is an MSK ultrasound examination for CTS identifying median nerve mobility or restriction within the tissue, questioning the presence of scar tissue restricting motion.

How have you used ultrasound in orthopedic surgery? What other areas of ultrasound are on the brink of emerging in a new field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Alan Solomon, MD, is a Board Certified Orthopedic Surgeon and Honorary Staff at the Metro West Medical Center, Natick/Framingham, MA.

Sonographer Stretches for an ‘A’ Game

For our first blog we introduced the reality that there is an epidemic amount of sonographer pain and injury. Almost 90% of sonographers work and live daily with that pain and injury as a result of doing our jobs. That is an epidemic and sinful statistic. As fellow sonographers, we should be incensed that more is not being done to quell the enormous pain and injury that we suffer from.

Coach Rozy and I have the solution. In our first blog with the AIUM, we detailed and gave examples of lower body stretches and exercises that sonographers should do. The folks at the AIUM relayed that our post was very popular among sonographers. Some of the feedback that we received was that many that read our blog thought it was silly that we would suggest doing lower body work for sonographers that predominately suffer from upper body issues (neck, back, shoulders, etc…).

In our 2nd blog we explained why lower body stretches and exercises are also crucial to good sonographer health and pain-free imaging. My favorite story that Coach Rozy tells is about his time in the National Football League. A prominent quarterback in the league at the time was having pain in his shoulders, and main throwing arm. He couldn’t follow through properly on his pass mechanics due to the pain in his throwing shoulder. Not good, if you are a quarterback in the NFL and you can’t pass properly.

Rozy immediately zoned in and started working the shoulder, with little positive result. A few days later Rozy noticed that this quarterback was walking into the locker room with a limp. He hit him up and was told that he had taken a hard hit on his hip and that it had caused him hip pain. Immediately Rozy started working on the quarterback’s hip. A few days later, the hip was better. At this time the shoulder pain also stopped, and life was good. The problem wasn’t the shoulder. The problem was the hip. The hip injury translated into the shoulder. Fix the hip, fix the shoulder. That’s why when you look at sonographer pain and injury, you must look at the body as a whole, not just the area of pain and injury.

For our 3rd blog, we want to share why it is absolutely crucial that your work as a sonographer must be done at the very highest level on each and every patient that you work on. An article entitled, “Making a Difference as a Sonographer, 100% Every Person, Every Time” details my own personal battle with my wife’s diagnosis of breast cancer. As you will read, a breast ultrasound is the only test that caught my wife’s cancer. The cancer was caught early, which made her course miraculous, given such a diagnosis. Amazing things happened in Yankton, SD, the day that my wife had her ultrasound study that caught ‘something’. Enough ‘something’ that a biopsy was done, the cancer was found early, and the course for my wife was incredible.  As sonographers it is CRUCIAL that we be on our ‘A’ game for every person that we work on.

The following are a few simple, quick, easy stretches that can be easily done at work or home. Working the body as a whole is important.

Lying thoracic spine rotation

Start by lying on the ground on your side (either side). With your arms extended straight out at chest level pull your knees pulled up to your chest. The hips and knees should both be at 90 degrees. Work to have your ankles at 90°. You can use a mat, and for added comfort and support use a pillow.

To begin, keep the knees together (place a rolled-up towel or small ball between the knees if you need more support), move your top arm over your body and toward the floor on the opposite side. The objective is to get the arm and s
houlder blade touching the ground, not just the hand.

    img_0450   img_0449

All images courtesy of Doug Wuebben.

The goal is to do 2 sets of 8 reps on each side. Tip: You want the movement to come through the thoracic spine — not just the shoulder area.

Kneeling thoracic spine rotation

After completing the lying thoracic spine rotation, progress to the kneeling thoracic spine rotation exercise. This is a more progressive move and requires enhanced control over your posture, movement, and stability.

Begin in a 6-point (some say 4-point) position, on your hands and knees. Take one hand and put it on the base of the skull behind your head. It’s important to keep weight evenly distributed between the legs and your other arm.  Keep the bent arm locked in position. The elbow stays pointed toward the ground. Rotate your torso with motion going through the spine, ending so that the bent elbow is pointed up.  The movement should come through the back/spine — and not just the shoulder! Take the movement through as large a range of motion as possible.  The benefit comes from movement from the thoracic spine. Don’t use your shoulders or hips.

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Do 2 sets of 8 reps on each side.

Psoas lunge

Most people consider proper lunge technique to include pushing the hips forward to stretch what they feel are the hip flexors and the psoas. The iliacus crossing the hip is what is stretched in the traditional lunge, but the psoas also crosses the hip and all lumbar joints.

The best way to stretch the psoas occurs when it is isolated with a lunge that includes lateral bending of the spine and twisting and extension motions. This is a great warm-up stretch before running or doing a lower body routine. Stretch and hold for 20 to 30 seconds. Repeat several times, both directions.

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Farmer’s walk

Another simple yet effective routine is what we call the farmer’s walk exercise. Pick one or two dumbbells and hold them by your sides. Then walk around your training area. Start by walking 25 yards or you can also time yourself, say for 30 seconds, to begin with.

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If you are a beginner, perform the farmer’s walk by carrying any object that has some weight to it. Increase the weight as you progress. The farmer’s walk is a simple yet effective leg-strengthening exercise that works your calves, quadriceps, and hamstrings. The core muscles that help support your spine also benefit. It also creates intra-abdominal pressure to prevent your spine from collapsing.

To vary this routine, hold the weights overhead, use only one weight, or hold one weight overhead and one at your side.

What stretches do you do? How do you improve your posture? Comment below or let us know on Twitter: @AIUM_Ultrasound.

 Doug Wuebben BA, AS, RDCS (Adult and Peds), FASE, is a registered echocardiographer and also a consultant, international presenter, and author of e-books in the areas of ergonomics, exercise and pain, and injury correction for sonographers. He has also been published on the topics of telemedicine and achieving lab accreditation.

Mark Roozen, M.Ed, CSCS,*D, NSCA-CPT, FNSCA, is a certified strength and conditioning specialist, a certified personal trainer, and a fellow of the National Strength and Conditioning Association (NSCA).

Wuebben and Roozen are co-founders of Live Pain Free — The Right Moves. They can be contacted at livepainfree4u@gmail.com.

 

Why I Love Credentials

My name is Mike. I am many things, including a veteran, a business man, a coach, and a sonographer. And while the “things” I am change over time, one thing has remained the same: I am a student! This is thompsonmost evidenced by the 8 professional credentials I currently hold.

I have found that after being in the field of ultrasound for more than 2 decades, credentialing and continuing education can distinguish the enthusiastic sonographer from the merely competent one. With the introduction of more focused credentials such as musculoskeletal, breast, pediatric, phlebology, and advanced cardiac subspecialties, sonographers can now stand out from the crowd in terms of awareness and competency while at the same time being on the cutting-edge of the latest techniques and literature.

Acquiring a new credential, or even just studying for the registry examination, requires you to learn valuable new knowledge that may impact the way you treat and diagnose patients. For example, while I was preparing for the RPhS registry, multiple sources recommended a pneumatic compression device to augment venous flow while a patient is standing as an alternative to the patient performing the Valsalva maneuver in order to induce and record venous reflux. For me, this method has helped me better evaluate for this condition with less strain on the patient while eliminating communication barriers that may exist. If I hadn’t been preparing for that exam, I probably would never have learned this technique.

While some credentials are necessary for certain jobs, multiple credentials prove to existing and future employers that you take your profession seriously and you don’t settle for the minimum standard. I am not saying you need to get multiple credentials. If your professional interest does not reach beyond one credential, that is fine, but few ultrasound labs today only perform only one specialty. Echocardiography labs and vascular labs are growing together as cardiovascular labs, and many departments are requiring a more comprehensive knowledge in ultrasound. Credentialing yourself to the highest degree may get you the new job you pursue or secure the one you have. While increased pay is always a motive, sometimes the satisfaction of being able to set yourself apart from others in the field can be just as rewarding.

Some sonographers have the position that if the credential doesn’t come with a pay raise, it’s not worth it. With reimbursement cuts and higher credentialing standards being proposed by private and government payors, my opinion is that keeping your job is a pay raise.

Why do you hold the credentials you have? 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.

Mike Thompson, MPH, RDMS, RDCS, RVT, RPhS, RVS, RCS, RCCS, is Owner of Diagnostic Resources in Perry, Georgia.

 

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