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.

What One Winning Sonographer Has to Say

 

d_mertonEstablished in 1997, the Distinguished Sonographer Award recognizes and honors current or retired AIUM members who have significantly contributed to the growth and development of medical ultrasound. This annual presentation honors an individual whose outstanding contributions to the development of medical ultrasound warrant special merit. This year’s winner is Daniel A. Merton, BS, RDMS, FSDMS, FAIUM, from New Jersey. Here is what he had to say about receiving this honor.

Congratulations on being named the 2016 Distinguished Sonographer. What does this award mean to you?

I appreciate being recognized for my contributions to the field and am honored to join the list of other sonographers who have received this award.

You are and have been very involved in several ultrasound societies. Why do you volunteer so much of your time?

I am passionate about the profession and want to contribute what I can to its future in terms of technology and its use to improve patient care.

How and why did you first get interested in medical ultrasound?

I learned of medical ultrasound in 1978 when I was a sonar technician in the US Navy. I was then, and am still, fascinated with the use of acoustic energy for many applications but particularly for diagnostic and therapeutic medical applications. After being discharged from the Navy I perused a degree in Diagnostic Medical Imaging. At that time (early 1980s) there were only 6 DMS programs in the country that awarded a degree so my options were limited.

When it comes to medical ultrasound, who do you look up to?

First and foremost, Dr. Barry B. Goldberg, FAIUM. He is a true pioneer with an insatiable appetite for investigating the unknown and attempting the untried. He is a mentor, colleague, and friend who provided the environment and support, without which I am quite sure I would not have accomplished what I have nor be receiving this prestigious award. I was fortunate to have worked with many other skilled and dedicated professionals, including Larry Waldroup, BS, RDMS, FAIUM and Dr. Fred Kremkau, FACR, FAIMBE, FAIUM, FASA, but the entire list would be too long to include here.

How did you first get interested in medical ultrasound? Who are your mentors? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Daniel A. Merton, BS, RDMS, FSDMS, FAIUM, in addition to being an AIUM award winner, is a Senior Project Officer at ECRI Institute, a nonprofit medical testing and patient safety organization in Plymouth Meeting, PA.

Rare and Sometimes Disappearing: The Tough Life of the Sonographic Expert

Everyday obstetricians hear the same questions: “Is my baby OK?” “Is there anything abnormal?” or, and this is may be the worst, “Should I be worried about anything?”

While innocent enough, these questions get for far more difficult when you consider that in the patient’s mind sonographic experts should be able to “see everything.” For Hershkovitz scanpatients, ultrasound has become a routine obstetrical practice that experts should be able to use to perform every type of diagnosis at the earliest gestational age—with 100% accuracy. This perception, however, means that developmental anomalies or disappearing findings are very confusing for the patient and her spouse.
An example of such a confusing sonographic condition is prenatal diagnosis of congenital lung lesions. One of the rarest lung lesions is Congenital Lobar Emphysema (CLE). This is a rare developmental anomaly of the lower respiratory tract characterized by hyperinflation of one or more of the pulmonary lobes and subsequent air trapping. The main fetal sonographic features of CLE include a bright echogenic lung with or without cystic or mixed cystic lesions (see image) without abnormal blood flow. A mediastinal shift, polyhydramnios, and fetal hydrops can also be observed and are predictors of severe respiratory distress or mortality.

CLE can decrease in size during pregnancy and even disappear on prenatal sonography or become apparent at postnatal evaluation, even though it is not observed during pregnancy. This can, obviously, become confusing for the patient. The main differential diagnosis of CLE is with congenital cystic adenomatoid malformation, pulmonary sequestration, and congenital high airway obstruction syndrome (CHAOS).

Once such a diagnosis is suspected, the patient is usually invited to a multidisciplinary meeting with the pediatric pulmonologypulmonologist, geneticist, and surgeon. Evaluation of the fetus is usually performed every 2 weeks and sometimes prenatal MRI is also suggested.

In many cases, depending on the size of the CLE and whether the fetus is hydropic by the time the fetus is delivered, the neonate is not in respiratory distress immediately after birth. However, sometimes CLE can lead to neonatal respiratory distress, and these neonates need to undergo surgical resection of the affected lobe. In the past, this has meant open thoracotomy, although recent advances in minimally invasive thoracoscopic surgery have resulted in decreased morbidity associated with resection of these lesions.

While innocent enough, the question, “Should I be worried about anything?” can get confusing and difficult when dealing with conditions like CLE. How would you handle it?

In a case like this how would you answer the question, “Should I be worried about anything?” How and when do you provide counseling to patients? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Professor Reli Hershkovitz is the Head of the Ultrasound Unit at the Department of Obstetrics and Gynecology of the Soroka University Medical, located in Beer Sheva in the Southern part of Israel. This medical center serves nearly 2 million people, with an average of 16,000 deliveries a year.

Get Rid of That Pain in the Neck in 3 Easy Movements

Have you experienced any of these situations?

  • Your shoulders feel like they are on fire after the first few scans of the day.
  • You have a hard time finding a comfortable sitting position.
  • Your wrist and arms feel like an iron apron has been laid across them.

If so, you are not alone. Nearly 90% of sonographers scan in pain. And of that 90%, nearly 30% will experience so much pain that they will have to find another career. This is an epidemic that must be addressed.

Earlier this year, we posted our first blog that focused on lower body stretches. We did that first because we have found that upper body manifestations can, and often do, occur as a result of lower body issues. Many times, in order to fix shoulder, neck, and back pain, we start by looking at the legs and hips. As we like to say, “train movement, not muscles.” To stay in line with that concept of not just training a muscle and one area, we want to share 3 easy movements that can help with neck, shoulder, and back pain.

  1. Overhead Reach
    1. Sitting at your desk, or standing behind your chair, take both arms and reach overhead as high as possible, with palms facing in and thumbs pointing behind you.
    2. As you extend your arms overhead, push your shoulders back (think pinching a pencil between your shoulder blades!).
    3. Now keep reaching as high as you can while exhaling as if you are blowing out a huge candle, actually 5 huge candles. Inhale through your nose and exhale through your mouth.
    4. This should open up your chest, allowing you to breathe easier while at the same time relieving stress and strain from your neck and shoulders.#3
  2. Thumbs Back Reach
    1. Again, sitting at your desk, or standing behind your chair, take both arms and extend them down by your side.
    2. This time, open the palms to the outside, rotating the hands so the thumb is again pointing behind you.
    3. Again, pinch the shoulders back (think of pinching that pencil between the shoulder blades!) and sit or stand as tall as possible.#6.
    4. Now keep reaching back as far as you can while at the same time blowing out those five huge candles! Inhale through your nose and exhale through your mouth.
    5. This is another great movement to open up your chest and allow you to breathe easier while at the same time relieving stress and strain from your neck and shoulders.
  3.  Head To Shoulder Reach
    1. In a seated or standing position, simply make yourself as tall as possible. With this movement, think that someone is taking you by the hair and pulling straight up!
    2. At the same time, push the shoulders down and back – pinch that pencil!
    3. Slowly tilt your head toward the top of your shoulder. Try to place your ear on top of your shoulder.
    4.  Now, slowly and gently, rotate your head, working to bring your chin up toward the ceiling, while still trying to keep your ear on your shoulder.
    5. Make sure to do both right and left side to use this movement to get great neck relief and release tension in the muscles in the upper neck/shoulder area!

You can do these movements 2-3 times a day, doing each one, two or three times at a setting (workout!) or any time you start to feel tension build throughout the day!

What stretches do you do? How do you improve your posture? What other areas would you like to see covered? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Doug Wuebben, BA, AS, RDCS, (Adult and Pediatric), 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.

Mark Roozen, M.Ed, CSCS*D, NSCA-CPT, FNSCA, is a strength and performance coach and also the owner and president of Coach Rozy Performance Centers.

Mark and Doug are co-owners of Live Pain Free-The Right Moves consulting company. They can be contacted at livepainfree4u@gmail.com.

A Word of Encouragement

One excellent online teaching tool for emergency ultrasound states that “scientists have been fascinated by the mechanism of acoustics, echoes and sound waves for many

Wake Course 5

Attendees get hands-on experience at AIUM’s Wake Forest 

centuries.”

I am not one of those scientists.

Frankly, I don’t like physics. I find it challenging to understand things I can’t see. Take gravity, for example. I know and can tell quite distinctly that it exists. The scar on my shin following a childhood attempt at flight is a faithful reminder of its existence. It still remains hard for me to understand the intricacies of this force because of its invisibility. To me, this is similar to a lot of physics concepts.

It’s therefore hilarious that I was somehow drawn to ultrasound. It must have been the enticement of being able to see more, although the ability to “see” is granted by what is unseen—ultrasound waves. The joke was definitely on me.

So how did I get here?

My journey with point-of-care ultrasound (POCUS) started with a remark by a friend of mine. At the time, she was an emergency medicine resident and she told me about a trauma patient that she had performed a “FAST” on. Close to completing 3 years of Pediatric residency, I had never heard of such a thing. I remained intrigued with the idea of quick decision-making scans performed by the provider actively involved in the patient care. Who wouldn’t want this given the chance? The challenge of course lies in acquiring the knowledge.

Things now got interesting.

During my Pediatric Emergency Medicine (PEM) fellowship, I sought to learn more about POCUS. My initiation was not spectacular to say the least. The words of my instructors bounced off the surface of my brain with very little being absorbed. This would have been OK if I were an ultrasound machine. It wasn’t very good when trying to learn how to obtain and interpret ultrasound images however.

By the second and third lesson, I was convinced that I would never learn ultrasound. But as in the majority of love stories, persistence paid off.

Gradually my images changed from what resembled a 1970s television screen after midnight to recognizable structures. By the end of my PEM fellowship, I had acquired a few rudimentary skills. I took an opportunity to pursue an Emergency ultrasound fellowship immediately after my PEM fellowship and the dread of my early ultrasound learning days came upon me again. So many applications, so little understanding.

One day as I scanned a patient, “Eureka!” I finally understood the parasternal long axis. There was hope for me yet.

How did I finally get here?

  1. Persistence – The old adage holds true. If at first you don’t succeed, try, try again.When the words or explanation didn’t make sense, I would try a video (YouTube has some great videos). I would get models of structures to understand the anatomy and relate to them to my scans. I would seek out others to explain concepts in different ways to help my understanding.
  2. Memorization – This provided a foundation and served as the means to the end. When using POCUS, there is a lot to remember and you have to put in the necessary study time.

Finally, I was able to understand what was going on and what the picture was telling or NOT telling me. I also learned not to beat myself up for not understanding everything. That is what colleagues, mentors, online resources, and practice are for.

I now understand a lot of POCUS–more than I ever imagined or thought possible. I didn’t let my dislike of physics or the challenge of image recognition stop me. I figured if others could learn this, I should at least give it a decent shot. And that’s what I ask of those I teach or anyone interested in learning.

What would you tell someone starting to learn ultrasound? What aspect was most difficult for you? How did you overcome it? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Atim Uya, MD, is the Point of Care Ultrasound Director, Division of Emergency Medicine, Department of Pediatrics, University of California, San Diego/Rady Children’s Hospital, San Diego, California.

3 Stretches All Sonographers Should Do

Have you ever thought about how you stand? Or how you hold a transducer? Or how you position yourself over your patient? Incorrect positioning in any form could increase your risk of pain and injury. Here are three easy exercises sonographers can do—even on the job—to reduce anterior pelvic tilt.

  1. 90/90 Hip Flexor Stretch
    On a mat, kneel down with the front leg up, with the knee at 90 degrees, the back leg is on the ground, but also bent at 90 degrees.  Make sure to tightening up the Hip flexorabdominal area. Then move your hips forward, maintaining shoulders back. You are looking for a stretch in front of the hip.You will feel the stretch in the front of your hip and the thigh. You are looking for a light stretch. You are not trying to rip the muscle apart. Hold that for about 20 to 30 seconds twice on each side, first the right leg, then the left. Alternate back and forth for the two sets.
  1. Side Lying Quad Stretch
    Lying on your side, reach back and grab the foot of the top leg with the same arm as the leg you are bending (i.e., right hand grabs right foot). As you grab the foot, bring the heel towards the butt. The key here is not to just pull the heel to the butt, but bring the thigh back a little bit in order to intensify the stretch in the front of the thigh and the front of the hip.stretch 2Think: Hold for 20 seconds as a light stretch and do it twice on each side alternating. Right leg first, then roll to the other side and do the left leg. Repeat.
  1. Deep Squat Stretch
    Stand up tall with a wider stance than shoulder width. From that position, squat down with hips below the knees. In the bottom position, place the elbows between the squatknees and then push the knees out with the elbows. You are looking for a stretch in the inner thigh and hips.This position and pressure will end up changing the position in the lower back and in the pelvis from an anterior tilt to a posterior tilt.  Doing just like the other stretches: 20- to 30-second hold, twice.

No matter what your occupation, a certain level of stretching and regular exercise will help reduce your risk of injury. This is especially true for sonographers. Please consult your physician (even if you are one) before beginning an exercise program.

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 Pediatric) is a registered echocardiographer and also a consultant, national presenter, and author of e-books in the areas of ergonomics, exercise and pain, and injury correction for sonographers.

Mark Roozen M.ed, CSCS*D, NSCA-CPT, FNSCA, is a strength and performance coach and also the owner and president of Performance Edge Training Systems (PETS).

Handle the Scan with Care

Anytime one begins an obstetrical scan, there is a ritual that precedes our privileged access into an otherwise inaccessible place pulsating with life, hope and promise. The trilogy of preparing the patient, applying the gel, and selecting the transducer helps us transition as we open a window to the womb, sharing a highly anticipated and treasured moment with the family.

old windowWhile this privileged access may provide priceless reassurance, it is accompanied by a huge responsibility for the sonologist who is attempting to make sense of what is seen while trying to decide how to share the information with the family.

As diagnosticians, we are taught to be vigilant, careful and meticulous, making note of every single finding. We employ the most sophisticated machines and the importance of being non-paternalistic is deeply engrained in our brains. Yet at the same time, care and caring must come into play if we need to break news that may shatter dreams or induce significant parental anxiety.

Personally I find that the most challenging cases are those in which various isolated sonographic markers may be detected. The struggle between wanting to be scientific, factual and transparent and the fear of labeling an otherwise healthy being and worrying a hopeful parent becomes paramount. This is becoming more commonplace nowadays with the advancing technology as we delve into fetal evaluations with much more detail and at earlier points in gestation. We must not mistake normal developmental findings with pathology. We must be careful with enhanced image resolution and the employment of harmonics as these may increase tissue echogenicity and lead to over diagnosis of physiologic “cysts” in fluid producing structures.

With the continuing advancement of the technological capabilities of this most versatile of medical diagnostic modalities and its evolving portability, the number of probe-handlers globally is increasing exponentially across the disciplines. The problem is that education, training and experience are not uniform. The expertise to discuss the implications of various sonographic findings, particularly soft markers, and to recognize serious abnormalities, may be lacking. Despite the well-established positive impact of prenatal diagnosis, allowing us to prepare families and formulate the optimal plan of care, it may also be a double-edged sword, particularly in inexperienced hands.  As such, and in keeping with the mission of the AIUM and its communities of practice, the importance of proper training cannot be overstated. One must adhere to the basic sonographic teachings, employ the ALARA principle, and implement practice parameters when incorporating sonography into daily clinical practice. Referral to centers of excellence, whenever there may be doubt, is critical. Sound judgment remains the key to utilizing ultrasound first.

A new life is purity in the absolute form: a blank sheet of paper. Much caution must be exercised before any marks are made. Every word uttered has the potential of tainting the page, of taking away hope, of falsely “labeling” this promising life before it has even come into physical being. “First do no harm” should continue to echo in our brains and we must always proceed with caution, and tread with care.

What’s your opinion on the quality issue? Do you see a wide range of quality in ultrasound scanning?  Comment below or let us know on Twitter: @AIUM_Ultrasound.

Reem S. Abu-Rustum, MD, FACOG, FACS, FAIUM, is the Director of the Center For Advanced Fetal Care in Tripoli, Lebanon. She has served the AIUM in several capacities, including her current role on the AIUM Board of Governors.

  • Image adapted from A Practical Guide to 3D Ultrasound. RS Abu-Rustum. CRC Press 2015.