Life Hacks for the 2018 AIUM Annual Convention

Plan
View the full program online and, to keep on top of all things #AIUM18, download the eventScribe app now from the Apple store or Google Play store and search for AIUM 2018. imageBefore and during the convention, use the app to plan your schedule, read about sessions, take notes, learn about exhibitors, and engage with other attendees.

Learn all about the app by checking out these videos on using the app: Quick Navigation Guide, Browsing Style, Taking and Sending Notes, E-mailed Notes, Messages, and Events.

Go
Travel to the convention via plane, train, or automobile. The hotel, New York Hilton Midtown, is located on Avenue of the Americas (6th Ave) between West 53rd and West 54th Streets. To get to the hotel from 1 of the 3 nearby airports, or Grand Central station, Penn Station, or Port Authority, which are all within approximately 20 minutes of the hotel, you can take a taxi or rideshare service. To get around the city, walk or take the subway, a taxi, or a rideshare.

 

Follow
Stay in the know by following the AIUM and the Convention on Twitter (#AIUM18), Instagram (AIUMultrasound), vimeo, LinkedIn, and Facebook as we share news and events, as well as photos and videos.

Learn and Network

  • Two preconvention postgraduate courses will be offered on Saturday, March 24. Additional fees apply.
  • We doubled the number of hands-on Learning Labs. Our Learning Labs provide an up-close and personal learning experience while earning CME credit.
  • Learn from leading ultrasound experts in small group settings in Meet-the-Professor sessions. There are a dozen Meet-the-Professor events to choose from. Each comes with lunch. Separate registration fee is required. If you haven’t registered, act quickly because more than half the sessions are sold out.
  • The AIUM has added 2 networking receptions to the Convention schedule. Plan to meet up with colleagues, explore the latest technology, and ask questions you may have during these cocktail and hors d’oeuvre events on the Exhibit Hall floor.
  • The AIUM received a record number of research abstracts for the 2018 AIUM Convention. This research will be shared by AIUM’s new investigators, abstract presenters, and e-poster submitters throughout the event.
  • Community and Interest Group Meetings: Meet with other ultrasound professionals who share your interests, plan future AIUM educational programs, and discuss the issues in your specialty.

 

Exercise
Start your day off with some exercise: join your colleagues and AIUM staff each morning from 6:30–7:15 am for a 3-mile run/walk around New York City’s Central Park. You’ll meet up in the Main Lobby at 6:30.

Hunt
Join the Scavenger Hunt at the convention: download the eventScribe app (search AIUM18) to get started on your chance to win one of several prizes that will be awarded upon completion of the game. A grand prize winner will be announced Tuesday afternoon.

Earn

CME      Earn up to 6.5 CME credits during the Preconvention and 29.5 CME credits during the Convention.

ARRT    Earn up to 6.5 ARRT credits during the Preconvention and 29.5 ARRT credits during the Convention.

SAMs     The American Board of Radiology (ABR) has approved 7 Self-Assessment Modules (SAMs) activities from our upcoming 2018 Convention.

UGRA    One session at the Preconvention and 8 sessions at the Convention have been added to the UGRA Portfolio program’s course offerings.

Please note that although the AIUM provides CME certificates to those who have participated in an AIUM educational activity, the AIUM does not submit credits to regulating bodies or certifying organizations on behalf of the participant. It is the participant’s responsibility to submit proof of credits on his or her own behalf.

Explore

Lid5nyGET

When you’re not attending the convention, check out some of what New York has to offer. Here is a short list of just a small portion of what is out there, including museums, parks, iconic buildings, and more. And, don’t forget to check out minus5° in the hotel’s lobby, where everything in the bar is made of ice, including the glasses.

The Expeditious Evolution of Emergency Ultrasound Fellowships

RJG Photo 2

Access to the internet was dial up through AOL, Bill Clinton was President, and ultrasound machines were big, clunky, and new to the emergency department. It was 1999 and I was in Long Island as a resident. As a resident, I saw the ultrasound machine lurking around the emergency department, but very few faculty seemed to know how to use it. A search of fellowships in emergency ultrasound found a single listed fellowship in Chicago, so I organized a rotation to see what ultrasound was all about.

Emergency ultrasound fellowships in the early 2000s were disconnected, isolated, and in many ways under the radar. As the ultrasound interest group president in SAEM (soon to become the Academy of Emergency Ultrasound) I heard firsthand how difficult it was for fellows to find ultrasound fellowships and how difficult it was for fellowship directors to find applicants. Partnered with Pat Hunt, we started EUSFellowships.com as a platform for fellows and programs to meet. Ultrasound became more mainstream as ACEP, SAEM, and CORD fought to have ultrasound integrated into residency training and general emergency medicine.

Eventually EUSFellowships.com evolved into the Society of Clinical Ultrasound Fellowships as a more robust organization focused on advanced training for bedside ultrasound. The first couple of emergency ultrasound fellowships started around 1997. Within 5 years there were 12 fellowships, and within 10 years there were 27. Today there are over 100 emergency ultrasound fellowships graduating more than 70 fellows each year. There are more ultrasound fellows graduating each year than in toxicology and EMS combined.

Emergency ultrasound fellows today join a large vibrant group of specialists across the United States and the world. Physicians use ultrasound to diagnose, monitor, and guide procedures everywhere from the African savannah to the neighborhoods in New York City. The initial meetings in the 1990s involved small groups getting together to discuss cutting-edge research and new applications. Now ultrasound meetings in emergency medicine involve hundreds of people discussing topics such as board certification or ultrasound program management. Research has evolved from single “we can do it too” projects to multi-center collaboratives. The change in ultrasound over the last 20 years is mind blowing.

When I interview medical students now, I ask them why they went into medicine. What do they want to achieve? One of the best answers I hear is that they want to make a difference in medicine and improve care for all patients. I feel that I have been lucky enough to witness the birth of a new subspecialty that will improve how patients are cared for in the future.

 

What was your initial experience with ultrasound education? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Romolo Gaspari, MSc, MD, PhD, FACEP, is the Executive Vice Chairman of the Department of Emergency Medicine at UMASS Memorial Medical Center. He has also served as the president of a number of Emergency Ultrasound Societies including what is now the Academy of Emergency Ultrasound and the Society of Clinical Ultrasound Fellowships.

Flying Samaritans, the Seed to Pediatric Point-of-Care Ultrasound

There are some experiences in life that seem to have a tremendous impact on the person you become, and the career path you decide to take. When I started working with the Flying Samaritans in medical school, little did I know that it would change the trajectory of my career.

Kids from El Testerazo Mexico

The kids I fell in love with in El Testerazo, holding the pictures I had taken and shared with them. They came by even if they weren’t sick. Of note, they are now in their 20s with families of their own.

Since the UC Irvine School of Medicine was so close to the USA-Mexico border, the UC Irvine Flying Samaritans chapter was actually a driving chapter. Each month we drove down to El Testerazo, Mexico, to give medical care and medications to an underserved community. I immediately fell in love with the community and the children of El Testerazo, Mexico. They would all laugh at my then broken high school-level Spanish, but would appreciate my trying. There was also something about the group of undergraduates (who ran the clinic), medical students, residents, and attending physicians who volunteered their time there that brought back the humanity to medicine. The experience was challenging and rewarding at the same time—to work with limited resources, but to become a trusted member of their community was priceless. Each time I went to the “Flying Sams” clinic, I remembered why I went into medicine in the first place.

During my time with the “Flying Sams,” I worked with a then Emergency Medicine resident, Chris Fox. When he told me he was going to Chicago to do a 1-year Emergency Ultrasound fellowship, I thought he was crazy.

Old ultrasound machine

The ancient beast of an ultrasound machine that we had in the “Flying Sams” clinic.

Not only was he leaving sunny Southern California, but he was going to spend a year looking at ultrasounds? When I looked at ultrasounds, I could barely make out structures; images looked like the old tube TV’s from the 1980s. When Fox returned, he said, “Steph, the next big thing will be pediatric ultrasound.” Again, I thought he was crazy. But slowly, by seeing how ultrasound impacted the management of our patients in El Testerazo, I realized the brilliance in this craziness. Chris Fox’s enthusiasm and “sonoevangelism” was infectious. I think nearly everyone in the “Flying Sams” ended up eventually doing an ultrasound fellowship. Even though the ultrasound machine in the clinic was old, and images were of limited quality, we were still able to impact the medical care of this community that became near and dear to my heart.

And so it began…my passion for emergency ultrasound (now referred to as point-of-care ultrasound) and for Global Health. My initial goal was to become good at performing ultrasounds. As I quickly realized, I was one of the only people who had experience in pediatric point-of-care ultrasound. I felt a tremendous responsibility to become as knowledgeable and skilled as possible, if I were going to teach others this powerful tool. After 4 years of undergraduate education, 4 years of medical school, 3 years of a Pediatrics residency, and 3 years of a Pediatric Emergency Medicine fellowship, I decided to do an additional 1-year fellowship in Emergency Ultrasound. With medical school loans looming and so many years without a “real job,” I was reluctant to do this. This California girl moved from sunny Southern California, to Manhattan to embark on a 1-year Emergency Ultrasound fellowship. This was a move far outside of my comfort zone for so many reasons. And that was one of the reasons why it ended up being one of the best decisions I’ve ever made. It has been a privilege to be a part of this growing community… to take better care of the most vulnerable of patients… and to give this tool to other doctors around the world. I certainly would have never had these experiences or opportunities if it weren’t for the “Flying Sams” and Chris Fox; to both I am forever grateful.

 

 Are you involved in global medical education? If so, what led to your decision to go into the field? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie J. Doniger, MD, RDMS, FAAP, FACEP is the Editor of the first pediatric point-of-care ultrasound textbook “Pediatric Emergency and Critical Care Ultrasound,” and is currently practicing Pediatric Emergency Medicine and Point-of-Care Ultrasound in New York. She has additional training in Tropical Medicine and is in charge of Pediatric POCUS education for WINFOCUS Latinamerica.

Ultrasound-Guided Musculoskeletal Injections

I began using Musculoskeletal (MSK) ultrasound (US) in 2010. It has been incredibly exciting to observe to growth of applications of this amazing technology for both myself personally as well as for the entire MSK US practicing community. MSK US has become an integral part of my Sports Medicine practice and I certainly anticipate its’ role to continue to expand and be able to provide cutting edge medical care to my patients.IMG_8265

There is great variability with which MSK US is used among practitioners. Some providers do complete diagnostic scans of the shoulder for example, to evaluate the extent of a potential rotator cuff tear to guide with potential surgical decision making, while others perform selective nerve blocks and finally some practitioners simply use it to assist with the accuracy of various MSK joint and soft tissue injections. I would like to illustrate to all of you the applications for which I most commonly use MSK US to improve patient care.

Probably the most common application for which I use MSK US is to assist with the accuracy of joint and soft tissue injections. It has been clearly documented that MSK US improves the accuracy of certain MSK injections. While I do not use MSK US for all injections, ie, simple knee intra-articular and shoulder sub-acromial injection, I routinely employ MSK US to assist with certain injections. Common joints and soft tissue areas for which I employ MSK US for either cortisone or pro-inflammatory injections like Platelet Rich Plasma (PRP) are:

Shoulder: Glenohumeral and acromioclavicular joint and long head biceps tendon sheath

Hip: Femoroacetabular, hamstring origin (tendon or bursa), mid portion hamstring, pubic symphysis, gluteal tendons and bursa, iliopsoas bursa and tendon

Knee: Pes anserine and iliotibial bursae, patella and quadriceps tendons, Baker’s cyst aspiration

Wrist: Triangular fibro cartilage complex (TFCC), various wrist extensor and flexor tendons, aspirate ganglion cysts, numerous hand and wrist joints

Elbow: Lateral and medial epicondyle area, triceps insertion, olecranon bursitis, distal biceps and intra articular

Ankle: Achilles, tibialis posterior, peroneal tendons, numerous foot and ankle joints, plantar fascia

Back: Sacroiliac joint

I would also like to illustrate some interesting recent cases supporting the utility of MSK US in a Sports Medicine practice.

I am consulted numerous times a week by my orthopedic surgeon colleagues for diagnostic joint injections. Oftentimes, a patient’s hip pain may be multifactorial or difficult to specifically isolate. I will perform an intra-articular injection to see if it alleviates that patient’s pain, thus identifying that the area in which I placed the injection as the pain generating location. Correct identification of the pain generating source will help to assist with treatment considerations.

I also recently had a patient with greater than 1 year of hip pain. He had seen 8 different providers and had an extensive work up with imaging and injections only to have continued pain. He had hip joint and hamstring origin injections and felt no improvement. I was able to use the US to identify and isolate the obturator internus as the source of his pain by providing a diagnostic injection. This injection helped to make the appropriate diagnosis and ultimately influenced treatment.

Last month, an orthopedic surgeon asked me to evaluate a patient for refractory symptoms from a Baker’s cyst. The cyst persisted despite multiple intra articular-injections. I evaluated the cyst with US and noted that it was multilobulated. I was able to specifically aspirate each of the loculations and the patient has remained symptom free.

I was also asked to see one of our varsity basketball players for refractory lateral knee pain. His athletic trainer was treating him with rehabilitation and multiple modalities but the pain persisted and was affecting the athletes’ ability to play. I was able to identify an inflamed Iliotibial band bursa with the US and subsequently inject it. He became pain free and was able to play in that weeks’ game as well as the rest of the season.

Another exciting application of MSK US that has piqued my interest recently is the use of the US to assist with appropriately identifying the compartments of the lower extremity for chronic exertional compartment testing. I can employ the US to guarantee that I am in the appropriate anatomic compartment for testing.

With any new technology, the application and utility of MSK US can be user-dependent and it can be affected by a somewhat steep learning curve. MSK US curriculums are frequently being added to Sports Medicine fellowships to train some of the future leaders of medicine. I certainly anticipate that this technology with continue to evolve and its’ treatment applications will continue to expand.

 

How do you use MSK US? How has it improved your practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Bryant Walrod, MD, CAQSM, is Assistant Professor: Clinical at Ohio State University, is Team Physician for the Ohio State Athletics, and practices at The Ohio State University Wexner Medical Center.

Interest in Interest Groups

Ultrasound in medical education is a powerful idea whose time has come. With its value in the clinical setting being increasingly recognized, leaders of a point-of-care ultrasound (POCUS) movement are making a strong case for introducing ultrasound early in medical training. Not only is it a useful educational tool to illustrate living anatomy and physiology, but it is also an important clinical skill- guiding procedure, improving diagnostic accuracy, and facilitating radiation-free disease monitoring. As the list of POCUS applications grows exponentially across specialties, I believe that to maximize the potential impact, it is vital to introduce this skillset early during the pleuripotent stem cell phase of a young doctor’s career.

Wagner

Looking around, there are signs this movement is here to stay. Ten years after the first medical schools began integrating ultrasound into the curriculum, an AAMC report of US and Canadian schools stated that at least 101 offered some form of ultrasound education, with the majority including it into the first 2 years of the curriculum. If one visits the AIUM medical education portal (http://meded.aium.org/home), 77 medical schools list a faculty contact person involved with ultrasound curriculum development and integration.

It should be noted that the depth of content varies from school to school, as not all institutions value ultrasound to the same degree. Recommendations on core clinical ultrasound milestones for medical students have been published and results from a forthcoming international consensus conference will help improve standardization, though there will likely be much variability until it is required by LCME or included on board exams.

It is during this time of transition that the importance of ultrasound interest groups (USIGs) cannot be understated. USIGs provide a wider degree of flexibility often not possible within a formal curriculum, quickly adapting for changes not only for meeting times and group sizes but also topics and teaching strategies. Indeed, for schools without a formal ultrasound curriculum it is often how one gets started. For ultrasound faculty, USIGs provide fertile ground for experimenting with new teaching ideas and cultivating both student and faculty enthusiasm for POCUS at one’s institution. For senior students, USIGs can provide opportunities to participate in research projects, serve as near-peer instructors, and participate at regional and international meetings. The spread of local, student-run Ultrafest symposiums is a testament to the power ultrasound has to draw people in and the impact students can have beyond their own institution. The AIUM National USIG (http://www.nationalusig.com/) provides a nice resource for further collaboration while student competitions like AIUM’s Sonoslam or SUSME’s Ultrasound World Cup showcase ultrasound talent and teamwork in an anti-burnout, fun environment. I have no doubt that some of these exceptionally motivated students will become future leaders in the field, as some already have (http://www.sonomojo.org/).

While many of these students will pursue and jumpstart their careers in Emergency and Critical Care Medicine, students from varying backgrounds and interests are needed in USIGs. The frontier of Primary Care ultrasound is wide open and may become crucial as we see more emphasis on population medicine and cost containment as opposed to fee-for-service models. With the exception of in the ER, the utilization of pediatric ultrasound has been surprisingly lagging and more POCUS champions are certainly needed here. In addition, the early exposure to POCUS can increase comfort with ultrasound and help drive novel developments by future specialists. Some lesser known potential examples include advancing work already underway: gastric ultrasound for aspiration risk by anesthesiologists, sinusitis and tonsillar abscess drainage for ENTs, diagnosing and setting fractures for orthopedists, noninvasively measuring intracranial pressure by ophthalmologists and neurologists, and detecting melanoma metastasis by dermatologists. Until it is more widespread, a skillset in POCUS can be a helpful way to distinguish oneself in an application process and provides an excellent academic niche. After medical school, some USIG students will go on to form ultrasound interest groups in their specialty organizations, going beyond carving out a special area of interest for themselves and helping to advance the field and shape future policies.

Similar to other enriching things like viewing art and discussing philosophy, I believe all students should be exposed to ultrasound and given the opportunity to learn this skill. While I feel strongly that ultrasound should be a mandatory component of an undergraduate curriculum, I also recognize that not all will enjoy and excel in it, and many will settle for nothing more than the bare minimum. However, I believe the USIGs help us to motivate and empower those few individuals with the passion and grit to really help propel this movement forward and show the world what is possible. This is truly an exciting time. I hope you will join us.

Ultrafest

Are you a member of an ultrasound interest group? Has it improved your skill set? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Michael Wagner, MD, FACP, RDMS, is an Assistant Professor of Medicine at the University of South Carolina School of Medicine in Columbia. There he serves as the Director of Internal Medicine Ultrasound Education for the residency program, Assistant Director of Physical Diagnosis for the undergraduate curriculum, and faculty advisor to the student ultrasound interest group. You can view his 2017 talk for the USCSOM USIG here (https://youtu.be/FfO7SXRwjLY) and an AIUM webinar with Janice Boughton on a pocket ultrasound physical exam here (https://www.youtube.com/watch?v=ywuIeoEfG1I).

 

Patient Zero

My rock, my reminder, my inspiration, my failure

Soucy

 

Case 1
It was fall 2009 and early in my second year of residency. Having spent multiple months off service, I was excited to get back into the swing of emergency care in “critical” bay. The patient was a 44-year-old male presenting with syncope. Admittedly, he was an alcoholic who was an on-the-wagon, off-the-wagon type. His trip to the ED found him off the wagon for several weeks, deeply depressed, and outwardly self-neglected.

His story was not unfamiliar to the ED; lots of alcohol without eating or drinking much else and lots of time on the couch. Today, he got up to get something from the fridge but found himself at the bottom of a set of stairs. A housemate was kind enough to call EMS when it took more than a few minutes for him to wake up. He didn’t remember much and complained of a headache, some rib pain, and significant fatigue getting around the house recently.

It was early morning so I had a bit more time than usual to chitchat. He wore a Minnesota Twins jersey. Though I was from the northeast, I told him how I was a big Kirby Puckett fan growing up, which segued into discussion about their current season, game soon-to-be in progress, and the Vikings acquisition of Farve. “Who would have thought,” he said; “No kidding,” I reaffirmed. Our conversation was natural, comfortable, and enjoyable. Before I left the room, I recognized his oxygen saturation at 91% and blood pressure had dropped to systolics in the 90s but recovered into the low 100s.

All the usual suspects were considered but we thought his low saturations (sats) were most likely due to his smoking history and low blood pressure due to dehydration. Fluids and albuterol went in, labs came back, and time ticked by. Acute renal insufficiency, hyponatremia, hypomagnesemia, and normal chest x-ray without any improvement in vitals despite our interventions. Radiology called and said they could do the CT of the head but chest with contrast would have to wait until after fluids and a creatinine recheck. Critical bay became busy and his clock continued to tick.

I was surprised by how quickly my body reacted to the “code blue in CT” called out overhead. I didn’t know why I knew it was him, but I did. As my body turned the corner to CT, my mind was unprepared to absorb what I saw. His head and neck had turned a deep unnatural blue. He was confused and was asking for help. In between explaining that his heart had briefly stopped and quickly moving him from the scanner, a wide-eyed radiology resident appeared in the doorway, “saddle PE” (pulmonary embolism).

We rolled quickly. Sats and blood pressure were down, heart rate was up—mine included. I assured him everything was going to be okay and he believed me. “Wake me up when the Twins score doc,” he said with a smile. Intubation was smooth as lytics were mobilized.

With cardiothoracic surgery at the bedside, his tachycardia devolved into PEA (pulseless electrical activity). I ran the code while thoracics prepped ECMO (extracorporeal membrane oxygenation). Both groins were inaccessible and I was told we would do an ED thoracotomy. “Ready,” the surgeon said. “Yes,” I said confidently, not knowing what would happen next. The clamshell and cannulation were smoother and quicker than I could have imagined. The machine worked, but his body didn’t.

I still critique my conversation with his mother. It was my first time breaking bad news alone. I was inexperienced and unpolished, but honest and raw. We cried together. I wish I could have been better for him and for his mother.

Case 2
Several months and various rotations passed, including ED ultrasound, which I took a liking to. I again found myself in “critical” working with one of my favorite attendings. EMS patch was for a 78-year-old female being brought in from her rehab facility hypotensive, hypoxic, tachypnic, and ill appearing. The report did not disappoint. The patient was postoperative day 5 from a transabdominal hysterectomy for leiomyomas. The patient was doing well until the day before presentation when she felt fatigued and feverish and then in the morning when she felt shortness of breath and extreme fatigue, which had progressed. She looked like she might die any second.

My attending listened to the reports, watched my exam, and performed his own. “So, what do you think?” I hesitated. Literally any organ system or combination of systems could be failing. A trip down the wrong diagnostic or therapeutic pathway could lead to delay, decompensation, and death. I was relieved when he told me to prepare for a central line so we could start pressors and antibiotics for her septic shock. It was clear to me that she was dying and I did not know the etiology, but my veteran attending did.

The patient was sterilely prepped and ultrasound placed on the neck. The internal jugular (IJ) was plump, very plump, the plumpest IJ I had ever seen. “Cake,” I thought. Simultaneously it then dawned on me that physiologically this wonderfully plump IJ did not make sense in septic shock. I consulted my attending and given the patients worsening cardiovascular collapse despite fluid resuscitation, we proceeded.

As I secured the sutures, I ran through the types of shock, differential for each, and ways I could figure it out at the bedside. Antibiotics started and I pulled up to the bedside with the ultrasound. I was suspicious for an obstructive process; however, due to the patient’s postoperative status I performed the FAST (focused assessment with sonography for trauma) exam. “Negative belly,” I thought to myself as I quickly moved to the patients left chest. The focused cardiac exam quickly aligned all the puzzle pieces. I personally had never seen acute right ventricular strain at the bedside but the septal D-ing of her hyperdynamic heart on parasternal short and apical 4 was irrefutable.

My attending agreed and we changed our trajectory. Instead of MICU (Medical Intensive Care Unit) admission, antibiotics, fluids, and pressors, ultrasound indicated the patient needed something different. Given her recent extensive operation, an emergent CT was performed showing saddle embolus. In coordination with OB/GYN and critical care, the patient received thrombolytics. 2 weeks later, I was there when she walked out of the hospital with her children and grandchildren.

The Lesson
I could not reconcile the 2 poignantly different outcomes. Both were getting pulmonary embolism workup and I ordered all the right emergent testing. So, how could an elderly patient with every comorbidity in the throws of dying live while a middle aged otherwise fairly healthy patient who cracked a joke minutes before he arrested not? Ultrasound (and thrombolytics) of course!

Point-of-care ultrasound (POCUS) is an incredible diagnostic tool that is transforming clinical practice and medical school education. Numerous studies have shown it to be a critical component of directed resuscitation in the emergency and ICU departments’ critically ill population. In various disease processes, its use has been shown to decrease procedural complications, improve mortality, and decrease time to safe disposition. All technology is not created equal; ultrasound is unique. Instead of pulling me away from the patient, POCUS allows me to stay at the bedside gathering important information; improving my efficiency, addressing concerns, and talking with loved ones. Undoubtedly the extra time communicating and caring for the patient has improved my job satisfaction and is one of the reasons patients like it. But, there is an often overlooked significance to POCUS’s story, which has caused ripples to be felt for generations.

I believe the soul of POCUS rests firmly in what makes our profession exceptional; our willingness to self-evaluate, improve, and innovate for those we serve. POCUS stands as an early example of disruptive innovation, which has transformed the way we think about our job as clinicians. At the time of its introduction in the 70s and 80s this type of “out-of-the-box” thinking did not conform to the traditional framework. Its existence challenged many long-held beliefs and medicine’s titanic momentum perpetuated throughout generations. These innovators took the road less traveled and persevered in the face of adversity. Their gift has enabled countless others to save lives and improve patient care around the world as well as demonstrate our profession’s ability to adapt in rapidly changing times.

My path to ultrasound resulted from those emotions that remained unresolved and the process unfinished after medicine left its first mark. Feelings of inadequacy loomed, challenging my perception of the limitations of medicine and my own abilities. Painful at the time, I like to think that generations of physicians have constructively, therapeutically, applied this driving force to be better than they were the day before in whatever field their passions lie. Ultrasound is my tool, my promise to him, to her, to myself to be my best and help others be theirs.

 

What struggles have you overcome in your career? And how has ultrasound helped you overcome them? How do you think POCUS will change in the future? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Zachary Soucy, DO, FAAEM, is Assistant Professor of Emergency Medicine, Director of Emergency Ultrasound, and Co-Director of the Emergency Ultrasound Fellowship at Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, in Lebanon, New Hampshire.

Dating Pearls

Assisted reproductive technology (ART) dating trumps all other sonographic dating. If the dating is off with ART, think about asking if the embryo was put in the uterus at 5 days, and not zero days, as that is how it is often calculated. This can be important if the embryo is larger than expected, as ART pregnancies have an increased incidence of Beckwith Weidman Syndrome, which is an overgrowth syndrome. If the embryo is smaller than expected, then the embryo should be followed more closely for possible congenital or chromosomal anomalies.

If the pregnancy is not ART, dating should be based on the 2014 ACOG/AIUM Committee Recommendations (Methods for Estimating the Due Date. Committee Opinion No, 700. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129:e150–154).

Measurement of the embryo or fetus in the first trimester is the most accurate method to determine gestational age. In the first trimester, the 2014 Recommendations state that if the pregnancy is less than 8 weeks 6 days, the embryo should be within 5 days of LMP (last menstrual period) and otherwise should be re-dated using ultrasound dates of the crown rump length. One mistake often made at this time is to include the gestational sac size in dating; the crown rump length is more accurate than the sac size and thus it should not be averaged into the estimated gestational age.

Crown rump length growth curves have been updated by Pexsters et al (Ultrasound Obstet Gynecol 2010; 35:650–655) using 4387 exams, whereas Hadlocks curves (Hadlock et al Radiology 1992; 182:501–505) were only based on 416 exams. These have some significant discrepancies in the 5–7 weeks gestational age range so we recommend using the Pexsters curves.

Crown Lump Length

From 9 weeks to 16 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 7 days and be re-dated if greater than “7-day” discrepancy.

From 16 weeks to 21 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 10 days and be re-dated if greater than “10-day” discrepancy.

From 22 weeks to 27 weeks 6 days, the 2014 Recommendations suggest that the dating should be within 14 days and be re-dated if greater than “14-day” discrepancy.

From 28 weeks and beyond, the 2014 Recommendations suggest that the dating should be within 21 days and be re-dated if greater than “21-day” discrepancy.

We should not re-date a pregnancy in the second or third trimester if there are good ultrasound dates in the first trimester. If the patient gives “excellent dates” based on history (eg keeping a temperature chart, knowing date of conception based on specific dates of being with partner) and there is a greater than expected discrepancy of dates, then a follow-up sonogram should be recommended in 2–4 weeks, depending on the time of gestation (4 weeks in the second trimester and 2 weeks in the third trimester) so that appropriate growth can be assessed.

Serial growth is important in assessing dating. A fetus that grows 4 weeks in a 4-week period is likely dated appropriately. When the fetus grows more than 4 weeks in a 4-week period then accelerated growth should be reported, suggesting either an LGA (large for gestational age) or macrosomic fetus. History of prior pregnancies can be particularly helpful in these cases. Placement of the calipers at the outer edge of the subcutaneous tissue is particularly important in these cases. We often require 3 measurements, which are averaged to assess LGA/macrosomic fetuses.

When fetuses grow less than 4 weeks in a 4-week period then SGA (small for gestational age) or IUGR (intrauterine growth restriction) are suspected. Additional studies for well-being should be performed, such as umbilical artery Doppler, middle cerebral artery Doppler, maximum vertical pocket of amniotic fluid, biophysical profile, cerebroplacental ratio (CPR), or antenatal testing.

 

Do you have any tips on sonographic dating? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Dolores H. Pretorius, MD, is a Professor of Radiology at University of California, San Diego, and Director of Imaging at UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.

Andrew D. Hull, MD, is a Professor of Clinical Reproductive Medicine at University of California, San Diego, and Director of UC San Diego Maternal-Fetal Care and Genetics, an AIUM-accredited practice.