Internal Medicine and Bedside Ultrasound–A Match Made in Heaven

I am an internist who does bedside ultrasound. This has not always been true. From 1986, when I got my MD from Johns Hopkins School of Medicine, to November 2011, I was a traditional internist, taking care of a panel of patients in a small university town in Idaho. I saw my patients in the office when they could walk or wheel in with their problems and in the hospital when they were sicker. I took call for my partners on rotating weekends and holidays. I occasionally ordered ultrasounds and echocardiograms and thought of them as blurry representations of internal structures that could be magically interpreted by radiologists.

In 2011, events such as the growing up of our 2 children allowed me to reconsider my choices of what to do with my MD. I had always wanted to do medicine in resource-poor settings overseas. I had often been curious about locum tenens work in other states, which would involve adventure and exposure to new practice styles and surprisingly generous compensation compared to my predominantly outpatient practice. I also had an urge to binge on continuing medical education courses, which I had denied myself for years due to responsibilities at home.

Janice Boughton, MD

One of the CME courses I treated myself to was an introductory course in emergency ultrasound through Harvard/Massachusetts General Hospital. It was wonderfully taught and I was immediately hooked. Ultrasound at the bedside would transform my practice and had the potential to transform the whole practice of internal medicine! The Cupid of bedside ultrasound had sunk his arrow straight between my eyes.

I went on to take more courses in bedside ultrasound both in person and online and bought myself a small pocket ultrasound which rapidly developed my imaging skills. I began to use ultrasound clinically as a diagnostic tool within weeks of my first exposure. I discovered over-expanded bladders, failing hearts, pleural effusions, ascites, or lack thereof in my patients with big bellies. I became a better doctor, and enjoyed my job more. My patients were happy to have benefitted from what looked to them like Star Trek technology.

I expected at any point that someone in the diverse hospitals where I served as a locum tenens hospitalist would ask for my credentials or forbid me to use ultrasound. I expected skepticism by cardiologists with whom I worked. I expected radiologists to be upset at me. I even did a 1-month UC Irvine mini-fellowship and ARDMS certification as a sonographer. These experiences gave me a vast amount more expertise and confidence, but were mostly to ward off imagined disapproval. Yet nobody ever made me present my certification. Nobody disapproved to my face except one radiologist, who I’m still working on. Cardiology consultants were tickled to get imaging information in addition to history and vital signs. I may have benefitted from being in hospitals where people were too busy taking care of patients to fuss with me. It really seemed, though, that the vast majority of people with whom I worked realized that I was a better doctor with an ultrasound than without.

I have gone on to teach bedside ultrasound and participate in research on malaria and schistosomiasis with medical students in Tanzania. I have taught basic ultrasound to overburdened healthcare workers and physicians from Doctors Without Borders in South Sudan during its ongoing civil war. Knowing how to teach basic bedside ultrasound means I am valuable in resource poor settings even if I can only stay for a couple of weeks. I have been able to teach my internal medicine colleagues in the US along with residents and medical students, which has been a wonderful opportunity for a nonacademic rural physician.

So what’s my point here? As an “early adopter” of bedside ultrasound in internal medicine I have made myself a test case. So far these are the results:

  1. It wasn’t too hard to learn enough ultrasound to be a better doctor.
  2. There was never a time when I was too much of a novice to benefit from bedside imaging, yet every time I ultrasound a patient I learn something new. I can’t foresee a time when my learning will be complete.
  3. There has been surprisingly little push-back and a gratifying amount of appreciation.
  4. Bedside ultrasound is the perfect extension of the physical exam in internal medicine. It brought back my joy in physical diagnosis. We should all be doing it!

 

Have you used ultrasound in your internal medicine practice? Have you gone after ultrasound education after obtaining your degree? How can medical education be modified to encourage the widespread use of ultrasound by future internists? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Janice Boughton, MD, is an internist working as a staff Hospitalist at Gritman Medical center as well as is a locum tenens physician at other northwest hospitals. She also supervises and serves in rural health clinics, and blogs about bedside ultrasound and other issues at http://whyisamericanhealthcaresoexpensive.blogspot.com/?m=1.

The National Ultrasound Interest Group (NUSIG)

The National Ultrasound Interest Group (NUSIG) is a student-led organization founded in 2014 to promote ultrasound in undergraduate medical education. You may know us as the force behind planning national level events like SonoSlam. The bulk of NUSIG’s work, however, is sharing education and leadership resources between Ultrasound Interest Groups (USIGs) across the country. Each of the five regional representatives contact medical schools in their areas to exchange ideas, plan co-sponsored events, and see how NUSIG can assist them in evangelizing ultrasound.

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NUSIG provides everything from information on getting equipment and funding, to original educational content. Our podcast on iTunes (quickly closing on the 1,000 download mark) currently features a journal club series. Each episode is hosted by a different school evaluating an ultrasound-related article.

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Our next series is how to plan an Ultrafest, where we interview schools experienced in putting on these events. Our hope is that these USIGs can learn from each other, and other schools might be inspired to start their own UltraFest once it’s been laid out how. In the future, we aim to collect medical student level ultrasound lectures from across the country and publish them for anyone to view. Our vision is to serve as a central repository for the best medical student educational content available. Lastly, our twitter feed regularly features current ultrasound research articles, and retweets outstanding free open access medical education content.

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If you want to learn more about us or get involved, check out our website at www.nationalusig.com, and follow us on twitter and Facebook @NtlUSIG. You can find us on iTunes by searching for “NUSIG podcast.”

Are you a member of the National Ultrasound Interest Group? Did you attend this year’s SonoSlam? If so, share your thoughts and feedback. Comment below or let us know on Twitter: @AIUM_Ultrasound.

Mat Goebel is in charge of Social Media for the National Ultrasound Interest Group and is a medical student at University of California at San Diego.

Portable Ultrasound for the Win

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Tommaso Di Ianni, MSc
2017 New Investigator Award winner for Basic Science

 

What does being named the New Investigator Award winner mean to you?

It was an honor being appointed the New Investigator Award for the Basic Science category for “In Vivo Vector Flow Imaging for a Portable Ultrasound Scanner.” It means a lot to me to see my scientific contributions being recognized by some of the leading experts in the field. It provides a great stimulus to continue to focus on researching imaging solutions that will hopefully improve the clinical practice.

 

How did you get into working with ultrasound?

After the masters I was looking for open PhD positions, and I found an opening about portable ultrasound imaging at Professor Jørgen A. Jensen’s Center for Fast Ultrasound Imaging at the Technical University of Denmark. I didn’t know much about ultrasound at the time, but I was fascinated about its great capabilities as a risk-free imaging modality. Even more, I was attracted by the fact that ultrasound scanners can be scaled like any other electronic device and can become so small it can fit in a lab coat pocket. Currently, this does not apply to other imaging technologies, and I believe that ultrasound has a lot of potential to make a difference at the point of care.

 

What do you like the most about working with ultrasound?

I am overwhelmed about the patterns that the blood can depict when flowing into the vessels. With ultrasound, we can obtain a very high temporal resolution and we can visualize dynamic details on a millisecond scale. Sometimes, we can see vortices forming when the valves in the jugular vein close, or the helical flow in the ascending aorta. Also, the vortices forming in the heart are absolutely impressive to look at. I believe there’s a lot of diagnostic potential in that wealth of information.

 

What are your future research plans?

Currently, I’m completing my PhD and I will continue my research as a postdoc for some more months. In the future, I plan to continue to do research in the biomedical engineering field. I’m very interested in imaging the microvasculature in cancer to improve the characterization of the tumor’s functional activity and to track the response to the therapy.

 

Why did you becoming interested in ultrasound? Where did you learn your ultrasound skills? Comment below or let us know on Twitter: @AIUM_Ultrasound. Learn more about the AIUM Awards Program at www.aium.org/aboutUs/awards.aspx.

Tommaso Di Ianni, MSc, is a PhD student at Technical University of Denmark.

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 angio architecture 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 main stay 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.

Obstetric Ultrasound: Tips for Sharing Outcomes With Your Patient

“Are you comfortable? Am I pressing too hard?” I ask my patient these questions to assuage my own concerns and delay the inevitable as I study the ultrasound image of her 20-week-old fetus. Although she says she’s fine, my patient appears expectant and anxious as she, too, searches the black and white image of her unborn child. I wonder, of course, if she sees what I see—a cleft lip and palate.

If you’ve conducted ultrasounds for routine evaluation of your obstetric patients, you know that patients and their partners typically experience a mix of emotions, namely joy and worry, as they await results. You know, too, that delivering positive results is a pleasure as you share in your patient’s happiness and relief. In all likelihood, you also are relieved at escaping the discomfort of delivering bad news to your patient.

Dr and patient

Delivering Abnormal Ultrasound Results

Telling your patient about any pregnancy or fetal abnormality, however common or rare, can be devastating for her, her husband/partner, and her family. After all, every patient wants to know her pregnancy is progressing as expected and her fetus is developing normally. It also can be difficult for you to tell your patient there is a problem. But as a practitioner, you must be prepared to deliver all results, good and bad, to your patients.

A key to delivering abnormal results to your patient includes knowing and using phrases that clearly and honestly apprise your patient of the results without stirring alarm.

Sound easy? It’s not! Even the most seasoned practitioners suggest they never become comfortable giving patients abnormal results.

When results aren’t cause for alarm, patients, especially those in a first pregnancy, still can be highly sensitive to even the slightest aberration. Furthermore, the situation can become complex given varied models for delivering care. For example, when a primary obstetrician sends a patient for scanning at an antenatal testing unit that a maternal-fetal medicine (MFM) specialist oversees, the question is whether the MFM or primary obstetrician should deliver the results. In some cases, patients have scans in emergency departments. What then? Does the radiologist, emergency physician, or primary obstetrician deliver the results?

As an MFM specialist in an antenatal testing unit, I follow my center’s policy to immediately inform patients about their ultrasound results, whatever the outcome. With empirical knowledge to support them, practitioners in my unit know that the longer patients await results, the more likely they are to ruminate, worry, and, in some cases, develop unfounded concerns about their ultrasound results.

With focus on the shared humanity between physician and patient, we treat each patient with careful consideration for her dignity and the compassion we would want for ourselves and our family members.

Once you have told your patient her results, get in touch with her primary obstetrician. In addition to giving the primary obstetrician an opportunity to prepare for a discussion with her/his patient, this approach is integral to delivering high-quality, comprehensive, and continued care.

Follow these tips for delivering abnormal results to your patient:

  • Write down phrases you are comfortable using and practice them with a simulated patient (a family member or friend)
  • Consider how you would feel if you were in the same situation
  • When face to face with your patient, take a moment to gather your thoughts before speaking if necessary
  • Use a calm voice
  • Speak slowly and clearly
  • Look at your patient when talking to her; if her husband/partner is in the exam room, also look at him/her
  • Be straightforward and honest without creating alarm
  • Be sensitive to emotional ques from your patient to pace discussion appropriately. A sobbing patient is unlikely to hear what you’re saying, so wait patiently until she’s ready to listen
  • Ask your patient if she has questions; ask her husband/partner if he/she has questions
  • Answer as many questions as you can; if the patient asks a question you cannot answer on the spot, tell her you will get an answer within the next day
  • Reassure your patient of potential solutions for the situation without making promises
  • Recommend educational material that can help your patient better understand the problem
  • If the problem is genetic in origin, explain the value of genetic counseling before any future pregnancies
  • Take extra time to address your patient’s concerns if necessary
  • Ask your patient if she would like a referral for a counselor so that she can work through feelings about the results
  • Follow up with your patient the next day with a phone call

Telling Your Patient About Ultrasound Results: Practice and Prepare!

All fetal abnormalities on ultrasound, even the most insignificant, are understandably upsetting for parents to be. But being prepared before you break the news can help you and your patients feel more comfortable discussing the situation, including potential outcomes and solutions.

GuptaOne of the privileges of practicing obstetrics in the 2000s is that many of us deliver good news more often than bad news. But this also means that being adept at delivering abnormal ultrasound results requires practice outside as well as inside the office.

How do you deliver bad news to a patient? When do you provide counseling? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Vivek Gupta, MD, is a clinical instructor and fellow in maternal-fetal medicine at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin.

Who Has Time to Scan?

image001When I arrived to my shift in the Emergency Department one Thursday, there were 5 unassessed patients on my side with more than 25 in the waiting room, some waiting for hours to be seen. Anyone who works in a busy practice knows the pressure to expeditiously evaluate these patients, and point-of-care ultrasound (POCUS) may be the last thing on your mind.

However, when used properly, POCUS is a time saver. It can lead us to the diagnosis faster, allow for next-step downstream testing, and alert our colleagues in other specialties early that we might need them soon, perhaps even occasionally saving lives.

The excuses to not do an ultrasound are many. How do I fit it into my busy practice? The question is: truly how do I not?

  1. Have the equipment easily accessible.

Searching for an ultrasound machine can be extremely frustrating and a disincentive to using it. No one likes to walk around and search every patient room before you even start to scan.

Because of this, every area should have their designated machine with a home base that is clearly marked and known to everybody. There are additional smart ways to ease this process. We are using a Real Time Location System with RFID technology where equipment is easily located on a tracking board. Other institutions can page an assistant through their EMR to set up the ultrasound in the patient room. Though more cost-intensive, some have chosen to have a wall-mounted machine in every room.

Location board

  1. Bring the machine with you.

Don’t be lazy. There are many patient complaints such as shortness of breath, flank or upper abdominal pain, first trimester bleeding, or eye problems where I am likely going to do an ultrasound study. In these cases, I will bring the machine into the room when first meeting the patient, rather than excuse myself to get it later. Through this, the traditional fragmentation of patient evaluation—ordering a test and waiting for the results—becomes streamlined and sometimes provides the definitive answer immediately.

  1. Rethink your work-flow.

It does not help to bring the ultrasound system with you, if you first need to place an EMR order. Although institution-specific, some have found ways to break up the traditional work-flow (order > worklist > scan), allowing evaluation of patients right away. This requires a discussion with your IT department and administrator but can enable you to rapidly use ultrasound at the bedside.
Also get in the habit of doing an exam the same way every time and maybe set up your machine with predefined labels. You will be surprised how much more efficient you will be and how the quality of your scans will improve with repetition.

  1. Have learners leave the machine in the room.

Our more senior trainees are very versed with ultrasound and usually can get high-quality images without much hands-on direction. If you have learners at different stages, I highly recommend to have them leave the ultrasound machine in the room after completing an exam. You can then review their study right in the room and obtain more views as needed. This avoids setting up the equipment again just for a few additional images.

  1. Keep equipment on the machine.

Having commonly-used supplies on the machine can reduce frustration of going in and out of the room. The most common ultrasound-guided procedure at our facility is IV access. For this reason, we stock the special catheters as well as sterile gel packets on the machine.image003

Recall the last time you weren’t lazy, rolled the ultrasound machine into the room with you and found the ileocolonic intussusception and asked the pediatric radiologist to stay late to do the air contrast enema, or the surgeon to take the patient to the OR with a ruptured abdominal aortic aneurysm (AAA)? Perhaps it was as simple as knowing it was acute cholecystitis and not ordering the contrast CT scan, sparing the young person contrast and radiation. If I can do it on a busy night, so can you.

Do you have other tips how to fit ultrasound into your busy practice? How has ultrasound made your job easier? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Tobias Kummer, MD, RDMS, FACEP, is Director of Emergency Ultrasound in the Department of Emergency Medicine at Mayo Clinic in Rochester, MN.

Should You Include CEUS and Elastography in Your Liver US Practice?

 

Today, the liver is regarded with high importance by our clinical colleagues. The obesity epidemic, with its considerable impact in North America, is associated with severe metabolic disturbances including nonalcoholic fatty liver disease (NAFLD). Further, liver cancer is the only solid organ cancer with an increasing incidence in North America. Where do we as ultrasonographers fit into the imaging scheme to most appropriately deal with these new challenges?

The liver is the largest organ in the body, and certainly the most easily accessed on an abdominal ultrasound (US). It has been the focus of countless publications since the introduction of abdominal ultrasound many decades ago. Exquisite resolution allows for excellent detailed liver evaluation allowing US to play an active role in the study of both focal and diffuse liver disease. Focal liver masses are often incidentally detected on US examinations performed for other reasons and on scans performed on symptomatic patients. Abdominal pain, elevated liver function tests and nonspecific systemic symptoms may all be associated with liver disease. The introduction of color Doppler to abdominal US scanners many years ago elevated the role of US by allowing for improved capability of US to participate in assessment of the hemodynamic function of the liver as well.

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The well-recognized value of abdominal US, including detailed morphologic liver assessment, has made this examination the most frequent study performed in diagnostic imaging departments worldwide. However, in recent years, US has been relegated to an inferior status relative to CT and MR scan, as their use of intravenous contrast agents has made them the corner stone modalities for virtually all imaging related to the presence of focal liver masses. As we now live in an era of noninvasive diagnosis of focal liver disease, greyscale US has fallen out of favor, as it is nonspecific for liver mass diagnosis. While US is the recommended modality for surveillance scans in those at risk for development of hepatocellular carcinoma, today, all identified nodules are then investigated further with contrast-enhanced CT and/or MR scan.

In the more recent past, US has been augmented by 2 incredible noninvasive biomarkers: elastography, which measures tissue stiffness, and contrast-enhanced ultrasound, which shows perfusion to the microvascular level for the first time possible with US. These noninvasive additions are invaluable and their adoption in routine US practices may allow the reemergence of US as a major player in the field of liver imaging.

Most conventional US machines today are equipped with the capability to perform elastography, especially with point shear wave techniques (pSWE). In pSWE, an ARFI pulse is used to generate shear waves in the liver in a small (approximately 1 cm3) ROI. B mode imaging is used to monitor the displacement of liver tissue due to the shear waves. From the displacements monitored over time at different locations from the ARFI pulse, the shear wave speed is calculated in meters per second, with higher velocities associating with increased tissue stiffness. The accuracy for the determination of liver fibrosis and cirrhosis with pSWE as compared with gold standard liver biopsy, is now undisputable. Because of the great significance of liver fibrosis secondary to fatty liver and the obesity epidemic, the development of this technique as a routinely available study is essential. Because of the frequent selection of US as the first test chosen for any patient suspect to have undiagnosed diffuse liver disease, the opportunity for elastography to be included with the diagnostic morphologic US test should be developed as a routine.

Contrast-enhanced US (CEUS), similarly, is available on most currently available mid- and high-range US systems, allowing for nondestructive low MI techniques to image tumor and liver vascularity following the injection of microbubble contrast agents for US. This allows for a similar algorithmic approach to contrast-enhanced CT and MR scan for noninvasive diagnosis of focal liver masses. CEUS additionally offers unique imaging benefits that include no requirement for ionizing radiation and also imaging without risk of nephrotixity, invaluable in the many patients who present for imaging with high creatinine, preventing injection of both CT and MR contrast agents.

Incorporation of pSWE and CEUS into standard liver US in patients with suspect diffuse or focal liver disease is a cost-effective and highly appropriate consideration as this is readily available, performed without ionizing radiation, and at a considerable cost saving over all other choices.

Can you diagnose a hepatocellular carcinoma or other liver tumor with CEUS?  And, can you determine if a liver is cirrhotic or not?  With the addition of pSWE and CEUS to your liver US capability, yes, you can.

 

What is your experience with treating liver disease? What aspect is most difficult for you? What other area do you think would benefit from the addition of CEUS? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Stephanie R Wilson is a Clinical Professor at the University of Calgary.