Research in Ultrasound: Why We Do It

“Medicine, the only profession that labors incessantly to destroy the reason for its existence.” –James Bryce

We all know the important medical discoveries clinical research has given us over time. stamatia-v-destounis-md-facrYou could even make the case that the high standards of care we have today are built on centuries of research.

The world of medical ultrasound is no stranger to clinical research—dating back to the early work of transmission ultrasound of the brain. This work was especially important, as it was the first ultrasonic echo imaging of the human body.

Since then, research has brought about gray scale imaging, better transducer design, better understanding of beam characteristics, tissue harmonics and spatial compounding, and the development of Doppler. All of these research developments, as well as many others, were highly significant and have lead us to today’s high-quality handheld, real-time ultrasound imaging.

For me, the biggest and most important developments were and have been in breast ultrasound. In 1951, the research of Wild and Neal discovered and qualified the acoustic characteristics of benign and malignant breast tumors through use of an elementary high-frequency (15-MHz) system that produced an A-mode sonogram. These researchers published the results of additional ultrasound examinations in 21 breast tumors: 9 benign and 12 malignant, with two of the cases becoming the first 2-dimensional echograms (B-mode sonograms) of breast tissue ever published.

It is research that leads to landmark publications that change the way we practice. The ACRIN 6666 trial led by Dr Wendie Berg and her co-authors evaluated women at elevated risk of breast cancer with screening mammography compared with combined screening mammography and ultrasound. This pivotal study demonstrated that adding a single screening ultrasound to mammography can increase cancer detection in high-risk women. In our current environment this is even more relevant, as breast density notification legislation is being adopted in states across the country. With the legislation, patients with dense breast tissue are often being referred for additional screening services, with ultrasound most often being the screening modality of choice.

Screening ultrasound is an area on which I have focused much of my own research. I practice in New York State, where our breast density notification legislation became effective in January 2013. I have been interested in reviewing my practice’s experience with screening ultrasound in these patients to evaluate cancer detection and biopsy rates. My initial experience was published in the Journal of Ultrasound in Medicine in 2015, and supported what other breast screening ultrasound studies have found, an additional cancer detection rate of around 2 per 1000. Through my continued evaluation of our screening breast ultrasound program, I have found a persistently higher cancer detection rate by adding breast ultrasound to the screening mammogram–which is of great importance to all breast imagers, as we are finding cancers that were occult on mammography.

Participating in valuable research is important to me and my colleagues because part of our breast center’s mission is to investigate new technologies and stay on the cutting-edge by offering the latest and greatest to our patients. Participating in clinical research provides us important experience with new technology, and an opportunity to evaluate firsthand new techniques, new equipment, and new ideas and determine what will most benefit our patients. This is what I find the most important aspect of research, and why I do it; to be able to find new technologies that improve upon the old, to continue to find breast cancers as early as possible, and to improve patient outcomes.

Why is medical research/ultrasound research so important to you? What research questions would you like to see answered? Share your thoughts and ideas here and on Twitter: @AIUM_Ultrasound.

Stamatia Destounis, MD, FACR, is an attending radiologist and managing partner at Elizabeth Wende Breast Clinic. She is also Clinical Professor of Imaging Sciences at the University of Rochester School of Medicine & Dentistry.

Who Runs the AIUM?

Have you ever wondered what or who runs the AIUM? Of course you know about the elected officers, and the AIUM staff that works in the home office, but do you know that there are approximately a dozen committees and/or task forces that help the organization run throughout the year?

The volunteers may be elected or appointed to the committees and tasks forces, and they are not paid or compensated for their time. Frequently, there are many committee members who accept appointments and nominations year after year. Who would possibly be willing to take on extra work and added expense, just to help the AIUM?

Bagley_6Who are the volunteers?
Ordinary people like me! That is who! I have been volunteering with the AIUM since 2009, and have found, as they often say when you volunteer, that I get more than I give. My personal life mission is one of giving back, both to my profession and to my community. I believe anyone who volunteers for the AIUM will give you a similar answer: There is an obligation to give back because someone once gave of his or her time to help me.

How did I become a volunteer?
I did not wake up one day and think to myself, “Today is the day I should volunteer for the AIUM.” Instead, a mentor suggested to a liaison organization that I should be their representative to the AIUM Bioeffects and Safety Committee. At the first meeting, I was hooked. The work gave me new energy and excitement about my profession. I could not get enough bioeffect and safety knowledge.

When my time as a liaison ended, I asked a fellow committee member to nominate me to the committee. As luck would have it, my work proved that I was serious, and the members elected me to the committee.

How can you become a volunteer?
Maybe you are thinking to yourself right now, I am energetic and have a lot to give, but I do not know how to get involved. What should I do? If you have a mentor in the AIUM, ask him or her to nominate you to a committee.

If you do not have a mentor I suggest that you start by serving as a resource member to the committee that best matches your skills and interests. A resource member might assist the members on projects. You can offer up your talents by contacting the chair and letting him or her know that you want to help. Once your work is visible, you can ask a member to nominate you to be a committee member.

You Get More Than You Give
I have gained so much from working on a committee. I have new knowledge about bioeffects and safety that has allowed me to take on a larger advocacy role. I have new knowledge to integrate into the courses that I teach, and I have developed lectures to educate all medical imaging professionals about ultrasound bioeffects and safety. The work on the committee has inspired my own research projects that have resulted in award-winning manuscripts.

My confidence in my knowledge has improved, and I am willing to try new and difficult projects that I would not have dreamed of trying in my pre-committee life. I have made friends and have gained new mentors. I know that regardless of how much effort I have given, the committee has given me exponentially more.

Member, Pay it Forward!
None of us ever gets where we are on our own. In addition to our hard work, our mentors and our colleagues help us on our professional journeys. Volunteering is a way to pay it forward.

If you are an active volunteer, now is the time to make sure your good work is continued! Mentor a new member, and help him or her get involved. Suggest that he or she become a resource member or nominate him or her to a committee. Bringing new people into the volunteer world ensures that your good work continues, and it provides for the AIUM’s future.

Interested in volunteering for the AIUM? Check out the volunteer page. What has been your volunteer experience? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jennifer Bagley, MPH, RDMS, RVT, is an associate professor for the College of Allied Health at the University of Oklahoma Health Sciences Center, Schusterman Campus in Tulsa. She currently serves on the AIUM Bioeffects Committee and is a former member of the Technical Standards Committee.

My Chilean Experience

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

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

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

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

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

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

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

FOAMed Made Me A Better Lecturer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

How to Obtain Focused Cardiac Ultrasound Images

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

cardiac_pic2

Parasternal long axis demonstrating a dilated left ventricle.

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

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

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

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

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

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

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

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.

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.