POCUS: My Path to Be an Effective Global Citizen

Bus 22 from Stanford to Pacific Free Clinic (PFC) – 1.5 hours. Bus 22 and 25 from PFC to Santa Clara Valley Medical Center – 1 hour. Bus 70 from PFC to Foothill Family Community Clinic – 30 minutes. Bus 70 and 26 from PFC to Community Health Partnership – 30 minutes. Without a car, I managed the PFC and networked with community clinics and hospitals by bus. These bus rides provided me with a glimpse of one barrier disadvantaged patients endure in order to access the healthcare system. If my weekly navigation of San Jose’s health care system has been one long bus ride, so too has my medical training–a long seamless journey of exploring three vital components of medicine: community service to the underserved, translational/epidemiologic research, and internal medicine.

As stated in the opening of my personal statement for residency application (above) community service was one of my main motivations to go into internal medicine. Yet, despite 7 years of volunteering and managing 3 free clinics in 3 cities, I became focused on developing clinical skills and establishing an academic career instead. I pushed community service aside during my residency training and beyond until my trip to Gros-Morne, Haiti, where I, together with Atria Connect (https://www.atriaconnect.org), taught point-of-care ultrasound (POCUS).

Through Atria Connect, 14 other physicians from around the world and I trained 12 Haitian physicians at Hospital Alma Mater, where there were no echocardiograms, CT imaging, or MRI. There were 2 diagnostic imaging modalities available: a nonfunctional x-ray machine and an ancient ultrasound machine with just a transvaginal probe. For 3 months, we rotated weekly to provide hands-on training in a longitudinal POCUS curriculum that combined flipped classroom learning with online modules, onsite hands-on teaching (Picture 1), and remote hands-on training via a tele-ultrasound platform. At the end of the curriculum, the 2 youngest Haitian physicians then spearheaded a longitudinal training program for the remaining clinical staff within the hospital.

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Picture 1. Left to Right: Dr. Bruno Exame (Haiti), Dr. Ricardo Henri (Haiti), Dr. Jesper Danielson (Sweden), Dr. Michel Hugues (Haiti). Dr. Hugues, the Chief Medical Officer of Hospital Alma Mater, is shown performing focused cardiac ultrasound under the guidance of Dr. Danielson and Dr. Henri. Dr. Exame was evaluating the quality of the ultrasound image.

Similar to many global health efforts with POCUS, the 15 trainers, including myself, and the Haitian physicians experienced an evolution in clinical care. It ranged from expedited diagnoses of tuberculosis through the FASH protocol (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3554543/) to an unexpected evaluation of left heart failure possibly due to thiamine deficiency, to immediate trauma triages of patients from motor vehicle accidents in a town where traffic laws do not exist. With POCUS, Haitians have access to diagnostic medicine that would otherwise be denied in rural Haiti, where it would take a 4-hour bus/motorcycle ride on unpaved road to obtain. The evolution went beyond clinical management and access to basic health care, however.

Besides transforming medicine in resource-low settings, POCUS rekindled my initial drive to go into internal medicine: community service for the underserved. It empowers me to serve more effectively by training providers with an innovative technology of sustainable impact. With a tele-ultrasound platform and WhatsApp, POCUS draws me closer to the underserved in remote places, thus expanding community service on to a global scale, onsite and offsite.

More importantly, POCUS loops me back to community service at the local level, the original start of my journey to internal medicine. Similar to the Haitians in Gros-Morne, the disadvantaged in the United States face obstacles in which an additional trip to basic diagnostic radiology or cardiology, other than limited outpatient medicine encounters, proves to be difficult. An expedited evaluation with POCUS for simple clinical questions can maximize diagnostic capability and further advance clinical care as a way of improving access in this vulnerable population.

One instance in which I had a missed opportunity was during my residency in expediting care for my favorite clinic patient at an urban health clinic. She, unfortunately, suffered from multi-organ manifestations of sarcoidosis. One day, she presented with an acute onset of dyspnea and chest pain without hypoxia. Her examination was not significant for volume overload, pneumonia, or reactive airway disease. Her breath sound was mildly reduced on the right side. A chest X-ray was ordered. However, due to transportation cost and her inability to take off additional time from work, she did not obtain a chest X-ray until 3 days later. Her chest X-ray showed a spontaneous pneumothorax of 8 cm in size due to structural lung changes from her sarcoidosis. She was immediately sent to the emergency room for pigtail placement. Had I learned lung ultrasound, an immediate diagnosis would have been made and her care would be further advanced at minimal cost. While POCUS benefits all patients, POCUS magnifies the impact for the underserved by overcoming socioeconomic barriers.

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Picture 2. Left to Right: Dr. Michel Hugues (Haiti), Dr. Bruno Exame (Haiti), Dr. Jesper Danielson (Sweden), Dr. Gigi Liu (United States), Dr. Ricardo Henri (Haiti), and Dr. Josue Bouloute (Haiti) on the last day of the 4-month POCUS training.

My life-changing trip to Gros-Morne, Haiti (Picture 2), expanded my global awareness and revived my sense of social responsibility through community service locally, regionally, nationally, and internationally. This is the essence of global citizenship (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726429/?report=reader; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6076566/?report=reader). Instead of just providing much-needed medical care to the underserved, POCUS empowers providers to be a more effective global citizen by expediting diagnosis and care efficiently and cost-effectively. It has been a privilege to be trained as a physician and be taught by amazing mentors with life-saving POCUS skills. As a global citizen, I vow to train health care workers on POCUS on multiple geographic levels as part of my social mission to improve access and care for the disadvantaged, even if this requires a very long bus ride…

 

How has POCUS changed your practice? What do you do to be a global citizen? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Dr. Gigi Liu, MD, MSc, FACP, is a hospitalist and proceduralist at Johns Hopkins Hospital who leads the POCUS curriculum for Osler Internal Medicine Residency program and Johns Hopkins Bayview Internal Medicine Residency program.

 

 

 

 

 

Training Beyond Discipline – Developing Devotion in Ultrasound

Mathews Benji KA point-of-care ultrasound (POCUS) revolution is unfolding before our eyes, forever changing the way we interact with patients. It started with a revolution in specialties such as emergency medicine and critical care, and now it has entered into my sphere with internal medicine and hospital medicine. I see this whenever I’m on clinical service. A 3rd year medical student talks about diffuse B-lines as we stop antibiotics and start diuretics on a patient with pulmonary edema; a 3rd year resident asks to look at a patient’s kidney with ultrasound as we manage undifferentiated acute kidney injury; nursing staff curiously looking on as a patient is shown their weak heart as goals of care are discussed.

At the same time, we in internal medicine and hospital medicine are living in a medical world filled with many challenges towards implementation of POCUS. Though there are many devices in the emergency rooms and some in the critical care wards, there are not many in the inpatient wards nor in the clinics. Though numerous workshops and courses abound in POCUS, many attendees do not continue to use this skillset after training. Those that received initial training find it too challenging to discipline themselves to continue to scan.

It is that latter sentiment that caught my attention this last year. The concept of discipline and viewing POCUS through its lens. A quote by Luciano Pavarotti comes to mind,

“People think I’m disciplined. It is not discipline. It is devotion. There is a great difference.”

I’ve often heard the sentiments:

“It is so hard to learn POCUS, how do you find the time for it on a busy clinical service to get images?”

“I find it hard to set aside time during my non-clinical work days as other work and life piles up.”

I’m not sure about you, but the word discipline does not often carry an inspirational tone to it. There is a sense of drudgery, lack of passion surrounding the word. As an ultrasound director, that is the farthest from what I want my learners to experience with POCUS.

When I looked up the word discipline in the Oxford Dictionary there it was as well:

dis·ci·pline
noun
1.
the practice of training people to obey rules or a code of behavior, using punishment to correct disobedience.
“a lack of proper parental and school discipline”

2.
a branch of knowledge, typically one studied in higher education.
“sociology is a fairly new discipline”

Is it #1 that we were aiming for? Or at the very least, is that what people are sensing? Hopefully, we’re not using punishment to correct disobedience. The Pavorotti quote struck a chord in me. As a contrast to discipline, we have devotion.

The word “devotion” is defined by Oxford Dictionary as follows:

de·vo·tion
noun
1.  love, loyalty, or enthusiasm for a person, activity, or cause.
“Eleanor’s devotion to her husband”
synonyms: loyalty, faithfulness, fidelity, constancy, commitment, adherence, allegiance, dedication; More

•  religious worship or observance.
“the order’s aim was to live a life of devotion”
synonyms: devoutness, piety, religiousness, spirituality, godliness, holiness, sanctity
“a life of devotion”

•  prayers or religious observances.
plural noun: devotions
synonyms: religious worship, worship, religious observance

Devotion does have some concepts borne from religion or worship but that doesn’t make it an irrelevant word for the POCUS learner or teacher. The first definition of love, loyalty, or enthusiasm captures the essence of what most of us are hoping POCUS to be for our learners. As my good friend and POCUS enthusiast, Dr. Gordy Johnson, from Portland, Oregon, says, we need to remember “our first kiss.” What was the moment that grasped us with POCUS?

Don’t get me wrong, I’m not completely opposed to the word discipline, but it moves beyond that if we’re going to develop fully devoted clinicians in the realm of bedside ultrasound. Those that are equipped with the cognitive elements know when POCUS should be used, why it should be used, how to acquire images, and then how to clinically integrate it.

This post was originally intended as a follow-up of the AIUM webinar on the Comprehensive Hospitalist Assessment & Mentorship with Portfolios (CHAMP) Ultrasound Program with hopes to continue the conversation surrounding what makes for an effective training program. The program involved online modules, an in-person course with assessments, portfolio development, refresher training, and final assessments. The key lesson we have learned is that longitudinal training with deliberate practice of POCUS skills with individualized performance feedback is critical for skill acquisition. However, the intangible pieces of how people continued to scan was developing an enthusiasm and love surrounding ultrasound by seeing its impact in the marketplace. As they were continuing to scan, their patients, their students, the many nursing staff were partnering in a stronger way with this diagnostic powerhouse in their hands.

With all this, I cannot help but be optimistic when I see the commitment of many in the POCUS movement already. I would urge all of us to evaluate how we develop devotion in ultrasound, how to tap into the dynamism of the POCUS movement coming up the pipeline with our medical students and residents. They have the potential to disrupt inertia and be an impactful force to integrate POCUS more into internal medicine and hospital medicine.

If you are an ultrasound educator, how do you inspire devotion? What are some of your best practices surrounding training in POCUS? Which do you think is most important: discipline or devotion? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Benji K. Mathews, MD, FACP, SFHM, is the Ultrasound Director of the Department of Hospital Medicine at HealthPartners in St. Paul, Minnesota.

How Portable Ultrasound Got Me a Bottle of Wine

Well, Tuesday morning clinic was busy as usual. Hypertension, diabetes, depression, “it-hurts-here”s where troubling all my patients. My desk was across the hall from a colleague who had just seen a retired internist gentleman, 80 years old, reporting muscle weakness in his hips, fatigue, bitemporal headaches, and some odd jaw symptoms when he ate. Don (I called him that, mostly because that was his name.) was investing some quality phone time trying to arrange a temporal artery biopsy as this method for diagnosis seemed so reasonable to him and to his internist patient. I listened in on his conversation, always ready to help, invited or not.

“Don, you know, if we pull our portable ultrasound machine, look at his temporal arteries and he has bilateral halo signs, the specificity approaches 100% for temporal arteritis and you can avoid biopsy all together in 38% of patients.”  I provided him a few convincing articles. He was not quite sure as he had never heard of this before.

Halo

Both internists were game, the doctor and the patient. Portable US in the exam room showed bilateral halos around the temporal arteries. I showed them the finding. Both raised their metaphorical eyebrows.

Patient: “I practiced internal medicine for almost 50 years and I have never seen anything like this. That is pretty impressive.”

Don: “Let’s get a sed rate today… See what that shows. Start some steroids and we’ll follow-up next Tuesday.” (For those not in-the-know, sed is erythrocyte sedimentation rate.)

On Friday, after 3 days of steroids, he was starting to feel like his old self again. Headaches were resolving. Fatigue was much better. By Tuesday, with his visit to the clinic, he was ecstatic over his progress. Don reported that he kept remarking on that young man with his portable US machine (That was me.) and how that US would’ve changed his practice had he had one back then.

On Thursday, the patient wanted to show his appreciation to both Don and I by bringing in 2 bottles of red wine, 1 for him and 1 for me.

I had read about the utility of portable ultrasonography, oh, 12-15 years ago for the first time. I had drunk the cool-aid of portable ultrasonography. At our medical school, we provide 27 hours of didactics and hands-on training for our medical students in their first 2 years. Our internal medicine residents get formal didactics on echo, abdomen, vascular, as well as MSK, small parts, and many other US applications. We have provided CME for over 700 physicians in our 3- and 4-day courses. I have been convinced that we need to reach out and teach all who will listen that portable ultrasonography can fundamentally change the way we practice medicine in certain settings.

So portable ultrasound changed this patient’s experience; quicker diagnosis and quicker recovery of health. He was grateful and expressed his gratitude with the fruit of the vine.

So portable ultrasound changed my colleague’s thoughts on its utility based on one clinical exposure. Don asked me many times to use my machine for other patients of his.

So what did I get from this profound, thought-provoking intersection of patient, doctor, and too? Personal gratification of helping? An underscoring of my belief that portable ultrasonography is important?

I got a nice bottle of wine!

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Do you know of an instance in internal medicine in which ultrasound resulted in a quicker diagnosis? Have you incorporated ultrasound into your internal medicine practice? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Apostolos P. Dallas, MD, FACP, CHCP, is Assistant Professor of Medicine at Virginia Tech Carilion School of Medicine, Director of CME at Carilion Clinic, and Associate Program Director of the Internal Medicine Residency program at the Virginia Tech Carilion School of Medicine.

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.