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.

7 Tips for Scanning Overseas

So, you want to take that pretty little laptop ultrasound, put it into your backpack, and fly to parts unknown to help with patient care and/or to teach in a resource-limited setting? Not so fast, I say.

KuhnDonating or sharing your skills is a wonderful act and one that I highly recommend. But I don’t want you to end up on a 3-week scanning trip with nowhere to plug in your ultrasound machine and only 35 minutes left on your battery. It’s happened to me and it’s not pleasant. So below are some tips to consider if your next vacation finds you scanning in a remote village.

  1. The issue with electricity. There is a lot to consider when it comes to electricity. For starters, many countries have “rolling” power outages, which is a euphuism for no electricity when you need it most. How will you handle that situation? Oh, and don’t forget about voltage. Most machines will work on 110 or 220 volts, but I have had surges up to 400 volts. By the way, that is not good for ultrasound machines.
  2. Charging. How long does it take to charge your equipment? What about if you have to use solar power? And what if it’s rainy or you are scanning at night?
  3. How many tubes of gel do you need? I use about 1 tube per day per machine when scanning all day. Can you bring enough for your trip? If so, great. If not, do you make your own? Remember that homemade gel, while it does work, is of lower viscosity than commercial gel and gets very runny in the heat. Plus it smells like rotten vegetables after 1-2 days.
  4. Mind the heat. When you get hot, your machine gets hot. Use a cooling fan for both you and your machine when the ambient temperature is above 90 degrees Fahrenheit. If you need a break from the heat, give your machine a break as well and turn it off.
  5. What about the cold? Did you know that ultrasound probes are not engineered for cold temperatures? And when it gets below freezing image degradation is a problem. What do you do? Put those transducers and gel tubes into your pants pockets to keep them warm. Sure, you might get some strange looks, but the equipment and your patients will thank you.
  6. Do you want your teaching to leave a lasting impression? We all know that “the eye does not see what the mind does not know.” If you are looking to train people on your scanning vacation, you have to do what you have time to do. The key is to do what is best for the person you are training regardless of how much time you have. Make sure you have lots of hands-on and one-on-one time before you leave. Develop QA and QI plans in place before you leave or plan on multiple repeat visits to update and follow the progress of the person you are training.
  7. Avoid the bribe. What do you do if a customs official wants a $20,000 “deposit” before he will let you bring your machine into his country? The easiest first move is to tell him it’s just a laptop. We all know that most of the guts of ultrasound is in the probes. Luckily in many countries the customs officials have not figured that out yet–so don’t tell them. If this doesn’t work and you are not going to get out of the airport without a payoff, bond the machine. Bonding is a legal way of leaving your goods at the airport, and all airports around the world have a bonding process, which costs about $3 per day. Granted, you will have to leave your machine at the airport, but I have learned that there may be more to life than ultrasound!

Have you scanned in another country? What are your tips or suggestions? What have you learned from donating your skills? Comment below or let us know on Twitter: @AIUM_Ultrasound.

“Ted” Kuhn, MD, is professor of emergency medicine and professor of pediatrics at the Medical College of Georgia at Georgia Regents University. He, together with his wife, has lived and worked in Asia and led nearly 100 international medical trips.