Why Teach Ultrasound?

Sonosorority on ultrasound teaching rounds: (left to right) Michelle Nasal, Grace Rodriguez, Jessica Everett, Erin Wendell, and Tatiana Thema, with Creagh T. Boulger, MD.

Early in my career, I recall my choice to pursue my academicniche in ultrasound and more specifically ultrasound education being questioned. “Why would you do that?” “How are you going to get promoted?” “This is just a fad!”. For a moment I paused wondering if I should heed this advice. Was I making a mistake? I am happy I did not dwell on that moment because I would not be where I am, I would not have gotten promoted, I would not have touched so many learners, met so many amazing people, and helped so many patients.

One of my first patients as a doctor illustrates why I teach ultrasound. I was a brand-new doctor maybe 10 days under my belt. I walked in the room of my patient. They were in clear discomfort, I was nervous. I pushed on their abdomen. Unsure, I walked out to my supervisors and said: “I think I have an acute abdomen in bed 10.” We paged surgery and were ordering other imaging when my now-mentor, Dave Bahner, suggested we do a FAST exam. This was before the ultrasound invasion in medical school and my only exposure to ultrasound was limited and in OB and the trauma bay. He immediately noted significant free fluid and presumed rupture of a neobladder. The patient went promptly to the OR. This opened my eyes and sparked the passion for ultrasound that has fueled my career. I could use this machine to look inside and help patients on the outside.

So why teach ultrasound and who should you teach?

I teach ultrasound because…

It enables me to bring 2-dimensional anatomy to life. One of my greatest joys is showing a new medical student, undergrad, or high school student their own heart beating right in front of them and see the awe in their eyes.

It makes complicated concepts simple. I recall the challenge in medical school of the preclinical years 1 and 2. Understanding systole, diastole, cardiac valves, and flow. On paper, these are complicated and merely rote memorization. Watching these events occur on ultrasound in real time and how they are altered by simple maneuvers such as Valsalva or squatting truly aids in full understanding of the concepts.

Ultrasound is always relevant. One of my favorite courses to teach is ‘The Approach to Undifferentiated Shock’. This is attended by all fourth-year medical students. By the fourth year in medical school, many students are distracted by interviews and matching and have already chosen their respective fields. I love this course because as a teacher, I get one last chance to show them the light, or rather sound, and how it could help them if they encounter a patient in shock. I ask each of them their field of choice and if they see ultrasound having a role in their career. Many will nod affirmatively to appease me but by the end of the course, they are asking if we can teach them more ultrasound before they graduate. Ultrasound helps me connect and let them know how we use ultrasound to understand the causes of shock and how to manage these patients. This ability to break down silos and demonstrate how useful it can be across many specialties that care for patients is one of my favorite aspects of teaching bedside ultrasound.

Innovation

Ultrasound is such an exciting new tool and developed into a new field. New probes, technology, and applications are always evolving and changing how we use it to care for patients.

Ultrasound education is equally as exciting and dynamic. Because of challenges such as limited curricular time and tight budgets we have gotten creative to teach ultrasound. Ultrasound education has led the way with new concepts such as remote instruction, flipped classroom, near-peer training, learning through modeling, and gaming.

Mentorship

I have been fortunate to be blessed with amazing mentors who have given me amazing opportunities. The ultrasound community is small and welcoming, as well as young, fresh, and innovative. One of the greatest joys of teaching ultrasound has been the relationships I have made. I have found wonderful mentors but also been able to be a mentor. To watch my students turn into fellowship directors, division heads, and national speakers has been one of the greatest rewards. I have seen that hard work, loving what you do, and helping others learn ultrasound is a winning strategy for me and possibly you too.

Clinical Excellence

I make myself endlessly available to my learners and that offer does not end at graduation. More so than any award I have ever gotten, the greatest accomplishments of my career are the notes, emails, and texts saying thank you: ultrasound saved my patient last night. Those clinical wins where a patient benefits from a bedside ultrasound make every late night of lecture prep worth it.

So, why teach ultrasound? Ultrasound is the future of medicine and medical education. Get involved!

Why do you teach ultrasound? What do you value most about teaching the next generation of ultrasound users? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Creagh Boulger, MD, RDMS, FACEP, is Assistant Professor, Assistant Director of Ultrasound, and Assistant Fellowship Director of Emergency Ultrasound at Ohio State University Wexner Medical Center.

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 TVs 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.

The Rolling Sonograms

“Hold still and keep your eye shut tight,” I instructed, as I lathered my probe with gel and placed it carefully on my model’s left eye. Having just narrowly escaped the brink of elimination, we were riding a wave of momentum. The trophy was so close we could taste it, but the final round of SonoSlam 2017 was a real-time scan-off on model patients, and our opponents had already proven their skill. Having a live audience didn’t make imaging a pupillary reflex or calculating ejection fraction any easier, and we were feeling the heat.

The day began with scans on rotating stations testing basic knowledge and technique for various organ systems. We struggled with the hepatobiliary station (turns out most teams did over the course of the day; guess we all need more practice) and the physics/knowledge station (I still don’t know how Fourier functions are used to convert sinusoidal data to Cartesian data to produce an image). Still, we put in a strong showing, and at halftime, of 27 teams, 2 of the 3 Ohio State teams placed in the top 5.

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Round 2 was trickier but more entertaining than round 1, with stations designed to test our technique and creativity. Among the highlights: identifying an image acquired by a teammate via ultrasound charades, guiding a blindfolded teammate to acquire the correct scan using nothing but verbal cues, and acquiring a biopsy sample under ultrasound guidance. These were difficult, but despite a few groans of frustration, we enjoyed ourselves as we raced through the stations. We felt so good about our performance that we even let ourselves think ahead, speculating whether we would face our teammates in the final. That changed quickly, however, with the announcement of the finalists: we had made the final, but placed third, and were the only OSU team left.

The first challenge of the finals was Dr. Boulger’s favorite ultrasound game, the peel-and-reveal. Tiles filling the screen are removed one by one until someone correctly guesses the image underneath, with more points awarded the more tiles remained. Any hesitation or uncertainty meant more points for the competition, and only the top 2 teams would survive till the second round. Watching the other teams grab an early lead, we sweated bullets as we clawed our way back, only to fall behind again with a premature guess. It was neck-and-neck till the very end, when a gutsy call of McConnell’s sign from Sam edged us into second place. We collapsed back into our chairs in relief, and our attendings, watching from the back, let out their collective breath, probably.

For the final challenge, each team sent a representative to scan on live models behind a closed curtain, with their screens displayed for the audience to see. Each team member had to scan twice, and the audience would vote on the better image by way of cheers and applause. They were also allowed to give advice to the scanners, which meant the auditorium soon became a pandemonium of shouted instructions. Objectives included cardiac output and bladder calculations, MSK ultrasound, and ocular imaging. This time we took the early lead thanks to Charles’ affinity for shoulder scans, but quickly ran into setbacks as well (hard to measure bladder volume when the patient had just peed). We managed to keep up our momentum, however, and after 6 nerve-wracking rounds, we edged our opponents 4-2, clinching the SonoSlam championship for Ohio State for the second time.

Looking back on the day’s events, I am proud of our team’s accomplishments but also impressed with the competition. We have great mentors and almost a decade of ultrasound experience between the 3 of us, but some of the other teams were no less strong, and frankly we were very fortunate to take home the title. To me, this means a bright future for ultrasound education, as medical students across the country are learning valuable skills that will put them in good stead for residency and beyond. More importantly, it means that next year’s teams will have to step up their game, as Ohio State must now defend its title as 2-time SonoSlam champion. No pressure, guys.

Have you participated in SomoSlam? If so, tell us about your experience. Comment below or let us know on Twitter: @AIUM_Ultrasound.

The 2017 SonoSlam champions, The Rolling Sonograms, was composed of Samatha King, Charles McCombs, and Jeffrey Yu. Samantha King is a fourth year medical student from the Ohio State University College of Medicine planning to pursue a career in emergency medicine. Charles McCombs is a third year medical student at the Ohio State University College of Medicine and hopes to end up in pediatrics and/or emergency medicine. Jeffrey Yu is an anesthesiology PGY-1 at the Ohio State University Wexner Medical Center.

SonoSlam 2017

16SonoSlam_logoIf you attended the AIUM convention the past 2 years you may have heard mention of SonoSlam in passing. So what is it? SonoSlam is a medical student ultrasound competition and educational event. It was conceived as an idea to promote medical student ultrasound and was officially born in Orlando in 2015. A few members of the medical education committee were discussing how to get students more engaged in ultrasound at the national level. A national ultrasound student interest group had been formed and got behind the idea of nationalizing ultrasound activities for medical students. Many of us had been involved in regional events such as Ultrafest or had participated in Sonogames™, an emergency medicine resident ultrasound competition. As we brainstormed, SonoSlam came to fruition. We wanted this event to be more than a game, making sure to integrate education into the proceedings. Given the diversity of exposure to ultrasound in undergraduate medical education, the faculty wanted to ensure that this event would be appealing to students of all levels of experience. In addition, the unique offering of AIUM is that this event would be multidisciplinary. With these key components of education, competition, and a multidisciplinary approach SonoSlam was created. The inaugural SonoSlam was held in New York in 2016 with the winning team awarded the Peter Arger Cup, named after the famed radiologist who championed medical student ultrasound education at the AIUM. Seventeen teams from 12 different schools participated in this inaugural event with more than 30 faculty from across the country. This year in Orlando we grew to 23 teams from 17 schools from across the country—Oregon to New York to Florida and all in between. We had more than 50 faculty from a multitude of specialties, including emergency medicine, internal medicine, critical care, obstetrics and gynecology, radiology, and pediatrics. We plan to continue to host this event annually with the lofty goal of having representation from every medical school in the country. We hope to see you in New York March 24, 2018!

SonoSlam2017

For more information about SonoSlam or if you are interested in getting involved please email us: sonoslam@gmail.com.

Written by Creagh Boulger, Rachel Liu, and Dave Bahner. Creagh Boulger, MD, RDMS, FACEP, is Assistant Professor, Assistant Director of Ultrasound, and Assistant Fellowship Director of Emergency Ultrasound at Ohio State University Wexner Medical Center. Rachel Liu, BAO, MBBCh, is Assistant Professor of Emergency Medicine and Director of Point-of-Care Ultrasound Education at Yale University School of Medicine. Dave Bahner, MD, RDMS, FAIUM, FAAEM, FACEP, is Professor and Director of Ultrasound, Fellowship Director, Investigator, and Core Faculty at Ohio State University.

How do you make ultrasound education engaging? Do you have any ideas for bringing students from across the country together? Comment below or let us know on Twitter: @AIUM_Ultrasound.