The Buzz in Orlando

From the moment you stepped foot inside the Hilton Bonnet Creek Resort, you knew this was going to be a different kind of AIUM Convention. Maybe it was the new venue. Maybe it was all the new offerings. Maybe it was the excitement about connecting and reconnecting with colleagues from around the world.IMG_7012

Whatever it was, it caused a buzz in Orlando.

If you were in Orlando, we hope you felt the same. If you were unable to make it this year, here are a few of the highlights (you can see and learn even more if you search #AIUM19 on your favorite social media site):

 

IMG_7019 copyNew Offerings—Each year, the AIUM and the Annual Convention Committee look to enhance and improve the event. This year was no exception. To get the juices flowing, attendees could participate in a morning exercise class that varied each day. We added the Recharge Lounge where attendees could relax and charge up their devices. We partnered with the International Contrast Ultrasound Society on a one-day educational event. And we enhanced the Meet-the-Professor sessions.

SonoSlam—In its fourth year, 24 teams battled it out for the coveted Peter Arger Cup. The University of Connecticut’s team, PoCUS Maximus, came out on top–and defended their title! Save the date for next year—March 21 in New York City! Big thanks to headline sponsor Canon.

 

 

Social Media—From Instagram to Twitter to Facebook, Convention attendees were very active on social media at #AIUM19. And, for the first time, there was a takeover! Kristy Le, a recent RDMS graduate, took the reigns of our social accounts to give her perspective on the AIUM Convention! Search #AIUM19 to get her take!Twitter_AIUM19

Kristys Takeover

Networking–It’s not an AIUM event if there isn’t networking. IMG_6998 copyThis year there were even more opportunities to make new contacts and reconnect with colleagues from around the world. From the morning workouts to the Presidential Reception. From Community meetings to the Welcome Reception. From the intimate Meet-the-Professor sessions to the Exhibit Hall breaks. You almost couldn’t help but expand your network.

Global Plenary—AIUM President Brian Coley, MD, hosted the Plenary session that featured a lecture on reducing workplace injuries from Kevin D. Evans, PhD, RT, RDMS, RVS, FSDMS, FAIUM, Professor at The Ohio State University College of Medicine. This talk launched a series of sessions and events at the AIUM Convention that focused on ergonomics. The entire Plenary Session is available on the AIUM Facebook Page.

Fun Activities—Not only was #AIUM19 educational, it was also fun. Buttons_IMG_1967_EDITEDThis year attendees could participate in morning exercise classes (yoga, jogging, bootcamp); do a scavenger hunt with the AIUM app (Congrats to Julie Abe, MD, from Brazil for winning the free #AIUM2020 registration); collect specialty-specific buttons (Congrats to Joanne Richards, RT, RDMS, RT on winning the smartwatch for collecting at least 15 buttons); and participate in Industry Symposia.

 

Sold-out Exhibit Hall—This year’s exhibit hall was the most exciting and active it has ever been. There were more new companies at this year’s event than ever, making the exhibit hall vibrant and exciting! IMG_7035New product releases, special offers, and cool giveaways created a buzz we haven’t seen in years. Plus, there was cake! Thanks to all the exhibitors!

Award Winners—The AIUM was proud to recognize the following award winners (look for upcoming blog posts and/or videos from some of these individuals):

James A. Zagzebski, PhD–William J Fry Memorial Lecture Award
Steven R. Goldstein, MD, FAIUM—Joseph H. Holmes Clinical Pioneer Award
Keith A. Wear, PhD, FAIUM—Joseph H. Holmes Basic Science Pioneer Award
Kevin David Evans, PhD, RT, RDMS, RVS, FAIUM—Distinguished Sonographer Award
Michael Blaivas, MD, MBA, FAIUM, FACEP—Peter H. Arger, MD Excellence in Medical Student Education Award
Bryann Bromley, MD, FAIUM—Carmine M. Valente Distinguished Service Award
Liat Gindes, MD—AIUM Honorary Fellow
Tammy Stearns, MS, RT(R), RDMS, RVT, FSDMS—AIUM Honorary Fellow

The AIUM also recognized the life and achievements of these individuals who were inducted into the Memorial Hall of Fame:

Michael L. Manco-Johnson, MD
Terry J. DuBose, MS, RDMS, FAIUM, FSDMS
Donald Baker

Up and Comers—In addition to our national awards, the AIUM also recognizes its New Investigators. This year’s winners and runners-up are:

Basic Science
Winner—Viktor Bollen, Postdoctoral Fellow, University of Chicago for “A Comparison Of Thrombus Dissolution Efficacy With Single And Multiple-Cycle Histotripsy Pulses In Vitro.
Runner-Up–Lakshmanan Sannachi, PhD, Postdoctoral Fellow, Department of Physical Sciences, Sunnybrook Health Sciences Centre for “Quantitative Ultrasound Texture-Derivative Methods Combined with Advanced Machine-Learning for Therapy Response Prediction: Method Development and Evaluation.”

Clinical Ultrasound
Winner—Misun Hwang, MD, Assistant Professor of Radiology, Children’s Hospital of Philadelphia, University of Pennsylvania for “Quantitative Detection of Brain Injury with Contrast-Enhanced Ultrasound in Neonates and Infants.”
Runner-Up–Michal Fishel Bartal, Maternal Fetal Medicine Fellow, McGovern Medical School, University of Texas at Houston (UTHealth) for “Validation of 3D Power Doppler Volume Analysis in Patients with 2D Ultrasound Suspected Morbidly Adherent Placenta.

Convention attendees say that the reason they attend this event is because of the multi-specialty nature of the AIUM. This event brings together physicians, sonographers, scientists, students, and others from at least 20 specialties–all focused on medical ultrasound! No other event–or professional society–does this. To all of those who joined us in Orlando, thanks and we hope you were able to take back some contacts, a lot of information, and resources to improve patient care. For everyone else, we hope to see you in New York City for AIUM2020.

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Physics of Ultrasound

Snell’s Law [in-class demonstration]

The concept that sound reflects and propagates in varied angles is an abstract concept that many students struggle to understand. I review this concept by providing an in-class demonstration that makes this less abstract and something that can be seen with glasses of liquids.

Evans_Fig 1

 

If speed 1 < speed 2, then the incident angle < transmitted angle.

The difference in the stiffness and resulting propagation speeds helps to explain why the straw appears to be “broken” when you look through the side of the glass of water. The angle of transmission is measured against the vertical black line drawn on the glass of water. This helps to illustrate the 30-degree oblique incidence vs. the increased angle of transmission. A real-world example would be the change in imaging of a needle in a fluid-filled structure.

Example:

The propagation speed of sound through air is 900 m/sec while the propagation speed of sound through water is 1200 m/sec. To figure out the change in the angle of transmission, we form a ratio that will allow us to arrive at a percentage of change. So, 900/1200 = .75 and, therefore, that ratio of change from air to water in the glass is 100 – 75 = 25%. To figure out the angle, take 30 times .25 = 7.5 degrees. Therefore, 30 + 7.5 = 37.5 degree angle of transmission.

Now, consider a different glass of liquid as part of this demonstration by viewing a glass of Karo syrup.

Evans_Fig 2

This time, the glass is filled with Karo syrup, which is stiffer and denser than the water, and the transmitted angle is greater due to the increased ability to travel quickly in the second media.

 

If speed 1 < speed 2, then the incident angle < transmitted angle.

Example:

The propagation speed of sound through air is 900 m/sec while the propagation speed of sound through Karo is 1500 m/sec. To figure out the change in the angle of transmission, we form a ratio that will allow us to arrive at a percentage of change. So, 900/1500 = .60 and, therefore, the ratio of change from air to Karo syrup in the glass is 100 – 60 = 40% gain. To figure out the angle, take 30 times .4 = 12 degrees. 30 + 12 = 42 degree angle of transmission. The real world example for this is noting a speed propagation artifact.

A final demonstration can be a glass that has 1/3 air, 1/3 vinegar, and 1/3 cooking oil. Do not forget to add a straw so that several bends in the straw are noted by viewing through the side of the glass.

 

 

Kevin D. Evans, PhD, RT (R) (M) (BD), RDMS, RVS, FSDMS, FAIUM, is Chair and Professor of Radiologic Sciences and Respiratory Therapy at The Ohio State University in Columbus, OH.

 

Ultrasound at 18,000 ft.

A brief history of the making of Solar‐Powered Point‐of‐Care Sonography: Our Himalayan Experience (J Ultrasound Med 2019 doi.org/10.1002/jum.14923).

Dr Mark Kushinka and Dr Rob Razick are sitting at camp in Phirste La Pass at 18,208 ft. The camp is designated by banners of alternating color flags attached to the top of a pole and pinned to the ground. Mountains are shown around them with blue sky.

Dr Marc Kushinka (left) and Dr Rob Razick (right)
 in Phirste La Pass at 18,208 ft.

Full disclosure… I wasn’t actually there.  Anyone who knows me knows I am not the “sleeping with yaks, no shower for a month” kinda girl. I also have no shame in admitting that I had no chance of surviving the 80+-mile trek 3 miles high amongst the clouds. Fortunately for me, and the people who inhabit the Zanskar Mountain Range, I had 4 residents who wanted to spend several months hiking through a mostly impassable mountain trail providing care to those who live in this spectacular part of the world. Our Lumify’s passport had already amassed an impressive collection of stamps, but none of them as remote as the Himalayas. There is no electrical infrastructure in this region, and all sources of energy come from kerosene, dung briquettes, or solar power. As Dan and Zac departed for India, we had no idea if this crazy plan to operate the ultrasound solely off of a portable solar pad was going to work. Frankly, I was a bit worried that I was adding a few extra pounds to their pack for no good reason. But, after spending 30 days in one of the most remote locations on this Earth, the guys returned with some great stories, good images, and a ton more facial hair.

Dr Daniel Baker and Dr Zac Hardy are shown standing together in Phirste La Pass by a snow-tipped mountain peak.

Dr Daniel Baker (left) and Dr Zac Hardy (right) 

 As I sat curled up in my leather chair with a supple cabernet, I reviewed the data from their trip and realized just how awesome this was. There had never before been medical imaging accessible at this elevation, and its availability had a direct impact on patient care. We repeated the adventure the following year with a new set of residents and the same cheap solar pad from Amazon. After some minor modifications based on our lessons learned from our inaugural year, Marc and Rob yielded more consistent scan times and reliable use.

I truly believe solar powered POCUS can change the face of austere medicine. All you need is a solar pad, a portable ultrasound, and the desire and willingness to leave the comfort of home. Or at least have a few residents up for the adventure.

Cheers from Kashmir!


Have you performed ultrasound examinations in remote regions? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. Visit the Journal of Ultrasound in Medicine online.

Laura Nolting, MD, FACEP, is the Director of Emergency Ultrasound and the Ultrasound Fellowship Director for the Department of Emergency Medicine at Palmetto Health Richland in Columbia, South Carolina.

Teaching Point-of-Care Ultrasound

Ultrasonography (US) is now used in some fashion by most specialties, and in graduate medical education, performing a US examination is now a routine expectation in the fields of emergency medicine, surgical critical care, diagnostic radiology, pulmonology, and gynecology. The American Medical Association has confirmed that physician‐performed US is within the scope of practice of appropriately trained physicians and recommend that training and education standards be developed by individual medical specialties.

In light of its clinical and education utility, it is reasonable to expect that US would be taught during medical school. Some national and international bodies, including the AIUM, have proposed curricula for medical students. While its level of use is variable, several schools have described integrated US into undergraduate medical education. Several studies have shown that students are able to and want to learn point-of-care US (POCUS) in medical school. Let’s review some tips for engaging medical students while teaching POCUS.

1. Hands-on time

Allow the medical student to have hands on the probe as much as possible. Limit lecture time to only that which must be done in lecture format. Make sure group learning time is done in small groups with maximal time for each student to use the probe. Give them time to work through different positions and views to help identify windows and quality images. Use your verbal commands to direct them instead of taking the probe. If you are going to take the probe, put your hand over theirs.

2. Engage the student

Find a use for ultrasound that is relevant to the student’s specialty of choice. Most specialties now have some use for ultrasound. IF you cannot identify a use for ultrasound in the specialty of choice, consider teaching general skills like US-guided IV insertion. Describe how US was or would have been useful during residency.

3. Make it fun

Use simulation liberally. Consider having a game or competition (see Sono-games, SonoSlam, or other similar competitions for potential ideas). Multiple homemade procedural models have been described and are inexpensive. Medical students, in general, love practicing procedures and are mostly competitive by nature. There are several ways for the more experienced student to improve their US skills in a fun manner. Some ideas include identifying inanimate objects blindly that are immersed in water, a competition like fastest FAST exam, or making a procedural simulation competition.

4. Short and sweet

Keep sessions engaging by spreading practice out over time. Again, keep lectures as brief and need-to-know as possible. Most medical students will only need a brief physics review and do not, for example, need to know the Nyquist limit. They need to know how to answer focused questions with ultrasound. Students will lose interest if doing the same exam over many hours. Consider spreading sessions, especially image review sessions, out to 1 hour or less over several days. Intersperse different types of ultrasound (e.g., abdominal, cardiac, pulmonary, vascular) within the same session to keep students engaged.

5. Start early

Expose students to US early on in medical school. Consider adding it to anatomy or physiology classes while students are still in their pre-clinical years. If you do not have the swing to add a formal session to preclinical years, consider having voluntary “anatomy review” sessions using US. Try to get enough interest to start an interest group for students that is student-run. This will allow them to take some of the responsibility for scheduling and promoting events and you can focus on what you do best, teaching US.

Ultrasonography is coming to medical education and will continue to grow in use. While students going into specialties like radiology and emergency medicine may instantly be engaged in US teaching, consider ways to engage other students. There is a role for US in nearly every specialty.

Sonographers can and should play a key role in teaching medical students techniques for US. Sonographers perform these exams every day for many years. They have tricks for obtaining quality images and many sonographers are also quite good at interpreting exams, as well.

Embrace medical students and engage them with your passion for ultrasound. Show them how it will be helpful to them in the future. Take an active role in medical student education and watch the use of ultrasonography in medical practice continue to grow.



Do you have suggestions for teaching POCUS to medical students? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Joshua J Davis, MD, is an Emergency Medicine Resident at Penn State Milton S. Hershey Medical Center.

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.

Training and Integrating Sonographers via Dedicated Preceptors

Hiring new staff members is risky business. Despite all the resources invested in identifying and evaluating qualified candidates, there’s no guarantee they’ll be a good long-term fit for the department. As new staff members begin to settle into a new job, there are a variety of reasons why they might ultimately leave the position. Many of these reasons can be traced back to deficiencies in orientation and training programs. With this in mind, it is of the utmost importance to invest appropriately in the onboarding process. A successful onboarding and training program provides benefits to the candidate and the organization.IMG_2125

My experience with these processes comes primarily from my current position as the Ultrasound Educator at St. David’s North Austin Medical Center in Austin, Texas. A huge portion of our sonographers are hired and contracted to maternal-fetal medicine (MFM) clinics around the Austin area; working for Austin Maternal-Fetal Medicine. Expectations for these sonographers are high. They perform all ultrasound examinations common to maternal-fetal medicine practice, including fetal echocardiography and diagnostic 3D/4D techniques. The scarcity of qualified candidates means that we often hire candidates from out of state, and integration to the department and community are among our primary concerns; having a structured training program helps with that.

New employees spend their first 2 days on the job attending facility orientation. Their third day of work is their first day in the MFM department. They’ll meet with leaders and physicians, and tour all relevant areas. In addition, I spend some time with them reviewing the training process and setting expectations. At this time, we pair them with a Sonographer Preceptor. The preceptor/trainee assignment is, of course, subject to change, but we try to limit this as part of the goal is to provide some stability and consistency during the training period.

The standard training period is 3 months in duration, although, we have extended training in some cases up to 6 months. This period may look different for various candidates based on their prior experience level. However, there are several characteristics that remain fixed:

1. One-on-one work with a preceptor

The Sonographer Preceptor is expected to directly observe while offering real-time feedback, every part of the trainees workday. This level of intensity may only be reduced after consultation with the Ultrasound Educator.

2. Weekly preceptor feedback report

This weekly report is filled out by the Preceptor and reviewed with the trainee. They review things that are working well and also plan which tasks need additional focus for the following week.

3. Image review with the Ultrasound Educator

On a weekly or biweekly basis, the trainee will meet with the Ultrasound Educator to review the Preceptor feedback report and review a selection of examinations from the prior week.

4. Didactic and written material for review

Each candidate is supplied with protocols, American Institute of Ultrasound in Medicine (AIUM) guidelines, review articles, and some pre-recorded lectures that cover essential quality standards and approaches for the department.

This high-touch training period helps to ensure that we have a strong understanding of the progress being achieved and can quickly adjust if we do not see steady growth.

Many people will recognize that it takes years to develop strong, comprehensive skills, in the performance of MFM ultrasound examinations. So what can we expect to accomplish in only 3 to 6 months? Upon completion of the training period, the sonographer should be able to:

  1. Complete normal fetal anatomic surveys, fetal echocardiograms, and other examinations in non-obese patients, demonstrating an understanding of proper technique, measurements, and optimization.
  2. Exercise professional discernment by getting help when their own efforts do not produce the answers or quality they expect.

These two goals may initially appear to be overly simplistic, but they work together beautifully in the transition out of the training period and into independent performance. Completion of normal (relatively easy) examinations proves that they understand the target. They understand what normal looks like and the essential techniques involved. The second point is key as it gives department leadership the confidence to allow them to work independently, because we know that they understand what good enough is, and we know that they have the resources they need in order to help them when they cannot meet expectations on their own. This is an important skill that never expires. This is relevant for sonographers, physicians, and other health care practitioners throughout their careers. Knowing when you’ve hit your limit and when to seek additional counsel is key to providing the best care to our patients (regardless of one’s particular level of expertise).

These two benchmarks, along with ongoing quality assurance efforts, help give us confidence in our team even as they continue to grow their individual skills and proficiencies over the coming years.

A note on Preceptor selection

Key to the success of this process is the selection of Sonographer Preceptors. These team members fill two distinct (individually important) roles: technical trainer and social integrator. With that in mind, selection of the individuals who fill this role is very important. Social characteristics we look for are warmth, kindness, extraversion, and the tendency to be inclusive. Technical expertise is evaluated based on history, quality assurance, physician feedback, and ability to evaluate and explain abnormal cases.

Full-time training in a one-on-one environment for 3 months or more at a time can be emotionally and mentally exhausting (even if rewarding). With this in mind, we try to maintain several Preceptors on our team so that these sonographers are able to work independently for extended periods between training new employees.

The social and integrative aspects of our Preceptor Program are not formally defined, yet the benefits are clearly evident. We see that our new employees make strong connections with their preceptors and other team members, frequently having lunch together and engaging in other extracurricular activities during time off.

It is important to point out that preceptors should typically be individual team members—not leads, supervisors, or managers. These formal leaders have other administrative duties that will inevitably get in the way of the one-on-one, full-time training involved in a preceptorship. Of course, leads, supervisors, and educators, may set aside time for some training of new hires, and this is certainly beneficial. For example, in our departments, I frequently set aside time to work with new hires or existing employees on specific skills such as 3D/4D, fetal echocardiography, or abnormal cases. Sonographers enjoy these sessions and benefit from them, but that does not replace the benefit of having a dedicated preceptor.

People don’t stay in jobs where they feel disconnected from the culture and community. This training program, with assigned preceptors, helps to meet the human need for connection in addition to building and verifying technical skills that are necessary for success.

For additional reading:
https://www.forbes.com/sites/forbeshumanresourcescouncil/2017/09/21/seven-ways-to-integrate-new-hires-and-make-them-feel-welcome-from-the-first-day/#1282eff640f6
https://www.thebalancecareers.com/employee-orientation-keeping-new-employees-on-board-1919035
https://trainingindustry.com/blog/performance-management/dont-ignore-training-when-onboarding-new-employees/

Does your practice have a mentor program for sonographers? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

Connect

Will Lindsley, RDMS (FE, OBGYN, AB), RVT, is an Ultrasound Educator in Maternal-Fetal Medicine and Fetal Echocardiography in Austin, TX.

Ultrasound at the Zoo

Zoo medicine is quite the paradox. In one way, zoo veterinarians are specialists in that what we do daily; it is very unique and specialized and there are few licensed veterinarians that are employed as full-time clinicians in zoological parks. On the contrary, zoo veterinarians are also the ultimate general practitioners as our patients include everything from invertebrates to great apes and elephants (and all life forms in-between)… and for this wide variety of patients, we attempt to be their pediatrician, surgeon, dermatologist, cardiologist, radiologist, etc. I am fortunate to be the Senior Staff Veterinarian at the Louisville Zoo in Louisville, Kentucky.

In terms of imaging modalities, most zoo hospitals are equipped with plain radiography (film or digital) and have some ultrasound capabilities. A few of the larger zoos in the country have computed tomography (CT) in their on-site hospitals. In Louisville, when one of our patients requires advanced imaging, we make arrangements with local facilities with CT or MRI capabilities.

For ultrasound imaging, we have a portable Sonosite M-Turbo unit with both a curvilinear, 5-2 MHz transducer for primarily transabdominal imaging, and a linear array, 10-5 MHz transducer for primarily transrectal imaging. In addition, we have several donated large rolling Phillips Sonos units with an assortment of probes for both echocardiography and transabdominal imaging. One remains in the Zoo’s Animal Health Center and others are stored and used in animal areas for pregnancy diagnosis, echocardiograms on awake gorillas (through the mesh barrier), or just training/conditioning animals for awake ultrasound exams.

Zoo animals may present unique challenges when ultrasound imaging transcutaneously. In the case of fish and amphibians, imaging through a water bath (without even touching the patient!) can be very effective and noninvasive. The rough scaly skin of some reptiles makes a warm water bath similarly effective as a conductive medium for imaging snakes and lizards. Birds are not often examined via ultrasound because of the extensive respiratory (air sac) system they possess that interferes with the sound waves. For mammals, different species present different challenges. Many mammal species are thickly furred necessitating clipping of hair to establish good contact between the transducer and the skin. For transabdominal imaging, some species are very gassy (hippos, gorillas), which may complicate diagnostic imaging. Large or dangerous mammals that are examined awake via training need to be conditioned to present the body part of interest (chest, abdomen) at the barrier mesh and trust their trainer/keeper to allow contact with the probe. Often the greatest hurdle is habituating the animal to the ultrasound gel! When performing transabdominal imaging in our pregnant African elephant cow, rather than go through gallons of ultrasound gel smeared on her flank to fill in all the cracks and crevices in her thick skin, we run water from a hose just above wherever the transducer is placed.

DSC_4176

As general practitioners, zoo veterinarians have variable amounts of training in ultrasonography. We strive to do the best we can and are constantly learning, but the high variability in our daily tasks makes becoming an expert in ultrasound very difficult. So “it takes a village,” and we will regularly utilize specialists in our community to assist us in providing the best medical care for our patients. If I have a zebra or related species that requires a reproductive ultrasound exam, we will reach out to a local equine veterinarian that can apply their expertise in horses to a related species. Great apes have a high incidence of heart disease so whenever a gorilla or orangutan is anesthetized for an exam, part of the comprehensive care they receive is an echocardiogram by a human sonographer. Female great apes may get attention from our volunteer gynecologic sonographer as part of a reproductive evaluation. If the ultrasound exam is on a sea lion, wolf, or bear, I may contact a veterinary radiologist or veterinary internist competent in ultrasonography to assist.

In summary, ultrasonography represents a valuable, noninvasive, diagnostic tool for the zoo veterinarian.

Have you ever performed an ultrasound examination at a zoo? What was your experience? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Zoli Gyimesi, DVM, is the Senior Veterinarian at the Louisville Zoo in Louisville, Kentucky.