LLLLLLLLet’s get ready to UltraSoooooooouuuuuuuuund!!!! It’s what we have all been waiting for! It’s finally here! Weighing at a meager zero pounds (since it’s on the iPAD, oh yeah!), another amazing product of Drs. Mike Mallin and Matt Dawson of ultrasoundpodcast fame, and authors including experts in bedside ultrasound from around the world (and little ole’ me too). I’d like to present the SECOND volume of the Introduction of Bedside Ultrasound ! And, as Mike and Matt say it best, “If you already own Volume 1….” (which include topics in basic ultrasound applications & more filled with visual image and video clip tutorials – unlike any other “text”book that you have ever owned!) “…..this is much better. If you don’t yet own Volume 1….they’re equal…..get them both.” – Yes, trust me, you will not be disappointed. Take your iPAD to the bedside, place it on the ultrasound machine, or both to help guide your ultrasound education and that of others! Volume One pics:
Volume Two involves topics on TEE (which is an up and coming application of bedside ultrasound in cardiac arrest), MSK, Right Heart, EMS, Medical Education, Gallbladder, more Nerve Blocks (that’s where I come in..heehee , PIV, Soft Tissue, DVT, Appy, Peds, Diastology, and much more! 364 pages of interactive content, with HOURS of video demonstrations and tutorials. – doesn’t that make you drool!?! In volume two picture: …do you know what technique that is? you will…
To hear them speak on it, and to get a taste of perfection, go here.
The American Institute of Ultrasound in Medicine (AIUM) 2013 conference in New York City was the best AIUM I have ever been to, and it continues to open up my mind (having my ideas run wild!) to so many things that ultrasound will do for medicine, while reminding me of the up-to-date studies that clarify many ultrasound-related topics in medicine. It is true that Ultrasound should be considered first with many conditions, and as an emergency physician, point-of-care bedside ultrasound is definitely an example of that. It absolutely should also be implemented into medical school education to have a head-start at becoming an excellent physician. AIUM has an emergency and critical care section too and I have taken full advantage of the information there, as should you. (Jason Nomura has gathered all AIUM13 tweets for your reading pleasure for all AIUM13 topics)
YOU = Year of Ultrasound!
This post is a one part of a 4-Part Series where I discuss all the lectures, panel discussions, and events that i attended there, and what every emergency doctor should get out of it, and the literature that backs it up or discusses the controversy – all through my and other’s twitter feed with the addition of some links to relevant material.
The first day was one of my favorites! It was the Ultrasound in Medical Education panel discussion from the experts, coordinated by Dr David Bahner, who has recently published study after study after study after study with regard to how he incorporated ultrasound into medical education and how to standardize ultrasound education. You can even listen to and view the whole course if you have an AIUM membership, by going here. Dr. Richard Hoppman, the Dean of University of South Carolina, who has also published study after study after study after study on this topic, also gave his pearls and wisdom from the Dean’s perspective. (Hear/View his interview with UltrasoundPodcast by going here.) Other experts also gave their expertise in this hot topic, as they have also published and highlighted study after study after study after study as shown below in the tweet and panels’ pearls from the course (as well @SonoMedED tweets who provided more highlights for the course): Ultrasound in Medical Education (I posted on the comparison of Ultrasound to physical exam previously – but there is so much I need to add to it now!)
a. Provide clinicians with resources to guide medical student training in clinical ultrasound to better provide care for their patients
b. Provide educators with the resources and tools to coordinate clinical ultrasound in medical curricula
c. Provide researchers with evidence based resources to create and validate new knowledge through innovative and rigorous academic pursuits
d. Provide administrators with data and contact personnel at respective medical institutions who are applying novel ultrasound education across the medical spectra
e. Provide medical students with a one-stop portal to navigate current United States medical student ultrasound education and opportunities to get in school
1. David Bahner – This would involve changing curricula, training faculty, acquiring equipment, support staffing, quality assurance, OSCE or SDOT, establish “best-practices.” In 2004, the medical organizations differentiated & defined ultrasound into four categories: Comprehensive, Focused, Procedural, Physical exam aid
2. D. Lichtenstein - ”They call me Dr. Lung, but I do more.” There are exciting ways to show medical students the importance of ultrasound….New territories of ultrasound: mesenteric ischemia (“a bowel that doesn’t move is a dead bowel”), pneumoperitoneum, increased ocular use. Took 15 publications in order to publish the BLUE protocol that reviews 10 signs of lung US. Respiratory failure: BLUE http://crashingpatient.com/wp-content/uploads/2011/07/Lichtenstein-Slides.pdf … ; Circulatory failure: FALLS (if no B lines then good systolic fxn; if B lines then bad systolic function); Cardiac Arrest: SESAME protocol (lung sliding (if pneumothorax- immed interv), echo, then IVC and AAA at your discretion: http://www.slideshare.net/nswhems/the-arrested-patient … Lung Ultrasound in Critically Ill for Limiting Radiographs (LUCIFLR) project - to decrease CT and chest Xrays (but not to eradicate Xrays “or LUCIFLR will = LUCIFER”). Lung ultrasound can limit the need for chest X-rays in the ICU and the ED.
3. Creagh Boulger – speaking on literature review of ultrasound curriculum for medical students. MT “@SonoMedED: Medical students effectively use ultrasound in just 5 min in some situations.” [Even beating clinicians in diagnosis! See: this study.] . Study after study has shown that medical students benefit from ultrasound in medical education. How to fit it into the schedule? what they did – online didactics (like Fox’s iTunes series), then 16 weeks of hands-on, concluded with a checklist based assessment. Why teach it? Increases Anatomy Learning, increases diagnostic ability in radiology, assists in spatial relationships, and they see “live anatomy” with better ability to learn physiology in real-time.
5. John Pellerito – how to incorporate US into med school: buy in from Dean, faculty training, facility space, US equipment, MULTI-specialty involvement (emergency medicine, radiology, critical care, obstetrics, medicine, surgery). US in med school: online didactics, most time must be spent with hands-on: knobology, anatomy, physiology, pathology (- partner with pathology /radiology dept to show how ultrasound correlates with histology/specimens and CT/MRI [they will learn to read those better too by learning ultrasound!]). Society of US in Med Ed (SUSME) website to see sample curriculum. The Challenges of incorporating US into Medical Education: maintenance of longitudinal curriculum, keep faculty enthusiastic, budget for new equipment, space needs. MT“@SonoMedED: Challenges with med stud ultrasound educ 4yr curriculum, keep faculty interested. pic.twitter.com/UnRSCGs0vk”. Who to Train them? First will be faculty, then the seniors can teach the juniors. Essentials im developing an US curriculum: didactics and hands-on training, integration into anatomy, physiology, physical exam and diagnosis skills, clinical clerkships, and requires student assessment and image archiving and review. Faculty/Facility needs: classroom, bedside, anatomy lab, stretchers, gel, towels, monitors, models (students or patients), faculty from multiple specialties
6. Amponsah/Jackson – from Wayne State : how they incorporate US in med stud curriculum: didactics, 2nd yr competency test, multi-specialty involvement. Where US helps med stud in anatomy learning: spatial relations, pathology, live anatomy pic.twitter.com/MCI972lryO . Need high faculty:student ratio. LCME requirements are key to getting ultrasound into medical school:
LCME requirements are a great way to advocate for ultrasound education as part of active learning for medical students …..The following LCME requirements can be satisfied with ultrasound: ED-5-A: A medical education program must include instructional opportunities for active learning and independent study to foster the skills necessary for life-long learning; ED-12: The curriculum of a medical education program should include laboratory or other practical opportunities for the direct application for the scientific method, accurate observation of biomedical phenomena, and critical analysis of data; ED-28:A medical education program must include ongoing assessment of medical student’s problem solving, clinical reasoning, decision making, and communication skills.
7. J. Christian Fox – From UC Irvine. pic.twitter.com/znUAea1wew . Bridging the gap between pre-clinical and clinical students with simulations: How to do it: transitioning from pre-clinical to clinical medical students: podcast, then hands-on with healthy volunteer, then task trainer, then recognize pathology on simulator, then standardized patient with pathology, then clinical rotation utilization by way of an OSCE pic.twitter.com/ix4Rl2X4WS ”Sono-genic” models great to use- models with great US anatomy. Issues in real patients: obesity, COPD, pain- all limit scan ability but great for later training. Great models: Sono-Studs… Or, not so good: Sono-Mess MT“@SonoMedED: Terms for good sonographic models…Sonogenic…Sonolicious.” (Ah, I digress…). Solve issue of assessing pathology: simulation! Various simulators are on the market: http://Sonosim.com , http://bluephantom.com ,http://Vimedix.com , http://www.medaphor.com/ , http://www.medsim.com/ultrasim.html . MT “@SonoMedED: Dr. Fox signs up pts for modeling with various pathologies. Model pts with pathology compensated $80 for 4 hour session. Often challenging to schedule patients though.” Great way to get models who have pathology! Studies show increasing ultrasound performed in ED when increased medical student ultrasound learning, also that liver span size better when use ultrasound. Medical students are better with ultrasound in diagnosing cardiac disease when compared to cardiologists’ physical exam.
8. Michael Blaivas- The role of specialty organizations- AIUM, SUSME, WINFOCUS, and specialty specific: ACEP, SAEM, ACS, ACOG, ACCP, SCCM, Card, Rads. http://SUSME.org primary purpose is integrating US into med educ. http://WINFOCUS.org primary purpose to help proliferation of Ultrasound education, is worldwide, has detailed US educ curriculum, policy making depending on region/country. Summary- issues and specialty organization – how they help pic.twitter.com/ZsO9BKWa6B
9. Dean Richard Hoppman – from University of South Carolina: pic.twitter.com/hAx4Iqv9rR . US in medical education- A Dean’s Perspective, how to get them on your side: how to get US in medical education- get medical students on your side, show US enhances medical education, satisfies LCME requirements, fits all types curriculum. When ultrasound becomes part of Step 2 exams is when you know we’ve arrived… [Wow! Can u imagine?!]….Ultrasound competency could be an advantage to residency application. Even if they don’t use US in residency, can order/ interpret/understand ultrasound and other radiology studies better, they’ll think Ultrasound First! How ultrasound adds value to institution pic.twitter.com/dzJt0VAaNE . Hopefully one day ultrasound training will be a requirement for medical school graduation. How to fund ultrasound for your institution pic.twitter.com/uItTHJj2Jb . MT“@SonoMedED: Universities increasing focus on entrepreneurship. patent ultrasound ideas or devices. Help fund program” Great idea by Hoppmann -> MT “@SonoMedED: Advocate option for donors to contribute to medical school ultrasound programs.”The new stethoscope? MT“@SonoMedED: Grants supply equipment for med studs, even handheld units. pic.twitter.com/5t9wbOtsef” medical students love it, medical students become alumni, alumni become donors. Great way to advocate for it pic.twitter.com/TnxBLjhsJn. Dean’s summary message to all: Get it. Learn it. Do it. Teach it. For your patients & healthcare pic.twitter.com/LfUQv2SbJK . Yes!!-> “@SonoMedED: Great insight from Dean Hoppmann. pic.twitter.com/VcW1BUmbRl”
10. Teresa Liu – from GW (the one who is putting it all together for med studs at AIUM/SAEM/ACEP). White paper on ultrasound in medical student education is in progress. ACGME now incorporates ultrasound into EMed and RRC doing same for rheumatology. Medical students can get involved in specialty organizations/journals focused in ultrasound: JUM, Acad Med, SUSME/SAEM/AIUM/ACEP. Lower cost-Increased use! -> MT“@SonoMedED: Liu- need for making US tech more affordable to better penetrate into all specialties.”
11. Alex Levitov- curriculum and competency assessments: challenges & opportunities. Driving force for ultrasound are many clinical cases where it’s relevant & when time matters: its a busy day or patient critical.When people ask why – tell them this: pic.twitter.com/CUth7L3Vxj . US allows immediate diagnosis, immeidate data in patient care, & allow reassessment after intervention (CVC placement, chest tube, foley…). Competency in US- image acquistion in years 1/2 ; Simulators, clinical cases & they decide what to do next for years 3/4. US in meded-cardiac physiology usually rated low by medical students, but rated high after ultrasound used to enhance education. Best way to incorporate US in medical education- staged approach -& use clinical cases early, ask about interventions in clinical years
12. Vicki Noble- from Mass General – discusses Ultrasound Competency -NEJM article -Point of Care Ultrasonography shows how many use it . ”Numbers” for image acquisition competency- should it exist? Arguments for & against exist. Outcome need to be different? “Consensus is great, paralysis is bad”-concept of plateau-do more of same if literature show numbers don’t matter may mean we should change. US competency numbers may be different for different ultrasound applications; numbers may not matter for some applications- testing image interpretation requires clinical integration & “next step” questions. Online ACEP US test: http://www.emsono.com/acep/exam.html
13. James Palma- from Georgetown – web based & organizational considerations in ultrasound in med ed – organ based approach – online didactics; hands on. web based US curriculum pic.twitter.com/l9fuWycluk
14. Last but not least – MEDICAL STUDENT PANEL !! Medical students panel discussing how #ultrasound helps them -going into different specialties pic.twitter.com/4B8IjKjtTQ . Ultrasound helps spatial relations in anatomy, great for MSK in real time (ie. rotator cuff movement), heart great to match with physiology (“it’s hard to understand heart physiology by reading a book, and so much better when you see the valves opening and closing and how the heart pumps”) . Great to see kidney ultrasound because anatomy dissection takes all abdominal organs out & can’t appreciate spatial relations. “@SonoMedED: Med Student Panel-Ultrasound physiology best demonstrated for IVC collapsibility and ejection fraction.” When asking medical student their preference: separate course versus full integration in different classes with regard to ultrasound into medical education: all wanted the latter – unanimously! . Story by a medical student: Psychiatric ward patient w/ abdominal pain got hand-held ultrasound by medical student showing cholecystitis- comprehensive ultrasound confirmed; OR that day. MT“@SonoMedED: Med Stud Panel-key to making integration of ultrasound successful: make it clinically relevant in 1st/2nd year.” “Ultrasound makes me feel that I can contribute to the team.”
15. Prior advances in Ultrasound in Medical Education has been highlighted by others: I have posted about how ACEP, AAMC, and AIUM last year has started speaking about ultrasound in medical education; UltrasoundPodcast have a great podcast about it and how to incorporate it here and here; WesternSono posted about this from the Canadian perspective with an amazing and fun talk pitching ultrasound training in medical education here; the world is advancing this goal as well!
Some of the great slides that grabbed my attention from the AIUM13 course: (apologies for the blurry iPhone images)
The Medical Student Panel:
The Course’s Faculty: aka – the All-Stars!
And, to conclude with great insight and words of wisdom for why ultrasound should be in medical education:
And what he has done to spread the gospel of ‘sound! – go here to read more and hear a speech done by the Dean of UC Irvine Medical School on why its so important to incorporate ultrasound into medical education for our patients.
This SonoGift is amazing! I could have sworn that I sent this earlier (and I think i did on Twitter and Facebook), but for whatever reason, it is in my blog’s draft folder, and I was shocked! – How dare I keep this away from everyone who follows SonoSpot?!!!! So, I apologize… from the bottom of my subxiphoid window (…ha! yes i know, I have many of them). If you’re getting this for the second time, then take it as a friendly reminder of how awesome the UltrasoundPodcast guys are to provide this amazing gift to everyone to learn the up-to-date info on bedside ultrasound applications… for free. Now, if you are getting this for the first time, you are going to LOVE it….. Why? Well, first off, it’s free (did I say that already?). And, if that wasnt enough, it’s the pdf version of the AWESOME iPAD download-able iBook of Introduction to Bedside Ultrasound from the UltrasoundPodcast crew, with chapters written by so many of my friends. If you purchase the iPAD version (for pretty cheap, if you ask me) (including the iPAD mini and retina display), you can view all the clips and videos placed by the authors/experts in bedside ultrasound – which truly makes it the best “book” on bedside ultrasound that I know. It’s worth it.
You know what else Im excited about? SonoGames Part Deux at SAEM - this time, our crew is going to make it after the first round!!! You all better watch out! A sneak peak at SonoGames last year by the serious yet humorous, heavy yet light, good yet talented UltrasoundPodcast and their hilarious interviews:
Oh, and did I mention Castlefest2013????!! Im so excited to join them at CastleFest2013 – ultrasound, castles, wine, and festivities?—what more could a Sonogirl ask for?! You can even be there virtually! Yes, they did think of everything.
Got an email from ACEP and thought it was too good not to share: Hear Dr. Cliff Rice, an ultrasound extraordinaire and emergency physician speak about bedside ultrasound and its use in critical care medicine. At the end of this post are even more lectures that are free. As you will hear, he states “Think about how you would use it in some of our sickest patients that come to the emergency department….. where the differential diagnosis is quite broad, and the treatment for shock might be detrimental if we are wrong.”
As ACEP states in the email: “Practicing emergency physicians need to be able to utilize ultrasound effectively in the evaluation of the critically ill patient. In this free audio recording from the 2012 ACEP Scientific Assembly, Dr. Rice highlights the use of ultrasound to perform a FAST scan, to dynamically monitor and measure the IVC in the setting of hypovolemic shock, and to detect pericardial effusion and perform ultrasound guided pericardiocentesis [in 45 minutes]. This [lecture] explains where you should start scanning, narrows your differential and guides your resuscitation.”
Other free lectures for your viewing/hearing pleasure on bedside ultrasound:
Once again, our Stanford Ultrasound Workshop was a huge success. Why? Our instructors were phenomenal and from different specialties! Our participants were faculty from emergency medicine, internal medicine, critical care, surgery, and pediatrics! The ultrasound tips and tricks just kept on coming from our lecturers - and, everyone laughed at our jokes, which always makes things great. As always, I like to provide those tips and tricks to all of you (and maybe even some of the jokes), so that you can feel like you were there too!
Dr. Sarah Williams – First, the coordinator for the Stanford CME workshop welcomes everyone with a Star Wars phrase “Learning you are….May the force be with you, young padawans!” – always goes to a great start. She is also the creator of the Stanford Ultrasound Program and current Associate Residency Director (and the person who was kind enough to put up with my quirks and jokes to hire me as a fellow years ago). Her pearls on the EFAST: detects >600 cc (intraperitoneal) fluid, look around inferior pole in RUQ and subdiaphragm area of LUQ (free fluid develops first there!), it’s not good for pelvic fx/injuries (pelvic bleeding into pelvic cavity, and retroperitoneal, bowel gas obstructs view, bladder may be empty limiting visualization), it’s not done fast- FAST is part of RUSH, but dont rush the FAST. Look for your kidney, then look above it, around it and below it (thoracic fluid, morison’s pouch, paracolic gutter). FAST LUQ: higher, spleen smaller, stomach big -place knuckles on gurney, oblique probe in plane to ribs, free fluid can be between diaphragm & spleen. #ultrasound detects 15-20cc fluid in thoracic cavity, better than chest Xray. Have patient take deep breath to lower diaphragm. The longer the patient is supine (or trendelenberg) the better, so if you have a walk-in trauma, perform serial FAST scan. SX view: the liver is the heart’s protector, be sure to see it in view- it allows you to see the 4chambers. gas is heart’s enemy - if gas gets in the way, you cannot see the liver: slide probe laterally to patient’s right, get that liver in your view. For pneumothorax eval – use linear probe, find your ribs, ID pleur liine, decr gain (brightness) to see sliding better. Start high in midclav line, indicator to head – - then travel thru mult rib spaces to estimate size.
Dr. Laleh Gharahbaghian (since i cannot speak about myself, I let someone else write this part and promised I wouldn’t change anything – let us pray…): “With her usual stylish self, walking all around the workshop, giving hi-fives to everyone in her path, her dance moves came in handy as she spoke (can you point her out in this video from the mid 1990s of her past job?) - She is the current Director of the Stanford Ultrasound Program and Fellowship her pearls can be found below: Her pearls of Aorta US: use large footprint probe, if get gas, press down, takes time – as if you were reducing a hernia; start in the subxiphoid region, travel down thru to iliacs. Most AAA are infrarenal and may seem normal in size at sx and get large once you travel down. Doesnt evaluate for rupture – most AAA leak/rupture retroperitoneal – not detected by US (your FAST is neg) – correlate clinically to your patient symptoms and vital signs. Her pearls on Renal US: main indication: hydronpehrosis, but pay attention to everything (outside to inside); eval both kidneys AND bladder- without bladder, you wont know if the bilateral hydro may just be that they have to pee. If empty bladder, and bilateral hydro, then possible mass (if not chronic). If patient is >50yo with flank pain, dont forget to eval the aorta as well. Start outside to inside for pathology – free fluid around kidney, cyst from kidney, mass on kidney, stone within kidney, hydronephrosis. Her pearls on Gallbladder US: start in the subxiphoid region, indicator to patient’s right, use liver as window, fan thru it medial to lateral to find GB. Then, fan/eval in transverse & longitudinal planes. Fanning thru the GB is key- there’ll be sections where it looks normal, then you fan & a stone comes into view! See if the stone is mobile by turning patient and re-scanning to see if moved. Think of the number 4 (or multiples of it) with measurements: width 4cm, length 8-10cm, anterior GB wall <4mm, CBD 4mm at 40yrs old (adding 1mm for every decade beyond).
Dr. Phil Perera – our newest addition to the Stanford US team serving as the Director of US Research and the Associate Program Director gave quite an engaging talk on Echo and the RUSH protocol, putting it to action! As is highlighted by his Soundbytes website that is a free source of lectures for your viewing pleasure, he would keep asking the audience whether they would involve their consultants, if they would “write home to mom about this?!” The funny part is that one of the audience members responded with “I wouldn’t have to, she would call me before I get a chance.” Another participant concluded the point by saying, “You must work in a profitable community hospital.” Ah – gotta love the sarcasm! Phil continued his talk discussing when you should act fast by going through RUSH cases, giving props to others who also study and educate on resuscitation ultrasound. His pearls on Echo: PSL view is the favorite – lets you evaluate right ventricle size, left ventricle size and contractility, pericardial effusion, pleural effusion and mitral valve regurge; Echo should be done with IVC when thinking about fluid resuscitation – if hyperdynamic -can tolerate fluid; if hypocontractile, not so much; Echo can eval aorta too! PSL view visualizes ascending aorta and descending aorta; AP4 view shows descending aorta – look for aneurysm/flap. Intraperitoneal fluid and pleural effusion can be mistaken for pericardial effusion – know where your pericardium is! Pleual effusion in PSL view travels behind descending aorta; pericardial effusion travels in front of descending aorta. AP4 great for comparing RV and LV chamber size, contractility of RV and LV. To get the P4 view, slide lateral after parasternal views until get to apex, angle to body center. His pearls on RUSH: Case that inspired him: 67yo acute SOB, in shock h/o COPD/CHF/HTN, CXR neg, ultrasound showing the cause to not be sepsis, but cardiogenic shock. RUSH provides the answer to : sepsis? cardiogenic? hypovolemic? hypervolemic? tamponade? PE? trauma? tension ptx? AAA? First & most important is the cardiac echo: the PUMP, that’s why it’s first – lots of info from a single cardiac view (PSL). For semi-quantitative contractility eval: fractional shortening & EPSS are measured – PSL must be at approp long section. tamponade on #ultrasound - RV collapse during when it should fill (diastole)-also can see RA scalloping -do pericardiocentesis. pericardiocentesis: US studies show having pt in left lateral decubitus position & an apical view better for removing pericardial effusion than traditional SX technique. IVC – can use M mode to measure in both transv and long view 2cm from RA – can use your internal jugular as an alternate. Lung ultrasound – B Lines – think of fluids and your resuscitation when evaluating etiology of shock: FALLS protocol by Lichtenstein. Although rare, if your EKG has STEMI, do an ECHO – make sure its not a dissection before you start heparin!
and
Dr. Zoe Howard (our Director of Medical Student and Resident US Education) and Dr. John Kugler (coordinator for the internal medicine US elective and global health US instructor) spoke about the many awesome ways ultrasound can help with procedural guidance. The dynamic duo had awesome videos to assist in their lecture and went through the many procedures that can be done with US guidance. Their pearls on Procedural US: On central line access – first look for the vein before you prep the area; it’s possible that the vein you want (or the location of the vein you want) is not the best vein for the procedure. Your indicator should be to your left, the screen dot should be on your left, that way left means LEFT when you’re guiding your needle tip to the vein. On lumbar puncture – do it when you can’t feel the landmarks, when you only have one attempt, when you’ve already had one unsuccessful attempt. Use the ALiEM trick with a paperclip for drawing the straight line. On thoracentesis and paracentesis – make sure you view the area where there is at least 2cm of fluid between the probe and the lung/bowel to avoid lung/bowel puncture – it may not always be where you think. On pericardiocentesis – look for where the fluid is most, patient to left lateral decubitus position, and you’ll find that SX is not the best anymore. On nerve blocks – learn it, do it, and teach it! Your patients deserve it! Use the in-plane approach to visualize your entire needle, and use the dental syringe holder to have control over your syringe.
We then had 8 different hands-on stations with 11 different instructors (and 4 chickens used for central lines deserving of props, and lots of other simulators as you will see in the below pics)! Including those described above, we also had the above instructors (from left to right, top to bottom (hyperlinks take you to “other” images that come up when you google search their names)- Dr. Viveta Lobo – our current US fellow and future Director of the Visiting Scholars Program, Dr. Brita Zaia – our past US fellow and current Kaiser San Francisco Ultasound Director, Dr. Darrel Sutijono – US fellowship trained faculty at Kaiser Santa Clara and new to twitter and #FOAMed and the FOAM movement, Dr. Manish Asarvala – US fellowship trained at UCSF and faculty at Kaiser Santa Clara. Dr. Yoshi Mitarai – an emergency medicine/critical care specialist who recently saved a life while at the gym doing Zumba (yup, you read that right), Dr. Suzanne Lippert - a specialist in nerve blocks and international/global health who is faculty at Stanford EM. Dr. Jennifer Newberry – an MD JD (so, super smart) and one of our senior EM residents who is staying on as a fellow in healthcare/ public policy.
I just got back from the 2nd Annual UltraFest – a FREE (yup, you read that right, FREE!) medical student ultrasound workshop held at UC Irvine this year for any and all medical students in California who want to come and learn bedside ultrasound using simulation and live models along with hearing about the future and international ultrasound. It’s getting a lot of press – as it should. It started off with an idea that came by one of my friends and mentors, Dr. Chris Fox (an ultrasound guru in his own right), and with the help of his medical students (Lancelot Beier, Kiah Bertoglio, and MaryJane Vennat), they organized faculty from all over California (UCI, Stanford, UCLA, USC) from multiple specialties. As Chris states “If I can give medical students the confidence and curiosity to want to use ultrasound all the time, then I feel they will take better care of their patients, and will provide more accurate care without turning to radiation.” You know how many medical students showed up? about 300. On a Saturday. During their free time. Some even wore a tie! …even when they ate from the free taco truck at lunch (yum!).
You know what that means? They want to learn it …and it should be incorporated into all medical school curriculums. It has been well studied to improve their learning in anatomy, physiology, and pathology… not to mention their patient care in their clinical years. It’s time. I’m excited to host it at Stanford for 2014!
The Dean of the School of Medicine at UC Irvine gave a quick speech welcoming the medical students about “Healthcare”: the practice, the word, and the meaning – and how that relates to ultrasound:
Dean Clayman on Healthcare and Ultrasound
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In a recent addition of the AAMC reporter, they discuss the FIRST ultrasound workshop held for the AAMC members and how medical students, like Kiah Bertaglio, at UC Irvine, feel the need for ultrasound in medical education is a must. I posted about this fun AAMC event, that I was lucky enough to be a part of with some of my heroes, previously for your reading pleasure while SUSME and AIUM announced 2013 as the Year of Ultrasound (YOU) – highlighted by AIUM Ultrasound First group, the Life in the Fast Lane bloggers, the Ultrasound Podcast folks, and, of course, little ole’ me on SonoSpot while highlighting the ACEP US Section and the immense amount of social media interest/bloggers/tweets on the topic of bedside ultrasound.
In the AAMC Reporter. they state: “With rapid advancements in ultrasound technology, …a handful of the nation’s medical schools make ultrasound training a standard part of the curriculum. And there is a push to encourage more schools to use ultrasound….South Carolina is one of the first schools to implement a four-year interdisciplinary ultrasound curriculum. The program started in 2006 and is based on a training model for emergency medical workers. First- and second-year students learn how to read scans during lectures and lab sessions and through Web-based learning modules. In the third and fourth years, students use hand-held ultrasound devices to examine their first patients…..Richard Hoppmann, M.D., dean at South Carolina who also helped form SUSME, considers hand-held ultrasound devices the “stethoscopes of the 21st century.” “The technology is already here. What is lagging behind is the health care workforce who is knowledgeable and skilled in the appropriate use of these devices,” said Hoppmann, who stressed the importance of proper training….This portability allows doctors to perform bedside exams to detect acute emergencies such as internal bleeding, collapsed lungs, and intestinal obstructions. Ultrasound can be used to guide catheters with more accuracy, decreasing patient discomfort and saving time for staff. In addition, ultrasound is safer than other types of imaging because it does not emit potentially harmful radiation.
[A medical student said “It makes it exponentially easier to see real things, happening to real patients in real time. You are better able to identify something if you have seen it before.”] He added that seeing things in real time has a powerful effect on patients. Clarkson recalled one patient who, after viewing fluid buildup impairing his heart and kidneys on an ultrasound, realized he needed to improve his diet and take his medication….Like South Carolina, the University of California, Irvine, School of Medicine (UC Irvine), offers a four-year fully integrated ultrasound curriculum—the only one of its kind in California. What started in 2003 as a fourth-year elective in emergency ultrasound has expanded across the entire continuum….Students at UC Irvine have shown an extracurricular interest, organizing an Ultrasound in Medical Education Interest Group with guest lecturers and hands-on sessions. …Kiah Bertaglio, a third-year medical student at UC Irvine, helped arrange [UltraFest]. “The response was overwhelming and shows how important tomorrow’s doctors and health care workers see portable ultrasound becoming. It provided an incredible opportunity for students to learn and improve bedside ultrasound skills in multiple fields,” she said. Efforts to reach this goal are picking up at medical schools and teaching hospitals. The emergency medicine department at the Ohio State University Wexner Medical Center, East Virginia Medical School, and Wayne State University School of Medicine are incorporating ultrasound residency programs and fellowships. If this trend continues, Hoppmann predicts the technology could become a core competency that will enhance patient care across the board.”
2012 was an amazing year for bedside ultrasound. There were more conferences that included bedside ultrasound in their pre-conferences festivities, but also there were more discussions on what was next for bedside ultrasound, while SUSME and AIUM announced 2013 as the Year of Ultrasound (YOU) – highlighted by AIUM Ultrasound First group, the Life in the Fast Lane bloggers, the Ultrasound Podcast folks, and, of course, little ole’ me on SonoSpot while highlighting the ACEP US Section and the immense amount of social media interest/bloggers/tweets on the topic of bedside ultrasound. There are two conferences I went to, each with it’s own powerful voice with regard to education, medicine, and ultrasound. The excitement I felt was truly unprecedented – I was giddy, I was hopping around, I was all smiles.
The American College of Emergency Physicians (ACEP) meeting had more ultrasound lectures and workshops than ever before with a turnout at the ACEP US Section that was more than any other (although I dont have the exact numbers, the ballroom it was held in was huge, and those who came late had to stand because all the seats were filled). ACEP was amazing. period. From the great lectures/workshops (even the on-site resuscitation of an emergency physician who went into cardiac arrest in the lobby of the convention center (revived by fellow emergency physicians through use of the handy-dandy convention center defibrillator to then have his heart checked for cardiac activity by Dr. Chris Fox with the ultrasound machine he was using during his workshop, which was happening right next to that location) and the Aurora Mass Casualty Response Video, (also seen here), which was one of the most moving videos I’ve seen about emergency response, teamwork, and humanity (I’ve said this many times, but Ill say it again – I LOVE my job – but even better than that, I love those who I do my job with – side-by-side – and what a privilege to be able to feel that way) to everything inbetween and afterwards, ACEP was once again a success.
The Association of American Medical Colleges (AAMC) meeting in San Francisco was equally amazing, particularly with regard to the future of medical education, discussing the concept of the flipped classroom, and the time given to discussing the incorporation of bedside ultrasound into medical education for medical schools – with the first ultrasound workshop being held in its history lead by the “God’s of Ultrasound in MedEd” (that’s my term of choice) -Drs. Richard Hoppmann (Univ South Carolina), Chris Fox (UC Irvine), and Michael Blaivas (all of whom will be at the World Congress: Ultrasound in Med ED)…. with help from ultrasound educators from Wayne State, Ohio State, and Stanford (yup, little ‘ole me again and my star medical student models). There was even a separate day at Stanford where a 60 minute slot was given to discussing The Stanford 25 (by none other than Stanford’s Dr. Abrahim Verghese himself) and one of it’s aspects, Bedside Ultrasound (by one of our ultrasound team members, Dr. John Kugler, an internal medicine doctor who is starting to incorporate ultrasound into internal medicine residency education – yup, it’s spreading!! – and it’s about time!). No tweets on this conference, but the above should be stated anyway.
The Ultrasound First conference went on with tweets happening every hour! I was unable to attend this one, but so happy that my twitter friends did. It is obvious that 2013 truly is the year of ultrasound. Spreading to medical education, being a multi-disciplinary educational and practical tool, and having a united voice on its value were all discussed – in addition to some pearls on the hot topics including pelvic ultrasound and MSK ultrasound, as well as how ultrasound is becoming an acceptable tool for renal colic and breast masses.
Since I learn from all my Twitter friends, I figured the best way to share is to take out the middle person (yes, Im talking about me). That way you could get it from their own words: Here are only a few posts from #ACEP12 and #US1st that made me go “Hmmmm….” – with a little commentary every now again from me, because I just can’t NOT give my opinion – I know that’s shocking to those of you who know me. Heehee. My tweets are in here as well.
ACEP:
From @USEDCDN : Emergency US management course ”From Blaivas: Starting to see 1st lawsuits for lack of US use in vascular access” – This definitely sparked my attention – lawsuits for LACK of US use?? Wow, well the standard of care is changing, and if a proven tool to minimize complications is right next to you and you dont use it and that complication occurs… there’s a legal risk. Learn it, use it, love it and maximize patient safety.
Also from ”@USEDCDN: EUS MC Resnick: Emergency US is not an extension of physical exam. Big difference. It answers clinical questions.” Ok, this needs mention, but I already posted a rant about this - of course – so will not bother you with another rant… not right now, at least.
From @jeremyfaust - “Weingart: 4. When is CPR futile? End tidal < 10 after 10 min. Confirm with US #acep12.” Enough said – and honestly, anything that Scott Weingart says, i will believe. period.
“Rice #ACEP12 echo in cardiac arrest- can see if cause PE/tamponade, or if standstill or beating heart. Look or you may waste time/resources” and “echo and IVC in critical patients: LV fxn, IVC collapse, RV size, contractility- will differentiate PE, CHF, hypovolemia, hypervolemia” – you never know what you may find, and what may be an intervention that you didnt think of until you saw your ultrasound (ie. tpa in a dilated RV).
@bedsidesono: lung #ultrasound talk from ACEP athttps://vimeo.com/51212231 brush up on A-Lines, B-Lines, lung sliding and more…#FOAMed” – what a giver he is! Stone is one to listen to, hear his opinion, and read his immense amount of publications.
Point of care US dominating new speakers forum so far at #ACEP12! Msk, soft tiss, pleural…”
Congrats @GeriaSonoMD on being new Chair of #ACEP12 US section mtg. Our fellow, Viveta Lobo said you talked her into EM. Awesome. So thx!
Raj Geria – new #ACEP12 US section Chair! Highest priority: pathway to US fellowship accreditation : to ensure safety and quality
Find @SAEMAEUS on twitter and follow to see what’s new with the ACademy
Nova panebianco at #ACEP12 taking about SAEM Academy of Emerg US and SonoGames – also subcommittees they are involved in..
Resa Lewis #ACEP12 US section mtg- talking ACGME US milestones and how ACEP can help in achieving them for all residencies
Blaivas #ACEP12 - TEE will show potential causes of hypotension & shock ..Valvular dz..And can be electrically linked :pace & defibrillate. No need to interrupt chest compressions for TTE as can see what’s happening with heart from across rm c TEE. Can use TEE when bad view on TTE or unable to do TTE due to habitus, lung dz, chest compressions. TEE can assess quality of chest compressions too. TTE can tell you if there is standstill, clot in RA, dilated RV, tamponade, and to see a beating heart. TTE (echo) better than checking for pulses for need for chest compressions. AAMC mtg in SF! Spreading to med schools!. WINFOCUS and AIUM EM and crit care goals… Going global!
Congrats Vicki Noble and @ultrasoundpod for your well deserved award for your contribution to emerg ultrasound!!
Ultrasound First Forum:
Jason T Nomura MD @Takeokun ”To engage the patient groups you need people who are interested in patient advocacy not just the disease state. #us1st
Jason T Nomura MD @Takeokun ”Lev demonstrating high res eval of ankle tendons with dynamic scanning for function, something that can’t be done with MRI #us1st
Jason T Nomura MD @Takeokun ”Nazarian MRI does not have the resolution to evaluate the fibrillar pattern of the Achilles compared to US. #us1st
Jason T Nomura MD @Takeokun ”Hoppmann- if education and integration of US starts in medical school it can change the paradigm. #us1st“
Jason T Nomura MD @Takeokun ”Hoppmann has graduated several classes of medical students who had US integrated into their med school curriculum. #us1st“
Mike Stone @bedsidesono ”Levon Nazarian at #us1st speaking on MSK imaging. It’s not just more convenient than MRI – higher res, no contraindications, pt’s prefer it”
Jason T Nomura MD @Takeokun ”Nazarian US for sports med is portable to get the technology to the field and locker room, MRI not portable. #us1st“
Jason T Nomura MD @Takeokun ”Pellikka 2011 joint guidelines from ACC,ASE, ACCP and others about the appropriate times to use echo in the assessment of pts. #us1st“
Jason T Nomura MD @Takeokun ”Moore bringing up the ASE and CV Anes guidelines for US guided vasc access. Advocates real time US guidance #us1st“
Mike Stone @bedsidesono ”Leslie Scoutt from Yale – ACR appropriateness criteria for recurrent renal colic – US & Noncon CT equal ratings #us1st“
Jason T Nomura MD @Takeokun ”Scoutt 50% of pts with renal colic will likely have another episode. #us1st that rad exp can build up.”
Jason T Nomura MD @Takeokun ”Scoutt noncon CT is the “gold standard” for renal colic imaging in the US currently. #us1st but there is the rad “risk.
Joshua Copel @jacopel ”Lynn Fordham (Pedi Rads) US optimal for pyloric stenosis now. No more need for upper GI or other radiation. #us1st“
Jason T Nomura MD @Takeokun ”IOTA group from Europe with close to 2,000 pts showed very good discrimination of malignant vs benign ovarian mass on US. #us1st“
Jason T Nomura MD @Takeokun ”Advances to 3D US allows volumetric imaging that could only be done previously with CT or MRI. But US spares the radiation of CT #us1st“
Joshua Copel @jacopel ”#us1st opening of US First forum now at Marriott NYC. Over 100 attending from medical profs, industry, payors. Very exciting & energetic”
Since the last installment of SonoLinks, there have been several more awesome US related websites/links that 1) I have found in my search for more, 2) are new ones that just came on to the horizon or 3) I totally forgot to add before – - – They are all free!They are all listed on our Blogroll (scroll down, on the right of the screen) that we keep updated. If anyone knows of any other great sites, send them on over!
SonoCloud – a new and excellent website for free and easy visualization, downloading, uploading, and learning of US clips and images – by Matt & Mike (of Ultrasound Podcast) and Mike Stone (current ACEP US Section President). Can you say A-W-E-S-O-M-E! You can help fill up their library of clips by downloading your own on there too.
WikiSpaces to De-identify/Crop/Edit your image/Clip – thanks to Ben Smith for creating and sharing! A great way to post/share your stills and clips without violating HIPAA by cropping out the MRN/patient name. A simple way to keep you out of HIPAA jail.
EchoBasics – Mereles, a cardiologist from Paraguay, has an excellent website of all things cardiac echo, from basic to advanced evaluations, including explanations and clips, and even 3D and 4D clips! very cool.
ICU Sonography – along the same lines as above, there are a couple sites that are worth mentioning for ICU Sonography: Beth Israel’s website and Stanford’s website. Great review/images of critical care US and echo/IVC.
Yale’s Atlas of Echo – a complete site of everything you need to know about cardiac echo
Neuraxiom – A great website for US guided regional nerve blocks!
Sonic Nerve Blocks – another excellent website by Sanjay Sinha, an anesthesiologist at the University of Connecticut, to review all US guided nerve blocks
EFSUMB – free US textbook reviewing US applications (and includes resource limited US utilization and HIV related views)
Partners in Health book – an excellent manual for US use in resource poor/limited settings by Sachita Shah et al.
SonoWorld – an all-inclusive website that has cases, lectures, images, and articles
Ultrasound Village - another all-inclusive site with from our colleagues in Australia filled with lectures, images, and quizzes!
Qstream – a great free way to test your US skills through email question and answers by Sam Ko.
Emergency US Fellowships – in the time of application review, I thought I would send out the link for those interested in applying for emergency US fellowships
Emergency US Research articles – Chip Schmier does a GREAT job in sending out the new US related research articles every month; allows us to feel “in the know” when our colleagues ask us questions about it.
And… a website for free medical education testing and media sharing using a social networking and incentive paradigm: GMEP – Global Medical Education Project – as you can see SonoSpot has already created a folder and adding to it with US images of all applications.
In case anyone out in the Sono world was wondering what friends we have out there in Radiology, include this guy on the list… someone who understands what is best for patient care, how bedside US can save lives, and how every specialty has the capability and patient population to help their patients through this tool.
Handheld Units Shift Ultrasonography From a Diagnostic to a Clinical Evaluation Tool, Broadening Its Appeal
This is HUGE news! Does it change things at all… no. But, does it help our cause? YES! Back in the day, the AMA passed a resolution stating that ultrasound was as tool that can be widely used whose specific use and application should be defined by each specialty with specific hospital privileging. That was a HUGE step for OBGYNs, cardiologists, trauma surgeons, and emergency physicians to take it and run with it, defining ultrasound in a way that was specific to each of those specialties, with more guidelines being thought of for critical care, internists/hospitalists, and ambulatory care doctors. Well, this week, with the help of Dr. Michael Blaivas and others, the AMA passed another resolution, amending the prior stating that ultrasound is a safe, effective and efficient tool, that should be used throughout medical education. This is great for those attempting to incorporate bedside US into their school of medicine. Awesome!!!!
, PIV, Soft Tissue, DVT, Appy, Peds, Diastology, and much more! 364 pages of interactive content, with HOURS of video demonstrations and tutorials. – doesn’t that make you drool!?! In volume two picture: …do you know what technique that is? you will…
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