SonoStudy: Trends in Radiology orders over last decade – effect of POCUS? #FOAMus

I am going to say a statement that is going to be shocking to some of you: There has been a decline in CT use by the emergency department over the last 2 decades, according to Raja et al. Can you believe it? I couldnt either. I previously thought, now that CT is so easy to get, of course everyone is ordering them more. There have been several studies showing an increase in ionizing radiation exposure over the last decade, so the results are a bit confusing. Im sure when compared to 20+ years ago, we are ordering more in total, but the trend may be that we are declining in ordering. Well, not only has Raja came to this conclusion, but when seeing how the FAST scan has affected abdominal CT scan orders, then it makes me wonder if point of care ultrasound (POCUS) is one of the main reasons for this trend. Yeah, I know, it’s a stretch, but I cannot imagine it isnt a factor, along with ALARA, and other discussions on radiation exposure.

In a study by Sheng et al – which includes some of my heroes, Drs. Vickie Noble and Andrew Liteplo – they looked at the trend of abdominal CT orders in adult trauma patients at their institution. Could it be that bedside ultrasound has effected CT orders everywhere? Their abstract is below:

Objective. We sought to describe the trend in abdominal CT use in adult trauma patients after a point-of-care emergency ultrasound program was introduced. We hypothesized that abdominal CT use would decrease as FAST use increased. Methods. We performed a retrospective study of 19940 consecutive trauma patients over the age of 18 admitted to our level one trauma center from 2002 through 2011. Data was collected retrospectively and recorded in a trauma registry. We plotted the rate of FAST and abdominal CT utilization over time. Head CT was used as a surrogate for overall CT utilization rates during the study period. Results. Use of FAST increased by an average of 2.3% (95% CI 2.1 to 2.5, P < 0.01) while abdominal CT use decreased by the same rate annually. The percentage of patients who received FAST as the sole imaging modality for the abdomen rose from 2.0% to 21.9% while those who only received an abdominal CT dropped from 21.7% to 2.3%. Conclusions. Abdominal CT use in our cohort declined while FAST utilization grew in the last decade. The rising use of FAST may have played a role in the reduction of abdominal CT performed as decline in CT utilization appears contrary to overall trends.

SonoCredentialing: ACGME ultrasound milestones summarized by @Takeokun

@Takeokun is not only one of the authors for the CORD article on this topic, but also has summarized the ACGME milestones’ ultrasound portion quite nicely on his site. It is well deserving of mention -

Go here for the full post.

Some Downloadables from his post:

  1. Core vs Advanced Emergency Ultrasound for Residents
  2. Assessment methods with skills tested, limitations, and associated milestones
  3. CORD US-SDOT Forms
  4. New Innovations version of the JMTF US milestone evaluation form

SonoMetaAnalysis: Errors in Emergency Ultrasound – When/What/Why & the lawsuits #FOAMed

In the July 2013 issue of Critical Ultrasound Journal, the authors did a meta-analysis of all studies relating to emergency ultrasound and the diagnostic errors that occur and Ill explain why It’s fascinating. When you read through the details, the reasons are clear and the issues may be obvious. The authors (from Italy who practice ultrasound in different settings with description of emergency ultrasound a bit different than the way we do it here) searched utilizing different association of the following terms from 1990-2013: (1) emergency ultrasonography, (2) error, (3) malpractice and (4) medical negligence –  restricted to human studies and to English-language literature. The abstract of 171 articles appeared appropriate while other articles were recognized by reviewing the reference lists of significant papers. The full text of 48 selected articles was reviewed.

I do disagree with some of the way the authors described emergency ultrasound. I believe in their effort to show their study’s importance, they state: “Emergency US is particularly susceptible to errors, more than any other diagnostic imaging technique: in fact, the misinterpretation of sonographic images should be considered as a serious risk in US-based diagnosis [8]”  – they are referencing an article by radiologists on US artifacts on clinical sonography. So, that’s weird.

Another item that I felt was strange was that many of the references to emergency ultrasound were actually those done by radiologists. I couldnt find one emergency medicine ultrasound article. Thi sis likely due to the practice differences between europeans and Americans with emergency ultrasound, but ….hmmm, it gets even more interesting, and I will likely get even more critical. Im sure the radiologists did an outstanding job in their (or their lab tech’s) image acquisition, but the reasons for diagnostic errors stated by the authors of this study now make sense when you take into account the above:

Reasons for Errors in Emergency Ultrasound: “Causes of error in emergency ultrasonography are multifactorial, frequently exist in combination as in other diagnostic imaging techniques [9,10] and include: lack of attention to the clinical history and examination, lack of communication with the patient (who may be uncooperative), lack of knowledge of the technical equipment, use of inappropriate probes, inadequate optimization of the images, failure of perception, lack of knowledge of the possible differential diagnoses, over-estimation of one’s own skill, failure to suggest further ultrasound examinations or other imaging techniques (such as CT or MRI) [11-16]”

The authors then go on to further describe the errors. The discuss the importance of the amount of gel, the correct probe used, the adequate technique, and how artifacts can get in the way. They also state something that i completely agree with – it also depends on the operator. But, they use the example of:  “Modern ultrasound equipment is certainly adequate for producing images that permit diagnosis of anomalies such as open lumbosacral spina bifida or atrioventricular septal defect. However, such diagnoses can only be made if considerable operator skill is associated with knowledge and experience.” So, not sure how to put this, but that’s NOT emergency ultrasound. So, I cannot relate. But, good on those who do it in emergency practice…who am I to say differently – you never know, as our scope of practice continues to increase.

The authors finally discuss errors in the emergency setting, again done by radiologists with references authored in radiology literature from over 10-15 years ago…. and state what we all know and can appreciate: “Quick diagnosis and treatment of patients with whom we have had no previous contact, and who, quite often, may be uncooperative, and/or under the influence of alcohol or drugs creates an environment with significant risk [27]. The frequency of reported “missed diagnoses” depends on how the frequency of error was assessed: based on trauma registries, error rates were approximately 2% [28], while retrospective chart review found approximately 40% [29], and retrospective review of all admissions revealed missed or delayed diagnoses of approximately 8%-10% [28-30]……Moreover, the sonographer should evaluate the patient in terms of physical constitution (in obese patients, the thickness of subcutaneous fat and the sound-attenuating properties of fat present challenges) and the presence of conditions potentially limiting the examination (such as obliged decubitus, scars, etc.). The sonographer should be aware of the limitations of the technique in the evaluation of the traumatized patients, asking for other diagnostic imaging procedures (Multidetector row Computed Tomography).” – The authors dont state the errors made nor any litigation made in the emergency setting – interesting, right? That may be because the studies that were queried were not including those of emergency medicine bedside, limited, focused, goal directed, – or whatever you want to call it – ultrasound. There was something interesting though:

As far as litigation is concerned, the authors state ” The earliest litigation related to diagnostic ultrasound occurred in 1974 and involved obstetric measurements. Before 1974, images were so difficult to interpret that ultrasonography was considered of little value apart from obstetric measurement data and for characterizing masses as cysts [19]” They reference an article by J Ultrasound in Medicine done by ObGyn and is a fascinating read on ObGyn litigation as relating to ultrasound, but also does not necessarily speak about emergency ultrasound and our limited studies that we perform. That article states (in relation to ObGyn litigation): “There has been a change in the main target of litigation over time: in the 1980s, ectopic pregnancy was the most common reason for litigation; today, litigation related to a missed fetal anomaly is the most frequent indication. Invented lesions, often seen in past years, almost never occur today. With greater adherence to guidelines, failure to perform sonography for a recognized indication has become a cause of litigation. Well-recognized obstetric ultrasound guidelines, in one respect, provide protection for those who perform faultless series and yet find no abnormalities when they are present and, in another respect, cause problems for those who do not document all the images required by the guidelines when abnormalities are subsequently found.”   Why is this interesting? Well, one of the best studies to date on true emergency medicine ultrasound litigation comes from Dr. Michael Blaivas and Dr. Pawl. First off, there were no law suits on emergency physicians who performed and interpreted bedside ultrasound studies in their review of 659 cases. But, there was one on a physician who chose not to perform it when it was available and indicated – and ectopic pregnancy case.

Lastly, I do agree with this : “Ultrasound scanners, however, are relatively inexpensive and highly effective in the hands of a trained operator. More importantly, ultrasound is a “sustainable technology” for developing and impoverished nations because of its relatively low cost of purchase, low cost for maintenance and supplies, portability, and durability in comparison with all other imaging modalities [47]. Moreover, early education of operators is a priority that can begin to be addressed in medical school. The practice of ultrasound has clearly been shown to be operator-dependent, and the way to train better operators is to start early, provide opportunities for practice, and standardize curriculum that will ultimately align with residency requirements in the various specialties [48]” – This latter reference was the first emergency medicine one I saw – Nice job Dr. David Bahner ! (who was the coordinator of the Ultrasound in Medical Education at AIUM in April 2013).

Other great articles relevant to this and what we should do about incidental findings:

Blaivas M, Pawl R. Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period. Am J Emerg Med. 2012 Feb;30(2):338-41. doi: 10.1016/j.ajem.2010.12.016. Epub 2011 Jan 28.

Lanitis S, Zacharioudakis C, Zafeiriadou P, Armoutides V, Karaliotas C, Sgourakis G. Incidental findings in trauma patients during focused assessment with sonography for trauma. Am Surg. 2012 Mar;78(3):366-72

Fox JC, Richardson AG, Lopez S, Solley M, Lotfipour S. Implications and approach to incidental findings in live ultrasound models. West J Emerg Med. 2011 Nov;12(4):472-4. doi: 10.5811/westjem.2011.2.2054.

SonoNews! AIUM President on Ultrasound in Medical Education & the US in MedEd portal #FOAMed

When I read this message, a light shined so bright inside my little head, that I had to share it. I got the usual emails from AIUM (American Institute of Ultrasound in Medicine), a multi-specialty organization with thousands of members, who educate/study/encourage/collaborate on issues related to ultrasound in medicine. But, the email that came out today, a message from the new AIUM President, discusses with such ease and obviousness about how ultrasound should be integrated into medical school education.

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I have been to a few of the national AIUM conventions and my most recent post about it discusses one of the best days of my life, the course in NY at AIUM2013 about ultrasound integration to medical school curriculums where the experts spoke of their experiences, their advice, their ideas ….followed by a panel of medical students who shared their point of view of how it affected their education. It was amazing! Even now, when i think about it, i am inspired, and continue to be excited about how we are starting to do the same at Stanford School of Medicine. I have posted about the reactions that Ultrafest (a free medical student workshop in California) brought to everyone, including what UC Irvine’s Dean Clayman stated about it all. It was quite honest and encouraging. All of this, brings me to this message that i keep reading over and over again. Is it because 2013 is the Year of Ultrasound? Well, likely so, but for that reason and so many more, I just cant stop reading it – please read it below, especially the end when the link to the Ultrasound in Med Ed portal is introduced.

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July 25, 2013

Dear Colleagues:

I believe there is no more important issue facing ultrasound than its incorporation into undergraduate medical schools’ curricula. Many of you saw the visionary presentation of Dean Richard Hoppmann, MD, at the 2012 AIUM Annual Convention in Phoenix, Arizona. Here at New York University School of Medicine, Uche Blackstock, MD, RDMS, an emergency department physician, is developing a multidisciplinary collaborative integrated preclerkship and clerkship curriculum. Consider the following:

It’s another typically busy day at the medical center. A critical care fellow supervises a senior resident placing ultrasound-guided central vascular access in a hypotensive septic elderly patient in the medical intensive care unit. In the outpatient surgery suite, an anesthesiologist prepares a patient for rotator cuff surgery by performing an ultrasound-guided interscalene brachial plexus block for regional anesthesia. In the echocardiography lab, a cardiologist assesses a patient admitted the night before with a non-ST segment elevation myocardial infarction for wall motion abnormalities and cardiac function. An obstetrics and gynecology attending performs a pelvic ultrasound examination on a young woman being ruled out for an ectopic pregnancy, appreciates an intrauterine pregnancy, and discharges the patient home safely.

Over the last 20 years, ultrasound performed at the bedside, by clinicians, has revolutionized the way medicine is practiced. In these diverse cases, the use of ultrasound was critical in providing patients with effective and quality clinical care. Although currently being used for diagnosis, management, and procedural guidance by physicians in numerous and diverse specialties, a significant gap currently exists between what medical students are being taught and how they are expected to practice on completion of their training. Future physicians will be expected to be familiar with the use of ultrasound in their clinical practice, regardless of specialty. At this time, medical educators have a unique and timely opportunity to use ultrasound at the bedside as an innovative teaching modality in the undergraduate medical curriculum.

Handheld ultrasound will transform how medical students are taught in the preclinical curriculum as well. Students will never experience learning medicine the same way. They will be able to scan a live model and appreciate the gallbladder as its lies within the main lobar fissure of the liver. They will have a deeper understanding of the cardiac cycle by viewing the diastolic and systolic phases of a live beating heart. During clerkships, students will learn how bedside ultrasound can be used to make important diagnoses and to allow them to safely perform critical procedures. Bedside ultrasound as a teaching tool will enhance what students have learned traditionally and help reinforce important concepts.

An integrated ultrasound curriculum will require a multidisciplinary collaborative effort by a medical school faculty. This approach will ensure that students receive comprehensive exposure to ultrasound from all perspectives. Medical educators are responsible for ensuring students are well equipped for future clinical practice. Ultrasound, as I see it, will have a dual role in undergraduate medical education. First, it can and should be incorporated into preclinical learning to teach anatomy, physiology, and pathology. Second, there is almost no clinical clerkship, as outlined by the scenarios above, that does not already or else will soon utilize bedside ultrasound. The future is now.

The AIUM’s Ultrasound in Medical Education Interest Group, chaired by David P. Bahner, MD, RDMS, has developed an outstanding online portal to assist those with an interest in integrating ultrasound into medical school curricula. This one-stop clearinghouse includes a mentor program; educational information from multiple organizations; and a tool kit that features curriculum examples, links to online lectures, sample proficiency assessments, tips on discussions with medical school leadership, instructor pools, equipment, and more. We encourage you to explore the Ultrasound in Medical Education Portal. If you know of additional resources that should be included, e-mail MedEd@aium.org.

In closing,

AIUM membership for students, residents, and fellows allows these individuals access to helpful ultrasound-related resources and the opportunity to network with experts in medical ultrasound–an excellent complement to the clinical training they receive. This membership category is $25 and offers students the full array of member benefits. The students of today are the future leaders of the AIUM. I hope you will share this opportunitywith those with whom you are in contact.

Sincerely,

Steven R. Goldstein, MD
AIUM President

SonoPearls&Politics: ACEP2012, AAMC2012, AIUM-US First- future of bedside ultrasound

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..

A great resource from the new academy of emerg US : http://SAEM.org/academy-emergency-ultrasound-resources …

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!

http://Sonocloud.org  and http://sonoguide.com  : 2 great online resources for images and education! – plus the test: http://emsono.com
@sinaiemus: Rob Blankenship at Ultrasound section meeting: over 56,000 ACEP US tests completed at http://www.emsono.com/acep/ACEP_EUS_Exam.html … #ACEP12
Congrats Vicki Noble and @ultrasoundpod for your well deserved award for your contribution to emerg ultrasound!!
Ultrasound First Forum:
  1. Jason T Nomura MD @Takeokun “To engage the patient groups you need people who are interested in patient advocacy not just the disease state. 
  2. View image on Twitter
  3.  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 
  4. Jason T Nomura MD @Takeokun “Nazarian MRI does not have the resolution to evaluate the fibrillar pattern of the Achilles compared to US. 
  5. Jason T Nomura MD @Takeokun “Hoppmann- if education and integration of US starts in medical school it can change the paradigm. 
  6.  Jason T Nomura MD @Takeokun “Hoppmann has graduated several classes of medical students who had US integrated into their med school curriculum. 
  7. Jason T Nomura MD @Takeokun “Moreau most common imaging modalities for Team USA is X-ray and US, very little CT use.
  8. Mike Stone @bedsidesono “Levon Nazarian at  speaking on MSK imaging. It’s not just more convenient than MRI – higher res, no contraindications, pt’s prefer it”
  9.  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. 
  10. 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. 
  11.  Jason T Nomura MD @Takeokun “Moore bringing up the ASE and CV Anes guidelines for US guided vasc access. Advocates real time US guidance 
  12. Mike Stone @bedsidesono “Leslie Scoutt from Yale – ACR appropriateness criteria for recurrent renal colic – US & Noncon CT equal ratings 
  13.  Jason T Nomura MD @Takeokun “Scoutt 50% of pts with renal colic will likely have another episode.  that rad exp can build up.”
  14.  Jason T Nomura MD @Takeokun “Scoutt noncon CT is the “gold standard” for renal colic imaging in the US currently.  but there is the rad “risk.
  15. Joshua Copel @jacopel “Lynn Fordham (Pedi Rads) US optimal for pyloric stenosis now. No more need for upper GI or other radiation. 
  16. Jason T Nomura MD @Takeokun “Fordham N/V can be pyloric stenosis, malro, intussusception, and gastroenteritis. US for dx.
  17.  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. 
  18. Jason T Nomura MD @Takeokun “IUD placement or misplacement easy to note on US; can present for DUB and pain. t
  19. 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 
  20. Joshua Copel @jacopel “ Dr. Beryl Benacerraf making case for US over CT, MR in female pelvic imaging at forum. pic.twitter.com/vCQYvpi8 View image on Twitter
  21. Jason T Nomura MD @Takeokun “ is not only about when &where US can be used but education for practitioners and patients per @AIUMPresAlfred
  22. Jason T Nomura MD @Takeokun “@AIUM_Ultrasound represents 9,200 members from 36 specialties with a focus on advancing US use 
  23.  Joshua Copel @jacopel “ opening of US First forum now at Marriott NYC. Over 100 attending from medical profs, industry, payors. Very exciting & energetic”
  24.  Jason T Nomura MD @TakeokunIt does seem to be a who’s who of US at the reception.

SonoNews: Radiologists should guide point-of-care ultrasound training? …lets think about this…

In an insert of Diagnostic Imaging, Dr. Michael Blaivas (an emergency physician, past president of ACEP US Section, Section Chair of Emergency/Critical Care for AIUM, and basically about 3 or 4 more titles that would take a few more lines in this post to mention because he is that amazing) spoke about how radiologists have historically been threatened by and become obstructionists in its use by non-radiologists, then became less so as it was apparent that radiologists didnt have the time to do it  – possibly due to radiologist shortages and becoming focused on CT and MRI (according to Dr. John Cronan – chair of Radiology at Brown Univ), and now are not involved or part of the team with point-of-care ultrasound training – but they should be, according to Blaivas in this article by Sara Michael. However, this article concludes the wrong thing – in my opinion – and has misunderstood Blaivas’s point. Instead they reaffirm the angst felt by radiologists today and fail to explore why. Radiologists have submitted a “National Curriculum” for medical student education in ultrasound as well, that has come to add to further controversy as there are no other specialties involved in the discussion…. But, of all the medical student US curriculums out there, most, if not all, are coordinated by non-radiologists.

“Point-of-care ultrasound has become ubiquitous in medicine, from emergency departments to OB and trauma surgery. But that doesn’t mean it’s taking the modality away from radiologists.In fact, radiologists should be the ones guiding its training and promotion – not bemoaning and pushing back on the trend. “Radiologists are not involved in ultrasound education and promoting its use in point of care or elsewhere, but it would be nice to have more involvement,” Michael Blaivas, MD, an emergency medicine physician and past chair of the American College of Emergency Physicians ultrasound section, said during a presentation at RSNA 2012 this week. “It’s better to be seen as proponents of an application, guide it, and help with it, especially an application that is seen as critical at the bedside.” Radiologists are the ultrasound imaging experts, Blaivas said, and should be the first to share their expertise. The specialties shouldn’t be fighting each other, he said, but working to make sure the modality thrives for all clinicians. If radiologists were more involved in teaching, they could ensure quality in its use. “There really is a need for ultrasound education, and this is somewhere we can meet,” he said.”…”Today, [Dr Cronan] said, radiologists are “working feverishly to protect our income,” and the profession faces threats of commoditization with the rise of teleradiology and service-live imaging. Although ultrasound is likened to the stethoscope in its extension of the physical exam, Cronan noted, it’s used by many, understood by few.”

Ive been thinking a lot about it recently, and trying to understand radiologists’ continued angst about non-radiologists performing point-of-care ultrasound. I’ll start with these few points: radiologists do perform ultrasound studies – both limited and complete – and that hasn’t and shouldn’t change, they ARE imaging specialists. I do rely on them when my point-of-care ultrasound shows that a complete ultrasound study or a CT scan is needed. Many radiologists do not see the ultrasound studies that non-radiologists perform or how they are quality assured, and the fear of the unknown can drive quite a few political decisions. They have not been involved in point-of-care ultrasound training either, and this, in combination with the above, will give even more angst. I do agree, they SHOULD be a part of the education (and I know some will disagree with me) – this will have those who perform point-of-care ultrasound learn more techniques (with the applications that are also performed by radiology) and the radiologists will learn/see what we do, how we do it, and why it’s so important for us (and our patients) at the bedside. They will see that our images are actually quite good and that our QA and training direction is strict enough through our ACEP guidelines. Should they be in charge of it’s training? I dont think so. Is it an extension of the physical exam? No, it’s so much more than that. Here’s what keeps coming into my head:

1. The AMA passed a resolution that states ultrasound does not belong to any one specialty, but it can be incorporated into any specialty as defined by that particular specialty – later to also have a resolution that ultrasound is safe, effective, and efficient when used under the direction of an appropriately trained physician and should be supported in its educational efforts when integrating into medical education.

2. Many of the point-of-care ultrasound applications are not ordered/performed through radiology. Before emergency medicine and critical care docs started performing bedside ultrasound, they did not order an orbital ultrasound, an IVC ultrasound, a musculoskeletal ultrasound, a soft tissue ultrasound, an Aorta ultrasound, a cardiac ultrasound, a thoracic ultrasound, a procedural guided central or peripheral venous ultrasound…. through radiology. And, cardiologists did their echoes, OBGYN docs did their pelvic ultrasound over the last 15-20+ years, and, for the most part, trauma teams performed their own FAST scans.

3. Time matters. When there is a patient in shock, a crashing (or stable) trauma patient, and a patient who is acutely short of breath or with acute chest pain or acute abdominal pain or acute pelvic pain or with acute vision loss… and any procedure where ultrasound is needed…. we rule emergent conditions in and out and get that procedure done, quickly.

We need to have this conversation with our radiologists, let them know of our QA process, educate them on the way and the reasons we perform bedside ultrasound, and alleviate their (and all of our consultants’) angst about our ultrasound studies. The team approach to ultrasound training for medical students is very important, and they should be a part of that.

SonoPolitics: Bedside Ultrasound is NOT an extension of the physical exam – it’s much more

Ok, get ready for another rant….. I know, I just keep ‘em comin’, but this needs to be discussed. I know you’ve heard it before: “Ultrasound is an extension of the physical exam.” I heard it before too – when I was first learning it, when someone was trying to explain it’s use in patient care. But, the fact of the matter is, it’s so much more. Just because it’s in the bedside clinicians’ hands, and not a radiologists hands, doesn’t mean it’s not an equally important diagnostic tool. More than that, its a tool used when procedures are performed that has proven to minimize complications and thus affecting patient safety. It answers the questions that even the best and most complete physical exam (which is unfortunately hardly ever done) cannot.

ACEP 2012 in Denver, CO was amazing…. and I still plan to post all that I learned from that conference, but one of the statements that were said in the Emergency US management course that is so clear to me yet seems to be hard to grasp by others is that “Ultrasound is NOT an extension of the physical exam, so stop saying it is. It answers clinical questions.”  – Now, when I heard from my friend who attended the course that this was said, I knew it already, and it makes complete sense to me, but, interestingly, it appeared that those conducting the course felt it important enough to state it clearly and concisely – as they heard this statement spreading, needing clarification. It was apparently spoken about by basically every leader in bedside ultrasound before, during, and after the course.

Ok, let’s talk about this. The physical exam is an evaluation of the patient; a use of ultrasound is to evaluate the patient – there is a difference. A physician will perform their history and physical exam, then think of what is needed for diagnosis, work up, management, and treatment. Sometimes, but not all the time, that involves bedside ultrasound (just like any other imaging modality that is chosen to be ordered to work up a patient, except it will be a focused study). Ultrasound CAN extend the physical exam, but Ultrasound is a diagnostic tool; Ultrasound is used for procedural guidance; Ultrasound is an expensive machine that is used as a procedure in overcoming physical exam limitations (like a chest XRay done to evaluate whether the crackles you hear on your physical exam is pneumonia or an effusion). It does answer clinical questions. Why this matters, and why am I going on this rant? Well, one reason is that the statement “ultrasound is an extension of the physical exam” is a simple statement that gets a lot of attention but it’s not complete, and some would argue that it’s just plain wrong, for the reasons stated above, but allow me to explain further. It is true that soon after the physical exam, a bedside ultrasound can be performed after an indication presents itself, but just because it’s temporally related or performed by the same physician who does the history and physical exam, doesn’t mean it’s an extension of it. It’s a focused study to answer a clinical question, answers that cannot be obtained by the physical exam (instead of the chest Xray, using ultrasound to differentiate pneumonia from effusion). Is an IV line or lab test an extension of the physical exam (which is sometimes performed at the same time as the history and physical, and sometimes by the physician when the nurse or phlebotomist is unavailable or the nurse is unable to get the IV)? Is an echo done by a cardiologist right after they performed a history and physical exam an extension of their physical exam? Is an ultrasound performed to evaluate the fetus of a pregnant mother by the same OBGYN doctor who just performed the physical exam an extension of the physical exam? Is a CT scan an extension of the physical exam (which can be ordered right after the physical exam)? No. Another important reason is that if it was considered by us physicians simply as an extension of the physical exam, then the risk of eliminating reimbursement from insurance companies for performing this procedure, this important diagnostic and procedural tool, exists. If the physician is using it as an extension of the physical exam, you cannot bill for it because it is an extension of the Evaluation and Management (E/M) examination. If a physican is using it for an accepted medical necessity for diagnostic or procedural purposes with appropriate documentation and image archiving abilities (which I would argue is the way we should be using it), then we can bill for it (however small that charge actually is, but let’s not go there), giving us the funds to purchase more machines and hire more ultrasound-savvy physicians to teach others who will then use this tool to ultimately save a life…..

I do get why some people say it to others: it sounds good, minimizes the fear of learning it, makes it sound easy, and is encouraging to others to believe in its utility. The intent is good. But, it’s just not enough – it’s not an extension of the physical exam, but it is an amazing imaging tool that diagnoses, helps manage, and minimizes complications of procedures of patients.

Ultrasound does not, and should not, replace the physical exam. “There is a natural synergy between the physical exam and the ultrasound machine. They should not be enemies, but instead should be allies. It can extend your evaluation of the patient, and add to your physical exam. But, it is also a diagnostic tool that is equivalent to a standard ultrasound. When it only was used for a few applications, it was thought to be an extension of the physical exam, but now with all that we know about it, it’s not simply an extension of the physical exam, it is much more.” – Dr. Michael Blaivas to the World Congress of Ultrasound in Medical Education.