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. #us1st
2. 
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 #us1st
4. Jason T Nomura MD @Takeokun ”Nazarian MRI does not have the resolution to evaluate the fibrillar pattern of the Achilles compared to US. #us1st
5. Jason T Nomura MD @Takeokun ”Hoppmann- if education and integration of US starts in medical school it can change the paradigm. #us1st“
6.  Jason T Nomura MD @Takeokun ”Hoppmann has graduated several classes of medical students who had US integrated into their med school curriculum. #us1st“
7. Jason T Nomura MD @Takeokun ”Moreau most common imaging modalities for Team USA is X-ray and US, very little CT use.#us1st
8. 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”
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. #us1st“
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. #us1st“
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 #us1st“
12. Mike Stone @bedsidesono ”Leslie Scoutt from Yale – ACR appropriateness criteria for recurrent renal colic – US & Noncon CT equal ratings #us1st“
13.  Jason T Nomura MD @Takeokun ”Scoutt 50% of pts with renal colic will likely have another episode. #us1st 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. #us1st 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. #us1st“
16. Jason T Nomura MD @Takeokun ”Fordham N/V can be pyloric stenosis, malro, intussusception, and gastroenteritis. US for dx.#us1st“
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. #us1st“
18. Jason T Nomura MD @Takeokun ”IUD placement or misplacement easy to note on US; can present for DUB and pain. #us1st
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 #us1st“
20. Joshua Copel @jacopel ”#us1st Dr. Beryl Benacerraf making case for US over CT, MR in female pelvic imaging at #AIUMforum. pic.twitter.com/vCQYvpi8 
21. Jason T Nomura MD @Takeokun ”#us1st 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 #us1st
23.  Joshua Copel @jacopel ”#us1st 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 @Takeokun: It does seem to be a who’s who of US at the#us1st reception.

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

In the most recent 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.

“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.

SonoNews: Medicare adds Iatrogenic Pneumothorax to list of hospital acquired conditions!

What does that mean? If a pneumothorax results from that central line attempt or that thoracentesis and any other procedures with this complication, Medicare will not reimburse for it. In the new issue of SonoSite news, it discusses this and how the tool that could prevent pneumothorax from occurring, if used during your procedures, is the exact tool that is best to diagnose at bedside. How ironic is that?!

“Effective October 1, 2012: If, during the performance of a venous catheterization procedure, the clinician accidentally causes a pneumothorax, Medicare will no longer reimburse the hospital for the extra costs of a resulting pneumothorax (collapsed lung) complication.

SonoNews: American Institute of Ultrasound in Medicine (AIUM) Practice Guidelines released

AIUM  - an organization that truly is an “institute” that is all about ultrasound – it used to be a community of only radiologists, but over the last few years, as bedside ultrasound has become part of many other specialties, there are now more sections for those specialties to become their own ‘community within a community’ – so to speak. Emergency physicians who are ultrasound enthusiasts, of course, are a growing section within AIUM – and if you ever want to meet every single leader in bedside ultrasound, this is the conference to go to! They also have AIUM and ACEP joint workshops in bedside US and promote research among all specialties. AIUM has been releasing their Practice Guidelines of each application and has recently completed quite a few. Each specialty define their own use of bedside ultrasound, and there are “complete” and “limited” (or “focused”, which may not include every detail listed under the AIUM guideline) scans, but its always nice to see what AIUM considers as their guideline to others.

SonoNews! – The AMA has passed a resolution in regards to bedside US – thanks to Blaivas et al!

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!!!!

SonoNews: ASA Guidelines for central venous access now includes ULTRASOUND!

Now I know that many of you may already be using ultrasound to help guide your needle when obtaining central venous access, but when a governing body announces its importance, it’s a big deal! If any of you are like me, you learned how to place all central lines using the “blind” technique – despite your eyes being wide open – but now that the ultrasound machine is your eyes beneath the skin, there is no longer a reason to be so blind about it! Isn’t it nice to know where “big red” is? Here, I’ll answer for you – Heck YEAH! So why am I excited? Well…

SonoNews: EM Milestones from the ACGME report are in!: Go Ultrasound!!

EM Milestones came out and just heard from SAEM that ULTRASOUND is one of them!!! Nicely done everyone! Scroll down to P12 to read through the bedside goal-directed ultrasound section. http://www.saem.org/sites/default/files/EM_Milestones_ABEM_Final.pdf