It’s here! SonoDoc: A fun, online game to learn bedside #ultrasound in a case-based way. Learn #POCUS indications, how to’s, integrate into case mgmt, how to use it for next steps/dispo. Play FREE or Stanford CME ($25). HUGE thanks to many folks for authoring cases/beta testing/feedback/support. 5 years in the making, and so happy to share it with you all. Enjoy! http://sonodocgame.com
Dr, Tarina Kang, the Ultrasound Director at USC, wrote to the Editor of Advances in Medical Education and Practice in the Aug 2013 journal . She poses quite a good argument for ultrasound in medical education ( with references ) and also discusses how she found it to be best done in the first year – a great read:
“Dear editor,
For over 100 years, medical schools throughout the United States have typically followed a standardized curriculum that clearly delineates the preclinical (basic and clinical sciences) and clinical years (patient encounters and care).1 However, the transfer of learning that is derived from isolated data of basic science to clinically relevant information has been a topic of much debate and study throughout the years.
Recently, educators have attempted to unite the preclinical and bedside principles in an effort to make the basic sciences more relevant to medical practice. Basic, clinical, and social sciences are taught simultaneously to reaffirm “the importance of the relationship between the practitioner and patient. Further, the practitioner should focus [on the patient] as a whole, be informed by evidence, and make use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”2 Although implementation of an integrated learning curriculum in medical school poses political, logistical, and financial challenges, its rewards for the student may be profound.
The ideal approach to integrating basic science material with the practice of medicine is complex in that educators often have to incorporate innovative and pertinent student experiences, without compromising the existing curriculum requirements. The sheer amount of information that first year medical students are required to learn makes inclusion of additive curriculum difficult. However, it behooves course directors to constantly test, change, and expand course curriculums to maximize the educational benefit to students.
There are a number of ways to implement clinical practice into the first year courses of medical school, with the theoretically most successful ones being those that can be brought to the student during class, where other students and instructors are present for more in-depth and collaborative discussion. Point-of-care ultrasound was developed by emergency physicians in an effort to better evaluate the patient at the bedside. More recently, ultrasound has become an important educational and clinical tool across all specialties due to its ease of use, portability, and applicability at the bedside. Many institutions have integrated bedside ultrasound teaching into the clinical years of medical school. Several US institutions such as Wayne State, Ohio State, and the University of South Carolina have implemented ultrasound curriculums that span from the first year to the entire 4 years of medical school.3–5 In 2012 Fox et al6at the University of California (Irvine, CA, USA) implemented a novel medical curriculum which integrated web-based lectures and peer instruction for Year I students. They were successfully able to maximize teaching and practice time and integrate practical medicine into the basic science courses. Given the success of these programs and the potential educational benefit they afford students, a seamless introduction of ultrasound into the first year courses at our affiliated medical school seemed like a natural progression.
The goal of the project was to integrate ultrasound, a practical clinical modality, into the preclinical educational experience, specifically, during the anatomy and histology classes and laboratory sessions. The ultrasound instructors successfully completed a 10-week course which combined anatomy and histology laboratory sessions, small group sessions, and lectures. After a year of planning, we successfully integrated ultrasound into the course in a way which emphasized how teaching in a dynamic and safe manner with the ultrasound can illuminate the structural relativity of human anatomy.
The novelty of this curricular change in a course that has never had this type of teaching before was itself an impediment. I think that, in retrospect, the adage “There is strength in numbers” is a proverb one should follow when attempting to implement a new course at a medical school. The more people you know who represent different specialties and ranks in both the hospital and the medical school, the higher the likelihood for continued success of the course.
When I started this project, I was naive to the accepted conduct and decorum that one is expected to follow when trying to introduce unprecedented ideas into the medical school curriculum. I had an idea worthy of pursuing, I created a plan to implement it, and I spoke to the directors of the course, but I did not attempt to gain crucial allies in the medical school who could have accelerated its acceptance. The legacy of new projects and teaching initiatives at medical schools will constantly be endangered unless there is consistent support at the administrative level. As a result, although I had the full support from the course directors, I did not have the complete acceptance of the laboratory professors and instructors who taught the course. This disconnection manifested in frustration and bewilderment by some students attending our course during their teaching time. In addition, because there was no formal explanation of our pilot to the students, some were unable to fully grasp the concept of an integrated educational forum, and noted on course feedback their lack of understanding as to why, and how, point-of-care ultrasound correlates with anatomy and histology. This problem could have been curtailed, at least in some part, by a formal acknowledgment made by not only the course directors but also the administration. With this knowledge, we reached out to several medical school administrators, and we are in talks with them to gain valuable insight and input for further direction for next year’s course. In addition, we are recruiting physicians from different specialties to broaden the type of expertise in our curriculum.
Although I encountered barriers, the experience was invaluable. It helped me understand, with startling clarity, the political structure of medical education. I have since moved to another academic medical center, and we are scheduled to begin talks to create an integrated curriculum with first year medical students. The next time I introduce myself though, I think I’ll bring my friends.”
Go to this article’s link for a list of the references as well.
To read posts on US in Medical Education done at AIUM and other institutions, and see what others are doing and saying about it, go here.
A paper in this month’s edition of Global Heart (the journal of the World Heart Federation advocates including ultrasound in medical education programmes to realise the full benefits of the technology as early as possible. The review is by J. Christian Fox, Professor of Clinical Emergency Medicine and Director of Instructional Ultrasound at the University of California Irvine School of Medicine, CA, USA, and colleagues.
Ultrasound technology has advanced to the point that many point-of-care examinations can be carried out using ultrasound, including the advent of hand-held devices similar in size to smartphones. “Emergency physicians, intensivists, and other acute care clinicians are using and relying on critical care ultrasound imaging to better triage and diagnose patients at the point of care. As this new frontier of medicine continues to forge forward using this new and improving technology, we strongly believe in integrating ultrasound training earlier into the medical education curriculum,” say the authors.
They outline a number of medical scenarios such as patients with chest pain, shortness of breath, and shock, and detail how ultrasound can be much more accurate in helping healthcare workers diagnosing problems in these circumstances. However, they also caution about the limitations of ultrasound, saying that “it is sometimes difficult to determine the difference between acute versus chronic problems in an individual. This can be a confounding finding in an acute setting, in the event that a physician needs to make a treatment decision that could be attributed more to a chronic diagnosis.”
However, overall they point to findings that show “Not only is ultrasound more comprehensive and accurate than physical examination, but it also helps with earlier detection of potentially life-threatening conditions, such as cardiac tamponade* and confirmation of pulseless electrical activity… it is argued that point-of-care ultrasound should be, rather than optional, an essential part of any examination to help physicians develop and narrow down their differential diagnosis.”
The authors also refer to a study by Kobal et al demonstrating the potential in extending ultrasound education into the medical school curriculum. Their study compared the physical exam (using non-ultrasound devices such as stethoscopes) done by trained cardiologists to the diagnostic accuracy of ultrasounds done by medical students. This study concluded that not only were students capable of capturing images of cardiac pathology on patients, but their diagnostic skills were far superior in detecting valvular disease, left ventricular hypertrophy, and cardiac dysfunction than those of trained cardiologists performing physical exams.
The authors conclude: “It is becoming increasingly apparent that training our medical students to use ultrasound earlier in their careers can allow them to develop diagnostic skills that far exceed the traditional exam that physicians have been taught for centuries. Thus, it is impossible to ignore the impact ultrasound has made within medical education. Ultrasound has played an essential role in point-of-care cardiac diagnostics, and implementing ultrasound training into medical education is the next logical step to enable the progression of point-of-care ultrasonography.”
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.
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.
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
The First Conference on Ultrasound in Anatomy and Physiology Education took place in March 2013. It was coordinated by a guru to medical student ultrasound education, Dr. Richard Hoppmann (a Dean and a proponent of US in medical education), with some of his good friends in ultrasound education, including one of my favorites, Dr. Michael Blaivas, an emergency physician that was one of the Godfather’s to bedside ultrasound and proving through his insane number of research studies that emergency physician (and others) can and should be performing bedside ultrasound for their patients.
It’s exciting, it’s relevant, and it matters. Doesn’t that feel good to your medical education?! Of course it does! What is even better, is that the lectures can all be found online for FREE here. Thank you Dean Hoppmann, and looking forward to the Second Conference coming in September. Sign up now!
To read more on Ultrasound in Medical Education and insights from the best of the best at AIUM and more, go here.
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. You can also get Volume 1 on inkling chapter by chapter purchasing ability where you can read it on your iPHONE too!)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!)
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.
4. Social Media and Ultrasound Learning – MT “@SonoMedED: @EDUltrasound and @EDUltrasoundQA Uses Twitter with daily tweets to teach ultrasound with social media.” …In addition to little ole me (@SonoSpot), @SonoTron, @TheSonoCave, @bedsidesono, @Ultrasoundpod, @westernsono, @sinaiemus, @UTS_Australia, @USEDCDN … and many others who are in emergency medicine/critical care and highlight ultrasound with their own pearls.
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 (also found here chapter by chapter purchasing on inkling that can also been read on iPHONE) 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:
Dr. Chris Fox’s comprehensive emergency ultrasound lectures in iTunes
Dr. Phil Perera comprehensive emergency ultrasound lectures on Sound-Bytes
AIUM UltrasoundFirst lecture series on various ultrasound topics
UltrasoundPodcast with a variety of lectures on bedside ultrasound
UltrasoundVIllage website on a variety of ultrasound topics
Vanderbilt’s excellent lectures library 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!
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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.
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SonoSpot: Topics in Bedside Ultrasound 
