American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, May 22, 2013

How to learn bedside (point of care) ultrasound: tips for the interested internist

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble, MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was three days long and cost a little under $700 and changed my life forever and made me a better doctor.

Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.

Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret the images takes time and is inaccessible. The American Academy of Chest Physicians (ACCP) is the professional organization that represents critical care and pulmonary doctors, and their journal, Chest, has recently adopted ultrasound education via an online section called the Ultrasound Corner. The editorial by Seth Koenig, MD, accurately describes the power of the technique in critically ill patients, and the educational offerings of the ACCP for intensivists.

So, first of all, why might an internist want to learn bedside ultrasound and how might it be merged effortlessly into patient care? When I see a patient now, instead of taking their pulse and placing my stethoscope on their chest and back, hearing the vague taps and clunks and bubbles and whooshes of the internal organs I have come to trust are in there, I open the ultrasound machine that lives in my white coat, squeeze a little gel from a tube I keep warm in my pocket, and the patient and I look at heart, lungs, liver, spleen, kidneys and bladder. Most of them, those not blind or in a coma, think this is incredibly cool.

At the end of this exam, which takes all of 5 minutes if I am thorough, I know whether their heart squeezes normally, whether there is excess fluid in the lungs or pericardial sack, whether there is fluid in the belly, whether the kidneys are blocked and whether the bladder is emptying normally. Sometimes I also see things like gallstones or tumors or blood clots. I can often evaluate whether the patient is dehydrated by looking at the inferior vena cava, the vein that returns blood from the lower body to the heart.

If a patient loses consciousness, like one of them just did today, I can quickly rule out a major heart attack as the cause of the problem. My little machine is not quite as sensitive as the huge expensive ultrasound machines, but it is pretty good and I can usually be sure about the answers to the questions that are most vital to treating my patients immediately. If a patient has chest pain and my ultrasound of their heart is good, I can be much more confident about whether the chest pain is due to a heart attack.

Several times since I have been doing this, I have found an unexpectedly poorly functioning heart in a patient whose story of chest pain was not particularly convincing for coronary artery disease and was able to advocate for quick or aggressive treatment which expedited treatment and saved heart muscle. The ability to evaluate bladder size is powerful. The ability to rule out hydronephrosis (urine backed up in the kidneys) allows me to avoid excessive imaging in patients who have a change in their kidney function. We often see patients with big bellies who may or may not have excess fluid due to cancer or liver failure or heart failure, and it is so very convenient to be able to make the distinction between fat and fluid without waiting for an imaging procedure to be done.

But how does a person learn how? I took three emergency ultrasound CME classes with live models and hands on instruction, one on line ACCP class in critical care ultrasound and bought the pocket Vscan ultrasound from GE, which I use at least once on just about every patient, friend and family member. The dog has barely escaped due to excess fur. I then took a mini ultrasound fellowship with the department of emergency ultrasound at UC Irvine under the direction of Chris Fox, MD. This involved 4 weeks of scanning in the ER, going over saved scans, teaching medical students and studying online material.

It was kind of expensive: $5,000 for the fellowship and 4 weeks off of work in a place where I had to stay at a hotel. But I am way better at it than I was, I know what the protocols are and can do ultrasound of things that internists don't usually examine that way, including eyeballs and uteruses and testicles and thyroids and skin structures. My Vscan doesn't have a linear transducer, so I haven't been able to improve as fast at procedures that need shallow scanning, such as blood vessels, muscles and joints. I'm thinking that I will need to have access to a machine that I can use whenever I want, so I will probably buy an ultrasound machine with a linear transducer from China where the technology costs about 1/10th what it does here.

There are other ways to learn bedside ultrasound, including year-long fellowships, which are usually based in emergency rooms. There is a program at Harvard that lasts 5 or 10 days that involves participating in scanning at the radiology department, and reviewing many scans every day. I would love to do that. The limitation of learning ultrasound techniques from real ultrasonographers and radiologists is that they do a more thorough exam than we usually have time for, and the perfect protocol for quickly determining relevant information in an internal medicine patient is not the same as what an ultrasonographer does when we order specific tests.

The ACCP has excellent courses with live patient scanning, which are apparently quite expensive. I would also love to take one of these. There are many for-profit groups that offer training as well. It's not hard to find a course that will get a person started, but it does take many hours of practice and the ability to review scans with experts in order to feel comfortable. If our hospitals or clinics decided to embrace bedside ultrasound, and radiologists bought into it (and I actually think they would) we could really benefit from the teaching of our radiology technicians and MD radiologists.

It continues to astonish me how much more effective I am as a doctor with an ultrasound than I was as a doctor without one. I make diagnoses I wouldn't have thought of, save patients radiation and hospital days and quickly have information I need to focus treatment. I understand why my busy colleagues haven't embraced this technology yet, but when they do they are going to love it!

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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