Thursday, November 7, 2013
Why it is cool to have an ultrasound in my pocket
I admit it. I am an ultrasound nerd. Zealot would be another word. I am someone whose enthusiasm for bedside ultrasound is strong enough to overwhelm my desire not to bore other people. Still, it has taken me to very interesting places and put me in contact with good, devoted people whose passion to make medical care and teaching better and more accessible mirrors my own values, even the values I had when I thought that ultrasound was something that technicians did in little dark rooms which produced un-readable blur-o-grams.
After learning the basics of bedside ultrasound in an introductory course 2 years ago and working on becoming proficient through hours of practice and other formal training I got to go with medical students from UC Irvine to Tanzania to teach basic ultrasound and practical anatomy to students in Clinical Officer training school and other physicians. They have kept in touch and presented their work in a meeting in Columbia, South Carolina, the Second Annual World Congress in Ultrasound in Medical Education.
This was a gathering of physicians and students from around the world who push the concept of using ultrasound in the hands of caregivers at the bedside to both teach students to understand anatomy and physiology and to diagnose and treat patients more effectively. It was a great meeting. There were almost no dry and boring talks delivered by people who would clearly rather be elsewhere. People were passionate about their desire to have bedside ultrasound become more common, and presented lots of the research about how it improves our safety and effectiveness.
Nobody talked about how it can make us more money. That piece was conspicuously absent. The reason it was absent was because that isn’t something these people were passionate about, and it doesn’t usually make us any more money. There were people from Italy who use it routinely for diagnosing lung conditions and wanted to make sure that everyone knew how to do that and how useful it was. There were people from the Middle East and Africa who use it to deliver healthcare where there are no CT or MRI scanners and where basic imaging of a trauma victim or a pregnant woman can routinely save lives. There were American physicians who have been pioneers of using it, swimming against the current because it doesn’t increase the revenue stream and makes folks whose livelihoods rest on the overuse of expensive imaging very uncomfortable.
Columbia is the capitol of South Carolina, the largest city in South Carolina at 129,000+ people, and the home of the University of South Carolina and its School of Medicine. The meeting was held in the convention center, just next to the university and near art galleries and shops, restaurants and bars and not too far from the Congaree River that runs through town. The medical school is one of a small but growing number which teach ultrasound to the medical students as part of their curriculum, and so they were an appropriate and gracious host for a meeting devoted to ultrasound in medical education.
The dean of the medical school, Richard A. Hoppman, MD, FACP, was a personable guy who gave one of the short, sweet and useful speeches at the plenary session, and he was clearly devoted not only to ultrasound but to all kinds of projects that would benefit people domestically and in other countries who have very little. Since ultrasound is a technology that gives excellent value and costs nothing after the price of the machine, it is an excellent tool for doctors who want to take their skills to some place where people need medical care but where there is little to no infrastructure to deliver it. The meeting was packed with such doctors.
In addition to people talking about what they were doing in their hospitals and on their travels and presentation of research in various aspects of teaching ultrasound and documenting that it was accurate as a diagnostic tool, there were hands on sessions where doctors who had a tremendous amount of practical expertise shared how they did what they did. I learned about basic obstetrical ultrasound and something called transcranial Doppler which actually looks at the brain through the very thin area of the skull at the temple to determine blood flow in the cerebral arteries.
Next year the meeting will be held in Portland, Ore., which is much closer to my stomping grounds, and will use the new teaching facilities at Oregon Health and Sciences University. The ultrasound champion there who will facilitate the meeting is Jenny Mladenovic, MD, an internist and long-time academic administrator who recognized that ultrasound makes internists better and happier doctors and that the best time to introduce all of us to it is as medical students.
Since I was hanging out with medical students and ER physicians at the meetings, the evenings were not boring. Also the companies that produce ultrasound machines, companies like Fujifilm and General Electric, funded a dinner at the Columbia Art Museum and at the zoo. This is part of the unholy industry physician connection, but was also an opportunity to make meaningful connections with cool people who were doing groundbreaking things. After the dinners there were bars with good ambiance and excellent live music which conspired to get me back to bed later than would have been optimal. I got the idea that Columbia produces really good musicians, which is supported by the Wikipedia entry on the city.
On my way home I was sitting in my airplane seat trying to decide whether to watch a movie on the pay per view tiny screen in front of me or study medicine when the flight attendants asked for a doctor. I went to the aid of a very old man who was just regaining consciousness after walking back to his seat with his daughter from the bathroom. Losing consciousness when one is very old is a bad thing, often a sign of something life threatening.
The story the daughter gave lead me to a differential diagnosis that included dehydration, heart attack, arrhythmia or blood clot to the lung. We were still 4 hours from our destination with a full flight and, although it would have been nice to have this man be on the ground and at a hospital there was no chance of this happening expeditiously. Airplanes have little first aid kits that are bigger than the one I carry, and have blood pressure cuffs, intravenous fluids and some basic pharmaceuticals. I could tell that the patient’s blood pressure was very low but the exam was otherwise limited by loud engine noise and no room to move around. Luckily I had my handheld ultrasound and could determine that he was not suffering from a heart attack or a blood clot to the lung, because these two events, when severe enough to cause a person to lose consciousness would usually show characteristic changes on the images, and that he was definitely dehydrated, which fit best with the history that he gave me.
He perked up nicely with an anti-diarrheal pill, some 7-up and the old time doctor’s best remedy, tincture of time. He was able to get off the plane looking much better and see his own doctor who knew him rather than be rushed to an emergency room in an unfamiliar city where they would have to piece together his medical history and probably do a bunch of potentially unnecessary tests. Hooray for ultrasound and tough little old people!
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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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.
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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.
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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.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
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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.
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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.
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