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

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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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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