Teaching Using Portable Ultrasound Richard Usatine MD Bill

Teaching Using Portable Ultrasound Richard Usatine, MD Bill Rodney, MD

Objectives • Describe the value of ultrasound technology in family medicine clerkship learning experiences. • Discuss the methodology to incorporate portable ultrasound into family medicine clerkship teaching. • List the resources available to learn and teach ultrasound within the settings and scope of a procedurally enhanced family physician.

Procedurally Enhanced Family Physician • May use ultrasound in – the office – labor and delivery – emergency department – acute care clinics – International missions – others

Future of Family Medicine • Embrace technology in your practice • Enlarge the basket of services • Ultrasound can enhance your practice and can be an exciting skill to teach students • STFM task force just recommended ultrasound as an essential skill for FM residents

Leaders in ultrasound in family medicine • Ric Hahn, MD • Bill Rodney, MD • Mark Deutchman has created wonderful interactive CD-ROMs on – OB ultrasound – abdominal ultrasound – emergency medicine. – mark. deutchman@uchsc. edu

Portable ultrasound • Units can be purchased from $7, 000 -$35, 000 • $12, 000 can do it for a new machine • $7, 000 for a used machine • Ultrasound transducers can be plugged into laptop computers • Demonstrations to follow

Grant funding • Allowed UTHSCSA to purchase 3 portable ultrasound units • Part of a visualization and simulation Grant funded by AT&T • The Paradox of Misaligned Incentives • University of Tennessee; disallowed by faculty group, purchased with discretionary funds but created revenue • Meharry- same; published data $ • Medicos—self funding; same+

Clerkship curriculum • 90 minute hands-on workshop using portable ultrasounds • A pregnant volunteer is recruited • Often it is a pregnant student from within the group or a fourth-year student • Students practice on each other

Ultrasound basics • Explain the use of sound and how sound is transmitted differently in liquids versus solids • White shows reflection and dark shows transmission • Shadowing occurs when in the bones or stones reflect the sound back to the transducer

Transducers • Curvilinear or linear • Fixed frequencies • Variable frequencies are newer • Image tweaking transcends physics – Contrast and brightness • Depth of scan be adjusted • Increasing gain increases the white in the picture

Start with Fetal ultrasound Demo • Students enjoy seeing the moving fetus and identifying the body parts • Fetal heart motion is easy to see and heart anatomy can be visualized • Pregnancy dating can be demonstrated by showing how measurements are taken of biparietal diameter, head circumference, abdominal circumference, and femur length • Maternal gallbladder easy to see without fasting

Abdominal ultrasound • Demonstrate the gallbladder in the pregnant woman and look for stones • A new student volunteers for a view of the nonpregnant abdomen • The liver and diaphragm are demonstrated • The diaphragm is easy to see when the subject takes in a deep breath and holds it • The use of controlled breath-holding is demonstrated

Abdominal ultrasound continued • The right kidney is visualized using the liver as an ultrasound window • The abdominal aorta is demonstrated in a sagittal and transverse plane • The abdominal aortic diameter is measured easily • Don’ t waste time with more difficult organs - pancreas

Thyroid ultrasound • The higher frequency linear transducer is connected • The new volunteer has the neck scanned to see thyroid gland, the trachea, and the carotid arteries • It is easy to identify the thyroid gland on both sides of the trachea • Look for thyroid nodules and cysts

Musculoskeletal ultrasound • The linear transducer can be used to look at the structures of the shoulder and the rotator cuff • Emerging area with no published studies

Trans. A Pelvic ultrasound • Occasionally the curvilinear probe for the abdominal ultrasound can be used to look at the uterus and ovaries in a willing volunteer • A volunteer can remain fully clothed but the transducer must point downward toward the pelvic structures • Main problem is jelly on the clothing which can be washed off

Practice time • To massage tables are set up each with a portable ultrasound machine • Ultrasound gel or K-Y gel are used to help transmit this sound at the transducer skin interface • Plenty of tissues, paper towels or cloths need to be available to clean the gel up afterwards • These materials are also used to keep the gel off of clothing

Student participation • Students jump in and start using the ultrasounds on each other immediately • There always many volunteers willing to lift up their shirts and show their abdomens • The students enjoy holding the transducers at looking for the structures • Belly button rings do not get in the way • Adiposity is the enemy of ultrasound

Student surprises • Some students will reveal a new pregnancy • One student showed us her single abdominal kidney • The heart could be visualized in some students with the curvilinear transducer

Student feedback • For many students it is the first time that they have had a chance to see or practice ultrasound • Students are intrigued to know that family doctors can do this type of work • Anatomy is reinforced and comes to life outside of the O. R. or the gross anatomy lab

Portable ultrasound in community outreach • Portable ultrasound machines are used in the student-run clinics • In one free clinic there are women in a residential drug rehabilitation program • Ultrasound is used to show the women in their developing babies to help them connect with the reality of pregnancy • Hoping to encourage them to stay sober and drug-free

Future Directions • Encourage Family Medicine educators to incorporate ultrasound into their essential basket of clinical skills • Follow standardized clinical formats as available on www. psot. com • Computer assisted technologies are increasingly user friendly and diagnostically precise • Elvis Winternational Ultrasound Courses available 2007 -2011. wmrodney@aol. com • Others

• PRACTICE TIME

FM References • Dresang LT, Rodney WM, Rodney KM. Prenatal ultrasound: a tale of two cities. J Natl Med Assoc. 2006 Feb; 98(2): 167 -71. • Dresang LT, Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med. 2004 Feb; 36(2): 98 -107. • Rodney WM, Deutchman ME, Hartman KJ, Hahn RG. Obstetric ultrasound by family physicians. J Fam Pract 1992; 34: 186 -94, 197 -200. • Hahn RG, Davies TC, Rodney WM. Diagnostic ultrasound in general practice. Fam Pract 1988: 5(2): 129 -35.

Portable Ultrasounds • Terason http: //www. terason. com/ • Sonosite has a selection of handcarried ultrasound units. http: //sonosite. com/ • A less expensive portable My. Sono 201 ultrasound can be purchased at http: //www. medison. com/eng/pd/bw /mysono 201/more. asp

live demonstrations • Bill’s machine