Post on 19-Oct-2014
description
transcript
Teaching Using Portable
Ultrasound
Richard Usatine, MDBill 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 can 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 the 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
TransA 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 hand-
carried ultrasound units. http://sonosite.com/
• A less expensive portable MySono 201 ultrasound can be purchased at http://www.medison.com/eng/pd/bw/mysono201/more.asp
live demonstrations
• Bill’s machine