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