Office Ultrasound

[paiute]

I'm intrigued by the use of US for PIV- this is the first i've heard of it. Is there a course to learn this?

i had to learn by trial and error back in 1994 when there were not courses or even guidelines. it took me about 4-6 months to figure it out. once you discover the trick, you will never want to be without an US machine.

BTW, i have put a down payment on the M0-turbo machine from Sonosite. it has color doppler and the resolution is fantastic.

i just took the course on US PIV at the mammoth mtn emer med conference. UC Irvine hosted the course. it was nothing new for me, but i discovered that they are using an inferior technique (watching for blood flash back) and only get a 92% success rate. i must say my success rate for PIV is over 99%. they mentioned my technique (follow the needle tip), but didn't teach it.

this summer i want to take the UC Irvine ER US course. It costs $5000 and you spend a month in the hospital playing with US. i can't hardly wait to get started! this is a revolution you guys.

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[civic4982]

I like the way this thread is developing. Subscribed for sure! Where are good resources for finding more about US in new settings?

 

[paiute]

I like the way this thread is developing. Subscribed for sure! Where are good resources for finding more about US in new settings?

just get ahold of one and start looking. this field is wide open. they are draining peritonsillar abscess, diagnosising retinal detachments.

it's instant gratification. don't have to wait for the radiologist. learn new things. see new things, maybe something nobody noticed before. it's live, real time.

i bet they poo-pooed the stethoscope when it first came out. this is a new, fancier, stethoscope. it will catch on. one in every practioner's pocket. they get cheaper and lighter, smaller, all the time. it's the electronic revolution. digital signal processing getting faster every day.

lots of new textbooks coming out: J. Christian Fox, Emergeny Radiology or something like that.

 

[paiute]

just saw a guy with a palpable left neck mass; also has a funny looking thing (mass) posterior r lobe of his liver; send for cxr, cervical spine xr and formal us of abd; plan to get mri if cervical spine xr looks ok (might be a cervical rib);

 

[paiute]

just saw a guy with a palpable left neck mass; also has a funny looking thing (mass) posterior r lobe of his liver; send for cxr, cervical spine xr and formal us of abd; plan to get mri if cervical spine xr looks ok (might be a cervical rib);

oops...
mass posterior to r lobe of liver is actually a muscle, probably the psoas. i will cancell the formal US. but i will get the neck xr's since i need to r/o a mass, even though it's probably a cervical rib.

 

[deleted87716]

oops...
mass posterior to r lobe of liver is actually a muscle, probably the psoas. i will cancell the formal US. but i will get the neck xr's since i need to r/o a mass, even though it's probably a cervical rib.

I appreciate your honesty. You're not helping your case, though.

 

[EdibleEgg]

just saw a guy with a palpable left neck mass; also has a funny looking thing (mass) posterior r lobe of his liver; send for cxr, cervical spine xr and formal us of abd; plan to get mri if cervical spine xr looks ok (might be a cervical rib);

I really like the idea of office ultrasound. There is tremendous potential. However, this is just the opposite of what should happen. If u/s expands your skills and save the patient money/time/suffering... great. If it leads to more expensive and unnecessary tests... we already have plenty of things to do that.

 

[paiute]

dr fox from UC Irvine just emailed me and, yes, med students there are using US starting the 1st year. he did NOT confirm that students are actually GIVEN their own machine, so that may just be a rumor.

he says he finalizing the CME course in US and will let me know when i can apply. i plan to spend the whole month of august there, if things work out.

 

[paiute]

well, i'll add to my own thread if everyone else is sleeping...

despite my misadventures and false turns, i'm still having heck of a lot of fun..

i've learned how to get beautiful 4 chamber views of the heart: i show the pt, explaining how blood flows from the body in the RA, then the RV, to the lungs, back to the heart into the LA, then LV, then to the body again. some of the pts walk out loudly telling their friends, "that's cool!"

this way i hope to get these guys (some of the most violent criminals california has to offer) interested in their health care.

on a sad note, i showed one of my pts the large, 6 cm, metastatic melanoma in his liver, surrounded by a layer of fluid. we are trying to get him compassionate release.

 

[paiute]

i have discovered a new side effect of office ultrasound: some people get nauseated when they see their guts displayed on the monitor screen. i've had 2 pts get nauseated and feel faint. no actual collapses yet. now, i will warn them to tell me if they feel faint, so i can sit or lay them down. (i do the exam with the pt standing).

 

[VA Hopeful Dr]

i have discovered a new side effect of office ultrasound: some people get nauseated when they see their guts displayed on the monitor screen. i've had 2 pts get nauseated and feel faint. no actual collapses yet. now, i will warn them to tell me if they feel faint, so i can sit or lay them down. (i do the exam with the pt standing).

Why? Everything I've been taught/seen has the patient lying down.

 

[paiute]

it may be better to have them lie down for the reason i cited above.

positioning may be impt in certain situations. for instance, i think air filled bowel tends to float upward. so lower abd scans may be improved by upright posture. also, the heart may be a little bit more caudad in the upright position, aiding the subxyphoid cardiac view.

the cardiac scan seems to be the most challenging. i think you have to experiment with several positions in each individual to get the best views.

 

[EdibleEgg]

I was reading one the throw away FP journals this morning when I came across an article regarding use of US in joint injections. I didn't read the studies quoted, but it mentioned that 50-60% of joint injections guided by palpation do not reach the intraarticular space. Very suprising. I had not considered this use of ultrasound for joints before. I'm still not rushing out to buy one, but I thought the article was interesting.

 

[VA Hopeful Dr]

I was reading one the throw away FP journals this morning when I came across an article regarding use of US in joint injections. I didn't read the studies quoted, but it mentioned that 50-60% of joint injections guided by palpation do not reach the intraarticular space. Very suprising. I had not considered this use of ultrasound for joints before. I'm still not rushing out to buy one, but I thought the article was interesting.

We use it here for just that reason. Every ankle injection gets one, few shoulder injections get one, no knees get one, and anything else is very attending dependent.

 

[paiute]

i received my new m-turbo from sonosite this week. it was definitely worth the money. the resolution and noise cancelling is much better than the mysono. i compared the two on an obese patient. the mysono was useless (white out) but structures were clear with the m-turbo. i have three probes: abd/card, vascular and intracavity. so far, i have just used the abd/card probe. they say you can use the intracavity for draining tonsillar abscesses. i will have to try that, but i think you are going to need good topical anes and sedation because the gag reflex is strong.

there may also be a use for the intracavity in prostate ca screening.

the vascular (small parts) probe is really high definition. i could see a the hand flexor tendons in my carpal tunnel. i moved each finger and could identify the associated tendons.

the color doppler is really cool for finding the arteries. also, you can see venous flow.

 

[JackADeli]

...I was always lousey at feeling livers, spleens, etc. But now, I slap a probe on the belly...

US isn't indicated for "routine examinations," ...creates potential liability issues.

...creates potential ethical issues.

...US isn't a toy...

...Most nurses can do that easily without using US...

Any of those things can be diagnosed using physical examination. You shouldn't need US.

...over-reliance on technology rather than basic history and examination skills is a pervasive problem among doctors today...

...The greatest disconnect is the doctors inability to use US well & the US tech's ability to do a physical exam & come up with a differential ...IMO, rather than teach US techs medicine, it's better to teach doctors USography...

The problem is stated in the original post... the physician is apparently not very competent in the foundation/basic physical exam. It is one thing to do a physical exam and find an abnormality and proceed to US. It is another thing to simply accept you suck at physical exam and are moving to US everyone. Further, the OP has already declared his/her imaging anatomic understanding to be lacking... when diagnosing a mass while imaging the psoas.

I'm really excited about a new thing I'm doing. ...US ...using it routinely in my medical exams. I was always lousey at feeling livers, spleens, etc. But now, I slap a probe on the belly and I can see almost everything important. I have the patient watch while I do it. The last organ I image is the heart. ...The whole exam only takes about 1-2 minutes. I explain that I am not an expert so I am not making final diagnoses, but just doing a survey to look for obvious problems. ...

oops...
mass posterior to r lobe of liver is actually a muscle, probably the psoas. i will cancell the formal US. but i will get the neck xr's since i need to r/o a mass, even though it's probably a cervical rib.

...not helping your case, though.

...this is just the opposite of what should happen. ...If it leads to more expensive and unnecessary tests...

...despite my misadventures and false turns, i'm still having heck of a lot of fun...

...i showed one of my pts the large, 6 cm, metastatic melanoma in his liver, surrounded by a layer of fluid...

I like technology. I encourage folks to learn new things... but this is troubling at the very least. It raises so many questions. You are misdiagnosing a mass that turns out to be normal muscle anatomy and having fun. You are "diagnosing" in your office then sending the patient for a "formal" repeat study... are you billing for your study?

You are ultrasounding and diagnosing? a metastatic melanoma in your office... you have already shown yourself to be less then accurate in your earlier statements. You have poor physical diagnosis skills and you called the psoas a "mass". Again, troubling, especially trying to contemplate your sequence.... patient with melanoma, you perform office ultrasound and make "diagnosis" and show patient, patient then goes for formal diagnosis? Or, patient already has formal diagnosis via oncology team, CT/MR scans and you now repeat study in office.... then bill? Maybe you do NOT bill specifically for the US... but, I guess you bill for the physical exam, which you have apparently replaced with the US cause you are not so competent on physical examination.

Having fun?

You should see if Oprah has a couch for you to jump up and down on and really be T. Cruise.
http://www.msnbc.msn.com/id/10309963/

 

[paiute]

yes, i'm still having fun.

that guy with the untreated htn and funny looking heart came back to me the other day. he finally decided to take his bp meds. his bp is better, but his heart still looks huge on US.

i will be doing more w/u on him. he has lost wt here in the SHU (security housing unit), but is still overweight. he says he used to weigh much more. i suspect Pickwickian syndrome.

as they say, you need to see 100 normals before you recognize the abnormal. this is true with US also. after doing over 100 exams, i now am seeing some interesting stuff. it has definitely been worth the expense and time.

billing? we never bill here.

prostates are interesting. after the DRE, you can do a transabdominal US and check from a different prospective. sometimes you see the spermatic vesicles, too.

we have a lot of people who fake paraplegia. i just checked one who had a condom catheter on. his bladder was nearly empty (25% full). that seems odd to me. a paraplegic with a condom catheter would more likely have a full bladder, unless he just had done an "in and out" catheterization. i would expect a full bladder, with the condom cath there to take care of the overflow incontinence. he also has normal leg muscle bulk and normal knee reflexes.

most doc's know that a full bladder can increase the bp. so if i get a guy with a high bp, whose previous bp" were normal, i check the bladder with the US.

another reason for high bp in a normal individual is anxiety, of course. here, that is usually because they a carrying a "kite" (illegal inmate message) in their mouth. so if I see the high BP, i check the mouth for the "kite". the patient will then oblige me by swallowing it because they don't want the officers to see the message. i can't reach in their mouth to retrieve it. that would be "illegal search and seizure. "

pacemaker wires and IVC filters are also fun. it's easy to verify their presence with US.

 

[JackADeli]

yes, i'm still having fun.

that guy with the untreated htn and funny looking heart came back to me the other day. he finally decided to take his bp meds. his bp is better, but his heart still looks huge on US.

i will be doing more w/u on him. he has lost wt here in the SHU (security housing unit), but is still overweight. he says he used to weigh much more. i suspect Pickwickian syndrome.

as they say, you need to see 100 normals before you recognize the abnormal. this is true with US also. after doing over 100 exams, i now am seeing some interesting stuff. it has definitely been worth the expense and time.

billing? we never bill here.

prostates are interesting. after the DRE, you can do a transabdominal US and check from a different prospective. sometimes you see the spermatic vesicles, too.

we have a lot of people who fake paraplegia. i just checked one who had a condom catheter on. his bladder was nearly empty (25% full). that seems odd to me. a paraplegic with a condom catheter would more likely have a full bladder, unless he just had done an "in and out" catheterization. i would expect a full bladder, with the condom cath there to take care of the overflow incontinence. he also has normal leg muscle bulk and normal knee reflexes.

most doc's know that a full bladder can increase the bp. so if i get a guy with a high bp, whose previous bp" were normal, i check the bladder with the US.

another reason for high bp in a normal individual is anxiety, of course. here, that is usually because they a carrying a "kite" (illegal inmate message) in their mouth. so if I see the high BP, i check the mouth for the "kite". the patient will then oblige me by swallowing it because they don't want the officers to see the message. i can't reach in their mouth to retrieve it. that would be "illegal search and seizure. "

pacemaker wires and IVC filters are also fun. it's easy to verify their presence with US.

the whole thing from the origin of this thread to your last post is bizarre.

 

[paiute]

bizarre: from Italian bizarro ca 1648 - "strikingly out of the ordinary"

yes, i guess so. when i first came to work here, an officer said, "welcome to Disneyland." now, i know what he meant.

which is bizarre, my use of the US, or my pts? maybe both?

this is the "end of the line." my patients are the most violent criminals california has to offer. we are the california version of "supermax." sorry, it's reality. tune to another channel if it offends you.

 

[JackADeli]

bizarre: from Italian bizarro ca 1648 - "strikingly out of the ordinary"

yes, i guess so. when i first came to work here, an officer said, "welcome to Disneyland." now, i know what he meant.

which is bizarre, my use of the US, or my pts? maybe both?

this is the "end of the line." my patients are the most violent criminals california has to offer. we are the california version of "supermax."...

Either you are just trolling or you are simply playing fast and loose with both your patients and basic medical ethics... because it's "fun". End of line/death row/incarcerated/etc.... none of which have relevance to ignoring standard of practice or engaging in the conduct you describe.

You have described yourself as not particularly competent in basic medical examinations.... you have all but replaced basic medical examinations with entertainment usage of US...that you have also demonstrated significant lack of competence. You imply somehow that it is OK because you are dealing with the imprisoned population. In actuality, prisoners are regarded as "protected"/"vulnerable" population just like pregnant women, fetuses, children, and the elderly. Yet, it seems, their VULNERABLE status makes you more comfortable using them for entertainment.

I am all for advancement of science and technologies. The issue is not opposition to utilization of US. This is not someone/anyone trying to hold back progress and healthcare advance. The issue is what you are doing with it and how you are going about things.

 

[paiute]

i'll post this to bump "help me" off the headline.
my new m-turbo is very powerful. i think the other manufacturers need to catch up, if they can.

i'm using the us for detecting retinal detachments (if i can get any more patients). i tried it on myself: you can see the lens, retina and optic nerve. i think you can measure the optic nerve diameter to detect neuritis. btw, the fda limits the power on the ocular exam, so you have to tell the machine that you are going to image the eye. no other exams seem to have power set limits on this machine.

if the eye is severely traumatized and lids won't open, that's when the us comes in handy. just don't press too hard in case there's a rent in the eyeball.

 

[JackADeli]

yes, i'm still having fun...

...as they say, you need to see 100 normals before you recognize the abnormal. this is true with US also. after doing over 100 exams, i now am seeing some interesting stuff...

...another reason ...usually because they a carrying a "kite" (illegal inmate message) in their mouth. so if I see the high BP, i check the mouth for the "kite". the patient will then oblige me by swallowing it because they don't want the officers to see the message...

...Prisoners are regarded as "protected"/"vulnerable" population just like pregnant women, fetuses, children, and the elderly...

"Volunteers" for medical school physical exams and/or other educational activities undergo informed consent and are appropriately compensated according to guidelines established prior to such activities. The process in using individuals for education and/or experimentation at ALL levels is expected to involve a complete application process and an IRB approval process. You have/continue to describe experimentation without proper trained individual, without proper protocol, and without proper oversight. You also describe incidents in which you use US to search the oral cavity... again an example of not being the patient advocate. It is not pioneer work to experiment on the incarcerated without the proper foundation/s as described.

Please discontinue encouraging this improper experimentation and/or application of medical devices. There are proper means of advancing education and the application of medical technologies.

I hope a moderator will end this thread as well. I hope the troll ban on sight rule starts to apply......