Hello and welcome to our presentation today, titled Beyond Musculoskeletal Ultrasound, Ultrasound Use Cases for Inpatient and Clinic Settings. Cliff, are you there with us? Yes. Okay. Can you hear me now? There we go. Yes. Yes. Welcome, Cliff. Again, the title of today's presentation is Beyond Musculoskeletal Ultrasound. My name is Kyle Josephson. I'm presenting from Mary Free Bed Hospital, where I am currently an interventional spine fellow. I also do my residency training at Mary Free Bed, and I have a passion in ultrasound. We're glad that you've joined us here today. The goal of today's presentation is to discuss ways that you can bring ultrasound at the bedside and really direct patient care. We'll be doing that by going through five cases. We'll be discussing DVT screening, soft tissue evaluation. We'll be discussing bladder scanning. We'll also be talking about lung evaluation and IV placement. Cliff's going to also be doing some live demonstration today as well. Cliff and I met at AAPMNR, gosh, Cliff, three years ago now. I was a young PGY2 at the time, had great interest in growing the ultrasound curriculum at Mary Free Bed, and Cliff has been instrumental in shaping the growth of our curriculum here. Cliff, please introduce yourself. Yeah. Cliff Grunseth, Boulder, Colorado, in prior practice. I've been doing ultrasound for about 20 years. I started a nonprofit organization that teaches non-MSK ultrasound to low-income countries, nurses and doctors working in remote villages that have no access to diagnostic imaging. I met Kyle a few years ago. He was an eager Beaver resident. They asked me to help their residency learn MSK ultrasound. I taught them from my office in Boulder. We've become good friends, and I talked Kyle into doing this presentation. Yeah. For disclosures here, I have no financial disclosures. Cliff? I have two potential disclosures. One, my nonprofit, Niagara Project, which teaches ultrasound around the world, and then I have a software company called 70 Imaging, which teaches ultrasound via an app, but we will not be discussing those during today's presentation. Yeah. So, Cliff, when we talk about ultrasound beyond musculoskeletal ultrasound, really, who is this targeted towards today? Well, you can almost help me with this, Kyle. You know, you've incorporated this into your residency program, I think. The bottom line is that you can use ultrasound anywhere, anytime. It's totally portable with the small units. It's safe. It's immediate. It's dynamic. And so, if you're in the inpatient unit, consultation service, outpatient clinic, even not necessarily MSK clinic, but a general clinic, you can have use cases for ultrasound on almost every patient, to be honest, if you're really looking to try to find a diagnosis. The ultrasound is really an extension of your physical exam. It makes you an uber-physician because it allows you to be able to see inside the body rather than just like poking and listening. So, it's just a fantastic tool that you should get. I'm a huge advocate. Yeah. Totally agree. To give some examples of where we're using it from our end, we've developed research protocol that we're working on implementing for performing DVT screens on high-risk population. I've been working with the wound care team on being able to better view and describe some of the wounds that we're having on the inpatient side. We've been using it in the EMG lab. We've been using it in the outpatient setting. So, really, its uses have no bound. Wherever you're practicing medicine, wherever you're seeing patients is where it can be used. So, point of care ultrasound, really, what are we focusing on today? The goal of today is to review ways in which you can take a quick look at the bedside to ask us to answer a specific clinical question. So, the scanning is going to be done by the healthcare provider, by the person who knows the patient, who knows their physical exam, and is going to then make an interpretation based off of those imaging findings. Cliff, any other thoughts on point of care ultrasound? No. I think you summarized it well, Kyle. We're going to be going back and forth with this presentation. Just a quick warning about all the research Kyle has done. He has done an amazing reference guide looking at all the research with this. There's going to be some slides in this presentation that are very text heavy. The slide deck is designed for you to go back and look at later. There's no way in an hour you're going to learn how to do ultrasounds, nor all the details and the statistics. But we're hoping that the slide deck that Kyle has put together will be useful for you to go back and reference. And as far as ultrasound, yeah, this is an ultrasound machine right here. If you haven't seen the butterfly, they're now handheld. It plugs into your phone. There's no reason that you can't have it on the wards, et cetera. Easy access. Pull it out of your pocket. Take a quick look. Liver, heart, lungs, belly, bladder. We're going to go through cases. We're going to have some fun today. Yeah. Good. Point of care ultrasound. This is an image demonstrating the results of searching the term point of care ultrasound. As you can see, over the last 20 years, there's been a tremendous amount of growth in the amount of research that's been published. There's been 90 articles in 2000 and 2020, over 1500. And one of the reasons for the influx in 2020 was in part due to COVID-19. So we're really seeing a huge wave in the amount of work that's being done and the energy that's being poured in into looking at how point of care ultrasound can be brought to the bedside. So the question here, should ultrasound be in every physician's pocket? I think both Cliff and I would answer this question as a resounding yes, and that's due to the current trends that we're seeing in point of care ultrasound. Really it's four things. One, it's expanding its use to most medical specialties. Two, these probes are affordable, they're portable, they're readily available. There's been evidence to show that there's improved diagnostic accuracy. So this just goes beyond excessive gadgetry, if you will. And then finally, patients really enjoy when you are demonstrating to them what you're seeing. And so it also can improve patient satisfaction as well. Cliff, any thoughts here? Yeah, you know, from a personal perspective, ultrasound to me is magic. The patients love it. You have a diagnosis right away. And it's been in use in the emergency medicine department for a long, long time. The other specialties are starting to catch up. I know there may be some politics in different hospitals and things, but the bottom line is that it's the right thing to do for your patient. Like I said, it's portable and safe. And the younger generation, the medical students, et cetera, that are coming through the education system are going to be doing ultrasound. They will. In fact, I'm a big advocate of replacing the stethoscope for the ultrasound, except for maybe listening to wheezes in the lung. But otherwise, why would you listen and poke when you can look? You can look at the lungs. You can look at the heart. You don't have to listen to murmurs. You can actually see the heart beating, et cetera. So it will be in every physician's pocket. It will become standard of care probably in 10 to 20 years. And our goal today, talked to Kyle earlier, is to lower the fear factor, the barrier for using ultrasound, to pull it out and just take a look at anything you want, because it's really very, very safe. So one of the questions that some of you may be having, whenever there's new technology, what about the legality? So Cliff, can you speak to this? Well, you know, Kyle found this interesting article from an emergency medicine journal that basically found that the only lawsuits that have been filed for doing ultrasounds were for physicians that did not do ultrasound. Now, this is in the ER, which is a little bit different with ectopic pregnancies, et cetera. But no one has been sued, at least reported in the literature, for using ultrasound. And for those that are just starting and fairly naive to ultrasound or neophytes, the goal is to just know what normal looks like. If it's not normal, then you're going to refer, you're going to order more tests, et cetera. If you're not sure, you're going to order more tests. So it's really just a supplement to your diagnosis and to the data. So the bottom line is, lawyers are not going to be barking on your butt if you use ultrasound in the consult service or inpatient unit, outpatient clinic, et cetera. No harm, no foul for looking. There's no radiation. It's totally safe. Yeah, I totally agree. So what about the training? Here's two articles where we kind of see the wide range of training that's needed to perform this with a fair degree of accuracy. One study looking at DVT screening, the other looking at lung evaluation. And so on one side, just a one-hour training session as part of normal didactics resulted in a high accuracy of diagnosing DVT and contrasting that to lung ultrasound, where a little bit more work and time and practice is going to be needed to be able to accurately diagnose. So moving on here to our next slide, let's talk about potential uses. So this is our patient here today. This looks a lot like the interventional spine fellow from Mary Free Bed. He's going to- The one who's speaking. Yeah, you know, is his vitamin D level look a little low to you, Cliff? I think his residency is in Michigan, so that might explain it. That's right. So let's envision we walk into the room, we see this patient, he complains of some shortness in breath. We can pull the stethoscope out, or we can pull our ultrasound machine out and actually do a pulmonary evaluation. Blood pressure has been a little soft. Let's assist with IV placement. He may have some bowel distension, some pain in the bowel. Let's perform a bowel evaluation. While we're there, let's also look at the bladder volume. Let's see if he's retaining any volume there. Why squeeze? And we can actually look at the veins. So let's perform a DVT evaluation. Patients are often going to be at risk for wound development. Ultrasound can assist with soft tissue evaluation as well. So as you can see, from head to toe, the ultrasound can be used as a tool to assist your physical exam as an extension of your physical exam. We're going to get started here with some cases. Case one, the case of tachycardia. So we have a 42-year-old. She's admitted. C7, A should be over the last 24 hours, has been having increased heart rate, EKG showing sinus tachycardia on exam. She's noted to have no calf tenderness, no asymmetry in calf circumference. She's got a negative Holman sign. You have a high suspicion at this case, right, for a PE. So you place an order for a CT angiogram. While you're waiting on that to come back, pull your ultrasound probe out, right? So we pull the probe out and we actually take a look at the veins. This is an image depicting what we're seeing. So in the right inguinal region, we see the common femoral artery, the common femoral vein. We apply pressure and the vein completely collapses. This is indicative that there is likely no thrombus in this location. We then check the other side. And with compression, the vein remains patent. And so what we can see here is with compression, the vein is not collapsing, which is indicative that there may be a blood clot. So the question I have is why squeeze a calf muscle when you can actually visualize the veins? Well, what we know is that the symptoms for DVT are nonspecific. We also know that our clinical examination, unfortunately, isn't sensitive nor is it specific. And we also know that the incidence of DVT is very high in the patients who are coming to the inpatient unit, highest in specific groups like spinal cord injury, brain tumor, et cetera. There's numerous diagnostic tools of varying degree of sensitivity and specificity. But one of those tools is compression ultrasound, and that's what we'll be discussing here today. So what are we talking about when we speak about compression ultrasound? Really what we're saying is we're putting the probe over top of, in this case, both the femoral artery and the femoral vein, and we're putting pressure down to seeing if the vein completely collapsed. The artery should pulsate. The vein should be able to completely collapse. If it's not collapsing, that may be indicative that there may be a thrombus. Cliff, any thoughts on this slide before you demonstrate? No, I think you covered it well, Kyle. The bottom line is the DVT screen is probably the easiest and the most lifesaving study you will do. As Kyle said, if you can screen for DVTs prior to coming on to a rehab unit or upon their arrival on the rehab unit, doing a quick screen of even their femoral veins is very fast. It's highly accurate, as Kyle was pointing out. And if there's no clot in the femoral vein, in the popliteal vein, there's a 95% chance that there's no clot in that leg. And it's so easy to do, as I'll demonstrate in a second. So this is probably the best place to start for those that are interested in using ultrasound on the inpatient unit or consular service, in hospital. Exactly. And what Cliff is referencing is kind of a focus techniques, right? So the inguinal region and the popliteal region. And there's two different techniques, the two-point compression and three-point compression techniques. Cliff's going to go through the anatomy here shortly. And how this differs from the duplex ultrasound that you're going to send the patient for formally is that with the duplex ultrasound, they're going to be using Doppler in addition to compression-based ultrasound and visualize the entire venous system in the lower extremity. Cliff, are you ready? Yes, I am. Let me get my assistant, Adam, going here. I'm going to stop sharing my slides here. All right. I'm going to do some live scanning here. I'm using a linear probe. The femoral artery and vein are quite superficial. So I'm going to just slide the shorts down, get things rolling here. You can kind of see this is ultrasound world. It looks like a London foggy weather map that is hard to decipher. But once you find your way around, you'll feel more comfortable. So the bottom line is I'm going to change my depth a little bit, change the gain. You can see something that's beating right here. That's the artery. That's a no-brainer. And you don't even need Doppler for it. And what you can do then is sitting right medial to the artery right here is the vein. And you can see the vein. And I'm just going to compress it. You can see it collapse down. The artery collapses too. But you see that the vein will collapse a little bit better. Let me get the gain, get that a little bit better gain. Right there is the nice little artery there. And you can kind of see that the vein collapses, the artery keeps pulsing. And so what you want to do is just go through and just collapse and collapse. And you follow the vein down. You can throw Doppler on there if you wish. But again, it's very pressure sensitive, especially the vein. Because of the low pressure system in the vein, the artery keeps beating. Same thing you can do on the opposite side or behind the knee. The popliteal vein is smaller, a little harder to see. But bottom line is you can hide it right behind here. You can see right here that there's already a little black circle right there, anechoic circle. And you can compress it. And you can see the artery down deep. And then the vein up on top right there. I'll change the depth a little bit so we can zoom in. And you can see right on the screen here, the vein easily collapses. You can follow that down. You can see where it splits. There's a vein over here. There's a vein over there. And you can just track it up and down and just see if there's any kind of clot in the system. Again, the artery is going to be sitting a little deeper. If you press down, you'll see something that's pulsing down deep. So there's the artery right there, the popliteal artery. So it's very easy to do. Two-second evaluation. Somebody comes in, suddenly short of breath. You can almost rule out a DVT within a minute if you're facile with the probe. Back to you, Kyle. All right. Thanks, Cliff. All right. So we're going to move on to our next case here. Case number two, cellulitis or abscess. We have a 69-year-old female. She's admitted with multi-trauma. She's been having left lower extremity cellulitis versus abscess. As we can see in our pictures here, day one to day three, this is evolving. This is getting bigger. By day six, while she's on antibiotics, we can see that this degree of erythema has increased and we see a focused zone here. So we pull our ultrasound probe out and we actually look underneath the skin and see what's going on. As you can see here, each of these images are going to correlate with the location of where we were scanning. So image A, we can see that there's evidence of some increased edema or brighter tissue at the top here, some increased echogenicity. And then deeper down, we see this pocket of fluid. So this is suggestive that there is cellulitis and there's a deeper abscess in this case as well. Image B, we can see kind of where this abscess is tracking down distally, down the leg. And then in image C, we can also see here that this has gone down a fair bit of ways down the leg. So this was then used to assist our wound care team who is ultimately going to be doing the incision and drainage. So this patient actually, after IND, did much better and was able to maintain their rehab course. So point of care ultrasound for soft tissue evaluation. So when we have undifferentiated skin and soft tissue infection, ultrasound can be used to confirm the presence of cellulitis and detect deep abscess, and then can also be used to direct accurate aspiration or incision. Traditionally, the history and physical examination has been used to diagnose abscess and cellulitis, but again we have this extra tool in our tool belt, and ultrasound has been beneficial of being able to, one, accurately diagnose cellulitis, two, be able to diagnose the location of where an abscess is located, which can then assist with invasive procedures, and then it's also going to prevent invasive procedures over vasculature or potential neoplastic lesions that may mimic abscess. So this can be very beneficial. The normal appearance of soft tissue, it's going to be more dark, hypo-echoic appearance. You're going to see some irregular strands of brighter hyper-echoic connective tissue. In the case of cellulitis, it's going to have almost this cobblestone appearance, so you're going to see increased echogenicity, kind of these lattice bands that are going to be more dark amongst the bright fluid, which is going to be due to edema. And then an abscess is going to be, typically going to be a well-circumscribed, well-demarcated area, maybe spherical or interdigitated or lobulated. And this is, the contents of the abscess is going to vary as well, and you can notice that based off of the more brightened side, which may be evidence that there could be impurulence or it could also be dark. Cliff, does your demo, does your model over there have any soft tissue that we can evaluate? Yeah, so I've got a little, in the inset here, I've got a little tofu, extra-firm tofu that I got at the store, and I made a little phantom model, little simulator for looking at veins and abscesses and things like that. For those that are interested, you can reach us and we can tell you how to make it. The bottom line is, this is a tofu block with a couple of balloons in there, and the bottom line is that you can see, sometimes you can see if the tissue, it looks irregular deep inside, and you can find fluid pockets. Like if I slide over, you can see this right here looks disorganized, it's compressible, and it is, this is what an abscess may look like, a little pocket of fluid, something along, that tracks along the fascial planes. So, this is a simple way to really just assess whether or not it's just swelling in the soft tissue, or if there's a little pocket of pus or an abscess that might be in there. Now, here's another channel right over here that shows, I can try to fill it up here, that shows some different types of fluid. You can see it's got a lot of different signal in the skin, that may be just edema in the soft tissue right here, but the abscess is going to be a little pocket of fluid underneath. That's a huge differential, because if you can send that for drainage, or you can drain it yourself, that could be a real game changer for your patients. Thanks for that, Cliff. Moving on to our next case here, case number three. So, case number three is going to be the case of bladder retention. So, we have a 23-year-old female, C5 Asia A, she's had increased blood pressure, pounding headache. You have a high clinical suspicion that this patient may be developing autonomic dysreflexia. The nurse goes in, she goes to drain the bladder, and pulls off about 50 cc's of urine. You mentioned that she's had challenges with draining the bladder previously, and so you bring your ultrasound probe out, and you start scanning. And what you notice is that the bladder is a little more distended than what you were anticipating. So, in this case, we see the volume of about 350 cc's of volume here. So, point of care ultrasound, when can we use the ultrasound machine to assist with bladder assessment? One of the ways that I think commonly is used is the bladder scanner. Well, there are times where we should interpret those findings with caution. For instance, if a patient has abdominal obesity, or tissue edema, or large volume ascites, these are cases where an ultrasound probe, and actually looking at it yourself, is going to be a little bit more beneficial. And it can also be beneficial to look at, look for the identification of a clot, or an obstruction, or to confirm urinary catheter placement. The bladder volume, you're going to look in both a transverse and a longitudinal view. And I'm actually, looks like Cliff has that set up over there already, so I'll let Cliff kind of take it away. And Cliff, looks like we have some time here. Do you also want to look at the kidneys as well? Sure, sure. So, you can look at the whole general urinal system. As you can see, there's a big black pocket of fluid right here. Urine transmits ultrasounds really well. In fact, it's such a good transmitter that you can see a lot of brightness on the backside, which washes out the tissue behind, or deep to the bladder. But you can easily do a cross-sectional view, or longitudinal view, depending on the angle of your probe, and make, you can do some measurements. You can freeze it up, and do some linear measurements. And as Kyle pointed out, you can literally just make a quick calculation of the depth, and the width, and the diameter of the bladder, and then do the calculations, see what the volume is. I think the most practical thing is just looking at, is there a lot, or is there a little? It's going to be post-ward residuals that you're looking for, for the most part. If somebody's got a huge bladder, and they've got autonomic dysreflexia, of course, I mean, that's the first place you want to start. You can also use it to, while you're down there, if they've got pain in the pelvis, maybe it's from a distended bladder. It could be from something, especially for women, maybe a pregnancy, or something going on. You can actually use the bladder as a window, look behind at the tissue behind the bladder. You can turn it down, and you can start looking at things in the, on the backside, and looking for other potential sources of problems for causing pelvic pain, or lower abdominal pain. You can also look at the kidneys, and let me jump up, and those are very easy to find, because they're, they're nice and large. So, you can just go to the mid-axillary line, on the right side, right here. Let me just change the game, and there, you can see the liver just pops right into view, right here. The liver is a nice uniform, what they call, homogeneous echo signal, and let me just drill in a little bit. If you look around the kidney, excuse me, the liver, you'll see the kidney, right there, that just pops up, right next to it. There's a nice view of his, the kidney, right here. You can see this nice white interface between the liver and the kidney. If there's any kind of black fluid in there, that is a representative of fluid in the belly, which may represent some kind of, either ascites, or bleeding in the belly. That's called Morrison's pouch, right there. You might be able to do a quick scan of a, of a kidney stone. If you see a shadow coming down, you can see a, perhaps a cyst, or fluid collection. You might even be able to, you know, catch an early renal tumor, or something like that. Anything that looks abnormal. This kidney, obviously, looks really pretty good. From here, you can go up, you can do a sweep through the liver, just to see what's going on. On the other, the other kidney, the rule of thumb, if you're going to do it, is you have to put your knuckles to the bed, and you have to kind of aim up, and the, the left kidney sits higher than the right kidney, simply because the right kidney is pushed down by the liver. And you can see, right here, there's Adam's left kidney, right there, in long axis, going in. You can see, again, this nice bright white interface between the spleen, which is a fairly homogeneous looking tissue, and the kidney. Very easy to find. The kidney looks like a kidney. So, not a big deal. If you slide up a little bit, you can see the base of the lungs, and we'll talk about that in a little bit. The other thing you can do, if you're, if you want to explore a little bit more, is, if you're looking at the bladder, you can look, look at the bowels. So, you can just take a look at his, at, at the abdomen, if they've got belly pain, and you can see all this bright white reflection. That's all bowel gas. Again, air is the enemy of ultrasound. So, you have to kind of get around that, and if you, if you slide the probe around, you might see some non-gaseous, it looks like he's had a good lunch, because he's got a lot of gas going on right here, but the, but you can see the small intestine, which does not show that dirty shadowing going on. So, it's just a matter of taking a look and practicing. All right, back to you, Kyle. Thanks for that, Cliff. All right, moving on to our next case, case four. I can't start the IV. So, we have a 72-year-old patient with a left AKA, past medical history of peripheral vascular disease, diabetes, morbid obesity, a previous smoker. He's developing an AKI, and the nurse gives you a phone call, says, I just can't start that IV. I tried to have the charge nurse come by, we can't get it, we just can't get the IV started. Five o'clock on a Friday, you got your bag over your shoulder, you're on your way out the door. You work at a standalone rehab facility, so the only other option, really, at this point, is to send them to the emergency department. So, what's your next move? You can, in this case, we're going to go grab our ultrasound machine, and we're going to go up, and we're going to use ultrasound guidance to assist with peripheral IV placement. You know, I think in this example, a lot of us are familiar with procedural guidance as it pertains to musculoskeletal ultrasound, so this technique is rather straightforward if you've used ultrasound to assist with guiding a needle. Just identify the vein, and you can get the IV started, and in this case, move on with your weekend, labs tomorrow are going to look great, because the patient has received the IV fluid. Ultrasound guidance increases the likelihood of successful peripheral cannulization, sorry, cannulation in patients with difficult venous access. This has been demonstrated throughout numerous studies, systematic reviews, meta-analyses, and really, there's three steps. So, the first step is going to be to identify the appropriate vein to cannulate. So, to differentiate artery and a vein, an artery is typically going to pulsate, a vein is going to easily collapse. You can also perform proximal augmentation, so squeeze in the area above the vein that you're looking at to look for backflow by using color doppler. You can also measure the depth of the vein, so you want to make sure that we're targeting veins that are about 0.3 to 1.5 centimeters from the surface, and then you're going to direct the needle into the vein using ultrasound guidance, and that can be done either in short axis and long axis. One of the pitfalls as demonstrated in this picture in short axis, if you aren't visualizing the tip of that needle, you can puncture through the posterior wall. So, really, long axis, if you're able, is going to be really the way to go here. This is demonstrating some of the veins actually up in the arm that you can target as well if you're having a harder time in the forearms. The falc and the bacillic vein can also be targeted. Cliff, are you able to perform a demonstration here for us? Yeah, sure, and let me just show you the, let me see your arm here, Adam. So, I'm going to, the key for finding a good vein in the arm is start at the antecubital fossa, and then you can go up, up or down from there. What you want to do is probably stay away from, you want to find superficial veins, if you can, you can go to the deeper veins as needed. If you go towards the medial arm, you're going to end up next to the brachial artery and the median nerve, so you may want to try to stay away from the upper inner arm, but the outer arm, the cephalic vein, you can follow, you can oftentimes follow up. You can see that this is an artery, this is beating, so you don't want to be close to that, and you can see the vein that's sitting right next to it, so unless you're really good, I wouldn't, I wouldn't really, I wouldn't really go after that one because you got the nerve on one side, you got the artery on the other, but you can follow the vasculature down, and you can find, you know, very nice superficial veins anywhere, anywhere in the arm that might be, might be deeper, especially if it's a hard stick, and, and then you can isolate those, and I'll show you how you can direct the needle using ultrasound guidance down into, into the vessel. All right, so, so yeah, so this is, ultrasound is really, you know, it's almost like cheating because you can, you can actually see where you're going with, with, with your, with your needle, so let me just show you what, I'm not going to do it on my, on my very kind model today, I'm not going to place an IV, but I made this phantom model, I'll show you here, you can see this little, this is a short axis view or a cross-sectional view of a little balloon that I put into the tofu, now, so you can come at it from short axis this way, and what you'll see in the short axis is, you'll see a little white peekaboo thing kind of coming up right there, so you know I'm, so there's the needle tip, and I'm going to be, you want to get it centered, so the needle, and you can redirect the needle tip as you wish, you always want to know where the needle tip is when you're going down. I think the best way to actually find, to actually cannulate the, the vein with a, with a cannula is to look at it in long axis, you can see the needle tip coming in this way, and you can see that you can drive that needle right into, right into the vessel right there, and you know you're in, and you can just, and then you advance the catheter. The rule of thumb, if you're going to place an IV, is you want the catheter, half of it in the vessel, half of it outside, so making a measurement of the distance from the skin, from the skin down to the vessel, this one in this case is two and a half centimeters, so it's about an inch, so you're going to want at least a two-inch catheter to start this IV if you're going for a deep vein like that. So that's, that's it, it just takes practice, I would practice on your, practice on your, your, your medical students, on your residents, or just grab some tofu, extra firm, back to you, Kyle. There you go, I like it, extra firm tofu, excellent, all right, let's, let's go here with case number five, this is going to be our, our final case that we'll be discussing here today, so case five is a case that is titled shortness of breath, so a 74-year-old left MCA has been admitted about, and in three days ago there was a concern for possible aspiration, they're now on three liters nasal cannula, and you have some concerns that they may be developing in pneumonia, there's decreased breath sounds over the right lower quadrant, and also some crackles at the bases, so you place an order for a chest x-ray, you also update your, you place an order to update the CBC, and you pull out your portable ultrasound, and what you see here is actually the right lower quadrant, in this image, we see diaphragm, and then we see, we see liver here, and lungs should always appear black, and in this case, we see an increased consolidation, so this tissue, it looks very similar to that of the liver, so this is something called tissue sign, or hepatization of the lung, which is consistent with, with the consolidation in pneumonia, the chest x-ray comes back, and, and it confirms what our ultrasound has, has already shown us, the patient has started on antibiotics, and, and is managed appropriately, so this is, this is a table from a French intensivist, who was basically going out to show that lung ultrasound can be accurate, and sometimes even more accurate than chest radiography and auscultation, when diagnosing pleural effusion, alveolar consolidation, and interstitial syndrome, so, so this is a, an accurate tool that you can use in your clinical practice, so what do lungs look like? Cliff is going to demonstrate here shortly, but just as an overview, a lot of this is going to come back to the physics of ultrasound, and the patterns that we're going to expect to see with shadowing, and other things, so A lines are going to generally be normal, we see shadowing here from the rib, and then we see these A lines, which are reverberating off of the pleura. B lines, whenever we're seeing B lines, we got to be thinking that the lungs are wet, okay, so this is pulmonary edema, and this is going to be due to the fact that, that, that sound, sound wave is easily transmitted through the wet tissue, and then pneumonia, in the case of pneumonia, we're going to see consolidation, as, as I saw, as we saw in our image previously. Cliff, back to you, have you, have you take us home here with the lung evaluation? Okay, can you go back to the, your, your original slide there for a second? Yeah, the slide before? Yeah, so the, so the bottom line is, with lungs, is that air does not transmit sound well, and so if you see lung, it's abnormal, if you, you can see fluid, which is abnormal, you can see, if you see lung, it's abnormal, if you see just artifact, which is just reverberation artifacts, or this, what's called B-line artifact, that is, those are, can be quote-unquote normal lungs, but the, yeah, so on this, on Kyle's slide, you can see these A lines, the A lines represent reverberation artifact, and it's simply the, the, the signal going back and forth between the pleura and the probe, and it just reiterates itself, and it just leaves an echo, kind of like if you yell into a canyon or an empty hall, it goes, hello, hello, hello, hello, and you keep hearing it, that's normal, because the, the sound bounces off the, the air-filled normal lung. If the lungs are wet, then you start to get these B lines. B lines, you can have two B lines per rib section, and that's quote unquote normal. But if you have more than two, it's abnormal. The lungs are wet. And if, again, in the consolidation, you actually see the lung tissue, and that's definitely abnormal. The, in COVID, what you'll see is B lines and A lines mixed all over the lung. So it's going to be a patchy distribution. You'll see B lines in some area and then normal A lines and then B lines and then A lines. So that's the, that's the pathognomonic finding for COVID versus a lower lobe pneumonia, which is really going to have normal lung all up on the top, and then these wet lungs at the bottom, and maybe even a fusion at the bottom. So let me, let me go ahead and I'll scan, Adam, if you slide down just a little bit for me. There we go. All right. So we're going to go back to my, my ultrasound machine here. And what we're going to do is going to look, look at Adam's, Adam's lungs. I'm going to, I'm quite deep here. So you can, the gain here you can see is almost 20 centimeters, 18 centimeters. And so you always want to start, if you can look at the lungs, always start deep and then you can always dial it back and look, go, go more, go more superficial. So here you can see ribs, rib shadows. Here's a rib right here. There's a rib right there. And you can see the shadows behind because the sound does not travel through bone. But if you watch Adam breathe, go ahead and take a breath, you'll see the pleura and just blow it out slowly. There you go. You can, it looks like marching ants and that's a sign that that lung is normal. It's moving. It is not a, it's not a pneumothorax because if it was a pneumothorax, you would not see that, that marching ant sliding lung sign. If I go a little bit deeper and I changed my gain a little bit, now suddenly you can start to, and you, and you toggle back and forth with the probe, you'll start to see these A lines. Let me go. So I'm going to go, I'm going to really bring up the gain here. But if I glide back and forth there, you can see the reverberations coming in normal. If you see A lines, you're in pretty good shape unless you're expecting a pneumothorax or something. But if you see A lines, that's normal. That's good. A is good. And then you can see if you slide down the lung and you want to scan kind of the, the kind of two areas in the front, maybe the mid axillary line in the middle. And then you want to take a quick look in the base of the lungs in the backside. But if you, if you slide, if I go over here, right above the liver, you can see the you can see the tip of the lung right here. Take a deep breath for me, Adam. And you can see the lung slide in with A lines and blow it out. And then you see the edge of the lung blowing out. And that's right where the lung meets the diaphragm and the liver right there, if you want to. And then you can look for these, what they call lung rockets, which are the B lines. And you don't, luckily with Adam, we don't see any. And, but if you, yeah, you almost, I almost saw one a little while ago. You can sometimes see these little shooters that shoot down into the depth of the lung. And you want to go again, you want to have a very deep focus to look and look for those B lines and the B lines are going to go all the way down to the bottom of your image. They're going to, they're going to go right through the water of the interstitial tissue or in the alveoli. And they're going to go all the way down to the base. So, so those are, if you see more than two B lines, it's abnormal. And, and then the other thing you can look at while you're here, if you're, if you're looking at the, at the left lung, you might also just have some fun and you look, look at the lung over here and, and then you can come down and you might see something that is, that's beating in here. And that would be, that would be his heart right in here. So there, you can see, take a deep breath for me there. There's, there's his heart beating away right there. So why not take a look? If you're going to be playing with ultrasound, take a look at it, see if you can see the heart. You can also just, this is a little aside, but if you're worried about somebody having something wrong with their heart, you can use the liver as a guide and you can kind of tuck it underneath the ribs here. And you can see if you can see he's full of, he's full of lunch. So I may not be able to see, see his, see his heart underneath the rib caper right there. You can see a pretty good view of what's going on there. So that's another use case for ultrasound. Somebody coming in with shortness of breath. Do they have congestive heart failure? Yeah, you can look and you can just see if the, if the heart's beating, if they, if you've got tamponade, if they, if they're low volume. So, so many, so many use cases that you can, you can use. I can think of for inpatient unit. Go ahead. Back to you, Kyle. All right. So in summary, so we went through now five cases, DVT screening, soft tissue evaluation, bladder evaluation, IV placement, and lung evaluation. So really our goal today wasn't to make you experts in these specific techniques, but it was really to encourage you to find ways in your practice to really start using ultrasound. You know, you can palpate, you can listen. So, so, so why not look? Cliff, any other thoughts here before we close and take time for questions? Yeah. I mean, as you say, Kyle, you can, you can use this, you can use this tool from, like I said, from the eyeballs right down to the toenails. So it's, it's totally safe. I mean, why not? You can look at thyroid, you can look at carotids, you can look at just about anything inside the body totally safely. You can't see through bone very well. So looking at the brain, not that great, unless it's a, you know, an infant's brain, but sometimes you can see the middle cerebral artery, but it gets a little complicated. The bottom line is that this is a, this is a portable diagnostic radiology department almost. When I, when we teach internationally, they have, they have maybe two CT scans in Haiti. They have one MRI machine in Haiti. They have, they have probably seven x-ray machines and four of them don't work. This is what we provide them and they are saving lives with this. And you can save lives too, in my mind, on the inpatient unit, just by screening for DVTs, save somebody a PE, get them, get them early coagulated, finding somebody with a pneumothorax with a pneumonia, a pericardial tamponade, blood in the belly, even a, you know, a pregnancy that you didn't even know about for a spinal cord patient that came in, young woman. So you, there's so many use cases that you can, that you can apply the ultrasound to that it, it seems a shame that everyone focuses on the MSK world, which is great. But I think for the people that are doing more in-hospital work, it should be something that you just feel very comfortable pulling out. If you don't know what you're looking at, no harm, no foul. If you, if you can rule something out, you see this, you see there's a distended bladder, boom, you've already made a huge, huge advanced diagnosis and it's about the speed, it's immediate. So that's, that's a beautiful thing about it. Kyle, maybe you can talk to your residency program after you guys started using ultrasound, what, you know, some of the use cases for yourself, just saves that you made. Yeah. Yeah. So we've been using it, as I mentioned, for, for screening for, for DVT. And there's been a lot of growing interest in that amongst the, amongst those in the hospital, really, because unfortunately, as we've alluded to, we don't have a great way to screen for DVT outside of sending these patients for a formal duplex ultrasound. So this can be something that you can do while you're, while you're examining the patient during your initial time meeting the patient. And it takes a couple minutes. We've also been using this, as I mentioned, in conjunction with our wound care team. So our, one of our wound care nurses will commonly shoot me a call or shoot me a text or call me and say, Hey, can you come, come down and take a look at a wound for me? So there are really lots of different settings and, and you just got to kind of be creative about how you can use it. And then the biggest thing I think is Cliff has alluded to is, is lowering the fear. You know, there are times where I don't know what I'm seeing and that's okay, because I'm going to manage the patient the same way that I would have otherwise, you know, at least I, at least I was able to take a look again, as an extension of my physical exam. So here are reference slides as Cliff mentioned you know, please feel free to go through some of these and go through the slides if you have, if you want to see some of this content in greater depth. At this point, I do want to say a quick thanks to Carla and to Megan and to the Academy for, for allowing us to present today. And at this time, we'll, we'll, we'll answer your questions. Please put your, your questions as you have them in the chat box. And I'm going to take a look here just to see what we have so far. Yeah, I'm looking at the chat box right now. The first question was trying to incorporate into PMR programs. There was a concern about the, the teaching, and then also the, the legal ramifications. And like we said before, you know, you will not get to the skill set of a, of a seasoned sonographer or radiologist, but are you going to get sued for using your stethoscope and missing a diagnosis, missing a heart murmur, something along those lines? It's, it really is the full package. It's the, it's the clinical scenario that you're working within, right? So if you rely totally on ultrasound, then you're missing the point of the message, which is it's an extension of your physical exam. And it really becomes, you have a super exam because now you can actually look inside and see if you can confirm or refute what you're thinking is causing the problem. So as far as the, you know, lawsuits, et cetera, you can talk with your hospital staff, et cetera. But the bottom line is as we pointed out, there have been no lawsuits for using ultrasound. So I, I think if you can get rid of that fear of ultrasounds, you know, malpractice cases, it's going to be pretty small. And again, it's the right thing to do for your patient because you can actually save them. You can actually save their life if you diagnose a DVT just with a simple ultrasound, you know, femoral nerve screening. So, and then as far as the training is concerned, you're right. The, the ultrasound is new technology and the attendings, many of the attendings don't know about it, or they don't feel comfortable with it. It's the younger, the younger guard, which is coming in, it's going to bring ultrasound to the wards, to the clinics, et cetera. I think it should be a, you know, a full effort on all sides. The PM&R program should, should be using it on the inpatient and, and encouraging it. They should be learning the MSK ultrasound as well. It's just the way of the future. So, and, and again, the medical students that will come out in 10 years, they will be very savvy in doing ultrasound. We have a question here. What are the three common uses for ultrasound in office? And what are reimbursement? What about reimbursement? Cliff, any, any thoughts on that one there? Sure. So, in the office, it depends on, you know, it depends on your practice type. If you're a generalist and you're, well, let me back up. If you're an MSK specialist, you're going to be looking mostly at the muscles and tendons, but you know, I've made some amazing diagnoses that are not MSK related in my, in the 20 years I've been doing ultrasound. The, for, for a generalist, I would, I would imagine that somebody comes in with a lower extremity edema, right? There's a, there's a very common presentation. Is it medications? Is it a clot, et cetera? Quick DVT screen? Boom. Okay. You rule that out. You can look at their heart while you're doing that. Do they have a little congestion, little heart failure? Is the vena cava full? We didn't talk about the vena cava today, but you can just see, is it full or is it flat? And if, if the vena cava is flat and they, but the heart is you know, then the heart's probably not, not pumping because the pressure's low. If they've got a PE, all the right side of the system is going to back up. So, their right ventricle is going to be enlarged. Their, their vena cava is going to be enlarged. And then you can send them for the appropriate tests that you're, you're thinking about doing. And then you can look at lungs like today with COVID. I mean, if somebody's coming in with a cough, you can do a quick screen, look to see if they've got B lines versus A lines. If it's a patchy distribution of, of abnormal and normal lung findings, then you can, you can presume they've got COVID because that's the pathognomonic ultrasound finding for COVID is that, is it's, it's in patches, normal next to abnormal and versus a low bar pneumonia, which is sitting down low. And yeah, I mean, you could look at carotids if they're, if they're feeling dizzy, you could see if they've got a block in their, in their carotid arteries. So, I could go on and on. We've made, we've made some, I've diagnosed somebody with lung cancer that grew up. They, they missed, they were floating around town for a month, excuse me, a year, came to me. I saw a little lump right up here in the shoulder and it turned out not to be captured on the neck MRI, not to be captured on the shoulder MRI, but it turned out to be a lung tumor that had grown up through the clavicle into the supraspinous fossa. And it was just sitting there like this little egg and diagnosed it in a minute with ultrasound. Cause I knew it wasn't normal. And that was the, that's the differentiator is like, is learn what normal is. Is it normal or abnormal? Is it? No, you're normal. Learn to ride a bike on a plain flat road, and then you can go up on the curb. Then you can go in the dirt and you can go in the terrain park. Then you can do the X games. You just build your confidence up, but you got to piece it together. It sounds daunting, but it's just one bite at a time. And, and you will get more and more confident as far as billing is concerned. It's up to you. You, you, the, the, the rule of thumb is take a picture. If you take a picture and you document what you're, what you're seeing, then that could be a limited diagnostic ultrasound. And there's different codes depending on if you're doing a limited DVT screen or a complete, et cetera, the complete DVT screens are probably going to be the domain of the sonographer and the radiology department, but, but you can do a limited screening and, you know, take a picture, show some, show some collapsible veins, et cetera, or a non collapsible vein. And you can bill for that. Most of the study, most of the billing is going to be unlimited codes and we can't get into that today. And then as far as, as far as the, the bowel evaluation, which is the next question you can see Adam's got a fair amount of gas. The big thing for bowels is you want to try to find windows that you can see into the, into the belly and you can see the small bowel moving. You'll see it peristalsis. You'll see it, you'll see a gliding, but you're not going to see this dirty shadowing that you see on this, this image right here, which is kind of this white fluffy stuff. That's usually air. And that's going to be large intestine. But if they've got a, if they've got volvulus or some big pocket of air, you're going to see that it's going to be, you'll see a, a lump right there. You can also diagnose appendicitis with it. If you, you know, once you get that far, yep. You can see stool in the colon, it's going to be in the small bowel, not so much in the large bowel, but you'll see it moving around the bowel. The bowels are a little bit more advanced you know, but, but take a look, no harm, no foul for looking. And it looks like the final question here is, is about reimbursement, which we touched on a little bit. And then any data that one could use as a way to influence the department to pay for the ultrasound to demonstrate its worth and cost savings. Sure. Well, I, you know, what, what you might do is talk to your billing, billing team or person, et cetera. Find out what the, the reimbursement codes are in your area. Every region has its own Medicare fee schedule, et cetera, and then, and different insurance reimbursements and all that. So I can't really answer that question for you specifically, but I would talk to your billing person, find the, the ultrasound codes, and you can, you can probably use the codes that are in the emergency medicine, emergency medicine specialty, because those are the ones that you're probably going to be using. DVT, bowels, you know, limited pelvic exam, heart, lungs, et cetera. That's what, that's what they do. So I would see what those codes are and then see what the, see what the reimbursement is for your, for your area. And then you can just guesstimate how many patients you might see, you might use, et cetera. You know, if you, if you go past the money, from my perspective, it's ultrasound is just the right thing to do. Again, it's safe. The patients love it. You can get an immediate diagnosis. You can, you can rule out other things if you don't, if it doesn't confirm your diagnosis, like if it's, there's no clot in the leg, then think of something else that's causing the shortness of breath, et cetera. So it is, it is a, and it's, it's fun. It is just, it adds so much excitement to your practice just to be able to look inside the body real time. You almost feel like you're cheating a bit doing medicine instead of just poking and listening. You actually can, you know, you can see the heart beating. It is just magic. All right, I'll shut up. Well, Cliff, this has been fun. We, we're coming to a close here. So, so thanks for joining me today. Everyone who's watching currently, or those who are streaming later, thanks for, thanks for coming on board and giving us a listen. If you have any questions, you, our contact information should be available. I would be happy to answer any questions in the future. Thank you. Thank you, Kyle. And thank, thank you to AAP Menard for letting us present this along with Carla and Megan to, you know, to facilitate. And again, if you have any questions, reach out to Kyle or me, I'd be more than happy to, you know, guide you on some of the things we talked about today, where to get, where to get taught and some of the billing questions, et cetera. Have a good one. Thanks.

Musculoskeletal Ultrasound

Inpatient Settings

Clinic Settings

DVT Screening

Soft Tissue Evaluation

Bladder Scanning

Lung Evaluation

IV Placement

Portable Ultrasound