Don’t worry: you are not going to be reading about energy and the stability of molecules. Not my style. Nor is this a review of the POCUS literature or clinical use cases; too many people have done that well already. This blog is simply putting pen to paper (or keystroke to software/hardware) regarding some longstanding musings that recur every time I am on clinical duty or wandering the hospital for teaching purposes. Hopefully, you will even find a few helpful tips! I like to call this “trolling1 the wards” for nice patients who are up for visitors wanting to practice their ultrasound image acquisition skills. Trust me, you’ll get many more suggestions and approvals than if you ask for specific pathologies or conditions. And often we provide a bored patient or a curious family member the benefit of conversation, companionship, music2, and education.
For over a decade (long before easy access to handheld machines), there have been certain patients we would avoid when solely performing educational ultrasounds. Clostridium difficile? No thanks. Even with a cover, the transducer needs low-level disinfection via a bleach wipe, which is harder on the rubber/plastic. The same is true for patients on contact precautions due to drug-resistant bacteria. As a nearly lifelong Oregonian, I cannot stand waste, and medical waste is no different. Keep those 3-5 disposable gowns for the actual care team members! Finally, the last and most awkward of the usually hard passes is the patient on another floor or in another building on a unit with no ultrasound machine. The learner(s) and I pause, look at each other uncomfortably, write down the building/floor/room, thank the team…and then leave to find additional suggestions. Sometimes, these lovely, lonely people who enjoy learners are above our activation energy.
What am I talking about? According to Merriam-Webster, activation energy is “the minimum amount of energy required to convert a normal stable molecule into a reactive molecule.”
I also enjoy the graphic shown below. (source: https://jamesclear.com/chemistry-habit)
You see, the learner(s) and I are operating at level A, have scheduled time together, do the prerequisite lecture or video review, come to the hospital, get a machine, etc. But in case you haven’t personally experienced this…. hospital elevators are crowded, slow, sometimes out-of-order for maintenance, and the list goes on. To make it to the patient at the peak of B in the graphic, we might have to wait for an elevator to take a cart-based machine down 4 floors, then through a long hallway into another building, then up an elevator 3 more floors. We could have done a full kidney/bladder scan in that time! Having completed Grand Rounds, visiting professorships, and other engagements at multiple other hospitals, I will tell you we are not alone in this.
And this is where wireless (aka handheld, aka HHUS, aka ultraportable, aka probe in a pocket, etc) comes in. Stairs become your best friend. The ability to “cast” the image from one wireless device to multiple phones with the app is clutch. Sometimes, I bring the phone I jokingly refer to as my “burner” so the patient and family can watch along on their own. We can keep rolling and scan/communicate with and learn from patients all over, and most really enjoy the experience3.
Now, let’s quickly picture you are on the clinical service, and your patients are not geographically isolated in one unit. Hospitalists and consultants likely know exactly what I am talking about! You’re not just here for teaching; you have multiple patients to see and a million different responsibilities, and sometimes ordering consultative or radiology-based exams is the A, and getting that ultrasound machine to the patient is the B. Even if you know you can probably get the answer faster yourself.
You might think this sounds terrible, but I hear it from many, many providers. “I just don’t have time for POCUS.” “I don’t have easy access to a machine.” “My patients are all over the hospital.” Ultimately, for increasingly busy clinicians, the most effective tool is the one they will actually use. And in my personal practice, having an ultrasound device in my right pocket with my stethoscope in my left is the natural way to assess that new hypoxemia, chest pain, reduced urine output and more. Of course, handheld units are not perfect. I will schlep to get a cart-based machine if needed for penetration in a morbidly obese patient or a calcs package I don’t have on my own. But far & away, a scanner in the hand is worth two in remote storage closets.
Footnotes
1: This has been in use since long before social media trolls with bad intentions…
2: for both educational POCUS and procedures, I ask patients if they would like to listen to music to soothe their nerves, distract them, or simply lift their mood. I create a XXX station with whatever song or artist they choose, and we all enjoy it. HT to Andrew Liteplo at MGH for this one he included in a lecture back in prob 2016
3: I have a financial conflict of interest as an employee and Chief Medical Officer of Vave Health. My other clinical employer-approved mitigation plan includes my disclosure of this to learners, and disclosure to/approval from any patient I want to scan with my Vave device. I do not believe in billing scans on a device from a company for which I work, so it is largely used when needed on the fly on rounds/patient care, or for teaching purposes.
Author:
Renee K Dversdal, MD, FAIUM, FACP
Chief Medical Officer, Vave Health & Professor of Medicine