Ask Us Anything With Mike & Matt

I fell in love with US because I saw the INCREDIBLE advantage it gave to docs who knew how to use it. I remember having an “aha moment” in residency when I needed help on a critically ill patient and I chose to grab the attending who was better at ultrasound over the other attending who I really thought was a smarter doc. It just elevates your game that much. I really wished the smart attending knew how to use it, but I chose the guy with the skills for this crashing patient.

I like the visual aspect of diagnosis, always have. Plus it gives you so much information, it almost feels like cheating. I love being able to confirm diagnoses or suspicions immediately at the bedside.

The biggest I see coming is TEE in cardiac arrest care for directing CPR and pulse checks. Other areas with promise are us guided TPA administration, and appendicitis ultrasound.

Line placement, aorta, fast, cellulitis/abscess, basic cardiac. Thats a good start, once you get the hang of just one scan type, you won’t be able to stop. It’s like Pringles for physicians.

I think you have to be able to guide a needle to a target. Whether we’re talking about central lines, thoracentesis, paracentesis, or whatever. Even if you “trained without it”, get that skill. You don’t have to dive into nerve blocks and advanced stuff, but if you’re doing blind central lines……be afraid, very afraid.

Huge! In my opinion thats how the millennial generation is learning. I can’t express enough the importance to interact with students outside of the classroom, on their own time and their comfortable environments.

Agreed. Obviously, there are issues, and having personal, live mentors is really important. However, to let you in on a dirty secret, I probably learned half of what I do with ultrasound asynchronously, on my own after getting a solid base in residency training.

Not sure yet, we need to work out some Kinks. Not sure if it will be google glass or another form of wearable video conferencing, but there is a clear advantage to sharing images of patients, clinical cases and other questions in real time with educators and experts.

Tough question since they just pulled the rug out from under us by removing the live hangout feature that we used in our study of google glass in cardiac ultrasound. Probably a better UI and next iteration will make it easier. 3 things that make it the most appealing: Heads up display POV of provider Hands free to do procedures with guidance

We want every doctors, everywhere to be capable of wielding an ultrasound probe. To do that, we need leaders all over the world. ULA’s goal is to bring expert level ultrasound education to any corner of the world no matter what educators are there on the ground.

Honestly, it came out of frustration. We were proud of the ebooks, podcasts, apps, etc. But we were very frustrated that people would email us about coming to learn with us, and we weren’t able to take them on in a more formal, organized, intimate, robust way. So we created a way to do that.

My career goals have always been to make Dawson look slow and unsuccessful. I’ve got a ways to go, but I’m committed.

That’s a tough question. I think I’ve reached the point of expansion by deletion. I almost feel like I’ve personally gotten into too many things and I’m thinking I should scale back and focus on the things that are the most rewarding and seem to be working.

Bluetooth to ipad/iphone, single probe with linear, curved and high/low frequencies. US directed medication administration (TPA), therapeutic ultrasound (clots). Wearable, real time flow measurements (carotid doppler during cardiac arrest), those are just a few thoughts.

2 ridiculous things right now: 1. The cord 2. The price There are companies that have solved both problems, but it’s just getting them to the market that is going to be tough. We’ll probably start to see major shifts in both of these in the next couple of years. That will be the real catalyst that puts this in the pocket of every doc. These things being solved at the same time as our first generation of large numbers of med students coming out who had integrated curriculums.

Consumer ultrasound, thats the next big push.

I don’t think we’re at a holy grail yet, but carotid VTI / flowtime has a lot of promise. I wouldn’t be surprised if we start looking at a combo of carotid, SMA, and renal artery flow and responsive in spont breathing patients to help with fluids versus pressers question.

Start thinking about research ideas and areas where you can improve on your resident curriculum. Also, try to start teaching some. Teaching is the best way to learn.

Show them it matters. Don’t just scan every body part that you can. They’re busy and probably don’t have time to “just practice”. So use it when it makes a difference.
If that doesn’t work, then embarrass them. There are plenty of opportunities to go scoop them on the diagnosis after they’ve ordered a ridiculous X-ray or something like that. Much better than scooping them, though is going to the bedside with them immediately after presentation and show them how much more accurate their assessment could have been with a probe in their hand. Show, don’t tell.

Can’t wait. I still have my robe from last year. In fact I may or may not be wearing it right now!

I learn on Ma. It’s hard to beat, but Arntfields new Point of Care Ultrasound book is pretty awesome.

Also, I heard someone made an ibook/ebook. But i’m sure it’s crap……..

Would be weird to recommend our own ebooks…..but also weird not to. Since I’m recommending it, I’m also going to make it free on iTunes and .99 on inkling.com today (inkling prohibits us from free now) so I don’t feel like a douche for mentioning it.
If you’re long on cash, get Arntfield’s new ebook.

It was my idea. I’ve been carrying Dawson for years.

Definitely my idea. If there’s a good idea on the podcast it’s mine. If you disagree with something, that’s Mallin. Good rule of thumb.

Just kidding, I think we came to the idea over the course of our fellowship and doing QA together, cracking jokes and teaching the students and residents. We both were big EMRAP listeners at the time, and wanted someone to dod it with ultrasound, eventually we just decided to give it a go since no one else was doing it.

Thats BS Dawson, i remember calling you with the idea. in fact I recorded the conversation in case you ever tried to claim it, like you do all my good jokes.

Oh, I remember that call: Mallin: Hey, you got any good ideas? Dawson: Yeah, we should start a podcast. That’s the exact transcript I just copied from my records.

hmmm, good question
TEE is a big one for me. Most people don’t have the equipment.
Appy is another big one, probably the hardest exam I can think of, but so rewarding when you save an 18yo F the radiation.

Seriously, everyone should know TEE? You are one warped cardiophile. I’m sure I’ll eat those words 10 years from now, but I think we can go after some lower hanging fruit. 1. Lung 2. MSK 3. Nerve block Those are the biggest bang for the buck that very few are actually doing. Even lower hanging fruit out there, but those are the ones that few people do outside of ultrasound freaks.

Tool #1 – #foamed.

I listen voraciously, and then go and read when I hear something new that I want to dig into.

Tool #2 – colleagues – I’m shameless in getting colleagues at my hospital or elsewhere to show me any new skills, techniques, or other things they know that I don’t.

FOAM and Twitter are huge for me. I have trouble keeping up, so I depend on 100-200 people all over the world to keep me up to date. Just read their tweets to help figure out where the good resources are.

I think a fellowship helps, and right now is a good time, since it’s not ACGME yet, but I don’t think you have to have one. Creating a niche for yourself and being academically productive is usually enough, with or without a fellowship.

Definitely don’t have to do an US Fellowship to land a faculty position in general. However, depending on where you’re applying and where you came from, a fellowship could be huge in determining hired or no. If you’re considering, you should go for it. I’m sure many more people regret not doing it than doing it.

Fellows will be paid as PGY4 or 5s for starters, plus, there will likely be less programs- harder to run them. But there will be more standardization amongst the fellowships.

1. Pay – probably lower most places (complicated)
2. Standardization – Will be much more standard education across the country
3. Recognition? This one very debatable. Many thought this was a big plus, but others feel like we’ve already arrived.

Catching a Ao Dissection in a STEMI and getting pt to OR instead of cath lab. Or picking up an ectopic in a young women who was combative with AMS. Misses: my most recent was a false positive appy – whoops. She turned out to have a ruptured ovarian cyst. #cantwinthemall

Great question. Not sure there is a good answer. Obviously the more the better, but I hardly scanned at all with mine, and I know a lot of good ultrasonographers that had the same experience. We can teach ourselves a lot of this through FOAM and online education.

Did a podcast on this. Plenty of things that could be helpful in certain circumstances:
http://www.ultrasoundpodcas…

I am also a fan of the RUSH exam, but I’ve changed the order. Lungs, heart, IVC, FAST, Aorta. Also, happy to change the order based on the patients appearance. for example, CHF hx with confusion, inc RR, and crackles, I’m starting with lungs and heart. Distended belly with syncope, I’m starting with aorta.

Not really tweaked. Twerked it a bit, though.

Why not just Shake it out?

Cordless probes walk away, also the power needed to run the crystals is significant and the battery would be heavy and not last long. Those are the excuses the companies give me. I’m sure google or apple could fix that in 12 hours if they were interested.

They exist. Just not commercialized yet. Of course, some are available, but if you put a proprietary screen with it, then I don’t give you credit for it (I’m looking at you Siemens).

Absolutely! Yes, we developed a basic curriculum for our IM residents that they’re going through this year. Starting with the basics (central line, etc), then getting more advanced. They’re loving it. We use #foamed videos and then get together for workshops every week or two.

Depends on the surgeon on call. We’ve worked really hard to get them to trust us. That takes time. A 50 yo would be a tough sell. I feel like getting them involved in looking at the images is huge.

Depends on which surgeon is on.

Honestly, the math is totally different with that patient, though. Much less harm from radiation than in a kid. Still less cost possibly and time saved, but when you take out the radiation harm and the slightly lower pre-test probability with a 50 year old, then it should be a pretty good story and pretty convincing ultrasound.

Constant badgering, only calling when I know I’m right, reminding them when I am, and trying to get them involved in reviewing the images with me.

You’re credibility is always on the line. Don’t be caviler.

This was a problem for me a few years ago, but not as much now. Obviously, there are PLENTY of doubters left at my University, but there are SO MANY people who believe and want to learn that I’m too busy teaching to be spending a lot of time trying to convince the non-believers. I just teach the believers and let them run laps around the nonbelievers. Much more fun and less frustrating that way. Let my students do the convincing for me.

I put the US probe on the cric-thyroid membrane to try to block the trauma surgeon from applying cric pressure.

Yes, for kids to confirm tube is in right place. Here is link to the podcast……oh crap, haven’t published that yet! Well, look for that podcast on how to do that in the next week or so. Occasionally also confirming dynamically occasionally if resident using DL. Just makes me more comfortable.

Well, obviously in no particular order that is:
Castlefest 2012
Castlefest 2013
Castlefest 2014
Castlefest 2015
oh, and yellowstone.

Mike: Do you have any disclosures?

I’m not sure there is a right answer to that question. Matt and I put on a few and have a good time with it, but there are a ton of courses out there. The important thing is that you find one that fits your personality and get the education however you can.

Wow, great question. TOTALLY depends on the type of learner you are. Personally, I’d just go where there is the most pathology possible. I’m a pretty independent learner and feel like there’s so much education out there that I just need the probe and sick patients.

Of course, also think about what you want your career to look like and maybe go somewhere where someone has such a career. That way they can guide you down tha
t path.

Honestly, pretty personalized decision depending on your needs and style.

I would track down Mike Stone and harasses him until he let me hang out with him

Quality education mixed with entertainment is key in my book. Otherwise I get bored quickly. Organization is also huge, which is something I think we even struggle with.

No, all mine were completed.

Still do. Luckily the residents catch me before I finish the job.

jk. I do remember one specifically. Elderly lady who had chest pain and I signed out to fellow resident that she was awaiting troponins. Found out the the next day she deteriorated and they found tamponade on RUSH exam. She survived, but probably didn’t do as well as she would have if I’d thrown the probe on her chest immediately.

Matt and I had a patient during residency that we both “tried to kill” and ended up catching the other ones mistakes on alternating call shifts. It’s good to have backup and multiple people caring for the same patient.