All posts by Manny Singh

Ask Me Anything With Mike Stone, MD (@bedsidesono)

Update: This AMA will be happening Friday, December 12th from Noon-1:30pm EST.

We’re very pleased to announce that our next Ask Me Anything will be with Mike Stone, MD, RDMS. Dr. Stone is the Division Chief of Emergency Ultrasound and the Emergency Ultrasound Fellowship Director at Brigham and Women’s Hospital in Boston, MA, and can be found on Twitter as @bedsidesono.

  Ask Me Anything with Mike Stone, MD (@bedsidesono) (12/12/2014) 
11:53
Adaira Landry: 

Welcome everyone to this Ask Me Anything with Mike Stone (@bedsidesono)! We’ll get started in a few minutes!

Friday December 12, 2014 11:53 Adaira Landry
11:57
[Comment From Alex koyfmanAlex koyfman: ] 

In your eyes, what’s in store for the future of EM ultrasound?

Friday December 12, 2014 11:57 Alex koyfman
 
Mike Stone: 

2 big things
1) increased utilization by more providers. Point of care ultrasound is a very attending-dependent and institution-dependent modality at this moment. I see more widespread adoption as we move forward
2) outcomes-based research and evidence-based imaging guidelines that incorporate POC ultrasound and clinical/lab features (aka ultrasound-assisted decision instruments)

  Mike Stone
11:58
[Comment From Alex koyfmanAlex koyfman: ] 

How do you motivate residents/faculty to use US on a regular basis?

Friday December 12, 2014 11:58 Alex koyfman
 
Mike Stone: 

Shame is a great motivator. JK. We promote great saves and pick-ups and once the residents and PA’s catch the US bug, the attendings tend to see it as something they better become skilled at performing (or at the least interpreting)

  Mike Stone
11:58
[Comment From guestsguests: ] 

For someone starting a new ultrasound section in their department, what are a few must-haves?

Friday December 12, 2014 11:58 guests
 
Mike Stone: 

1) an ultrasound machine
2) a supportive chair
3) some protected time to spend on the mundane but critical things like hospital privileging, QA system development, image archival, etc

  Mike Stone
12:00
[Comment From MarkMark: ] 

What are some must know papers in your field that all residents/attendings should know?

Friday December 12, 2014 12:00 Mark
 
Mike Stone: 

http://www.ncbi.nlm.nih.gov…
http://www.ncbi.nlm.nih.gov…
http://www.ncbi.nlm.nih.gov… Would also suggest the 2008 ACEP ultrasound guidelines (available at acep.org) which are due for an upcoming revision

  Mike Stone
12:02
[Comment From alex koyfmanalex koyfman: ] 

what are 3 EM myths you hope would go away?

Friday December 12, 2014 12:02 alex koyfman
 
Mike Stone: 

that we should use kayexalate
that nerve blocks are very high-risk procedures
that ketamine is anything other than the best sedative/analgesic available to us

  Mike Stone
12:04
[Comment From EMdudeEMdude: ] 

Hey Mike! thanks for doing this…what are some cool ways you’ve incorporated ultrasound into resident education at the various places you’ve worked?

Friday December 12, 2014 12:04 EMdude
 
Mike Stone: 

It’s my pleasure. Glad to have the opportunity. Incorporating hands-on sessions into traditional didactics, having a “most scans in a day” record, and giving residents the chance to record and post great cases online have all been fun ways to get residents engaged in learning point of care ultrasound

  Mike Stone
12:06
[Comment From JohnJohn: ] 

What do you think are the biggest pitfalls/bad habits residents have when it comes to utilizing POCUS?

Friday December 12, 2014 12:06 John
 
Mike Stone: 

not scanning all the way through a structure (failing to define boundaries of a structure) in both planes. rushing to a diagnostic conclusion based on u/s without taking into account the full clinical picture. ultimately, it’s really about getting good fundamentals down and then applying them (transducer selection, preset selection, image optimisation, enough pressure, good technique)

  Mike Stone
12:06
[Comment From AnnonymousAnnonymous: ] 

Why do the ultrasound probes have to have cords? Any reason they cant be cordless? They are gross and always getting caught in the wheels!

Friday December 12, 2014 12:06 Annonymous
 
Mike Stone: 

They don’t have to have cords. Siemens makes a cordless transducer and I can only assume there’s more coming from other manufacturers. I’m a bit afraid of them losing cords and developing legs, though…

  Mike Stone
12:07
[Comment From bakerbaker: ] 

do you think there’s a role for integrating ultrasound into other kinds of technology in the ED (smart phones, the EHR, etc.)? if so, what would you envision?

Friday December 12, 2014 12:07 baker
 
Mike Stone: 

Yes. It’s happening already. Will see more commercial releases in the coming months. Can’t say much more on it I’m afraid but stay tuned

  Mike Stone
12:08
[Comment From AnnonymousAnnonymous: ] 

in the trauma bay, what order are you doing your EFAST? Some trauma attendings yell if I don’t start with the cardiac view first… are you a stickler on this?

Friday December 12, 2014 12:08 Annonymous
 
Mike Stone: 

Penetrating trauma to the box = cardiac first for me
Blunt trauma = abdomen and lungs first generally
Ultimately I think the order isn’t too important if you can do the exam in ~2 minutes, but trauma attendings do sometimes yearn for the excuse to yell about something

  Mike Stone
12:09
[Comment From Alex KoyfmanAlex Koyfman: ] 

How do you balance work and family life?

Friday December 12, 2014 12:09 Alex Koyfman
 
Mike Stone: 

A constant struggle. The short answer is I make sure I have 2 full days off every week (whether weekend or not) and I do most of my non-clinical work at night after everyone’s asleep. Will never look back and wish I spent more time at work so I’m trying to live that principle now.

  Mike Stone
12:10
[Comment From Adaira LandryAdaira Landry: ] 

What system do you use to stay organized and productive?

Friday December 12, 2014 12:10 Adaira Landry
 
Mike Stone: 

Largely Google-based with Any.do as a task manager and a “someday I’ll get to that” list. Have tried a TON of products but the answer for me to staying productive lies more in taking stock of my current projects on a regular basis than in any particular product.

  Mike Stone
12:12
[Comment From davedave: ] 

somewhat considering a fellowship in U/S…What are some things I can do aside from being an ultrasound director after training?

Friday December 12, 2014 12:12 dave
 
Mike Stone: 

I think ultrasound fellowship is a great step for people who want to teach and/or perform research in point-of-care ultrasound. not a necessary step to get skilled in performing/interpreting ultrasound. Think I’d advise against it unless looking to start/maintain a program, looking to educate others (MD’s, NP’s, PA’s, students, pre-hospital) or looking to do US research

  Mike Stone
12:14
[Comment From alex koyfmanalex koyfman: ] 

What are your 3 favorite papers that you’ve published?

Friday December 12, 2014 12:14 alex koyfman
 
Mike Stone: 

I suppose I still like the EPSS paper and the supraclavicular nerve block papers. Haven’t done nearly enough with good quality research but feel lucky to have had the chance to goof around and get published

  Mike Stone
12:15
[Comment From alex koyfmanalex koyfman: ] 

who has influenced your career the most?

Friday December 12, 2014 12:15 alex koyfman
 
Mike Stone: 

On the medicine side – Dave English, Barry Simon, Mike Blaivas, Dave Adler, Arun Nagdev, Andrew Herring, Ron Walls
On the personal side – my father (retired urologist – yes, named Dr. Stone) and my wife and kids

  Mike Stone
12:15
[Comment From davedave: ] 

also….if you could only do one scan over and over for the rest of your life. just that one scan…what would it be?

Friday December 12, 2014 12:15 dave
 
Mike Stone: 

appy. no question

  Mike Stone
12:16
[Comment From alex koyfmanalex koyfman: ] 

Having lived on both coasts, what’s your favorite city and why?

Friday December 12, 2014 12:16 alex koyfman
 
Mike Stone: 

Oakland vs. Brooklyn is a tough call. I’d go with the west coast due to weather and general laidback attitude. If my family wasn’t all east coast I think we’d still be out there.

  Mike Stone
12:17
[Comment From alex koyfmanalex koyfman: ] 

Have you been able to use US in conjunction w/ consultation to dispo pts faster?

Friday December 12, 2014 12:17 alex koyfman
 
Mike Stone: 

appendicitis is a good example. as is ruptured ectopic. both of those are diagnoses that our consultants are now used to seeing expedited with US.

  Mike Stone
12:18
[Comment From alex koyfmanalex koyfman: ] 

What are the go-to uses of US for trauma besides the EFAST? Anything else out there you are doing on all of these patients?

Friday December 12, 2014 12:18 alex koyfman
 
Mike Stone: 

I think EFAST has a role in unstable or near-unstable trauma patients. Use ultrasound for regional anesthesia in trauma patients with orthopedic injuries. Can’t say I do a ton of hemodynamics or ocular or other applications in trauma though.

  Mike Stone
12:19
[Comment From NANA: ] 

favorite off-service to teach ultrasound to?

Friday December 12, 2014 12:19 NA
 
Mike Stone: 

intensivists. it’s just so critical to their daily practice and it’s awesome watching the lightbulbs go off. the surgeons can be a lot of fun too (no seriously, they can be)

  Mike Stone
12:21
[Comment From Steve CarrollSteve Carroll: ] 

Hi Mike- with increasing numbers of EM people getting RDMS certification- do you see this as a rising baseline standard of training? Should we all be training to that level? In the future- do you think we will be limiting wide use of EM US by creating all of these certifications (and making them the de facto standard) and excluding those who trained in the earlier days of EM US?

Friday December 12, 2014 12:21 Steve Carroll
 
Mike Stone: 

Hey Steve. Great question. So much to say on this but my short answer is no, RDMS isn’t a standard of training. Would highly recommend the Pro/Con debate article on this in Annals at http://www.ncbi.nlm.nih.gov…

  Mike Stone
12:23
[Comment From AdairaAdaira: ] 

TEE for cardiac arrest patients? Are you doing this? How long until this is actually happening everywhere?

Friday December 12, 2014 12:23 Adaira
 
Mike Stone: 

Not doing this in our institution(s). It’s a very cool concept, much like ECLS is a very cool concept. I think you need to have a LOT of cardiac arrest patients in your ED to make either a worthwhile investment. Would love to see our community get REALLY good at TTE (and core applications like DVT, early pregnancy, Lung) before we start moving to TEE. All that said if a probe showed up in my ED tomorrow I’d probably look for a way to incorporate it…

  Mike Stone
12:24
[Comment From JohnJohn: ] 

What first attracted you to ultrasound?

Friday December 12, 2014 12:24 John
 
Mike Stone: 

I played music semi-professionally for years and can actually hear very little with a stethoscope. Realized in my intern year at a very ultrasound-heavy program that it made a lot more sense to look (for me at least) than to listen

  Mike Stone
12:26
[Comment From Alex KoyfmanAlex Koyfman: ] 

How do you feel US will continue to change the practice of EM?

Friday December 12, 2014 12:26 Alex Koyfman
 
Mike Stone: 

I think as we transition to more outcomes-based reimbursement and accountable care that the opportunity to incorporate low-cost non-ionizing imaging modalities like poc ultrasound will result in more widespread adoption. renal ultrasound for suspected renal colic is a great example (as opposed to CT – http://www.ncbi.nlm.nih.gov…)

  Mike Stone
12:27
[Comment From Alex KoyfmanAlex Koyfman: ] 

Give us a few cases where US led you down the wrong path for pt management?

Friday December 12, 2014 12:27 Alex Koyfman
 
Mike Stone: 

there have been a few times where we’ve picked up free fluid in trauma patients and prompted further imaging that was subsequently negative. hard to always know what’s a normal amount of physiologic and/or post-resuscitative free fluid…

  Mike Stone
12:30
[Comment From AdairaAdaira: ] 

Best ultrasound conferences? Best apps? Best books?

Friday December 12, 2014 12:30 Adaira
 
Mike Stone: 

best conferences: castlefest, AIUM, new england ultrasound course
best apps:
Trauma app (biased!) – https://itunes.apple.com/us…
Books: Emergency ultrasound (Ma, Mateer, etc), New book by Arntfield et al, Cosby and Kendall

  Mike Stone
12:32
[Comment From GuestGuest: ] 

what has been your struggle with getting nerve blocks to be more widely incorporated in everyone’s ED practice?

Friday December 12, 2014 12:32 Guest
 
Mike Stone: 

A few major issues
1) lack of education – ultrasound-guided (or landmark-based) blocks beyond digital, wrist, ankle are not a routine part of everyone’s ED practice or mentality
2) fear – concerns about LAST, nerve damage, compartment syndrome. none of these are outlandish but there are risks to everything we do and these can be minimised pretty easily
3) culture – as always eats strategy for breakfast. takes a long time to change institutional/consultant beliefs about blocks.

  Mike Stone
12:35
[Comment From JohnJohn: ] 

What advice do you have for EM residents about to graduate in regards to career and/or life in general?

Friday December 12, 2014 12:35 John
 
Mike Stone: 

Career – try to figure out what makes you happy professionally and take control of your own destiny (i.e. don’t go into fellowship or academics or community b/c you feel like you need to/are expected to). pick a job and amount of shifts and geography that you find rewarding

Life – I’m no expert. I’d say be sure to always put family before work and anything else for that matter. Takes constant vigilance to make sure this is happening if you’re an academic EP.

  Mike Stone
12:36
[Comment From GuestGuest: ] 

Regarding the earlier question about TEE, does it make you nervous that there is pool of patients with some cardiac activity that we are just not picking up on our bedside TTEs? Makes me nervous… any strategies or resources to help make sure we aren’t missing anything b/c we call a code based on “no cardiac activity?”

Friday December 12, 2014 12:36 Guest
 
Mike Stone: 

I have to confess it doesn’t make me that nervous. We know very little about the long-term (or even short-term) survival of patients with “some cardiac activity” but still without pulses. If there’s no activity on TTE but fine VF on TEE there’s a reason to shock but not sure there’s a significantly increased reason to hope for a good outcome

  Mike Stone
12:37
[Comment From bakerbaker: ] 

what are your favorite FOAM resources (that you either use yourself or recommend to your fellows), and what do you separates these from the rest?

Friday December 12, 2014 12:37 baker
 
Mike Stone: 

I love SMART EM from Dave Newman. More thorough than most things out there. LITFL does a great job collecting and reviewing FOAM resources. Otherwise I’m a huge EMRAP fan (though not FOAM for most)

  Mike Stone
12:38
[Comment From JeffJeff: ] 

I always have a hard time visualizing the ovaries on TVUS. any tips for this or good videos for me to watch?

Friday December 12, 2014 12:38 Jeff
 
Mike Stone: 

start coronal, fan up and down until the uterus is as big as you can get it to appear. angle transducer to one side and insert it another 1-2 cm into the fornix. fan up and down (ceiling to floor) and you’ll find the ovary – it’s also usually midline and superficial to the iliacs which can help you localize it

  Mike Stone
12:40
[Comment From JohnJohn: ] 

What do you read/listen to in order to keep “up to date” with the constant barrage of new medical knowledge?

Friday December 12, 2014 12:40 John
 
Mike Stone: 

I listen to EMRAP, Emcrit, ERCast, SMARTEM. I get a list of recent EM US articles through a listserve. Trolling the literature in JUM, Annals, Chest, AEM, etc as well. Still don’t feel like I’m “up to date” though…

  Mike Stone
12:41
[Comment From EMSwamiEMSwami: ] 

How do you think/deal with the fact that when your niche is in a technology related area that technology may get replaced by something better. i.e. what if in 10 years microwave for imaging replaces US? This doesn’t just apply to US but also to FOAM etc.

Friday December 12, 2014 12:41 EMSwami
 
Mike Stone: 

I don’t spend much time thinking (and certainly no time dealing) with the possibility/certainty of eventually becoming obsolete. Am pretty sure I’ve learned some non-ultrasound stuff along the way that I can probably parlay into a career :)

  Mike Stone
12:42
[Comment From JeffJeff: ] 

How often are you using ultrasound to confirm ETT insertion? and clear indications?

Friday December 12, 2014 12:42 Jeff
 
Mike Stone: 

I don’t regularly use it for this indication now that I’m surrounded by video laryngoscopy devices. Was an AWESOME technique when I was supervising trainees doing DL and didn’t have to worry about whether they really saw the cords anymore

  Mike Stone
12:43
[Comment From JeffJeff: ] 

why does it seem like the italian literature is always ahead of what we are doing over here in the states?

Friday December 12, 2014 12:43 Jeff
 
Mike Stone: 

The Italians are doing some incredible stuff with lung sonography and have certainly been way more organized with regards to prospective multi-center evaluation of POC ultrasound. Have collaborated with an Italian group and they were very impressive to work with. Not sure why. Better wine?

  Mike Stone
12:46
[Comment From EMSwamiEMSwami: ] 

Just to clarify on my question. I think my question is how do you ensure that you are adaptable, flexible and ready to shift as technology advances?

Friday December 12, 2014 12:46 EMSwami
 
Mike Stone: 

Couldn’t help giving you a bit of a smart-ass reply, Swami. Thanks for following up. I think keeping up to date with change is more relevant now than ever in medicine (academic or community). If new technology comes around to replace ultrasound, it’ll probably still require training, incorporation into existing care pathways, etc. I think the best strategy is to stay up to date on new developments and have a hand in a bunch of different projects/endeavors so that you’re not locked into just doing/teaching one thing

  Mike Stone
12:49
[Comment From AdairaAdaira: ] 

This is a question asked to Strayer when he was on….”What’s the best way to educate residents? Do you think conference attendance matters? Should we do more asynchronous learning and how do you keep track?” Thoughts?

Friday December 12, 2014 12:49 Adaira
 
Mike Stone: 

I think educating residents at the bedside (or at least in the ED away from the patient) remains the most valuable interaction. Giving real-time feedback is a must, but being sure they’re ready to receive it first is a nice step.

I think conference attendance is probably a proxy for commitment to their education. Not sure there’s a ton of high yield learning at each conference but there’s certainly some and it builds community.

Would be great to track asynchronous learning. We don’t do it currently, but we do ask our residents about material they should have learned on the online resources and get a sense of whether they’re participating.

Ultimately they’re adult learners who we’d all hope really want to get good at EM during residency?

  Mike Stone
12:50
[Comment From JohnJohn: ] 

Craziest case you can remember where point of care US changed or drastically altered patient management?

Friday December 12, 2014 12:50 John
 
Mike Stone: 

Ripping tearing chest pain and syncope. US showed normal aorta but RV strain. Prompted LE eval showed popliteal DVT. Arrested and ROSC and then tPA despite head contusion (fall) and neck hematoma (failed EMS EJ). Walked out of hospital neuro intact 5 days later

  Mike Stone
12:51
[Comment From AdairaAdaira: ] 

Aside from ultrasound…whats your favorite piece of equipment (anything/everything) in the emergency department!

Friday December 12, 2014 12:51 Adaira
 
Mike Stone: 

EZ IO. Game changer. The humeral IO in an adult patient has become my new central line

  Mike Stone
12:53
[Comment From JohnJohn: ] 

Do you have a hard time not grabbing the probe when teaching someone and they just aren’t getting it? How do you stay hands-off?

Friday December 12, 2014 12:53 John
 
Mike Stone: 

I think knowing the regular/routine ways that people struggle helps you correct them without grabbing the probe. i.e. if they’re showing me an RV-inflow view and they want a PSLA, they just need to aim towards the patient’s head. most EM residents don’t use the RV inflow view but recognizing it can help them get to the view they do want.

having a standard way to communicate what you want them to do (slide, rotate, fan, rock) will also help avoid taking over.

then again sometimes you still gotta bite the bullet and take the probe

  Mike Stone
12:53
[Comment From GuestGuest: ] 

hey Mike! how do you deal with difficult patients?

Friday December 12, 2014 12:53 Guest
 
Mike Stone: 

difficult how?

  Mike Stone
12:58
[Comment From EMSwamiEMSwami: ] 

We all like to think of residents as adult learners but are they? All of us were relatively spoon fed in high-school, college and medical school. We were told what to read and when to read it. How should we work in residency to transform residents from spoon-fed learners to adult learners?

Friday December 12, 2014 12:58 EMSwami
 
Mike Stone: 

where’d you go to high school, Swami? JK. i know.

i think we need to expect a lot from our residents if we’re going to get a lot in return. Not sure there’s a one size fits all answer to this but generally I feel like identifying a knowledge gap or opportunity for a practice style modification while in the ED has the biggest impact on learners. Asking tough questions (why do you want that test? would you order it on your family member? what’s keeping you from admitting/discharging that patient?) and questions about their education (what are you reading or listening to? best article you’ve seen this month?) goes a long way to getting an idea of what they think of themselves as clinicians, learners.

  Mike Stone
1:00
[Comment From GuestGuest: ] 

*Difficult like angry, drug seeker, or hungry

Friday December 12, 2014 1:00 Guest
 
Mike Stone: 

Aha. I try to remember some great advice I once received about not letting the patient influence your mood/attitude. I usually sit down and try to figure out what’s up. Will often ask “What were you hoping would happen when you came to the ED?” or something similar. Apologizing for the wait can often diffuse some anger. Drug seeking – complicated – will check prescription database and have direct conversation about opioid addiction and resources. Hungry – feed them – it’s just humane. All this tends to work unless they’re violent/acutely psychotic etc, in which case I find that either Geodon or Haldol will usually do the trick

  Mike Stone
1:00
[Comment From JohnnyJohnny: ] 

Most important component of a successful resident US curriculum?

Friday December 12, 2014 1:00 Johnny
 
Mike Stone: 

Teachers who believe in the value of US and are willing to put in more time than their contract specifies

  Mike Stone
1:02
[Comment From Alex KoyfmanAlex Koyfman: ] 

in your eyes, what’s in store for the future of EM US?

Friday December 12, 2014 1:02 Alex Koyfman
 
Mike Stone: 

I think we’ll see some transformative technology in the next 5 years. Computer-assisted diagnostics (i.e. machine will give an interpretation based on echoes). Smaller devices, more detailed understanding of how/if EM US impacts things like length of stay, cost, satisfaction, etc

  Mike Stone
1:04
[Comment From UltrasoundMDUltrasoundMD: ] 

Hey Mike, This question was sort’ve asked previously, but Steve was asking it as far as making certification standard across the board for EM to be able to use US (from how I understood it). What about for someone who would like to make US their niche in EM. Would you suggest getting RDMS/RDCS? Is it worth it?

Friday December 12, 2014 1:04 UltrasoundMD
 
Mike Stone: 

Totally depends on your practice environment. When I went to Kings County it really helped pave the way for collaborative research with Cardiology and was a good thing for some political struggles with Radiology. I let mine lapse a few years back as I didn’t think it was helping, didn’t think (and still don’t) that it accurately reflected my ultrasound training/skills, and was too cheap to keep paying an annual fee. If you think it will help you where you’re going (ie there are some political battles to fight), I’d say go for it. Can always decide it’s not worth it.

  Mike Stone
1:06
[Comment From JohnnyJohnny: ] 

Something you wish someone told you earlier about being an EM physician and about being a teacher?

Friday December 12, 2014 1:06 Johnny
 
Mike Stone: 

EM Physician – Diversify. You are not going to enjoy night shifts nearly as much as you get into your 40’s (and I’m sure your 50’s).

Teacher – Don’t think you’re good at it just because the residents are listening – they feel obliged to listen. Ask for feedback from your learners regularly and you’ll be surprised what you find

  Mike Stone
1:09
[Comment From MattMatt: ] 

f/u question…how do you actually give feedback to residents? how would you like to?

Friday December 12, 2014 1:09 Matt
 
Mike Stone: 

I like to ask them if they want feedback first. If so, I ask if they want congratulatory or critical feedback – nobody wants to hear how they can be doing this better after a tough shift or after/while struggling with a personal issue.

If they’re ready for critical feedback I try to pick 1-2 things at maximum that they could improve, and give them concrete ways to work on doing it. Can be awkward at times but mostly I think it’s appreciated. I had a great attending during residency who would always give direct feedback after shifts – didn’t always feel good at the time but those are some of the best lessons I learned about medicine

  Mike Stone
1:13
[Comment From RichRich: ] 

Can you explain what you mean by diversify as an EM physician? Fellowship? Work at multiple hospitals? Projects?

Friday December 12, 2014 1:13 Rich
 
Mike Stone: 

For me it’s getting involved in administrative and consulting opportunities. For others might be expert witnessing, involvement in urgent care or student health centers, pre-hospital teaching, working at multiple hospitals. Don’t get me wrong – there’s absolutely nothing wrong with being a shift-driven community or academic EM doc. In fact I still feel like it’s truly a privilege. I just mean that it’s worth exploring other career options to supplement and/or replace some of the day to day challenges of a full time shift complement.

  Mike Stone
1:14
[Comment From RichRich: ] 

Separate question: what are some tips for the upcoming graduating class on how to maximize remaining time as resident?

Friday December 12, 2014 1:14 Rich
 
Mike Stone: 

Work on the things you feel least confident about. For many residents that’s ophtho, dental, ortho. Think about the complaints that make you nervous and figure out how to do an elective where you see lots of those (within reason obviously as it’s hard to find the cricothyrotomy clinic for a senior elective)

  Mike Stone
1:17
[Comment From emMichiganemMichigan: ] 

how often are you doing U/S guided or assisted LPs? Why is it that it sounds so great but doesn’t work that well? any tips?

Friday December 12, 2014 1:17 emMichigan
 
Mike Stone: 

I do them when I can’t feel palpable landmarks. Always upright. As long as you reliably find midline and don’t let the patient move I find this is a really useful technique. If they aren’t cooperative, move in between, or can’t be LP’d upright it’s not going to add much if at all

  Mike Stone
1:17
Adaira Landry: 

Hello all, only a few minutes left! Get those remaining questions in!

Friday December 12, 2014 1:17 Adaira Landry
1:21
[Comment From emMichiganemMichigan: ] 

in the trauma bay, if someone has a completely swollen eye and you can’t tell if anything is wrong with the globe. are you doing an u/s with liberal amounts of gel or just CT to look for rupture?

Friday December 12, 2014 1:21 emMichigan
 
Mike Stone: 

I think “suspected ruptured globe” as a contraindication to ocular ultrasound is a bit of a myth. Have looked at a bunch of ruptured globes and have yet to see ocular contents explode from the globe as a result. I think liberal amounts of gel and no direct pressure is a safe way to go. That said, most of these patients are getting head CT anyway d/t trauma so no big deal if it’s out of comfort zone

  Mike Stone
1:22
[Comment From emMichiganemMichigan: ] 

another one, if you have a trauma with a very low mechanism injury, nontender belly and stable vitals…but on RUQ you can’t tell if its the gallbladder or free fluid… CT scan for sure?

Friday December 12, 2014 1:22 emMichigan
 
Mike Stone: 

should be able to tell if GB or free fluid. can always repeat ultrasound and serial abd exams. try hard not to CT abd/pel with no pain or tenderness or vital sign abnormality

  Mike Stone
1:23
[Comment From JohnnyJohnny: ] 

What point of care US exam do you find is the most technically difficult to perform? Any pearls you have learned?

Friday December 12, 2014 1:23 Johnny
 
Mike Stone: 

of the core exams, probably biliary. have a structured way to approach it, use the three common windows to find the best look at the GB (subcostal, intercostal, R flank). know the relationship of portal vein (and CBD) to GB and you’ll find your way

  Mike Stone
1:25
[Comment From MattMatt: ] 

how has ultrasound changed the way you manage critically ill patients over the last 3-5 years?

Friday December 12, 2014 1:25 Matt
 
Mike Stone: 

i can’t imagine managing a sick patient without knowing what their heart’s doing. being able to get a sense of LV function, obstructive shock (RV strain, tamponade), valvular failure, pneumothorax, pulmonary edema, in ~2 minutes is pretty invaluable to me as a clinician.

  Mike Stone
1:26
Mike Stone: 

Thanks so much for having me, and thanks for all the great questions everyone! Still here for a few more minutes but wanted to say thank you before the stream shuts down.

Friday December 12, 2014 1:26 Mike Stone
1:26
[Comment From MattMatt: ] 

are you a redsox fan now?

Friday December 12, 2014 1:26 Matt
 
Mike Stone: 

nope. but my older son seems to think he is.

  Mike Stone
1:28
[Comment From JohnnyJohnny: ] 

How do you manage to get through the Boston winters coming from Cali?

Friday December 12, 2014 1:28 Johnny
 
Mike Stone: 

I grew up in New Jersey and spent 5 years in Providence, 10 years in Manhattan/Brooklyn. Boston winters aren’t much worse (but definitely a lot worse than the Bay Area!)

  Mike Stone
1:28
[Comment From MattMatt: ] 

best place to eat in Boston?

Friday December 12, 2014 1:28 Matt
 
Mike Stone: 

I’m currently infatuated with the Painted Burro in Somerville – good Mexican food (close to West Coast) and great drinks.

  Mike Stone
1:29
Adaira Landry: 

Thanks everybody for participating and a SPECIAL THANKS to Dr. Mike Stone (@bedsidesono) for taking the time to answer our questions. We hope to see you all again at the next AMA!

Friday December 12, 2014 1:29 Adaira Landry