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

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)

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)

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

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

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

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

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)

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…

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

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

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.

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.

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

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

appy. no question

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.

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.

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.

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)

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…

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…

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

I think as we transition to more outcomes-based reimbursement and accountable care th
at 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…)

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…

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

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.

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.

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

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)

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

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…

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 🙂

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

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?

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

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?

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

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

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

difficult how?

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.

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

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

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 ac
curately 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.

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

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

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.

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)

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

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

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

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

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 clin
ician.

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

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!)

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