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Wednesday, May 2, 2012

Ultrasound education and why ER physicians are different (Castlefest) (CORRECTION)

(CORRECTION PART: WOOPS. WHEN I FIRST PUBLISHED THIS, NOT ONLY DID I LEAVE IN ALL SORTS OF WEIRD STUFF, BUT I ALSO SPELLED MIKE MALLIN'S NAME WRONG AND GOT THE WEB ADDRESS OF HIS AND MATT'S SITE WRONG. I THINK IT'S ALL FIXED NOW.) Northern Kentucky is lushly, jaw droppingly beautiful in the spring. Green fields of grass stretch out from smooth highways and thoroughbred horses graze languidly. (Also I got some mild version of influenza and am hideously allergic to whatever particular grass pollen collects here so I’m thinking and seeing everything through a small amount of edema fluid.) The town of Versailles (pronounced ver-sails) has a small castle on its outskirts that was originally partially built by someone whose love grew cold before he could finish it. It stood partially finished for years, changed hands, burned down and was rebuilt, so it now exists as a venue for weddings and things like that. It was the location of an emergency and critical care ultrasound course sponsored by the University of Kentucky and organized by Mike Mallin and Matt Dawson who have produced an excellent website, podcasts and smartphone apps to share the good news of how useful and cool and profoundly game changing the practice of bedside ultrasound can be.

This course was the third one I have attended since November 2011 in bedside ultrasound, also known as point of care ultrasound.  The first was at Harvard Medical School, put on by their department of emergency ultrasound (yes, there is an actual department there.) Before that course I had been mostly unaware of ultrasound applications but had heard a few things about it and chose to go to the Harvard course because I figured that an institution like that would be likely to be on the leading edge in terms of research and teaching. It was an excellent course, organized by Vicki Noble MD who has been involved in developing the field and doing the hard work of both research and communication with physicians of all types who are set in their ways but also needing the boost that being able to do ultrasound can give them in terms of job and patient satisfaction.  I learned enough in the course to start doing ultrasounds with the machine that non-radiologists share in my hospital, looked at more stuff using various online resources, bought myself a pocket ultrasound, scanned anyone who got within arm’s length of me and went to another course, one given by Yale University emergency physicians, scanned more parts of more people and just now returned from course number three.

Castlefest was delightful. The instructors, beside Matt and Mike, were Chris Fox MD who heads the emergency ultrasound department at University of California at Irvine and, according to Matt, is something like the father of emergency ultrasound. He amended that to say “creepy uncle of ultrasound,” which seemed to fit a little better. Cliff Reid MD came from Australia where he practices emergency medicine and teaches and flies helicopters to remote areas to save people (also has a website and podcast called  and Vicki Noble MD came from Massachusetts General Hospital. Dr. Tim Jang came from the USC department of emergency ultrasound and taught us about techniques for diagnosing intestinal maladies such as small bowel obstruction that are simple and surpass x-ray and rival CT scans in accuracy. Medical student volunteers were models and there were lots of machine reps who brought their nifty and expensive ultrasound machines so that we could learn to find the organs and structures that we heard about in lecture, visualize them (which is really tricky) and interpret their abnormalities.  There was also good food and Kentucky themed activities such as visiting a whiskey distillery and touring a thoroughbred farm owned by the ruler of Dubai. The subtext of the conference was that you could do excellent medicine, care about your patients, do new things and also not take yourself too seriously. As conferences go it was kind of expensive, probably because of the extra activities, but worth it because of the excellent faculty.

I learned lots of stuff:  new ways to put in central venous catheters that reduce risk and discomfort, new ways to look at the heart and evaluate its function, how to evaluate the appendix and small bowel with ultrasound, how to find that pesky gallbladder and what to do with it once I do find it. Most of the things I learned will impact the way I practice medicine, which is really unusual in medical education. The new and interesting stuff I learned really deserves its own post, so I’ll save it for a bit.

Besides learning about ultrasound I also got a chance to observe my fellow doctors, almost all of them emergency physicians. There was quite a variety--men and women, mostly from the US Southeast, but also from Australia and Canada and the Midwest.  Some had been in practice for as long as 40 years, some were pretty fresh, having practiced only a few years. They all knew how to deal with an emergency room full of people, sometimes acutely dying, most presenting with problems that were time sensitive and with some level of mystery. Most of them worked 12 hour shifts, a few still did 24 hour shifts, and most were on some sort of salary, either paid by a hospital or by an incorporated group of emergency physicians.  There was a nurse practitioner who had trained in emergency and critical care medicine who did just about everything that an MD would do in the hospital including most critical care related invasive procedures and also ultrasound. He had done it for years and was probably as capable as most physicians and more capable than others. There was a young woman who practiced in Canada after having finished her family practice residency. Apparently in Canada it is rare for emergency physicians to have completed an emergency medicine residency, much like it was here 10 or 20 years ago. She had gotten bedside ultrasound training on her own after residency because she thought it would be important. Her ER was always full, she saw 14-30 patients per shift, made a flat fee of $30 per patient or $86 if they took more than 30 minutes with an extra $14 for every 15 minutes more after that. She worked for a few hospitals and was self employed, responsible for billing the state health insurance and buying her own malpractice insurance. Patients she cared for would wait weeks for a non-emergency CT scan and months for an MRI scan. A surgical consultation for a condition that did not require surgery immediately would be scheduled 2-4 weeks out or more.  They would wait in the waiting room to see her for 8-24 hours.  I’m sure this isn’t representative of all of Canada, and, other than the financial arrangements, I think that similar wait times may apply to some inner city hospitals in the US. Still, it was interesting to hear about what she considered normal.

Emergency Medicine is really popular in the US. After medical school a sizeable number of graduates want to be emergency physicians. It’s not too hard to see why. The pay is good. When you work you get a chance to treat all kinds of things, cure people, send them home, resuscitate near dead people and then send them to the intensive care unit for another doctor to take care of the details and clean up the numerous loose ends. When you are not working you are really and truly off, no patients calling in the middle of the night, no waiting for the cell phone to ring while hanging out with the family.  Maybe this is why the emergency medicine docs I have been meeting at these ultrasound courses seem to be overall happier than the internists at the internal medicine conferences. Maybe it’s just that the folks who choose something fast moving and demanding have more self confidence. It can also really suck to be an ER doctor. Patients respect them when they reduce a dislocated shoulder or treat a pneumonia.  Other physicians are grateful to them because they are on the front line and so we don’t have to be there. But then they call us because the patient really can’t get what they need in the ER, either needs to see us in followup or be admitted to the hospital and then sometimes we are not at all nice to them. We ask if we really have to come in now, at 2 in the morning, for this. We wonder why they couldn’t figure out that the patient had this, not that, which is so clearly obvious to us who have a much narrower specialty and are only seeing one patient at a time. We share our unhappiness with them as we emerge from sleep to their phone calls. They also deal with patients who are very unhappy with them because they have waited for hours to see anyone and now it turns out that their problem is not that dire and only requires some reassurance.  The ER is where the patient who is addicted to prescription pain killers comes to get a fix, complaining of some kind of pain that may be real or may be imaginary, hard to tell since pain is truly subjective, and angry at the ER doc who won’t give out pain meds for non-surgical pain on principal, to keep from feeding the system. They get sued pretty often. They get lots of complaints from patients because the patients don’t know them very well and they don’t have the time to establish a good doctor patient relationship. Perhaps it’s all this adversity that makes them interesting.

For whatever reason, my experience of the medical education courses that I’ve attended that are coordinated by emergency physicians and for an ER audience are interesting, fast paced, practical and make me smile.  In bedside ultrasound they are also the ones who are most involved in pushing the limits of what the technology can do and making the advances practical and accessible.

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