I do quite a bit of teaching on the basics of ultrasound and try to coach our trainees through the their first experiences with bedside US. Over the years I have learned a few tricks and tips which I think are very useful to optimise the learning and development of “hands on” sonography skills.
I have compiled this list – it my Top 10 Tips for clinicians starting out in bedside scanning. Some of these are practical, some theoretical some more cognitive.
I sent this through to my amigos in Trumpland and we decided to make it into a podcsat for those of you who prefer the visual medium / looking at nerds.
You can see the podcast over at the ULTRASOUNDPODCAST with Mike, Jacob and NOT Matt as he was too lazy to get up and Hangout with us at 5 AM or whatever time it was in Kentucky.
So here we go – my best advice to a rookie POCUS trainee:
1. Scan yourself, wife, kids, dog – you don’t have to learn in front of the patients. Play around with the settings, knobs etc on your own, somewhere quiet. Explore what they do in your own time. Very difficult & potentially embarrassing to do this in front of a real patient
2. Save images: and correlate with later images, CTs or what the surgeon sees! Follow up to check your Dx, criticise your shots, ask for others to do so – form an “image club” with peers. You can also upload them to The POCUS Atlas — for all to share. Watch your skills improve over time as your images get sharper and your skills sexier!
3. Find a mentor – local sonographer, ED , buddy, or online. Somebody who can give you hands on , practical advice. Learning alone can lead to bad habits. Have a mentor to teach you before they become part of your routine.
4. Become GUMBY again. Like when you first used a stethoscope in Med school. Start out with the expectation your scans will not change management. Avoid overcalling… embrace the grey. Experience will reduce the grey areas, though they never really disappear.
5. Hand position: keep it steady, brace against body. Especially when scanning moving objects: hearts, lungs, Doppler. If you are doing procedural US – then having a comfortable / ergonomic position that allows your hand to stay frozen is very important.
6. Use BIG moves to find window, then small moves to refine. Doing small moves up front wastes time, frustrates you and saps confidence. Be bold when you are looking for a window, then subtle once you find it.
7. Move the patient, roll em, sit them up, make it easy for yourself. Don’t be shy! It can be very frustrating to search for a gallbladder for 10 minutes in an unfasted, tender patient. Do both you and your patient a favour and choose the position of comfort that will allow you to get the scan done quickly.
8. Visualise what you expect to see. e.g., hyper dynamic LV in sepsis… then when you see something different, it makes the ‘lesion” more obvious. Often “normal” is not what you expect, think further afield. If your pre-scan visualisation doesn’t match what you see then either your scan is suboptimal or the diagnosis is wrong. Frame the question you want to answer before you pick up the probe. Guessing based on a limited scan can lead to diagnostic error.
9. Acknowledge when you need to stop scanning and do something else. Sometimes in a sick patient you just need to make a decision. In an obese, unfasted patient you may need to get a CT or act blindly.
10. Read. Know the evidence for our diagnostic tests. Know what you can and cannot answer and integrate this into your decision-making at the bedside. Use likelihood ratios to integrate US findings into the clinical picture. Don’t be black & white – ultrasound has 256 shades of grey. Correlate clinically continuously.