stethoscope or dermatoscope?

 

dermatoscope

When attempting to describe the utility of POCUS, the use of US has been described as the stethoscope of the future and that the stethoscope, born with René Laennec 200 years ago in 1816 was dead.

However I posit that within the Australian general practice setting, the dermatoscope is the better comparison. The dermatoscope aids in treatment by improving accuracy of diagnosis, allowing benign skin lesions to remain and confirming concerns about suspicious lesions.

  • Using the dermatoscope well is a skill that benefits the patient with less benign lesions removed through better accuracy in diagnosis
  • The clinician benefits from extension of diagnostic skills and satisfaction gained from assisting the patient
  • The dermatoscope is not required for GP clinic accreditation, unlike some other clinic equipment (a stethoscope is mandated)
  • There is no direct remuneration for acquiring the skills to use the dermatoscope and no MBS billing number for using it (there are some cases when there are Meidcare items for clinic US use)
  • The dermatoscope is at least ten times the cost of a stethoscope (US ranges from dermatoscope cost second hand to ten times again).
  • Patients appreciate you taking the extra time to use comprehensive equipment for a comprehensive examination

Where my comparison falls down:

  • Dermatoscope examines only one organ (although stethascope only really does 4 – heart, lungs, bowel, blood vessels). POCUS does them all (even brain with optic nerve diameter measurement!)
  • Dermatoscope use is not as broad in the medical family as stethascope or POCUS, only GP and dermatology.

 

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Exporting images from older US machines

If, like myself you have a old machine, it may not talk easily to a modern computer.  My 2004 General Electric Logiq 100 apparently could talk to computers via a parallel port and a Windows 95 program however I would need a legacy computer just to talk to it, even if the program was available!

My machine does output a analog video signal however, provided for use with a thermal printer or a external monitor.Mini-CDVR-VideoAudio-Recorder-Motion-Detection-TF-Card-Recorder-for-IP-Camera-Blue_800x800

These C-DVR sell on ebay for USD15-25, coming with leads in and variably a manual and 12V power pack.  They seem popular for those recording video for drone flying.  Video comes out of the co-axial port on the back of the machine, into this blue box and onto a mini-SDHC card.  There are no real controls – if there is video coming in and 12V power to the C-DVR it is recording.  All live video coming into the box is recorded as an .AVI, you can then transfer the card to a computer and view with a program like VLC or MediaPlayer.

C-DVR installed on US machine
C-DVR installed on US machine

It is working well for me, only fault is that I have not worked out how to get rid of the time stamp on the bottom of the saved video.

GP clinic lung consolidation diagnosis

This is a case from last week – 21month old boy, one week of cough, had seen another practioner 4 days prior, started on amoxycillin/clavulinic acid, persistent fevers, up all night coughing, drinking, not eating.  Child looked unwell. T38.5, HR140, RR40, Sp02RA 93%, slight rib retraction, warm peripheries, well hydrated, nil rash. Red TM, flat tonsils, crepitations right lung base. GPPOCUS with linear probe, lung 6 region, this is region 2 on the right:

2yearShredEffusion
(guardian consent obtained for image and case use)

Demonstrating shred (breaking up of the visceral pleural line), effusion and increased density in the lung (hepatisation – the lung looks like liver in terms of echogenicity).

These are the lung zones:

LungPOCUSzonesLichenstein
Lichenstein CHEST / 134 / 1 / JULY, 2008

They went to the local ED with mother and chest radiograph confirmed right peri-hilar consolidation. POCUS did not definitely change my management here – Sp02 was low, there was persistent fever and they looked unwell.  However knowing there was right dependent lung consolidation confirmed that I wasn’t sentencing the family to an ED wait in vain.  I called family today and after a change of oral antibiotics the fever is down, eating better and more interactive.

Useful references:

Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134:117–25.

Varshney T, et al. Point-of-care lung ultrasound in young children with
respiratory tract infections and wheeze Emerg Med J 2016;0:1–8.

 

DIY US stand

My aged US (GE logiq 100) machine came without a stand, as it is 12 years old, there was not going to be any available to purchase from GE.  Time to get out the circular saw – first, a donor wheeled base from hard rubbish, a nice heavy steel base (made in Australia!):

Donor

Seat removed and recycled, a simple box with slots for probes from 12mm MDF was made and fixed to the tilting/gas lift base:

BareStand

Primed, painted and the addition of a tie down strap to prevent it leaping off and here it is in it’s natural habit of the consulting room:

GE Logiq US stand

FOAMed, MOOC’s and POCUS

In the era of the MOOC (Massive Open Online Course) what are the options for FOAMed, particularly around ultrasound? There are anatomy, psychology and ethics MOOC’s aplenty but less about clinical practice. Academic Life in Emergency Medicine have their MOOC which is obviously about EM, particularly pharmacology of EM. I have looked around and found one created by the University of Twente in the Netherlands, accessible through the British Future Learn website. It is free to register and access all the teaching material, consisting of videos and text, formative quizzes and summative MCQ exams. You can purchase a final certificate for $19, or complete the course with no certificate for no cost.
MOOC_poster_mathplourde
The course starts with some clinical vignettes and how US may be used in these settings, some physics (more detailed than a basic POCUS course – you need to calculate velocity changes in different media, doppler shift, think about resolution and lenses) then artifact description, probe varieties and then circling back over the clinical vignettes with more knowledge and detail. The overview of the six week blocks:
Course Breakdown
The course suggests it requires three hours per week of study, I have found a week takes about 2 hours.

wiendelt

Nearly all the teaching is done by Wiendelt Steenbergen who gives various overview talks in the gardens around the University and then slide type presentations.

Shadowing

There is an interesting use of the padlet website/app for digital pin boards for the students to contribute on which I found really efficient.

How useful are MOOC’s? There is discussion that not that many actually get finished (around 7%), that they do not allow previously disadvantaged people to access university  as the people actually taking them usually already have degree . However some UK universities will now accept some MOOC’s as credit to a more standard undergraduate degree .

So overall – an excellent quality MOOC for the new learner to US. Obviously there is no hands-on component and for such a skill where knobology, surface perception and spatial visualisation is so important, you still need to have time with a probe in hand, ideally while taking the MOOC.