Transcript

All right, now it's 7 0 3.

So we're gonna go ahead and get

started with the, uh, webinar.

Um,

Okay.

So just a brief introduction about, um, Institute

for Advanced Medical Education, webinars and training.

Um, the Institute

for Advanced Medical Education is a membership, uh,

based organization.

Um, when you are a member,

you get these webinars every month for free,

included in your membership.

You also have unlimited access to, uh, ultrasound courses

and other courses for physicians

and others that need them for, um,

continuing medical education credits.

These credits are good for the A-R-D-M-S-C-C-I, um,

the State Medical Boards, A-C-C-M-E accredited,

and, uh, they're good for physicians, sonographers

and other healthcare providers like, uh, Diana

that we have here today.

Um, so

whenever, uh, you know, at this, at this, uh, webinar,

you know, you're, you're welcome to attend for free.

Um, if you want credit, stay till the end

and then, uh, eligible members can claim credits.

All right. Um, the Institute

for Advanced Medical Education has been around since, um,

the early nineties, 19 91, 19 92.

Um, I became program director about four years ago,

and, um, we have focused primarily on ultrasound education

of physicians, sonographers and others.

Um, we educate more sonographers

and physicians in ultrasound than any other organization in

the United States, believe it or not.

And, uh, we have a membership of around 30,000 members.

Um, whenever we're, um, planning education,

we are looking at doing activities

that are a team-based approach.

We want to have physicians, sonographers, nurse midwives,

uh, nurse practitioners, anybody who's utilizing ultrasound

to be a part of the team, and learn together so that we can,

uh, have better outcomes for our patients together.

Um, tonight, uh, we're actually doing this, um, um,

this webinar, uh, with one of our new educational partners,

uh, W POCUS Consulting, uh, Diana Dowdy, who's a, um,

nurse midwife, um, advanced practitioner,

and, um, sonographer, uh,

who's very passionate about obstetric ultrasound.

And, uh, we're gonna give her a little bit of,

uh, introduction.

But, um, I just wanted to introduce W POCUS Consulting.

Um, and Diana will be able

to tell you a little bit more about that

when she introduces herself.

So, Again, let, let me just reiterate that

these courses are for both physicians and sonographers

and other people that are doing sonography.

Um, it's my philosophy that, you know,

whenever we have a closer relationship to the machine,

to the people who take the images

and to the person interpreting it,

you have better outcomes with patients.

And, you know, POCUS will demonstrate that as well.

So, uh, before the activity gets started here,

we're gonna go ahead and read our mandatory

statement from the A-C-C-M-E.

This activity has been planned

and implemented in accordance

with the accreditation requirements

and policies of the accreditation Council

for continuing medical education.

IAME is accredited by the A-C-C-M-E

to provide continuing medical education for physicians.

IAME designates this live online webinar for a maximum

of one, uh, credit physicians

and attendees should only claim the amount of credit

that they have participated in.

So if you're only here for 30 minutes, claim, claim,

you know, 30 minutes of credit 0.5 credits, uh,

in compliance with the essentials

and standards of the A-C-C-M-E, the authors

of the CME activity are required

to disclose any significant financial

or other relationships that they may have

with commercial interests, myself, Jason Cox, md

and Diana Dowdy, um, DNP and MW

and RDMS, amongst other things,

disclose no such relationships exist.

IME has assist conflicts of interests with any faculties,

authors, editors, moderators,

or any other one else that are involved in the,

uh, planning of this activity.

And found there to be no conflicts of interest

or have mitigated getting those, uh, risks.

Now that that's out of the way.

So, tonight we're gonna be talking about

diagnostic versus point of care.

Um, ultrasound purpose-driven ultrasound, um, pocus as, uh,

you hear a lot about is one of the top trending words

in medical literature and online.

Um, all the socials love it.

And, um, you know,

whenever point of care ultrasounds started, um,

really being driven by, uh, new technology,

um, you know, it, it was, you know, there was a quote that

ultrasound would become the new physician's stethoscope

and medical schools started even issuing, uh,

ultrasound probes to their medical students.

So, where does that fit in?

And that's what we're gonna talk about tonight.

Uh, the structure of this program is, first I'm gonna talk,

give you the background about, um, kind of a history

of ultrasound and where it's come from, where it's going.

Um, I'm a practicing radiologist,

so I'm gonna give you the point

of view from the radiologist workflow.

Um, I also work with a lot of OB, GYN doctors

and nurse midwives.

So, um, I kind of understand it from my, my perspective and,

and, and Diana's here

to give you her perspective from the nurse midwife side.

So, just a little bit of background about myself.

Um, I'm a practicing radiologist.

I'm medical director of ultrasound, first in St.

Louis, Missouri. That's a specialty ultrasound clinic

that focuses on, uh, all things ultrasound.

Um, we do about six to 7,000 ultrasounds a year there.

Um, I'm a staff radiologist at the University

of Missouri at the Capital Region Medical

Center, um, campus.

And then I read, um, obstetric

and gynecologic imaging on a daily basis.

And, uh, other specialty ultrasound exams and general

and musculoskeletal radiology.

I'm an author of numerous courses at IAE

and other publications.

Um, I'd like to introduce Diana Dody.

Diana, can you say hello?

I think you're, you're muted there.

Hi. Hi, Diana,

Great to be with you.

Okay, thanks for joining.

So, Diana, and correct me if I'm wrong about any

of this stuff, she's a certified nurse midwife

and OB GYN sonographer with 45 years

of experience in clinical practice and education.

She has taught at multiple nursing schools

and is committed to training midwives

and point of care ultrasound worldwide.

And, you know, just knowing Diana, myself,

she's very passionate about it, and she has a great mission.

Um, and I, and, and I, she's gonna tell you more about that.

Um, this small statement does no justice for

what she has done and what she's

accomplished and what she's going to do.

Um, as director of Women's ultrasound for Rad Aid,

rad aid's a, uh, international nonprofit organization.

She leads global ultrasound

initiatives in underserved regions.

In 2022, she was honored as nurse with global impact

of the United Nations.

That's, that's pretty impressive, Diana.

So, um, Diana, she's just gonna hang out there.

And, um, you know, if, if, um, you know,

if we get a question from the audience

or something, you know, we'll, we'll bring it up

to her if it's, if it's better for her to answer.

But I'm gonna start off from the radiology side.

Uh, and, you know,

it doesn't mean the radiology side's better

or worse or anything like that.

'cause this is a controversial topic somewhat.

But what we're talking about tonight is where it came from.

And, and, um, Diana's gonna

give us the backend or the new part of the story,

and I'm gonna start from the beginning and move forward.

Okay. So tonight, um, people who

participate in this activity are gonna be able

to articulate key differences in the purpose equipment

and clinical application between diagnostic ultrasound

and point of care ultrasound.

Most people can't even articulate this out loud.

So you're gonna, you're gonna leave here with that.

Um, and specifically we're talking about the

obstetric setting.

Uh, we're gonna look at a historical

and practical overview of ultrasound.

Um, learners are gonna be able to demonstrate,

uh, increased competence by accurately identifying the, uh,

distinct contributions of physicians, sonographers,

nurse midwives, and other practitioners.

And obstetric ultrasound.

Uh, we're gonna talk about

how they all fit into the workflow for the patient care.

Um, and this includes image acquisition,

documentation interpretation,

and team-based learning principles

and scope of practice outlined.

Uh, just learners will be able

to describe the accreditation requirements for professionals

who perform and interpret, um, obstetric ultrasound

based on, um, a lot of organizations

that you probably already know about, uh, such

as A-I-U-M-A-C-R, A-R-D-M-S, acog,

and, uh, nurse midwife, um, organizations

that Diana will be able to tell you about,

and then other principles that kind of govern

where you should be practicing

and where you shouldn't, um, common sense,

but also some not so common sense.

Okay. So my part of the talk, I'm gonna talk about

the history and development of ultrasound machines briefly.

Um, I'm gonna review the traditional radiology

and OB GYN workflow for obstetric

and gynecological imaging,

just basically my day-to-day practice, um,

and a lot of other people's day-to-day practice, um,

who traditionally performs

and interprets diagnostic ultrasounds.

Where does POCUS fit into this workflow?

And who performs pocus and what are their qualifications?

And then, um, how do we work together

for the best patient outcomes?

Alright, so, ultrasound, um, very interestingly,

um, was developed early in, you know, physics

by physicists, um, even

before the 1950s

where the technology came out through radar.

And then was applied through, um, you know, ultrasound, um,

a physician who was the, well,

he was an obstetrician Ian Donald.

Um, he, uh, spearheaded the development

of clinical ultrasound by, um, working with engineers

to apply ultrasound to medical diagnostic imaging.

Um, and he created the dia sonograph

and published their work in the Lancet.

Um, he created the first sonographic image of a fetal head.

Um, so, uh, you know, back then this was a, a big deal

because up until then, everything, you know, the,

the crown jewel of diagnosis was to identify, uh, problems

with pregnancies, especially, um, with placenta previa

and with, um, fetal abnormalities

or, um, fatal, fatal, uh, problems that would, would have

to do with the mother or the, or the fetus.

So that was what his real passion was about.

And, um, once they moved into clinical diagnosis,

they focused on placenta previa.

In 1968, a paper was then published on fetal biometry.

By 1969, um,

was when the first estimated data delivery could be, um,

you know, generated by ultrasound, um, throughout the 1970s.

And in the 1980s, uh, there was a lot

of work published about diagnostic ultrasound in early

pregnancies, um, diagnosis of neural tube defects

and fetal cardiac diagnosis that include the development

of color doppler imaging.

And by the two thousands, 3D imaging,

and of course by now four D imaging, um, the

fetal anatomic screening was developed in the 1990s.

Um, which, you know, everybody sits around now

and they're thinking like, wow, the nineties was 10

years ago, but guess what?

It's, it's, it's now 34 years ago, so 35.

So it, it's, it's a lot longer ago.

And just for perspective, I'll just tell you that, you know,

MRI came out in 1978

and CT not too long before that.

So as a technology, ultrasound's been around

for a little while, and, um, it's, you know,

rapidly developed

and become a, uh, mainstay of obstetric care.

So, talking about equipment, when,

when ultrasound first came out, uh,

the first patients were actually dipped into a tub of,

uh, deionized water.

Um, and there was a lot of interference between the skin

and the tissues underneath, and the,

and the, uh, medium that had to get worked with.

Um, the first skin contact probes came out in about 1958.

Um, and that was the di sonograph.

And then by the 1990s, um, they were able to get multi, uh,

multi element or multiry, uh, transducers

with high spatial resolution and contrast resolution.

And, uh, these were in conjunction with cart based systems.

So a big computer on a cart.

Um, as this moved through into the nineties, um,

as computer technology advanced, you know,

faster processing smaller computers, um, more

and more, um, the machines got smaller.

And then that's when the first laptop,

laptop style machine was released in the late 1990s.

The first pocus, you know, labeled POCUS handheld machine,

which is a ultrasound that connects to like a smartphone

or a tablet, came out in 2017.

So that's very relatively new.

And the reason we're talking about this is some

of these innovations, many

of these innovations have really driven the proliferation

of ultrasound, and especially point of care ultrasound

because, you know, a big cart based system, maybe $200,000

and one of these smaller systems starts at around, you know,

10,000 and goes all the way down to like $2,000.

So that really puts the machine in the, uh,

economically feasible range for people

and practitioners to use.

That typically wouldn't be in the regular

radiology workflow.

So, most of the people here are sonographers

or OB GYN doctors or radiologists, or nurse midwives.

Um, you know, what the traditional radiology workflow is

like from the, you know, depending on where you're at in

that pantheon, um, you're,

you're pretty well familiar with it.

But let me just cover it real quick, and,

and we're just gonna demonstrate by talking about this,

how it's not hard to get an ultrasound, but it's difficult.

You know, all the steps you have to go through

to get from your healthcare provider

to get your diagnostic ultrasound.

This will demonstrate it. So, first,

a patient sees a healthcare provider,

that healthcare provider determines

that they need an ultrasound to help them

with their diagnosis and treatment.

Uh, that provider then puts in a order for that ultrasound,

sends that order to an ultrasound facility, uh,

that has the equipment to do it,

usually at radiology department

or an outpatient imaging center.

They process the order, um,

we're not even talking about insurance here,

but it'll have to get, uh, pre-certified

and all that kind of stuff.

The patient's then scheduled

and registered at the radiology department.

Uh, that could be, if they're in the er,

it might just be right there at the time.

But if they're, you know, say in an outpatient clinic or,

or, um, you know, seeing their primary care doctor

or whatever, or, you know, they're, they're seeing their ob,

um, then they would have to, you know, come

to the hospital wherever that machine is.

Okay. Um, once they get to the radiology department

and they're registered, they then have to be brought back

to the room with the cart based system.

The cart based system, obviously, is a bigger machine.

It may or may not have a battery.

Um, it's not very mobile in most cases.

And the, uh, sonographer is gonna take them in there.

They're gonna input all their information into the machine

and make sure that it's correct.

Um, they may be pulling that up from a work list system

that is provided to them,

that a radiology information system.

Um, and then they'll perform the exam

and then prepare a sonographers report for what they saw,

and then send all of that information over

to the PAX and complete the exam.

Uh, it's at that point that either a radiologist

or an OB GYN physician would then receive the

images to be interpreted.

They then open the case, interpret the images,

and then issue a report.

Um, at that point, the report has to be transmitted

to the ordering provider.

They have to receive it,

and then they have to open it up and read it.

So you can see that a lot of steps went into

the traditional radiology workflow,

or, um, you know, like this is, this is definitely

what you would see at a hospital, um, very close to

that in an outpatient imaging center.

And then, you know, maybe some

of the differences here would be, like, if you're going

to your OBGYN's doctor office

or you know, the patient's, um, at a nurse midwife's office,

they may have their ultrasound machine there, um,

and they could have a traditional workflow like this,

or they might have a POCUS workflow.

So, we'll, we'll see about that.

Um, so let's talk about all of the stakeholders

who get together and decide who performs, uh,

OB GYN ultrasounds

and, um, sonographers, uh, role in the sonography.

So, you know, a traditional radiology workflow is gonna

utilize a, uh, sonographer

that's typically A-R-D-M-S registered in OB GYN.

And, um, according to the SDMS position statement,

sonographers perform the obstetric ultrasounds.

Um, they conduct gynecological ultrasounds to evaluate

for normal maternal anatomy, fetal anatomy.

Um, they're gonna use different techniques for, um,

performing either transabdominal

or transvaginal ultrasounds.

Um, they actually have the, um, the, um,

discretion to choose between proper protocols, um,

based on their scope of practice.

Um, they're able to document normal

and abnormal findings for physician's review.

And then, um, they're also, uh, able

to provide some sonographers report.

You know, what we, what we call it, you know, it's, I,

I've heard it called different things, sonographers reports,

sonographers, uh, notes.

Um, but it is part, typically it, you know,

when I first started, it wasn't part of the medical record,

but now it's in most places.

So, um, they're also able to assess, uh,

assist in specialized tasks like procedures, uh, you know,

like amnio, sesis providing, uh, support

for ultrasound guided procedures.

Um, and then, you know, depending where, um,

where they are, you know,

there are states in the United States that have, uh,

what are called advanced practice sonographers.

Um, they do more advanced training,

and then depending on which state they can do different

things, including providing diagnostic interpretations

of the scans, performing the scans,

and consulting with other providers about the results.

Um, regardless, sonographers typically follow a, uh,

a protocol based exam.

And, uh, they typically operate under a

physician's supervision.

Um, other physicians,

and this is where we start to get into pocus.

Physicians that are not radiologists, are not OBGYNs.

And then also other healthcare practitioners like nurse

practitioners, PAs, uh, nurse midwives, of course, um,

are able to perform

and interpret OB GYN sonography based on their training

and scope of practice, depending on where they're at.

And Diana is gonna have a lot

of information about that for you.

So who's gonna interpret these?

So there are multiple organizations

and associations that have input on this.

Um, this includes A IUM, the American College of Radiology,

the A-R-D-M-S, the SDMS, state Medical Boards,

hospital Credentialing Committees,

and different departments and hospitals.

Um, so there are numerous different, um,

system wide pressures

and guidelines on who actually interprets these exams,

who performs them, who supervises them.

And again, um, you know, when we look at

what is pocus, the definition according to A-R-D-M-S

is the simultaneous acquisition

and interpretation of ultrasound images at the patient's

bedside by a healthcare professional

to immediately inform diagnosis or treatment,

or to aid in the completion of procedures.

So, um, you know, I think that's as good as a, a definition

as we can get, um, Diana,

I know we'll have some more nuances on that.

So according to a IUM physicians performing or interpreting,

and now we're, we're gonna talk about is the level

of training, the level of expertise, the level of comfort

and experience people are required to have as,

uh, either physicians or, um, sonographers.

And then I'll actually let Diana take it for the, uh, nurse,

nurse midwives, 'cause she's the expert on that.

But according to the IUM physicians, um, that are,

they're gonna interpret the ultrasounds.

These could be people

or physicians that are certified in radiology, um,

breast ultrasound, urology, anesthesiology,

OB GYN, and emergency medicine.

Um, they could have subspecialty certifications in maternal

fetal medicine and urogynecology.

Um, and then when you get into these, uh,

if you go into the practice parameters on A IOM,

they'll actually have very specifics about each specialty.

So, just because you are a, um, you know,

you're an MFM, you had to have performed so many exams

during your training, or have another qualifying, um,

event such as say, you know, 60 60 CME hours,

and, uh, which I'm just making

that up right there, that's not the exact one.

But you, you have to have so many CME hours

and then do so many cases

and, you know, a certain amount of time to remain qualified

or to become qualified under the

supervision of another physician.

So basically, when you look at all of these organizations,

what they have in common is, um, initial training, um,

experience, maintenance of experience,

and CME continuing education.

So, um, you know, when you look at these, you know,

if I hadn't read any OB ultrasounds in 36 months,

then I would have to become requalified to do it.

And the reason I'm making this,

and we'll, we'll see this in common for each,

um, organization.

The reason I'm making this, I, I'm making this

as an emphasis, is Diana's gonna talk about it and,

and how that plays into your comfort level

and how you use pocus.

Okay? So according to a CR,

and so say if your facility is a CR accredited.

So if my diagnostic imaging center is accredited

to perform obstetric ultrasounds by the a CR,

which is required by a lot of insurance companies, um,

you have to have a physician who's the

lead interpreter there.

Um, you have to have that, uh, physician, um,

qualified to, to read the ultrasounds through training such

as a, a radiologist.

Um, the initial training has to be completed

and an A CGE approved radiology residency.

So if they came, you know,

if you've got somebody from overseas that went to, uh, uh,

a residency in somewhere like India or England

or Australia, they can't just come over here

and then be your supervisor and, and, and look at these.

Um, if you are, if you, if you've,

if you're not a radiologist, you have to have done, um,

six months of ultrasound training.

Um, so that's actively working, getting paid

to do ultrasound in training.

Um, the training has

to include 300 ultrasound exams across relevant specialties.

So 300 exams.

Um, just think about your patient load and how much time

and, and that would take you to get 300 exams.

So for ongoing experience, we have

to do 200 exams every three years in OB GYN.

Luckily, I do that, you know, in a very short period

of time in my practice.

Um, but, you know, depending on

where you're at, you may not get that.

Um, if you're in a very small town, you may not be able

to get 200 exams every three years,

and you might have to get proctored exams.

Um, if you can't do that, you also have to have 15, uh,

A-M-A-P-R-A category one CME credits

and ultrasound within that three year period.

Um, CME has to be earned within the past three years,

and then it expires, and then you have to redo it.

So, again, that was for physicians according to A-R-D-M-S

or according to A A CR.

So now let's talk about, um, physicians for A-R-D-M-S.

So A-R-D-M-S, you have to have an MD DO, or MDBS degree.

You have to have done, uh,

500 clinical diagnostic ob gyn ultrasounds.

These have to be, uh,

completed over at least a six month period.

And then you have to have, um, current medical license,

you have to have validation

and certification of all of your actual completing,

uh, clinical experience.

And then, uh, enable to maintain your certification,

you have to have a log of 500 plus studies

that you would submit to the air DMS.

Um, and this is if you were to become certified.

So like as a, as a physician radiologist, I could go get my,

uh, RDMS just based on my training.

I could go sit for the exam and,

but I'd have to show this stuff.

Um, and then you also have to have, uh, clinical experience.

So this was something that new that came out.

You know, it used to be like you could do, um,

proctored exams, like a hundred, you know, for a lot

of these, you have to have like a hundred,

like for this one, 500.

It used to be that you could just sit there

and go through a case bank

and get certified on these 500 exams,

but now you have to have actual clinical setting,

not volunteerism or simulators.

Um, and so that was new in 2020.

So American College of Gynecology,

so in two 20 2023, they updated their requirements.

Um, there, they say there's no certification needed for

OBGYNs to use, uh, sonography in the scope

of their practice, because that's integral as part

of their training when they go through their residency.

Um, they do acknowledge that advanced imaging, such

as like complex anomalies with, uh,

maternal fetal medicine cases with, um, say, heart

or neuro tube defects, um, other, um, you know,

like gastro esis, things like that.

Um, so they do have some balance within their scope

of practice, but that's, you know,

not difficult for them to obtain.

Um, there're also, there's also something

that Diane's gonna talk about, about quality control, um,

documentation, and then the difference between our workflow

and a POCUS workflow in making those

required documentations.

And, um, di you know,

just maintaining the medical record on these exams.

So there is a joint statement with most

of these groups participating, include the American College

of Radiology, American College of Gynecology, the IUM, the,

uh, society of Maternal Fetal Medicine,

and the Society of Radiation Ultrasound.

And they basically say that it comes down

to the ultimate judgment regarding the propriety

of any specific procedure

or course of action that must be made

by a practitioner considering all the circumstances

presented on their scope of practice in performing

and interpreting diagnostic ultrasound.

So, um, I've presented all this information

and just, I have a statement here that I'm not trying

to discourage people from pocus.

What I'm saying is that it you people that choose

to do POCUS or have it in their practice

or beholden to a higher standard of ethical and moral

and, uh, training obligations to make sure

that they're doing the right thing.

And I, I know Diana's gonna talk about that.

So, uh, real quickly, um, my,

my impression of what has influenced the rise

of pocus number one, uh, teleradiology, when PAX came out,

um, back in the late nineties, um, it opened up the eyes

for, hey, people can do things remotely.

You don't have to be in the same department.

So that was the first step. The next thing was, uh,

affordable ultrasound equipment.

Um, small portable, uh, affordable ultrasound equipment is,

is making this more possible.

And then the outs and the big driver is need.

Um, we are very fortunate in the United States to have lots

of care, even though there are big geographic areas

that don't have the care that they need

because they're in rural locations

or they don't have the equipment at the hospital.

Um, so there are areas of need in the United States, um,

but in the rest of the world, it's very much in need.

And Diana's gonna talk about that.

Um, there's also been an expansion of training

and scope of practice for physicians

that are non radiologists

and non O-B-G-Y-N physicians, um, in the growth

of non-physician healthcare practitioners, uh, such as, um,

you know, nurse practitioners, PAs, um,

I know they're rapidly growing in numbers.

Diana will have to fill us in on the

numbers on the midwives.

Um, I did look up today certified cer,

or like certificates issued by the A DMS for nurse

or nurse midwives, and it was around like 68.

So I'm assuming they're getting their certifications from

the nurse midwife side, not the a RDU mess right now,

but you'll have to fill me in on that.

So, um, again, just real quick, these portable ultrasounds

and pocus, you know, you have these, these handheld type

units where, um, they just plug into a phone,

and that's kind of like

what everybody has in their mind, what POCUS is.

Um, you know, you just plug that into your phone,

you're talking to your patient, you throw it on the,

the abdomen and you say, okay, here's your, the, you know,

the fetal heart rate's there, you know,

it's 160 beats per minute, you know,

the gestational sac looks good,

you're just doing a transabdominal ultrasound

right there on the spot.

You're able to, you know,

you can measure the gestational sac diameter,

you can give them an estimated data delivery based on this.

Obviously, if you can see everything, you know,

um, within those limits.

Um, then there's the, uh, laptop style ones that, you know,

the handheld ones I see cost between 2000

and $8,000, whereas the laptops start around 8,000

and go up higher all the way up to like 40,000.

Um, and there's some really, really nice systems out there.

I just went to the Radiological Society

of North America meeting, saw all the new stuff.

It was very cool. Um, so, you know, all

of this stuff is cheaper, more easily transported.

I don't know if you've tried to like move a cart based

system in your car, but it's not possible.

I bet Diana's done it. Um, so then rural areas.

So I'm in Missouri.

Missouri has a very large rural population.

You know, we have two big cities where, you know, half

of our population lives in.

And then we have a big open middle area,

uh, southern and northern.

And in the mid part of the state where, you know, we have,

uh, non-tertiary care facilities that are providing most

of the care people usually have to drive, you know, 30 to

30 minutes to an hour

and a half, maybe even two hours to get to a, a facility

that has an ultrasound machine.

Um, so if a rural clinician were

to have their own ultrasound machine in their office,

and they were able to perform a point

of care ultrasound on their patient, they could, number one,

um, prevent the need to drive that hour to somewhere else.

They could, um, reaffirm

or support their diagnosis

with the findings on the ultrasound.

Um, or they could raise their level of suspicion

and decide to send somebody that they thought maybe wasn't

as sick as they thought they were.

Um, you know, just think about it, like how, how easy is it

to perform A BPP?

Um, I think a lot of people could be trained to do that

with a point of care ultrasound.

Um, in the United States, less than four, uh, 40%

of rural counties have access to POCUS right now.

And most of POCUS is actually in urban areas, um,

which is kind of, you know, not defeating the purpose,

but it's a little bit opposite of

what we wanna achieve here, because most urban areas have

all the card base systems

and all the staff and all the sonographers.

Uh, 49%

of rural counties in the United States actually lack OB GYN

care from, you know, OB GYN physicians.

That's physicians. Um,

the sonographer workforce is another thing.

Um, there's 134,100 sonographers in the United States,

according to the Bureau of Labor Statistics, I checked today

on the A-R-D-M-S, and there's currently 64,431

OB GYN certified sonographers in the us.

And there's 10.8

to 12 million obstetric order sounds

performed annually in the United States.

That's based on like billing codes.

So there's probably more than that.

Um, and, you know, we'll, you know,

that number could, could be much higher.

Um, I would suspect it's, I feel like I did

that yesterday just on work.

But, um, sonographers, as you can see,

there's not a whole lot of 'em, you know, uh, you know,

64,000 sonographers to care for all of our,

our pregnant population

or females for gynecological reasons, is not as much

as you would think it would be.

And then furthermore, most of the sonographers are centered

around cities or areas

that have the big cart base systems to hire them.

Sonographers aren't cheap and you know, well deserved.

So it's also very hard

to hire a sonographer into a rural area

where they're only gonna have three

or four ultrasounds a day

because they can't afford to have the sonographer there

because they don't have the case value to support 'em.

So that brings me to the end of my talk

and the transition into Diana's talk.

So, um, you know, we're gonna have a lot of questions

for Diana, and she's gonna elucidate how,

from her perspective on POCUS is, uh, being performed

and how it works into the patient care workflow.

So with that said, Diana, take it away.

Great, thanks so much.

Give me a second to share my screen

and, uh, we will get started

with some slides that I have.

Great. Okay.

And, uh, uh, I appreciate the chance to talk about pocus

and having been a clinician,

a nurse midwife in obstetric care for a long time,

and also being a registered sonographer,

sometimes I feel schizophrenic

because I want to give the perspective of the importance

of training and education and doing things right.

And, and then I also have the perspective of,

I have a woman in front of me who needs a decision.

Now she's six centimeters. Is she breach? I don't know.

I can't wait for six hours to, for a sonographer to tell me

what, whether this woman is breach.

So, you know, I I I, I see through the lens

of both types of clinicians.

So I want to go through these slides that I've put together,

and it's going to be a little bit of a hodgepodge of,

um, slides.

But, but to restate the obvious, a PO point

of care ultrasound is done in direct response

to a patient's need at the moment.

You can't always wait for, uh, an appointment

with a radiologist

and an OB in particular,

it seems like every Friday afternoon at five o'clock,

someone presents with a problem that needs an ultrasound.

And, and if you don't have an ultrasound in your hand,

then you either have the choice of waiting

until the next week for that patient to get an an,

an appointment, or you have to, um, send them

to the er, which means that they won't be seen for,

you know, 10, 12 hours.

So anyway, just, this is all pretty self, self-evident here.

Um, but, but the point

of care often involves an advanced practice provider.

Uh, it's not meant to pre

to replace comprehensive ultrasound.

It is a clinical ultrasound.

And in fact, what's interesting is that, um,

the PAs or physician assistants don't recognize the need

for a certification for this,

because they call this a clinician's ultrasound

or clinical ultrasound that doesn't require training

or a certification process.

So it's kind of interesting the perspective there.

The core components, and this is what I teach the,

the people in my classes, is that first of all, you have

to have an indication, then you have

to have an image acquisition.

You have to have an image in your record to demonstrate

that you did this interpretation.

What did you decide?

What was your assessment and integration

into your plan of care?

Now, what's interesting is that in Europe, in the,

which is the International Society of ob, GYN

and ultrasound, they recently had a, um, a seminar on point

of care ultrasound and OB GYN in many countries,

they, uh, don't even record.

They don't document anything.

They just do the ultrasound,

and then they record a general

impression in the patient's record.

Uh, in the United States, I feel like,

and in North America, we probably have a little bit stricter

guidelines on what we need to record and documentation.

And I personally feel like if you put your, your, um,

your probe on a patient, you really need to capture an image

to show what you, what you saw.

That's just my own personal opinion on it.

So the A IUM has specific definition of point of care,

and it's really basically what we have already talked about,

except that they have included

the statement about diverse set of providers,

including nurse midwives, nps, PAs, uh,

and other types of providers.

And the other thing is that lay midwives or,

or CPMs, professional midwives that are not nurse midwives,

are now purchasing the handhelds and are using them.

So that begs the question is, who should be credentialed?

Does it have to be someone with medical

education background?

So that's a whole other, uh, issue to be talked about.

I like to bring up the concerns

because this is what comes up in people's minds,

especially if you're talking about

to sonographers or radiologists.

Is, is POCUS gonna replace diagnostic imaging?

Uh, no, I don't think so.

Is POCUS accurate, as does or does limited mean incomplete?

No, uh, they, there's a, a difference between limited

and well limited has its own definition.

And if you do the, uh, the uh, uh, uh,

CPT codes, there are certain criteria components

that must be met to, to bill as a limited exam.

So that is a real thing, a limited exam.

And how can somebody

with less ultrasound education perform these,

uh, and be accurate?

Uh, do radiologists

or physicians have to overread a point of care ultrasound

and know, not necessarily

because there's, you don't always have a radiologist

available or even a physician available

if you're in another country.

And how are the standards different for POCUS than

for diagnostic imaging?

And we'll talk about that in a second.

And what are the organizations that provide guidelines?

And that's been elusive for me to try

to write white papers on what it is

that POCUS is in different countries,

because it's all over the place.

Uh, there are really are no O-B-G-Y-N POCUS standards.

OG is about to publish their version of a standard of POCUS

for OB GYNs probably this year.

The other concern is, again, inadequate training

clinicians going beyond their training.

And I hear this in other countries a lot, the ministries

of health have a lot of concern about

if these clinicians will go beyond what their scope is.

Another thing is bias.

And I have a real issue with that myself, in that

as a clinician, I might have a bias about what I'm seeing.

In other words, if I think this woman is probably gonna be

okay to deliver in a, in a low risk setting,

I might be biased in how I do my a FI,

my amniotic fluid index,

because I'm thinking, oh, I think it's okay,

let me look at this again.

Or if I think that, that there's some concern about, um,

gestational age, well,

maybe the abdomen circumference isn't quite

what it should be, but maybe I can make it be.

And so you have to remove yourself from that bias

and be really careful when you put in the machine the

parameters of the, of the,

the woman's last menstrual period.

Put it in and don't look at it again.

Just do your measurements

and let the measurements speak for themselves

and not try to, to be biased.

Failing to maintain skills is another problem.

Uh, risks, uh, would be suboptimal imaging

or erroneous interpretation.

That's what commonly you hear from physicians, radiologists

who don't believe that, that, that non-physicians

or non sonographers have the skill to, to do that.

Uh, and, and the intention

and the scope of the scan

of exams should be clearly communicated to the patient.

The patient should not call you doctor.

The patient should not call you sonographer,

because you have, you have to,

you can't mis represent yourself.

This is just an outline of the, uh, progression of

focus by specialties

and how that's come along over the years.

This, and, and I, since I'm a nurse midwife, I tend

to focus on OB GYN specialty,

but I realize there are many other specialties out there.

Advanced practice nurses who do ultrasound venous access,

all kinds of use for point of care.

Ultrasound is not just for obstetrics.

This is just another list of POCUS indications

for all the different types of, uh, applications.

So who decides who can perform POCUS

and who makes the rules?

The A IUM says radiologists, MFMs sonographers,

uh, non radiologists, uh, physicians such

as OB GYN physicians and advanced practice, uh, providers.

And I will say, just as a side, that,

that sometimes the physicians, the OB physicians

that I've worked with will be the ones responsible

for looking at my, uh, point of care ultrasound exam.

But they themselves have not had, uh, training in that.

The a CR, the American College of Radiologists, uh, says

that radiologists, sonographers physicians, uh, can do, uh,

a point of care ultrasound.

And I'm not sure, Jason, you may wanna, uh, chime in on

that, whether they have made some change recently.

But that was the latest statement that I could find,

that they're, they're not embracing

advanced practice providers.

So a hospital, hospital credentialing

for an advanced practice provider would, uh,

probably depend on whether that hospital's,

radiology service is, uh, credentialed

by A IUM or a CR.

So there's a difference there.

You may be able to practice point

of care ultrasound in your practice, in your office,

but if you're doing it in the hospital setting,

then you may be restricted if your hospital's radiology

department is accredited by a CR.

So those are just some differences.

So, provider differences.

And the biggest thing that I see between sonographers

and physicians in terms of who can do what

and who has to have overreading by, by a physician

or radiologist, is whether you're a billing provider

and if you have an NPI, which is a billing number,

sonographers, uh, are not billing, they bill under their,

the, uh, umbrella of the hospital

or the practice they're working for.

Whereas nurse midwives, nurse practitioners, uh,

if tend to be more in independent

or interdependent practices,

and they are billing providers so they can bill directly,

so they don't necessarily have

to have a physician to overread.

Now, for liability sake, I think it's really important

to have somebody overread

or at least review a certain number of exams that you do.

And in some states, like where I practice in Alabama, all

of my, all of my, um, charts have to be reread

or reviewed, or not all,

but 20%, uh, of my charts have to be read by my, um,

collaborating physician, uh,

circumstances affecting POCUS practice,

your state practice laws, the scope of practice, definitions

of your professional, uh, group institutional culture,

the burden of disease,

and we'll talk about that in a second about international

work, your patient population, uh, skill of the provider

or the consulting physician, the type

of machine you have available,

and availability of practice resources.

Do you have an outside physician you can refer

to a radiology service that you can refer to

for complications?

I wanted to just touch on emergency medicine

because they were pretty much the, the forerunners of,

of pocus because they had a very huge need

to do urgent, urgent assessments

and found POCUS to be very helpful.

But even as of a few years ago that there's some tension

between er, uh, physicians

and radiology departments in some institutions, uh,

especially in the, um, large, um,

university-based hospitals.

But emergency medicine physicians, asep,

the American College of Emergency Physicians develop their

own guidelines for point-of-care ultrasound,

but they also embrace nurse midwives in this,

in this umbrella of the need for expanding pocus

because they also do a tremendous amount of pelvic pain,

GYN ruling out ectopic

and these types of emergency situations.

The other thing that, that I wanna mention is

that they found that in, just to take away from this slide,

is in 2019, there was a study

that showed there was a decreased length of stay.

And hospitals are all about length of stay in their ERs

because they, they need to have fast turnovers in, in ERs,

but it's also important for ambulatory care, timely access

decreases healthcare costs.

There are some rural areas

where patients don't have insurance,

and it's a matter of, do I just need to do a heart rate on,

on a patient, on the, on the baby

or send her for a $400 scan?

Because if the philosophy is,

if you put the transducer down, if you do any scan,

you gotta do it all.

And then you're ob obligated to check for other things

and obligated to, to bill for the entire scan.

And so there's, that's where my schizophrenia comes in

because I feel like, can I just do a quick heart check

or do I need to check to see if

that there's anything else going on?

So those are the dilemmas that we all face here.

And the other thing is it frees up,

and I'd really like to hear, uh, Dr.

Cox's thoughts on this, it, it, as far as downstream effect

to, for radiology services, it really frees them up

to do the type of diagnostic scans that they have,

the training and the expertise to do.

So that's another important point.

So what do you gain by diagnostic versus pocus?

These are pretty self-evident.

This is comprehensive, this is limited.

But the other thing, the advantage is that the,

the clinician has a better picture of that overall

clinical picture of the patient.

What's going on with her? What is her situation?

Is she amenable to induction?

If there's a problem, induction of labor,

if there's a problem, the radiologist may not have this,

this information, he's just looking at the, uh, the,

uh, assessment and then the clinician also has

to make the interpretation.

And what, how does that impact that clinical decision?

And I, I'll just tell you a story.

I'm having trouble freezing these slides, but,

but, uh, you know, um, I had a patient that came in,

the radiologist sent her to labor and delivery triage,

and she had, uh, supposedly an amniotic fluid index of

around 28 to 30, which is huge.

And so when she got there, I did my assessment

and I looked with my own scan.

I thought, this woman does not have that a FI,

but in the meantime, the, the expectation had been set

that she was going to be induced.

So she was not really at term, should she have been induced?

Probably not. The chief resident said,

no, let's not induce her.

Let's send her home. Bottom line is that she decided

to stay and be induced.

Well, that ended up in a three day induction baby.

She got choreo am united as complications

of baby babies in the NICU for four or five days.

These decisions have consequences.

And we are in the clinical position

to see those consequences and see how that affects outcomes.

It's not just numbers to us.

It's what, what affects the patient in the long

run workflow we talked about.

So this is the typical workflow that,

that Dr. Cox described with pocus.

We do it at the bedside. We incorporate the findings into

the clinical assessment into the HPI, the, the, um,

um, history and physical exam.

And the clinician integrates the findings into

the clinical decision making.

And so there's no set workflow.

So we don't have appointments for us to do scans in

between our work workflow.

So again, this is just a decision tree where typically the,

the clinician sends a patient out, scan is done,

reports written, gets back to the physician,

and then the decision is made at the, for the patient

with the clinician doing pocus, it's right there.

You've seen it, you're gonna make your decision and move on.

So downstream utilization, again, the lines

between what's done for diagnostic

and point of care are sometimes blurred.

We, when we're doing point of care, we don't even pretend

to know that we're doing a complete exam.

You know, we might see an abnormal complex ovarian cyst,

but we're not gonna be saying, oh,

that's a cyst adenoma, or that's a whatever.

You know, we can put color flow on it and,

and describe the characteristics,

but we may not be able to make that diagnosis.

So we're gonna send that patient on.

So we have certain parameters of what constitutes, uh,

the need to send on for further scanning.

Um, and then there are problems when the POCUS operator's

not sufficiently confident.

They may know what they're seeing,

but they'd only do it once or twice a week.

So they really may not be confident in their skills.

And the, there was a study that was done to look at

the reasons why clinicians requested sub subsequent imaging

and did it affect downstream, uh, radiology services.

And they found that there was a minority

of POCUS exams in tertiary care center, followed

by additional imaging, which tells me

that they're doing a pretty good job of figuring out, say,

looking for appendicitis or those types of things.

And that they found that there were actually very few

diagnostic discrepancies.

There was a study by Hines that just just showed

that ultrasound diagnostic and POCUS are complimentary

and that POCUS has not replaced,

and that there should be optimization of cooperation

and concentration, uh, consultation between radiologists

and POCUS providers

and NESS also looked at emergency physicians

and sh showed that there were outcomes demonstrated

that there was no harm done as a result of physicians doing,

uh, POCUS exams in the ed.

So again, the, uh, WHO has POCUS guidelines of

position statements, acog, American College of ob, GYN,

American College of Nurse Midwives, the American Association

of Nurse Practitioners

and Nursing organizations such as a one.

They've had guidelines for nurses doing ultrasound for

since the 1970s.

Uh, ISSA we mentioned is an international society,

and they, they are just extremely, uh,

helpful in providing all kinds of education and guidelines.

This is the position statement that came out from the, uh,

uh, American College of Nurse Midwives.

It came out in initially in 2012.

It was updated in 2018,

and it's been re-updated this last year.

And this gives us the permission

from our national organization

to incorporate ultrasound into our scope of practice.

So any nursing organization, our nursing

provider that wants to, to incorporate pocus

must have a statement of this kind.

Otherwise, you're practicing out of your scope of practice.

So it must be well-defined in your scope of practice.

And the A CNM went on to mimic

what a IUM said in determining what their guidelines.

These are the educational components

that you must have when you're getting education about POCUS

required elements, anatomic landmarks, indications,

clinical indications, SA safety, uh, complete components

of the complete exam client education

and additional didactic plus continuing education.

So how did they determine what scopes of practice?

When I was initially working with A-R-D-M-S, uh,

in developing the midwife, uh, exam for ultrasound,

they spent a couple of years.

We spent a couple of years looking at how do you determine

what are the practice scopes?

We started out thinking, well,

this should be just like a mini OB GYN, uh, course.

Well, no, it's really different

because our scope of practice is different.

So they did a survey of, uh, knowledge

and skills in the nurse midwifery community,

looked at the core competencies

and to see what kind of practice do nurse midwives do.

And this is just for nurse midwives, and it varied,

but they did what's called a joint task analysis to look at,

uh, what were the core competencies,

and this is what we came up with that, uh, this is what

is included in ob first of all, principles

of ultrasound machine basics.

And you don't have to know all the physics formulas

to be able to work a machine any more than you have to know

how a car operates

and the engine, how the engine works

to be able to drive a car.

And that's maybe a poor analogy,

but you need to know enough to be safe,

and you need to know enough how to minimize artifacts

and help you make a better, a better image.

So safety and document and QA documentation.

And then it goes into gynecology.

Basic things that we look at first trimester, um, uh,

biometry fetal growth.

Fetal anatomy is not point of care.

Fetal anatomy is something

that can be done in a routine exam

and can have an appointment.

But biometry, if you're get taking someone at,

with no prenatal care,

and you have to have a baseline of,

is she, is she near term?

You know, you have to be able to do biometry.

Uh, fetal growth is the same, uh, biophysical profile,

fetal presentation, intrapartum ultrasound is, is later on.

But those are some basic components

of the, the point of care.

So these are narrowing it down

to even more basic viability in dating biometry, a FI,

which is part of the biophysical profile.

Cervical length can be important to know,

although there are certain, uh, organizations that,

that say states you have to have specific training.

Um, there are other organizations that said that that's,

that, that, uh, it really doesn't necessarily, you don't,

you don't necessarily have to have that training.

It's called a clear training to be able to do that.

So, uh, again, ACOG has their, uh, list of, of, uh,

standard versus limited, uh, and they've defined it

and POCUS scope for, for emergency physicians.

I mean, these are the scopes of practice for pocus for

ER physicians or er, uh, aams,

which are nurse practitioners.

So you can see it's limited.

It's not as detailed as, as what a radiologist

or sonographer would.

The other thing I wanna bring up too is the idea

of competency versus proficiency,

because I think we have the expectation

that if you learn ultrasound,

you must be extremely proficient at it to be able to do it.

Competency means that you've passed the basic safe level

of being able to do a competent exam and,

and hit the required tasks and be accurate.

Proficiency means that you are not a novice,

that you've done this and you have the

expertise in doing this.

So who interprets point of care ultrasound?

And that's been a, a real sticking point as far as you know,

do physicians interpret diagnostic tests?

Do nurses interpret?

When I teach ultrasound classes, I try to avoid the word

diagnosis or interpretation

because it has a connotation

that we are making a medical diagnosis.

So instead, when we're doing pocus, I encourage people

to use the word impression or assessment.

And if it, if it's something straightforward,

like if the baby is vertex or,

or breach, that doesn't require a physician

to sign off on it, you, you create your image, it's evident

that that baby is head down or breach.

So those are really simple things that don't require, uh,

physician oversight.

I wanted to talk briefly.

I know we're getting close to time about ultrasound in

remote areas, and I have a great, a great, uh,

heart for doing that.

Uh, there are medical deserts, not just worldwide,

but within the United States and,

and in many rural areas like Dr. Cox suggested.

This is a, a, um, just a diagram that shows that in,

in the whole world, that they're probably more maternal,

maternal care providers than anything else

because nurse midwives

or midwives deliver most of the babies in the entire world.

Even with that, there's a shortage of 900,000

to meet the, the need.

Then there's even smaller number of medical providers

and an even smaller number of radiologists.

And there's also a smaller number of people who are capable

of using the digital, uh,

capability capabilities that they have.

Uh, again, international concerns of, of providers using,

um, ultrasound po point of care, lack of training, lack

of resources, consistency and standards.

And the ministries of health don't always hav

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