Good afternoon. Welcome. Welcome to everybody. My name is Danielle Feinberg, and I am HCCI's coordinator for education and research, and we would like to welcome you to our monthly HCC intelligence webinar. Our topic for this month is introduction to point of care ultrasound for the home care provider. Before we begin our webinar, I'd like to go over just a few household items with you. First, all attendees are muted. Secondly, we will have a question and answer period at the end of the presentation. If we do not get to your question, we will do our very best to answer it after the webinar, and then post the question and answer transcription for everyone to download and save. Third, the webinar will be recorded today, and an archive link will be made available within 24 to 48 hours on the HCCI HCC intelligence page. If you do have any questions as we're going through, please feel free to type those in, but know that we will not address any questions until the very end of the presentation. Our presenters today are Dr. Wallace. Dr. Wallace completed medical school and residency at the University of California, San Francisco. He is a former ultrasound fellowship director at the University of Pennsylvania, and currently the medical director at Insight Home Physicians in Philadelphia, PA. Dr. Kim received both his undergraduate and medical school degree at University of Michigan. After completing his internal medicine primary care training at Penn, Dr. Kim completed a clinical ultrasound fellowship at Penn, where he developed and implemented a point-of-care ultrasound curriculum for the geriatric fellowship. Our objectives for today are to gain awareness of the highest yield POCUS modalities for the homebound patient, to understand the indications for POCUS and the evidence behind it, to understand the basic principles of POCUS and image interpretation, and lastly, but not least, to identify strategies and resources for ultrasound skill building. Without further ado, I'd like to turn it over to Dr. Wallace. Great. Well, thank you for the introductions and thanks for HCCI for the opportunity to do this. Thank you all for joining us. I wanted to first give a little background on myself. I'm probably like most of you in that I didn't get any formal training for diagnostic ultrasound in medical school or residency. It's something that I picked up on my own mid-career. So I thought I would give a little bit of what got me interested in ultrasound with the hope that that might also inspire you. So next slide. So I remember the exact day that I found out about point-of-care ultrasound and got excited about it. This guy, Abraham Berghese, was giving a talk on a physical examination. And interestingly, he didn't really highlight the diagnostic utility of point-of-care ultrasound, but more spoke about its importance for rapport building. Next slide. But at the end of the talk, he also showed what is in his black bag. And it turns out he carries around a portable ultrasound, which I thought was highly revealing and intriguing. Next slide. And around the same time, the Institute of Medicine came out with this report, Improving Diagnosis in Health Care. And the Institute of Medicine is the organization that put out the To Err is Human report in 1999 that kicked off the quality improvement movement. So very influential group. I mean, they've changed their name now. But in any case, in this report, we're highlighting the harms done by diagnostic errors. So it got me thinking about how I could become a better diagnostician. I felt that was sort of plateauing mid-career. And when I think about diagnostic excellence, this guy comes to mind. It's a colleague of mine from Residency Goop, Dollywall. He's the guy that can go up in front of an audience of 2,000 people at a conference and diagnose a cold case of leptospirosis in like 30 seconds. So really a master diagnostician. And so how does one become a master diagnostician? Next slide. Here's the schema that the Institute of Medicine proposed for the diagnostic process. It's an iterative process of working diagnosis, information gathering, integration. And Dr. Dollywall excels in the information integration interpretation largely because of his encyclopedic knowledge. And he got there by reading thousands of New England Journal case reports over the course of medical school and residency. And for me, as a mid-career guy with two kids, I didn't think reading 1,000 New England Journal case reports was really in the cards. So I thought maybe I can get the same results by just getting higher quality data with ultrasound. Next slide. But ultrasound is pretty intimidating in its scope. If you look at the ED who have the most experience with this over the last 30 years, they scan everything from eyeballs to Achilles tendons. And I didn't think that that was really something that was in the cards for me to take on that entire broad scope. And it's probably not relevant for a less acutely ill population. So next slide. So what I tried to do over the first few years that I was scanning was to try to narrow it down to a high yield subset of examinations. And by high yield, I would define as exams that are easy to learn how to do, fairly quick to perform, and are relevant in some of the more common disease processes. Next slide. And what I found was that the exams that I ended up using the most were things like IVC, bladder, IJ, especially lung ultrasound, and limited cardiac ultrasound. And this covers a lot of the acute complaints, a lot of the most common conditions that we treat. Next slide. And ultrasound enthusiasts do like their acronyms. So we came up with an acronym representing this exam called the HOUSE exam protocol, the Home-Oriented Ultrasound Exam that's covering, again, JVP, lung, bladder volume, limited cardiac, IVC, and also DBT. Next slide. And Dan used this, the HOUSE protocol, as a framework for developing a curriculum for geriatric fellows that was quite successful. They had a half day workshop followed by eight hours of hands-on instruction at the end of the curriculum. The participants felt highly confident in this subset of examinations. Next slide. So a big part of this talk is going to be to try to convince you that ultrasound has a lot of advantages over physical examination. So I do want to talk about statistics and test characteristics to some degree to allow for those comparisons. I prefer rather than sensitivity and specificity, I prefer likelihood ratios. So to review, for some of you may have not thought about this for a while. Next slide. The likelihood ratios are a more intuitive way to look at these test characteristics. And the way you use them is you will take your pretest probability for disease in a patient, multiply it times the likelihood ratio gives you the post-test probability. In other words, if a patient had, for example, a test at a positive likelihood ratio of 10 and it was positive, the patient has a 10 times more higher likelihood of having the disease. So next slide. So when you get to that threshold of a positive likelihood ratio of 10, then that's kind of a gold standard rule in test. And similarly, the lower the negative likelihood, the better. So for a negative test, if the negative likelihood ratio of that test is 0.1, then a negative test means that disease has essentially been ruled out for that patient or 10 times less likely to exist. Next slide. And just to illustrate, here are some of the likelihood ratios for diagnosing CHF. And you can see that physical exam findings in history like orthopnea, JVD, leg edema, especially for the negative likelihood ratios, very close to one. So not really going to change your post-test probability if that test is negative. Whereas something like lung ultrasound, very high positive and negative likelihood ratio. So useful for both ruling in and ruling out disease. And with that, I will pass it off to Dan to talk about some of the modalities in detail. Thanks so much, Paul. So I'm going to start off by talking about the lung ultrasound. Next slide. And so in scanning the lungs, there are different techniques that divide the lungs into a different number of zones. And clinically, I can tell you that most of us will use the eight zone method that divides each lung into four zones, the upper and lower anterior and the upper lateral and basal lateral lungs. And we find that this is a nice balance between time efficiency while maintaining its accuracy. If you look in the literature, though, and in research, you'll find that a lot of research will utilize the 28 zone method. Next slide. To scan the anterior lungs, you'll place the probe in the mid-clavicular line. And for the lateral lung zones, you place it in the mid-axillary line. And you'll want to anchor yourself between two ribs and the resulting rib shadows. And that first bright white line that you see represents the pleura. And once you have found these landmarks, you'll slide down examining each intercostal space until you hit the level of the diaphragm. Next slide. And in lung ultrasound, we don't see what we normally expect to see an ultrasound. And that's because air in the lungs scatters all the ultrasound waves, resulting in artifact. But thankfully, we can use this artifact to understand what's going on in the lungs. And the two artifacts I want all of you to become familiar with are called A lines and B lines. Starting with the A lines, A lines are what we expect to see in normal air-filled lung. And it's a reverberation artifact of the pleura itself. And it occurs when sound waves bounce back and forth between two parallel surfaces that are perpendicular to the ultrasound beam. I have a diagram that will help illustrate this a little better. So next slide. So when sound waves hit the pleura and goes back to your probe, you get your first bright white line representing the pleura. Some of the sound waves bounces off your probe, goes back to the pleura, and back to your probe, resulting in your first A line, an artifact of the pleura. And this occurs again and again and again, resulting in multiple A lines being repeated down your display. And as I said, since A lines are simply an artifact of the pleura itself, you can also see it in patients who might have a pneumothorax or a COPD asthma exacerbation, and even a PE. Next slide. Now moving on to B lines. B is for bad, and that's how I want all of you to remember it. And B lines occur when there's any process in the lung that increases its density. And that could be due to interstitial edema, any kind of alveolar filling process, fibrosis, pneumonia, atelectasis, and even ARDS. And B lines are another reverberation artifact, except now in our patient with an increasingly dense lung, sound waves can now travel beyond the pleura into the interstitial alveolar space. Next slide. And then it can bounce back and forth again and again and again, resulting in a B line. This is also known as a comet tail artifact. Next slide. And to give you a more concrete definition, B lines are vertical laser-like beams that begin at the pleura, and they extend all the way down your display, and they move synchronously with lung sliding. Next slide. And we can actually count the number of B lines. You can have up to 10 within each intercostal space, the number of fingers on your hands. And if you have three or more within a zone, that generally indicates pathology in someone who has undifferentiated shortness of breath. Next slide. And so we know B lines are an excellent indicator for pulmonary edema for patients who have congestive heart failure, with a positive likelihood ratio of 10 and a negative likelihood ratio of 0.06, which is far better than our physical exam of RAILS and JVD. And the great thing about B lines is that you can count them and quantify the amount of congestion, and you can track it over time and how it changes as you're diuresing your patient. Next slide. Along those same lines, someone whose volume overloaded will often have a pleural effusion. And with the ultrasound, we can actually visualize the fluid above the level of the diaphragm. We can not only help quantify the amount of effusion that someone has, but you can also tell whether it's a simple effusion or a complex effusion. Next slide. Lung ultrasound is also excellent for the diagnosis of pneumonia, again, with positive and negative likelihood ratios near the gold standard, far better than our physical exam of bronchial breath sounds. Next slide. And this has been studied pretty extensively in the literature for over the past 30 years. And we know from meta-analyses that compared to chest X-rays and CT scans, lung ultrasound has a sensitivity and specificity in the high 80 to 90 percentile, which is really good. We also know that it allows for a faster time to diagnosis, and we can also avoid radiation in our patients. Next slide. And so what do you see in lung ultrasound for pneumonia? You can see B-lines, except the B-lines, except now they're more focal and unilateral in one side of the lung, as opposed to being symmetrical as we see in heart failure. Next slide. You can also see thickening of the pleura and irregularity instead of the nice thin white line that you're used to seeing. Next slide. And in someone who has a beginning stages of pneumonia, you can also see what's called small subpleural consolidations right underneath the pleura. Next slide. And when you have areas of focal consolidation that's surrounded by normal area of the lung, the border between the two can often appear jagged and irregular, and this is called the shred sign. And finally, when you have whole lobar consolidation, the lung can take on the properties of a solid organ like the liver, and this is often termed hepatization, and it can be difficult to differentiate between the lung and the liver itself, and so it's important that you orient yourself. Next slide. Now I'm going to move on and talk about the IVC and IJ ultrasound. Next slide. For the inferior vena cava, you'll place your probe right below the sternum, and you'll get both the long axis and the short axis. In the long axis, you can often visualize the hepatic vein draining into the IVC, and in the short axis, you'll want to have enough depth so you see the spine, because right above it, you'll see the IVC and the aorta. Next slide. And so in looking at the inferior vena cava, we're assessing both the size and collapsibility. We're asking ourselves, what is the largest diameter, and how much does that change with respiration? Is it really small, less than one centimeter, or is it really large, greater than 2 to 2.5 centimeters, and is it collapsing really well or not collapsing at all? Next slide. If your IVC is small and collapsible, then that correlates to a low central venous pressure of less than 10, and we can see here in both the short and long axis that the IVC is less than one centimeter based on the calipers you see on the right, and 100% collapsing. If you look at the short axis, you can barely make out a slither of an IVC right above the spine. Next slide. On the other hand, if your IVC is large and plethoric, that correlates to a high central venous pressure of greater than 10, and we can see here in the short and long axis that the IVC is greater than 2 centimeters with minimal change in collapsibility with respiration. In the long axis, you can actually see the hepatic vein draining into the IVC. Next slide. And so how good is our IVC compared to our physical exam? And so for the JVP for correlating to a high central venous pressure above 8, it's actually pretty good with a positive likely ratio of 9.7 and a negative likely ratio of 0.3. Unfortunately, as many of you experienced, you can't always find the JVP due to body habitus and other factors, and that's where the IVC can be helpful in the extremes. And so a large and plethoric IVC can correlate pretty well to an elevated central venous pressure above 10, and a small and collapsible IVC, again, can correlate to a CVP of less than 10 with decent likelihood ratios. Next slide. And we also know that the IVC is dynamic, and it can change within a matter of hours of someone getting diuretic therapy. This is a large study that looked at 400 patients who were admitted for heart failure and diuresed, and by the time they were discharged, all patients had an improvement in their IVC diameter and also collapsibility. And so the IVC is something we can track over time as we're treating patients for heart failure. Next slide. We also know that the IVC can help prognosticate these patients who are admitted for heart failure. This is a small study that looked at patients on the day of discharge and found that patients who had a large IVC still with minimal collapsibility had a higher risk for readmission within 30 days compared to their counterparts who had smaller and more collapsible IVCs. Next slide. And this also is true in the outpatient setting as well. We know that patients in clinic who at baseline have a large IVC diameter have the highest risk of death and hospitalization compared to their counterparts who have smaller and more collapsible IVCs. Next slide. And so this is a patient that I saw recently in the home, a 77-year-old female with Parkinson's who's wheelchair-bound with morbid obesity, half-path chronic edema, and she was having a couple of days of shortness of breath. And so we went to see her in the home and it was hard to assess how adherent she was to taking her Bumex every day. We weren't quite sure. We were, you know, it seemed like she had some edema in her legs and we were considering whether or not to increase her Bumex for a couple of days to diurese her more to see if that would help. We had my ultrasound with me, so we took a look at her IVC. And her IVC, as you can see here in the short axis, is small, less than one centimeter, and 100% collapsing with respiration. So her central venous pressure was low. And then we took a look at her lungs and we saw all A lines, which is good and normal, and no B lines. And so after this, we were fairly confident that our patient wasn't volume overloaded, did not have pulmonary edema, and it turned out that she actually had a lot of anxiety secondary to COVID, and we ended up focusing a lot of our visit on helping her with that. Next slide. Now I'm going to talk about the internal jugular, which all of you are familiar with in assessing for the JVP. You'll place the probe right above the clavicle and you'll visualize the IJ, usually on top of the carotid. And then you'll slide up the neck gently until you see the point where the walls of the IJ collapse. This point correlates to the JVP on the patient's neck. Next slide. Next slide. If you simply rotate the probe 90 degrees, you'll get the IJ in long axis, where it takes on the shape of a paintbrush or a wine bottle. And the point where the walls come together, again, correlate to the JVP and the patient's neck. Next slide. And we know this from studies that have mainly been done in patients who are critically ill in the ICU, many of whom are intubated. And overall, we know that the IJ ultrasound collapse point correlates pretty well to the CVP and overall underestimates it. We also know that the IJ ultrasound is more accurate, quicker, and easier to attain than the IVC. And it's going to be better than your physical exam, the JVP, because you can visualize it 100% of the time. Next slide. So this is a patient that highlights that really well. She's another patient I saw a month ago, a 70-year-old female in the home who's morbidly obese, has HFPEF and asthma, and chronic edema. And she was also having intermittent shortness of breath and also maybe some increased swelling of her legs. And this is what her legs look like when you go to her home. And you can tell right off the bat that her physical exam is going to be incredibly challenging. You can't really hear her lungs anteriorly. She can't sit up for you. And you cannot see where JVP is on her neck. Thankfully, I had my ultrasound with me. And so we took a look at her IJ. And through that thick sternocleidomastoid muscle that you see on top, right beyond that, you see a small collapsed IJ. And this is at the level of her clavicle with her lying completely flat. So her JVP was low to normal. And you could imagine you would have never seen this on your physical exam. We also took a look at her lungs. And again, saw all A lines, which is normal, and no B lines. And we ended up treating her for an asthma exacerbation. And her symptoms improved in the next couple of days. Next slide. Now I'm going to talk about the cardiac ultrasound. Next slide. And looking at the heart, we like to view it in different axes. We'll start off with the long axis, followed by the short axis. And then we'll end with the four-chamber view called the subxiphoid. Next slide. For the parasternal long axis, you'll place the probe between the third and fifth intercostal space. And you'll visualize four chambers, three on the right and one on the left. Starting with the right, you should see the right ventricle closest to your probe, followed by the aorta and the left atrium. On the left, you should see one large left ventricular cavity. You should also be able to see the aortic valves and the mitral valves opening and closing as we see here. Next slide. And if you simply rotate the probe 90 degrees, you'll get the parasternal short axis, where you can expect to see a crescent-shaped right ventricle, followed by a donut-shaped left ventricular cavity. You should also be able to see two symmetrical papillary muscles like we see here. Next slide. And for the subxiphoid or four-chamber view, you'll place the probe right below the sternum and look up at the heart to see four chambers. And this is the view that's best for looking for the presence of an effusion around the heart. Next slide. And so many of you might already know that cardiac ultrasound is going to be the most difficult for all of you to master. And you might wonder how feasible it is for all of you to actually learn and use it. Well, here's a study that looked at emergency physicians who received just three hours of training and performed only five proctored cardiac exams. And by the end of that, they were able to achieve 92 percent accuracy in time when someone had a normal ejection fraction and 70 percent accuracy in someone who had an abnormal ejection fraction, which is not bad. Next slide. Comparatively, this is a study that looked at medical residents who had a little bit more training with three months and performed about 80 cardiac examinations. And by the end of that, they were able to achieve a sensitivity and specificity in the 90 percentile for assessing a patient's ejection fraction, which is pretty good. And so, yes, all of you can learn the cardiac ultrasound pretty rapidly. And with practice and time, you can become pretty proficient in assessing a patient's ejection fraction. Next slide. And we're not calculating an exact number when we're looking at the ejection fraction, but we know that we can do a good job in telling whether a patient either has a normal ejection fraction, a moderately reduced, or a severely reduced EF. And we can do that by two methods that will help us make this assessment. The first is called the fractional shortening method. And this is simply looking at the diameter of the left ventricular cavity and how it changes over time from diastole to systole. A decrease by more than one-third correlates to a normal ejection fraction. And you can see that below in both the long axis and in the short axis. Next slide. The second method is called the E-point septal separation or EPSS. And this is looking at the excursion of the mitral valve and seeing how close it comes to hitting the septal wall. In a normal heart with a normal ejection fraction, the mitral valve should nearly hit the septum as we see here. Next slide. And so how good is our cardiac ultrasound compared to our physical exam of third heart sound and looking for a reduced EF? Well, if you see it on your ultrasound, this nearly doubles your positive likelihood ratio and has a far better negative likelihood ratio of 0.14. Next slide. And the ultrasound is far superior for looking for the presence of a pericardial effusion. There's nothing on our physical exam that will help us or help indicate that there is a presence of an effusion unless the patient is in cardiac tamponade. And so the ultrasound is great in looking and finding any effusion around the heart. Next slide. And so here's an example of a patient who has a normal ejection fraction greater than 50%. And so if you look at both the long and short axis, you can see that the diameter of the left ventricular cavity is decreasing clearly by more than one third. And if you look at the long axis and the mitral valve, you can see that it is nearly hitting the septal wall. Both of these, again, correlating to a normal ejection fraction. Next slide. Compare that to this patient who has a moderately reduced EF of 30 to 50%. You can see here that the diameter of the left ventricular cavity is decreasing, but not nearly to one third. And you can see that the mitral valve excursion has also decreased as well. Next slide. And finally, here's a patient with a severely reduced EF of less than 30%. Here you can see that the diameter of the left ventricular cavity is barely changing from diastole to systole. And you can see that the mitral valve excursion is severely reduced and really far away from hitting the septal wall. Next slide. Now I'm going to end my portion of the talk by talking to you about the DVT ultrasound. Next slide. This modality is unique compared to everything else because it involves a technique of compression, where you apply firm and steady pressure perpendicular to the vessel of interest until you see wall-to-wall compression of the vein, like we see here on the image right. If you see this, this effectively rules out the presence of a clot at this location. Next slide. And this compression technique was born out of a study back in the 90s where they took patients who had DVTs and found that all of them had DVTs either in the palpiteal region and or the common femoral region. And they hypothesized that if we could rule out the presence of a clot in just these two locations with compression, you could effectively rule out a DVT in that leg. Next slide. Subsequent studies found that you can have isolated DVTs in the superficial femoral vein, and that's where the three-point compression technique was born. And this is what most of us prefer to use clinically. Next slide. Mainly because with the three-point compression technique, we have increased sensitivity in looking for DVTs of the leg, and it only takes a couple more minutes to perform compared to the two-point compression technique. Next slide. And so where do we scan anatomically? For the common femoral vein, you're going to place a probe near the inguinal ligament pretty high up, and you'll compress this region looking for a clot. You'll slide down to look for the superficial femoral vein, which occurs right after the drainage of this great saphenous vein. And then you look at the posterior knee for the popliteal vein. Next slide. And so what does the clot look like? Here's a clot in the left common femoral vein next to the common femoral artery. You can see that as we're compressing the vessel, the vessel is not budging. Here's a clot in the left superficial femoral vein next to the femoral artery. Again, we're applying pressure and the vein is not collapsing at all. And here's a popliteal vein right above the popliteal artery. You can see that as we're applying pressure, we're nearly completely collapsing the artery, but the vein itself is not collapsing at all. Next slide. And so how feasible is it for all of you to learn how to do DBT ultrasound? Here's a study that looked at emergency physicians that received only 10 minutes of training, scanned about 200 patients, 25 of whom were positive for DBTs, and they achieved a sensitivity of 100%, and a specificity of 99%, which is really astounding. But if you dig deeper into the literature, you'll find that the sensitivity can range pretty broadly, as low as 40%. Next slide. And we see that here in this study that compared emergency physicians to radiology, and even broke down emergency physicians to residents and attendings. And this study showed that overall, the sensitivity can be low, as low as 40%, especially in residents compared to attendings due to their lack of experience. And it was low, particularly in the palpiteal region. The good news, however, is that the specificity remained high in the 90% top for both residents and attendings. And so what does this mean for all of us as home care providers? This means that, yes, all of you can learn how to use DBT ultrasound pretty rapidly. And if you find a DBT, then you can be pretty confident that there is one, and go ahead and treat if indicated. If you don't see a DBT, you're gonna need to order Doppler's and confirm your finding. But again, as you practice over time and gain confidence, you may be able to forego that step. Next slide. All right, so I'm gonna turn it back to Paul, who'll take us home. All right, thank you, Dan. So the next two modalities that I wanna talk about are bladder and soft tissue. And they're pretty similar in that they're both looking, in both cases, you're looking for a large collection of fluid, and that's really where ultrasound excels in identifying fluid collections. So next slide. So with bladder ultrasound, the technique is fairly trivial. You just find the bony prominence of the pubic symphysis. You go above the pubic symphysis and then angle down into the pelvis, looking for a large black area, large fluid collection. And if the patient has clinically significant urinary retention, it's gonna be very obvious. You're not gonna miss a liter of fluid in the pelvis. And as you can see, relative to physical examination, ultrasound has a lot of advantages for ruling out urinary retention. Next slide. And what do you do once you've found the bladder? You can calculate the bladder volume by taking two measurements in the transverse plane, and then one measurement in the sagittal plane, multiplying them together, and then multiplying by a correction factor of 0.75. Next slide. Another approach that they outlined in this study was just taking the single largest diameter of the bladder. And if the single largest diameter is less than 9.7, then it's very unlikely that they have significant urinary retention. If it's greater than 10.7, likely they do have urinary retention. The 9.7 to 10.7 range is kind of a gray area. The study also showed that portable ultrasound had very similar test characteristics to either 3D bladder scanner or Foley catheterization. Next slide. A few cases and images. This was a patient that Dan had who had syncope when straining to urinate. And when he scanned him, he had this large distended bladder. So not something that is gonna be at the top of your differential for syncope, but certainly something that's easy to identify and easy to treat. Next slide. This slide highlights the utility of ultrasound in managing patients with a Foley catheter. So here you can see the circular Foley balloon surrounded by a bladder that is not collapsed over the Foley. So that's indicating that there is a kink or a clog in the Foley, and that's what explained the decreased urine output in this patient. Next slide. And sometimes you're gonna have some surprises. And this woman, unfortunately, who had a high post-void residual on her bladder scanner, when she had a 2D ultrasound, she was found to have this large bladder tumor that was causing an obstruction. Next slide. So moving on to soft tissue ultrasound. Next slide. And what I'm talking about with soft tissue ultrasound is identifying occult abscesses in patients with cellulitis. So again, the technique is very simple. In this case, you're using a linear probe for better resolution, not as good penetration, but you're essentially just scanning over the area of cellulitis, looking for a large hypoechoic or dark fluid collection, using plenty of gel so as to decrease discomfort. Again, very advantageous relative to physical examination, especially for ruling out, so negative likelihood ratio. It's good, but not perfect for ruling in because sometimes you're gonna find a large fluid collection or a fluid collection that's actually a non-infected phlegmon rather than an abscess. And this first case, the image that you can see here, and I'll give you a caveat first that a lot of my cases, or some of my cases are in patients who I took care of in the hospital. I was a hospitalist for many years before I started doing home care medicine, but I think these cases are still relevant. So in any case, this was the first patient I ever scanned when I got a brand new linear probe. She came in with a cellulitis of her knee and I thought just, well, let's get in some practice. I put my probe down and immediately found this huge eight centimeter abscess that ended up requiring surgical debridement. Next slide. Similar patient, this guy came in with a shoulder swelling and cellulitis. And when we scanned him, we saw these white flecks that the arrow is pointing to, and white on ultrasound, hyper-echoic indicates that either there's something with high density like bone or metal or it's air because the air reflects ultrasound waves. And in this case, these were air pockets in the patient's muscle. So he had a necrotizing myositis as well as a septic arthritis. Next slide. Another image of the same patient. Here, you can actually see an abscess pocket and you can see the abscess fluid sort of sloshing back and forth as I'm pressing down on the area of interest. And this is what we refer to in ultrasound as the squish sign for identifying an abscess. Next slide. Last case was a guy with hand cellulitis who got better with antibiotics, but was still having some discomfort at the time of discharge. So I scanned him and saw this linear density in the subcutaneous tissue. So we had the hand surgeon come back and under ultrasound guidance, he dug out this huge chunk of wood that I'm sure would have caused additional problems if we'd left it in, but it was not identifiable on X-ray. Next slide. So what's the evidence behind soft tissue ultrasound? It's actually pretty extensive, mostly again from the emergency room literature. But in this representative study, patients who had equivocal physical exam findings or just in all comers basically with cellulitis, ultrasound when added to the algorithm changed the management in 56% of patients in regards to the decision whether to perform incision and drainage versus treating with antibiotics alone. So physical examination, a clinical impression was essentially a coin toss in terms of identifying an abscess. Next slide. So I wanted to circle back to one of my favorite topics that's I think the most compelling use case for ultrasound, which is heart failure and talk a little bit about a disease specific application. And the reason why I think why ultrasound is particularly applicable to heart failure is because ultrasound excels at determination of volume status. Next slide. So this is a great case that Dan had was a veteran who had been recently admitted with heart failure and was sent home on an increased dose of Lasix, ADBID. And Dan saw him at home and he shortness of breath was about the same. His weight had gone down and then up a little bit, same thing with the creatinine. Couldn't see his JVP, his breath sounds were diminished. But he did have three plus pitting edema up to the knees. So pretty equivocal clinical picture, maybe leaning a little bit towards volume up with the pitting edema. Next slide. And here's a series of ultrasound images that were obtained. These first two images are the jugular vein and you can see that the jugular vein is collapsing in this case, just about the clavicle. Next set of images. Next slide. Shows the IBC also fully collapsing with inspiration. Next slide. Long ultrasound showed A-lines throughout and the absence of a pleural effusion. Next slide. And the patient had a severely reduced ejection fraction which was known from prior. So I'll give you a few seconds to think about this and see if this changes your clinical impression. Yeah, so this, the ultrasound findings are very suggestive of a patient who's either hypovolemic or euvolemic. So in this case, Dan decreased his LASIX back down to his maintenance dose. Next slide. And the evidence for use of ultrasound and CHF, Dan has mentioned some of it. Long ultrasound showed that there was a decrease in the amount of CHF in the lung. So some of it, lung ultrasound in particular is highly sensitive and specific. And again, we're talking about not just single studies here but this is a evidence-based that's been built up over a period of decades in emergency department patients. Next slide. In terms of, if you add, so if you add the echo and IBC to the lung ultrasound for diagnosing CHF, the performance is even better with a likelihood ratio of 21, negative 0.12. And interestingly, the time to diagnosis, not surprisingly is a lot faster with ultrasound compared to conventional care at 24 minutes versus 186 minutes, which would probably translate to two, three days in the outpatient home care setting. Next slide. I didn't mention here, but the number of B-lines is a, found on lung ultrasound is a strong predictor of heart failure, exacerbations and hospitalizations. And in addition to that, we now have some small randomized trials looking at using ultrasound to manage patients with chronic heart failure. In this study of 244 patients, lung ultrasound guided therapy resulted in a 56% reduction in heart failure hospitalizations compared to usual care with a number needed to treat at eight. So quite good. Next slide. Similar in this small study, also showing a 50% decrease in event rates. And so these are not large definitive multi-center trials, but a pretty compelling evidence, which is consistent with our clinical findings that heart failure is, that ultrasound is very applicable in the setting of heart failure. Next slide. Also some other modalities, additional lung ultrasound, even in isolation can have prognostic significance. In this case, the jugular vein, change in jugular vein diameter with Valsalva did predict heart failure, exacerbations and mortality. Next slide. So I probably spent too much time talking about likelihood ratios, but we are sort of sticklers for evidence. And I wanted to just give this sort of a broad overview of the test characteristics of ultrasound versus physical examination. Ultrasound in yellow, physical examination in orange. And you can see sort of across the board for a variety of different diagnoses, ultrasound has some pretty big advantages over exam in terms of positive likelihood ratios. Next slide. And for ruling out disease too, pretty distinct advantage of ultrasound over exam across a variety of diagnoses. Next slide. So all this may sound great on paper, but there's definitely some challenges. You need to have access to the technology, access to teachers. You have to have the time to be able to learn and perform ultrasound. I think an even bigger one is tradition. A physical exam still in medical school is taught with a reverence that may not be justified. I think that gets in the way of teaching ultrasound. Next slide. But there may be some upfront costs, but in the end, the idea is that this makes you more efficient and a better diagnostician. Next slide. We're still at a fairly early stage on a national level. The ACP came out with a statement in support of ultrasound and we're developing guidelines and curriculum. Next slide. The real tipping point though, I think is gonna be, has been the development of explosion of new types of portable ultrasound. A lot of them using iPhones or tablets for their screens. Next slide. And even more exciting now is the new, some of the newer devices use silicon microchips as the ultrasound transducer, as opposed to piezoelectric crystals. The piezoelectric crystals are very expensive to produce. So using microchips really lowers the cost dramatically and also puts us on sort of that exponential curve of technology growth in terms of improving performance, decreasing costs that we've seen over the last 10 or 20 years with smartphones, for example. Next slide. So the other advantage of the microchip technology is that you can alter the frequency of a single probe. So you can use it as either a linear or a cardiac or abdominal probe. So really improving portability if you only have to carry one probe and setting the stage for ultrasound to be the stethoscope for the 21st century. Next slide. Also some pretty interesting things you can do with the newer devices with remote mentoring and teleguidance. Next slide. And so finally, you know, this was a lot of material, certainly wouldn't expect you to go out and start scanning at a high level after this, it's more kind of to wet your whistle. But what would next steps be in terms of learning ultrasound? Prior to COVID, there were a lot of pre-courses at national conferences where you could get hands-on instruction. And there's really no substitute for hands-on instruction, having someone at your elbow, helping you guide the probe, helping you interpret images in real time. But in the meantime, there are just an endless supply of really high quality online resources. And if you scan this QR code, it'll bring you to some of our favorite links and lectures. And I would say really, you know, pick a couple of exam types, you know, the simpler ones like Bladder, IJ, and you'll be surprised at how quickly your confidence will improve. And put things like Echo, DBT, maybe on the back burner for now until your skills are better. But the real key to learning, you know, ultrasound or anything is just getting out there and doing it, getting your repetitions in. And with that, I will open it up to questions for the virtual office hours. Thanks. Thank you so much, Dr. Kim and Dr. Wallace. We really appreciate it. Just as we transition into our virtual office hours, we're also joined by Dr. Paul Chang, HCCI Senior Medical and Practice Advisor and Brianna Plintzner, HCCI's Manager of Practice Improvement. We have received some excellent questions from our learners ahead of time. Please remember that you can also still submit questions via the Q&A pod and the chat pod. So by all means, go ahead and do so. Couple of the questions that we have received is, do you use POCUS for musculoskeletal applications such as needle guidance for joint injection? Yeah, I can take that. So, you know, procedural ultrasound is a whole other topic. And for most procedures, like whether it's joint aspiration or putting in lines, ultrasound dramatically improves safety. But it's something that I think is, depends a lot on your clinical context. And it's gonna come up more frequently for some people than others and whether or not it justifies learning how to do it. It's pretty easy to learn ultrasound guidance aspiration. And it's something that they do a lot, like rheumatologists do a lot in the ED as well. Okay, and kind of piggybacking off of that question, any recommended training programs to improve skills in this area? So there is, in terms of, you know, IM, there's certainly no home-based curricula at this point. In terms of IM programs, as I mentioned, the ACP is developing a curricula. And so that's kind of in the development process. There are certain, you can get an advanced ECHO certification, but we're still kind of in the process of developing curricula specifically for internal medicine and home care. Do you have anything to add, Dan, or? Yeah, I mean, you know, I think we're hoping that at some point we can host an actual workshop for all of you at ACCI, you know, maybe sometime next year, where we can join you in person and do it with you guys. And then to kind of piggyback to that question, any recommendations on how to minimize POCUS knowledge decay? I can take that. That's a great question. And that's one of, you know, that's one of the barriers to, you know, if you're a learner starting off at ultrasound, you know, you can learn it, but then, you know, like any other skillset, you know, if you don't use it as often clinically, just because you're not as confident or because of the hassle, perhaps, you know, you're not gonna, you know, you're gonna lose that skillset or that kind of the physical skill, the acquisition part. But, you know, I can tell you that it's, you know, like with anything, it's the more you practice it and the more you force yourself to incorporate into your clinical practice, you know, you'll really realize that it's such a minimal amount of time for you to just use it like you would as a stethoscope, use it like you would any part of a physical exam. And the more you do it, you know, really it will help you with your confidence. It will help you with your decision-making as you incorporate it into the patients that you take care of. And so, you know, as I started off, like that was like a big barrier, you know, that's a barrier that everyone faces that all of you will face when you start off, but I really encourage you to really kind of force yourself to take it out, you know, take the Dorfstein gel and start using it. And as the more you do it, you'll realize, wow, this is actually really useful. It only took me an extra five, 10 minutes to do it. And I promise that you'll kind of see the results of doing that later on. But yes, it's very important that you incorporate it into your daily practice, because otherwise, you know, it can, it's really easy to just have it sit in the back of your room or in your bag. Yeah, I would also add that, you know, I think if you start out small and just choose one or two or three exams to focus on initially and not feel like you have to learn echo or, you know, gallbladder ultrasound, certainly not anything like first trimester ultrasound, I think kind of starting small and gaining confidence is gonna make it easier to master the skillset and incorporate it and make it easier to, like Dan said, incorporate it into your daily practice. And kind of a follow-up question to that is, how can you, or can you share, excuse me, strategies to create organizational buy-in to invest in POCUS for providers? That is a good question, and there's definitely challenges. I think a lot of the organizational buy-in ends up being kind of a grassroots thing, like whether it's residents or medical students, sort of, you know, who are more technology-oriented, kind of demanding it. It is, you know, like anything that's new, there's gonna be some institutional inertia and resistance to it. But I think, you know, getting, you know, actually better than anything else is having people actually do it. And sort of when, it's harder to make a convincing argument to a non-clinical administrator since there's not a revenue stream that you can generate with it necessarily. But, you know, once, especially with clinicians, it doesn't take many cases to see where something just kind of dramatically changes management until people are sold on it. But I think it's also, there's, that challenge is also diminished now that devices are much cheaper. I mean, some of these devices are less than, you know, $2,000, the newer ones. So it's not like the old days where you had to document a really strong return on investment to be able to buy a $75,000 CART device. So I don't know if that answers the question or not, but. I can chime in and kind of talk about, you know, as for myself, I'm a geriatric fellow at Penn. I can tell you that the geriatrics division at Penn in the beginning has, you know, was very resistant to, you know, even me teaching the fellows and incorporating into the curriculum. You know, a lot of the attendings, you know, really didn't understand what the value of ultrasound was and how they could even learn how to do it and use it. And so I can tell you that, you know, since I've started the curriculum like last year and I've worked with attendings and kind of have educated them on, you know, what the high modalities are, how easy is it, how to actually try it. You know, like there's a big shift in kind of their perception. And I can tell you that now, like I'm constantly asked by my fellow geriatricians at Penn to like, even today, I got a call from my nurse practitioner for the home care program who asked me if I could go scan a homebound patient who was on hospice, who there, you know, was going to the ED again and again for urinary, for UTIs and they're worried about urinary tension. And so, you know, I went and did it and she found out that she did have a significant amount of urinary tension. And so this is just goes to say that, you know, I think like educating your fellows and your colleagues kind of what it can be used for and how it's useful and having them actually try it themselves can really change their perception of it and really gain more support around it. Thank you. And just to give everybody, we've got about five more minutes, four more minutes, excuse me. So we will ask one or two more questions and then we'll begin to wrap up our presentation. Our next question is, are there any special considerations for use of ultrasound in the geriatric population relative to adults age 20 to 64? Yeah, I mean, I can, you know, take that. And I think, you know, that's, you know, Paul kind of highlighted in the beginning of his talk of how, you know, you can really ultrasound anything and, you know, it wasn't quite clear what would be the most beneficial and highest yield for home care providers who take care of an older adult population in the home. And, but now we do have a sense based on kind of case studies that we've done at Penn and based on kind of the curriculum that I taught and what we use it for. And, you know, just to kind of reemphasize, you know, we know that heart failure is probably going to be the most high yield because of, you know, tracking pulmonary DEMO with B-lines. We know it's helpful. We know it can help prognosticate our patients and help manage diuresis and help improve outcomes even. So heart failure is definitely on the top of the list, which, you know, is very prevalent in the older population and is a leading cause of hospitalization in that population. You know, and the kind of the other modalities that we talked about, like bladder for urinary tension is going to be extremely useful, soft tissue ultrasound, you know, DVT and cardiac are, I would probably put that more on the bottom of priorities just because they're a little harder to learn and, you know, they'll probably be harder to rack up the number of scans that you can do as opposed to doing, you know, looking at the lungs or the bladder, you can pretty do that frequently, but someone, if you're looking for DVTs, you know, you might not be able to do that for indication as frequently. And so, but yeah, so now we have a sense of like, these are the modalities that are most useful in that, you know, you should all probably focus on trying to learn for your home care patients. Excellent, thank you. As we finish up our presentation today, I would like to thank Dr. Wallace, Dr. Kim, Dr. Chang and Brianna for joining us today for sharing their knowledge, their expertise, providing additional support should we have any additional questions that come through. It is truly appreciated. I'd like to let everybody know about the HCC Intelligence Resource Center. We have a hotline. We have our webinars, our virtual office hours and our tools and tip sheets. We invite you to take time, go around our HCC Intelligence page and click around, see what you find that might be helpful. Our upcoming HCC Intelligence events, the third Wednesday of every other month, we will host a free webinar on either a clinical or practice management topic. Our 2021 Coding Impacts for Home-Based Providers and Practices, it's scary to say that, but it will take place on January 20th from 4 to 5 p.m. Central Time. Our presenters will be Dr. Chang and Brianna Prenster and we'll review CY 2021 Coding Changes as a result of Medicare Physician Fee Schedules, discuss documentation requirements to ensure compliance and discuss the impact for providing virtual services beyond the public health emergency. If you would like to reach out and contact HCCI, you can reach us through our website, through our phone, as well as through our email. We truly thank everyone for joining us today and hope that this provided you some knowledge, some skills, maybe a new area to venture into your home-based primary care practices. We wish everybody a wonderful evening. Please stay safe out there and thank you to you all. Take care.

point-of-care ultrasound

home care providers

lung ultrasound

pulmonary edema

IVC ultrasound

bladder ultrasound

soft tissue ultrasound

cardiac ultrasound

ejection fraction

home care practice