Echocardiogram: Basics

The first thing I teach my students is probe orientation. Know the human heart.  The probe must correspond to the anatomy.   The heart is not square with human anatomy.  It is in a strange plane.  Most human hearts sit at a 45 degree angle to the chest, unless you  are hypersthenic, or hyposthenic, your heart is in a predictable place.  Performing an echocardiogram requires a ZEN mind set.

Orient yourself to the plane of the heart and observe. We must be free of the telephone, and the buzzing of our stomachs.  I refuse to answer a phone in an echo lab.  Most Admins understand this.  First:  Look at the heart.  Adjust gain and depth.  Then just look and let the patients heart become part of you in a professional way.  Look without any prejudice.  The worst thing an echocardiographer can do is judge a person based on social criteria.  YOU KNOW WHAT I MEAN.  This does not preclude a great history on the chart or in oral questioning.  I never start an echo without chatting with my patient about history etc.  Body habitus is everything.  A smoker will likely require many sub-costal images, a well-nourished patient may need a higher probe position near the left axilla.  Many Americans are obese, look at it as job security.  But on occasion you get a skinny person. They are hard to scan because of the nervous nature.  Not a bad thing IMHO.  I Love all my patients thick or thin.

Be at peace, and make a professional analysis of this person's heart.  Do it with total concentration.  Make accurate measurements.  If you cannot make an accurate measurement, tell the cardiologist on your technical form.  The planes of the examination are for most part PSLA, PSSA, APICAL 4, 5, and Apical 2 chamber and 3.  The substernal views are great for PE's, and ASD, VSD, and the pulmonary trunk.  Do not forget the supraclavicular views for AI and AS.

Once more, Concentrate.  This person's heart is in your hands.

PS:  I blog when I am Damn Well Ready.  Most writers will tell you they do not write when they are not in the mood.  My blogs are from the heart.  I write when I am in the mood.  Blessings to the Hemingway, you old sot.  Rest in Peace, and do not be so down on yourself Earnest.  I can do that for you.  I am my own worst critic.  TJW

PPS: the picture is of my cat dressed up in frills by my wife of 17 years.  My wife is a silly person.  I love her very much.  I would never understand her in a trillion years.  My wife is my first and last wife.

Retrospective Part Seven

This post is cross referenced from my main BLOG wwwsonographersblog.blogspot.com

I am a big fan of of the history of medical ultrasound.  Please remember echocardiography started out as a mewling baby in a crib.

So I had the knowledge, now it was time to take it home and teach the non-human primates how to interpret the proper echocardiogram.  What I am referring to is my quest to teach the steadfast, un-yielding cardiologists how to interpret an echo with more information than a cardiac catheterization (at the time).  Folk's these were the days that cardiologist raped the insurance companies for billions of dollars doing "Diagnostic" cardiac coronary arteriography.  The interventional stuff was nascent, and still in clinical trials.


I managed to get them all in a room at one of the "Big" hospitals in Tyler Texas.  After they grazed on donuts, coffee, and bagels with onions, lox, and sour cream I sat them down and gave the first persuasive lecture of my life.  This lecture painted the picture my life would follow many years down the road as a teacher.

I had made a video of an echocardiogram on VHS tape that presented both 2-D, M-Mode, Pulse, CW Doppler, and Color Flow Doppler.  In the thirty minutes I was granted, I presented basic color flow interpretation, and the correlation with standard PW and CW Doppler.  I demonstrated mitral regurgitation, aortic insufficiency, and basic right heart imaging.  The right heart was not considered important at this time.  Everything I learned back in the early eighties had to do with systolic function.  The lecture and video were met with very polite applause. Then the leader of the dominant cardiology group unfolded himself.  This cardiologist who I will not name was a 6'8" tall person who was a kind and wonderful person.  His rising out of the chair was like a space shuttle taking off.  awesome!  He cleared his throat and said:  "Tom, Great presentation.  We all love this new technology.  Can we bill for it?"

I had a Butthead moment.  The owners of my business were in the crowd.  That was one thing WE as in myself and the owners of my business never looked into.  Medicare and private health insurance reimbursement for color-flow Doppler echocardiograms had no codes.  I stumbled for a response.  The cardiologist made a waving gesture and dismissed me saying we do not want to be liable for the color images unless there is a reimbursement in the package.  I had failed.  There was no CPT code for Color-Doppler echocardiograms.  It was too new.  My boss took me out for a drink at 9am.  To be continued......