Echocardiography Underwater

OUCH!  An article I will link reveals that scuba diving may be hazardous to divers older than forty years!  I have been a diver since the age of 16, and this is NOT good news.  Both my wife and I are certified divers.  I have logged hundreds of dives, and only had one emergency, which I dealt with as you can see.  To become a certified diver, one must undergo rigorous classroom, and practical experience.  I am fortunate enough to have been trained by a late student of Jacques Cousteau in the early 1970's.  The traditional and flawed bi-tubed regulator was replaced with a single hose regulator around then.  I was trained how to calculate diving times by depth charts, thus to avoid many horrible medical conditions caused by early de-pressurization.  The curriculum includes many issues as relates to health and safety.  All programs are centered around safety including the buddy system, emergency procedures and basic first aid.  I saw first hand 8 years ago what happens to a diver when they do not follow the rules of decompression.  My wife and I were on a cruise to the caribbean, and we took a sport dive near Roatan.   We dove in calm seas, and 45 minutes later rose to find the seas were troubled by ten foot swells, and dark clouds with windy conditions.  Tropical Storm!  We quickly got on the dive boat with horrible thoughts about getting shipwrecked.  Nobody said anything about a possible tropical storm.  We chugged back to Roatan fighting waves the size of  humpback whales, and made it to the cove in time to see another dive boat dock.  As we were carrying our gear towards Antony's Key Resort http://www.anthonyskey.com/diving/dive-operation.htm  We spied a gurney with a diver on it being pulled towards the recompression facility.  We watched in horror as the diver was convulsing on the gurney, and all that diving training came back into my mind.  Diving is serious stuff.  My wife is a nurse, and she had a fit as this guy was pulled into the medical facility.  Did he survive?  We have no idea.  The most probable explanation was the dude surfaced too rapidly because of the weather. This was certainly a dramatic part of our vacation.

So what about my emergency?  I bet you are waiting to hear my story.  Simply put, I started after a manta ray (docile and looking like a Klingon Warship) wanting to ride it.  I have ridden a manta ray once when I was younger.  The are plankton feeders, so no teeth to worry about.  I descended too rapidly and became hyper-ventilated.  The dive master realised my issue and assisted me in a controlled ascent.  It was an emergency.  I got on the boat and breathed through a paper bag for a few moments and got back in the water knowing that if I did not attack my fear, I would never dive again.  That happened 30 years ago.  Good training is key.  I recommend sport diving (Not cave diving, which I have done) to all who are trained rigorously.  Here is the link to the article I mentioned at the top.  Thanks for your time.  TJW

Scuba diving is growing in popularity among older Americans and heart attacks and unknown heart rhythms are the most common cause of diving-related deaths after age 40, according to the Divers Alert Network, a nonprofit research group.

The study, conducted in Italy, involved 18 scuba divers, including 16 men and two women. The participants were about 42 years old and each had made at least 100 dives. None smoked or had hypertension, heart or lung disease.

http://online.wsj.com/article/SB10001424127887324324404579045020481386890.html

Thanks WSJ

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......

Maybe It's A Glitch

Echocardiography world does not have it's own URL for some reason.  I have worked for an hour for an answer.  Perhaps Larry, and Sergei can help me out.  Many people have located echocardiography world through diligent searches.  I thank you for finding me.  For now I am trying to link echocardiography world to sonoworld. Bear with me.

TJW

Embolisms And Diagnosis

One of the many issues sonographers have to deal with is the source of an embolism.  Currently, when a patient has a CVA (Stroke) or RIND (resolving intermittent neurologic defect), and echocardiogram and a carotid Doppler are ordered.  This post does not deal with these issues, rather I am posting something far more reaching.  Guidelines for ordering vascular testing.  Often times we are called up at 3am for a DVT study.  Most  people do not understand that DVT does not cause a stroke.  It may cause a pulmonary embolism.  Patients who suffer from atrial fibrillation have a high incidence of stroke.  This is why they are commonly prescribed medications that reduce the incidence of clot formation in the left atrium of the heart.  I have no issue with this therapy.  I think it is common sense.  As an echocardiographer, I must always be vigilant for masses in the heart.  But here is something I came across at Sonoworld.  Blessings to you folk's.

Applicable to patients with venous disease and severe chronic kidney disease

A new report issued today by the American College of Cardiology (ACC) and developed in collaboration with 10 other leading professional societies provides detailed criteria to help clinicians optimize the appropriate use of certain noninvasive vascular tests when caring for patients with known or suspected disorders of the venous (veins) system. Also included are first-time recommendations for when and how to use these tests to plan for or evaluate dialysis access placement.

"Vascular lab testing is central to the care of patients with most peripheral vascular disorders, but appropriate use criteria for these [technologies] have lagged behind those for cardiac testing," said Heather Gornik, MD, FACC, cardiologist and vascular medicine specialist at the Cleveland Clinic and chair of the writing committee. "With this report, we now have multidisciplinary criteria upon which we can start maximizing the quality and appropriateness of what we do in the vascular lab every day."

Vascular testing is often used to help evaluate possible venous thromboembolism, which is the third most common cardiovascular disease, after coronary disease and stroke, and includes deep vein thrombosis (DVT) as well as pulmonary embolism (PE). These conditions can be fatal and result in hospitalizations and long-term complications. Therefore, identifying the best methods for detecting clots in the veins early on can be lifesaving, Dr. Gornik said. "But we must know that we are ordering the right test for the right reasons," she added.

Here is the link  Thanks Sonoworld

http://www.eurekalert.org/pub_releases/2013-07/acoc-nrh071913.phphttp://www.eurekalert.org/pub_releases/2013-07/acoc-nrh071913.php

Just a note to friends: My son is in the air at this moment traveling to Guatemala to do some hard work for our church. My wife and I are not on the plane. This is his first real journey to see what the world is like without McDonalds, and Taco Bell, and the air conditioning we Americans have come to accept as something we are used to. He did not take his X-BOX. Our family is all about health care. All three of us have been to Guatemala on mission trips. My trip was 7 years ago to deliver an ultrasound machine and provide education to the doctor and nurse who take care of thirteen tribes of Mayan Indians who live near lake Atitlan. My wife traveled there 3 years ago to administer vaccinations as a nurse. Today mark's a family tradition. My son, Trevor will put muscle and intelligence to work to assist people to get better living conditions. I am proud of my entire family. Pray for his success, and safe return.

Blessings all.  This post is on the Sonographers blog.  wwwsonographersblog.blogspot.com  

What Is a Sonographer? (Editorial From The Heart)

A sonographer is a human.  We are not computers.  We are the people that greet you and treat you with respect.  We tell you we are going to probe your body in intimate ways.  We are some of the most intimate health care providers you will encounter in the medical world.  We look into your chest, into your arteries, and into the womb.  We are people who know you from your ass-hole to you appetite.  We love our patients.  We know when the bulge in the abdominal wall is a hernia, or a sign of cirrhosis of the liver.  We are frequently the first people to find that your foetus has a heart beat, or not living.  We are not nurses, or doctors.  We are the people that try to figure out what is wrong with your tummy at 3AM in the morning.  We are frequently questioned by doctors as to what the diagnosis is.  Many of us offer non-legal opinions.  Most of our opinions make or break a medical decision.  We sonographers are careful, and thoughtful people.  We make our decisions based upon extensive medical histories, lab results, and physical findings.  Sonographers are some of the most valuable people on the planet. Sonographers are often very well educated.  Most sonographers are certified by an agency in the USA. Many sonographers suffer constant callbacks, and scrutiny by scruffy radiologists, cardiologists, and other medical doctors who think they know how to interpret ultrasound images. Many sonographers must interpret the images for the physician because the physician lacks knowledge.  All patients ask the sonographer if there is something wrong.  We are trained to be poker-faced.  Some of us do not know how to play poker well.  We are all human.  Next time you have a sonogram, echocardiogram, carotid ultrasound, venous ultrasound remember that we sonographers are humans also.  We care about you.

Written with Respect.

TJW