Wednesday, December 25, 2013

Merry Christmas All

This sonographer is celebrating another Christmas with family.  We ventured out of Houston during one of the worst storms in American weather to travel up to north Texas to visit my mom and pop.  They are both in the mid eighties.  They are as well as you can be when you are that seasoned.  We made it up in 10 hours due to the ice storms plaguing Texas last Friday.  It was rough.  My Daddy took us out to dinner on Saturday night.  We ate steaks at a restaurant in Wichita Falls, Texas.  McBrides is a wonderful place to go if you crave mesquite broiled cow.  We ventured down on Sunday morning to visit my mother and her husband.  Not all families stay together as many of you know.  We were met with ribs, and brisket, and warm rolls and the usual array of veggies and salads.  Mom made some pies.  I am not a person that likes sweets, but I will eat what my mother cooks.  The outside temperature in the wee hours (8 am) of monday was 27 degrees F.  We loaded up and shoved off at 11:00 am.  Smooth sailing till we hit Houston.  Always a nasty place for cars and trucks (Mostly big ass trucks....Why do people drive them now with gas so high)?  I guess they make more money than I do. This morning I was woken by my wife's pekinese dog opening packages under the Christmas Tree.  I kid you not!

The dog found his chew toy in a box, and managed to get it out.  It was squeaking at 7:30 AM. and he had also managed to open other boxes. My wife posted the video on here facebook account.  My wife and son soon came down to enjoy the usual Christmas festival of spreading paper all over the living room to see what Santa left us.  I got some wonderful dress pants.  My son got his new HD TV for his bedroom. (I had nothing to do with that gift).  My wife got muk luks(spelling).  Boots that are warm.  I have a new wide screen monitor for my computer.  My old Samsung monitor was gently going to the grave.  Thanks Samsung for a flat screen that lasted 12 years.  My son gave me a new computer keyboard because I tapped on the old monitor to wake it up.  He thought I was making noise on an old keyboard.  Old monitors need to be tapped to life.

Today is a balmy 53 degrees F.  My son got some cash, and he will use it to buy a new skateboard.  I think he is great.  He is athletic, and has so many GF's, He must be careful lest he gets molested.  He is a smart looking gentleman!

Anyways.  Be blessed all.  I am now an ultrasound contractor.  I will travel anywhere to see patients or provide education.  I am hoping 2014 will be a better year for business.  Contact me if you need some help in the ultrasound business.  Merry Christmas.  Be safe.  TJW

Wednesday, December 18, 2013

God Bless You All. Merry Christmas. Here is Krampus. A German Legend. Off Topic

This is Krampus.  He is the Anti Santa Claus  He is nasty and is a Germanic favorite for many years.  I post this because my wife who is a nurse likes to do the Krampus march in Houston.  We could not go this year because the weather was bad.  We wanted to go.  Conditions were unsafe to travel down town.

On another note, be safe in your travels.  Do not drink and drive, and do not piss off the TSA people.  They are already pissed off at themselves. Police are pretty mad nowadays also.

Be well prepared to celebrate the birth of Jesus Christ.  Blessings to all.  I will post many things in the New Year.  TJW

Monday, December 16, 2013

Great Stuff! Clots busted with Ultrasound!

I am happy announce that ultrasound has entered main-stream thrombolysis.  Here is the article I have been waiting for.  There is hope for people with DVT and clots to the brain.  God Bless you researchers who have documented this wonder procedure!

Here ya go.  Merry Christmas and Happy New Year!

WASHINGTON, D.C. Dec. 13, 2013 -- Ultrasound-stimulated microbubbles have been showing promise in recent years as a non-invasive way to break up dangerous blood clots. But though many researchers have studied the effectiveness of this technique, not much was understood about why it works. Now a team of researchers in Toronto has collected the first direct evidence showing how these wiggling microbubbles cause a blood clot's demise. The team's findings are featured in the AIP Publishing journal Applied Physics Letters.

Blessing to all at Applied Physics Letters.


Sunday, November 24, 2013

Cross Posted From EchoWorld: Ultrasound Will Be A Great Job In The Near Future

I have an article here which is optimistic.  In this time of misery in terms of employment I hope the predictions are correct.  BTW, I am a teacher of sonography, and I am looking for a FT job.  If any of you readers would like to hire me, please contact me at   Thank you. Happy holidays and be safe driving.

According to a five-year jobs projection report from CareerBuilder and Economic Modeling Specialists, 26 of the 50 jobs projected to grow the fastest from 2013 to 2017 are in the healthcare industry.
The jobs range from high-skill jobs like occupational therapy to lower-skill personal care roles.
The following are the 26 medical, allied health or health-related jobs projected to grow the most in the next five years, listed by percentage growth:
1. Biomedical engineers: 23 percent change
2. Personal care aides: 21 percent
3. Home health aides: 21 percent
4. Physical therapist assistants: 16 percent
5. Occupational therapy assistants: 15 percent
6. Diagnostic medical sonographers: 15 percent
7. Medical scientists (except epidemiologists): 15 percent
8. Physical therapist aides: 15 percent
9. Medical secretaries: 14 percent
10. Nurse midwives: 13 percent
11. Nurse anesthetists: 13 percent
12. Audiologists: 13 percent
13. Physical therapists: 13 percent
14. Marriage and family therapists: 13 percent
15. Emergency medical technicians and paramedics: 13 percent
16. Dental hygienists: 12 percent
17. Nurse practitioners: 12 percent
18. Health educators: 12 percent
19. Mental health counselors: 12 percent
20. Healthcare social workers: 12 percent
21. Occupational therapists: 12 percent
22. Ambulance drivers and attendants: 12 percent
23. Occupational therapy aides: 12 percent
24. Medical equipment repairers: 11 percent
25. Cardiovascular technologists and technicians: 11 percent
26. MRI technologists: 11 percent

Here is the link.  Thanks Sonoworld

Saturday, November 16, 2013

Ketamine, The Impact On Health

I picked up this lengthy article out of curiosity.  I subscribe to many blogs, and I am always the cat looking for the bug in a dark corner.  The reason I repost this article is because nobody I know has published any data on the long term effects of the drug known as ketamine.  I know it increases heart rate, and BP, but who knows what the lasting effects are?  I have never taken this drug, but I have seen it used in the early 1970's on old patients in surgery.  I was appalled.  These patients were not "OUT" they were mumbling and groaning.  I thought it was barbaric.  How does this drug which many asians take daily affect them?  What diseases and conditions are we missing?  Drug use in China is on the up-surge.  This indeed an interesting topic.  I am sure many of you will comment.  Great.

The first thing you notice are the straws: long, bright, pink-and-purple-striped, with bent necks reminiscent of childhood parties. They’re all over the place, on benches, tables and trays, being passed around like lemonade. Otherwise, the room is exactly as you’d expect a private karaoke room would look like in Guilin, known as south China’s most beautiful city, if you were to wander in at two in the morning.
A rumpled Taiwanese businessman makes eye contact. As his friends gear up for the next big song, he enthusiastically bids me enter. There’s a lot of collar loosening and hugging, flabby, middle-aged male bellies and toasting. A couple of women have lost their tops. Everyone takes a big hit of the enormous lines on the tray, and then they ignore me.
Thanks Joann

Saturday, November 9, 2013

Debakey Type One Update

Update.  The patient "I" sent to the ED in Houston is stable on beta blockers, and is in hospital at this moment.  His surgeon was in contact with the referring physician to tell him all is well for now.  The surgeon is mulling over options including stints or an open procedure.

I will include a YouTube video regarding surgical resection of this lesion is addressed.  Not for the weak stomach.  TJW

Monday, November 4, 2013

Editorial. Interpreting Physicians Should Do A Better Job

Number one, I hate writing on a laptop.  The keys are small, and my fingers are big and bony.  Number two, I hate writing an editorial when I have not had coffee.  I hate editing my own words on a laptop.  Please forgive me my gentle readers.  What I am going to write is horror.  Do not eat before you read the following.

A patient presented to me for an echo, CIMT, Triple A screening, and a carotid U/S.  His symptoms included DM, and HTN, and mild obesity.  Typical patient.  He did not speak English, his grand daughter did so, and we go a few tidbits of information.  He said he had no problems.  I was there to screen him for underlying issues.  Usually i find no medical issues when I do these screenings. I noted this very kind gentlemen of Hispanic origin to be short of breath.  I applaud the physician for referring him for medical testing in the non-invasive manner.  I did the CIMT testing which was positive for PAD.  Bring in the cellos and tubas for the remarkable test. (Que the Orchestra).

I performed a standard TTE (Transthoracic echocardiogram) and found a 5.2 by 6.0 cm ascending aortic aneurysm.  I left the examination room to phone the doctor.  We spent the next 30 minutes getting the family to take him to a great hospital next door.  From what i have heard, this patient is doing well.  He went to surgery on MY CALL!  This should not happen!

Here is the horror:  Our interpreter has failed to provide a final interpretation of the echocardiogram.  His failure to provide a timely interpretation is unacceptable.  After many E-Mails, and phone calls, he has been unresponsive.  This should not happen.  I am a sonographer, not a physician.  And I am pissed off that this has happened.  The final report was posted at 13:36:45  Interesting.  He got the message while eating some very spicy food we think. No substantive evidence of course. Most pajama radiologists/cardiologists care less about the patients images they view.  They wake up and boot the computer and do thier thing, then go to bed.  I wish I could share the details.  Federal laws will not allow that. isn't that a shout!  Patient in surgery and out without a physicians interp?  How many of you sonographers deal with this?  Mark of Honor? or another lump to put in our backpacks as health care providers?  Really!  TJW

Comments are welcome.

Saturday, October 26, 2013

MRI Guided Ultrasound Can Help With Knee Pains

An article on Sonoworld has piqued my interest again on the relationship between MRI and ultrasound.  It seems that MRI can guide therapeutic HIFU (high intensity focused ultrasound) to area of the knee, and potentially other areas to deliver nerve blocks.  I think the acronyms are silly.

medwireNews: Magnetic resonance-guided focused ultrasound (MRgFUS) is a potentially valuable noninvasive treatment for knee osteoarthritis, a pilot study suggests.
MRgFUS was associated with a reduction in pain intensity both immediately and at 6 months after treatment, supporting further evaluation of the technique.
MRgFUS is a way of delivering localized thermal ablation to precisely defined sites. It has recently been used to cause local bone denervation in cancer patients with bone metastases for pain palliation.

Thanks Sonoworld

Monday, October 14, 2013

Mindray Ultrasound Review

I had a very positive experience with a per-diem apps specialist from San Jose CA today.  His name is Joseph.  I will not give out a last name because his job is as a per-diem associate.  This laptop ultrasound machine was heavy.  But it busted me in all areas of ultrasound.  I was impressed. The promised DICOM transfers to the secure net are still being worked on.  I think we can get this sytem and others like it going in a few weeks.  We will work with Mindray to produce great quality ultrasound exams soon.  I seldom endorse a company.  I guess I just did.  The company is from China but has a base in Bothell, WA home to ATL, one of the early leaders in ultrasound tech in the 70's and 80's.

Pros: great configuration, and standard factory installs went smooth.  Echo presets made me sing.  Great color, and a darn sharp screen.  Color was great.. 300 gigs of storage, but no simultaneous storage to WI/Fi or thumb drives.  We mobile people need that. Calcs are actually understandable! The package has a 3-D 4-D package.  We did not purchase that. They must have had a Sonographer on the development team!  This is one of the best machines I have seen on the market in years.

Cons: No on-board tissue Doppler.  Perhaps this is because it was not purchased.  No real help with DICOM or internet security.  We all need that.  I will see if we can do wireless secure transfer soon.  Message to Mindray: be prepared to deal with upload issues and times.  We sonographers hate reading books while the files upload, but we HATE having to populate the echo preliminaries with M-Mode measurements and AVA area and LA volumes by hand!  Most cardiologists are lazy (Very lazy) and refuse to type in the measurements.  We need this issue to be resolved.

Bless you Joe, and have a nice trip back to CA.  and TYVM.

Thanks, TJW

Sunday, October 13, 2013

ASE New Guidelines For Pericarditis

The patient depicted to the left has hepatitis.  He also has pericarditis.  The echo diagnosis is pretty hazy.  We look at the pericardium, and usually look for anechoic space between the epicardium and the pericardium.  when we see a separation on M Mode or 2-D we call that out.  We have no idea what is going on until we do a pericardiocentesis.
here is a post to a link to the PDF that explains the new guidelines.  This is a must see for Echocardiographers, and Cardiologists.  Thanks ASE.  I am a Fellow there. :)

Be well all.  Here is the link.

Follow the link for the PDF file

Thanks ASE.  TJW

Monday, October 7, 2013

Contrast Enhanced Ultrasound Useful In Treating Children

I like this article!  It seems that contrast enhanced ultrasound (CEUS) is a better way of monitoring treatments in children, than CT or, perhaps MRI.  CT and MRI are costly, and CT uses X-rays that are not very good for a child.  I will applaud the efforts of the authors and say keep up the good work!.

Thanks ICUS and Bless you!

The Food and Drug Administration, physician groups and providers are concerned about increasing use of diagnostic imaging tools that expose patients to ionizing radiation, especially when alternative, radiation-free imaging options are available. Radiation exposure may increase a patient's risk of cancer and the effects are cumulative over a patient's lifetime.
This is the first pediatric study of CEUS using a sizeable number of patients. Thirty-four pediatric cancer patients received a total of 134 ultrasound contrast agent injections without any serious adverse effects. The initial phase of the study is now complete and a new clinical trial will be starting shortly at St. Jude's.
"Children, with their smaller body parts, make ideal candidates for CEUS," according to Dr. Kassa Darge, Pediatric Director of ICUS and a professor of radiology at Children's Hospital of Philadelphia. "Moreover, the absence of radiation makes it particularly safe, no sedation is required, it is well tolerated and it has the potential for lots of applications in pediatric oncology in the diagnosis and follow-up of solid tumors."
ABOUT ICUS: ICUS is an international, multidisciplinary, not-for-profit medical society that represents physicians, scientists and other professionals from over 55 countries who are interested in CEUS. For more information about ICUS, please visit

Sunday, September 29, 2013

Sliding Lung Sign Better Than a Chest X-Ray!

I have preached it !  Now it is in Cement and Granite!  The sliding Lung Sign is now Standard of Care!  Forget the rattled x-ray tech being called to the ED or ICU for a STAT portable chest X-Ray.  Let's use the ultrasound machine to look at the lungs.  The image to the left is the sea-shore sign.  When you do not see undulations in the bottom portion of the image, there is a problem.  This is an M-Mode image.  I will post the article.


Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax.

Many Thanks Sonoworld and the Writer

Saturday, September 21, 2013

A Note About Being Green

Many of us fish about the interwebs and encounter strange things.  The following is funny from a sonographers point of view because it is obvious what the disease is doing to the patient.  The reporter has no clue, (most reporters have no clue) which makes me laugh. The reason the patient is sick is because the worms blocked his biliary system, which the journalist refers to briefly. We are taught about these diseases here in the USA.  Enjoy!

Chinese man turns green after eating river snails

He Yong, 24, had abdominal pains for two months before his skin and the whites of his eyes turned green from a parasitic infection. 'I looked like the Incredible Hulk,' he said.

Read more:

Thanks NYdaily

Saturday, September 14, 2013

Ultrasound Gel And Surgical Procedures

Many studies have been conducted about the safety of ultrasound gels in the operating room environment.  It is well known that the probe and gel must be sterile to perform invasive procedures.  Without naming any manufacturer, I will stress that all ultrasound procedures that involve breaking the skin, or other invasive means should be sure that the probe and the gel is sterile.  Many gel manufacturers provide sterile gel in packets that are marked.  I urge all clinicians to use these packets and observe sterile techniques.  Here is the link:  Thanks TJW


Ultrasound gels may contain propylene glycol and glycerol, which are neurotoxic in high concentrations. If the needle passes through gel during regional anesthesia, gel may be injected near the nerve. It is unknown if this practice poses a risk for neurotoxicity. Using an animal model, we assessed the histological changes of perineural propylene glycol on nerves. We then assessed three commonly used sterile gels for evidence of neurotoxicity.

Thanks Sonoworld

Sunday, September 8, 2013

Underwater Echocardiogram Reveals Risks To Older Divers

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  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.

Thanks WSJ

Monday, September 2, 2013

I Will Now Publish A Wonderful Reply To My Post About OB-GYN Ultrasound

A great sonographer from Israel posted a reply to my BLOG post about OB-GYN male sonographers.  I will post his reply without his name as I have not received permission to use his name. 

I will comment below.

Hi Tom. I fully appreciate your commentary on doing ObGyn sonography as a male. I am horrified by your boyfriend encounter and would certainly have wanted to notify the police. I would have been challenged by the dilemmas of having to reveal a patient's name and would have consulted with medical professionals and administration to determine the correct  of action here. But this was a dangerous person.

That being said, I have always been aware of the fact that I am a male who walks into a room with a woman, asks her to take off clothes and lie down and then turns off the lights. Even in echocardiography, this is a situation that can be severely misread by anyone. Part of my solution for most of my career was to always dress in a business shirt and tie and wear a white lab coat. This was to transmit a sense of professionalism and formality, and to say that I take my profession very seriously. If I were to dress like that here in Israel, I would be more formally dressed than top administrators of the medical center, much more so than any physician and I would look weird and out of place. So I simply dress more formally than anyone in my department (button down shirt and a short white jacket) and leave it to my obviously more senior age to give me that air.

All that being said, my corollary to what you have said is my first job in Echo, which was at Maimonides Medical Center in Boro Park in Brooklyn, New York. This area has a large ultra-Orthodox Jewish community. As an example of their conservationism, during an Orthodox Jewish wedding nobody touches someone of the opposite sex. Dancing is done as men with the men and women with the women. If I recall correctly, the groom and bride may dance by holding opposite corners of a cloth. So when I told my boss (and he was Orthodox although not Ultra) about six months after he hired me that I was surprised to get the job, he was startled and said that he hadn't really thought about it as he was a man and we were practicing medicine.

And now I work in a lab in Haifa, Israel, where we have a certain number of patients who are Orthodox Jews and a significant number who are Orthodox Muslims. Of course, we treat all equally and if a specific request is made for a male or female technologist we try to honor it. But a large number of times, whomever is assigned to take the patient does so without any preference and generally there is no objection.

All this being said, I did do ObGyn as a student back in the late '70s. At that point it was so new and there were no endo-vaginal exams so it was much simpler than it probably is today. One shocker was that at one of my clinical sites where the sonographer was an attractive young woman, I entered on one of my first days to where she had begun an exam to find her with a patient who was stark naked on the bed. Apparently, as we were using straight, very runny mineral oil as our contact material, she felt that she did not want to get oil on the woman's clothes. It was a maturing experience for me to try not to react in anything but the most professional way, but I think I succeeded.

Anyway, enough of my ramble. Back to the unpacking I should be doing as we have just moved into our new apartment, purchased and fully renovated.

Best wishes to you,

Thanks, I will publish your letter with no name out of respect.  TJW

Update  My friend has allowed me to use his name as the author of this letter.  He is Gershom Lichtenberg of Haifa, Israel.  He is a great contributor to the  

Give him a round of applause

Thursday, August 29, 2013

Update, And a Wonderful Assumption Gone Sour

This was too funny.  I had to post it.

I assumed that Google Blogger would correct my mistakes in formatting.  I was wrong.

My block text has the worst colored background since farmers came in and wrote notes on papers before washing their hands.  Forgive me for the unruly  background color of the text regarding the past few postings.  I dabbled.  I failed.  Yes, I am English.

From now on, I will type in plain text, and not try to look pretty.

 This is a Science Blog!

Science!  TJW

OB S/D Ratio Useful In The Health Of The Fetus

I seldom write about OB-GYN ultrasound, though I am board certified by the ARDMS in this profession.  One reason is because I do not practice OB-GYN ultrasound much anymore.  The reason is complicated.  To be honest, I quit most of my OB/GYN practice because of where I live and the cultures that are present in the Houston area.  Many cultures here do not want a male person to perform medical examinations on the women of their culture.  Have any of you had similar experiences?  Please EMail me with your stories if you like. My E-Mail address is at the bottom,  I may post them without the name of the writer. For those of you who are seething here is the quick link to my Email address:  

 I respect this, and have backed up like a crayfish on many occasion when confronted by this cultural issue.  I have no problem with it.  Back in the 80's I had no issues in this area because the technology was new and mesmerizing to the family which often came in to look at the anatomy.  Nowadays it is like watching TV.  Most expectant parents DEMAND a 3-D image, or 4-D (Moving image) of the fetus.  Most parents DEMAND to know what the sex of the baby is.  I quit doing most (not all OB-GYN ultrasound ) When I walked out of an imaging center and was accosted by a young male you whispered in my ear: "You did what to my girlfriend?  I almost lost my life...

His knife drew a bit of blood on my neck until I wrestled the knife away in a fit of panic and self-preservation.  I ran and found my car, and drove home with tachycardia, and never reported it to the police.  We sonographers do very intimate procedures on people we do not know.  We walk in and expect a patient in need to embrace our skills. I make it a point to tell the patient exactly what I will do.  It is the point of being a professional.  We sonographers are as professional as doctors in many instances.

  Enough of that stuff.  I respect the wonderful world of OB-GYN ultrasound, and I maintain my skills in more controlled places.  With that in mind, I came across a recent post that has validated my thinking for many years.  Systolic/Diastolic ratios.  The blood provided by the mother is filtered by the placenta, and nutrients are handed off in placental exchange.  The fetal blood is powered in the later stages of pregnancy by the fetal heart.  This exchange is important. When the pipeline becomes stiff for whatever reason, fetal circulation becomes compromised and IUGR can rear it's ugly head.  This does not allow nutrients and O2 to get to the fetus.  The result is a baby that is malnourished and feeble.  We can measure this using the S/D ratio.

SAN FRANCISCO – An umbilical artery systolic-to-diastolic ratio of less than 3 as measured on weekly Doppler ultrasounds in a fetus with 30 weeks’ or more gestation and suspected intrauterine growth restriction suggests that the fetus probably is doing okay, Dr. Vickie A. Feldstein said.
That "ballpark guideline" is most helpful if physicians at your institution have agreed to use the umbilical artery systolic/diastolic (S/D) ratio as the parameter for assessing fetuses with intrauterine growth restriction (IUGR) and have agreed on which anatomical location is preferred for the ultrasound interrogation, so that there is some uniformity in how results are presented and interpreted, she said.

Thank You for reading.  Thanks    Comments are always welcome

Sunday, August 25, 2013

This is a cross post from EchoWorld.  BTW that is my cat and my son.

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

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......

Saturday, August 24, 2013

Ultrasound And MRI TEAM UP

Wonderful news folk's.  We are making some great progress in the war against prostate cancer.  I have posted previously on this blog about the use of high intensity focused ultrasound (HIFU), now we have a firm alliance in the medical arena.  MRI and ultrasound.  I am pleased to repost the following article regarding such an alliance.  Blessings once again to you people at UCLA.  Perhaps we can do away with traditional prostatic surgeries.  I watched my Daddy (Yes Caps for my Daddy)  recover in the ICU after a traditional prostatectomy.  He was coddled with opiates, and barely looked at me two days after surgery.  I will not have that happen to me if I get prostate cancer.  I will consult with my buddies at MD Anderson Cancer Center in Houston, Texas.  They are part of the University of Texas.  My Daddy recovered, and is back to his normal self.  He does not talk about his sex life. I do not want to know.  He is in his early eighties.  Here is the link.

Fusion of 3D images with real-time ultrasound

During the biopsy, 3-dimensional information derived from the multi-parametric MRI is color-coded and fed into an innovative guidance and imaging device that fuses the images with real-time ultrasound (MR-US fusion). This blending of images provides a map of the prostate and areas of suspicion for needle navigation and permits direct targeting of the lesion in question.
Moreover, lesions outside the normal catchment area of conventional biopsies can be identified. Once mapping and targeted biopsy have identified a tumor suitable for active surveillance, follow-up typically requires fewer biopsy samples than standard biopsy.
Teams from the National Institutes of Health pioneered targeted biopsy in 2009. Research at UCLA has improved image fusion technology, and UCLA clinicians have now performed more than 900 targeted biopsies — more than any other institution.

Thanks UCLA and Sonoworld

Monday, August 12, 2013

Retrospective Part Six

The wonderful image you see at the left is not my memory of working at the Heart House at UAB 28 years ago.  When I arrived in Birmingham those many years ago I had hair.  I saw Iron Man the  on the hill with a green light from the plane. A green light in his hand means nobody has died in Birmingham of trauma.  Please correct me on that if I am wrong. I left the airport and took a cab to a non-descript motel that I hardly remember.  I do remember waking up and having no coffee in my room, and having to shower and don my scrubs and walk down a hill to the Heart House where Dr. Navin Nanda held court for ten hours a day.  I live for coffee.  I remember Sally Moose RDCS.  She always gave me a cup of joe for the sojourn into medical education.  We began abruptly.  Here is patient number one.  She has a systolic murmur.  We would watch as a sonographer would perform a echocardiogram on a patient using an Aloka or Toshiba color flow machine.  The doctor would walk in and perform a flawless PW and CW calculation using the continuity equation. This was new technology to me.  I was mesmerized. I was amazed at how he would work from one room to another, flowing like an amoeba to see patients.  So fluid, so patient-friendly.  At the end of the day Dr. Nanda would host a one hour lecture on what he had found in his tireless effort to take care of cardiac patients.  The ebb and flow of the gurneys was like a procession in a Catholic church during Easter.  The people in the background were in perfect synchrony with the work in the lab.  I remember getting antsy one night from so much learning.  I called a cab, and asked him to me take to a place where I could buy some beer.  He took to me to a club that had a band that did Beatles stuff..  It was wonderful.  In all I had a great experience in Birmingham.  I went out once with a student and we had a great steak dinner.  Folk's remember this was in the early 80's.  Steaks were great then.  The people of Birmingham were great, unlike the unrest of earlier years.  I met a lady that I almost married in birmingham.   I am happily married to my part American Indian wife.  Dr Navin Nanda has retired as of one year ago.  I know this because one of his students told me.  I hope you are well sir.  I hope you read my BLOG.  Thanks for imparting your knowledge to me sir.  Part Seven will "Soon Come" as the Jamaicans say.  Peace.

Beat Back Pain With Ultrasound?

I have had back problems.  Most people I know have had an issue with a strained back, or more serious issues with the vertebral bones.  Most back issues resolve without surgical intervention.  The weeks it takes for the pain to go away are horrid.  I have a few messed up vertebrae, specifically herniated vertebral bodies that impinge upon the nerve roots that cause pain.  Mostly, this is treated by muscle relaxers and pain pills, and the statistics show that the body cures itself within a couple months.  I used a TENS unit once to help heal a broken humerus that used magnetic fields to help create bone growth.  It did not work IMHO.  Here is a snippet of a company who plans to use lower frequency ultrasound to help people with back pain.  I am not convinced.  But here it is.

TRUMBULL — Who needs ibuprofen when you can strap an ultrasound to your back?
Early-stage medical device startup ZetrOZ, LLC is working on just that, and recently received $2.6 million in funding to relocate to Trumbull from Ithaca, N.Y. Connecticut Innovations Inc. (CII) ponied up $1.3 million of that figure through its Eli Whitney Fund.

Thanks Sonoworld

Tuesday, July 23, 2013

Retrospective Part Five

I apologize.  It has been many months since I sat down in my mancave to compose the fifth in a series of retrospectives on the history of diagnostic ultrasound, and my part in it.  Please read the first four by scrolling down through my archives to get a feel for what I am writing about.  My last post was about echocardiography.  To the left you will see one of the first real time ultrasound machines I used as a sonographer.  Echocardiography was pioneered  Dr. Harvey Feigenbaum.  His book is widely thought of as the bible of echocardiography.  ISBN 0-8121-1692-7  That is the ISBN number.  Google it.  The machine you see to the left was crafted partially by Donald Baker, who is the husband of Joan Baker.  Joan is (As far as I can tell without doing google search) is the first ARDMS registered sonographer.  I did a quick search.  Google has no idea, neither does  Let's leave it to popular legend. But I know Joan.  She currently travels the world and teaches Sonographers how to scan properly without damaging muscles and tendons.  I have never met Donald.  I would love to shake his hand.

 I worked in a hospital in north Texas in the 1970's.  I took care of people with my new ATL machine until the salesperson of the machine greeted me.  His name was Clark Ulmet.  I hope he does not send the Nazgul down on me and my family for using his name, because he got me really started in the ultrasound business.  His daughter continues the tradition selling healthcare products. Clark got me in touch with a radiologist in Tyler TX.  He and his partner asked me to help out starting a mobile business.The owner actually flew me home in his private plane.  He and his partner got me interested enough to eventually gain my own private pilot's license.  At that time I had a full head of hair. When you have a head of hair, anything is possible. I said let's do it.

I arrived in my toyota pickup truck with a 70-ish boat on the hook and got a cheap apartment on the south side of Tyler.  I reported to a cheap ass office that smelled of smoke and other substances like cheese, and vanilla, and I would grab that big machine and  I would bully it up on a wheel chair lift on a Dodge Ram Van and wrestle it into place with cords, ropes, whatever was around.  I would then take off to visit three or four hospitals and see patients. We kicked the crap out of East Texas.  James and I delivered damn good health care to so many people.  We both arrived home and ready for a shower. All sonograms recorded on a video tape.  Echos were a combination of video and some pink thermal paper.  We used a microphone to tell the interpreter what we were looking at.  Most interpreters had no idea what they were looking at.  The tradition stands to this day.

Needless to say I learned how to fish. Crappie, Bass, Catfish.  I pursued my other love:  Music.  I played 5 days a week in a band called the "Country Boogie Band", and made some good money playing keys.  I met my current (and only) wife there at one of the hospitals I took care of.  In the next installment I will tell about my journey to the University of Alabama.  And a meeting with a most wonderful doctor named Navin Nanda MD.  He taught me everything about color flow Doppler, Pulse wave, CW and a KFC bucket load of other things.  And Yes, I am a Texan.  Be well.  TJW

Sunday, July 21, 2013

Vascular Testing, DVT, And the Lot

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
This post has been crosslinked to Echocardiography world

Friday, July 19, 2013

Off Topic, But Important

Here is something I need to post.  I put it on FB, but I must post it here.  Our family is proud that our son is going on an epic journey to another country.

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.

Be safe all and drink water.  Hot summer.

Blessings.  TJW

Thursday, July 18, 2013

Blogger Is Hot Today Editorial and Apology

My post below has some obvious errors in formatting and other stuff.  I have tried three edits.  They have not worked.  I want you all to read the articles I have posted below on ultrasound brain stimulation and ablation.  I apologize for the errors, I think the excessive heat may have something to do with it, but I will take all the blame.  I try to speak about ultrasound only here, but we are having a hot summer, which may influence the internet.  I am not sure.  Perhaps the heat of a nation in political strife?

Ultrasound Brain Stimulation? Can We Really Do It?

A year ago I came across a lecture on TED by a Jewish neurosurgeon Yoav Medan that discussed a single case of taking out a disease in a few seconds using MRI guided high intensity focused ultrasound (HIFU).  I published this article before, but it seems we have a call to be optimistic about the results of further studies along these lines.  I present the original TED video, along with some other interesting articles.  Thanks you folk's who lead a wonderful cadre of untiring researchers looking for answers.

First off the TED Video:

The URL did not show up on the Blog.  Please go to and use the search box to find Yoav Medan.  You will find it.  Sorry for the glitch.  Thanks TED for your wonderful lectures.

PLEASE watch the whole thing.  You will be amazed.

Second, I would like to discuss an issue that affects millions of people around the world:  Depression.  There seems to be preliminary data that suggests stimulation of brain tissue with ultrasound helps the brain to re-organize the neurons into harmonious units, thus allowing for a elevation in the mood of patients who suffer from depression.  This article is astounding, and will blow the sock off of anyone who is not a particle physicist.  But I will post it anyway.   Perhaps the author is on to something.  Blessings.  TJW

Imagine that you've just come home from a hard day at work. 
Maybe you had a run-in with your boss or were stuck in a meeting than ran an extra hour. Perhaps a project deadline forced you to skip lunch. 

Instead of working out or having a drink to relieve your stress, you plop down on the couch and put on an odd-looking hat. You open an app on your smartphone and choose a setting called “mood.” High-frequency sound waves begin to pulse from the hat into your brain. You start to feel more relaxed.
Thanks SonoWorld and Wilcox news and

Sunday, July 14, 2013

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.


Ultrasound Gel And It's Proper Use

I have two stories here for your reading pleasure.  One about the safe use of ultrasound gel, and another about using guacamole as an imaging medium in scanning non-human primates.  This first story deals with a pet peeve of mine:  tossing out old ultrasound gel bottles.  I think most sonographers are aware that ultrasound gel can harbour bad pathogens, and the gel warmer is a great incubator.  Most but not all sonographers regularly toss out used gel bottles on a monthly basis.  One further note before I paste the link regards the use of bottled ultrasound gel as an endovaginal lubricant.  I find that practice horrendous.  Why introduce pathogens into a females vaginal canal from a warm bottle of gooey gel that has been in the warmer for a few months?  Always use sterile KY jelly packets as the lubricant when performing these procedures.  Here is the link all sonographers should read regarding this subject.

CHICAGO (November 12, 2012) – In the December issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America, guidelines have been proposed by epidemiologists from Beaumont Health System to reduce the risk of infection from contaminated gels. The recommendations are based on the authors’ own experiences with an outbreak traced to contaminated ultrasound transmission gel.
In December 2011, researchers uncovered an unusual cluster of Pseudomonas aeruginosa in a cardiovascular surgery intensive care unit during routine infection control surveillance. The outbreak was found to have stemmed from bottles of ultrasound transmission gel that were contaminated during the manufacturing process and that were being used for intraoperative transesophageal echocardiography.  This information ultimately led to a national recall of the product.

Thanks Sonoworld

Next I present a novel use of guacamole as an imaging medium in scanning non-human primates as seen in the picture above.  It make sense that the female can feast on the treat while allowing the sonographer to image the unborn child.  Blessings!

Getting an orangutan to agree to an ultrasound is as hard as it sounds, but Fresno Chaffee Zoo keepers found the solution - guacamole paste instead of ultrasound gel.
In Atlanta, zookeepers armed with fruit snacks have trained gorillas to place their arms into blood pressure cuffs.
Zookeepers are relying increasingly on behavioral management to provide better health care for animals in captivity.
Advancements in training have allowed animals to help themselves, said Grey Stafford, director of conservation at Wildlife World in Phoenix and an animal trainer for 20 years.

Thanks Times-Tribune

Friday, July 5, 2013

HOCM I Found One This Morning

I found a HOCM.  It pleased me because the cardiologist did not hear a murmur.  The lady was very offensive.  She was a little old tweety bird with leg artery disease.  She hated me for invading her birds breast thorax.  She never complained about the procedure, but she bitched about the time it took to perform an echocardiogram.  The cardiologist wants to invite her in for a sniff test.  Amyl Nitrate.  Let's see if she will come back in for the test.  Comments will be welcome.  I have not done a sniff test in years. Blessings all.

Friday, June 28, 2013

Robotic HIFU Is Now One Step Closer For Prostate Cancer

Amazing!  I wrote about this technology last year I think.  Now we have a way to destroy cancer in the prostate gland with thermal ablation through focused ultrasound.  I am so happy the normally bureaucratic people in charge of the FDA have allowed us to really investigate high intensity focused ultrasound (HIFU).  Now let's use a cattle prod on the FDA to let Americans use the ultrasound contrast mediums available in the USA namely: (Optison and Definity) to reveal the results of the treatment of prostate cancer with HIFU.  There is another contrast medium used overseas called Levovist. The research goal here is to find places in the prostate that are necrotic, versus the areas that are still living. They are trying to get FDA approval for marketing a safe medium here in the USA.  I wish them well.  

I am flying home tomorrow morning from Maryland where I did some intense training for the National Institute of Health this week. You bet it is on my resume.  I have met many good people where I taught some high level ultrasound techniques.  Bless you all here in Maryland.  

EDAP TMS of Vaulx-en-Velin, France received CE Mark approval for its Focal•One robotic High-Intensity Focused Ultrasound (HIFU) system for non-invasive treatment of prostate cancer.
pre treatment Focal•One Robotic High Intensity Focused Ultrasound for Prostate Cancer Gets Green Light in EU
The system overlays and fuses 3D MR imaging data with that captured using ultrasound. The tumor is contoured within the system’s software and then attacked using ultrasound. The combination of MRI and live ultrasound allows for real-time guidance of the energy beam during therapy.

Blessings.  Thanks SonoWorld