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