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.