2.4 Understand the indications, contraindications, and potential complications of common clinical procedures and perform the basic clinical procedures expected of a new PGY-1.
One of the first student organizations I got involved in in medical school was the Ultrasound Interest Group (USIG). I had heard about their extracurricular learning opportunities during my interview day, and I was very excited to do hands-on learning as a first-year and step away from listening to lectures and reading my notes all day. I didn’t know exactly what specialty I wanted to go into at this point, but I figured that it would help me to develop a skillset for my future career regardless.
I started out at the beginners’ level during my first year, we learned basic knobology and probe motions, how to scan the aorta, the heart, the shoulder, and even the eye. During my second year, I was able to refine some of those scans further as well as learning the hepatobiliary scan, some gynecology scans, and how to place lines with ultrasound guidance using the NALTA (North star, angle, leapfrog, tenting, aspiration) technique. Also, during my second year, I was able to proctor scans at the beginners’ level, that is, teach the students in that course how to perform a particular exam.
I really enjoyed being involved in the ultrasound curriculum, so during my third year, I took the advanced level of the ultrasound course while coordinating the intermediate level with one of my peers. From this experience as a coordinator, I was teaching scans much more frequently than before, and sometimes giving lectures to our level students prior to their scans. This helped me to further develop my teaching skills, which I hope to continue to improve on during residency and as an attending.
During my fourth year, I enrolled in the honors ultrasound curriculum to further develop my scanning skills, and to learn more about what ultrasound can be used for (more advanced applications). This course required that I complete many video modules for different types of scans, attend lectures (via zoom), journal clubs (via zoom), and in-person scanning sessions to further practice and hone my scanning skills.
Throughout my years following the USIG curriculum I learned the “I-AIM” for each scan that was taught to us. This acronym starts with the indication, followed by the acquisition of the image, the interpretation of the image, and the subsequent medical management. For example, let’s say that a 31-year-old female comes in complaining of abdominal pain. On further questioning, her periods are irregular, her last period was more than a month ago, she is sexually active, and she doesn’t use any contraceptive methods. We order a urine pregnancy test, which comes back positive. Imaging to determine if a pregnancy is intrauterine or extrauterine is the next step in her management. She has many indications for this ultrasound study. Starting with a transabdominal view of the uterus using a curvilinear probe, the patient’s bladder should be full, followed by transvaginal imaging using an intraluminal probe with an empty bladder. (The following images were obtained using a model in the CSEAC).
Here we can see that there is not an intrauterine pregnancy. This is just a still image, but I scanned through the entire uterus. The endometrial thickness is 0.73cm. There is also fluid present in the pouch of Douglas. After scanning in the long axis, the probe is rotated 90 degrees to scan in the short axis.
Here is the uterus in short axis with an endometrial stripe of 0.86cm. You can appreciate a round mass-like structure on the right side of the uterus deep to the right fallopian tube. There is a hypoechoic inner circle with a hyperechoic round structure within that.
Here is another image of the mass in the long axis. This mass is suspicious for an extrauterine pregnancy. Especially in the setting of a positive urine pregnancy test. That completes the image acquisition and interpretation steps. The plus side of bedside ultrasound performed by the provider is that these two steps work simultaneously. As far as medical management is concerned, she could be treated medically with methotrexate with follow-up imaging and beta-HCG or surgically with an exploratory laparotomy to remove the pregnancy.
During my intern year, I would like to keep continuing to build on my ultrasound skills. I have much less experience in pelvic imaging compared to other areas of the body, like the gallbladder. As a medical student, it was very difficult for me to gain experience performing OB imaging myself, but I was able to observe a lot of cervical length checks during my time in triage on L&D. My goal is to do 10 cervical length ultrasounds during my first year and 7 amniotic fluid indices. I haven’t matched yet, so I’m not sure exactly what rotations I’ll be doing my first year, but I believe that would be attainable numbers no matter what program I end up at.