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Putting Point-of-Care Ultrasound (POCUS) in Every Clinic

01/07/2019 Listen to Daniel Nash, DNAP, CRNA, Owner of Maverick Training, talk about his vision for POCUS and how he wants to help put POCUS in every clinic around the United States. Looking for additional inspiration? Sign up for our POCUS Post™ newsletter to receive monthly tips and ideas. Transcription: James Day: Hello, and welcome to the Point […]


Listen to Daniel Nash, DNAP, CRNA, Owner of Maverick Training, talk about his vision for POCUS and how he wants to help put POCUS in every clinic around the United States.

Looking for additional inspiration? Sign up for our POCUS Post™ newsletter to receive monthly tips and ideas.


James Day: Hello, and welcome to the Point of Care Ultrasound Certification Academy podcast, where we focus on POCUS. Here, we will discuss all things related to point-of-care ultrasound, the practice, the trends and its impact on healthcare. Our program will engage thought leaders who are defining global patient care with the stethoscope of the future.

James Day: James Day here today, recording live from the Focus on POCUS studio. Today we have Daniel Nash, CRNA, as our guest. Daniel has been in the medical field for over 30 years. He has been a CRNA for 25 years. He graduated from Texas Wesleyan University with a MHS degree, and became a CRNA in December of 1994.

James Day: He received his DNAP from Texas University in 2012. For the past six years, he has practiced as an independent CRNA group in Oklahoma City. He is a founder and partner in Maverick Medical Education, LLC. Maverick has been teaching regional nerve blocks to anesthesia providers for over 10 years. They are also owners of a patented pulsatile cadaver teaching method, and have recently begun to teach health care providers point-of-care ultrasound.

James Day: Daniel is passionate about teaching, and has a lifelong desire to push the boundaries of knowledge and learning. He feels that point-of-care ultrasound is the new frontier of physical assessment, and wants to reach every medical provider who wishes to learn about this exciting new partnership between ultrasound technology and it’s use for frontline healthcare providers.

James Day: Dan, what gets you excited about point-of-care ultrasound?

Daniel Nash: Well, first I’d like thank you James, for putting this podcast on and inviting me to join you.

Daniel Nash: But I can tell you I was involved in a task force a couple of years ago for a simulation for teaching medical tasks and just different training using simulation, and we went out to, I think it was Portland, and I went to the world congress. Were you at that? Isn’t that where I met you?

James Day: Actually yeah, I was out there in Oregon. Yeah, University of Oregon.

Daniel Nash: Right. I think that’s when I met you.

Daniel Nash: Anyway, I went to some of these lectures talking about point of care and using ultrasound as an assessment tool. Up until that point, I’d just use ultrasound for doing regional nerve blocks and we taught it through Maverick, but I learned that ultrasound can be used much more as a diagnostic tool for assessing cardiac and pulmonary functions.

Daniel Nash: You can look at the gastric contents, you can do airway assessments and things like that. So, I thought this would be a perfect thing to learn more about so that we can add that into our Maverick teaching company, because I think everybody needs to learn this. I think it’s sort of new cutting edge stuff. Ultrasound . has been around a long time, but not not being used on the front lines for our nurse practitioners, PA’s, doctors in their clinical setting, to put an ultrasound machine in every clinic around the nation and use it as a diagnostic tool.

Daniel Nash: I think you would agree with me that it’s a fantastic tool and it’s not that hard to learn. You don’t have to be an expert. You don’t have to be a cardiologist to look at the ventricles, and you don’t have to be a pulmonologist to make some baseline assessments of lung function. So, I think that’s something that we can push.

James Day: You know, Dan, you speak the truth and I agree. I just want to know more about what a CRNA and what they know regarding needle guided ultrasound, and what’s kind of being done now with most CRNA’s?

Daniel Nash: Nurse anesthesiologists are out there in the trenches working every day, especially in the rural areas of our country. And it’s hard to get the training for doing ultrasound guided blocks in our training places, just because there’s a lot of demand for that kind of skill between all of the levels of people that are training. So a lot of times, CRNA’s don’t get in depth training.

Daniel Nash: So, that’s kind of why we built Maverick, and we like to give people the opportunity to do nerve blocks using ultrasound, where you can actually put a needle into a human being, and we use cadavers. And like you mentioned earlier, we do have a patented process of making cadavers pulsatile. We put lumens through their existing arteries, and we have a patented pump system that we hook up to that, and it makes the artery pulsate under ultrasound. The ultrasound, most of the regional anesthesia we teach for nerve blocks, for arms and legs and hips and things, utilize a artery as the main landmark. And then, from that landmark you know the rules to either look laterally, medially, superiorly, inferiorly, however, to find the nerves, and it just makes training that much easier.

Daniel Nash: So we think that if somebody can come to our weekend courses and do 40 to 50 blocks on lifelike human beings, when they leave, they’re proficient and confident to go back and start doing blocks. It’s just one more awesome way to use ultrasound.

James Day: Wow, that’s brilliant man. A pulsatile cadaver, that sounds creepy and also brilliant at the same time. And you came up with that, right?

Daniel Nash: Myself and my partner, David Gaskin. Yeah. That’s our baby.

Daniel Nash: So, it is a good thing. It’s a powerful learning tool for sure, and there’s nobody else anywhere in the world doing it like that. So Maverick has it patented and we’ve got it refined to the point to where we can take it on the road and we go all over the nation teaching this.

Daniel Nash: So if somebody has a large group out there that they want trained in a weekend, we’ll ship some cadavers out to you and we’ll ship ourselves out to you, and we’ll teach you in one weekend.

Daniel Nash: We use the flip classroom idea, which is how we’re going to teach our POCUS, also. You do online learning, we take modules, deliver them online so you get all your pre-learning ahead of time, so when you show up to the lab it’s all hands on. Nothing but probe time. And as you can attest, that’s how you get to learn ultrasound by sticking a probe on somebody and manipulating it around until you see the picture you want. So, once you get comfortable with that, you do that a dozen times, 20, 30 times, and it gives you confidence to go back to your clinical site and start using ultrasound, and take care of your patients.

James Day: You know, I agree with that. I remember teaching at the medical school and seeing my students eyes glazing over, and it’s like golf or tennis, you just have to get on the probe and get the time in. It’s not so much didactic anymore. That’s definitely old school and it’s changing, and that’s very progressive of you guys.

James Day: You know, I got a quick question about nerve blocks. So, tell me, I remember we had some nurse anesthetists come out and teach us nerve blocks during the CRNA program. Can you talk a little bit more about that particular effort? Because I know you’re moving more into teaching, and with that question also, another one, I have so many questions for you about how you’re moving from just doing needle guided ultrasound, but you’re doing also diagnostic ultrasound in case maybe somebody crashes in the OR?

Daniel Nash: Correct.

James Day: Okay.

Daniel Nash: Correct. What our main focus has been the last 10 years is regional nerve anesthesia. So for instance, if you need a total knee replacement or a total hip or shoulder surgery, things like that, nerve blocks help with your post op pain control.

Daniel Nash: There’s multiple studies over the past 20, 30 years that show regional anesthesia helps with superior pain control, decrease the chances of a blood clots, and you know, bad things happening. As you know, this opioid epidemic that’s rampant in our society is a big problem. People are getting addicted to pain medicines, and this is a good way to avoid all that, and it’s just better superior pain control. It’s better for the patients, better for the surgeon, and you have less nausea and vomiting. You have less chance of chronic pain setting up postoperatively, and it’s just better pain control.

Daniel Nash: So if you put local anesthetic on a nerve, it will go numb. That’s what my mentor Hank Doherty, who was a CRNA that mentored me when I was a youngster, he came up with that. It’s the simplest thing on earth, but it makes sense. If you put local anesthetic on a nerve, it will go numb. Well, if you numb those nerves prior to surgery, it just makes the perioperative course much more satisfactory from a patient standpoint.

Daniel Nash: So, that’s what we do. That’s what we’ve taught for years, nerve blocks, and we had great success with this flip classroom technique of doing all the didactics ahead of time so you don’t kill them with PowerPoint. Death by PowerPoint. It’s so boring. I mean, they do get glazed over, and then you put them in a lab after that and they’re already tired, and then their brains are overwhelmed by all the anatomical terms and everything.

Daniel Nash: So, we put all of our stuff online and everybody kind of learns what they’re going to do in the lab. Then when they show up in the lab, they’re fresh, they’re wide awake, and they’re ready to go.

Daniel Nash: So this POCUS thing, we decided might be a good thing for us to teach using that same method in a flip classroom. So, what we’re starting, our whole goal is to teach a skill. The Maverick Essential Techniques course that we’ve taught, we teach you seven basic blocks, and we’re really teaching you the skill of using ultrasound to do regional nerve blocks. And once you learn that skill, you can go out and learn the multiple other blocks that are available.

Daniel Nash: We also have an advanced course where we teach you more advanced blocks once you’ve learned that skill. But once you have the skill, you can kind of learn anything you want because you have the skill of finding the anatomy and being able to drive your needle to that target accurately, repeatedly.

Daniel Nash: So, the same thing we feel would hold true with POCUS, point-of-care ultrasound. You take our online didactics, come to our class, and we’re going to teach you the skill of using ultrasound. You’re not going to be a echo cardiology technician when you leave. You’re not going to be a pulmonologist or anything like that, but you’re going to have the skill of being able to recognize what normal should look like, and how to find it on a human being, and then we will go over a a handful of abnormalities. And so, we’ll teach you how to recognize, how to train your eye in your brain to think, okay that looks normal, or no, that does not look normal. That looks abnormal, we need to move further down the realm of diagnostics, and then maybe send them to a cardiologist or a radiologist or a pulmonologist or whoever the the expert is.

James Day: So I’m thinking you guys are almost like the ER, very critical care of a fast, a cardiac, a lung. That’s the diagnostic in that you’re adding to your ultrasound guided coursework.

Daniel Nash: Right. Now, we are eventually going to teach the e-fast and the rush protocols and all those. Those are going to be courses that we will offer, but our original courses that we’re going to offer are just introductory to sort of the front line people in clinics and in ER’s. In the 24 hour emergency room.

James Day: Right. You mean the docs in the box.

Daniel Nash: Doc in a box type of thing, yeah.

James Day: Right, right.

Daniel Nash: Those people that are out there can really, really utilize ultrasound to their benefit and to their patients benefit, because it’s very easy to take a handful of views of a person’s chest and find out a lot of information, and it’s instantaneous.

Daniel Nash: So, that’s kind of what our push is for POCUS, is we want to introduce ultrasound to everybody that they don’t even, they’ve heard of ultrasound, but they’re not really sure how they can use it and how it can help them. So, that’s what our push is, is just try to get the word out that ultrasound, it’s becoming much more available. It’s becoming cheaper.

Daniel Nash: There’s some of these companies are coming out with probes that you can hook up to your iPhone that give you an astonishingly accurate picture. So, as the technology gets better and the price point goes down, the knowledge base expands, and we’re trying to ride the tip of that spear and teach anyone who wants to know how to use ultrasound in their clinic, in the ER, in the OR. CRNA’s all need to know this. Anesthesiologist’s, everybody needs to know how to use ultrasound for pulmonary and cardiac assessment, and to evaluate for stomach contents and things like for a general anesthetic. There are many things you can you can use ultrasound for.

James Day: Yeah. It’s just definitely becoming a standard of care, for sure. You kinda touched on a lot of topics. I think you’re doing awesome work. I know the CRNA programs around the country are the elite of nursing. So, you touched on it. I know the butterfly is coming out now, so you know, what do you see about the future for point-of-care ultrasound? Where do you see it heading?

Daniel Nash: Well, when I went to the world congress, one of the lecturers made the statement that one day the ultrasound probe will replace the stethoscope, and I think that’s true. I think that is where it’s heading. I think ultrasound will become so ubiquitous in medicine that everyone will be able to use it.

Daniel Nash: Right now a lot of hospital systems use ultrasound to teach their nurses how to use it for IV access, because these difficult sticks, we get people in here where you just can’t see or feel any landmark IV’s, but with an ultrasound you can find a vein very easily. And it’s so simple to learn how to use it.

Daniel Nash: So, I see the future of ultrasound moving right into the entry level practitioners, nurses on the floor, ICU nurses, CRNA’s, anesthesiologists, ER physicians, clinic physicians, internal medicine, family practice. It’s been in obstetrics for years, and it’s been a hallmark ultrasound in obstetrics for a long time.

Daniel Nash: So I just see it expanding into every aspect of medicine, and it’s just gonna take some time. That information needs to get out there, the knowledge needs to be disseminated, and that’s what David and I with Maverick are hoping to do. We’re trying to answer the clarion call of need for this.

James Day: Well listen, Daniel Nash, thank you for taking the time to be here on today’s show, and I appreciate the audience for listening.

James Day: And don’t forget, for even more POCUS talk, follow us on Twitter @POCUSAcademy, and on Facebook @POCUSCertAcademy.

James Day: Dan, it was an honor to have you on our podcast today. Have a good one.

Daniel Nash: You too. Bye Bye.

James Day: We hope you enjoyed today’s podcast, Focus on POCUS. Be sure to tune in with us next week for more interviews with thought leaders that are on the forefront of global point-of-care ultrasound.

James Day: The thoughts and opinions expressed in this podcast are the views and opinions of the guests and not those of Inteleos. This podcast is for information purposes only.

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