POCUS: A Learnable Skill

11/04/18 Victor Rao, MBBS, DMRD, RDMS is a radiologist by training and is one of the pioneers to introduce and develop Point of Care ultrasound learning content for medical students, PA students and residents and CME content for physicians at the USC School of Medicine in Columbia. He was the director of ultrasound education at USC […]


Victor Rao, MBBS, DMRD, RDMS is a radiologist by training and is one of the pioneers to introduce and develop Point of Care ultrasound learning content for medical students, PA students and residents and CME content for physicians at the USC School of Medicine in Columbia. He was the director of ultrasound education at USC School of Medicine from May 2008 to Aug 2018. He also trained physicians overseas in Tanzania and Philippines to establish POCUS programs. He loves teaching ultrasound and to travel. He has written some chapters in POCUS ultrasound textbooks and in an upcoming eBook. Victor has also worked as a primary care physician in mission hospitals overseas where he enjoyed seeing patients in the clinic and also managed inpatients and performed deliveries, C-sections and minor surgeries. Victor is presently involved with Innovation and The Pocus Certification Academy at Inteleos (formerly ARDMS) as a Global Clinical Content Manager.  Some of his interest include travel, photography, fishing, flying drones and fixing things.

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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 Dr. Victor Rao as our guest. Dr. Rao is a radiologist by training and is one of the pioneers to introduce and develop point-of-care ultrasound learning content for medical students, physician assistants, and residents, and continuing medical education content for physicians at the University of South Carolina School of Medicine in Columbia. He was the director of ultrasound education at the University of South Carolina School of Medicine from 2008 to 2018. He has also trained physicians overseas in Tanzania and the University of Santo Tomas in Manila, Philippines to establish their point-of-care program. He loves teaching ultrasound, he has also written some chapters in POCUS ultrasound textbooks, and in an upcoming eBook, he had some chapters regarding point-of-care ultrasound. He has trained and assisted physicians in the use of high-intensity focus ultrasound for the treatment of BPH and prostate cancer during clinical trials in the United States. He is thankful to God for the opportunity to be able to develop learning content, and train medical personnel and students in the United States and around the world to utilize ultrasound as an imaging tool to enhance the physical diagnosis and to also improve healthcare delivery to the patient population. He is thankful to the scientific and engineering community to miniaturize the device, and also to make it affordable to the masses.

James Day: Oh wow, that’s an impressive bio, Dr. Rao and it’s so great to have you here today.

Dr. Victor Rao: Good to be here, thank you.

James Day: I guess let’s start out with our first question, could you share perhaps a couple of stories of a time when you used POCUS, point-of-care ultrasound, and how that made a difference in your patients’ care?

Dr. Victor Rao: Yeah, there’s a bunch of stories. Point-of-care is so interesting and it really makes a big difference. But one that I really remember is one time I was training a physician in rural South Carolina, and this patient came in with a history of abdominal discomfort. We scanned her and I was surprised to find that the patient was pregnant and the patient was not aware that she was pregnant. And we did the fetal biometry and found out that actually, the fetal age was around 19 weeks gestation. Another thing we observed was that the internus was open and the patient’s externus was still closed. So that means she going to abort if nothing is done immediately. So we sent the patient for Cerclage procedure to the OBGYN clinic and they did the procedure. It was uneventful after that, and then the patient delivered at 34 weeks. And this is the first time she actually had a viable pregnancy, because before she already lost 3 fetuses like that. And nobody had ever diagnosed that she actually had a short cervix. That’s why she was having these problems. So, just an interesting story.

Dr. Victor Rao: Another one that I remember distinctly was somebody in South Carolina, again rural South Carolina, the patient actually came in for a AAA screening. We scanned her and we found that she had multiple plaques, but there was no evidence of abdominal aortic aneurysm. So, I asked the question if she had any more questions or concerns, and the patient mentioned that she actually has pain in her leg. And she works at Lowe’s, she says it’s so bad that when she’s working at Lowe’s she falls down with pain, excruciating pain. And she had been on pain meds for a couple of years.

Dr. Victor Rao: So, decided to rule out the possibility of maybe ischemia problem in the lower extremity. So, when we checked the blood pressure there was a definite difference, a significant difference in the blood pressure in both extremities and that all already was indicating that direction. So, did the scan and on the doppler, we found the patient had stent changes in the lower extremity on the affected side. Traced it all the way up, we found a stenotic segment, sent the patient to radiology for angiography, and then it was confirmed, the stent was placed and now the patient’s pain is gone and the patient is also off pain meds. But those are interesting stories.

Dr. Victor Rao: Again, this is a little bit different, this is like the fan practice setup. But of course, point-of-care makes a difference in internal medicine while doing focused cardiac exams, and also lung exams, as well as the FAST exam.
James Day: Wow, you really made a difference in patient’s lives, that’s impressive.

Dr. Victor Rao: Yeah, we have a baby running around in South Carolina. Well, there have been lots.
James Day: You’ve probably got thousands of stories like that, thank you for those two.

Dr. Victor Rao: Thanks for asking.

James Day: So when you think about others that are considering learning about point-of-care ultrasound, what would be your advice for them?

Dr. Victor Rao: Advice would be don’t get intimidated. I think that one of the major issues I’ve seen with some physicians trying to do this is they are only comfortable doing what they’ve been doing. You know this is something new for them, they were not taught ultrasound in med school. So they feel kind of antsy about holding a probe, and thinking that they may have made a mistake, you know. So let everybody know, that this is a learnable skill, and we just have to understand the basic physics and biology, which people find kind of boring. But it is very important to be able to be an expert stenographer or to be able to understand what the image is telling you. And once you understand that, then you have to get up the hand-eye coordination skills. And you can use advanced tools, like simulators, which are really great tools, too. I’ve had great success teaching people who are having a hard time learning ultrasound, but the simulation did make a big difference.

Dr. Victor Rao: And then of course, once they start scanning, they need to focus on what their prime interest is. Like, we had one physician who said I want to learn lung ultrasound. Somebody said I want to learn right upper quadrant, to be able to rule out is there any gallbladder disease, or cholecystitis, or gallstones. So decide what you want to do and learn it really well, and practice. You have to scan normals as well as abnormals.

Dr. Victor Rao: And one of the ways that I’ve seen that really works well, is if you are scanning and you actually plan to send the patient for an ultrasound exam or CT scan, do a scan yourself and note the findings. Not on the patient chart, but just note it down someplace, in a notebook. And then send the patient for study and then look at it to find does it match up or not.

Dr. Victor Rao: Another way you could do it, is you already have a patient with an ultra report, you can actually scan yourself and see do the ultrasound finding match up or not. Or, if you already know the diagnosis … Say, for instance, somebody says the patient has pericardial effusion, scan the patient’s heart and see can you find that effusion. The patient has pleural effusion, can you find it yourself? The Patient has gallstones, can you find those gallstones? And that’s how you start building the confidence, you know? But it’s very much learnable and …

Dr. Victor Rao: Of course there will be times the patient will be a difficult patient. We know sometimes that doesn’t work at all. Ultrasound is not the absolute answer, that’s why we have a CT scan and [inaudible 00:08:44] database. So understanding that it is limited at times. The patient [inaudible 00:08:51] on the bowel gas may be a problem. But when you have an ideal patient and we already have a patient with a diagnosis it will be in the early phases very helpful to actually go ahead and do retrospective scans.

Dr. Victor Rao: Also one thing not to be forgotten is that do not forget that we are a physician. So you definitely have to do the patient’s history, a good history taking, and of course your physical examination. And the other lab tests available or that you’re considering, go ahead and do that as well. And then put everything together. Come up with a differential, and then approach with ultrasound. It’s just an extension of the examination actually. The point-of-care, that’s exactly what it is. And you’re trying to figure out, you know, I think the patient may have an effusion, I think the patient has gallstones. And then you can scan, to see if it’s there or not. That’s just a yes or no answer. So with time, more confidence will develop.

Dr. Victor Rao: But I’m telling you in my experience, even with medical students, even a first-year medical student with one-hour training was able to tell me that there is something not right. So be aware of what the normal images look like, and what is not normal will be obvious once you start scanning a bunch of patients.

James Day: You know, Dr. Rao, I really like that extension of the physical exam, and sort of the overall clinical judgment that’s involved with a point-of-care scan. So I was sitting here thinking about something, so what do you think the future of POCUS is? And another thing is, why the sudden wave of point-of-care enthusiasts?

Dr. Victor Rao: Yeah the point-of-care ultrasound … I know initially when we first started out ten years ago in South Carolina, but a lot of people were doing the same thing at that time, so they had early movement. And basically what is happening is, this is definitely going to be here, so it’s not going anywhere. Initially people were calling it bedside ultrasound or hand-carried ultrasound, but of course, I like the POCUS term better. And you’re just delivering better patient care. Essentially you’re using a 21st-century tool, that delivers the ability to see inside the patient’s body.

Dr. Victor Rao: And, by the way, that was always the wish of the physician. Every physician wanted to be able to examine with a tool that you could see inside a body what’s really going on. But now it has is actually possible. And I would say to definitely give credit to the unsung heroes in this movement, the engineers and the scientists who have actually miniaturized a device and also at the same time made it very affordable. Imagine, I couldn’t possibly think of buying 40, 50 thousand, $100 thousand dollar device, but something that cost $1000 dollars, or $2000 dollars or less? That’s a real game changer, you know? So it’s very affordable, that’s why we are seeing this. People are saying hey, I can afford this.

Dr. Victor Rao: And also there’s awareness, and the social media has played a big role. And of course, the organization out there, like WINFOCUS, and the [inaudible 00:12:12], all these movements are going on, [inaudible 00:12:14]. And lots of other organizations and societies actually making this very, very possible to access. And so people are realizing that this is very doable and not only that, patients love it. Patients love ultrasound and you get an opportunity to share the experience with the patient.

Dr. Victor Rao: And also in the future, you will have a lot of these devices with AI built into it, artificial intelligence, that will guide the physician with the diagnosis. But again there will have to be a human intervention required because the device may, James, as you know it might actually tell you the systolic pressure is this, when it isn’t. [inaudible 00:12:58] actually look at you know that’s just an artifact. So you maybe have to do your override on it, but most part it will work pretty good.

Dr. Victor Rao: And that’s what makes it so exciting today, is that it’s so affordable and would be a great tool, not just in the US and developed countries, but also in the developing nations, and third-world countries. It would make a huge difference in delivering great patient care. I think the eventual beneficiary of this movement is going to be the patient, and that’s what makes it so exciting.

James Day: Excellent, excellent. Dr. Victor Rao. Wow. We really appreciate you taking the time to be here on today’s show. It’s our inaugural show this week and it’s an honor to have you on our podcast. And thank you for the insights into the future, the technology, and patient care. Thank you so much.
Dr. Victor Rao: Thank you for having me. Have a great day.

James Day: Bye-bye.

Dr. Victor Rao: 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.

Speaker 3: The thoughts and opinions expressed in this podcast are the views and opinions of the guests and not those of Intelios. This podcast is for informational purposes only.

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