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The Promise of POCUS

11/11/18 James A DellaValle, MD, MBA, Chairman of the POCUS Assessment Committee, talks about the Promise of POCUS, how it renewed his interest in his work, and his experience volunteering in Haiti. Dr. DellaValle graduated from Drexel University School of Medicine. Board-certified in Emergency and Family Medicine, focusing on those in rural areas and under-served […]


James A DellaValle, MD, MBA, Chairman of the POCUS Assessment Committee, talks about the Promise of POCUS, how it renewed his interest in his work, and his experience volunteering in Haiti.

Dr. DellaValle graduated from Drexel University School of Medicine. Board-certified in Emergency and Family Medicine, focusing on those in rural areas and under-served populations. Served as medical advisor and member of the Board of Trustees of Hands Together. Involved in undergraduate and graduate medical education and is an Associate Professor of Emergency Medicine at The Upstate Medical University in Syracuse, NY. Dr. DellaValle is Chair of the APCA POCUS Certification Assessment Committee.

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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 health care. Our program will engage thought leaders who are defining global patient care with the stethoscope of the future.

James Day: James Day, live, from the focus on POCUS studio. Today, we have Dr. James DellaValle as our honored guest. James DellaValle is a 1977 graduate of the Medical College of Pennsylvania, which is now known as Drexel University School of Medicine. He trained in family medicine at the Abington Memorial Hospital in Abington, Pennsylvania and has been licensed to practice medicine since 1978. His professional activities have been focused on those who live in rural areas and underserved populations while also practice emergency and family medicine. His current practice of emergency medicine is in an urban environment, caring for those who have limited access to health care. Dr. DellaValle has served as medical advisor and a member of the board of trustees of Hands Together, an NGO working with the poorest of the poor, in the Republic of Haiti, for the last 15 years.

James Day: Throughout his career, Dr. DellaValle has been and continues to be involved in undergraduate and graduate medical education. He has served as both a faculty member and residency program director. He is an associate professor of emergency medicine at the Upstate Medical University in Syracuse, New York. Dr. DellaValle is board certified in emergency medicine and family medicine and medical acupuncture. He holds certificates of added qualifications in geriatric medicine and hospital medicine from the American Board of Family Medicine, and a certificate in tropical medicine from the University of Minnesota. He has been awarded a fellowship by the American Academy of Medical Acupuncture and the American College of Emergency Physicians. He has been certified by ARDMS in abdominal, cardiac and vascular ultrasound. Wow, so how are you today, Dr. DellaValle?

Dr. DellaValle: Today is a rainy day in the southern tier of New York, so we’re expecting about two inches of rain. So I didn’t bring my amphibious car but I have my regular car. I should be able to get in and out pretty easily. So how are you today, James?

James Day: I’m doing good. It’s also raining down here. We have a lot of rain from a hurricane. Always makes me nervous in this mountainous terrain. It’s got nowhere to go. It doesn’t really soak up like the sandy loam down south. So hopefully all will be well. And, wow, such a long, illustrious career with all these accolades and alphabet soup behind your name. I don’t even know where to start.

Dr. DellaValle: Thank you.

James Day: It’s impressive. A man’s life all in front of me with all the great things that he’s done. So what we have here is just a little, loose discussion on point-of-care ultrasound and its applications. So I’m going to ask a broad question. And I’m going to call it, what is the promise of point-of-care ultrasound?

Dr. DellaValle: Well, James, that has many different meanings. So the first is that a clinician can have a much better idea of the diagnosis of the patient in front of him by adding, to their standard, 19th-century physical examination, an ultrasound evaluation. So no matter how good that I can be as a clinician, I cannot detect a pericardial effusion unless it’s at the point where it’s causing a person to be critically ill, as in cardiac tamponade. But by turning the ultrasound machine on and waiting 20 seconds and knowing what to look for, I can see it and tell you whether it’s there or not. I can remember, several months ago, a woman who had a history of metastatic cancer came to the hospital because she was short of breath. She had undergone multiple treatments and was in somewhat of a distress. What she ended up with was a malignant pericardial effusion. Not because I could detect that with a regular chest X-ray or my physical examination, but I was able to pick up the effusion with the ultrasound machine. And the diagnosis was made within three or four minutes of her arrival in the emergency department. To me, that’s very powerful.

Dr. DellaValle: Also, the promise as well as bringing technology, which previously resided in large facilities, hospitals, and other locations, that it’s actually being able to be present in a clinician’s pocket if you’re using a pocket ultrasound machine. And so this is an incredible thing. It’s a game changer. It changes the way you not only make diagnoses but also the way you think. And so the promise, in addition, becomes being a much better physician because of the fact that the anatomy that we studied back a million years ago, when I was in school, it was static. And then, when you do ultrasounds, you see that it’s very dynamic and not static at all. And it renews, at least it did for me at least, renewed a major amount of interest in my work, simply because of the fact that I was exposed to another way of looking at the human body.

James Day: Yes, it is impressive and, as you said, becoming more and more an extension of the physical exam. So I know you do a lot of work down in Haiti. Maybe you could talk about the point-of-care ultrasound in the third world and why is it the time for it?

Dr. DellaValle: For people in the third world, it’s really hard for most Americans to understand how people live and what their lives are like. Those who live in other countries, especially countries in the third world. Access to medical care is limited or difficult. People sometimes have to travel multiple miles, sometimes by bus, to get to a facility. Imaging may or may not be present. In Haiti, for example, the government, for reasons that I’m not sure of, closed the hospital in a city called Gonaives. It was the only hospital in the city. It’s a university town. So, in order for people to have access to different services that would be provided by the hospital, they have to get on a bus and they have to go for hours in order to get to the next facility. And that may not even be bad compared to some other countries where people will ride for 10 hours or 11 hours in order to obtain medical care. And, again, that may or may not be with imaging. And I’m not saying that imaging is the end of the rainbow. But what I am saying is that imaging assists in making a better diagnosis. It doesn’t take the place of history. It doesn’t take the place of the 19th-century exam. But it adds.

Dr. DellaValle: And then, for example, with fracture care. You can diagnose the fracture without any difficulty using a physical examination. However, given sometimes the multiple pieces that are present with a fractured bone, you may not be able to treat that fracture properly without having some kind of imaging available. And then, when you’re providing obstetrical care for people in order to identify pregnancies that are perhaps at higher risk, having access, again, to medical imaging can assist in identifying high-risk pregnancies, diverting resources as necessary to assist moms who are in a high-risk situation. So I think that in general the third world extremely benefits from this technology because it adds to the definitive diagnosis being made hopefully where the people are living, instead of having to send them someplace else. And, in addition, the extra costs that are generated by having to go elsewhere for imaging.

James Day: Yeah. And staying with the Haitian, third-world theme here, can you tell me a little bit more about your involvement with Hands Together and with the poorest of the poor in the Republic of Haiti, I think for the last, what, 15 years?

Dr. DellaValle: 15 years, yeah. I’ve worked primarily in the slum district of Port-au-Prince called Cite Soleil. And Cite Soleil’s population is about 300,000 to 400,000 people. Most of the people came from the countryside to seek a better life. And where they live is they live in corrugated tin shacks that, interestingly, they pay rent for. I didn’t know that they actually paid rent for the places where they live.

James Day: Wow.

Dr. DellaValle: There’s no running water. There are no toilet facilities. So people will stand in line for multiple hours to get a bucket of water from a spigot or tap or from a truck that will bring water into the area. And then they, for going to the bathroom, they’ll simply go outside or dig a hole. And in Cite Soleil in particular, an interesting dynamic is that it’s right next to the ocean. So some of the buildings actually flood during high tide and bring with them not only the waste that’s floating around in the water but also there’s a large number of flies and other insects that are present. Not to mention the rat population. So life is very difficult in this part of Port-au-Prince and in this part of Haiti in particular. Their access to medical care is very, very limited.

Dr. DellaValle: So organizations, for example, like Doctors Without Borders, Medecins Sans Frontieres, they will go into an area that is bad. If it becomes too bad, however, they will leave because it’s dangerous. Which I can understand. At the same time, if it becomes too nice, then they will leave. So they did have a couple of facilities in the part of Port-au-Prince called Cite Soleil. But because, again, of urban violence, they would end up leaving. And the only presence, at least as far as I knew, for medical care, was Hands Together. And what made Hands Together somewhat different was that Hands Together employed Haitian physicians. And so what would happen is that the work would go on whether or not there were volunteers from the first world who had come down to offer their assistance. So that’s the area where I worked. And I would say that unemployment is someplace around 80% to 90%. So gang violence is common. It’s also a source of employment for people. And so you could understand, to some extent, why people get involved in gangs, especially in a place like that.

James Day: Wow. And they just had a, 5.2, earthquake in Haiti. It’s right there on those two tectonic plates. And I believe I read somewhere that 98% of the population is living on less than $1 a day.

Dr. DellaValle: Yeah, that’s incredible. It’s incredible.

James Day: Wow.

Dr. DellaValle: It’s really incredible that people live under those circumstances. And, at the same time, they seem to handle the desperate aspect of their lives in a way that I could only wish that I could be half as good as they. And, for the most part, they are cheerful people, despite the fact that there are limited facilities for going to the bathroom and for washing. Many times people will take three showers a day. They use an eight ounce tumbler cup and manage to soap up and clean up. And I have to say, since I’ve had the privilege of examining people, and some of them were the intimate circumstances, I have to say that people were extremely clean. And when they wash their clothes, they do it with rocks. And so there are no washing machines. But, at the same time, they wouldn’t think twice about having shirts ironed because publicly polite is a very important thing for the Haitian people. Even the underwear, they will iron the underwear just as part of their thing. So despite the fact that they’re housing is so limited, people take great pride in their physical appearance. They shine their sneakers, which I found myself, when I looked at my own sneakers I thought to myself, “How can I do that?” And they’re shining theirs on a regular basis, just because that’s the way to do it.

James Day: Wow.

Dr. DellaValle: So I have a lot of admiration for the people of Haiti and enjoy their company very much. And, as I said to you at a previous time, they certainly have given me more than I’ve given them. And they’ve made me, I think, a better person for having had the opportunity to spend time with them.

James Day: Yes. Wow. So I was just thinking about your associate professorship and working at Upstate Medical University in Syracuse. Maybe you could speak about some of the challenges of instructing point of care.

Dr. DellaValle: Actually, James, many of the schools do not have what I would call a robust curriculum in point-of-care ultrasonography. In fact, I just had a meeting discussing this very point this morning before I had this interview. It seems like the medical school curriculum is bursting at the seams with many different requirements. And, at the same time, a large number of schools have very little time for ultrasonography training. It’s hard to believe that mainly because of the fact that my prediction is that within five years that physicians will be demanding training in this mode. Because most of them have not had any experience with it. And it’s been something that imaging physicians, radiologists in particular, have done. But, at the same time, progress is progress. And this is truly progress. It’s not just modern or something new. It really is progress.

Dr. DellaValle: So teaching medical students in many ways is kind of easy, simply because of the fact that they have been used to using computers and mouse pads and other things that are part of obtaining a diagnostic ultrasound image. So many times I’ll try not to say too much to the students and I’ll just hand them the probe. And I’ll say, “I want you to look at this for me,” and not give them a lot of instructions so that they’re not trying to be right or to do what I’m telling them to do. And I’m amazed at how quickly they’re able, without telling them much, to obtain quality images that could be used for diagnostic purposes. So the skills are certainly there. But, at the same time, I think that schools, as they look at the amount of time, have to ask themselves the question of how they should be spending that time. And I think bedside evaluation of patients is important because you can save an incredible amount of money.

Dr. DellaValle: I’ll give you an example. I had a patient about, I think it was a week ago, who came in and wasn’t sure whether she was pregnant or not. She had taken some home pregnancy tests and some were positive, some were negative. I could’ve ordered a serum pregnancy test, which has a price. Maybe it’s $100. I put my point-of-care ultrasound probe on her and I saw a gestational sac and I could see the embryo growing inside her. And I could count the baby’s heartbeat. I didn’t have to order that test because I knew that she was pregnant. There wasn’t any doubt in my mind about it. And there are many, many stories that I could tell that speak to the value of this diagnostic tool. Which, with some of the newer products that are coming out, is not very expensive at all. It’s just a matter of getting used to the fact of using it and becoming more comfortable with it.

James Day: All good stuff. This has been awesome. You are a mighty man walking on the stage of life. And I really appreciate you taking the time to be here on today’s show. It’s been an honor to have you on our podcast.

Dr. DellaValle: James, thanks a lot. And I look forward to doing what I can to spread the good news of ultrasound.

James Day: Thank you.

Dr. DellaValle: Thank you. Bye.

James Day: Bye-bye.

James Day: We hope you enjoyed today’s podcast focused 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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