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Point of Care Ultrasonography (POCUS)
11 Plays4 years ago
In today’s podcast episode, we will discuss Point of Care Ultrasonography (POCUS). We examine key trends in technology, the relationship of POCUS to consultative ultrasonography, growing clinical applications, and challenges with POCUS.
Our guest is Dr. Jose Luis Diaz-Gomez. Dr. Diaz- Gomez is the Chief of Transplant, Cardiovascular, and Mechanical Support Critical Care, and Director of Critical Care Echocardiography at Baylor, St. Luke’s Medical Center in Houston, Texas. He is a Senior Faculty in Cardiovascular Anesthesia and Critical Care at Baylor College of Medicine.
Additional Resources:
Point of Care Ultrasonography. By J.L. Diaz-Gomez et al. New England Journal of Medicine 2021: https://bit.ly/3JftVPt
Multi-organ point of care ultrasound for COVID-19 (PoCUS4COVID). Expert Consensus: https://bit.ly/3mrXvaF
Society of Critical Care Medicine Resources for critical care ultrasound: https://bit.ly/3yZsW1m
Point of care ultrasonography Certification – CHEST: https://bit.ly/32bZfyd
Books Mentioned in this Episode:
The Myth of Artificial Intelligence: Why Computers Can’t Think the Way We Do. By Erik Larson: https://amzn.to/3ySWDRm
Essentialism: The Disciplined Pursuit of Less. By Greg McKeown: https://amzn.to/3EfVeFT
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Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
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And now your host, Dr. Sergio Zanotti.
POCUS in Critical Care: Trends and Challenges
00:00:33
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In today's episode of the podcast, we will discuss point-of-care ultrasonography, POCUS, in critical care.
00:00:39
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The application of ultrasound at the bedside continues to evolve and grow within critical care.
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However, there is still significant variability in its adoption among ICU practices.
00:00:49
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In today's episode of the podcast, we will discuss key trends in technology, the relationship of POCUS to consultative ultrasonography, growing clinical applications, and challenges that we might face with POCUS.
Meet Dr. Jose Luis Diaz Gomez: POCUS Expert
00:01:02
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We are honored to have
00:01:03
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Dr. Jose Luis Diaz Gomez as our expert guest today.
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Dr. Diaz Gomez is the Chief of Transplant Cardiovascular and Mechanical Support Critical Care and Director of Critical Care Echocardiography at Baylor St.
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Luke's Medical Center in Houston, Texas.
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He is also a senior faculty in Cardiovascular Anesthesia and Critical Care at Baylor College of Medicine in Houston.
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Dr. Diaz Gomez is a recognized expert in critical care echocardiography and the lead author of a recent review article on this topic in the New England Journal of Medicine.
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a consummate clinician, a master educator, and a wonderful person.
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Jose, welcome to Critical Matters.
00:01:41
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Dr. Zanotti, thank you so much.
00:01:45
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It is my privilege to be in your now very famous podcast.
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I have no words to express my appreciation, and I would say most of my friends are always
00:01:59
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very, very committed to your podcast.
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So once again, I'm looking forward to have one of my best discussions in my life with you.
00:02:08
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Excellent.
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And as I said before we started recording, this is a conversation among friends.
00:02:13
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So it's Sergio and Jose.
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That's how we roll here.
Defining POCUS and its Clinical Integration
00:02:18
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Jose, let's start with terminology.
00:02:21
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Just define POCUS for us and what it is and what it's not.
00:02:28
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Sergio,
00:02:30
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This is probably one of those moments that I feel absolutely humbled in my life.
00:02:37
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And when we submitted a previous work to the New England Medicine several years back, it was actually, it was a video in clinical medicine regarding the left ventricular systolic function.
00:02:53
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And at the time, we actually have, of course, a very, very rigorous review
00:03:00
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And as far as the terminology is concerned, we needed to actually become to an agreement that we will not be using ultrasound.
00:03:09
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We're going to be using the term ultrasonography.
00:03:12
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So in our review article, we define point of care ultrasonography, defined as the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging
00:03:29
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performed by a treating clinician at the patient's bedside, rather than a radiologist or cardiologist.
00:03:39
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That definition has created so much, so much controversy.
00:03:43
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I already have been invited to meetings with many parties and on behalf of the authors of the article, Dr. Paul Mayo, Dr. Seth Coney, and myself, we do believe
00:03:59
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point of care ultrasonography is well defined in the article.
00:04:03
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So somebody will tell you, well, Sergio, what's the deal between saying ultrasound and ultrasonography?
00:04:10
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Well, the fact, the matter is that when you are just describing the tools ultrasound, but how to apply the tool is ultrasonography.
00:04:20
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And I'm telling you in that previous process with the New England Union of Medicine, we needed to accept
00:04:28
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that moving forward we're going to be using ultrasonography.
00:04:31
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So we are all focused on knowing how we're going to make the best application of a tool.
00:04:42
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And that we will go more in detail about it.
00:04:45
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But it's not about the gadget.
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It's about how we will incorporate in our practice.
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So I just wanted to clarify that a specific
00:04:57
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term of ultrasonography, prior to the ultrasound.
Adoption of POCUS: Overcoming Skepticism
00:05:01
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Thank you.
00:05:03
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And that's a great point.
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And it just, it's impossible for me to not think about the stethoscope.
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And when I was preparing for our conversation, I came up about a quote from over a hundred years ago, Jose, and I'll read it to you and I'll let you react.
00:05:24
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Sure.
00:05:24
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That it will ever come into general use
00:05:27
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notwithstanding its value, I'm extremely doubtful because its beneficial application requires much time and gives a good deal of trouble both to the patient and the practitioner.
00:05:39
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That was a comment on the stethoscope when it first was presented as a tool.
00:05:43
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What do you think of that and how it can be made into an analogy into your journey with ultrasound as an anesthesia critical care clinician?
00:05:53
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I think...
00:05:54
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This is demonstrating once again why you are one of the most educated, eloquent, articulate friends that I have.
00:06:04
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And I have to say that if we apply the same to ultrasound and ultrasonography in that specific, you know, sequence, meaning incorporating this in our practice, that's what's gonna happen.
Technological Advancements in POCUS
00:06:22
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It's a matter of time.
00:06:24
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The widespread availability of the tool is there.
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But think about how people are using the tool.
00:06:33
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They are adopting that tool utilization to the scope of practice, to political issues they might have in their institutions, to lack of resources in some parts of the planet.
00:06:47
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So because of that, you just inspired me.
00:06:50
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I think what you just described is what actually
00:06:55
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will describe the utilization of point-of-care ultrasonography moving forward.
00:07:03
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And I think it just speaks to how it takes time in medicine, even though we've been talking about point-of-care ultrasonography for some years now, as we mentioned earlier, as of now in Houston where we both are, there's probably plenty of critically ill patients who are having
00:07:20
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problems that are questions that could be answered with the point of care ultrasound that are not having that as part of their care.
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And yet there might be some that do have it as part of their care.
00:07:31
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Yet we don't see anybody walk around the hospital without a stethoscope today.
00:07:34
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So I think that over time, we definitely need to move in that direction.
00:07:38
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It's just a technology that is 150 years newer and better.
00:07:45
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But let's dive into this then.
00:07:49
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Why not talk about technology a little bit, Jose?
00:07:51
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So obviously there's been an evolution in technology that always is required for adoption, right?
00:07:58
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One of the big limiting factors many years ago was just the acquisition of technology that allowed you to obtain ultrasonographic images at the bedside.
00:08:09
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That was prohibited for most clinicians.
00:08:12
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But there's been some key trends in the evolution of ultrasound machines, but also in other
00:08:18
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technology that might really have an impact on the adoption of the sonography throughout the critical care arena.
00:08:26
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Could you talk about those?
00:08:29
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Absolutely.
00:08:31
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Sergio, without having any bias, some of the largest and more prolific and successful companies in the planet
00:08:45
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has been able to evolve in that direction because only one single word, simplicity.
00:08:53
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They may seem simple.
00:08:55
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So if you think about it over the last decade, what has happened with point of tail ultrasonography is that the technology has made it much more simpler, that application to the clinical practice.
00:09:10
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Why?
00:09:11
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Number one, the handheld ultrasound systems became
00:09:15
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more affordable.
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I'm not going to mention any specific names here for obvious reasons, but when you have a device that probably is in the range of the $2,000, then it became more accessible to others that need it.
00:09:33
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They probably much higher presence of internet in every single country on the planet and having sophisticated wireless technology, then everything
00:09:46
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comes together.
00:09:48
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So now from there, now we have a tool that I will tell you, and let's do a contrast what you just said about the stethoscope.
00:09:57
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Would you imagine that the stethoscope will bring pulmonologists, anesthesiologists, and paramedics together?
00:10:06
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That's unreal.
00:10:09
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Ultrasound does.
00:10:10
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Ultrasonography does it.
00:10:11
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Why?
Role of AI in Ultrasound Diagnostics
00:10:13
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Now you have
00:10:14
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these wireless technology, more affordable handheld systems, and people want to collaborate.
00:10:22
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They want to take better care of their patients.
00:10:24
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So I have engaged since probably in the last seven years in tele-mentoring.
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I go to some countries, some places, hey, would you mind, you can guide me?
00:10:36
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I should, absolutely.
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If I can, then now in real time, I can guide somebody how to improve the skill and
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and actually even make better diagnosis.
00:10:47
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The companies have been actually able to produce some specific advancements.
00:10:52
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For instance, now you have silicon chip arrays micro sensors instead of piezoelectric crystals elements to make one probe that actually can have a wider range of frequencies.
00:11:09
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So instead of having two probes, one for linear and one for
00:11:13
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phase arrays to take a look at the heart versus blood vessels.
00:11:17
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Now you can have that capability in only one probe.
00:11:23
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In moving forward, we're actually now empowering the tool with different modalities of ultrasonography, such as Doppler and mode.
00:11:36
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And even you're going to incorporate now
00:11:40
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analytics and quantitation features if you are now even involving the concepts of artificial intelligence.
00:11:47
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Are you seeing that repertoire?
00:11:49
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It's not that amazing that in the coming decade, you can have something connected to your iPhone or other, you know, Galaxy phone, whatever phone is, whatever smartphone is, and then all of a sudden you are connected with an expert and all of a sudden you have tools to have a more objective evaluation of your patients.
00:12:09
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That's tremendously helpful from the technological standpoint.
00:12:13
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That's not an issue.
00:12:14
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And it just will be promising and promising year after year.
00:12:20
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Yeah, certainly the evolution is a rapid pace.
00:12:24
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I mean, and we think about our lifetimes, just what has happened with computers, right?
00:12:28
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I mean, very similar or analogous evolution we're seeing with ultrasound.
00:12:33
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I remember that...
00:12:35
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Obviously when we were all training, there was echocardiography that usually would be ordered and somebody would do it.
00:12:41
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Either a technician would do a transthoracic or a cardiologist would do a transesophageal or anesthesiologist would do it in the OR.
00:12:49
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And that's the way you would get these images.
00:12:52
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And now, like you said, I mean, there's people walking around the hospital with their own ultrasounds, there's portable ultrasounds in a lot of ICUs and it's being utilized a lot more.
00:13:01
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But I wanna probe a little bit more
00:13:03
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into that last portion that goes beyond the evolution of the hardware, which is the software, right, which is the AI.
00:13:11
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And that seems to be rapidly approaching us, right?
00:13:15
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And my vision of AI in medicine is not that AI replaces our thinking, but that it supplements our thinking and that a clinician plus AI is the way to go probably.
00:13:27
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And that seems to be happening already in ultrasound.
00:13:29
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Can you talk a little bit about that, Jose?
POCUS in Procedural Guidance
00:13:32
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Well, I'm really impressed with this interchange as colleagues and friends, and now I understand we get along so well.
00:13:42
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There is a book by author, his name is Eric Larson.
00:13:49
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The book is The Myth of Artificial Intelligence, Why Computers Cannot Think the Way We Do.
00:13:58
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And although I have participated in one study,
00:14:03
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having artificial intelligence to have automatic, you know, calculation of ejection fraction, I can tell you that we need to put things into consideration.
00:14:18
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In that book, you have the three different reasonings that any focus user should keep in mind.
00:14:27
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We have deductive reasoning, we have inductive reasoning,
00:14:32
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And we have abductive reasoning.
00:14:35
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So I don't want to confuse the podcast membership.
00:14:39
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As you know, I love Latin in that deduction, induction, and abduction, actually, all those three words are based on the Latin du chere, meaning to lead.
00:14:54
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So when you have deduction, derives from generally accepted statements or facts.
00:15:00
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When you have induction, leads
00:15:03
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you to a generalization those two we we got it and that's the reason artificial intelligence is powerful however the prefix app for abduction reasoning means away and this is the component this is the component that away means that sometimes we will have the application of focus in a clinical context
00:15:32
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And the common sense that we might apply sometimes in some of our critical decision making, it cannot be incorporated at this time in artificial intelligence.
00:15:42
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Artificial intelligence is not up there.
00:15:46
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And for that reason, I can go on a specific clinical situations later on with you.
00:15:52
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So the way I look at it is I'm open to the concept, but it will take many years to really
00:16:00
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have that equalization on performance to say that artificial intelligence will solve all the issues of focus.
00:16:11
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Perhaps the application that is coming really, really fast, and I really applaud all the success that the software company have done on this, is the prescriptive imaging, meaning that when you are procuring the echocardiography view, you will have guidance
00:16:30
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to get it right.
00:16:32
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But one thing is to have an image.
00:16:34
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Another thing is to put that image into the context and take decisions for your patient.
00:16:39
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So, I'm open to it, but I will remain critical moving forward, and I will make sure that the application of point of cell ultrasonography is on the highest benefit for patient safety moving forward.
00:16:56
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Excellent.
00:16:57
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And I think that this is a good place to start moving towards
00:17:00
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the clinical application of a point-of-care ultrasonography.
00:17:05
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And perhaps we can start with its use as a guidance in performing procedures.
00:17:11
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I don't have data on this, Jose, but I would imagine that that is probably a more common use.
00:17:17
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I think that it's probably more likely that even people who were trained before the era of point-of-care ultrasonography are utilizing it for central line insertions and for A-lines.
00:17:27
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But why don't you tell us a little bit about
00:17:29
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In the critical care context, how do you see this use of guidance and performing procedures?
00:17:35
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Maybe some common procedures first and then some more novel or less common procedures that you've seen it being utilized for.
00:17:44
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Thank you.
00:17:45
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That's a very important question.
00:17:47
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And I would think as the procedural application of point-of-care ultrasonography is a valid one, separate one.
00:17:59
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is separate from the diagnostic one.
00:18:02
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So when we're doing procedures, if you are able to have real-time imaging, and that's the reason I was inspired to do one of my previous studies, performing thoracentesis or big catheter placement and the real-time ultrasonography is different than marking, you know, and I'm biased about it, but
00:18:26
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When you're talking about the applicability itself, I will always say, why cannot be done under real time ultrasonography?
00:18:35
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That's the first principle.
00:18:37
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Number two, I think for all your podcast membership, it's very valid that probably the most mature application, nobody can question, is the vascular axis of the internal jugular vein.
00:18:53
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When you think about it,
00:18:57
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the insertion belt to get the vessel is probably close to an inch the majority of the time.
00:19:06
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And if you even don't remember how much that inch is, it just folds your thumb.
00:19:15
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That's it in Spanish, that's a pulgada, one inch.
00:19:19
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You basically bend your thumb, that distance from the tip of the thumb to what is bending,
00:19:27
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you know, to the joint, interphalange joint, that is the distance that I believe 99% of the intensities, the critical care providers should feel comfortable and they should feel they are doing something safely.
00:19:45
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You are in that range.
00:19:47
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And that's actually one of the principles I apply on a daily basis.
00:19:51
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So to master that and from that one,
00:19:54
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you actually start migrating to any other body fluid you need to drain.
00:20:00
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You need to drain for therapeutic reasons or for diagnostic reasons.
00:20:04
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Let's say you have somebody with pneumonia.
00:20:06
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You want to see whether or not it's an exudate.
00:20:08
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There might be some findings with a person that's more for exudate, but you still want to do the likes criteria and all that.
00:20:16
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You go with that principle.
00:20:18
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So that's the way that a novice should start.
00:20:23
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And then
00:20:24
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I can show you cases where more challenging procedures such as pericardial synthesis.
00:20:31
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My approach, and I have shown this in meetings, that approach of having even one-inch depth, I have a case where I did an apical approach in the apical view, two centimeters, I was in the pericardial space, I inserted the pigtail, and I drained half a liter, and the patient had the outcome.
00:20:53
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The bottom line is you need to know how to start with the safest, you know, principle and you go from there.
00:20:59
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And you always need to understand that the real time visualization of the tip of the needle is an absolutely non-negotiable aspect.
00:21:08
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You need to see where that needle is going.
00:21:10
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You might become more sophisticated.
00:21:12
Speaker
Oh, Jose, I want a microcombex probe.
00:21:15
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Oh, I want the in-plane approach or out-of-plane approach.
00:21:20
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These are
00:21:21
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you know, variance to the performance of the procedure.
00:21:26
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But the fact of the matter is that you should try to see the tip of the needle as you are advancing in the body.
00:21:33
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And you can do that.
00:21:35
Speaker
And right now we have many millennials that are folks that actually are really good on video games.
00:21:42
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There is research in that regard.
00:21:45
Speaker
They compare video games performance between
00:21:48
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female and male provide, by the way, there is no difference.
00:21:52
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There was no difference.
00:21:53
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This is all this kind of knowledge that is out there in terms of how you improve your visual, spatial orientation with a personography.
00:22:04
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Because in the end, it's how you're moving your hands and how you're visualizing the tissues.
00:22:09
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So I hope with this general principle, do you imagine how really can enhance the safety on the procedural
00:22:18
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aspect of our practice, but you need to make sure you have control over the visualization of the needle.
00:22:24
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It's just not exploring blindly.
00:22:26
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No way.
00:22:27
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You need to see the people of the needle.
00:22:33
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Excellent.
00:22:34
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And I think that's a very valid point and something that all of us, I mean, should keep in mind.
00:22:40
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In terms of other procedures, Jose, could you expand maybe on some procedures that maybe 10 years ago
00:22:47
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or five years ago you were not doing with ultrasound that now you are?
00:22:52
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Absolutely.
00:22:54
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So, 10 years ago, parasyntesis.
00:22:59
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Yeah, we were all afraid of hitting the pigastric artery.
00:23:04
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Nowadays, you can do Doppler, you do it big time.
00:23:10
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10 years ago, when I have issues finding the
00:23:16
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the good spot to have actually having an LP, having attempts, multiple attempts and being afraid of causing a hematoma.
00:23:24
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Now you can do a lumbar puncture with ultrasonography.
00:23:29
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The years ago, you probably were not that, you didn't have alternatives to have a pericardiosynthesis.
00:23:40
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All, most of the techniques were actually only subcostal approach.
00:23:44
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Now you can do AP-12.
00:23:46
Speaker
and even a parasternal approach.
00:23:49
Speaker
So these are just examples of how we have been able to really, really advance our practice.
Enhancing ICU Safety with POCUS Suites
00:24:00
Speaker
So, lastly, I will say this.
00:24:06
Speaker
I'm envisioning how the ICU will have even a separate suite, a suite that
00:24:17
Speaker
we are able to actually embrace the next level of performance with procedures.
00:24:23
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And by the way, in one of my, the first institution after I was out of training, we actually had it and probably they still have it there.
00:24:32
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But 10 years later, I can tell you, I will advocate even in the, in the, in the designing of the ICU, having a room to have procedures, having, you know,
00:24:47
Speaker
even in the future, fluoroscopy in addition to ultrasonography, that will avoid patients even traveling in an elevator and having any safety issues.
00:24:57
Speaker
So, I'm a very, very strong advocate about empowering intensities for perceived ultrasonography.
00:25:09
Speaker
Excellent.
00:25:10
Speaker
And we'll talk more about the training towards the end and competence, but
00:25:15
Speaker
Before we go there, the other aspect of clinical application obviously relates to examinations, monitoring and diagnosis.
00:25:26
Speaker
Can we talk a little bit about the diagnostic accuracy first in terms of comparing bedside ultrasonography or POCUS ultrasonography to other modalities for common medical conditions that we might encounter in the ICU?
Cost-Effective Diagnostics with POCUS
00:25:41
Speaker
Thank you, Sergio.
00:25:46
Speaker
This was my personal experience.
00:25:49
Speaker
When I started doing ultrasonography out of my fellowship, I have huge roadblocks.
00:25:58
Speaker
And that actually, I'm not gonna deny that actually made me an excellent critical care ultrasonography user because it was a high-stage situation.
00:26:15
Speaker
probably one of the most prestigious groups of cardiology in the country, in the world.
00:26:21
Speaker
And anytime I was having the problem in my hands, like what are we going to say?
00:26:25
Speaker
And people will be, how are we going to document this in the chart?
00:26:29
Speaker
So I needed to find a way that I can, I actually can justify the application.
00:26:38
Speaker
And I still believe it's a good way to start.
00:26:42
Speaker
Jose, what do you mean?
00:26:43
Speaker
Well,
00:26:44
Speaker
I was just not with the probe, putting the probe on people looking for incidental findings.
00:26:51
Speaker
I put the probe on patients that were having a clinical problem.
00:26:56
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So from the very early stages in my career on ultrasonography, I recognized that acute respiratory failure and undifferentiated arterial hypotension were two common clinical presentations where the tool
00:27:14
Speaker
And the ultrasonography itself, that evaluation will allow me to take better care of my patients.
00:27:21
Speaker
And I want to make sure everybody understands that it's just not the image.
00:27:27
Speaker
I consider myself, at the moment I started practicing critical care ultrasonography, a good clinician.
00:27:35
Speaker
The secret here is how to actually build that hybrid between
00:27:44
Speaker
clinical excellence and excellence in point of view.
00:27:50
Speaker
If you are able to demonstrate that to me, you will most likely never will have a major issue.
00:27:57
Speaker
The problem is when you disconnect both.
00:28:01
Speaker
So going back to the question, I believe in acute respiratory failure.
00:28:07
Speaker
When I started reading about it and see how I have a case I will
00:28:14
Speaker
share with you very briefly.
00:28:15
Speaker
3 AM in the morning, patient go from a MICU to a cardiothoracic ICU for ECMO commencement.
00:28:22
Speaker
I put the probe and seen large period of fusion.
00:28:25
Speaker
I put two chest tubes, of course, you know, with a good amount of time to not create more pulmonary edema.
00:28:33
Speaker
And I was able to drain four liters between the two hemitorases
00:28:39
Speaker
Six hours later, that patient was back in the MQ.
00:28:43
Speaker
I have that case.
00:28:44
Speaker
I have the pictures.
00:28:46
Speaker
I will never forget that case.
00:28:48
Speaker
How I started with acute respiratory failure.
00:28:50
Speaker
What happened?
00:28:51
Speaker
Your chest's ray does not perform at the level of lung ultrasonography for characterization of pleural effusion.
00:28:59
Speaker
So I started looking more and more in detail.
00:29:03
Speaker
So I would say that the diagnostic accuracy as it is right now,
00:29:09
Speaker
first of all, is probably the most cost-effective and less with less side effects in terms of health problems than any other ones for acute respiratory failure and for shock.
00:29:29
Speaker
So obviously, our very common conditions in our practice, and I think hence the real interest in adoption or
00:29:36
Speaker
rapidly evolving adoption in the critical care world.
00:29:40
Speaker
Jose, you talked about obviously cardiac arrest, sorry, you talked about shock and respiratory failure, but cardiac arrest is often part of those diseases, unfortunately.
POCUS in Cardiac Arrest: Emerging Role
00:29:52
Speaker
Could you give us a little bit more of your thoughts of how to apply the utility from basic to more advanced of utilizing point of care ultrasound during a cardiac arrest?
00:30:05
Speaker
So you're always finding the way to really go to significant problems, and that's a problem.
00:30:14
Speaker
You just mentioned in the last statement, you need to really achieve an advanced training to make a call in a cardiac arrest.
00:30:25
Speaker
So why critical care of personography is not actually incorporated
00:30:35
Speaker
around the planet in every single cold blue.
00:30:38
Speaker
It is not.
00:30:40
Speaker
It probably will be one stain in there, but it's not, there is no recommendation about that.
00:30:45
Speaker
Why?
00:30:45
Speaker
Well, number one, when you go to these international recommendations, they go by the evidence.
00:30:54
Speaker
So what is the evidence on that?
00:30:55
Speaker
Well, the evidence that we have at the beginning came up from Europe.
00:31:02
Speaker
And there were hospital cardiac arrest.
00:31:04
Speaker
And then in the last decade, we have actually many more studies.
00:31:11
Speaker
And those studies actually have been showing us that might be some value making prognostication.
00:31:18
Speaker
Do I use a prognostication sometimes?
00:31:21
Speaker
Yes.
00:31:21
Speaker
I'm not, I'm not going to deny that, but to make it, to make it standard of care for the care of a caring for
00:31:31
Speaker
patients, victims from cardiac arrest, I do believe you need to have advanced critical care echocardiography competence.
00:31:45
Speaker
I will tell you why.
00:31:47
Speaker
The reason why is because you will be under pressure.
00:31:53
Speaker
You will have limitations to make a call.
00:31:57
Speaker
And I want to make clarity
00:31:59
Speaker
to the membership of the podcast about, I'm talking about transthoracic echocardiography.
00:32:05
Speaker
So what happened in the last five years is that several groups and more specifically, most of those colleagues have been more from the emergency department.
00:32:17
Speaker
They actually have been smart utilizing now transthoracic echocardiography or cardiac arrest because you decrease the variability on the assessment and
00:32:29
Speaker
To be sincere with you, TE is easier than TTE.
00:32:35
Speaker
You have transcephalial echoes, clear pictures, you are not in the way of anybody.
00:32:40
Speaker
Once the patient intubated, you put the echo probe there.
00:32:43
Speaker
So, during the last 10 years, that is mounting evidence.
00:32:47
Speaker
But the evidence, once again, is not at the level to incorporate in guidelines for management of cardiac arrest.
00:32:55
Speaker
So, the way I look at it, this actually is one of my
00:32:59
Speaker
has been in a cardiac anesthesiologist as well.
00:33:03
Speaker
I have a BAN certification in Transisfalial ECHO.
00:33:07
Speaker
But the reason I mention this is because people like me need to empower an average intensities.
00:33:17
Speaker
If for some reason there is a TEPRO in that institution, you shouldn't be afraid to use it.
00:33:21
Speaker
And that actually is our next step.
00:33:24
Speaker
I'm predicting that in the management of cardiac arrest,
00:33:28
Speaker
There is a good likelihood that TEE might be preferable over TTE.
00:33:35
Speaker
There is not that evidence there yet, but the way actually emergency medicine is doing what they are doing is becoming more and more resuming.
00:33:47
Speaker
And I think there is a good chance here that TEE will perform.
00:33:53
Speaker
So I just want to leave it up there.
00:33:57
Speaker
I think that's a very promising aspect of point of care ultrasonography, but there are many political issues that are potential danger because the patient might have a esophageal rupture.
00:34:12
Speaker
That would be very hard for the American Heart Association to say, yes, every single code blue will have a T or they have a TTE.
00:34:21
Speaker
How you can ensure that that person is competent to make a call that the patient
00:34:27
Speaker
will go to the OR or the patient needs TPA, whatever measure you are saying.
00:34:32
Speaker
So the bottom line is this, it's a promising area for point of telultrasonography.
00:34:39
Speaker
It's very exciting and at least you can start applying it.
00:34:44
Speaker
If you feel that your competency level is in the high end and be open to actually have that quality assurance with the cardiologist.
00:34:56
Speaker
If you believe that you make a good diagnosis, show those clips to the cardiologist.
00:35:02
Speaker
This is what I think you say.
00:35:03
Speaker
You have to have that kind of level.
00:35:07
Speaker
And you're able to do it, sure.
00:35:08
Speaker
And I will tell you, in publication I have made, or my respect that I gained in that first institution after I got trained, was based on saving people in cardiac arrest.
00:35:21
Speaker
But those anecdotes cannot actually let
00:35:25
Speaker
to be, didn't allow me to, to lead that discussion of, oh yeah, now it's a standard because that's not the way it's going to happen.
00:35:36
Speaker
We need more data.
00:35:36
Speaker
Yeah, absolutely.
00:35:39
Speaker
And Jose, any, any comments on the COVID-19?
00:35:43
Speaker
Obviously my experience has been that historically if people are older enough as us, they might remember that the argument was that ultrasound is not good for the lung because of air back in the day.
00:35:55
Speaker
And now obviously more and more people are putting probes on the chest looking at the lungs and more than just fluid.
00:36:01
Speaker
So any comments on how it's been integrated or studied in COVID-19?
POCUS During COVID-19 Pandemic
00:36:06
Speaker
Absolutely.
00:36:07
Speaker
I think the WIM Focus organization did a very good job with those international guidelines.
00:36:18
Speaker
I like the fact that actually they organized that really well because they
00:36:23
Speaker
they identified those nine clinical domains for diagnosis, you know, of severe acute respiratory syndrome in COVID-19.
00:36:35
Speaker
So you triage, you were actually doing that assessment, following the patient closely, and actually there were some investigations even correlating that with oxygenation, et cetera.
00:36:46
Speaker
So the initial triage and research stratification, that was huge.
00:36:52
Speaker
And then there were findings for the diagnosis of the pneumonia, not only that, cardiovascular disease as well, associated with it.
00:37:02
Speaker
And then screening for venous thrombobolic disease.
00:37:06
Speaker
And not only that, we were able to see what happens when we're proning the patients and whether or not there was a response to proning position and our fluid management.
00:37:17
Speaker
And then we are actually, whatever we went to,
00:37:20
Speaker
to reduce the potential spread of infection due to that infection control that we might have with these devices instead of having like the formal echocardiography from room to room.
00:37:40
Speaker
So I think has been very favorable and the personal standpoint, for instance, I remember
00:37:49
Speaker
I think, yeah, I think we include that in one, in my publication last year, I did with one of my career fellows and that's, this is the beauty of critical care of personography.
00:38:00
Speaker
You, it takes you to the next level of see what you can do better as a clinician.
00:38:07
Speaker
That day I prone a patient and actually the patient was in a roto prone, you know, bed.
00:38:17
Speaker
And I was trying to see the heart in prone position.
00:38:21
Speaker
And I needed to kind of see how that contrast obtaining the apical view versus when the patient was in the clinton supine.
00:38:31
Speaker
I was able to obtain the view.
00:38:32
Speaker
I was able to actually distinguish the diastology function in both positions, et cetera, try to see how the right ventricular function was different as well.
00:38:43
Speaker
And I learned.
00:38:44
Speaker
I learned on the fly.
00:38:45
Speaker
I never have done that.
00:38:47
Speaker
in a patient that was with that disease in a prone position.
00:38:51
Speaker
And it helped me out.
00:38:52
Speaker
And I think we put that, yeah, for one of our publications last year.
00:38:56
Speaker
So, definitively that.
00:38:58
Speaker
The other one was, oh my God, I've been rescuing patients that have refractory hypoxemia, receiving ECMO.
00:39:08
Speaker
Some of those patients have, you know, single lumen catheter.
00:39:13
Speaker
the catheter was a malpositioned, displaced, and once again, we were able to publish that as well.
00:39:20
Speaker
And although I have patients like that before that had the malposition, et cetera, but in the case of COVID, what happened was that the ELSO was recommending a specific calculation and somehow some of the providers were not following the recommendations.
00:39:40
Speaker
So that was another way
00:39:42
Speaker
to engage cardiology colleagues and do what is right for the patient, know what they were wanting to do.
00:39:49
Speaker
So once again, myriad, myriad of applications on COVID, definitely I think for any future pandemic, ultrasonography will be in their momentary, first line of momentary for any clinician.
Challenges and Feedback in POCUS Utilization
00:40:05
Speaker
Perfect.
00:40:05
Speaker
I want to talk a little bit about challenges.
00:40:08
Speaker
And I know that we've offline have talked about
00:40:11
Speaker
challenges with POCUS and really it, from my understanding of how you view it, it goes beyond just diagnostic errors.
00:40:18
Speaker
So if you could just give us some of your evident and hidden challenges with POCUS, I think that would be very valuable.
00:40:29
Speaker
That's probably the first question that any person who wants to utilize the tool has to know.
00:40:41
Speaker
What are your limitations?
00:40:44
Speaker
Some of them are obvious, other ones are not so obvious.
00:40:48
Speaker
So if I share with you, you know, the most common challenges, I will tell you the very number one, and please do not forget this from me, is time.
00:41:03
Speaker
Time.
00:41:04
Speaker
To do a good ultrasonography evaluation, you need time.
00:41:10
Speaker
I don't want to see you in a situation that you are not taking care of the patients.
00:41:17
Speaker
You know, you have, you have to round 15, 20 patients.
00:41:20
Speaker
I don't know what your practice is.
00:41:22
Speaker
It might be even only eight patients, but three of them actually are sicker or they need to, you need to discuss something with a patient about end of life, whatever.
00:41:31
Speaker
Ultrasound cannot deviate the attention of prioritization in your ICU.
00:41:37
Speaker
Ultrasound takes time to do it well.
00:41:40
Speaker
So time is number one.
00:41:42
Speaker
You need to become very organized.
00:41:44
Speaker
How are you going to do it?
00:41:46
Speaker
The ultrasound machine should be ready to go.
00:41:48
Speaker
You can have the wipes to get it ready, to get utilized.
00:41:52
Speaker
You can name a champion.
00:41:53
Speaker
It can be your fellow, your colleague, your nurse, you join a community hospital.
00:41:58
Speaker
The importance is that you have to be efficient.
00:42:01
Speaker
Okay?
00:42:02
Speaker
So the time is important.
00:42:03
Speaker
Number two, the other limitation is to acknowledge that
00:42:12
Speaker
always will be people who would disagree with you utilizing the tool.
00:42:20
Speaker
And that what the impact that should happen on you as a clinician will be only one, how I become competent.
00:42:32
Speaker
Once you are determined to become competent, the next step in that limitation is
00:42:39
Speaker
how I can relate to others, how I can start collaborating with others that are better than I on this.
00:42:47
Speaker
And that equals to radiologists and cardiologists.
00:42:51
Speaker
Right now, I can say here in this podcast, I'm very privileged because my cardiology leader in the institution I'm working right now is the president of the American Society of Cardiography.
00:43:05
Speaker
Our discussions are very, very deep.
00:43:09
Speaker
I have instances where there was an AI company wanted to come to the institution, they approached me directly.
00:43:16
Speaker
And, you know, just because he has access to all the resources and he has much more political leverage across the board, how can I put my ego first?
00:43:31
Speaker
Oh yeah, they are coming to talk to Diaz Gomez and probably want you to be the consultant for that company, et cetera.
00:43:38
Speaker
I don't care about that.
00:43:40
Speaker
What I care is like, I engage somebody who's a leader in a primary imaging specialty to be aware of that.
00:43:49
Speaker
I always tell him the problem that cardiologists have is they haven't been enough in the ICU to understand our reality.
00:43:55
Speaker
That's my primary interest.
00:43:58
Speaker
They come and they see what we face.
00:44:01
Speaker
So that's the third limitation I just mentioned is the lack of collaboration.
00:44:08
Speaker
If you don't know how to collaborate with others, you will have issues with ultrasonography.
00:44:14
Speaker
People are going to block you.
00:44:17
Speaker
And the number four will be that ability or the limitation itself will be not exposing you to feedback.
00:44:31
Speaker
You need to expose yourself to feedback.
00:44:33
Speaker
What I'm talking about is feedback from every standpoint.
00:44:37
Speaker
The nurses should tell you, I don't want to see patients with bruises, bleeding in the skin.
00:44:45
Speaker
I don't want to see gel on patients and not be cleaned up.
00:44:49
Speaker
That's part of your professionalism.
00:44:51
Speaker
But at the same time, I don't want to see you believing that your views are the best.
00:44:56
Speaker
And an expert or somebody who's more experienced tells you, hey, you know what?
00:44:59
Speaker
You should do better on this.
00:45:00
Speaker
I think you were describing a pleural effusion, but actually it was a pleural effusion.
00:45:04
Speaker
Where's your quality assurance?
00:45:06
Speaker
Pretty much.
00:45:07
Speaker
Those are probably my top four limitations and a way you transition even before talking about that you make, you have a misdiagnosis, you have a diagnostic errors.
00:45:20
Speaker
So if you join in that journey, I can predict that down the road, the possibility for you to end up on diagnostic errors is much less that is you
00:45:36
Speaker
from the beginning, you ignore these limitations, that you jump on this journey, but you become overconfident, you believe that you don't need anybody else, and you don't care about what other people say, and you just want to put this on the web.
00:45:50
Speaker
Look at my awesome diagnosis I made.
00:45:54
Speaker
And by the way, that diagnosis even might not change the outcome of the patient, to be honest.
00:45:59
Speaker
That diagnosis might not even change the mortality of our patients.
00:46:03
Speaker
So it's, it is,
00:46:06
Speaker
Point of field, the ultrasonography has made me more humble and I still believe I need to learn more.
00:46:14
Speaker
For instance, I'm not that strong in 3D echocardiography because that's more utilizing the OR and now I have spent the majority of my time in the ICU and going back to the cardiac OR in March
00:46:32
Speaker
And now I know I need to brush out my concepts in 3D.
00:46:35
Speaker
So see, everything becomes relative and you really need to have that self-awareness, how you're going to utilize the tool.
00:46:43
Speaker
So please keep in mind these limitations because what Sergio was mentioning is absolutely crucial in terms of preventing potential diagnostic errors down the road.
Overcoming Cognitive Bias in POCUS Proficiency
00:46:58
Speaker
So before we go, I guess, to the next phase, which I think is a perfect
00:47:02
Speaker
a segue, what I wanted to kind of encapsulate what you were saying is something that I've seen a lot over the last two years with the pandemic, which is obviously very well described as a cognitive bias, which is the Dunning-Kruger effect, right?
00:47:16
Speaker
Which is the bias that people starting with a low ability as they become more proficient slowly will tend to overestimate their knowledge.
00:47:26
Speaker
And I think that's very easy in the world of point of character sonography because
00:47:30
Speaker
from maybe not getting any images of the heart, you now start seeing the heart, right?
00:47:34
Speaker
And that humbleness that you mentioned, Jose, I think is very important for that journey, no matter what level of expertise you have, but to always seek for coaching, to seek for other people's opinion, and to be open to feedback because ultimately the goal is really to improve.
00:47:55
Speaker
Thank you.
00:47:57
Speaker
Go ahead.
00:47:59
Speaker
No, please.
00:48:00
Speaker
And I was going to say this might be a perfect leeway to talk about competence and training and certification for intensivists.
Standardizing POCUS Training and Certification
00:48:09
Speaker
As we wrap up, if you maybe can just give us some thoughts.
00:48:12
Speaker
I know from your review article and from others that more and more medical schools are introducing basic ultrasonography into their curriculum, but still only 30% maybe have something and there's tremendous variation there.
00:48:27
Speaker
More and more residency programs, more and more fellowships.
00:48:30
Speaker
but there seems to be still a lot of variation.
00:48:33
Speaker
And also as more and more trainees get trained in ultrasonography, there's still a large number of practicing intensivists who may have varying degrees of exposure to ultrasonography.
00:48:44
Speaker
So how do we advance the needle for everybody?
00:48:46
Speaker
And what are the thoughts on competence and certification would be very helpful.
00:48:55
Speaker
Thank you, Sergio.
00:48:57
Speaker
No better way to kind of
00:49:00
Speaker
Let's start wrapping up.
00:49:04
Speaker
This goes to the core of my existence.
00:49:07
Speaker
This goes to the core to have my own identity.
00:49:12
Speaker
If you think about that three layers, you start with the inner component of identity is who you are.
00:49:18
Speaker
And then the next one is process.
00:49:23
Speaker
And the last one will be basically the outcomes.
00:49:28
Speaker
So the problem people have is when they, when they, when they think about it, they, they just, oh, I was going to use this because they go, they jump to the outcomes right away.
00:49:38
Speaker
I will claim to just go to the basics, who you are.
00:49:42
Speaker
Okay.
00:49:43
Speaker
And an intensivist.
00:49:44
Speaker
Okay.
00:49:45
Speaker
Are you an intensivist and focused practitioner?
00:49:48
Speaker
Okay.
00:49:49
Speaker
Are you an intensivist focused practitioner and competent or even better proficient in point of care of personography?
00:49:58
Speaker
Once you answer that question, you can really, really go to that pathway or creating a community that have a unified identity.
00:50:10
Speaker
We don't have that yet.
00:50:12
Speaker
Why?
00:50:13
Speaker
Well, some people believe that you get a two hour training course, you're done.
00:50:18
Speaker
Some people believe half a day.
00:50:20
Speaker
Oh, some people believe you have to pay X and thousands of dollars to have a certificate of completion.
00:50:26
Speaker
Well, some people believe that you can do this online and come and have the tool for several hours.
00:50:34
Speaker
So to answer your question, we actually advised the Immune Evangelion of Medicine readership.
00:50:42
Speaker
What are the two questions remains to be answered.
00:50:47
Speaker
And one of them is that we don't have any uniformity on the way to obtain competence.
00:50:56
Speaker
Unfortunately.
00:50:58
Speaker
Because of that, anybody who wants to apply on that, that might be welcome.
00:51:04
Speaker
What I can tell you is that what we have is, number one, medical schools.
00:51:09
Speaker
Okay.
00:51:10
Speaker
We have our medical education.
00:51:12
Speaker
Big, big time.
00:51:14
Speaker
Big time.
00:51:16
Speaker
I will tell you why.
00:51:17
Speaker
When we wrote the, actually, the manuscript, that was right.
00:51:23
Speaker
It was like one-third or one-third of the
00:51:27
Speaker
medical school have curriculum.
00:51:30
Speaker
This past month, 57% in a new publication.
00:51:36
Speaker
It's going.
00:51:37
Speaker
And I can envision that in the next two years, it might be over 75%.
00:51:43
Speaker
That's a fact.
00:51:45
Speaker
So I think we need to go back to those bases.
00:51:49
Speaker
I think the medical schools will have it.
00:51:51
Speaker
So, Jose, but you're kind of,
00:51:54
Speaker
You're discriminating me.
00:51:56
Speaker
I'm not going to be in the medical school again.
00:51:58
Speaker
That was 30 years ago.
00:52:00
Speaker
What do you have for me?"
00:52:02
Speaker
Well, I do believe that we need to have an entry point.
00:52:09
Speaker
I think that entry point has been discussed.
00:52:14
Speaker
I think the next way to do this in a good way for you that were a tremendous leader in this country,
00:52:21
Speaker
for community hospitals, and I still respect you even more than many other academicians.
00:52:27
Speaker
You have the ability to start creating some strong focus committees on those community hospitals.
00:52:36
Speaker
Let's bring people together.
00:52:37
Speaker
Let's create a committee.
00:52:39
Speaker
Do your own course.
00:52:42
Speaker
Know your own equipment.
00:52:44
Speaker
Name your champion.
00:52:45
Speaker
Start actually collecting data.
00:52:47
Speaker
There are people who are doing it.
00:52:49
Speaker
I do not, I will not endorse ever
00:52:52
Speaker
one organization versus another organization course.
00:52:56
Speaker
Even though everybody probably has seen all what I have done for SCCM and I owe the SCCM probably the majority of my experience regarding education in critical health care person.
00:53:08
Speaker
But I want to be fair.
00:53:08
Speaker
Everybody should be able to do that.
00:53:11
Speaker
If you have the resources, if you can arrange that, you can put your hospital to go to that course, go for it.
00:53:19
Speaker
Whichever is the organization.
00:53:21
Speaker
But I think from the practical perspective, somehow, probably the organization has to think as well to offer those courses in the hospital.
00:53:29
Speaker
And for instance, I know that the SCCM is doing it.
00:53:33
Speaker
So we need to do that at that level.
00:53:35
Speaker
And once you do that, in terms of competence, okay, you ask me, Jose, does everybody has to become board-certified in critical care or cardiography?
00:53:46
Speaker
The straightforward answer is no, no way.
00:53:49
Speaker
You don't need that.
00:53:51
Speaker
We did a publication a couple of years back with and others from Europe and Asia.
00:53:59
Speaker
And we put there that probably it's reasonable to have at least one person that is advanced.
00:54:07
Speaker
The other ones have basic competence in the ICU.
00:54:12
Speaker
And I think that's reasonable.
00:54:13
Speaker
And that's what would you do.
00:54:14
Speaker
There would be people actually who would like to have that critical care or certification, go for it.
00:54:21
Speaker
But I will tell you, for the most part, when we are utilizing this in the ICU, it's unreasonable to expect that's the way to do it.
00:54:31
Speaker
And the certification, I'm part of that committee on the exam and the certification is another committee.
00:54:42
Speaker
And so far things are going well, I think.
00:54:46
Speaker
However, there is a huge opportunity here for
00:54:51
Speaker
As I said before, if we collaborate much more meaningfully with the cardiologist, we can actually ensure that our clinicians can have the number of examinations to prove the competency.
00:55:09
Speaker
And that's right now a roadblock there.
00:55:11
Speaker
And I want to be transparent.
00:55:13
Speaker
I receive calls, emails, who say, we need to have that 150 study, how to do it.
00:55:19
Speaker
It's not easy.
00:55:21
Speaker
I have done tremendous effort in my institution.
00:55:25
Speaker
My two anesthesia critical care fellows are expected to get out of the fellowship, which is only one year, with that certification.
00:55:35
Speaker
They work really hard and that requires a lot of effort from me.
00:55:40
Speaker
By just me, as I said, my identity, how will be in this podcast if I'm not ensuring that the next generation of leaders in anesthesia critical care
00:55:52
Speaker
to not have the certification to continue utilizing the tool and educator the following generation.
00:55:59
Speaker
I can't.
00:56:00
Speaker
So for that reason, it requires a multiple levels.
00:56:03
Speaker
The competence aspect requires, it's a multi-layer intervention.
00:56:08
Speaker
It's not only one piece to go into one course of spending $10,000.
00:56:11
Speaker
I have enormous sensitivity for our international and overseas
00:56:19
Speaker
clinical practices that actually don't have the luxury to spend even $500.
00:56:24
Speaker
I have been educating in countries that even $200 has been very hard for them.
00:56:31
Speaker
And I need to teach in a ratio of 20, 20 students and one faculty versus what we do in the U S and most of the time is between four and five.
00:56:41
Speaker
I could echo training it takes you to that ratio.
00:56:44
Speaker
So I want to say in the end that
00:56:48
Speaker
you know, regardless which pathway you are taking, remember my own pathway.
00:56:58
Speaker
My own pathway was putting things together myself.
00:57:01
Speaker
And did I pay for one course?
00:57:05
Speaker
Probably yes.
00:57:06
Speaker
If I recall well, yes.
00:57:07
Speaker
But actually it was a course where actually there were retirees that they have some
00:57:16
Speaker
pathologies and stuff because I want it real.
00:57:19
Speaker
I didn't want just the healthy volunteer.
00:57:22
Speaker
And I paid for that and asked that.
00:57:23
Speaker
I said, well, now I can see the real pathology.
00:57:26
Speaker
Now I can contrast it.
00:57:28
Speaker
And most of the people don't do that.
00:57:29
Speaker
They just go to the ones that are the beautiful pictures with the normal healthy volunteers.
00:57:36
Speaker
So anyhow.
00:57:38
Speaker
Remember the multi-layer intervention to tackle the issue of competency in POCUS is real.
00:57:45
Speaker
It's multi-layer.
00:57:46
Speaker
It's not gonna be that simple and requires everybody's commitment to take our practice to the next level.
00:57:55
Speaker
Excellent.
00:57:55
Speaker
And part of the intent, obviously, of having this conversation was to get everybody to maybe make a commitment as the new year comes
00:58:06
Speaker
to wherever they are in their journey of POCUS in the ICU to either move forward and learn something new and get better or more competent in answering specific questions or specific uses, or if they already feel that they've achieved the certification and consider themselves a master's to then help others move forward in that journey.
00:58:26
Speaker
But I think your points are well taken, Jose, that it requires really a lot of effort from the individual.
00:58:32
Speaker
It's much more than just going to a course and that ultimately,
00:58:36
Speaker
there are different levels that would be perfectly suitable for different practitioners, right?
00:58:41
Speaker
But no matter who you are, you probably can improve your competency in utilizing POCUS to answer specific questions at the bedside and help your care of your patient.
00:58:52
Speaker
And I think that should be the goal for everybody moving forward.
00:58:58
Speaker
I would like to wrap up, Jose, with a couple of questions that are not related to the world of ultrasonography, if that's okay.
00:59:08
Speaker
Absolutely, Sergio.
00:59:09
Speaker
Anything from you.
00:59:11
Speaker
So the first question is about books that have influenced you the most or books that you have gifted often to others.
00:59:17
Speaker
All right.
00:59:22
Speaker
Yes.
00:59:26
Speaker
I think perhaps the book that has influenced me the most has been
00:59:37
Speaker
Essentialism.
00:59:40
Speaker
Um, it's about the discipline pursuit of less.
00:59:46
Speaker
Um, it's written by Greg McKeown.
00:59:51
Speaker
And in that book, I will say, well, actually to understand that one, whenever in my life, or even very often in critical care,
01:00:06
Speaker
echocariography.
01:00:07
Speaker
If it's not a clear yes, then it's a clear no.
01:00:15
Speaker
Like black and white, as simple as it is.
01:00:17
Speaker
If it's not a clear yes, then it's a clear no.
01:00:22
Speaker
Because we are all busy.
01:00:24
Speaker
We're going to come to you with offers with this and that.
01:00:26
Speaker
And if people really now wants to have that prominence, social media, everything.
01:00:32
Speaker
And all of a sudden, during that involves
01:00:36
Speaker
many things, but you end up not doing even one meaningful thing for yourself, your family, and your patients.
01:00:47
Speaker
So that's one.
01:00:50
Speaker
The other thought I have in that book is that it really exemplifies really well about your highest priority is to project your ability to prioritize.
01:01:05
Speaker
If you don't prioritize for yourself, somebody else will do it for you and you will lose control and pretty much you're not going to do what you enjoy the most.
01:01:19
Speaker
So I always prioritize in my life based on that book.
01:01:25
Speaker
Excellent book.
01:01:26
Speaker
I was going to say that when you mentioned the book, the first thing that came to mind is if you don't set your priorities, somebody will set them for you, right?
01:01:34
Speaker
And that was one of the lessons I took.
01:01:36
Speaker
And I would definitely link this into the show notes.
01:01:38
Speaker
And sorry I interrupted you.
01:01:40
Speaker
You were going to say something else.
01:01:43
Speaker
No.
01:01:45
Speaker
The other, you know, basically, of course, I mean, not everyone that's coming to your podcast is a leader.
01:02:00
Speaker
But, you know, something that
01:02:03
Speaker
ultrasonography might allow you to do is to lead.
01:02:07
Speaker
And eventually, I think that that was my case.
01:02:15
Speaker
I ended up leading ultrasound courses and projects, academic projects, and all those kind of things.
01:02:24
Speaker
So that's an interesting aspect of point-of-care ultrasonography.
01:02:30
Speaker
So
01:02:30
Speaker
The other book that I like is actually the book on leadership and self-deception.
Leadership and Mentorship in POCUS
01:02:38
Speaker
And in that one, in that book for sure, that basically is the Autorist or Arbinger Institute, but the way I look at things is as a leader, you really need to go to the bottom of the problems.
01:02:53
Speaker
You cannot ignore things.
01:02:56
Speaker
And it's just to pretend that you are
01:02:58
Speaker
making out things and make them look beautiful once again, instead of actually going to the core and have that identity that you might have with others and really engage others with meaningful relationships is absolutely critical for your success as a leader.
01:03:21
Speaker
Absolutely.
01:03:22
Speaker
And I would like to end with just asking you, what would you want every intensivist
01:03:29
Speaker
that's listening today, every clinician, whether a physician or APP to know, it could be a quote, a fact, or just a thought.
01:03:41
Speaker
Thank you for asking that.
01:03:42
Speaker
I will say the following.
01:03:47
Speaker
In order for us to have better leaders in the future, if you are in a leadership position, you don't need to
01:03:58
Speaker
Spread the leadership everywhere.
01:04:01
Speaker
You should facilitate others to become leaders.
01:04:06
Speaker
And if you cannot be a mentor, you still can be a supporter.
01:04:10
Speaker
You probably wouldn't have seen me over the last decade in more than two societies.
01:04:16
Speaker
And that's the reason why.
01:04:18
Speaker
It is not my intention to be in ten societies in every single ultrasound meeting at the San Jose.
01:04:25
Speaker
No, no, no.
01:04:27
Speaker
I will be more interested in the people who wants to actually have the proper professional development to flourish.
01:04:35
Speaker
We need to give opportunity to others.
01:04:38
Speaker
We need to spread, we need to share that, you know, um, whatever, what makes you happen now.
01:04:49
Speaker
And I feel very strong about it.
01:04:51
Speaker
So that's the reason pretty much most of my.
01:04:55
Speaker
investment with my time goes to the SCCM and American Society of Ecocardiography.
01:05:02
Speaker
And I think I would like to support others in the other societies because once again, it's not about you, it's about everybody.
01:05:15
Speaker
And we really need to be more sensitive with this participation.
01:05:20
Speaker
And I will top the talent from the very early stages in their careers.
01:05:25
Speaker
If somebody has the drive, if somebody really wants to go to the next level, support that person.
01:05:31
Speaker
So that's a very personal belief.
01:05:33
Speaker
I know criticizing others probably has much more talent than myself and probably have better abilities to be everywhere.
01:05:41
Speaker
But in principle, I think we need to share more what we have with our, with our colleagues.
01:05:50
Speaker
That's my thought.
01:05:52
Speaker
And I think that's a,
01:05:53
Speaker
Perfect place to stop, Jose.
01:05:55
Speaker
I really want to thank you for taking the time to talk with us, sharing your expertise on this fascinating area of critical care, but also sharing your wisdom outside of ultrasonography in terms of being very regimented and picking up what's important for ourselves and making sure that we can help others move forward as well.
01:06:16
Speaker
So I hope to have you back soon to talk about other topics.
01:06:19
Speaker
And once again, thank you for your time.
01:06:22
Speaker
Thanks so much, Ariel.
01:06:24
Speaker
I look forward to see you in person soon in beautiful Houston.
01:06:28
Speaker
Thank you.
01:06:29
Speaker
Absolutely.
01:06:32
Speaker
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01:06:36
Speaker
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01:06:42
Speaker
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01:06:46
Speaker
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