Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: In today's episode of the podcast, we will discuss point-of-care ultrasonography, POCUS, in critical care.
Speaker: The application of ultrasound at the bedside continues to evolve and grow within critical care.
Speaker: However, there is still significant variability in its adoption among ICU practices.
Speaker: 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.
Speaker: We are honored to have
Speaker: Dr. Jose Luis Diaz Gomez as our expert guest today.
Speaker: Dr. Diaz Gomez is the Chief of Transplant Cardiovascular and Mechanical Support Critical Care and Director of Critical Care Echocardiography at Baylor St.
Speaker: Luke's Medical Center in Houston, Texas.
Speaker: He is also a senior faculty in Cardiovascular Anesthesia and Critical Care at Baylor College of Medicine in Houston.
Speaker: 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.
Speaker: a consummate clinician, a master educator, and a wonderful person.
Speaker: Jose, welcome to Critical Matters.
Speaker: Dr. Zanotti, thank you so much.
Speaker: It is my privilege to be in your now very famous podcast.
Speaker: I have no words to express my appreciation, and I would say most of my friends are always
Speaker: very, very committed to your podcast.
Speaker: So once again, I'm looking forward to have one of my best discussions in my life with you.
Speaker: Excellent.
Speaker: And as I said before we started recording, this is a conversation among friends.
Speaker: So it's Sergio and Jose.
Speaker: That's how we roll here.
Speaker: Jose, let's start with terminology.
Speaker: Just define POCUS for us and what it is and what it's not.
Speaker: Sergio,
Speaker: This is probably one of those moments that I feel absolutely humbled in my life.
Speaker: 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.
Speaker: And at the time, we actually have, of course, a very, very rigorous review
Speaker: And as far as the terminology is concerned, we needed to actually become to an agreement that we will not be using ultrasound.
Speaker: We're going to be using the term ultrasonography.
Speaker: So in our review article, we define point of care ultrasonography, defined as the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging
Speaker: performed by a treating clinician at the patient's bedside, rather than a radiologist or cardiologist.
Speaker: That definition has created so much, so much controversy.
Speaker: 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
Speaker: point of care ultrasonography is well defined in the article.
Speaker: So somebody will tell you, well, Sergio, what's the deal between saying ultrasound and ultrasonography?
Speaker: Well, the fact, the matter is that when you are just describing the tools ultrasound, but how to apply the tool is ultrasonography.
Speaker: And I'm telling you in that previous process with the New England Union of Medicine, we needed to accept
Speaker: that moving forward we're going to be using ultrasonography.
Speaker: So we are all focused on knowing how we're going to make the best application of a tool.
Speaker: And that we will go more in detail about it.
Speaker: But it's not about the gadget.
Speaker: It's about how we will incorporate in our practice.
Speaker: So I just wanted to clarify that a specific
Speaker: term of ultrasonography, prior to the ultrasound.
Speaker: Thank you.
Speaker: And that's a great point.
Speaker: And it just, it's impossible for me to not think about the stethoscope.
Speaker: 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.
Speaker: Sure.
Speaker: That it will ever come into general use
Speaker: 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.
Speaker: That was a comment on the stethoscope when it first was presented as a tool.
Speaker: 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?
Speaker: I think...
Speaker: This is demonstrating once again why you are one of the most educated, eloquent, articulate friends that I have.
Speaker: 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.
Speaker: It's a matter of time.
Speaker: The widespread availability of the tool is there.
Speaker: But think about how people are using the tool.
Speaker: 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.
Speaker: So because of that, you just inspired me.
Speaker: I think what you just described is what actually
Speaker: will describe the utilization of point-of-care ultrasonography moving forward.
Speaker: 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
Speaker: problems that are questions that could be answered with the point of care ultrasound that are not having that as part of their care.
Speaker: And yet there might be some that do have it as part of their care.
Speaker: Yet we don't see anybody walk around the hospital without a stethoscope today.
Speaker: So I think that over time, we definitely need to move in that direction.
Speaker: It's just a technology that is 150 years newer and better.
Speaker: But let's dive into this then.
Speaker: Why not talk about technology a little bit, Jose?
Speaker: So obviously there's been an evolution in technology that always is required for adoption, right?
Speaker: 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.
Speaker: That was prohibited for most clinicians.
Speaker: But there's been some key trends in the evolution of ultrasound machines, but also in other
Speaker: technology that might really have an impact on the adoption of the sonography throughout the critical care arena.
Speaker: Could you talk about those?
Speaker: Absolutely.
Speaker: Sergio, without having any bias, some of the largest and more prolific and successful companies in the planet
Speaker: has been able to evolve in that direction because only one single word, simplicity.
Speaker: They may seem simple.
Speaker: 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.
Speaker: Why?
Speaker: Number one, the handheld ultrasound systems became
Speaker: more affordable.
Speaker: 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.
Speaker: They probably much higher presence of internet in every single country on the planet and having sophisticated wireless technology, then everything
Speaker: comes together.
Speaker: 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.
Speaker: Would you imagine that the stethoscope will bring pulmonologists, anesthesiologists, and paramedics together?
Speaker: That's unreal.
Speaker: Ultrasound does.
Speaker: Ultrasonography does it.
Speaker: Why?
Speaker: Now you have
Speaker: these wireless technology, more affordable handheld systems, and people want to collaborate.
Speaker: They want to take better care of their patients.
Speaker: So I have engaged since probably in the last seven years in tele-mentoring.
Speaker: I go to some countries, some places, hey, would you mind, you can guide me?
Speaker: I should, absolutely.
Speaker: If I can, then now in real time, I can guide somebody how to improve the skill and
Speaker: and actually even make better diagnosis.
Speaker: The companies have been actually able to produce some specific advancements.
Speaker: 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.
Speaker: So instead of having two probes, one for linear and one for
Speaker: phase arrays to take a look at the heart versus blood vessels.
Speaker: Now you can have that capability in only one probe.
Speaker: In moving forward, we're actually now empowering the tool with different modalities of ultrasonography, such as Doppler and mode.
Speaker: And even you're going to incorporate now
Speaker: analytics and quantitation features if you are now even involving the concepts of artificial intelligence.
Speaker: Are you seeing that repertoire?
Speaker: 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.
Speaker: That's tremendously helpful from the technological standpoint.
Speaker: That's not an issue.
Speaker: And it just will be promising and promising year after year.
Speaker: Yeah, certainly the evolution is a rapid pace.
Speaker: I mean, and we think about our lifetimes, just what has happened with computers, right?
Speaker: I mean, very similar or analogous evolution we're seeing with ultrasound.
Speaker: I remember that...
Speaker: Obviously when we were all training, there was echocardiography that usually would be ordered and somebody would do it.
Speaker: Either a technician would do a transthoracic or a cardiologist would do a transesophageal or anesthesiologist would do it in the OR.
Speaker: And that's the way you would get these images.
Speaker: 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.
Speaker: But I wanna probe a little bit more
Speaker: into that last portion that goes beyond the evolution of the hardware, which is the software, right, which is the AI.
Speaker: And that seems to be rapidly approaching us, right?
Speaker: 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.
Speaker: And that seems to be happening already in ultrasound.
Speaker: Can you talk a little bit about that, Jose?
Speaker: Well, I'm really impressed with this interchange as colleagues and friends, and now I understand we get along so well.
Speaker: There is a book by author, his name is Eric Larson.
Speaker: The book is The Myth of Artificial Intelligence, Why Computers Cannot Think the Way We Do.
Speaker: And although I have participated in one study,
Speaker: having artificial intelligence to have automatic, you know, calculation of ejection fraction, I can tell you that we need to put things into consideration.
Speaker: In that book, you have the three different reasonings that any focus user should keep in mind.
Speaker: We have deductive reasoning, we have inductive reasoning,
Speaker: And we have abductive reasoning.
Speaker: So I don't want to confuse the podcast membership.
Speaker: 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.
Speaker: So when you have deduction, derives from generally accepted statements or facts.
Speaker: When you have induction, leads
Speaker: 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
Speaker: 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.
Speaker: Artificial intelligence is not up there.
Speaker: And for that reason, I can go on a specific clinical situations later on with you.
Speaker: So the way I look at it is I'm open to the concept, but it will take many years to really
Speaker: have that equalization on performance to say that artificial intelligence will solve all the issues of focus.
Speaker: 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
Speaker: to get it right.
Speaker: But one thing is to have an image.
Speaker: Another thing is to put that image into the context and take decisions for your patient.
Speaker: 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.
Speaker: Excellent.
Speaker: And I think that this is a good place to start moving towards
Speaker: the clinical application of a point-of-care ultrasonography.
Speaker: And perhaps we can start with its use as a guidance in performing procedures.
Speaker: I don't have data on this, Jose, but I would imagine that that is probably a more common use.
Speaker: 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.
Speaker: But why don't you tell us a little bit about
Speaker: In the critical care context, how do you see this use of guidance and performing procedures?
Speaker: Maybe some common procedures first and then some more novel or less common procedures that you've seen it being utilized for.
Speaker: Thank you.
Speaker: That's a very important question.
Speaker: And I would think as the procedural application of point-of-care ultrasonography is a valid one, separate one.
Speaker: is separate from the diagnostic one.
Speaker: 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
Speaker: When you're talking about the applicability itself, I will always say, why cannot be done under real time ultrasonography?
Speaker: That's the first principle.
Speaker: 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.
Speaker: When you think about it,
Speaker: the insertion belt to get the vessel is probably close to an inch the majority of the time.
Speaker: And if you even don't remember how much that inch is, it just folds your thumb.
Speaker: That's it in Spanish, that's a pulgada, one inch.
Speaker: You basically bend your thumb, that distance from the tip of the thumb to what is bending,
Speaker: 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.
Speaker: You are in that range.
Speaker: And that's actually one of the principles I apply on a daily basis.
Speaker: So to master that and from that one,
Speaker: you actually start migrating to any other body fluid you need to drain.
Speaker: You need to drain for therapeutic reasons or for diagnostic reasons.
Speaker: Let's say you have somebody with pneumonia.
Speaker: You want to see whether or not it's an exudate.
Speaker: 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.
Speaker: You go with that principle.
Speaker: So that's the way that a novice should start.
Speaker: And then
Speaker: I can show you cases where more challenging procedures such as pericardial synthesis.
Speaker: 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.
Speaker: The bottom line is you need to know how to start with the safest, you know, principle and you go from there.
Speaker: And you always need to understand that the real time visualization of the tip of the needle is an absolutely non-negotiable aspect.
Speaker: You need to see where that needle is going.
Speaker: You might become more sophisticated.
Speaker: Oh, Jose, I want a microcombex probe.
Speaker: Oh, I want the in-plane approach or out-of-plane approach.
Speaker: These are
Speaker: you know, variance to the performance of the procedure.
Speaker: 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.
Speaker: And you can do that.
Speaker: And right now we have many millennials that are folks that actually are really good on video games.
Speaker: There is research in that regard.
Speaker: They compare video games performance between
Speaker: female and male provide, by the way, there is no difference.
Speaker: There was no difference.
Speaker: This is all this kind of knowledge that is out there in terms of how you improve your visual, spatial orientation with a personography.
Speaker: Because in the end, it's how you're moving your hands and how you're visualizing the tissues.
Speaker: So I hope with this general principle, do you imagine how really can enhance the safety on the procedural
Speaker: aspect of our practice, but you need to make sure you have control over the visualization of the needle.
Speaker: It's just not exploring blindly.
Speaker: No way.
Speaker: You need to see the people of the needle.
Speaker: Excellent.
Speaker: And I think that's a very valid point and something that all of us, I mean, should keep in mind.
Speaker: In terms of other procedures, Jose, could you expand maybe on some procedures that maybe 10 years ago
Speaker: or five years ago you were not doing with ultrasound that now you are?
Speaker: Absolutely.
Speaker: So, 10 years ago, parasyntesis.
Speaker: Yeah, we were all afraid of hitting the pigastric artery.
Speaker: Nowadays, you can do Doppler, you do it big time.
Speaker: 10 years ago, when I have issues finding the
Speaker: the good spot to have actually having an LP, having attempts, multiple attempts and being afraid of causing a hematoma.
Speaker: Now you can do a lumbar puncture with ultrasonography.
Speaker: The years ago, you probably were not that, you didn't have alternatives to have a pericardiosynthesis.
Speaker: All, most of the techniques were actually only subcostal approach.
Speaker: Now you can do AP-12.
Speaker: and even a parasternal approach.
Speaker: So these are just examples of how we have been able to really, really advance our practice.
Speaker: So, lastly, I will say this.
Speaker: I'm envisioning how the ICU will have even a separate suite, a suite that
Speaker: we are able to actually embrace the next level of performance with procedures.
Speaker: 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.
Speaker: 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,
Speaker: even in the future, fluoroscopy in addition to ultrasonography, that will avoid patients even traveling in an elevator and having any safety issues.
Speaker: So, I'm a very, very strong advocate about empowering intensities for perceived ultrasonography.
Speaker: Excellent.
Speaker: And we'll talk more about the training towards the end and competence, but
Speaker: Before we go there, the other aspect of clinical application obviously relates to examinations, monitoring and diagnosis.
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?
Speaker: Thank you, Sergio.
Speaker: This was my personal experience.
Speaker: When I started doing ultrasonography out of my fellowship, I have huge roadblocks.
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.
Speaker: probably one of the most prestigious groups of cardiology in the country, in the world.
Speaker: And anytime I was having the problem in my hands, like what are we going to say?
Speaker: And people will be, how are we going to document this in the chart?
Speaker: So I needed to find a way that I can, I actually can justify the application.
Speaker: And I still believe it's a good way to start.
Speaker: Jose, what do you mean?
Speaker: Well,
Speaker: I was just not with the probe, putting the probe on people looking for incidental findings.
Speaker: I put the probe on patients that were having a clinical problem.
Speaker: 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
Speaker: And the ultrasonography itself, that evaluation will allow me to take better care of my patients.
Speaker: And I want to make sure everybody understands that it's just not the image.
Speaker: I consider myself, at the moment I started practicing critical care ultrasonography, a good clinician.
Speaker: The secret here is how to actually build that hybrid between
Speaker: clinical excellence and excellence in point of view.
Speaker: If you are able to demonstrate that to me, you will most likely never will have a major issue.
Speaker: The problem is when you disconnect both.
Speaker: So going back to the question, I believe in acute respiratory failure.
Speaker: When I started reading about it and see how I have a case I will
Speaker: share with you very briefly.
Speaker: 3 AM in the morning, patient go from a MICU to a cardiothoracic ICU for ECMO commencement.
Speaker: I put the probe and seen large period of fusion.
Speaker: I put two chest tubes, of course, you know, with a good amount of time to not create more pulmonary edema.
Speaker: And I was able to drain four liters between the two hemitorases
Speaker: Six hours later, that patient was back in the MQ.
Speaker: I have that case.
Speaker: I have the pictures.
Speaker: I will never forget that case.
Speaker: How I started with acute respiratory failure.
Speaker: What happened?
Speaker: Your chest's ray does not perform at the level of lung ultrasonography for characterization of pleural effusion.
Speaker: So I started looking more and more in detail.
Speaker: So I would say that the diagnostic accuracy as it is right now,
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.
Speaker: So obviously, our very common conditions in our practice, and I think hence the real interest in adoption or
Speaker: rapidly evolving adoption in the critical care world.
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.
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?
Speaker: So you're always finding the way to really go to significant problems, and that's a problem.
Speaker: You just mentioned in the last statement, you need to really achieve an advanced training to make a call in a cardiac arrest.
Speaker: So why critical care of personography is not actually incorporated
Speaker: around the planet in every single cold blue.
Speaker: It is not.
Speaker: It probably will be one stain in there, but it's not, there is no recommendation about that.
Speaker: Why?
Speaker: Well, number one, when you go to these international recommendations, they go by the evidence.
Speaker: So what is the evidence on that?
Speaker: Well, the evidence that we have at the beginning came up from Europe.
Speaker: And there were hospital cardiac arrest.
Speaker: And then in the last decade, we have actually many more studies.
Speaker: And those studies actually have been showing us that might be some value making prognostication.
Speaker: Do I use a prognostication sometimes?
Speaker: Yes.
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
Speaker: patients, victims from cardiac arrest, I do believe you need to have advanced critical care echocardiography competence.
Speaker: I will tell you why.
Speaker: The reason why is because you will be under pressure.
Speaker: You will have limitations to make a call.
Speaker: And I want to make clarity
Speaker: to the membership of the podcast about, I'm talking about transthoracic echocardiography.
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.
Speaker: They actually have been smart utilizing now transthoracic echocardiography or cardiac arrest because you decrease the variability on the assessment and
Speaker: To be sincere with you, TE is easier than TTE.
Speaker: You have transcephalial echoes, clear pictures, you are not in the way of anybody.
Speaker: Once the patient intubated, you put the echo probe there.
Speaker: So, during the last 10 years, that is mounting evidence.
Speaker: But the evidence, once again, is not at the level to incorporate in guidelines for management of cardiac arrest.
Speaker: So, the way I look at it, this actually is one of my
Speaker: has been in a cardiac anesthesiologist as well.
Speaker: I have a BAN certification in Transisfalial ECHO.
Speaker: But the reason I mention this is because people like me need to empower an average intensities.
Speaker: If for some reason there is a TEPRO in that institution, you shouldn't be afraid to use it.
Speaker: And that actually is our next step.
Speaker: I'm predicting that in the management of cardiac arrest,
Speaker: There is a good likelihood that TEE might be preferable over TTE.
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.
Speaker: And I think there is a good chance here that TEE will perform.
Speaker: So I just want to leave it up there.
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.
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.
Speaker: How you can ensure that that person is competent to make a call that the patient
Speaker: will go to the OR or the patient needs TPA, whatever measure you are saying.
Speaker: So the bottom line is this, it's a promising area for point of telultrasonography.
Speaker: It's very exciting and at least you can start applying it.
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.
Speaker: If you believe that you make a good diagnosis, show those clips to the cardiologist.
Speaker: This is what I think you say.
Speaker: You have to have that kind of level.
Speaker: And you're able to do it, sure.
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.
Speaker: But those anecdotes cannot actually let
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.
Speaker: We need more data.
Speaker: Yeah, absolutely.
Speaker: And Jose, any, any comments on the COVID-19?
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.
Speaker: And now obviously more and more people are putting probes on the chest looking at the lungs and more than just fluid.
Speaker: So any comments on how it's been integrated or studied in COVID-19?
Speaker: Absolutely.
Speaker: I think the WIM Focus organization did a very good job with those international guidelines.
Speaker: I like the fact that actually they organized that really well because they
Speaker: they identified those nine clinical domains for diagnosis, you know, of severe acute respiratory syndrome in COVID-19.
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.
Speaker: So the initial triage and research stratification, that was huge.
Speaker: And then there were findings for the diagnosis of the pneumonia, not only that, cardiovascular disease as well, associated with it.
Speaker: And then screening for venous thrombobolic disease.
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.
Speaker: And then we are actually, whatever we went to,
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.
Speaker: So I think has been very favorable and the personal standpoint, for instance, I remember
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.
Speaker: You, it takes you to the next level of see what you can do better as a clinician.
Speaker: That day I prone a patient and actually the patient was in a roto prone, you know, bed.
Speaker: And I was trying to see the heart in prone position.
Speaker: And I needed to kind of see how that contrast obtaining the apical view versus when the patient was in the clinton supine.
Speaker: I was able to obtain the view.
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.
Speaker: And I learned.
Speaker: I learned on the fly.
Speaker: I never have done that.
Speaker: in a patient that was with that disease in a prone position.
Speaker: And it helped me out.
Speaker: And I think we put that, yeah, for one of our publications last year.
Speaker: So, definitively that.
Speaker: The other one was, oh my God, I've been rescuing patients that have refractory hypoxemia, receiving ECMO.
Speaker: Some of those patients have, you know, single lumen catheter.
Speaker: the catheter was a malpositioned, displaced, and once again, we were able to publish that as well.
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.
Speaker: So that was another way
Speaker: to engage cardiology colleagues and do what is right for the patient, know what they were wanting to do.
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.
Speaker: Perfect.
Speaker: I want to talk a little bit about challenges.
Speaker: And I know that we've offline have talked about
Speaker: challenges with POCUS and really it, from my understanding of how you view it, it goes beyond just diagnostic errors.
Speaker: So if you could just give us some of your evident and hidden challenges with POCUS, I think that would be very valuable.
Speaker: That's probably the first question that any person who wants to utilize the tool has to know.
Speaker: What are your limitations?
Speaker: Some of them are obvious, other ones are not so obvious.
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.
Speaker: Time.
Speaker: To do a good ultrasonography evaluation, you need time.
Speaker: I don't want to see you in a situation that you are not taking care of the patients.
Speaker: You know, you have, you have to round 15, 20 patients.
Speaker: I don't know what your practice is.
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.
Speaker: Ultrasound cannot deviate the attention of prioritization in your ICU.
Speaker: Ultrasound takes time to do it well.
Speaker: So time is number one.
Speaker: You need to become very organized.
Speaker: How are you going to do it?
Speaker: The ultrasound machine should be ready to go.
Speaker: You can have the wipes to get it ready, to get utilized.
Speaker: You can name a champion.
Speaker: It can be your fellow, your colleague, your nurse, you join a community hospital.
Speaker: The importance is that you have to be efficient.
Speaker: Okay?
Speaker: So the time is important.
Speaker: Number two, the other limitation is to acknowledge that
Speaker: always will be people who would disagree with you utilizing the tool.
Speaker: And that what the impact that should happen on you as a clinician will be only one, how I become competent.
Speaker: Once you are determined to become competent, the next step in that limitation is
Speaker: how I can relate to others, how I can start collaborating with others that are better than I on this.
Speaker: And that equals to radiologists and cardiologists.
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.
Speaker: Our discussions are very, very deep.
Speaker: I have instances where there was an AI company wanted to come to the institution, they approached me directly.
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?
Speaker: Oh yeah, they are coming to talk to Diaz Gomez and probably want you to be the consultant for that company, et cetera.
Speaker: I don't care about that.
Speaker: What I care is like, I engage somebody who's a leader in a primary imaging specialty to be aware of that.
Speaker: I always tell him the problem that cardiologists have is they haven't been enough in the ICU to understand our reality.
Speaker: That's my primary interest.
Speaker: They come and they see what we face.
Speaker: So that's the third limitation I just mentioned is the lack of collaboration.
Speaker: If you don't know how to collaborate with others, you will have issues with ultrasonography.
Speaker: People are going to block you.
Speaker: And the number four will be that ability or the limitation itself will be not exposing you to feedback.
Speaker: You need to expose yourself to feedback.
Speaker: What I'm talking about is feedback from every standpoint.
Speaker: The nurses should tell you, I don't want to see patients with bruises, bleeding in the skin.
Speaker: I don't want to see gel on patients and not be cleaned up.
Speaker: That's part of your professionalism.
Speaker: But at the same time, I don't want to see you believing that your views are the best.
Speaker: And an expert or somebody who's more experienced tells you, hey, you know what?
Speaker: You should do better on this.
Speaker: I think you were describing a pleural effusion, but actually it was a pleural effusion.
Speaker: Where's your quality assurance?
Speaker: Pretty much.
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.
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
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.
Speaker: Look at my awesome diagnosis I made.
Speaker: And by the way, that diagnosis even might not change the outcome of the patient, to be honest.
Speaker: That diagnosis might not even change the mortality of our patients.
Speaker: So it's, it is,
Speaker: Point of field, the ultrasonography has made me more humble and I still believe I need to learn more.
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
Speaker: And now I know I need to brush out my concepts in 3D.
Speaker: So see, everything becomes relative and you really need to have that self-awareness, how you're going to utilize the tool.
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.
Speaker: So before we go, I guess, to the next phase, which I think is a perfect
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?
Speaker: Which is the bias that people starting with a low ability as they become more proficient slowly will tend to overestimate their knowledge.
Speaker: And I think that's very easy in the world of point of character sonography because
Speaker: from maybe not getting any images of the heart, you now start seeing the heart, right?
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.
Speaker: Thank you.
Speaker: Go ahead.
Speaker: No, please.
Speaker: And I was going to say this might be a perfect leeway to talk about competence and training and certification for intensivists.
Speaker: As we wrap up, if you maybe can just give us some thoughts.
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.
Speaker: More and more residency programs, more and more fellowships.
Speaker: but there seems to be still a lot of variation.
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.
Speaker: So how do we advance the needle for everybody?
Speaker: And what are the thoughts on competence and certification would be very helpful.
Speaker: Thank you, Sergio.
Speaker: No better way to kind of
Speaker: Let's start wrapping up.
Speaker: This goes to the core of my existence.
Speaker: This goes to the core to have my own identity.
Speaker: If you think about that three layers, you start with the inner component of identity is who you are.
Speaker: And then the next one is process.
Speaker: And the last one will be basically the outcomes.
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.
Speaker: I will claim to just go to the basics, who you are.
Speaker: Okay.
Speaker: And an intensivist.
Speaker: Okay.
Speaker: Are you an intensivist and focused practitioner?
Speaker: Okay.
Speaker: Are you an intensivist focused practitioner and competent or even better proficient in point of care of personography?
Speaker: Once you answer that question, you can really, really go to that pathway or creating a community that have a unified identity.
Speaker: We don't have that yet.
Speaker: Why?
Speaker: Well, some people believe that you get a two hour training course, you're done.
Speaker: Some people believe half a day.
Speaker: Oh, some people believe you have to pay X and thousands of dollars to have a certificate of completion.
Speaker: Well, some people believe that you can do this online and come and have the tool for several hours.
Speaker: So to answer your question, we actually advised the Immune Evangelion of Medicine readership.
Speaker: What are the two questions remains to be answered.
Speaker: And one of them is that we don't have any uniformity on the way to obtain competence.
Speaker: Unfortunately.
Speaker: Because of that, anybody who wants to apply on that, that might be welcome.
Speaker: What I can tell you is that what we have is, number one, medical schools.
Speaker: Okay.
Speaker: We have our medical education.
Speaker: Big, big time.
Speaker: Big time.
Speaker: I will tell you why.
Speaker: When we wrote the, actually, the manuscript, that was right.
Speaker: It was like one-third or one-third of the
Speaker: medical school have curriculum.
Speaker: This past month, 57% in a new publication.
Speaker: It's going.
Speaker: And I can envision that in the next two years, it might be over 75%.
Speaker: That's a fact.
Speaker: So I think we need to go back to those bases.
Speaker: I think the medical schools will have it.
Speaker: So, Jose, but you're kind of,
Speaker: You're discriminating me.
Speaker: I'm not going to be in the medical school again.
Speaker: That was 30 years ago.
Speaker: What do you have for me?"
Speaker: Well, I do believe that we need to have an entry point.
Speaker: I think that entry point has been discussed.
Speaker: I think the next way to do this in a good way for you that were a tremendous leader in this country,
Speaker: for community hospitals, and I still respect you even more than many other academicians.
Speaker: You have the ability to start creating some strong focus committees on those community hospitals.
Speaker: Let's bring people together.
Speaker: Let's create a committee.
Speaker: Do your own course.
Speaker: Know your own equipment.
Speaker: Name your champion.
Speaker: Start actually collecting data.
Speaker: There are people who are doing it.
Speaker: I do not, I will not endorse ever
Speaker: one organization versus another organization course.
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.
Speaker: But I want to be fair.
Speaker: Everybody should be able to do that.
Speaker: If you have the resources, if you can arrange that, you can put your hospital to go to that course, go for it.
Speaker: Whichever is the organization.
Speaker: But I think from the practical perspective, somehow, probably the organization has to think as well to offer those courses in the hospital.
Speaker: And for instance, I know that the SCCM is doing it.
Speaker: So we need to do that at that level.
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?
Speaker: The straightforward answer is no, no way.
Speaker: You don't need that.
Speaker: We did a publication a couple of years back with and others from Europe and Asia.
Speaker: And we put there that probably it's reasonable to have at least one person that is advanced.
Speaker: The other ones have basic competence in the ICU.
Speaker: And I think that's reasonable.
Speaker: And that's what would you do.
Speaker: There would be people actually who would like to have that critical care or certification, go for it.
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.
Speaker: And the certification, I'm part of that committee on the exam and the certification is another committee.
Speaker: And so far things are going well, I think.
Speaker: However, there is a huge opportunity here for
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.
Speaker: And that's right now a roadblock there.
Speaker: And I want to be transparent.
Speaker: I receive calls, emails, who say, we need to have that 150 study, how to do it.
Speaker: It's not easy.
Speaker: I have done tremendous effort in my institution.
Speaker: My two anesthesia critical care fellows are expected to get out of the fellowship, which is only one year, with that certification.
Speaker: They work really hard and that requires a lot of effort from me.
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
Speaker: to not have the certification to continue utilizing the tool and educator the following generation.
Speaker: I can't.
Speaker: So for that reason, it requires a multiple levels.
Speaker: The competence aspect requires, it's a multi-layer intervention.
Speaker: It's not only one piece to go into one course of spending $10,000.
Speaker: I have enormous sensitivity for our international and overseas
Speaker: clinical practices that actually don't have the luxury to spend even $500.
Speaker: I have been educating in countries that even $200 has been very hard for them.
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.
Speaker: I could echo training it takes you to that ratio.
Speaker: So I want to say in the end that
Speaker: you know, regardless which pathway you are taking, remember my own pathway.
Speaker: My own pathway was putting things together myself.
Speaker: And did I pay for one course?
Speaker: Probably yes.
Speaker: If I recall well, yes.
Speaker: But actually it was a course where actually there were retirees that they have some
Speaker: pathologies and stuff because I want it real.
Speaker: I didn't want just the healthy volunteer.
Speaker: And I paid for that and asked that.
Speaker: I said, well, now I can see the real pathology.
Speaker: Now I can contrast it.
Speaker: And most of the people don't do that.
Speaker: They just go to the ones that are the beautiful pictures with the normal healthy volunteers.
Speaker: So anyhow.
Speaker: Remember the multi-layer intervention to tackle the issue of competency in POCUS is real.
Speaker: It's multi-layer.
Speaker: It's not gonna be that simple and requires everybody's commitment to take our practice to the next level.
Speaker: Excellent.
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
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.
Speaker: But I think your points are well taken, Jose, that it requires really a lot of effort from the individual.
Speaker: It's much more than just going to a course and that ultimately,
Speaker: there are different levels that would be perfectly suitable for different practitioners, right?
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.
Speaker: And I think that should be the goal for everybody moving forward.
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.
Speaker: Absolutely, Sergio.
Speaker: Anything from you.
Speaker: So the first question is about books that have influenced you the most or books that you have gifted often to others.
Speaker: All right.
Speaker: Yes.
Speaker: I think perhaps the book that has influenced me the most has been
Speaker: Essentialism.
Speaker: Um, it's about the discipline pursuit of less.
Speaker: Um, it's written by Greg McKeown.
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,
Speaker: echocariography.
Speaker: If it's not a clear yes, then it's a clear no.
Speaker: Like black and white, as simple as it is.
Speaker: If it's not a clear yes, then it's a clear no.
Speaker: Because we are all busy.
Speaker: We're going to come to you with offers with this and that.
Speaker: And if people really now wants to have that prominence, social media, everything.
Speaker: And all of a sudden, during that involves
Speaker: many things, but you end up not doing even one meaningful thing for yourself, your family, and your patients.
Speaker: So that's one.
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.
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.
Speaker: So I always prioritize in my life based on that book.
Speaker: Excellent book.
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?
Speaker: And that was one of the lessons I took.
Speaker: And I would definitely link this into the show notes.
Speaker: And sorry I interrupted you.
Speaker: You were going to say something else.
Speaker: No.
Speaker: The other, you know, basically, of course, I mean, not everyone that's coming to your podcast is a leader.
Speaker: But, you know, something that
Speaker: ultrasonography might allow you to do is to lead.
Speaker: And eventually, I think that that was my case.
Speaker: I ended up leading ultrasound courses and projects, academic projects, and all those kind of things.
Speaker: So that's an interesting aspect of point-of-care ultrasonography.
Speaker: So
Speaker: The other book that I like is actually the book on leadership and self-deception.
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.
Speaker: You cannot ignore things.
Speaker: And it's just to pretend that you are
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.
Speaker: Absolutely.
Speaker: And I would like to end with just asking you, what would you want every intensivist
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.
Speaker: Thank you for asking that.
Speaker: I will say the following.
Speaker: In order for us to have better leaders in the future, if you are in a leadership position, you don't need to
Speaker: Spread the leadership everywhere.
Speaker: You should facilitate others to become leaders.
Speaker: And if you cannot be a mentor, you still can be a supporter.
Speaker: You probably wouldn't have seen me over the last decade in more than two societies.
Speaker: And that's the reason why.
Speaker: It is not my intention to be in ten societies in every single ultrasound meeting at the San Jose.
Speaker: No, no, no.
Speaker: I will be more interested in the people who wants to actually have the proper professional development to flourish.
Speaker: We need to give opportunity to others.
Speaker: We need to spread, we need to share that, you know, um, whatever, what makes you happen now.
Speaker: And I feel very strong about it.
Speaker: So that's the reason pretty much most of my.
Speaker: investment with my time goes to the SCCM and American Society of Ecocardiography.
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.
Speaker: And we really need to be more sensitive with this participation.
Speaker: And I will top the talent from the very early stages in their careers.
Speaker: If somebody has the drive, if somebody really wants to go to the next level, support that person.
Speaker: So that's a very personal belief.
Speaker: I know criticizing others probably has much more talent than myself and probably have better abilities to be everywhere.
Speaker: But in principle, I think we need to share more what we have with our, with our colleagues.
Speaker: That's my thought.
Speaker: And I think that's a,
Speaker: Perfect place to stop, Jose.
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.
Speaker: So I hope to have you back soon to talk about other topics.
Speaker: And once again, thank you for your time.
Speaker: Thanks so much, Ariel.
Speaker: I look forward to see you in person soon in beautiful Houston.
Speaker: Thank you.
Speaker: Absolutely.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
