One of the best things about being a radiologist is teaching others how to improve their ultrasound skills. After countless classes and labs, learning the concepts of ultrasound imaging and practicing on normal dogs, our senior students finally get into the clinic and the transducer is in their hand. The first challenge: performing a complete abdominal ultrasound exam.
They can all repeat the relative echogenicities of the tissues, and the location of the pancreas. And they have practiced finding the normal organs in laboratory sessions with normal dogs. But now the pressure is on, it’s a real patient with other appointments to keep, and they need to find all the organs in a limited time frame.
I remember one student who was concentrating on a screen filled with mesenteric fat in the left cranial abdomen. I asked what she was looking for, and she said she was trying to find the left kidney of the cat. I noticed that she was applying quite a bit of pressure to the abdomen, and suggested she ease up a bit. She did, and the left kidney popped into view, released from its forced exile to the margins of the abdominal cavity. She sat up straighter in surprise, then found some very nice sagittal and transverse views and proudly saved some images. There was a smile and a sigh as she put the transducer back in the holder and left the table.
Another student was trying to examine the spleen from tip to tail. It kept wandering off the screen and she would reposition, losing her place in the progression. I could sense the frustration of knowing the spleen was there, but not being able to keep it in view. I suggested not looking at her hand, and concentrating on keeping the spleen in the middle of the screen. I then gave directions like ” move the transducer cranially, now towards you, now cranial…” starting at the tip and moving right through the tail. At the finale, she threw up her arms and said “I finally followed the entire spleen!”
Knowledge and skill need to be integrated from many different sources before the “a-ha” moment. Everyone learns bits of information from talking to others, hearing stories, lectures, textbooks, and a bit of practice. But it takes the right combination and the right practice for all of it to meld into one body of knowledge. People learn differently, so the moment might come for some after reading an article, or seeing a diagram, or seeing the entire spleen. The moment itself is extremely satisfying.
Ultrasound is a combination of knowledge of normal anatomy, knowledge of disease, and hand-eye coordination. All of these things take a lot of studying and integration to become a honed diagnostic tool. I’ve had my own “a-ha” moments facilitated by mentors, by students’ questions, and my own observations. Some of them are from something you discover, and some are after something is missed. All are valuable lessons toward gaining skill in ultrasound.
What have been some of your “a-ha” moments? What are you frustrated with? Post your comments and questions; I’d love to share them.
As an ER doctor I am always frustrated by abdominal radiographs on potentially obstructed cats and dogs. After a few years of working on these cases with our radiologists, I have learned that even they often have a difficult time “making the call,” amd we need to wait and repeat rads, or resort to an ultrasound.
I have also seen cases treated as pancreatitis for several days, having had multiple radiographs and ultrasounds, only to be taken to surgery for j-tube placement, where they find and remove a peach pit.
Still, sometimes, there are cases where I sit around worrying all night long, only to bring up the image for the radiologist the next morning and have them say after 2 seconds, “sure … it’s obstructed.” Sometimes they’ll point to the bunched intestines I was sure were just intestines in a fat cat that, because of all the fat in the belly, had nowhere else to hang out except with one another. Other times they’ll point to gas shapes that failed to “impress me.”
Dear Allison, is there a database of radiographs from obstructed animals I can look through?
Hi David,
I agree, potential obstructions are some of the most difficult cases to deal with. In cases where the signs are minimal or absent, such as an early obstruction or a small, radiolucent foreign body, we’ll need to repeat radiographs in a few hours or think of an alternate imaging modality like ultrasound or an upper GI exam. I think that after seeing many normal and abnormal radiographs (radiologists have the advantage in volume here), you become more sensitive to the small or subtle changes that indicate an obstruction or other problem. I know many people struggle with these, and I plan to add more to the case collection on my MIRC site (link under Veterinary Radiology Links). The more cases you see, the better!
Allison
My moment “a-ha” was when I reading this blog!