The air is thick with silence as the three of us huddle around our patient’s bed, carefully moving the probe along the man’s midline and watching the screen of my work phone for the telltale flicker of blue and red that indicates coursing blood flow. It’s me, a first-year resident, with my third-year senior and our attending physician. Between us, we have no great knowledge of ultrasound, but our patient has a large aortic aneurysm, and we are trying to visualize it with our newly acquired ultrasound probe, the pride and joy of my residency program’s first-ever POCUS curriculum.
It’s Tuesday afternoon, which for us means Gel Rounds: a weekly endeavor to use the portable ultrasound probe to perform an exam on one of the hospitalized family medicine patients. Actually, it’s the first official Gel Rounds, and frankly, it’s anticlimactic.
“I don’t see it”, I say, and pass the probe to my attending to take over. We wander over the abdomen a little longer, speculating about anatomical landmarks and highly anticipated vasculature hiding between bowel loops, but it’s no use. We call it off. Cannot visualize aorta: exam limited by body habitus.
“Well, we tried,” I assuage, as we walk back to our workroom.
“Yes, that’s good,” we all agree. But I’m a little disappointed, and I bet they are too. It’s been a process, building a POCUS curriculum these last few months, generating interest and buy-in from the resident body and faculty, and I don’t want the program to be a failure. But, I chide myself, something has been learned. Now we know a little more about who we can expect to see an aorta on, and who we can’t. For me, the failure of the image capture is gradually overshadowed by the success of gathering at a patient’s bedside to just try. This is the start of what I’m calling our “learner-led POCUS curriculum,” in which residents have decided to take charge of their own learning and carve out time to learn this skill. Everyone agrees that POCUS is important for the field of family medicine, and steps are being made by our organizing bodies to create standardized curricula for learning it. But in practice, we face a knowledge gap between our faculty and our learners; POCUS is new enough that many attendings never learned much of it, even when most of our residents want to. So today, we are all learners here.
During didactics later this month, I teach our group of residents the specifics of the aorta exam and am sure to include tips to improve visibility on larger bodies. We take turns being the patient and sonographer, watching how the image clarity changes with inspiration or position. “It’s actually deeper than I thought,” I remark, alternating probe pressure on my classmate’s abdomen. Each of us completed online modules with core ultrasound before class, but in this case, hands-on practice makes perfect. “When struggling to visualize the aorta, try having your patient take deep breaths, or repositioning them to their left side,” I explain.
I have a vision that our program will graduate competent family medicine physicians who can reach for an ultrasound probe with confidence, and use it to visualize a gallstone in an abdominal pain patient or identify a B-line from heart failure. POCUS is monumental because it provides the opportunity for a safe imaging modality for patients; residents caught in the crux of changing times don’t have to perpetuate a knowledge gap into the next generation of physicians. Residents are the faculty of the future, and sometimes our development is in our own hands. Starting out can be intimidating, but we each need to get our hands dirty and get comfortable doing a little practice.
Since our first Gel Rounds, I’ve found myself making small strides using the ultrasound probe. On my clinic day, I grab it from the charger, and the probe glows white as it connects via Bluetooth to my phone. A medical student and I peek our heads into the cracked door of a patient room. “Ready?” I ask the mother laid supine on the exam table, 35-weeks-pregnant gravid belly exposed. Holding the screen in my left hand, I show her that her baby has moved to the head down position in preparation for birth.
“Wow, I never knew you could see it on your phone!” the student exclaims.
I adjust the depth and gain with my thumb.
“She’s really in there, isn’t she,” the mother remarks in awe as her baby’s profile comes into view.
There is a dual magic happening in this room—a mother, seeing her unborn child, and a student in awe of the possibilities of a new technology. Mastery takes deliberate practice. It isn’t always fun, and it doesn’t always yield immediate results. But standing here, soaking up a moment like this, I realize that all my prior effort has been completely and totally worth it.
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