256 Shades of Grey: Learning the Art of Ultrasound

I’m back in Perth again after another cross-country jaunt, to the sunny Gold Coast in Queensland. It wasn’t for a locum job this time, but rather to attend a week long obstetric & gynaecology ultrasound course at the Australian Institute of Ultrasound.

Anyone who’s been around twitter or FOAM would be well aware that ultrasound is revered with almost religious fervor by emergency docs, rural docs, retrievalists and anaesthetists alike. Every few days it seems there’s a new and exciting application for ultrasound popping into my twitter feed. There’s even a hashtag (#FOAMus) and lots of great blogs and online resources devoted to its use (see list below).

Of course, sonography has long been an essential tool in the world of obstetrics. Unfortunately, ultrasound training was not part of the DRANZCOG program when I was going through a few years back (although it is now) so my formal teaching in the area was pretty minimal. I’ve managed to work out which end is which on the probe, check if the baby is head down or head up, get a rough idea of the position of the placenta, look for a beating heart and see if the baby is moving. But I was definitely a user of the “bumble-bee” method – where I would just randomly move the probe around and hope that whatever I was looking for would magically appear on the screen!

However, as I’ve been working in more isolated and remote places, I’ve realised the importance of being able to scan and scan well. For example – when a patient comes in to the emergency department with PV bleeding, abdo pain and positive HCG at 6pm on a Friday after the sonographer has gone home, it’s really important to be able to rule out an ectopic. Or when a patient presents for their first antenatal attendance in late pregnancy with no idea of due date and is unwilling to stick around for a formal ultrasound it would be handy to be able to do a half decent biometry scan. Luckily I’ve been able to get-out-of-jail once or twice with the help of some very handy FOAM resources like this one.  But never-the-less, it was time to step up and learn the mysterious arts of sonography.

I was a bit apprehensive going in to the course; my understanding of physics was pretty rusty / non-existent, and with my very short attention span, five days seemed like an awfully long time to spend doing just one thing. However, I’m pleased to report that the course was actually really fantastic and easily exceeded my expectations. The facilities were excellent, we were well fed throughout, the tutors were experienced and very patient and the course was structured perfectly with a mix of lectures, demo-scans and small group hands-on scanning practice with volunteer patients. Also – those unborn babies are pretty damn cute! 

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The content covered:

  • basics of physics and knobology
  • The 3 P’s (patient, probe, position) and optomising the image with the oft-repeated mantra “depth, focus, TCG”
  • Gynaecology, first, second and third trimester assessments
  • CRL, Biometry, AFI, dopplers, signs of abnormal placentation, cervical length, fetal anatomy etc.

The learning curve was steep but I was feeling pretty pleased with myself by the end of the week when I could get a perfectly centred and horizontal femur length on a wriggly baby, calculate an MCA PSV and get a cute profile pic for the mums and dads. The intricacies of fetal cardiac abnormalities etc are still a bit beyond me but at least I have a better grip on what normal looks like and when I should be concerned. I certainly feel like I have achieved a baseline level of competence in both trans-vaginal  and trans-abdominal scanning and the problem now will be trying to consolidate my new skills in the absence of a regular workplace and patients – the perennial challenge for locums!

Outside of the clinical content, the course also provided a great opportunity to network with rural generalists, GP obstetricians and O&G specialist trainees from all over Australia and New Zealand. It’s always great be able to hear about how other places do things and particularly to discuss what’s new in tertiary obstetrics since I went through.

It was also pretty funny trying to explain the concept of GP obstetrics to one particularly intense Kiwi registrar, who was just astounded that the women in rural Australia would “accept a lower standard of care” by not having immediate access to specialist obstetricians and 24/7 operating theatre staff in their local hospitals! Had to bite my tongue a few times during that conversation… But, it was a good reminder that we rural GP proceduralists really do need to keep striving to be at the top of our game to be able to provide the “quality care, out there” that our patients deserve.

A few other non-medical highlights from the trip:

  • Staying with my dear mum and step-dad who live over there on the Gold Coast and who I only get to see once a year or so. Oh the luxury of mum-cooked meals and quality time chatting with a cuppa!
  • Witnessing the ultimate Australian cliche when a Kangaroo hopped down the street outside my parents’ suburban house. Seriously, this actually happened!!
  • A rare but treasured visit to see my wonderful grandparents, who will no doubt both be reading this blog post on their iPads. (Hi Nanna & Grandpa!) Perhaps they could teach some of our technophobic medical colleagues a thing or two…
  • Catching up with an old GP registrar / RLO buddy from Northern NSW. It’s always great to re-connect with like-minded friends who I’ve met along the way.
  • Meeting a fellow tweeter and blogger in the flesh for the first time – proving yet again that online connections really can and do translate into real life.
  • Eating an epic amount of cheap and delicious Queensland mango. So good.
The tech-wizard grandparents

The tech-wizard grandparents

So, to anyone considering undertaking further ultrasound training, I can indeed confirm that your “awesomeness will exponentially increase.” Also, the Gold Coast is highly recommended for a visit, even if your mum doesn’t live there. Why not come to smaccGOLD and kill two birds with one stone?

A few links:

Let me know of any glaring omissions from the list!

5 thoughts on “256 Shades of Grey: Learning the Art of Ultrasound

  1. Nice one Penny, will add AIU to the list of available courses for rural docs on ruraldoctors.net – been over 5 yrs since I went through a five dau AIU expereince, but it was worth it

    I am glad that your Kiwi obs registrar colleague will be moving to rural Australia to help deliver specialist care. We have a theatre 24/7 staffed by GP-anaesthetists, so remind him/her that there is always a place for a FRANZCOG in Dingo Creek.

    I suspect he/she will soon be seduced by the tertiary centre Ivory Tower though!

    • Thanks for the question. In many areas of rural Australia there might be only one sonographer in the town who can’t be on call 24/7, or there might be a sonographer who visits every week or two, or there might be no formal ultrasound service at all. It would be ideal if a trained sonographer could be available at all times for emergencies but in smaller towns it’s just not possible. Rural doctors in these areas need to be jacks-of-all trades and in the case of obstetrics doctors, having some level of ultrasound training is important.

  2. Sonographer shortages don’t just affect rural Australia. I spent 5 years in radiology training in Perth providing out of hours on call ultrasound service because, unlike the East coast, most tertiary hospitals utilise radiology trainees as the on call sonographer.

    My question is how come in many rural areas of Australia there is only one doctor, who is inevitably “on call” 24/7. For diagnostic imaging however you’ve said, “That’s just not possible.” Why? Somehow when it comes to a diagnostic imaging service with expensive machinery presumably either your practice or country hospital has decided that it’s worth the expense to purchase an ultrasound machine and pay for a specialist trained to use it during occasional business hours, but then stop there.

    With respect to diagnostic ultrasound taking the images is only part of the process. Image interpretation (i.e. most of my day job because I also actually perform ultrasound and procedures as well) is something that can easily be done remotely and in an out of hours emergency situation I’d like to see all West Australians have access to specialist opinion.

    Most of my maternal family live in rural Western Australia. If they (especially the younger women) had an emergency ultrasound to exclude ectopic, or locate pregnancy, I would tell them to snap a photo with their iPhone and call me directly for an opinion if their on call GP was not comfortable performing the ultrasound and then interpreting the images. Otherwise I might get a call the next day that their ruptured ectopic was fatal.

    I don’t see why funding stops at paying a rural GP to have to cover everything when something as easily accessible as tele radiology from locally trained specialists from the same state could be provided 24 hours a day.

    I’m glad you trained with Kristy; I’ve trained with her too.

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