Incredible India

What an experience! was kindly invited by the Indian Academy of Echocardiography to hold a joint session on basic echocardiography at the annual meeting of the Society in Bangalore. We know that we have many friends in India, but the response and praise we received were simply overwhelming. Talking to many of our users, we sensed an incredible enthusiasm and willingness on the part of doctors and sonographers in India to master the technique of echo.




123sonography “Hands on session” at the EchoIndia2013 meeting
Unfortunately, there was just not enough time to answer all the questions during our symposium - especially questions that dealt with improving imaging skills. To make up for this shortcoming, I will give a few powerful imaging tips in this post. I trust this information will also be of value to the rest of our community.

Here is the first part of the 123 golden rules for improving your imaging skills.

Rule 1: Document your study
Digital documentation is very important because it allows you to compare your findings with previous studies.
Here is an example that shows a super-responder to cardiac resynchronization therapy (CRT). After implantation of the CRT device one clearly sees the improvement in LVF and how mitral regurgitation diminishes:


Patient with dilated CMP, mitral regurgitation and significant dyssynchrony.

Four-chamber view of the same patient after resynchronization therapy.
The left ventricle is smaller, function is improved, and mitral regurgitation has diminished.

Documentation also has an important side effect: It improves your imaging skills because you simply try harder when you know that others might see what you have done.
Rule 2: Position the patient
This is especially important for the parasternal window. Turn the patient to the far left. For the pulmonary valve the patient can be positioned even further to the left so that she/he is almost lying on his stomach.
Here is a video that demonstrates just this:

Note how the patient is positioned.

Rule 3: Stabilize your hand
Even small adjustments in the position of the transducer can make a big difference. You will need fine motor skills. My tip: rest your palm and forearm on the patient's chest, just the way you would rest your hand on paper when you write. The following demo will show this.

How to hold the transducer.

Rule 4: Be creative
Don’t restrict yourself to the standard views. Look at the heart from other perspectives as well. Experiment - it will help you to understand the true anatomy of the heart and allow you to detect pathologies you would otherwise miss. In essence the word “scan” means just that. You can scan the valve, the myocardium (for regional wall motion abnormalities), or a thrombus, as shown in the following example.

The thrombus was only visible on a rather atypical apical view, with the transducer positioned
far left and rotated somewhere between a four-chamber and a two-chamber view.  

Rule 5: Use patient's respiration to your advantage
Air is an enemy to ultrasound. But there are some situations in which it is to your advantage when the patient inhales. The downward motion of the diaphragm and the filling of the lungs also change the position of the heart within the chest. Such a change in position might bring the heart just into the field of view. This trick works quite often when you perform a two-chamber view. Let the patient inhale slowly until the view is perfect and then let the patient hold his breath just there. This demonstration will show you what I mean:


How you can improve image quality by letting the patient inhale.

Getting good images is not always easy, but if you are more skilled than others you will obtain more images, be quicker, and have more fun performing echo. It does not take very much. Sometimes you just need to know a little trick like the ones I showed you here. I will be glad to show you a few more in one of the next posts.
On a final note, I cannot end this post without mentioning how colorful, inspiring and beautiful India and its people are. Now I understand the true meaning of “incredible India”



The many colors and beauty of “incredible India”. If you want to see more images from the EchoIndia2013 meeting click here




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