Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.
Dr. Arvind Srinath: From UPMC Children's Hospital of Pittsburgh, welcome to That's Pediatrics. I'm Arvind Srinath, associate professor of pediatrics, your co-host, along with.
Dr. Allison ‘Alli’ Williams: And I'm Alli Williams, a pediatric hospitalist here at UPMC Hospital.
Dr. Srinath: Today we have the opportunity to talk with Dr. Jennifer Marin. Dr. Marin is a professor of pediatrics in the divisions of emergency medicine and radiology at The University of Pittsburgh School of Medicine, and as well as UPMC Children's Hospital of Pittsburgh. She serves as the medical director for point of care ultrasound at our hospital and completed her pediatric residency at Ann and Robert Lurie Children's Hospital, followed by a pediatric emergency medicine fellowship at Children's Hospital of Philadelphia, where she also earned her Master of Science in clinical epidemiology. She spent an additional year learning point of care ultrasound in the department of emergency medicine at the Hospital of The University of Pennsylvania. She's one of the pioneers in pediatric point of care ultrasound and has published extensively in the field and lectures and teaches internationally. Welcome, Dr. Marin. Thank you for-
Dr. Jennifer Marin: Thank you, guys. Thank you for having me.
Dr. Williams: [inaudible 00:01:45] your face reddening with all of that. You should.
Dr. Marin: I know, such a fine introduction. Thank you, guys, so much. It's such an honor to be here. I'm a big fan of the show.
Dr. Williams: It's an honor to have you.
Dr. Srinath: So Dr. Marin, thanks again for joining us. Can you tell us about the path that you took to get interested in this really what I think we think is novel area?
Dr. Marin: Yeah. So when I was a fellow, we did not have point of care ultrasound in our emergency department. It was not something that we did in pediatrics. And my very first rotation as a fellow was at the adult trauma center, so I hadn't even stepped foot in the children's hospital. And I was on my trauma rotation, and our job as the pediatric fellows were to just do the primary, secondary survey. So I practiced this at home and thought I was getting really good at it. And so one day, I'm doing my primary, secondary survey, and one of the trauma attendings yells at me to quote, "Do the fast." And I didn't really understand what he was talking about. I thought he was asking me just to be more efficient, go a little bit faster in my survey.
And so I went a little bit faster, and he continued to say, "Jennifer, do the fast, do the fast." And suffice it to say, one of the trauma fellows sort of came in and rescued me and did this FAST exam, which of course we all know now is the focused assessment with sonography and trauma. And this is an exam that we do with bedside ultrasound for trauma patients looking for free fluid. And I went home that night and decided that I was no longer going to feel that shame and humiliation, which I don't know about for you guys, is a very potent motivator.
Dr. Williams: Yeah.
Dr. Marin: And I learned about the FAST exam and really from there, it grew and became an interest of mine to use this technology. So I came back to the Children's Hospital and realized no one was doing this. We didn't have a machine. And what could I do to get things moving? And how could I learn it? And that really is how I became interested in it.
Dr. Williams: So can you tell us a little bit more about what we use it for in pediatrics as well? Because I as a clinician have a hard time understanding what this is used for versus just ordering a regular ultrasound.
Dr. Marin: Yeah. So the answer is it depends on where you work, I think that's the first thing, and what resources you have available. We here at Children's Hospital have 24 hour around the clock radiology ultrasound. And our ultrasound techs and our ultrasound faculty are amazing. So we don't have the need for doing pyloric ultrasounds for example, which is something that maybe some of our community partners would learn to do at the bedside. Similarly, appendicitis, gallbladder pathology, things like that.
But in our emergency department, and I can speak to other divisions that are using the technology as well, in our emergency department, we find that it is really useful for evaluating soft tissue infections, whether there's an abcess or a cellulitis. We do it pretty routinely for patients what or limping or have hip pain to know if there's an effusion as the cause of their pain. We do it a lot for procedural guidance, ultrasound guided peripheral IVs, we place all the time with ultrasound guidance, obviously. We use it for cardiac function. We use it for paracardial effusion, for trauma patients, for plural effusion. So we do it for patients who are hypotensive or who have unexplained tachycardia and we want to know the reasons for why they're in shock. And I think if we were to sum it up, it would be for a patient where you really need the information pretty quickly. You can incorporate it into your clinical examination. And it's also a really nice tool because we can repeat it.
So if we do an intervention, say we have a child who does have undifferentiated tachycardia and they get fluids and they get better or don't get better, we can repeat our exam. We can look again at the IVC and the heart and we can see what's changed now, and we can compare it.
Dr. Williams: Interesting.
Dr. Marin: And that's just what we're doing in the emergency department. I can tell you that our global hospital wide program has 15 divisions in it, which is really amazing if you think about it. You'd be really surprised to learn all the different divisions that are using point of care ultrasound. So just to name a few, our anesthesiologists, both of our ICUs, excuse me, all three of our ICUs, the PICU, CI, and NICU, our general surgeons, our nephrologists. Ophthalmology uses it all the time.
Dr. Williams: What?
Dr. Marin: I know. There's more, rheumatology, nephrology, urology, they are probably our biggest users believe it or not, adolescent gynecology, and neurology.
Dr. Williams: Wow.
Dr. Marin: Yeah.
Dr. Williams: All of these are using just the bedside kind of point of care-
Dr. Marin: Correct.
Dr. Williams: That you've developed, my goodness.
Dr. Marin: That's correct. And PMNR, I forgot PMNR, yeah.
Dr. Williams: Wow.
Dr. Srinath: So without ... And I swear I'm not being a salesman for this, but at the same time it sounds like I might be, but I'm doing it for everybody's benefit. But without this type of mechanism, what do you think care would be like?
Dr. Marin: It's interesting because for so many decades, we weren't using it. Right?
Dr. Williams: Right.
Dr. Marin: And as with many things, pediatrics is sort of the last to get on board. Right? And there's good reasons for that. But emergency medicine has been using this for decades and decades, since the 80s pretty consistently. So arguably, our care would be perhaps not as efficient. There's studies that really have shown that length of stay improves when this is used, that accuracy of diagnoses is improved, that patient satisfaction is improved. I will tell you that in addition to the evidence, anecdotally, our patients really appreciate it when we can do the exam at the bedside and show them the images, explain it to them, and make a diagnosis quicker and potentially more accurately.
Dr. Srinath: That's really interesting because what I think about is the technique and what expertise one needs to do this. And I'm looking at your credentials again, and you are under two divisions here and one of them is radiology. So what type of training was involved for you to become an expert in this? And what does that entail for your colleagues to be able to do this too?
Dr. Marin: Yeah. So the training that I did was coming from a place where I wasn't getting any training as part of my residency, as part of my fellowship, and I'll also say as part of my medical school education. And we can talk about that because that's a really big area of growth. But the training that I did was in that context of being completely a complete novice. And I also was training to be a director to start a program, and so that training is above and beyond just learning how to do it and how to interpret the studies. And I think that we have gotten really good here and at many other Children's Hospitals at creating a program that effectively trains our fellows over the course of their three years to be very comfortable and very competent in their ability to go out and perform these exams unsupervised, and just like they do with any other skill that we teach them in terms of intubation and all kinds of procedures.
Dr. Srinath: That's amazing you've integrated that into your fellowship here, which is quite fantastic.
Dr. Williams: I know. I was thinking that too just because your fellows are so lucky, your emergency medicine fellows are lucky to have that. And you mentioned all of these other divisions that have this as well. What type of training are they getting through your work as the medical director of this program?
Dr. Marin: So interestingly, it was such a timely question, Allie, because we are currently working on a series of about 35 educational modules that are going to be posted online that all the divisions are putting together. Each are relevant to the applications that they perform, and our hope is that this will standardize the training process, not just within a division when you have people who are learning to use that application, but also across divisions when you've got for example, vascular access is probably the most common one. There's six different divisions that place ultrasound guided either central lines of peripheral lines, so we want to make sure that everyone is learning it in the same manner and doing the same kind of exam.
So it's interesting, I think that a lot of the surgical subspecialties have been incorporating ultrasound into their residency training for a really long time. And so a lot of the faculty that start, it's just part of what they do. It's not a novel tool. It's just a very different way to think about it.
Dr. Williams: This is probably a very silly question. Is it the same ultrasound machine as if I were to order one and an ultrasonographer were to do it? Or is it a different actual technological machine that you have to use for it?
Dr. Srinath: Thank you, Allie.
Dr. Williams: I mean, I'm just thinking at community hospitals, they might not, like you said, they don't have 24/7 ultrasonographers. We're very lucky here. And I'm just wondering what kind of not only expertise you need, but equipment you need to achieve this.
Dr. Marin: Yeah. So the short answer is it really doesn't matter. The machines are comparable in that they have the same basic functions and we could certainly do our exams on their machines and they could almost certainly do their exams on our machines. That said, point of care ultrasound machines typically are more portable and smaller, lighter, a little less expensive.
Dr. Williams: That makes sense.
Dr. Marin: And have not the variety of transducers or probes that maybe the radiology suite would have because we're doing very specific applications on very specific patients. So we have three to four transducers on our machines and the radiologists may have more than that. Our ophthalmology colleagues have one transducer because that's really all they do. They're looking at eyeballs.
Dr. Williams: Very small area.
Dr. Marin: Very small area. You'd be surprised how much information they can get from that little eyeball.
Dr. Williams: That's amazing.
Dr. Marin: It's impressive.
Dr. Srinath: Which makes you wonder, and I'm sorry, I'm thinking medical shows here because of what you do. I can imagine part of your training was on the field, at the quote, unquote, field. Right? But can you use this technology on the field? And for the audience members, what I'm getting at, which is probably wrong, but I'm just going to say it, is you are in an emergency and it's not in the hospital, but you're elsewhere. And you're trying to figure out how best to approach a patient and help someone. Can this technology be used that way?
Dr. Marin: Yeah. It's such a good question, Arvind, because one of the areas within the community of point of care ultrasound is field use and using this in underdeveloped countries, using this in times of war, using this in areas where there is not an X-ray machine or a CAT scanner for miles. And in the department of emergency medicine, I'm told that their pre-hospital folks are actually using it now more, and so they will carry this with them and they'll go to codes and have this very tiny, very portable ultrasound machine available to use that in a patient's home.
Dr. Srinath: Wow.
Dr. Williams: Wow.
Dr. Marin: Which is really interesting.
Dr. Srinath: Wow.
Dr. Williams: That's wild. I was also thinking too, you have said a couple times, "Well, that depends because this is new technology, and this is very much so evolving quickly," and you're doing a great job here training. Is there a national push to have this done as well? Or how do you centralize this across state lines, across county lines? What are we doing to utilize this in all kinds of places?
Dr. Marin: Yeah. Well, I will say that the American Board of Pediatrics has started to include point of care ultrasound training in certain specialties.
Dr. Williams: That's awesome.
Dr. Marin: So for pediatric emergency medicine, we have it on our sub boards. There's a few other specialties that have it listed. At what point will it be part of the pediatrics residency requirements for board training? I imagine it will happen. I think it's only a matter of time. It's absolutely part of the training for emergency medicine residents, the surgical residents. I think that it's becoming standard of care and it's only a matter of time. I can remember a time when I trained where when we placed central lines, you placed them blind.
Dr. Williams: Right.
Dr. Srinath: Right.
Dr. Marin: It's a terrible term the use, but you'd use landmarks. Right?
Dr. Williams: Palpating, yes.
Dr. Marin: Right. There's no blindfold, but you're using landmarks. And now that would actually be considered inappropriate to do. That would be considered substandard care. And now that's all we do, we use bedside ultrasound to place those central lines. And I think that with a lot of the applications that we are using it for, it's going to ultimately become standard of care. And so if you're not using it for certain conditions, if you're not using it for certain procedures, then you're going to be providing suboptimal care.
Dr. Srinath: So I'm going to bring up something, speaking of suboptimal care, it's going to be controversial. When I was training back in the day, there was always this talk of utilizing your physical exam, utilizing your clinical gestalt for what we're doing and how we have the luxury of being in a quaternary care hospital and have the technology to be able to do thing, and how much is being taken away from the physical examination and utilizing what we're doing. So what I'm getting at in my really roundabout loquacious way is: What resistance have you met to this technology and dissemination? And have you had to advocate and/or reeducate, or bring up utility against some of that mentality that I'm getting at?
Dr. Marin: Yes. Next question. I'm kidding. So absolutely, I think what I can say is fortunately here at UMPC Children's Hospital of Pittsburgh, things have been great. Everyone has been very supportive. That is not the case for many of my colleagues around the country. And there is resistance. And I think that a lot of the resistance does come from just a lack of understanding of what it is. At the end of the day, everyone's goals are the same to provide the best patient care and to do what's best for the patient.
I will say that I have found that in certain cases, just educating people about what it is that we're doing and what it is that we're not doing does tend to overcome some of that resistance. But there does still remain some, and it's part of the reason why not every single hospital has a program like ours, why every single pediatric emergency medicine fellowship doesn't have a program like this. The majority of it has to do with the support that you get from the people who are in charge.
Dr. Williams: I imagine too, it's also important because you mentioned that not everywhere has the same resources. Right? So while you have the opportunity to train to utilize this, depending on where you get a job, you may or may not use this in your career. I mean, we hope, I would assume you hope as the medical director of this program that eventually everywhere gets these tiny little machines that we can do all of this great work with. But for now, it's not like that right now.
Dr. Marin: Right. No, that's absolutely right.
Dr. Williams: So we've talked about the past and the present of this program. Where do you see the future of this program going? What's your next steps?
Dr. Marin: Yeah, that's an interesting question, Allie. So I would say the next goals for our program would be to have the pediatric hospital medicine team on board.
Dr. Williams: I was thinking it.
Dr. Marin: As well as the pediatric gastroenterology team.
Dr. Srinath: Love it. I love it.
Dr. Marin: On board.
Dr. Srinath: Firm yes.
Dr. Williams: Going to have to talk to those fellowship directors about this.
Dr. Marin: Yeah.
Dr. Williams: I'm sure they would be on board.
Dr. Marin: And your division chiefs.
Dr. Williams: We have lots of fellows that would love to learn this.
Dr. Marin: Yes. Yes. And your division chiefs, tell your friends. Yeah. I mean, I think that the technology is coming down the pike. These medical students are graduating with a ton of experience and a ton of knowledge in point of care ultrasound. And the expectation on their part is that they're going to train and practice in an environment where that is used, where it's standard of care. So I think that it behooves us on many levels to use it where it's applicable, to use it where it can help us, where we can benefit patients.
Dr. Williams: For all of our listeners out there that have enjoyed this as much as I have listening to this, is there anywhere online that they can look at your program, or find more information about it, or contact information to get in touch with you? We always like to talk about any sort of social media handles or websites that they can look at so that they can get more information.
Dr. Marin: Yes, Allie. In fact, there is. We have a website. Our program has a website. Anyone who's interested in more information on the program can go to chp.edu/our-services/pocus, P-O-C-U-S. And on that website, just tells you a little bit about what we do, all the different divisions. You can see all of the different POCUS leads, those are the leaders in each of the divisions who are in charge of point of care ultrasound and serve on the team.
Dr. Williams: Thank you again so much for coming today. We were so excited to learn about this. And we'll have to have you back to learn more about the growth of this program.
Dr. Marin: That will be great. You guys can report back to me on your divisional progress.
Dr. Williams: That sounds excellent. Sounds great. And thank you all for listening to That's Pediatrics.
Dr. Marin: Thank you, guys.
Voiceover: You can find other episodes of That's Pediatrics on Apple Podcasts, Google Podcasts, Spotify, and YouTube. For more information about this podcast or our guests, please visit chp.edu/ThatsPediatrics. If you've enjoyed this episode, please be sure to rate, review and subscribe to keep up with our new content. You can also email us at podcast.upmc@gmail.com with any feedback or ideas for topics you'd like our experts to cover on future episodes. Thank you again for listening to, That's Pediatrics. Tune in next time.
Jennifer Marin, MD, MSc
