Power of Ultrasound with Emergency Medicine Dr. Resa E. Lewiss

KKH Trailer Wide


Dr. Resa Lewiss: [00:00:00] Knock,

Will: knock,

hi! Knock, knock, hi!

Hello and welcome to Knock, Knock, Hi! with the Glockenfleckens. I am Dr. Glockenflecken, also known as Will Flannery. I am 

Kristin: Lady Glockenflecken, also known as Kristen Flannery. We’re 

Will: so excited to have you here today. Thank you for joining us. We have a wonderful guest, Dr. Risa Lewis, Professor of Emergency Medicine.

Yes. Ultrasound champion. 

Kristin: That’s right. She’s got like three Ivy league degrees. Yes. 

Will: Uh, and she’s also a physician healthcare designer. Uh, and, uh, she has helped redesign, uh, environments and, uh, around ICU and infectious disease units in Malawi. And she’s just done a lot of stuff. Yeah. And now an author. Now an author has got a new book, micro skills.

We’re going to [00:01:00] talk about that. She has a podcast. She does. She does it all. 

Kristin: She’s a Renaissance woman. 

Will: A lot of things that we talk, we try to get to all of them as many as possible. Um, and, and so just, it’s, and we just talk about ultrasound. 

Kristin: Yeah. And it’s got you a little riled up. You’re not, you’re, uh, you’re a little touchy, a little 

Will: touchy.

Kristin: No, it’s fine. For those who may not know, he has a longstanding internet vendetta against using ultrasound on the eyeball. It’s not so 

Will: much a vendetta as like, uh, what are you doing? Why are you doing it? We talk about We get into it. Yes. We don’t really, it’s not a big argument. It’s just kind of like, let’s talk about it for a bit.

But I really appreciate her perspective on things and how 

Kristin: to Yeah, I gotta go on, right? I think you’re wrong. I think you’re wrong about it. You’re being kind of a 

Will: jerk. All right. Well, let’s talk about something else for a second. Um, how about our live show? Yes, 

Kristin: we’re very excited! 

Will: It’s, it is, uh, right around the 

Kristin: corner here.

Right around the [00:02:00] corner. We’ll be at the Improv in, uh, Southern California. Three locations. That’s right. We’re not at 

Will: all nervous, no. Irvine, Ontario and Oxnard. Mm hmm. Um, I’ll be honest, I didn’t even know, I’ve never heard of Oxnard before. Yeah, same. I had heard of Ontario, but the Canadian version. Canada, right.

So I’m excited to get over there and see those venues, see the places. Yeah. Has it been surprising to you, like how much work it’s been to put together a live show 

Kristin: like this? No, I mean, I planned events professionally in the past. Okay. Different things. So I kind of know what goes into it all, but Uh, I mean, not into a live show at a comedy club.

That’s a new one. Yeah. Yeah. Just in general. Yeah. It’s a lot more work than you would think to make things like that happen. 

Will: It is. And, um, you know, mostly whenever I give talks and I know you do too, it’s, it’s, it’s mostly a keynote type stuff. And so it’s, you’re kind of, [00:03:00] as the speaker. You’re going to the organization and doing something for them, for their audience that’s more on their terms, uh, that has a tone already set for you 

Kristin: and you’re more academic and expectations are kind of set.

Everybody knows what 

Will: it is. That’s great. That’s the way it’s supposed to be. Um, but this is different because like now it’s, it’s really on our terms, right? We could do whatever we want. We can, and so we, we, you know, have, uh, turned this show, used our, our insane story. Yeah. 

Kristin: Mm. Yes. Insane is, is true. It’s like if you were writing this for a movie script.

You’d get sent back many times saying, this is too on the nose, like way too many things are happening. A little melodramatic here. A little dramatic. Right. 

Will: But it’s true. And this time around. And so, um, and so we’ve been doing some, we’ve got some really fun things planned with the [00:04:00] show. I’m gonna, uh, I’m gonna incorporate some, some characters in it.

Um, and it’s just a, it’s a story. Yeah, 

Kristin: it’s our story. So there’s, there’s a lot of comedy. You know, some tragedy and then just 

Will: a lot of major tragedy, but 

Kristin: hope and resilience because I survive. Yeah, I don’t think that’s a spoiler because here you are talking about alert. 

Will: I am not dead. Yeah, and I just can’t.

I can’t wait to. To do it, you know? Yes. Just wanna get there. Yes. And, and see the crowd. 

Kristin: You like an audience. I mean, as a comedian, you really need an audience. Oh, yeah. You know? Yeah. 

Will: I love an, I love an audience and, and I know it’s gonna be a, a great crowd and Yeah. I’m just, 

Dr. Resa Lewiss: yeah. Really excited. So we get to 

Kristin: meet some of 

Will: you.

Yes. I, I’m excited for the meet and greet and just it’s, it’s really. Just stepping back. It’s such a cool thing that like people are coming. Yeah, I know 

Kristin: this is another thing like you have other than the [00:05:00] fact here’s here’s my theory I think that so many terrible things have happened to you health wise because Otherwise, your life has been ridiculously charmed.

Like, you’ve never had any career setbacks. You’ve been very successful. You’ve gone to all the best places. You’ve, you know, done all these things. You’ve made a second career as this internet comedian. Like, who does that? Like, nobody can be that lucky. And so it’s the universe’s way, yes, of evening everything out.

So we’re going to tell all of that. At the live show and we’re excited if it goes well, then, you know, hopefully we’ll go on toward 

Will: 2024. So, fingers crossed. And thank you all for the support. You know, I’ve been thinking about that a lot just as this date for the live shows has come up. Um, how lucky we are to have that kind of support from all of you listening.

Everybody on social media, like we can’t do it without you guys, and [00:06:00] so, and so thank you. I can’t laugh at all 

Kristin: of his jokes all the time. Yes. So I thank you. Someone else has to. For being there to do that. She’s 

Will: heard them all. Alright. You guys still laugh at mad me. So my kids do too, by the way, they still think I’m funny.

So, all right. Well, should we get to it? Let’s do it. Let’s do it. All right. Here is Dr. Risa Lewis.

Today’s episode is brought to you by the Nuance Dragon Ambient Experience or DAX for short. This is AI powered ambient technology that helps physicians be more efficient. And reduced clinical documentation burden that we all know causes a ton of burnout, takes up so much time, makes you feel overwhelmed.

Well, DAX is here to help. To learn more about how DAX can help you reduce burnout and restore the joy of practicing medicine, stick around after the episode or visit nuance. com slash discover DAX that’s N U A N C E dot com slash discover. 

Kristin: Hey Will, do you know what my [00:07:00] favorite December holiday is?

Christmas? Nope. 

Will: Hanukkah? No. Our 

Dr. Resa Lewiss: anniversary? 

Kristin: No! It’s Wife and Death, live at the Improv! 

Will: Oh, that is a good holiday! Yeah, we’re telling our amazing story, live, in person, and we have a meet and greet before every show. You can get a photo with us. We’d love to meet you. December 9th, 10th, and 11th in Southern California.

Kristin: We’ll be at the Improv in Irvine. Ontario, 

Will: and Oxnard. You can buy tickets and check out dates at Glockenflecken. com slash live. We also have a special offer for our Patreon members, all the Glock flock out there. Free meet and greet with your normal ticket. Just tell us your username and you’re in. See you next month.

Well, thank you for joining us, Dr. Lewis. It’s uh, I feel like we’ve been trying to connect for quite a while now and we’re finally able to do it. Thank you for being here. 

Kristin: Thanks for having me. You’re a very busy person, which just speaks to all the incredible things you’re doing, which is one of my questions, which is how do you do all of [00:08:00] that?

Dr. Resa Lewiss: Gosh, uh, first of all, I want to thank you both so much for… Inviting me to join. I had, it’s true. I, I actually reached out during Covid to Will. Um, we were trying to do something for fun games wise, and I asked if you would be a judge and you’re like, well, can I have a little bit of time? You had just had your cardiac arrest and you were, you were 

Will: like, I had a little bit going 

Dr. Resa Lewiss: on.

We were like, do you mind if we touch base? Like, I don’t know if tonight, this is like the right time. And I was like, holy Moses. And then of course it all went on social. 

Will: Well, you know, it’s, it’s, it’s a great, uh, um, for a while there, it was a great thing to use to get out of stuff. So, you know, it’s, it’s, it’s one of those things, but, but yeah, you, you are incredibly busy, uh, briefly before we started recording, you’re just going over all the things that you’re doing.

Uh, and so I’d also like to know how you keep your head on straight. Hmm. 

Dr. Resa Lewiss: You know, I’m a big fan of, uh, deliberate practice, deliberate [00:09:00] rest. Um, you know, I mean, I chose emergency medicine, so I like doing many things and having a lot going on, but I think we fool ourselves into thinking that we’re really good at doing everything at all times.

And, you know, if you read the literature. or as they say sometimes, literature, the literature, uh, you know, we really can’t multitask. And so, although I think most emergency doctors think they can multitask, uh, you know, I’ve sort of succumbed to that thought process and I’ve slowed down and tried to do Each thing, piece by piece, one at a time, kind of like the Pomodoro, 25 minutes on, five minutes off, 25 minutes on, five minutes 

Will: off.

So it is a, it is a, an established thing that multitasking is not possible, right? 

Dr. Resa Lewiss: If we believe the literature, yeah. 

Will: I want, Kristen, I want you, cause you always lord that over me. You say like, you’re a great multitasker and I’m, I’m a terrible multitasker. Well, I 

Kristin: think if you did, I’m Well, hold on. Because I am curious about if you dig into what the literature [00:10:00] says about it.

Uh, because I, I very, very briefly, like, ten years ago, um, saw some of that in the attention realm, because I was in a psychology graduate program, um, and so it depends on exactly how you’re, you know, operationally defining things, if you really want to split hairs here. All right. Like, I think what’s really happening is task switching, right, juggling tasks.

So, I suppose when I, when I say you can’t multitask, what I mean is you can’t, I can’t 

Dr. Resa Lewiss: switch yes. 

Will: Which means what exactly? Well, 

Kristin: just being able to kind of have all of those things going all at the same time, all the plates spinning in the air and not letting any of them fall down. You prefer to just like stack all the plates on top of each other and spin them all at once.


Will: sounds very efficient. I think it sounds great. 

Kristin: Right. I don’t have that luxury, so I have to have, like, all the different things, you know, a little bit here, a little bit there, a little bit there. Like, I’ve got the [00:11:00] laundry going and then, um, I have some writing to do and, oh, the kids need picked up and, you know, just all the 

Will: things.

Well, speaking of spinning a bunch of plates in the air, though, emergency medicine, that’s like the definition of what, what that job is. Yeah. And I think it’s also important for our listeners to know that, uh, Dr. Lewis, you don’t. Um, you’re not exactly the, the, uh, uh, stereotypical emergency medicine that I play in my videos.

Dr. Resa Lewiss: Right. Um, I, you know, I definitely have watched your videos and your character analysis of different specialties, but whenever I saw emergency medicine, I was like, that’s not me. That’s not me. And so, but. I do think there are aspects that are credible, definitely there’s a Pacific Northwest injection. Uh, but yeah, I’m not walking around with my bike helmet, I don’t bike to work, some of those outdoor sports.

It is true though that when you speak with emergency physicians in general, like people have many things that they’re doing, you know, outside of their clinical [00:12:00] practice. 

Will: Right. 

Kristin: Yeah, so maybe you’re a different kind of adrenaline junkie. Is that what you think it is? Maybe more of an academic adrenaline junkie or a creative adrenaline junkie?

Will: Reading 

Dr. Resa Lewiss: peer reviewed studies. Well, I definitely was brainwashed academic. I definitely actually, yes. And by the way, you know, I so enjoy listening to the two of you and to your episodes and Kristen. You nail it. Like, you nail medicine, you nail medicalese, you speak medicalese, you have had to translate medicalese, you know.

But, um, you’re right. I think probably I’ve been more of an adrenaline junkie via academics than maybe the sports. 

Kristin: Mm hmm. I can recognize that in you because that’s how I am too. I’m more of an intellectual adrenaline junkie. I’m not so interested in hiking and biking and whatnot, but get me into something I’m really interested in reading or writing or thinking about and it’s hard 


Will: pull away.

Maybe I’ll have to have a spinoff character. Ooh! Another… [00:13:00] Rival, not rival, but colleague of emergency medicine, my emergency medicine physician that’s, um, Perhaps female. Obsessed with, uh, with, you know, uh, journal 

Dr. Resa Lewiss: clubs. I don’t know. I think it’s like this obsession with productivity and, um, you know, circling back to what you were saying about the, you know, the plates, I see it as, you know, patients get triaged as emergent, urgent, or non urgent.

And then when I go to a restaurant where there’s an open kitchen. I watch them and cooks are just like emergency docs, like which plates are up next, like what’s boiling, what’s not boiling, what can simmer slowly on the stove, sort of. Cooks are like emergency doctors. Yeah, 

Kristin: I can see that. That’s a really good analogy.

Will: Another aspect of, of your career that I find fascinating is, um, the ultrasound, the, so you’ve done, um, uh, you laugh because, because I think you know where I’m going with this. Um, so you, you’ve given a, a Ted Med talk about point of [00:14:00] care ultrasound. It’s a, uh, a, um, , a frequent topic of my comedy. Uh, so let’s just, let’s just get this out of the way now.

How are we feeling about eyeball ultrasound these days? 

Dr. Resa Lewiss: Uh, I had a feeling we would go there, and I’m so glad to have arrived with the two of you. I feel psychologically safe, so it’s good. Okay, good, good. Um, you know, truth be told, when I finished my emergency medicine training, I learned no ultrasound.

There were no ultrasounds in the emergency department. That’s, speaks to when I graduated. I finished residency in 2001. However, there were three very important people who are still important to me. who had used ultrasound and it was generally in limited resource environments. One did a lot of global health in Africa, one trained in a county hospital in LA, and another had done disaster medicine in Kosovo.

And so they used this thing called ultrasound and they just seemed to be really clinically good. And, you know, that’s, at the end of the day, emergency [00:15:00] medicine is a clinical specialty and you want to be good. And so the opportunity came up to do a fellowship and one of those mentors said to me, Risa Lewis, ultrasound has never gone anywhere and it’s not going to go anywhere.

Why are you going to go do a fellowship in ultrasound? And it’s the only time I have not listened to this mentor’s friend’s advice. And years later, he said to me. Risa Lewis, I was wrong. Because within emergency medicine, as you probably know Will, because the emergency doctors call you, they’re like, the ultrasound is negative.

You’re like, I don’t care. I don’t know. So it became really hot. And you know, people started finding all these applications. You could say, you could argue that people were looking for applications, looking for a case report to do some sort of study using ultrasound. You know, it is required for emergency resident doctors to learn it.

And um, we usually are able to integrate it into our care so that when we do speak with our ophthalmologists, you know, there’s a [00:16:00] little more information we can provide. And also, you know, most people that are reasonable know that there are limitations. Like, I don’t think there’s an expectation you’re going to go to the OR based on my ultrasound.

Maybe if I can share these images or if it’s an open globe and therefore you shouldn’t be. Putting an ultrasound probe on that globe, you know, that’s 

Will: different. Yeah. Yeah. No, I I’ve um, you know over the years gotten in my fair share of arguments with with the ultrasound aficionados and I I’ve kind of come around on I mean

I’m trying to be I’m trying to be very diplomatic here It’s in general. It doesn’t really bother us too much with the traumatic eye injuries. That’s, that’s when it gets kind of like, yeah, why, why are you really doing this? But for other things like flashes and floaters, where you’re looking for a retinal tear or a retinal detachment, I got to get it like this.

There’s no harm in doing that. Um, my [00:17:00] point that I always make, which really makes some people angry for some reason is just that. It doesn’t matter to ophthalmologists. That’s, that’s the thing, like it, 

Kristin: it could be your word choice. I don’t know. Just a 

Will: thought. It could be. Now, maybe you could say, maybe I occasionally will say things in a somewhat inflammatory manner, um, for comedic effect, but, uh, uh, in general, it, it doesn’t, that application in a typical resource setting, I should say.

Doesn’t really move the needle for us one way or the other and people make good arguments about it. People in emergency medicine about low resource environments, which is what you mentioned. And if, if it’s a matter of like, you don’t have a readily available ophthalmologist and you have to decide, okay, I have, I get like one helicopter trip per month to send to the academic medical center for something and you have to decide, okay, is this worth it or not?[00:18:00] 

Uh, yeah. I totally get it, you know? Yeah, 

Kristin: cause like, I mean, to be frank, I don’t, I don’t know that, um, emergency medicine clinicians I don’t really care if it does anything for you, the ophthalmologist, right? Like if it helps them do their job better in some way and it does no harm to the patient, who cares if the ophthalmologist 

Will: needs it?

That’s why I’ve softened a little bit. 

Dr. Resa Lewiss: Yeah. Yeah. But I think also, I think people definitely lose sight that this is a data point, right? It’s a data point that you mix it in with your history, your physical examination, the patient in front of you. and the discussion. I think the people are like, everything’s normal, everything needs to be acted upon based upon these results.

They’ve lost, they’ve lost the tree in the forest, the forest and the trees. You 

Will: know, this would all be kind of a moot point with eyeballs if it was just easier to look back there. I mean, why does the, why is the eye make it so hard? To see back there. That’s, that’s, that’s, that’s all another thing. That’s kind of ironic.

Kristin: There’s a metaphor in there somewhere. [00:19:00] I’ll find it someday. 

Will: But, uh, but this, your experience with ultrasound, that’s, it sounds like that’s really set you on this path in your career, in your academic career in particular. Can you speak a little bit about that? 

Dr. Resa Lewiss: Yeah. Thanks for asking about that. I, I, you know, again, I had these three people and they really, I just had so much respect and so much love for them.

And They just seemed to be on to something and that ability to be better clinicians, to take better care of patients, of course, was very attractive. And so I did this fellowship and literally within emergency medicine training, all of a sudden it became required for residents. Medical schools started being interested in teaching their medical students, fellowships exploded.

Um, and a lot of faculty were stuck feeling very uncomfortable because they never learned it but had this pressure to learn it. But let’s be clear, and you two nail this in terms of healthcare, it’s all about dollars. You know, leadership in hospitals, emergency department leaders became [00:20:00] very enticed because it meant getting paid for a procedure.

It’s a billable procedure. Um, that was never my… impetus or my drive and also I think that is one of the reasons why it caught fire so to speak is it was it’s a billable procedure and you know all the codes have been amended to do a focused ultrasound versus a complete ultrasound etc and Yeah, I think within emergency medicine, um, I always say 80 percent of people identify as educators, 20 percent as researchers.

I never identified as a researcher, although I’ve published research, but I, I’m not NIH, I’m not sitting in the lab. And it was a fantastic means to educate residents and again, all those levels of trainee as well as nurses and, you know, ultrasound guided IVs. Like there’s been so many applications that really have made us able to provide safer care with fewer negative outcomes and deaths like with central line placement as an example.

Will: [00:21:00] And so it’s, it’s amazing actually that It’s kind of striking that when you talked about when you first started training, there were no, no ultrasound machines in the emergency. And that was really not that long ago. Right. And, and now what is the, I guess, give me a sense for what the workflow is like in a typical emergency department in incorporating ultrasound, like what.

Is that, is that just, is that like the go to thing for, for most, I guess, internal medicine type concerns? It 

Dr. Resa Lewiss: depends on with whom you speak. And I said it like that so I don’t end my sentence in a preposition. With whom you speak. Very good. We’re all about… Well, looking at your background, I mean, I want to make sure that, you know…

We’re all about grammar here. Proper English here. I mean, it’s very important. So, no, it’s, it all depends on with whom you speak and also, you know, it depends on also the practice environment. If you’re… with a group of faculty that never learned it, then there’s a lot of hesitancy and you don’t see the machine pulled to the [00:22:00] bedside or actually just brought to the bedside because as you both know, you can plug it into an iPhone or the equivalent of an iPad or an Android equivalent.

So there’s the portability piece and, you know, in our lifetime, These machines, I used to push around this, I don’t know how many pound GE that literally I have to put my whole body behind and move around to move to the patient’s bedside. There was no room. And then it became laptop size and now it’s, you know, pocket sized.

So there are some of us that, um, wouldn’t practice, would never take a job in a department that doesn’t have the ability to perform ultrasound. And there are some people that, are just so resistant to changing, well, this is the way we’ve already practiced, that they don’t practice. But without question, central line placement, peripheral IV placement in patients where it’s hard to get an IV, people in cardiac arrest, like, you know, so much of what we did was like, I feel a pulse, I don’t feel a pulse.

And then, you know, if someone’s in fine V fib or, you know, fast A fib, you may not feel a pulse. And so the ability to see that [00:23:00] heart is just game changing. Uh, and again, using it as a data point. So anybody, first of all, every resident who graduates from an emergency medicine residency must be credentialed, must have completed a set of ultrasound competency examinations.

So that’s in this country. And uh, anybody who has trained within the last decade, I think would not take a job if ultrasound wasn’t present in the department. 

Kristin: So for the non medical among us, can we, can you break it down? I mean, you’re a healthcare designer, so I’m sure you think in terms of problems and solutions.

Yeah. Why is ultrasound such a big deal? Why do people get so passionate about these arguments on Twitter? You know, how is this a whole… I mean, it’s been, you know, through most of your career that you’ve been doing, you know, ultrasound in some way or another, focusing on, on ultrasound. So, for the people who are not in medicine, why is this such a big deal?

What problem is 

Dr. Resa Lewiss: it solving? Yeah. Great question. [00:24:00] Great design question. Approaching with curiosity, as we are. And by the way, the two of you could be health designers. With the way, like, Kristen, if I could just bring up the example of when, um, you were in the hospital with Will and you were trying to make a phone call, but you couldn’t because you were in radiology and you couldn’t get a lot 

Kristin: of healthcare design things to say about that experience.

Yep, I sure do. 

Dr. Resa Lewiss: You have a lot of, like, you know, and that’s, I think, and as you both know, I tie my experience with ultrasound To design like the reason I have a sense of how to Think about whether it’s a device or workflow, fill in the blank, it’s because of seeing these changes in ultrasound. So quite simply, ultrasound just gives you that data point, like I said, but you can see things that otherwise you were just looking for indirect methods.

So if you’re trying to see if someone has a pulse, you would feel, whereas if you have ultrasound, you could actually see the heart beating. So it’s a, it’s a visualization and it’s very compelling when you have that aha moment. Take a woman who’s pregnant, first trimester. and is bleeding. [00:25:00] And the question is, is she bleeding because it’s normal bleeding?

Is she bleeding because she’s having a miscarriage? Or is she bleeding because that pregnancy is in her tube and not in the uterus? Ultrasound lets us look to see, just a very focused question, yes, no, is the pregnancy in the uterus? Now, if there are fertility meds that kind of adds a bit of, uh, yeah.

addition to what we must consider, but like there are just, it’s the simplicity and the direct way to be able to answer focus questions. Um, and to make better decisions because not everything is an emergency. Not everything needs to be done. Right away, not everybody goes, needs to go to the operating room, but it helps you say does this, can this patient go home and go back to the doctor tomorrow?

Does this patient need to go to the operating room right away? Do I need to call the specialist? Or you know what? We’re all reassured. You know, it just, it just provides this data and this reassurance. Um, but quite simply, there are images that allow you to see things that before you were not [00:26:00] seeing directly.

Right, so it’s just a 

Kristin: way to get a clearer picture, literally and figuratively, of what’s going on with that patient, and is it relatively cheap compared to other kinds of technology or where does it fall for there? Is that another reason it’s used so much? Like why ultrasound over other 

Dr. Resa Lewiss: types of imaging?

Back in the day, ultrasound machines ranged in, 50, 000 to 100, 000. Nowadays, if you get one of these more handheld, portable, it goes down to less than 20, 000, some in the 5, 000 range, and again, all different companies, all different uses, but it is, it’s much more affordable. And as it’s gotten smaller, more affordable, pluggable into your phone, you know, people talk about getting their own home devices.

And in fact, we’re seeing it. This is, you know, in our lifetime, we’ve seen these machines being only in the department of radiology part, literally because they’re so big and heavy, to now being sent to patients at [00:27:00] home to do home monitoring of fluid in the lungs. You’re asking, Will, about internal medicine.

So congestive heart failure, they have patients doing their own home monitoring and looking at their lungs. There are case reports from COVID where COVID patients were noting their progression. of their lung findings using ultrasound. And we recently did a study, um, to see if people with no familiarity with ultrasound, no familiarity with teleguidance, could you or will teleguide, if you were trained, you could teleguide someone with no experience where to put the probe, how to position it.

Oh, look, I can get the picture on the screen and therefore answer some questions. I think it’s just a matter of time before. We see ultrasound at kiosks, in an airport, or in a drugstore, uh, or, you know, patients are sent one from their doctor’s office just like you’re sent other, like, home tests, um, and they don’t need to do it, but they’ll be guided, teleguidance wise, to do it.

Kristin: Interesting. And I wonder how AI will interact [00:28:00] with that. You know, I could envision a future where you can do your own ultrasound at home and AI can interpret results for you and, and with your doctor there to provide that human check. Um, I don’t know. Do you think that’s where it’s 

Dr. Resa Lewiss: headed? Well, so this is why you speak medical and you know, medical, because yes, some of these companies have AI integrated.

So one application is to evaluate the heart and it’ll It’ll stay red until you manipulate the probe enough on your chest, up, down, right, left, rotate, clockwise, counter clockwise. And when you hit it, it’ll go green. Like the outline of the heart will go green on the screen, which means stay right there.

And now that, that, uh, ultrasound machine can automatically calculate, for example, what percent of blood is being pumped out to the body. And is it a, you know, a normal percent that we call it the ejection fraction, or is it a decreased? And so AI is already, you know, integrated with some of these companies machines.

I mean, that’s 

Will: impressive, but can it, but can it measure the amount of aqueous humor production? I mean… That [00:29:00] remains to be seen. I 

Kristin: don’t know. You won’t let them find out, because you won’t let them ultrasound the 

Will: eyeball. I’ll be impressed if that ever happens. You’re, you just, it’s, it’s such an… Awesome technology.

In fact, the way you talk about it, I always joke that, um, uh, that after residency, emergency medicine graduates, they, they’re like required to do an ultrasound fellowship now. Um, but you’re actually maybe convincing people now, like, yes, maybe they should. Maybe that should be universal. Not just a joke.

Cause it’s such a, it’s, it’s so valuable now. And, and so many different. areas and I think it’s fascinating what you’re able to do with it. 

Dr. Resa Lewiss: If I can just add, no longer, fellowships are not required, but residencies are required. So actually, I think a lot of people are opting out of fellowship these days because they can get what they need during their residency training.

But I think the way we’ve seen it spread is emergency doctors learn ultrasound now, Pediatric emergency medicine [00:30:00] doctors are learning ultrasound, critical care doctors, so it’s spreading into other specialties, hospitalist medicine, like it’s sort of these, you know, it’s just so compelling the safety that you feel you can provide that everybody wants to learn it.

Will: That’s cool. Well, let’s take a short break. We’ll be right back. Dr. Lewis.

Hey, Kristen. Yeah. Do I look like a cardiologist when I hold 

Kristin: this? You look like you’re trying to be a cardiologist. 

Will: Because I’m an 

Kristin: ophthalmologist. Well, and just, like, what are you even doing with your 

Will: hands there? I do, I feel like a cardiologist. Yeah. And that’s the most important thing because of the stethoscope.

Yeah. This is so cool. It is the tool of the 

Kristin: trade. 

Will: It’s an Echo Core 500 digital stethoscope with 3 lead ECG. It even makes an ophthalmologist feel like a cardiologist. That’s saying something. Right? And it’s got 40 times noise amplification, noise cancellation, 3 audio filter modes, and a… full color display.

Yeah, it’s bananas. It’s, it’s, it’s, and what stethoscope has all of that? 

Kristin: I know, we live in the future. 

Will: No, just the Echo [00:31:00] Core 500. That’s right. That’s it. Uh, and you can also record, review, save, share. Yeah. All the things you’re listening to. That’s right. As, uh, it’s great for teaching. It’s great for, for just learning yourself.

And also we have a special offer for our U. S. listeners. Visit echohealth. org. dot com slash KKH and use code NOC50 to experience ECHO’s Core500 digital stethoscope technology. That’s EKOHealth slash KKH and use NOC50 to get a 75 day risk free trial and a free case and free shipping with this exclusive offer.

All right, we are back with Dr. Risa Lewis and, uh, we, I want to talk now about, uh, your new book. Uh, but actually first, just, it’s, the book’s called Micro Skills, Small Actions, Big Impact. What are micro skills? Can you, like, first tell us that? What are micro skills? 

Dr. Resa Lewiss: So, because you [00:32:00] two both speak medical, you’ll understand it.

It kind of comes from the fact, my co author, Adaira Landry, who’s also an emergency medicine physician, she practices in Boston. We started talking about how to be better at work and that there are ways to be better at work, but no one sort of told us how, like we felt like if we were to make a sports reference, there’s a playbook and we wish someone had given us this playbook.

And If someone says, you need to be a polished speaker, you’re like, great. And then you’re like, I have no idea how to do that. So we thought about breaking things down into small, digestible steps that build upon each other. And so medically speaking, when you’re taught to suture to, to stitch someone up, if they have a cut, you know, first there’s all these steps.

You’re supposed to confirm their name and their date of birth. You’re supposed to, you know, wash your hands. You’re supposed to, you know, clean the wound, anesthetize the wound. Irrigate the wound. Then suture. Like there’s all these steps. And so, small, digestible steps that then build upon each other and then they become rote routine and then you can actually apply those step by step when you’re…[00:33:00] 

I don’t know, basting your turkey for Thanksgiving, something like that. Like you’re like, Oh, I can apply these. So they’re just, um, eventually they are small steps that lead to the ability to accomplish greater goals. And then they spread out because you’re like, Oh, I know how to stitch. So now I can do fill in the blank or no, now I know how to speak.

So I know how to speak in front of a large audience, but now I can have a one on one conversation with, you know, um, A colleague at work. You know, just how they can translate. These skills can translate. 

Kristin: That’s interesting. It reminds me of some work I had done in the past, but not in the medical field for um, high school students who were learning how to do university level research, uh, through a summer residency program.

Um, and I was involved in, in teaching them like a lab class essentially, you know, at night about how to be successful in a research lab and, and that was one of the, the things that we developed was kind of this curriculum around, we called it Invisible Systems, right? And it’s what you’re talking about.

All these things that you’re [00:34:00] supposed to know, but, and you know, are expected of you, but no one ever actually sits down and explains it, you know, and breaks it down for you in an, in an explicit 

Dr. Resa Lewiss: way. 100%. Okay. Thank you. 

Kristin: Yeah, so that’s very cool. I love this idea for a book. And I think it, who do you think it would be?

Is it just for people in the medical field or is it relevant for 

Dr. Resa Lewiss: everybody? So we intentionally wrote a book that is not just for women and not just for health care. That it’s really the category that the publishers tell us is business self help. So it’s literally like Every industry and we did a lot of beta testing beta readers who said, oh this would have helped me So we really think it’s gonna land well with early career professionals.

And when I say professional, we’re not I’m not saying like lawyers doctors business people I’m just saying someone who’s entering the workforce early career but we’ve had people who are firmly mid career even late career who are like, wow, I just learned some things or commonly we hear Uh, I wish I [00:35:00] had read this sooner or I wish I had read this when I first started out.

So we’re saying like 18 to maybe 40, but certainly even older is going to, uh, they’ll get something. And if anything, Adair and I have, uh, injected, I’d said that word on purpose, but no, that we put in like little vignettes that are from our own experience, mostly in emergency medicine and medicine, but not solely, but, uh, to kind of, you know, uh, you, You probably have this when you go to a dinner party.

Everybody likes doctor 

Will: stories. Yes, and I’m sure you have plenty. So, I mean, you, so you did the Ted Med thing, by the way, um, which, which probably taught you a lot about storytelling and what goes into creating a story. 

Dr. Resa Lewiss: Yeah, I think, you know, I, as I said, I was brainwashed academic, I definitely did the bullet points, like quote the literature, and just like there was not a lot of Risa in there.

And sometimes Risa speaks about Risa in third person. And then, you know, when, [00:36:00] when I was asked, um, to participate in TEDmed, I mean, they really, they gave you a storyteller, they gave you all these They gave you a team to help you and it was very much about telling stories and it was not completely comfortable.

Like I don’t know how you two are about telling your story now you might be, I don’t know, but it was pretty uncomfortable and there’s this element of HIPAA and privacy and confidentiality like what can I say? What can I not say? But I saw the power of those stories when I gave that TedMed talk and Just the extent to which people related and it’s I mean, I don’t even know why I was so slow on the uptake with that It’s so obvious.

Like we like reading we like stories. Why? But ever since then I’ve never gone back. I’ve never not utilized stories in my writing or in my speaking 

Will: And as an emergency physician, I mean you actually shared with us a few stories that you have from your career Uh, and one of them I have to ask you about, um, that has to do with Shrek.[00:37:00] 

Anytime, if you’re going to throw Shrek out there, like, we got to talk about it. 

Dr. Resa Lewiss: Well, so, um, I’m going to start back. I grew up in a small town and my parents always said, Risa, if anything happens, if you ever do anything, if you’re going to get in trouble, please tell us first. Meaning like we don’t want to hear about it from the police.

We don’t hear about it. Like come to us, let us know first. So, um. That should have translated to when I was working in New York City, I worked in an emergency department in New York City for 12 years and one of the hospitals, two hospitals, and you know, our shifts were divided, was right near Broadway. So we often had tourists visiting, Broadway actors, you know, people that were Known for their acting or I don’t know how you want to consider them, but quote famous, whatever famous means.

So, one time someone who had been in a theater production had a visible bad outcome incident on stage and I took care of the patient and the [00:38:00] patient went home and the next day the medical director said, Risa, did you take care of this patient? I said, yeah. And she said, it was in the New York Times, like, I need to know, uh, before it’s in the New York Times, and I was like, oh my gosh, well, it’s because I knew he was okay, and I, whatever, but I, I was like, you’re right, sorry, like, won’t happen again.

Wait, wait, you, 

Will: you were contacted by the New York Times? No, the story 

Kristin: of the actor being injured. 

Dr. Resa Lewiss: Oh, oh, I see. Okay. Right. Cause every, all the audience witnessed it and they said, oh, and he reported to this hospital and I was like, oops. So, um, next time I had, um, someone Broadway. So this patient came in and he had not had an incident while on stage at work, but didn’t feel well, came in and he was basically like, well, you know, I, I was at work and, you know, then explain symptoms.

And I, and I said, what kind of work do you do? And he said, Oh, I’m in a play on Broadway. And he had this perfect hairline rim of bright green Shrek colored paint. And so I [00:39:00] said, Shrek? And he’s like, how’d you know? And I said, um, just, 

Kristin: it was amazing. It was a lucky guess. It was amazing. It’s a very Shrek, uh, Shrek 

Will: hue of green 

Kristin: here.

Yeah. It’s very specific. Oh, that’s funny. It was amazing. 

Will: I wonder how that play is. I hope it’s good. It’s on 

Kristin: Broadway, right? I guess so, yeah. But why do all of its actors keep ending up in Risa’s emergency room? That’s right. 

Will: Um, you also have, uh, I’m sure you have a lot of CPR related stories, um, but that also piqued my interest, given our history.

Right. Um, you have a story about CPR being performed on a dog. 

Dr. Resa Lewiss: Oh. So, you know, I have practiced in, a little bit in Providence, Rhode Island, Boston, Massachusetts, New York, New York, Denver, Colorado, Philadelphia, Pennsylvania, and actually, you know, I’ve done ultrasound work around the world. New York without question has provided some of the most interesting, like bananas, [00:40:00] I say bananas stories.

You’re just like, I cannot believe that just happened. Or people would never believe that this is what happens in the emergency department. But so New York, plus New York is just like, I’m still in love with that city without question. I. I love Philadelphia. I am in love with New York City and because anything goes and that even goes with the medicine and the people that come into the emergency department, the cases that I cared for, like the most extreme was New York City.

So I was working a shift and this woman came in and she had a huge cut on her face. And, uh, I was like, oh, what happened? And she, and, you know, I immediately went into wound mode. Like, you know, when was the last time you had a tetanus shot? Oh, we’ll have to sew your face and da da. And she, um, was a, uh, a dog lover.

And she was at the dog park. And it wasn’t her dog. She had seen a dog frothing at the mouth. And… Um, then go unresponsive. And so she decided, as she shared with [00:41:00] me, that she was going to perform mouth to mouth and CPR on this dog. So it was a little less CPR, but it was, she performed mouth to mouth on this dog.

And of course, you know, I was envisioning Stephen King’s Cujo and rabies and biting the mouth. And then of course, you know, more like, okay, was this a seizure? Was this syncope? Like what? It was a dog though. And so, you know, she. Interestingly, was very concerned about the animal, but not at all concerned about herself or her face that had a very visible gash with, um, you know, anybody would look at it and say, I think you need some stitches, but she was very resistant and was very unconcerned about herself and was more concerned about the dog.

And I said, you know, um, because we didn’t know what had happened, I was really saying that I thought that we needed to update. Um, her tetanus and speak about, uh, rabies and rabies vaccination. And she really wasn’t interested in that. And then somehow, the people’s whose dog it was found us in the emergency department and [00:42:00] um, she was able to speak to them on the phone.

And so. I mean this is, she’s talking on the phone, she’s sitting at, you know, the place that we would normally be charting and doing our work, and she’s taking a long time, and I was just like, you know, trying to, yeah, and make sure she was asking questions, trying to, but she was very focused, and I, um, she got off the phone and I said, so um, And I had said to her that the one most important thing was to know about the rabies vaccination of this, this dog because it wasn’t hers, it was just some dog at the dog park that she decided to resuscitate.

And she said, she got off the phone and I said, so, and my intention was, is the dog immunized? She said, he didn’t make it. 

Kristin: Oh my god. That is not what I said, well, 

Dr. Resa Lewiss: what about, what about the rabies? She’s like, oh, I didn’t ask. And I was just like, oh my goodness. Oh my goodness. And it took a lot of discussion.

About convincing her. I mean, like this was a big gaping wound that we needed to do some wound care and some, anyway, but it was [00:43:00] just, um, you know, yeah, hopefully no one got rabies. Yeah. I mean, this was now like a few decades ago, so 

Kristin: yeah. Oh my 

Will: goodness. What, just, I’m just out of curiosity, what is the a rabies vaccinations series like?

That’s the whole 

Kristin: process, right? Like, that’s a big deal. Yeah. Have to get a rabies shot. Yeah, it’s, 

Will: it’s like several, 

Dr. Resa Lewiss: several. Yeah, it’s a whole series, and in fact, it used to be more, uh, it’s fewer number, but, um, at the time of the incident or the exposure, There are two things. Number one, you get immune globulin and that’s usually injected at the site of the wound.

And then you start your vaccination series. So you get also like And then you come back and I think it’s like day zero, day four, day seven, day fourteen. It used to be one more, but then it stopped. Yeah, so it’s a series, but it’s like, yeah, it’s like getting 

Will: a shot in your arm. I bet those are painful. It sounds like It should 

Kristin: be a painful one, 

Will: yeah.

It feels like it should be a painful vaccination. Well, 

Kristin: and I think they’re expensive [00:44:00] too, right? Probably. Like, if you don’t have insurance, 

Will: that’s… Well, you gotta get a prior authorization, I’m sure, 

Kristin: on, uh, the rabies. That’s right. Why didn’t you check first to see if that dog had rabies before you let it bite you?

That’s right. Can we 

Will: talk to the dog first? Please. Have the dog call us. We need 

Kristin: to make sure. We’re a little bitter about prior authorization. As if 

Dr. Resa Lewiss: you can’t tell. What you, how you are educating people and bringing this issue up is commendable and keep going. 

Will: Oh, thanks. Oh, thanks. Yeah. Well. We have enough spite to last a fun of those companies, so it’s a lot of fun for me.

Um, alright, I have a little activity for us to do real quick. I think this will be educational and also hopefully a little fun. Um, I was trying to come up with a name of it. I thought like, uh, you know, um, Will It Ultrasound? Or, uh, actually, Hocus Pocus. Hmm. Okay. I think it’s probably a good one. Anyway, uh, the, the, really what we’re doing is I’m just gonna give you a thing, and you tell me if, if, like, it’s worth it to [00:45:00] ultrasound the thing, okay?

Alright, so we’re gonna start off, I’m gonna give you some obvious ones, and then get into some kind of weird the spleen? Can you ultrasound it? You ultrasound it? Yeah. What do you look at? What can you tell about the spleen on 

Dr. Resa Lewiss: an ultrasound? Parts of the body that are fluid filled are very sonofriendly, as we say.

So yeah, spleen’s chock full of blood. It’s sort of the filter of, you know, all of our blood. So yeah, definitely. 

Will: Okay, explains ago. Uh, we already mentioned the lungs. These are like lung fluid. So it’s fluid around the lungs you’re looking for. What else can you be looking for with lung ultrasound? 

Dr. Resa Lewiss: Back in the day, they said don’t even bother Ultrasounding the lungs because it’s chock full of air and air scatters ultrasound waves.

The course is completely changed. It’s one of like the top organs So, you can see fluid, you can see pneumonia, if someone drops a lung, the pneumothorax, you can see that. Um, I mean, if someone has fluid from either [00:46:00] a stab wound, um, or, I mean, even, this is sort of an extension of the lung, but when patients are intubated, you can indirectly see is there movement of the lung to indicate that you’ve correctly intubated the patient.

A lot of 

Will: applications. Oh, really? Instead of, uh, as opposed to, like, the x ray that’ll show the tube in the right spot, you can just see the inflation 

Dr. Resa Lewiss: of their lungs. The direct and the indirect, and, uh, ultrasound is one of those that you can see. Oh, 

Will: interesting. Mm hmm. Alright, here we go. The brain. 

Dr. Resa Lewiss: Well, you know, I, I went 

Will: way back.

The eye does not count, even though the eye is an extension of the brain. 

Dr. Resa Lewiss: So, um, one of the first medical applications of ultrasound was, um, I think his name, anyway, he was a neurologist psychiatrist and he imaged the brain looking for brain tumors using ultrasound. So yes. Interesting. 

Will: But there’s a skull there.

Dr. Resa Lewiss: How does it work? So, it’s true. So, [00:47:00] um, you do have a 

Will: bit of a See, I got that anatomy correct. I know there’s a skull surrounding the brain. Good job! 

Dr. Resa Lewiss: Thank you. But there are, depending on the depth to which the ultrasound penetrates the tissue, you can actually see Um, sometimes you can see beyond the bony cortex or if people have had surgery and therefore there’s like a, um, portal of entry.

Um, I was going to say though, there are parts of the skull that are thinner versus thicker in terms of the bone. So one of the applications actually when in acute stroke is people, um, look at transcranial Doppler. So, uh, the answer is yes, you can. Ultrasound in the brain. How 

Kristin: does bone affect ultrasound?

Dr. Resa Lewiss: So it’s really obviously solid as you’d imagine. So, uh, ultrasound waves generally don’t go beyond and they are reflected right back. So if you were to look at lungs, for example, when there are ribs, you just see this long, [00:48:00] dark stripe because sonographic waves don’t go through. 

Will: But I guess it’s strong enough to pin it some some ways you can 

Kristin: parts of the skull.

Yeah. Yeah, right Okay. All right learn something new today. There you 

Will: go. Um, all right, how about kidneys? I’m sure you can ultrasound 

Dr. Resa Lewiss: kidneys big time Yes, it’s a common one. They 

Kristin: have a lot of 

Dr. Resa Lewiss: Fluid in there, right? That’s right. That’s right. 

Will: I would think they do. Absolutely. You’re right about that one. 

Kristin: All right, let’s do it.

Cause they make urine. See, I 

Will: got you on that one. Um, what about like joints? Like, like now I’m just like, kind of curious, like ankles and like knees. Like, do you guys ultrasound those in an emergency for any particular 

Dr. Resa Lewiss: reason? Well, we, we ultrasound virtually everything. Like, everything. So, big time, yes.

It’s like, why are you even 

Will: asking? It’s like, yes. 

Dr. Resa Lewiss: Any joint that might have fluid accumulated, um, you know, actually you were asking about, like, bone. Um, because there’s [00:49:00] often motivation to avoid x rays in kids because they’re growing and the radiation of x rays or CT scans, you can even look to see if there’s a break in the cortex suggestive of a fracture.

So There are a lot of applications of bones and joints with ultrasound. Muscular skeletal ultrasound is a whole thing. 

Will: It’s a thing. Okay. Gotcha. It’s like you could do another. There’s always ways to incorporate new fellowships into medicine. That’s a wonderful thing. Do sub sub fellowships. Alright. How about the stomach?

Why would you… Ultrasound the stomach, Dr. Lewis. Great 

Dr. Resa Lewiss: question. Great question. So, we actually wrote a case report about using ultrasound to confirm the NG, the nasogastric tube, um, as opposed to an x ray or listening, you know, with the pushing air into the stomach. That’s one. Um, they, I mean, this is the, uh, exiting the stomach, but in children, um, looking for pyloric stenosis is a big thing.

Um, as you’re exiting the [00:50:00] stomach, there have been studies in anesthesia, cause you know how pre op you’re supposed to have, be, have an empty stomach, be quote NPO, nothing by mouth after a certain number of amount of time. So you can see whether or not there’s any fluid. Cause in theory you should not see, um, The stomach is either collapsed because it’s muscular or it’s full of air, but if it’s, if it has liquid in it, then that means maybe, you know, the patient hasn’t been NPO the way they’re supposed to be pre op.

Um, finally, um, it’s, uh, there’ve been studies looking at, um, looking for foreign bodies like, uh, watch batteries and other things. Toxicologists have really wanted to look at it to see if you’re looking at pills that have been ingested. And, you know, is it worth? trying to, uh, flesh out the stomach, stuff like that.

That’s kind of old school to even try to irrigate in that way. Usually they kind of just have you drink something to push it all through. 

Will: And how about the other end? How about the rectum? [00:51:00] 

Dr. Resa Lewiss: This is a good one. So trans, I mean, transrectal ultrasound is a whole thing. Um, and in fact, they do ultrasounds to look, um, uh, at the prostate in men.

Um, it’s definitely not an emergency medicine application, although rectal and peri rectal abscesses. So. You wouldn’t use a rectal probe, but you could use a linear high frequency, you know, probe to look to see if there’s a collection of pus. There you 

Will: go. That’s just… Where would you put the ultrasound probe in that situation?

Dr. Resa Lewiss: So, let’s, let’s, well, let’s think about like a non peri rectal part of the body. Say someone has a thigh abscess, you know, we look at it. In two planes. I 

Kristin: have to excuse myself. Two planes on the other. This is the reason I’m not in medicine. I know, but you’re very good. I 

Dr. Resa Lewiss: mean, plus you’ve had children, so like, generally speaking, like, you’re pretty good.

You change diapers, [00:52:00] like, you know, well. 

Will: She’s good. She can handle it. If I 

Kristin: had to, he didn’t. He could. 

Dr. Resa Lewiss: Anyway, keep going. I’m sorry. No, but I mean, the goal when you’re trying to assess for an abscess, um, you know, you’re trying to look at The area in two planes, so usually at 90 degrees to another. And ideally you can compare it to an unaffected side.

So if someone has an abscess or what looks like an abscess on one, uh, butt cheek, you can look at it, uh, in the two planes and then look at the unaffected side in two planes to see if one looks similar or different from the other. 

Kristin: Obsessed butt cheek. Does not sound comfortable. 

Will: That sounds very uncomfortable.

Um, all right, let me, let me, uh, last one here. I just want you to tell me, like, what is one of the more, the most creative uses of ultrasound that you’ve seen done or that you’ve personally done? 

Dr. Resa Lewiss: Great question. She pauses. I put you on the spot. No, it’s okay. I’m comfortable. I feel safe. I told you I feel [00:53:00] safe.

So, I’m gonna first, you know, this is sort of a generic and then I can be specific, but generically speaking, ultrasound guided nerve blocks have completely changed the way we take care of patients and relieve their pain. So, elderly patients that don’t tolerate morphine or dilaudid very well, you can now say a patient comes in with a hip fracture, you can give them a nerve block which bathes the nerve with anesthetic and and analgesic and makes their broken bone, that area numb.

And they, number one, you don’t have all the side effects of making them having problems with breathing or low blood pressure or, you know, being mentally out of it and you completely take care of their pain. So I think that’s just like a really positive aspect of ultrasound. And, you know, all the conscious sedation that many of us learned actually.

When I trained, we didn’t do conscious sedation. Then all of a sudden conscious sedation became the most common thing in the world. [00:54:00] And now people realize that it’s very resource intensive and time intensive and et cetera, that nerve blocks, I think are going to change our need to have to do conscious sedation in very, very good ways.

Um, cool. Yeah. I’ve 

Kristin: had one nerve block before and I was a big fan. 

Dr. Resa Lewiss: What part of the body? 

Kristin: It was when I was having our first child. So I think I had an epidural and a nerve block and I can’t remember why. I had both, but I know it was 20 hours after being induced with Pitocin, and, and it just, I was gonna, I was out of everything I had.

I had given it my all, and I needed some rest, and so they gave me those two things. 

Will: Yeah, it worked. It 

Kristin: did. I took a nap immediately and then I think, I don’t know, like an hour later she was born or something like that. Yeah, it was nuts. Anyway, yeah, 

Dr. Resa Lewiss: big fan. Yeah, the one specific, you know, this isn’t the most unique.

In fact, this is one of the most common applications And, you know, I don’t know if this happens to you Will, but you’re [00:55:00] like, I’m sure, you know, what I do doesn’t make a difference, or do I really believe this? I don’t know, dilating the eye, looking in the back, but sometimes you’re like, is ultrasound really like that amazing?

And I’ll never forget this case in the emergency department, and I’ll tell you the case, and then I, kind of after the fact, I was like. Ultrasound really does make a difference. And then I’m, I was having this internal dialogue, I’m like, Risa, you’ve been doing this your whole academic career. You’re not sure, like, it’s just like, no, but like, it just continues to wow me and astound me.

And the amazing thing about this case is it was witnessed by one of the residents. And years later, she brought it up to me, she said, you know, Risa, I’ll never forget the time that we had that patient in New York City when blah, blah, blah, blah. I was like, oh, you witnessed that. I’m like, I’m so glad I had a witness to that case because it completely, everything changed.

So. Elderly man, very hard of hearing, came in, he had passed out, and supposedly for a week he had had crampy abdominal pain, so crampy stomach, stomach ache. And his doctor had said, Oh, you have gastroenteritis, which is kind of like, for you, [00:56:00] Will, everybody has a corneal abrasion. Like, you know, whenever people have stomach pain, like it’s just like, 

Will: it must be this.

Maculopapular rash. Yeah. 

Dr. Resa Lewiss: That’s the dermatologist. Yeah. It’s just like everybody has gastroenteritis, even though they’re not vomiting or having diarrhea. But it’s gastroenteritis. I’m like, that can’t be. Anyway, he had passed out, his blood pressure was low, and he was hard of hearing, and so we met him in the trauma resuscitation room, and they were like, alright, let’s get him to CT.

Which means, you know, bring him over outside the emergency department to get imaged, because it must have been, you know, the thought was, because he wasn’t responding, that he must have hit his head or something with his brain. And I realized that he was hard of hearing and that’s why he wasn’t responding because you know, everybody’s like screaming 20 things around the room, but also screaming things at the patient.

And as you get older and if you’re hard of hearing, you just can’t, you don’t process the same way. Plus, you know, it’s a stressful environment for many people. And I don’t know why. But maybe because I’m an ultrasound person, I put the probe over his aorta, which is the [00:57:00] big artery that, you know, goes down from the heart to the legs and blood to the body.

And he had what is called an aortic aneurysm. So the big artery was ballooned out and it was so big that it had burst and he was bleeding. into his abdomen. So that’s why his blood pressure was low. That’s why he had passed out because a lot of times when people pass out, everything’s it’s the brain and it’s in the head.

Um, and that was crampy abdominal pain that he had. It wasn’t gastroenteritis. So I basically said, stop, he’s not going to CAT scan. And I called the vascular surgeon. And you know, you know certain colleagues that will listen and will come and versus be like, I don’t know you. I’m not gonna do that. Mm-Hmm.

did you get the ct? But I knew him and I knew that he, it was one of the , one of the consultants that didn’t mind coming to the emergency department. ’cause as we know, a lot of consultants don’t like coming to the emergency department. . I said to him, she’s talking about you. Oh, no, no, no, no, no. Just, I get it.

[00:58:00] I totally Oh, get it. 

Will: I’m just scared. I’m just scared of it. That’s 

Dr. Resa Lewiss: all. And he came down and. Um, I also, because I was so sure of what was happening with this patient that I called the OR and I said, we’re going to need, uh, an, uh, an operating room. And I talked to anesthesia and he came down and he was someone that knew that we used ultrasound and kind of respected as part of our practice as a data point.

And he said to me, can you show me? And so live, I put the probe on the patient’s abdomen, showed it and he said, okay, let’s go. And so we’re taking him to the OR. And he went to the OR, he lived and he walked out. And it was one of those, you know, like these things happen, like for all those stories are plenty of stories that don’t go like this, but it was one of those, you know, it is actually one of the main applications.

It’s not a special or unique or case report type application of ultrasound, but I’m like, wow, it really does make a difference and can save lives. That’s so cool. That 

Kristin: is cool. Well, I [00:59:00] have, before we let you go, I have to ask about what is probably the most famous Or use of ultrasound in these particular kinds of ways.

Now this was before it was all portable, I think. So it was a bigger deal. Uh, Tom Cruise and Katie Holmes when they were pregnant with their daughter. I don’t know why I remember this. I have no idea where you’re going with this. But they got, there was, because it was like a big deal. They kind of, people were poking fun at them because they got an ultrasound machine or whatever it was at the time and purchased it for their home.

So that they could ultrasound their baby anytime they wanted to see it, I guess. And I remember there was like this public outcry that you shouldn’t do that because it was like. I don’t know, harmful to the baby or something. So why, but I don’t remember the details. So why is it that you would not want someone to, especially these days?

I mean, it’s a joke, but it’s also kind of serious now that ultrasound is becoming more affordable and more portable. [01:00:00] Should people be doing this in their home, you know, pregnancy or otherwise? Um, just on their own. 

Dr. Resa Lewiss: Yeah. Yeah. So I remember when that was in the news. I didn’t do a deep dive into the details and also, you know, I think that was sort of a situation where they could afford and perhaps I don’t know how they managed to get it in the home and I could be wrong, but that may have even been a 3D ultrasound, which is not what we do in the emergency department, but there are three, so you could really see the full structure.

So You know, I think their thought probably was, we’ll do this so that we can have ongoing monitoring. We can look at any time to make sure there’s movement and look at the heartbeat, et cetera, et cetera. And I think it was probably, you know, probably intention, well intentioned to be a part of seeing the ongoing growth in the uterus.

But I think, you know, it, Ultrasound could be the example, but we could talk about any device and you know, at what point is it something that’s for medical use only versus, you know, uh, purchasable and usable in the home. And I think [01:01:00] when there’s hesitancy or pushback, it’s like, well, will people know what they are interpreting?

And I don’t know what the ophthalmological equivalent would be, but we have a lot of people that come in. And they sort of have been taking their blood pressure at home over and over and over and over again. And they have a full list of all their readings. Now they’re doing The right thing. They’re told to take their readings, but then we come and they, we do it at triage and the reading is very different, you know, maybe rather than really, really high, it’s, it’s actually normal rather than really, really low.

It’s really, really high. And so I think sometimes it’s, you can obtain the measurement, but you know how to integrate it or understand it or interpret it. And I think when there’s hesitancy with some of these devices, um, there’s concern about how it’s going to be interpreted and you know, one could guess.

Will: That’s a deep cut. Right. Made it as a deep cut. Tom Cruise, Katie Holmes. There you go. You pulled that one out. Yeah, that’s 

Kristin: impressive. All this talk of portable ultrasound. That’s what it made me think 

Dr. Resa Lewiss: of. And I think when he had it, it wasn’t even that portable because [01:02:00] it was, it was years ago. It was a massive thing.

Yeah. Right. 

Kristin: Yeah. Right, that was part of why it was in the news is because it was just so ridiculous that a person would have one of these in their home. Like a 

Will: 1960s era computer. 

Kristin: Yeah, right. Takes 

Will: up a whole room. Well, Dr. Lewis, thank you so much for joining us. Let’s go over your book again before you go.

You go ahead and tell us where people can find it, when, what’s it called, all the things. Yeah, 

Dr. Resa Lewiss: I really appreciate that shout out. So it’s launching in April of 2024, being published by HarperCollins. Uh, wrote it with co author Adara Landry. It’s available for pre order now, Amazon, bookshop. org. Um, you can take a look at it in Goodreads.

We’ll be in all the outlets where you order your books and it’s called Microskills. 

Will: Awesome. Well, and you also have a podcast, Visible Voices. Yeah, which 

Dr. Resa Lewiss: you two are going to guest star on. 

Will: I know, we’re trying to make that happen, and we will eventually at some point. [01:03:00] Yeah, 

Kristin: videos are always tricky, 

Dr. Resa Lewiss: but… So, Visible Voices is um…

It was a pandemic, uh, era project. And, uh, just like you two probably enjoy these conversations. I just love the conversations, cover topics of healthcare, equity, and current trends. And the goal is to amplify people that are doing amazing things that are subject matter experts, but maybe even aren’t recognized as subject matter experts and some are and some aren’t, and, um, just trying to have good quality content with good people.


Will: I’d love to come on and talk about, uh, uh, dressing up as different specialties and recording myself alone in my bedroom. I’m sure there’s a 

Kristin: large audience for that topic. 

Will: Well, uh, again, it’s a pleasure to finally get a chance to talk with you. And, um, yeah, we’ll see you later. 

Dr. Resa Lewiss: Great. Thanks so much.

Will: All right, let’s take a look at a medical story that was sent in by a listener. So we have a story from Laura. Laura says, I’m a medical [01:04:00] physics resident working at a radiotherapy department in Denmark, and this story was told to me by a colleague a while back. The patient had to undergo radiotherapy for cancer treatment.

This meant coming into the clinic every day for six weeks to get a small bit of radiation. So every day you got to go in, get a little radiation, come back the next day, get a little radiation. Um. Um. This let us, let, this lets us slowly fry the cancer while giving all the surrounding healthy tissue time to heal in between treatments.

The patient had been told that it was really important that they show up every day for their treatment. A week or two passed and all was going well. Then one day, when the patient showed up for treatment, they seemed a bit off, disoriented. Like they didn’t recognize the place or they didn’t know the staff or who had been treating them.

Didn’t know their history, didn’t really understand what was happening. Luckily, the treating radiographer was alert to this and asked the patient for their name and social insurance number before starting treatment as is standard protocol. It turned [01:05:00] out that the patient had sent their twin to the clinic that day because they couldn’t make their appointment.

Apparently, they thought the treatment would work as long as someone, no matter who, came in and laid under the radiation beam every day. 

Kristin: I mean, if they’re twins, I guess you just assume they’re interchangeable. This 

Will: goes to show how important educating the patient is, and making sure that everyone’s on the same page, especially as, um, you know, medical technology gets complex, and that’s a wow.

Yeah, that is a good sibling though. It 

Kristin: really is. That’s above and beyond the call of duty, even for a twin. 

Will: I can’t make my cancer radiology appointment, can you go and get radiation for me? It’s not the correct thing to do, but it’s very thoughtful. It shows. 

Kristin: It’s very thoughtful. A and commitment. Yeah, that’s, that’s great.

I mean, don’t 

Will: do it. Pathologically so. Don’t do it, but it’s, it’s a great, uh, also Laura says, um, [01:06:00] that, uh, she wants to give a shout out to all the technical staff in medicine out there who make sure the patients get treated and diagnosed safely every day. So shout out and, uh, shout out to Laura who it sounds like is hanging out in Scandinavia.

All right, send us your stories, send, we want to hear them. Knock, knock high at human content. com. Uh, what a wonderful conversation. Yes, that was with Dr. Risa Lewis, uh, ultrasound, uh, extraordinaire. I’m glad we, I finally got to hash it out a little bit with, uh, with someone in ultrasound I’ve been, you know.

Um, kind of pokin for a while now. Pokin Yeah, pokin at the pokus for a while. Uh, no, yeah. Well, 

Kristin: some people don’t even know what that means probably, right? Like, do all medical professionals know what that means? Or is that a specific… 

Will: Point of care ultrasound? Yeah, well, I think all medical professionals are aware of it.


Kristin: but non medical people have no idea what you’re talking about. 

Will: That’s just me. The patient [01:07:00] comes in, and, and like… One of the first things you do after like talking to them, figuring out what’s going on, is you take that portable ultrasound, just put it on the patient and try to see what’s going on.

So it’s like what we’re talking about the whole time. Yeah, it’s like, you know, there’s point of care other things as well There’s point of care glucose checks. There’s point of care others things. Well, they’re now there’s point of care ultrasound So it’s like yeah, right when you come in when you see the doctor you’re getting that ultrasound to see what’s going on.

So Yeah, fascinating. Really 

Kristin: cool. Interesting stuff and such a great idea for a book Like somebody finally has come along and tell you all the things that nobody tells you Yeah, 

Will: check that out. And, uh, tell us what you think about eyeball ultrasound. I’d love to hear your thoughts and or anything about ultrasound or anything about anything else, I guess.

Kristin: I’m curious what the other ophthalmologists think about eyeball ultrasound because they have been suspiciously quiet online when you get yourself in these arguments. I think 

Will: I’m just the loudest one and [01:08:00] they all the rest of them have better things to do with their life and their time than get into Twitter arguments.

Twitter arguments are the most Soul sucking thing you can do on social media because it’s it’s never worthwhile And then after or even during you just feel bad like this isn’t real life Like I have things to do to make myself a better person. So what do you 

Kristin: think this says about you? 

Will: Not anything good.

Not anything good. I’m just as much of a part of the problem that I’m speaking of here But let’s not, this is not a referendum on my mental health, alright? So, there are lots of ways to hit us up. You can hang, uh, email us, knockknockhigh at human content. com. You can hang out us, hang out with us on social media.

We’re on all the platforms, check us out. Uh, also, uh, I’m just screwing this up. Hang out with us and our human content podcast family on Instagram and TikTok at [01:09:00] humancontentpods. Thank you to all the wonderful listeners leaving feedback and reviews. We love to see those. If you subscribe and comment on your favorite podcasting app or on YouTube, we can give you a shout out.

Like Meesan85 on Apple said thanks. Just came off a brutal pediatric emergency medicine shift and literally brought to tears by your soapbox about ED consultant calls. Thank you. We try so, so hard. You 

Kristin: do. Well, I would like to give Meecin85 a hug because it sounds like they had a very difficult day, and I hope their day is going better.

Will: Yes, I hope so too. Meecin85. Uh, full video episodes are up every week on YouTube at my, on my channel at DeGlocknFleckn. We also have a Patreon, lots of fun perks, bonus episodes of React to Medical Shows and Movies. Hang out with other people. That like being in the knock knock high community or knock knock I community.


Kristin: hmm, and share your opinion about, you know, what we’re up to and where you want to seek up. 

Will: You also get early [01:10:00] ad free episode access, interactive Q& A live stream events, and much more patreon. com slash glockenflicken or go to our website glockenflicken. com. Speaking of Patreon community perks, new member shout out to Ruth H.

Hello Ruth, how you doing? Shout out as always to the Jonathans. We have Patrick, Lucia C, Sharon S, Omer, Edward K, Steven G, Jonathan F, Marion W, Mr. Grandaddy, Kaitlyn C, Brianna L, Dr. J, Ross Fox, Chaver W, Leah D, Kay L, Rachel L, Ann P, Keith G, JJ H, Abby H, Derek N, Jonathan A, Mark, Mary H, Susanna F, and Ink Macho. I did it all in one breath.

Kristin: Yeah, and you ended with a flourish. I crushed that. Yeah. Way to go. 

Will: Good job. That’s just a good collection of names. It just rolls off the tongue. I love ending it with pink 

Kristin: macho. That really is the best. It’s an exclamation point at 

Will: the end of it. Please never cancel your subscription, pink 

Kristin: macho. We’ll keep saying it anyway.

Will: We need you, alright? [01:11:00] Patreon roulette. Random shout out to someone on the emergency medicine tier. We have, uh, Kelly B. Thank you, Kelly B, for being a patron. And thank you all for listening. We’re your hosts, Will and Kristen Flannery, also known as the Glockenfleckens. Special thanks to our guest, Dr. Risa Lewis.

Our executive producers are Will Flannery, Kristen Flannery, Aron Korney, Rob Goldman, and Shahnti Brooke. Our editor and engineer is Jason Portiza. Our music is by Omer Ben Zvi. Yes, I know I said Rob correctly. Alright, you’re welcome, Rob. To learn about our knock knock highs, program disclaimer, and ethics policy, I just like, like…

Such vitriol. Well, it’s like, like, I should be saying his name correctly. I don’t know why, like, it’s… Yeah, you’re 

Kristin: real aggressive today. You did okay. I’m 

Will: fine. We got, we talked about ultrasound 

Kristin: today. Oh yeah, I got you 

Will: riled up. It gets me going. To learn about our knock knock highs, program disclaimer, and ethics policy, submission verification, and licensing terms, and…

I know you’re all waiting for it, HIPAA release terms. You can go to glockenplugin. com or reach out to us at knocknockhigh at human content. com with any questions, concerns, or fun medical [01:12:00] puns. Knock Knock High is a human content production.


And Kristen, would you say we have a busy life? 

Kristin: Yes, I would say. That’s an understatement. We got the kids. 

Will: Yeah, the house. We got the podcast we run. Yep, our jobs. Yeah, I do film skits from time to time as well. 

Kristin: Yeah, we have a lot of demands on our 

Will: time. You know who else has a lot of demands on their time?

Who? You. Physicians. That is true. Yeah. And a lot of it’s documentation. Yeah. It really, it leads to burnout and everybody just feels overwhelmed. Like they can’t keep up. You know what would help with that? What? The Nuance Dragon Ambient Experience, or DAX for short. What a cute name! I love that name, right?

Yeah! DAX! It just rolls off the ticket, DAX! Give me some DAX! I need some DAX! Help us, DAX! We need to be able to, uh, improve [01:13:00] the patient physician relationship, and DAX is here to help. It’s this AI powered ambient technology that just helps you with your documentation and just allows you to return to doing…

What you want to do as a physician, take care of patients. To learn more about the Nuance Dragon Ambient Experience or DAX, visit Nuance. com slash discover DAX. That’s N U A N C E dot com slash discover D A X.