It was autumn 2006, I was at a (boring) conference dealing with many different subjects, none of them really fascinating to me. An American speaker had just finished talking about handling ischemic strokes and the session I was interested in was about cardiac arrhythmia. It would have been in the same room, in 30 minutes. I did not feel like leaving (the room was full of people and I was lucky enough to have a seat) so I stayed to listen (well, pretend to listen) to the next speaker. I expected it to be an incredibly boring talk since it dealt with breathing pathology, something I really was not into. I read the speaker’s name: Roberto Copetti, the head of the ER in Tolmezzo. He started the talk with a series of X-rays for me quite difficult to be understood and then he said something that changed my life: “in 20 minutes you can learn a technique to demonstrate that all these x-rays are not trustworthy… all by using ultrasound”.
Well…I thought that I used abdominal ultrasound to look for bile-stone and fluid in the abdomen but not to lungs! How can this be possible? There is air in lungs! Doctor Copetti explained how ultrasound could rule out, with 100% certainty, heart failure if white vertical lines (that he called B-lines or “comet tail”) were not visible. He showed how it was possible to identify a pneumothorax with an ultrasound while the X-ray was looking perfectly normal. In the same way a basal pneumonia would have look like pleural effusion or vice versa. He showed many videos of ultrasounds and quoted some references, always by the same author: Daniel Licthenstein. I noted the name. After 30 minutes I thought: “I have to try it out as soon as I get back to the hospital and see if it is so simple. I want to read the publications by Licthenstein.” When I went back to work, at the time I was working in the province of Reggio Emilia, I looked for Licthenstein’s works and I realized that there were just few papers but very thoroughly written, showing his enthusiasm for the subject. I plunged into a world made of A-lines, B-lines, C-lines, pleural sliding, lung point that really looked within everyone’s reach. I tested it on a patient and it looked like I was stepping into a different dimension, like Alice in wonderland: I managed to see the pleural line moving and the horizontal lines below it, without having followed any training course and I smiled thinking that maybe I had found a a technique that allowed me to face dyspnea in patients with less fear. In that moment a colleague of mine (a much more experienced doctor) entered the room and said: “What are you doing?”. I answered, in excitement, telling him that by using the ultrasound it was possible to see everything about lungs. He replied: “You are crazy!”. I have been known as the crazy guy doing the lung ultrasound ever since. I started detecting things that are not visible with X-rays and I took the liberty of performing some CT scans to validate my diagnosis: few were wrong but most of them confirmed the ultrasound output. At that point I felt the need of a detailed study of ultrasound applied to emergency medicine and I started following courses. In that way I started performing echocardiogram, vessel, soft tissues, eyes ultrasounds: basically I started probing everywhere without prejudice, trying to understand what I was seeing on the screen. And still I was the crazy ultrasound guy. One day my chief told me: “There is a selection to become instructor in an ultrasound course at the department of emergency medicine, do you want to try?”. I accepted but then I thought about my shyness and my speech issues, especially in public… I thought that they would have told me that I was not the right guy for the job. A warm spring afternoon in Reggio Emilia, during the ultrasound course, I met Aldo Sangermano (the director of the course) and Pier Carlo Scarone.
Aldo Sangermano: I started hacking on ultrasound in 1985/86 when I had to study the gallbladder motility by measuring diameters every 15 minutes at the Institute of Medicine and Gastroenterology at the University of Bologna; my mind was not for gastroenterology but I shall always be grateful to the persons who gave me the opportunity to get to know this fantastic medium that is then served in my second “professional life” as a emergency physician. Besides the good fortune of being a guest in Tolmezzo at his OU, Roberto Copetti enlightened me even making me realize that ultrasound in emergency settings need to make by the doctors who work there So when I was with Carlo and Gaetano to ask to work for the school, not only we were “crazy for ultrasound” but in perfect harmony on the latter. The mix of these things has created a unique experience from which have sprung other initiatives and finally the wonderful experience with nurses who still reserve enormous satisfaction.
Pier Carlo Scarone: It’s difficult for me to determine precisely when I started to get interested in US … My career has been long, dotted with different experiences, but always with a common thread: the surgical practice . And just working in surgical unity I gradually realized the enormous potential of US. When I chose to make a change in my professional career, devoting to emergency in the broadest sense of the term, this perception has increased even more. Meeting Gaetano and Aldo in Reggio Emilia represented the beginning of an exciting experience, in which three different characters share the same passion and succeeded in integrating with each other, conceiving and realizing, sometimes in spite of adversity, projects that none of us individually would have thought he could fulfill.
After a few words I realized that I was talking to two other “ultrasound crazy guys” facing the same kind of problems I had, following the same path I was. It was thanks to them and their enthusiasm that I could overcome my shyness (not really my speech issues). So we started to share with many colleagues what we were experiencing with our patients day by day. The most important thing of all was demonstrating that we were teaching an extremely useful technique for the patients. In this way we got the course to become important, followed by many people and providing new information such as the integration of the heart-lungs ultrasound.
At a certain point of our journey we realized that we were collaborating with professionals to which we could delegate surveillance duties of the patience that would have greatly benefited from the ultrasound technique: the nurses. Very relevant people such as Lorna Pagani and Daniele Vezzali joined our group and helped creating, with difficulties and skepticism from many, the ultrasound course in emergency medicine for nurses. It was a great success! Lorna and Daniele’s growth was exponential both from the technical and the educational point of view.
Lorna Pagani: One afternoon I go into the emergency room and I see that there is a great ferment! All the people are around a stretcher on which lies a guy, with a history of drug addiction, to which it’s impossible to find a vein! Gaetano take the ultrasound probe and, soon after, he ask for a (normal) venous catheter, he prick and blood flows back after a few seconds, with the amazement of everyone! Then he turns to us and he says to nurses: “This should do it too !!”. “YOU ARE FOOL !!! … I do not know anything of ultrasound!”. Thus began a squabble with him: he listed all the things I could do (better) with the ultrasound, and I (not too convinced, but … VERY curious) insist that “I do not know anything about ultrasound! “. We have, however, agreed on one point: that, first, we had to acquire the knowledge and skills! “It would take a training course!”. “Gaetano, teach us!”. And so we were able to realize a training course and I was getting comfortable with ultrasound of vascular access and bladder. After a few months, Gaetano ask me: “In the school of ultrasound of Reggio Emilia, we are planning to do a nursing course, do you want to come to teach? There’s also a your colleague, he is called Daniele”. And so it began the adventure, on the one hand as a teacher but, above all, as a learner in a training program which led me to acquire more and more knowledge and skills.
Now we are five persons (friends) and everything was proceeding well when I (Gaetano Dallavalle) decided to move to work in Lavagna and, after a while, Aldo changed ward and Pier Carlo move to Vercelli. I will not get into the details of these transfers. Our intention was nevertheless to keep the school going, especially the one for the nurses. Unfortunately it did not happen.
Every cloud has a silver lining and working in Lavagna allowed me to meet Matteo Cavallero: his crave for learning shocked me and his enthusiasm got him to become a reference on ultrasound in the department of emergency medicine in the hospital of Lavagna. Moreover his knowledge in cardiology allowed the integration of lung, heart and great vessels subject to further evolve.
So now that the course was over and time had passed how could we manage to keep this knowledge share alive? Internet was our answer.
First we created a small blog to probe the technique. After the blog gained a fair success we started thinking about a website to divulge the use of ultrasound in emergency medicine. We created www.ecografiaps.org: it was a difficult path especially because of informatics issues in managing the webpage but we learned a lot from the experience. Above all we realized that we could create a platform to teach the ultrasound technique without leaving home. Another relevant fact was realizing that people abroad were following us.
What you can find here is the evolution of the work done so far, the realization of a visionary dream projected into the future: this website, where we believe we proudly will be able to say something new and extremely innovative about training in emergency US.
First of all: why doing it in English? The first answer that comes to my mind is: because it is a challenge. None of us knows English very well (some of us knows it vary badly…) but thanks to English we will accomplish two purposes: to allow to anybody around the world (bold!) to read what we do and at the same time this will force us to focus even more on what we are doing and how to describe it.
Most important of all is that, possibly, we understood what we want to do when we grow up: to divulge a methodology that can help the patient. We are not interested in becoming famous or publishing on important journals. We realized that too many people became famous because of someone else’s work while we want to give credit to people such as Licthenstein, Jardin, Copetti and Soldati.
We also realized that we are not (and we do not want to be) radiologist or cardiologist, but we want to be doctors and nurses in emergency medicine that use the ultrasound in a COMPLETELY different way. Is this based on the EBM? No. So I ask you: why do you read these words if at page 2098 of Harrison, edition 2011 you can read: “Ultrasound imaging: not useful for evaluation of the pulmonary parenchyma”? The general use of ultrasound in emergency medicine is based on a mistake: lung ultrasound.
Look at the image at the head of the webpage: we want to be a lighthouse in the storm and the storm is not just created by people against the ultrasound methodology in emergency medicine but also and especially by people using it without embracing its true innovation and potentials but only to gain fame.
Our methodology is mainly visual (not for this it lies with the radiologists) therefore you will see many videos and not so many written words. This will require a long work from our side, therefore there will not be a post every day or every week, but each post will be a joy to us and I hope to you too because it will have to become like those 30 minutes at the conference: they could change your life.