Hello, and welcome to today's webinar, Liver POCUS Implementation in Clinical Practice. My name is Jose Reves, and I'm here today with Dr. Amir Gogol and Dr. Yuko Konno. This presentation will highlight the clinical applications of liver point-of-care ultrasound and the essential steps for POCUS training. In this session, we will also cover some guidance on billing and documentation procedures, and the session is designed to be interactive, so we will have some self-assessment questions. I need to tell you this activity will be offering CME credit as both a live activity and some enduring material will be available for a year. You will receive an email within the next day or so to complete an evaluation and receive your credits, and there will also be a recording of today's presentation. Financial disclosures for this program have been reviewed. You might find our list of financial disclosures on the website, and any potential conflict of interest has been mitigated. Thank you very much for participating in today's webinar, and we hope that you find this information extremely helpful. I will start my presentation right now. Perfect. I think you can see it okay. So what I'm hoping that will happen in the next 45 or so minutes is that I will be talking about an introduction to liver point-of-care ultrasound, describing a bit of the rationale, some small details on training and documentation, then Dr. Kono will talk about the basic concepts of liver POCUS and some of the clinical applications, and then Dr. Gogol will talk about the Stanford experience, how they did to train and implement in POCUS. We're hoping that this will take about 40-45 minutes, and then we will have about 10-15 minutes for questions and answers. Now, I do want to clarify that there has been some work on liver POCUS and the ASLD. There was recently a webinar on liver ultrasound from the Porta Hypertension Group that was led by Drs. Northup, Carvelas, and Bucaram, and there also has been a comprehensive resource on liver ultrasound in a review article by Prem Kumar in Hepatology a few months ago. These two materials are quite comprehensive and extensive, and I do recommend that if you are interested in this topic that you go and read them and watch them. Our focus today, though, will be more practical. How do we implement this in clinical practice? This webinar basically will be preceded with a liver POCUS course during the ASLD meeting in November in San Diego. There will be two separate sessions here involving both theoretical and hands-on training, and we will provide a bit of a path to certification and implementation of POCUS in clinical practice. Dr. O'Connor will talk a bit more about this in her presentation. So just to dive into point-of-care ultrasound in clinical medicine in general, this is thought to be an extension of the clinical exam, and that's how we see it. POCUS in clinical medicine has been around for about 15 years. If you haven't read this article in the New England Journal of Medicine three years ago, I recommend you take a look at it. It's very comprehensive and instructive. And POCUS, again, is so common now, I think, that about 40% of medical schools have POCUS in their curriculum, and a bit more than 40% of internal medicine residency programs do include POCUS in their curriculum. Moreover, there are some studies that have shown that the use of POCUS can confirm a diagnosis in about 50% of the times and can actually help in changing the diagnosis about 25% of the times. So it is a very useful tool to have available. More importantly, and Dr. Gogol provided this paper that is very helpful, there is better patient satisfaction with the use of POCUS. This is a study done among GPs, general practitioners, on POCUS, and we can see here that patients that had POCUS performed during the visit had higher feelings of being thoroughly examined, higher feelings that there was better trust in the assessment of the health problem. They had a better understanding of the health problem, and they also felt more secure about their evaluation. So not only is POCUS good for implementation and understanding the clinical situation, but also provides better patient satisfaction. I want to clarify the difference here between POCUS and standard ultrasound. Point-of-care ultrasound is performed by the person that is usually interviewing the patient, so there is a direct involvement with the patient. There is also a direct clinical and image correlation, but there is also a limited assessment. Standard ultrasonography is usually performed by a technologist, and a radiologist will do the reading. There is no direct interaction with clinical scenario, however, standard ultrasonography provides a more comprehensive assessment. POCUS has been used in different specialties, as I mentioned in the beginning, internal medicine is a typical one, but also critical care, rheumatology, and cardiology have been using POCUS now for a number of years. More importantly for us, recently gastroenterology started using point-of-care ultrasound. For this, I would like to share with you this paper published in the American Journal of Gastroenterology last year, talking about intestinal ultrasound, or IUS. In this paper by Mike Dollinger from Mount Sinai, there is a very clear description of the assessment of IBD via POCUS, but also they provide quite a bit of information on documentation and training for the use of IUS intestinal ultrasound. We have taken a lot from this manuscript, and we are actually working closely with Dr. Dollinger, and we are also preparing a white paper that will be helpful in providing a path to certification and use. Now, what do we see when we see liver POCUS or point-of-care ultrasound? We see it as an extension of the physical exam during clinic visits. Should we focus on specific findings to improve patient care or minimize patient burden? I think the typical example here, and I honestly do that very frequently in my clinic, is assessment of ascites. Sometimes we put a patient on diuretics, we want to see if the ascites has improved or not, and then you don't have to send the patient for another radiology evaluation, I have another meeting with you, you can just do that on the spot. Ideally, we'll extend your clinic by about five to seven minutes. That will vary a lot on whether you're doing a very focalized ultrasound or a more extensive one, and whether you're more experienced or not. And with proper approach and documentation, POCUS should be a patient-oriented, B-level part of hepatology practice. The next couple of minutes, I will talk about what is necessary for training, certification and implementation of liver POCUS. Now, Dr. Gogol will talk quite a bit more about this, sharing his experience at Stanford. So regarding training in liver POCUS, this is very similar to the training that you have for POCUS in other specialties. There is a theoretical component where you have theoretical knowledge of ultrasound that can be anywhere from one to four hours or more, and can be done virtually or in person. There's a practical component or a hands-on component, where you have to be evaluating patients via ultrasound. And I think most people agree that about 25 cases or different findings is what is necessary to be competent. And finally, there should be some evaluation, either could be theoretical or a direct evaluation over time. This last part has been made a lot easier with interface and virtual interfaces, where you could send an instructor some of the images that you collected and what they mean, and the instructor can tell you whether you were doing the right thing or not. Finally, it's important to understand that one thing is competency, the other thing is mastery. So I think we all believe that approximately 25 POCUSes, or POCUS, sorry, is what we need to do in order to be competent, but being a master on this requires a lot more, probably 50 or more. In terms of certification or credentialing in liver POCUS, one will be credentialed basically by their institution. So it's very institution dependent. Some institutions will require a different number of patients or findings or a different number of hours. We are hoping to provide some guidance on this, but if you are planning to use POCUS, it could be good to talk to your institution about it. They probably will have had some experience with the ED department or with cardiology, so they might be able to help you here. There should be a development of billing codes for POCUS, which are very similar to a focus abdominal ultrasonography, and your institution should help you create an interface. So how do you connect that ultrasound machine you're using to your electronic medical record in order to put pictures and to use it? And finally, you have implementation of liver POCUS, and the things that you need to consider here are the time in the clinic, how long it's going to take you, first time evaluation versus follow up for a specific clinical question, documentation, you should have a template to work on this, and you should upload pictures, particularly if you're going to bill. And if you're going to bill for this, one needs to have a very clear description of the billing codes. So in summary, we think that liver POCUS is a new reality that will help patients and providers increasing efficiency and increasing patient satisfaction. It will require, though, an appropriate approach with proper training, certification, documentation and billing, and this is what we hope to facilitate, not only with this webinar, which is more of an introduction, but also later on in the course at the ASLD. Now having said that, we do have some put in questions right now that we would like you to answer, please. Once you see the screen, it should take about 20 seconds. So this is the first question. How many of you have used POCUS during your practice or training, and that could have been during the ER rotation, ICU, internal medicine, etc. If you could click on what is for you the right answer, it would be great. And yeah, we have about 75% of the participants today have used liver POCUS, which is great. So what I will do right now, I'll give the space to Dr. Ocono, who will be talking about the basic concepts in ultrasonography. Yuko, the stage is yours. Great. I'm going to share my slide. Can you see it? Okay. Perfect. Thank you so much. Thank you so much for the introduction. So I'm going to kind of get started with liver POCUS, more practical how we're going to get started, and here are my disclosures. So like Dr. Deves already kind of discussed about what is liver POCUS and what can we do. And this is an extensional, more physical exam. That's what we think liver POCUS will be. And in the outpatient setting, we can use it as an initial assessment of our liver patient's consultation. Is there fatty liver, cirrhosis, poor hypertension, and other things. We can also use it as a follow-up visit, you know, what's the site is. You know, like Dr. Deves said, is the diuretic working or not. Of course, bigger site, as you can see, but, you know, smaller site is, it's pretty hard on the physical exam, even your very, very good physical exam. And these liver stiffness, fat quantification, these are not, we're not doing it right now, but it's a future potential applications. And in the inpatient settings, we can look at the site is, we can look at the portal vein patency and be a dilatation, IBC to assess sort of, you know, the volume status. These are options and that's a potential use. And of course you have, you know, the regular, the radiology ultrasound, you know, but we can do this in a deadbed site. And then of course for the procedures, I hope you're using it for paracentesis, liver biopsy. It's for your safety, you know, it's, it's very helpful. And I heard that some people, I don't know, some hepatologists or other people may send patient to radiology to mark the liver biopsy spot. I would not recommend that because if you do it yourself, you know how deep you need to go, your needle, how, what's your angle. And it's really important and helpful. Now you've probably seen many different ultrasound machines. And on the left hand side, this is a regular standard ultrasound machine. These are big machines, has a lot of advanced applications. These are the machines the radiologists, sonographers are using in the ultrasound department. And it's very expensive as well, you know, $100,000 or more. In the middle, these are the portable ultrasound machine. It's a laptop user, you can put on the cart like showing here. These are the machines usually used in a portable situation, in a trauma, in ICU. And these provide pretty good images as well. And it's a little less expensive than regular high-end ultrasound machine. And on the right hand side, we have this handheld ultrasound machine. You I don't know if you've seen it. It's basically the transducer, whether wireless or, you know, wired. You can connect to your iPhone. Some come with tablet. You can connect to a laptop. And it's very handy. It will provide pretty good quality image, enough for your liver focus. And it's very affordable. So we are going to use this left two side, the standard ultrasound machine and portable ultrasound machine for the initial training at the liver meeting. But then we expect for the actual your practice, you're going to purchase for either laptop machine or handheld ultrasound machines. And then you're going to experience all those kinds of different machines and get hands on at the liver meeting if you are participating in a training. Now we have different transducers, different shape, different frequency. And the shape, we usually use those micro convex or convex for ultrasound abdominal scanning. And the frequency of the transducer will determine your spatial resolution, higher the better resolution, but then the penetration. If you use a higher frequency with a linear transducer, you see much better spatial resolution. You can see a small things, but your penetration is very limited. So these are used for small parts for skin, you know, thyroid, et cetera. For the abdominal, like I said, we use convex transducer, micro convex, three to six megahertz is what we usually use. And if you purchase some ultrasound machine, you will get probably one transducer you'll be using. And you've probably seen different ultrasound machines have different knobs and dials. And it's kind of complicated, it looks like, right? Each machine has a different one. And to get started, you only need to know a few things. You can always learn all the knobs and dials, but minimum thing you need to do, you need to know where's the depth, how you can change the depth, how you can change gain, I'll explain to you. And then color Doppler button is very useful because you can see, is there flow or no flow? Is it biodeck or artery? You can kind of differentiate. And then you need to be able to freeze and save and then freeze. So those are the basic things that you're gonna get started with. Now, just about gain and depth. So this just image with liver and kidney. And I don't know if you can see on the right-hand side, there's numbers, these are centimeter. And then as you change your gain, I'm sorry, depth, you can see this, you know, now this left-hand side, your just liver is very small, right? You wanna use your whole, you know, the monitor. So it's too, depth is too long or too big. Or you make it too narrow, I mean, too small, your field of view, your depth is like, I don't know, five centimeter or so. You can see the superficial parts very well, but you can't see the whole picture. I actually had the experience with my, you know, like the, the Zapatosa already retired a long time ago. He was doing liver biopsy and, you know, he panicked. So he switched on the ultrasound machine as usual, but then he couldn't see anything. He didn't know where he is. So he asked for help. I looked at it. The depth was like, somebody made it like two centimeter. So you couldn't see anything. He didn't know where he is. He didn't know how to change the depth. And then gain is basically brightness on the middle. It's a nice kind of gain settings. You can just change it to left-hand side. You cannot see anything that's a very too dark, too low gain settings. And then on the right side, it's too bright. Now, so gain is very arbitrary. You just make it so that you feel you have a nice picture. Every body has a different kind of ultrasound impedance and all those things. So, you know, you need to kind of adjust yourself. And now, fatty liver, it's bright, right? But then why right side, you know, this is not a fatty liver because you just made it brighter. And that's why you need to check, you need to compare with a kidney to kind of decide is this bright liver or not? Because gain is, you are actually setting it. Now, so we have a transducer. There's an orientation on a transducer. Usually there's a marking, like it's shown on the picture. And that orientation marker is usually in the sidestep scan. It's head. So head is on that orientation marker. On the left lower picture in a sidestep scan, your transducer marker is headed, you know, towards the head. And the picture next to it is basically showing what you're seeing. It's a leftover of the liver. You can see on the left side, you see the heart and the liver, and then there's a IBC. So that's always when you're at sidestep scan, head is the marker. And then you see on the left side will be a picture. On the right side, lower picture, it's a transverse scan. So you are rotating the transducer to our left side. So the marker is now on your left side, patient's right side. And then that's the picture you see. That's a liver, a patient's liver, right lobe on the left side of the picture and the left lobe. So you basically seeing liver as it is. So that's always a rule. If you mess up, you know, it's hard for you, for other people to interpret the picture. You know, it's a black and white picture sometimes. What do you mean? Where is this picture? So it's very important to make a habit. Now we have some terminology about ultrasound. Echogenicity is basically a brightness of what you're seeing. Hyperechoic is basically more echogenic, more brighter than sound tissue. Isoechoic is the same echogenicity. Hypoechoic is lower echogenicity. So on the right hand side, you see the liver and kidney. On the left picture, the same color, that's normal. But when patient has a fatty liver, liver is brighter than the kidney. So there's a liver-kidney contrast, that's a fatty liver. And then anechoic is basically absence of echo signals and it's pitch black. So in the lower picture, you see in the Morrison pouch between the liver and kidney, you see a black thing, that's sinusitis, right? So the fluid, blood, gallbladder, bile duct cyst, they're all black. So we don't call it hypoechoic. This is anechoic, that's fluid. And then we already talked about liver and kidney contrast. And I'm not gonna have time to go over those details about movements, but we're gonna learn it. Once you have a hands-on training at the liver meeting, we're gonna get to do all this fun movement and then look at the liver. Okay, so we have a liver meeting, we'll have a didactic lectures, it's short, and then a lot of hands-on training with different machines and different models. So it will be exciting. And we'll do basic ultrasound knowledge and then identify key organs and findings and other important findings. We'll be able to identify those organs and findings. Now for the future, we can learn shear wave. This is, you know, liver stiffness measurements, as you know, like Fibroscan, but with ultrasound machine, with imaging. We can do fat quantification, AI is on the way. I know one of the handheld ultrasound machine already implementing AI to help your diagnosis. And then contrast ultrasound, that's what I do. It's kind of very advanced, but if you wanna learn it, you can learn it too. With that, I'm gonna stop here. Thank you very much. And then I think I have a polling question I'm gonna stop share. And I don't have a music for polling. But I don't know, it's taking time. Do we have a polling question? What should we do? Oh, here. Oh, no, that's okay. Let's go to the next. Should I close it? Can we go to the next polling question? I mean, if it doesn't work, it's okay. We can do it. I mean, I can ask question. So let's- You don't wanna move on. Okay, we're gonna move on. Thank you so much. Thank you, Yukon. We'll have now Dr. Amir Gogo from Stanford that will be talking about the experience that they had with training in liver pockets and share some of the insight. So Amir, the floor is yours. Thank you very much. Let me share my screen and just, okay, sorry about that. Okay, hello, everyone. My name is Amir. I'm a clinical assistant professor at Stanford in hepatology. And just wanna thank for everyone who is joining and people who are basically watching the video of this presentation. And my task in this webinar is to basically share our experience of like from A to Z, assuming that you are interested in pockets and you wanna just like implement in your practice, whether it's private practice or institution-based practice, how we can basically go step by step and start like basically using that. So these are like a simple step, like as Dr. Debas briefly mentioned, I think training is the key step, like probably the most difficult step that I'm gonna talk. And I spend most of my time about how to get to the training of the pockets, device allocation and the billing, which is also very important for a preservance of a program. In regards to training for pockets, as we all know, proficiency is what we are aiming for, which for either is endoscopic procedure or ultrasound or pockets, it takes long time. So anyone who is gonna be really good on any procedure should takes a lot of time. However, again, similar to endoscopy, there should be a minimum number to call it competent and just like that's gonna be like the number that we use for accreditation, meaning that the trainee should reach that number before starting the practicing independently. And not surprisingly, we don't have any guidelines for the accreditation or competency level for lever pockets because it's pretty new in this country and there was no study actually like about this, like what are the numbers that we have to aim? And we felt like that the best approach is to basically borrow from the groups that have higher experience. And in our experience, I guess like emergency department group has like this like highest level of experience. There is like multiple studies on the number of the cases as needed for each organ for the trainees to be competent and be comfortable. And one of the studies that I'm just coding here, the sensitivity and the specificity of like an image interpretation by trainees, in this case is gallbladder like findings, reach maximum at around 25 to 50 cases. And by looking at these numbers, like most of the emergency department group like pick 25 cases per each organ to sign off the trainee for doing the focus independently. And we kind of like follow the same pathway and in Stanford, like the consensus and like the meeting that we have, we chose 25 cases to be supervised, 25 supervised focus exam as a minimum number of cases that is needed for trainees to start scanning patients independently. And generally there is two pathway for this training, like just like a best, like well-established pathway is just going through a residency or fellowship. Mine are saying at this point we are not there yet because like just to having, just to adding the focus training to a fellowship program, variously like there should be like a few faculty members to train the residents or like fellows. And my goal is to just like add it to like transplant hepatology fellowship on one day, but I think we are not there yet. But to reach to that point, I think the approach that we are presenting is practice-based pathway, which means that like providers who are practicing take a few days off, a few hours a week to just get through trainings. And that's what we did at Stanford. Like the first step for the training that we went through is just like didactic course. And the didactic sessions can be both online and in-person. Of course it's like cheaper, more efficient to get it done as an online. And there are multiple companies providing these didactic courses or several books, which is like have like very, very comprehensive. At ASLD, we are going to have like just like a course which has like part of this like didactic information as well as DDW that we are starting to organize and set up. The second part, which probably did like the most cumbersome and expensive part is hands-on training. And there's two pathway again to get to do this hands-on training. Like the first one is just on-site training, meaning that if there is enough training and enough funding in your center, like you can invite expert to come to your center and invite the patients as we did at Stanford and basically get through training. But if you guys, if you do not have enough money or there is not enough like trainees to justify the like on-site course, ASLD, DDW, and Eazl have like POCUS courses. I think the first like POCUS course we are going to have at ASLD, this is going to follow with DDW. Hopefully we are going to learn from our experience and like make it better at DDW. And Eazl has been doing this courses for a few years too. So this is like what we did during our training at the Stanford University. We basically dedicated two days for the POCUS training, like seven hepatology in a group, like basically showed interest, they committed, they blocked their clinic, and they basically came to this course. We invited an expert, in our case from Europe, someone who is doing a POCUS for many years and has like published extensively about the liver POCUS. And in this two days course, which I just put some of like itineraries of like our training, you had like basically two, three hours of didactic course followed by like a scanning. We decided to spend most of our time on the scanning healthy volunteer and patients. We were able to scan 25 healthy volunteer, which were mostly like our like clinical staff and like patients. And the coordination was not too difficult. We basically tried to, you know, like ask the patient who were coming for the clinic within the same day, to just come to our like as POCUS training, like rooms and just get them a scan. So it was very convenient to just coordinate that. And after that two days, like all seven hepatology were able to scan at least 25 cases. The next step is going to be remote preceptorship. So although it's not needed for accreditation nor billing, we found that like, just like for us, because it's like a new, like just like program in our group, decided to just like extended our training with some remote preceptorship. This is again like optional, like we decided in our group, like you can just take it or not take it in your experience. But we just found that like, we are just going to feel much more comfortable to extend our training before like, just like doing it for patient care. And we discovered the same group were training us on site to like, just like we basically like ask the patient that we are still in training phase, scanning the patient, saving the video. Most of the ultrasound machine have this option of saving video in a USB device. And then we set up the readout sessions with our trainer and to reach another 25 case. And after that, this is a time that basically we decided to start scanning the patient in real practice. Okay. So the last part is basically competency assessment exam, which is mainly like done by the like, just like trainer that they just basically sign off and there's going to be like a very simple exam. And we believe like there should be like regular QA meetings like every three months in our center, that basically every three months we're going to meet together and just come up with the problems, come up with like issues that we face for POCUS care in hepatology. Now I'm just going to take a few minutes talking about billing. I think billing is very important to preserve and support POCUS in any institutes. And for POCUS coding is like the key. So according to 2000 national policy by American Medical Association, any qualified physician should be allowed to perform and bill for POCUS. And CMC also accepted too. So there is no need to get through training to bill for POCUS. The accreditation and the numbers that I presented is basically center-based. So like anyone who feels comfortable for POCUS can actually like scan the patient and bill for it. And just like roughly speaking about like this amount of reimbursement, the professional fee to do a POCUS exam is gonna be very similar to the limited abdominal ultrasound which is about 0.8 RVOs. We are actually working to actually include the technical fee in that RVO because usually we don't like, it's just like basically provider like doing the case and there is no technician involved, which is gonna like increase it a little bit. Also the facilities who are hospital-based clinics, they just basically have like just like possibly feel about 800. So for those of you who have their own practice or like having like a private practice group, like that's gonna be like very like a great way of like generating RVOs. And how to go through the billing, it's the workflow. Again, like it's very similar to the other things, other like procedures. Like we come up with like order base and basically we define certain orders and connecting them to the CPT codes. The CPT code is mainly like CPT codes that we were using for limited abdominal ultrasound and Doppler, which is 76705. And actually like just like our IVD group were also like using the same like CPT codes. And here you are. And then next we come up with like very standardized documentation, which is a key for billing. And this slide just presented what we come up in terms of like, it should be like, it's like a bullet point and like they provided you only click and choose it. It's not taking more than 30 seconds to fill this note. And what we come up like just like there is an order set connected to the CPT codes and our IT team made the interface that like the list of patient that I see in my clinic also show up on the like a screen of the ultrasound. So when we click the patient on the ultrasound machine, the images automatically uploaded to the patient chart and then the billing department by having the order note and the image upload, they can just basically proceed the billing. And that basically, that has been going on for multiple departments. So like in our center, it was not very cumbersome because they are already done it for like ED, for internal medicine, many groups. And we basically followed, we just basically created new order set based on our liver ultrasound orders. I'm just gonna like wrap up my talk with the summary that like we found in our experience that POCUS can be implemented in hepatology practice, training, creating order set, like making a template documentation and collaborating with the IDR key to just like get to this point. And like many department has already like established billing for POCUS. And we believe that like POCUS is a like, it's like great way of like generating RVs and reimbursement for provider and center. And training includes the both didactic and hands-on training. And we are happy that like to present that like at ASLA, we are gonna have the first didactic and hands-on training, which is gonna be followed by DDW, which is a great opportunity for people who are interested to start training on that. Thank you very much. I'm gonna wrap up my presentation and like pass it to Dr. Debes. I think Amir, do you wanna stop sharing and maybe do the poll questions? Yep. Okay. So, if you can do the questions, great. This is the first question. It seems we're having some issues with the poll questions. So we'll, oh, we have them here. Do you want me to read or? Sure, I think it's the same question I had before. If you wanna read them, we can put the questions we want. Same. It's gone now. Okay, I think we're gonna forget the questions. We are, I mean, the poll questions, we're gonna go to real questions. So thank you both for the presentations. I do now for the participants, please put any questions that you have in the chat. Otherwise we have some questions that we are curious about. We have a participant here asking, do you use Doppler for portal vein patency? I think I can let you answer that, but I think the answer is yes. I think a part of point-of-care ultrasound for the liver could be to identify the portal vein. It will be quite important. And I'm not sure, one has to be quite a master to define whether, you know, there is a clot, a partially complete, but I think the ability to identify the portal vein is patent or not, or if there are some issues in there that are enough to send for a standard ultrasonography or another test, I think that's part of focus. Would you agree with that or? I agree. And so it's a starting point. So, you know, you can learn just putting how to put the color Doppler. You know, it's just button. There are some physics and you need to learn adjusting color Doppler gains and stuff. And if you basically, if you see flow, you see blue or red, that's flowing. If you don't see flow, then, you know, you just try to just adjust things. I don't see anything. Well, that's, you know, suspicion for clot. Now it's not definitely, you know, sometimes portal hypertension, severe portal hypertension, just flow is so low that the, you know, below the Doppler threshold, filter threshold. So that's even like regular, the regular ultrasound, you get that, right? You get like, oh, I ordered ultrasound and then there's no color Doppler flow. They say portal vein no flow. And then you order CT. Oh, there's a flow that can happen, but that's the first step. And then that's something you can just do it. Oh, I don't see a flow. Then you can go to the next step. And I'm just going to add one point. I feel like just like as Dr. Davis and Dr. Yuko already mentioned, the main point of POCUS is like, you know, it's basically question-based. Like, you know, there is like minimum like part that you're going to like include just for billing. But if you have the like question on a certain patient based on the presentation, based on history, you can just basically look at it. And in my experience, like, let's say like, you know, you are thinking about like just like portal vein issues or portal vein thrombosis. And if you get POCUS and just find some like finding that like raising the concern, you can like directly send the patient to cross-sectional rather than just sending to ultrasound and then like cross-sectional, which is going to like be like time-consuming. And okay, so you want to- Thank you both. Then we have another question here says, I tried to register for the ASLD POCUS, but it is full. Is there any other way I can register for POCUS training? So there are, there will be two sessions and maybe you try it for a second one day. The first session got full right away. So we have to open a second session at ASLD. I think as of two days ago, there was a space in the second session. So you might want to try that. Otherwise, as Dr. Gogol said, there might be some sessions at DEW and we are planning to do this more fair of a permanent part of the meeting. So if you didn't make it for this one, there will be other opportunities coming next year for sure. A third question says, oh, how many sessions of POCUS trainings will be at ASLD meeting? As I said, we'll have two sessions. So there are two independent sessions that will be happening. And then while we wait, oh, so yeah. Same, I will try a second session. You're welcome. A bit while we, I don't know if there's any other question, but I had a couple of questions myself that I thought it was worth discussing. The first one would be for you, Amir. You mentioned about training for POCUS on trainees. And what do you think it would take to start training? I have two questions. The first one, do you think that GI fellowships should include liver POCUS on the training? And if so, what would you think that would be needed for that? A great question. And I think that's my goal. I think both the GI fellowship and more importantly, like just like transplant hepatology fellowship is a great avenue to get training for the POCUS. Like many program, including the program that I got trained on, like we were also doing liver biopsy. So it was very important. Always we had like ultrasound on our floor or clinic and we were not just able to use that. I think what is key to, I think the center who is providing this training should at least one like faculty member who is like expert to just like train the resident or fellow. And once they get to that point, I think devices are always there. Like, you know, patients, of course, like they're always there. And I think like trainees, including fellows and residents are interested to get this important like knowledge. And yeah, I think we are not just there, but I'm hoping like maybe in a few years after all these sessions, after like people like get like training and get to experience, we can just start including. And my hope is that like, you know, transplant hepatology fellowship should be probably the first place that we started and GI fellowship for fellows who are interested. Perfect. And I think that part of the question was that there is always this discussion, right? That a lot of trainees tend to gears towards advanced procedures or procedural GI because you do procedures and hepatology has less of that. So I was wondering if we start teaching more procedures related to hepatology, even at the basic GI level, the more GI fellows will be interested in hepatology, which I think we were looking for that. And I think there might be a question, the open microphone, is that right? James, I think you can talk now, I believe. You can unmute yourself. No, really? So maybe you can, James, can you type the question maybe? And we'll be happy to answer it. Sorry, can you unmute him? Or let's see. Oh, I need to unmute. Let me see here. No, I can't. That's okay. I think Jake can type the question. I think that could be better probably. And meanwhile, while we hear that, Yuko, I do have a question for you. You describe a little bit some of the difference between the expensive machines and the less expensive machines without obviously extending too much from here, but could you provide a bit more input in, you know, do we really need a fancy machine to do POCO? So you think handheld is enough or we should be somewhere in the middle? What are your thoughts on that? So I think everybody need to kind of decide which machine you want. That's why I think it's important to look at all the machines and stuff. These high-end machines, I mean, I use it all the time and it's nice. It has all the features including contrast, ultrasound, geowave, everything. But is it necessary? It's pretty big. It's not really portable. It's probably not for POCOs, right? It's for the regular radiology ultrasound machine. That's what we use. And then portable ultrasound machine, those laptop machines, it's pretty good. You know, it will give you a good image and it also has a lot of advanced features, but, you know, it's still a little more expensive. It's, you know, it's not gonna fit in your pocket. And then POCO, this handheld machine, it's really nice. It's not expensive. It's, you know, small. You can put in your bag, you can put in your pocket, but image is not as great as these other machines. But can you see things? Sure, you can see liver, you can see the kidney, you can see ascites. So depending on what's your need and what's your, you know, practice, what's your budget, I think you, you know, each practitioner should choose which one. Perfect, thank you. And then one more question, I'm interested in both of your opinions. When we started doing this and pushing this forward, it was always a question of resistance from the radiology department of each institution and whether there is an issue or not. I have my own thoughts about it, but I was curious from both of you, you're training in radiology, you do CS, you do contrast-enhanced ultrasound, what your thoughts are on that? And then Amir, what your experience was with the department of radiology at your institution, if you can both comment on that. So, yeah, maybe Amir has more experience because, you know, he's doing that, because I haven't, but- Exactly. In our experience, like we didn't get any resistance because I think like, as both of you guys mentioned, like POCUS is very different than what they are doing. It's like basically two scopes of like care. We are gonna like, the main purpose that we are doing POCUS is to do a better like care as an in-person like clinic visits. And it's not gonna replacing like the work. My experience, like it's like for the department of radiology, they're already like, you know, like, you know, overwhelmed with a number of like, you know, ultrasound requests and so they're more than happy if some of the like, you know, the POCUS can basically decrease their load and screen the patient who needs like MRI or CT scan. Our short experience, like zero resistance, zero complaint, zero, and actually a lot of them that are helping, actually the team who are helping us to get the billing, everything, they are from radiology team, who basically were experienced and we asked them to help and they basically shared. So the way that like we made this workflow part of that was the help by radiology. So basically they were supportive. That's nice to hear. And, you know, I hear, you know, we are really actually doing a little bit of POCUS at UCSD, but, you know, when I talk to, like we go to ultrasound meetings and there are lots of POCUS sessions and I hear a lot of like radiologists saying, well, you know, POCUS, that I see that sometimes, but I think it's a communications and in your own institutions, you communicate with them. I think they'll be, you know, always supportive and helpful. Okay. So what I hear luckily is that there doesn't seem to be a lot of, or there won't be a lot of resistance, which is nice. And I did not see the question from James typed in here. So he's not able to type right now. And I don't see any further questions. I don't know if Dr. O'Connor, Dr. O'Google have any questions for us. Otherwise I think we'll probably wrap it. And see if any other questions from here. Not really. Okay. So I think if you guys are okay, I think we can wrap the session. I think to me, this has been great because it's been very informative. That has been a good discussion. As Dr. O'Connor, Dr. O'Google said, we will be at ASLD in San Diego this year and we'd be providing two training sessions for point of care ultrasound. And hopefully this can be the start of a new era. I think that of a tool that we can all use to become better physicians and to improve patient care and decrease the burden. Having said that, I want to thank you both of you for this and thanks to the ASLD for supporting this. And we'll see you all in November, hopefully. Thank you. Thank you. Thank you for this.

Liver POCUS

Clinical Practice

Training Steps

Billing and Documentation

Ultrasound Machines

Medical Curricula

Diagnostic Capabilities

Patient Care