When most people hear the word ultrasound, they picture a pregnant woman getting to see the baby growing in her womb. But for emergency physicians like Dr. Paul Olszynski, an ultrasound can be the gateway to correctly diagnosing patients in the emergency department.
Dr. Paul Olszynski
The Saskatoon Health Region Emergency Department (ED) Physician and Director of ED Ultrasound recalls one patient in particular who presented to emergency in what was suspected to be septic shock, a life-threatening condition that happens when a person’s blood pressure drops to a dangerously low level after an infection.
“As part of the assessment, I decided to do a cardiac ultrasound scan to assess how the patient’s heart was pumping and to see how she would handle the intravenous fluids we were going to give her,” he says. “To my surprise, I found that she was not showing signs of septic shock but of right ventricular strain, which can occur in someone who develops a massive blood clot in the main pulmonary arteries. Suddenly, the picture changed dramatically. This was no longer a patient who needed antibiotics and fluids but a patient who needed blood thinners and ultimately clot busting drugs.”
As a result of the ultrasound, the patient’s care was appropriately redirected and she made a full recovery. Ultrasonography – a technology that interprets echoes of ultrasound waves to produce images of internal body structures such as muscles, joints and internal organs – is so effective that Dr. Olszynski says it is becoming as prevalent in medicine as the stethoscope.
“Just like a stethoscope can be used by a paramedic, nurse, family physician and cardiologist at different levels to assess patients, ultrasound is being used to help clinicians in different disciplines assess patients at the bedside and answer specific questions we might have,” he explains, adding that in Saskatoon 80 per cent of emergency physicians are now trained in the core applications of emergency department ultrasound.
“Emergency medicine is a specialty that has embraced the use of this technology enthusiastically,” he says. “It is often said that in Medicine, the diagnosis is 80 per cent history, but often patients who come to emergency can’t provide us with their medical history because they’re too sick or injured. Ultrasound allows us to see inside the patient and get a better sense of their injuries; for example, a hole in the lung, kidney obstruction or blood in the abdomen.
“The beauty is that it’s not invasive,” he continues. “We don’t need to put needles in people or expose them to radiation, and it can be done right at the bedside because ultrasound devices are portable. With ultrasound, it has been proven it takes less time to make a diagnosis, we’re more likely to get the correct diagnosis, and it decreases cost by allowing for more targeted management and therapy early on.”
Dr. Olszynski’s passion for advancing the use of ultrasound at the bedside spans a decade, when he was introduced to it shortly after completing a residency in emergency medicine. But the route to find his passion was anything but direct.
“It took me seven years of training – four years of medical school and third year of residency – to find something I was passionate about,” he says, explaining that he initially wanted to be a pediatrician.
“I came to realize that wasn’t the best fit, so I changed direction and went into family medicine thinking I would work in a rural area. When I finished training in family medicine, emergency and acute care terrified me, so I thought I needed at least an extra year of training in emergency medicine to get more comfortable.”
It was three or four months into his third year of residency in emergency medicine at Royal University Hospital when Dr. Olszynski realized that he liked the challenge of managing acutely ill or injured patients.
“I like the quick pace, the problem solving and the team dynamics,” he says enthusiastically. “There’s very little hierarchy in the emergency department. Each member of the team plays a really important role, and I really like that collaboration. I tremendously value the colleagues I work with, whether they are doctors, nurses, residents or paramedics. There’s such a great team dynamic that is really rewarding.”
As the Director of Emergency Ultrasound, Dr. Olszynski is also responsible for ensuring that all physicians and residents who use ultrasound in the emergency department have completed approximately 50 hours of training with supervision, in addition to a three-hour exam, to show they have an appropriate standard of expertise.
“The hardest part for people learning to use ultrasound technology is image generation,” he says. “If you don’t have the image generating skills, you’re going to create bad data, and bad data is going to lead to bad decisions.”
Another important aspect of ultrasound is monitoring for quality. Recently, with funding from the Royal University Hospital Foundation, the emergency department acquired Q-path software, a wireless image archiving system that enables emergency department physicians who perform ultrasound examinations to wirelessly export a still image or four-second video to an internal server for review, store the exams and manage quality assurance, credentialing and reporting.
“It’s very exciting – it’s the next level,” he says, explaining that before Q-path, the performance review process was cumbersome because the ultrasound images could not be saved.
“We did chart audits, but chart audits are really difficult when you don’t have images to compare to. All we had were patient chart notes describing the ultrasound findings and supporting evidence from other images like a CT scan the physician may have ordered.”
Last year, the data generated by these chart audits showed that 94 per cent of ultrasounds performed by emergency department physicians were concordant with other imaging results. Nearly four hundred scans during a six-month period in 2015-16 were reviewed.
“Where we made mistakes was in calling false positives. If you’re going to make a mistake, that’s the kind of mistake you want to make – overly cautious. For example, someone said a kidney was blocked when it turned out it wasn’t,” he explains. “The most important thing was that there were no false negatives. There was not a single case of a patient being sent home and told they don’t have a condition when it turns out they did.”
The Q-path software is an enterprise-wide system, meaning that within the next few years, other departments like anesthesia and intensive care that use ultrasound will also be able to access the system.
“I fully expect it to become this multidisciplinary, point-of-care, quality assurance and improvement system that will enhance our research and training capabilities by allowing trainees to upload and send their scans to instructors who can’t always be present at the bedside. That’s really exciting, especially as we’re a training hospital,” says Dr. Olszynski, who is also a Clinical Assistant Professor in the Department of Emergency Medicine and Director of Clinical Ultrasonography with the College of Medicine. This past year, he received an award for Preclinical Teacher of the Year through the Student Medical Society of Saskatchewan.
“It’s quite a privilege,” he says of teaching medical students. “You’re working with some pretty bright minds, and it’s amazing what they can do. Paul Kulyk is a great example. He approached me about five years ago after a couple of lectures and said, ‘I have a background in engineering, and I can help you build an ultrasound machine.’ My answer to him was that I have a great machine in the emergency department, but what I didn’t have was a good way of using ultrasound during training simulations.”
The next day, Kulyk emailed Dr. Olszynski with an idea that led to their invention of an emergency department ultrasound simulator for critical care simulation, the edus2TM – a portable bedside ultrasound device that provides trainees with the opportunity to practice generating and assessing ultrasound scans. The edus2 is linked to a probe that, when passed over radio-frequency identification cards placed under the skin of a mannequin, triggers predetermined video clips to play. The videos can help simulate multiple scenarios, including cardiac, abdominal and pelvic pathologies that may benefit from assessment with ultrasound.
“We didn’t patent it or commercialize it, we made it open source so that anyone with a used laptop and about $70 in hardware can build it by following the instructions on our website,” Dr. Olszynski says, adding that several residency programs across Canada and the world are now using it.
In 2013, Dr. Olszynski travelled to the London Specialist School of Emergency Medicine as an Honourary Academic Fellow to study the impact of the edus2 on resident learning for a Masters of Education that he completed in 2014 and to learn how to perform focused/limited echocardiograms (cardiac ultrasound).
“We had the residents use the ultrasound simulator for some cases and not use it for other cases. Everyone felt that the better learning experience was with the simulator,” says Dr. Olszynski, who is also the author and curator of SaskSonic – a virtual hub for all things related to point-of-care ultrasound at the University of Saskatchewan, and contributor to the creation of an emergency ultrasound curriculum proposal for emergency medicine trainees that he and his colleagues are hoping will be adopted nationwide.
“With advances in technology, and everyone walking around with smart phones, I think there’s a societal expectation that physicians are going to be able to do a lot more at the bedside than they once could, and the reality is that with ultrasound we can,” Dr. Olszynski says, adding that his goal is to ensure Saskatchewan can keep up with worldwide advances in point-of-care ultrasound.
“I’m excited that we keep moving forward and making progress in ultrasonography,” says Dr. Olszynski. “Every year, we’re improving patient care and making advancements in emergency medicine. But I think the best is still to come – there’s still more we can do.
“Whether I’m using ultrasound or not, I find that the most gratifying thing about emergency medicine is when a patient presents with an illness and I’m able to identify what is going on and initiate treatment – that’s medicine at its most satisfying,” he adds. “I also really enjoy teaching. The most satisfying thing about teaching is that look on a student’s face when it clicks – the fog clears away and it’s obvious that they grasp what we’re talking about. That’s pretty great.”
When not treating patients in emergency, breaking ground in the area of ultrasonography or teaching, Dr. Olszynski likes to spend time with his family – his wife and three children, aged 12, 10 and seven.
“The way to cope with the stress of emergency medicine is to have a balanced life and to be active physically, which goes hand-in-hand with raising children – we love camping, canoeing and going for bike rides,” says a man who grew up with an identical twin brother, who is now an environmental lawyer.
He and his brother were two when their parents, also physicians, immigrated with them and their sister to Canada from Poland.
“I love Poland. It’s a beautiful country – people are passionate and full of energy,” he says, seemingly unaware that he embodies the same qualities – he also trained in a rural health centre in Mozambique as a medical student for six weeks to learn about community engagement and participatory action in health care.