HN user
ICU physician / anaesthetist
For circumstances like this I create a VM with a version of MacOS that the app works with, and keep it on life support that way (doing this at the moment for Finale, music notation software that works well with Piano Marvel and thus gamifies piano practice for my kids…)
Similar program in Melbourne [1] https://sjtrem.biomedcentral.com/articles/10.1186/s13049-023...
(There are similar programs around the world with different models of care, notably in Paris, Albuquerque, the Netherlands and Regensburg, Germany).
I had this question and needed this answer - thank you
A counterpoint on focused ultrasound for essential tremor - just because you don’t penetrate the brain with a physical object doesn’t mean you don’t have side effects - as usual, benefits come with risks
https://jamanetwork.com/journals/jamaneurology/fullarticle/2...
I own the 1st gen of the Butterfly - in my opinion, it wasn't great image-wise compared with the contemporary conventional crystal based probes (thinking of cart-based machines with less flexible, more expensive probes etc so perhaps an unfair comparison). Would be cool if the newest ones mentioned in the article are becoming comparable with the crystal based probes - I can't comment. But I can say image quality is absolutely key. There are lots of cool AI based applications coming out all the time (I know much more about echocardiography AI than the foetal ultrasound AI mentioned in the article, but this is a similar paper where some ultrasound novices had AI guidance and were able to obtain useful echo images https://www.ahajournals.org/doi/10.1161/CIRCIMAGING.123.0155...). I get to use various machine vision based tools on echo images at work to automate various measurements - but at the moment, I find they fail badly if the imaging is anything but great quality, whereas humans can interpret them. Maybe future training sets will include more "technically difficult studies" (code for poor imaging) and AI tools will do better than they do now? Or there will be more augmentation of data sets with realistically degraded versions of images to add robustness? AI that worked on suboptimal images would be awesome, particularly in my setting (ICU).
Read this on mobile and the identifier longWindedNameThatYouCantReallyReadBTWProgrammersDoThatALotToo overflowed into the margins - I regard this not as a bug but a feature which helped make the author’s point :-)
Not quite the same but when we were rebuilding during COVID we knew we wanted two good WFH spaces but really only had room for one (tiny) office - as our second we built a shelf in our bedroom wardrobe that lifts up to reveal a work surface and a 32" monitor - inspired by this guy's work on ikeahackers:
https://ikeahackers.net/2020/10/fold-out-desk-home-office-pa...
Works really well and given the cost of space for a second desk it was a very cost effective solution - only minimally affects the utility of the wardrobe as a wardrobe. (We didn't build the laptop holder this guy describes, the laptop just gets sat on top of the clothes in the drawer below that shelf with attention to make sure we're not blocking a fan intake. We had a powerpoint and a ethernet port put into the back of the wardrobe but actually we just end up using Wi-Fi mostly.)
I'm a doctor (ICU) who also does some IT stuff for work (nothing complex, mainly writing small web apps). I really enjoy writing stuff where you know the requirements, make all the decisions, write the code and maintain it. However, doing this has allowed me to get some exposure to what bigger projects with lots of moving parts, data sources, stakeholders, regulatory requirements etc look like - and it's seriously hard work. Nothing like "coding, the hobby".
I guess this commonly occurs in many fields at a certain level of seniority - the "managing a large system involving many people" aspect can dominate the domain-specific part, be it software engineering, accounting, manufacturing etc. As such I'm really glad I chose medicine rather than SWE (even though I've been writing and loving code for >35 years, and it was a real toss-up when I went to uni) because:
1. You can still stay very hands on, even as a senior clinician, especially procedurally.
2. If you so choose, there's a lot of variety in what you find yourself doing as a doctor (my mix looks like making clinical decisions / talking to patients / families / doing procedures / performing and interpreting ultrasound / going to other hospitals to retrieve super sick patients and bringing them back in ambulances / mentoring / teaching / coding / managing a clinical service / etc - but there are lots of other options too). I'm not sure if this kind of variety is as easy to arrange as a SWE? (though I suspect I'm about to be corrected, thanks in advance.) Variety is quite important if you're easily bored, which is a common problem for bright people.
3. Although AI is coming to all fields, I do think the impact will look more like "better tools", rather than "job replacement", or "vast reduction in number of people needed", for longer in medicine (at least in my area). As a breadwinner this is a not inconsequential consideration.
Hope you find the career you love, and that it leverages the work and study you've already done in some way.
A 27 or 30G insulin needle with some lidocaine (still often called lignocaine here in Australia ) is a nice addition to this procedure. I rarely omit it unless the patient is unconscious. If you inject the local anaesthetic under real time ultrasound, it can also serve as a seeker so you see if you’re off target with the 30G needle and adjust based on that information, which improves your success with the larger (commonly 22G) needle used to take the gas. Not unreasonable to request local anaesthetic, really - it is known to be a painful procedure.
For really small kids we tend to use a transilluminator rather than ultrasound for peripheral IVs (though it doesn’t tell you the depth like ultrasound does). For CVCs or bigger people, ultrasound is often very useful. Like all things, experience makes a big difference! In my opinion, for known tricky veins (in adults at least) it’s best to use local anaesthetic from the outset - it does make it slightly harder but if (when?) you miss it’s easier to keep the patient on side for the next attempt.
Edit: YouTube link to a transilluminator being used - beware the video does have an unhappy child in it
The documentary The Crash Reel is about a snowboarder who gets a traumatic brain injury, but the comments of one of his brothers (who has Down’s syndrome) on his life and on his family form part of it - really interesting to watch
I also wonder how much it might heat up the brain? And whether that would be a problem for sustained use? (In practice this heating effect is occasionally limiting for some other forms of ultrasound (e.g. TEE) requiring you to take a break or reduce the power.)
What other tools did the hospital open source this year?
In my experience the commonest current mainstream use of this is for Sezary Syndrome / mycosis fungoides (cutaneous T-cell lymphoma). See for example:
https://my.clevelandclinic.org/health/articles/8493-mycosis-...
As others have commented above, reducing the rate of spread (social distancing and hygiene, and convincing others to do likewise) so that this is a more smeared out event with a lower peak need for equipment and staff is the most important intervention. It's also very hard to do; not sure if there is a technological lever that will move the needle on this (advertising?)
Agree. I'd add that my comment above about exhalation being passive is true in adult ICU practice. In high frequency oscillatory ventilation (HFOV) exhalation is active (a piston actively creates a negative pressure in the breathing circuit). I understand this is still used quite a bit in neonates (though I don't do NICU, so not an expert) but has gone out of favour in adults in a big way due to the results of trials like OSCILLATE (https://www.nejm.org/doi/full/10.1056/NEJMoa1215554). Probably still used in some centres as a rescue therapy, but I haven't used it in years (we'd use VV ECMO for that purpose).
Actually exhalation is passive, not active, in modern day ICU ventilation.
- COVID-19 seems to be mainly hypoxic respiratory failure, not hypercapnic respiratory failure
- NIV (Non invasive ventilation, CPAP is essentially a form of this) doesn't typically perform well (on a patient outcomes, mortality basis) for pneumonia with hypoxia compared with invasive ventilation. However, this is thought to partly be because NIV delays the decision to proceed with intubation and ventilation. If there is no ventilator available, that might change the value of NIV.
- NIV will also likely cause aerosolisation of the virus facilitating spread if there are others in the area. Most sleep apnoea CPAP masks are vented which would probably make this worse (cf unvented masks commonly used on ventilators in an ICU setting)
- Many sleep apnoea CPAP machines don't allow entrainment of supplemental oxygen, which would be likely to be needed in critical COVID-19 infection
Source: I'm an intensive care specialist
I’m going to wait on this until at least a few months have elapsed and the reviews / forums indicate the keyboard is fine.
I'm sure I'm not their biggest customer, but I have bought in the hundreds of dollars worth of books each year from O'Reilly for the last few, consumed as DRM free PDFs. Definitely going to re-evaluate that. When I want to buy a book on a topic I used to Google "O'Reilly <insert topic here>" as my first port of call. That just ended. I'll look to other publishers first instead, and cease recommending O'Reilly.
As an intensive care specialist (what would be called an attending in the US) I find it best to control my emotional response to my job. Also, empathy is probably not as wise as compassion in this context, from a career longevity point of view. If you find during your training that you have difficulty setting emotional boundaries and regulating your emotional responses, consider choosing a specialty with fewer unhappy endings (though probably not something with a strong pattern recognition component such as radiology or anatomical pathology, given technological progress in that area - you'd have to expect that we will need less of them as time goes by). There's lots of scope to do less emotionally taxing but still very useful and satisfying work if that fits your aptitudes better.
I'm a doctor who is qualified in echocardiography and other ultrasound techniques, teaches ultrasound to other doctors, and who uses machines from multiple manufacturers regularly. I've also been computer programming, and generally interested in comp sci, for 30 years.
My 2 cents worth on differences between more expensive vs cheaper ultrasounds, how ultrasound has changed over time, etc is: * ultrasounds are getting cheaper and better. Harmonic imaging was probably the biggest advance for me. * because of cheaper, better machines, many more doctors are using ultrasound than before. A real challenge is making sure they are appropriately trained to use ultrasound to get the most useful images, that they appropriately interpret what they see, and recognise their own limitations. The results you get from ultrasound are highly dependent on the training and experience of the operator, more than most other imaging modalities. Although some techniques are easy to learn, many require substantial training and experience. Putting ultrasound in the hands of someone who doesn't know how to interpret the findings is not risk free. * there is a significant increase in image quality and the modalities available with more expensive machines (although this does not seem to be a linear relationship over the range of price; once you get into the top echelon of machines, differences in cost between them doesn't necessarily correlate with their capabilities). * With more challenging assessments, these differences in image quality and modalities can mean the difference between a diagnostic and a non-diagnostic scan, and change management and outcomes for patients. However, there are some techniques (e.g. vascular access) where entry level machines are usually adequate, particularly if you have access to a better machine for challenging cases.
Although I'd love to see the quantum leap in imaging quality that some startups are apparently aiming for, I'm not holding my breath. That doesn't mean I don't see a lot of potential for technology to improve though - some things I expect or hope to see over the next decade or two are:
the application of computer vision and machine learning techniques to assist with the interpretation of scans. This is already happening a bit (e.g. strain imaging, automated 3D ejection fraction) and it's an active area of research. It has the potential to improve reproducibility of assessments. Maybe, just maybe it will get good enough to help mitigate the problem of less experienced operators using ultrasound.
multimodality fusion for interventional procedures - already, you can do a TEE (a kind of heart ultrasound) and fluoroscopy (video version of X-ray) and fuse the two images in real time to guide cardiac interventions. Maybe this will extend into other areas: e.g. guiding vascular access by fusing accelerometer / gyro / magnetic positioning / video camera data with ultrasound
virtual reality or augmented reality applications to accelerate the acquisition of ultrasound skills. There are already simulators but they're expensive; as they become cheaper and more doctors have access I'm hopeful we can improve the learning curve for image acquisition a bit!