SCCM Pod-515: Ultrasound Training and Humanitarian Missions

Host Maureen A. Madden, DNP, RN, CPNP-AC, CCRN, FCCM, is joined by Susanna Rudy, ACNP, DNP, to discuss her journey from developing ultrasound training programs to volunteering in conflict zones and pandemic hotspots. She also highlights the crucial role of advanced practice providers (APPs) in critical care. Dr. Rudy is an acute care family medicine and emergency medicine nurse practitioner at Vanderbilt University in Nashville, Tennessee, USA. Dr. Rudy believes in seizing opportunities for professional growth and humanitarian service.

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Transcript:

Dr. Madden: Hello and welcome to the 2024 Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Maureen Madden. Today I’m joined by Susanna Rudy to discuss APPs’ crucial role in ultrasound and international medical missions. Dr. Rudy is an acute care family medicine and emergency medicine nurse practitioner at Vanderbilt University in Nashville, Tennessee. Welcome, Dr. Rudy. I’m going to talk to you as Susanna. Before we start, do you have any disclosures to report?

Dr. Rudy: I have no disclosures. Good morning to our listeners. I’m happy to be here.

Dr. Madden: Excellent. I’m so excited to talk to you. You have an amazing history of your advanced practice role, your humanitarian missions, and you’re continuing to develop so many other aspects that I think APPs, as well as all other people involved in medicine and critical care, could really benefit from hearing some of this, even if you’re like a little bit of an armchair warrior in that regard. I know that you’ve taken on some of the role of learning the ultrasound and the utilization of ultrasound. Tell me a little bit about how you got involved in that.

Dr. Rudy: My quest with ultrasound really started in my advanced practice program. I trained in Vanderbilt School of Nursing in 2012 and, at that time, ultrasound wasn’t a skill that we had been using.

Dr. Madden: No, I think it was just starting to really make sure everybody knew the value.

Dr. Rudy: Right. I had had an interest in it because I had done part of my clinicals at the University of Maryland and they used it frequently. They’re heavy on advanced practice run and up on all the latest and greatest things there so they were frequently using point-of-care ultrasound. When I came back from that clinical experience, I had mentioned to my course directors, hey, they were using this point-of-care ultrasound, do we have an opportunity to do this?

Being as supportive as Vanderbilt has always been, they thought that was a great idea, so we contacted the various ultrasound companies and asked for some representatives to come during our workshops. That’s how the introduction to point-of-care ultrasound came for me and I fell in love with it. From there, I went on to continue to use it during our workshops, just a brief little introduction, but no formal training. When I had my first formal training in point-of-care ultrasound was when I did a fellowship. I did a critical care fellowship at Emory. An excellent opportunity.

Dr. Madden: Another great environment for APPs.

Dr. Rudy: Yes, excellent opportunity. Part of the program was learning point-of-care ultrasound. From there, after I did my critical care fellowship and I finished school, finished the doctorate program. Vanderbilt actually tried to recruit me back successfully to come and teach in their emergency medicine and critical care programs. It was at that time that I knew that this was a fundamental skill for nurse practitioners.

At the time, training and education in it was limited. It was expensive, typically remote, and it wasn’t as available to us as nurse practitioners, even students. So I thought, well, let’s try to develop a program that we can incorporate into our curriculum. So that’s what I did. In 2018, I developed a 14-week program for Vanderbilt University School of Nursing that all of our critical care and emergency nurse practitioners took, and even the pediatric nurse practitioners took.

The great thing about that was, because it was evolving as we did it every year, we recognized that not everybody needed to learn the 12 emergency ultrasound exams. The critical care group was able to pull off and develop their own focused program for the acute care folks. Then the pediatric acute care folks also were able to pull from that and then develop their own program. So it was just moving, you know, paying it forward, so to speak, so that we knew our graduates, when they left the School of Nursing, would have a nice foundation and have a good start on being able to learn point-of-care ultrasound. Always encouraged to, obviously, it’s a skill that you have to use repeatedly, be able to go to other courses and pick up more information and hone their skills.

Dr. Madden: This is fascinating to me because I will say, I predated you in terms of educational time frame, and a lot of the training that I had was direct visualization, landmarking, etc. Tell me how you’ve had the experience on trying to help and educate people who, their psychomotor skills are so ingrained to do it differently. I feel like I try ultrasound and I need a third hand and I don’t have it.

Dr. Rudy: Right. I modeled a lot of the program after the opportunities and the education that I got just in my clinical experience and with my fellowship and also attending other courses. I came to the Society of Critical Care Medicine’s courses. I also went to the CHEST courses. I did that on my own because I knew I needed to kind of learn to a different level.

I learned a lot from those courses and I brought them back and I basically developed the courses and embedded into their curriculum. It’s a semester course and they have hands-on in the front and in the back and they have testing all throughout and learning modules all throughout consistently. But we used the ultrasound companies that would allow us to have their machines. They had representatives who would come. We were able to have a full-on workshop with hands-on training.

Dr. Madden: I think there’s going to be a lot of people trying to contact you after they hear this podcast, to hear about how you managed that.

Dr. Rudy: Feel free to reach out to me.

Dr. Madden: Be careful what you ask for.

Dr. Rudy: I have it all laid out. But anyway, so the students, it’s a new skill, it’s fascinating. They understand it’s probably the stethoscope of the 21st century. What we first could only feel here, we can now see in real time. So they understand and it’s obviously now a standard of care in a lot of places. Students are absolutely excited. They’re wanting more hands-on. That was the limiting factor. Like with any course, you have it a couple times because of logistics and things like that; they want repeatability.

Dr. Madden: That’s the other thing that I’ve learned as people talk about it, and it’s with anything, you have to have the repetitive exposure, repetitive experience, and that’s how you improve your skill set. Depending on where those opportunities lie or the concept that other people also need to do the same thing in the clinical environment, sometimes it becomes a little bit challenging to carve out. You’re practicing on people who don’t necessarily, you’re not intending to do anything but just taking a look or things such as that.

Dr. Rudy: The other thing that was really great about this for me personally was that I just saw how it empowered the students and the nurse practitioners to know a skill and to feel confident in the skill, because by the time they were done with the course, they really felt confident and proficient in being able to do basic skills, the basic FATE exam, basic eFAST exam, and they were confident enough that they could actually teach somebody else to do it, which is really important when they’re going out into clinical practice.

Maybe at a facility or site that has an ultrasound machine, but it’s either, nobody really knows how to use it, or they don’t really use it, or they’re not comfortable using it. So this gives them the feeling that they’re empowered, hey, I know how to use this. I know how to turn the machine on, I know what these probes mean, and they go into it. From there, as I said, I had come to the SCCM courses, very dedicated in doing that, the fundamental course and the advanced critical care course.

Through there, the physicians have all been fantastic and wonderful, and they recognized my passion for learning ultrasound and they took me under their wing, so to speak. I joined the Ultrasound Committee and from there, they wanted to start a junior faculty program, so with that, meaning a novice faculty working for Society of Critical Care Medicine teaching in the fundamental course.

Dr. Madden: Excellent.

Dr. Rudy: So that’s how I started learning and it’s just through the people that you meet here. SCCM is very supportive, very encouraging.

Dr. Madden: How many years have you been teaching?

Dr. Rudy: The fundamental course, not very long, less than two years.

Dr. Madden: Did you have the opportunity here at Congress already?

Dr. Rudy: Yes, actually I did.

Dr. Madden: How’d it go?

Dr. Rudy: It was actually in San Francisco was the first course, which was like last year. Yeah.

Dr. Madden: But you taught in Phoenix this time too?

Dr. Rudy: No, this time we trialed a new introduction to point-of-care ultrasound course in managing sepsis. We’re looking at the subcostal view and all the things that we can do with looking at the subcostal view. It’s a fantastic course. It’s new. Hopefully it’ll be okay that I’m mentioning it because I know it’s kind of like a pilot. It’s a fantastic course and we had a lot of APP representation for students this time and it just gives you what you know. It’s very focused, honing in on the skills of obtaining these views and then being able to interpret the views and then giving management strategies that are very algorithmic and kind of what we in critical care like to be able to have this process. That of course is going to take a lot of repetition, a lot of visual memorizing what a normal is and what an abnormal is and then how to manage that.

Dr. Madden: I love that you have all of this passion and experience. Unfortunately for the podcast, we don’t have so much time to talk about everything I’d love to talk about because you have so many other things that I think the utilization of the ultrasound and just some of your own visions and passions have led you to do something. Tell me about your recent experiences that you’ve worked with the Society because of your own initial endeavors. I want you to lead into that without telling the surprise.

Dr. Rudy: Without prompting me. Okay.

Dr. Madden: What I really want to know is, tell me about Ukraine.

Dr. Rudy: Okay. Yes, in order to talk about Ukraine, I’ll talk backwards a little bit about humanitarian work. That’s my passion. If I could do that full time, I would. Eventually maybe I will. I’ve been doing humanitarian work since 1994, so that gives you a little idea.

Dr. Madden: In what capacity, when you talk about that?

Dr. Rudy: Well, I did a lot of education and training in the Baltics.

Dr. Madden: As a healthcare individual?

Dr. Rudy: I was working as a nurse at the time. I have 30 years of nursing experience prior to my advanced practice.

Dr. Madden: How did you choose the Baltics?

Dr. Rudy: Well, actually, I taught ACLS and PALS over there, a train-the-trainer kind of thing. We set up that system over there back in the 90s. From there, I did a lot of kind of first responder emergency stuff. During the tsunami I was a part of a first responder team that went over to the island of Neos after that earthquake. I had gone two other times.

Dr. Madden: I think several of us are going to have to pull out a map to figure out where Neos is.

Dr. Rudy: In Indonesia. One of the many islands of Indonesia. I was also part of the disaster medical assistance team, DMAT team, in California. So I have a lot of humanitarian training, disaster management training. I always have that passion whenever there’s a disaster, a world event, it’s just the nature for me and for many people I’ve met in the medical field to want to go help.

So of course, when the war broke out in Ukraine, it was personally devastating for me for reasons I couldn’t explain other than I knew I needed and I wanted to go there. And it just so happened, because of my previous experience, there had been some friends who had reached out and said, hey, we know some teams over there that are looking for medical people who want to do basically medical things.

It really wasn’t spelled out exactly what I would be doing, but I was like, yeah, sure, sign me up. So I went over there supposedly to meet up with an initial NGO team. But when I had gotten there, they had not set their medical up yet. So they said, we’re going to put you with another group, which happened to be the Life Changer. So circumstances always happen in your favor.

Dr. Madden: What was the time of this? What month?

Dr. Rudy: It was in March. The war broke out in February. This was March. I ended up with a team called the Academy of Emergency Medicine, a Slovakian NGO that was established in 2014. They do humanitarian and disaster response in austere environments, tactical medical. Only their interpreter spoke English. The other ones didn’t. I arrived in Ukraine and ended up being forwarded to this team, who was gracious enough to accept a total stranger, that didn’t speak any English. They basically handed me a helmet and a chest plate and said, OK, we ride at dawn, basically. We’re getting our medical kits and we’re going. I said, well, where are we going? They said, we go to the east, and I said, OK. So literally, I was in a car for 8 hours riding, and we ended up very close to the front lines. And our job was to train combat medics.

Dr. Madden: At any point in time, were you saying in your brain, what did I just agree to?

Dr. Rudy: Yeah. But the key is, I think the thing that saved me was I didn’t know what I was getting into until I got there. Then, you know, obviously there was fear there for the first couple days. But I was focused on the mission, and the mission was we had to train these combat medics, and the combat medics consisted of civilians, civilians who had zero medical experience. Fortunately, we had a lot of medical gear and stuff, but they had zero idea what to do with it.

Our job was to give them a very intense training period of 2 to 3 days and then they sent them out to the field. Unfortunately, the medics in Ukraine are very high-value targets. So we had a lot of training to do consistently, and they’re still doing it today. That was my first experience. I came back from that experience directly off a plane to go to a course in Chicago for SCCM. So I literally came hot off the plane to do my training session.

Dr. Madden: Which course?

Dr. Rudy: It was one of the fundamental courses, I think. To see how well I could scan, make sure I was okay to be a junior faculty. Everybody evidently was fascinated with that story. I ended up speaking to them about logistics and things like that, and the needs. There’s a forward need for ultrasound capability on the front lines for these guys who are in the forward cash units, so to speak. The casualties come off the field, and they’re stabilized in the stabilization area, and then they’re transported by various means to the hospitals that are hours and hours away.

There’s no air travel at all in Ukraine. I recognized that need and, through some collaboration, SCCM did ask me to come to the ultrasound course that they were going to be offering in Lviv the second time. I was able to have my interpreter that was my lifeline come to the course, and I was able to get some of the AEM guys I worked with trained in ultrasound. They recruited physicians from the front line to come to the first course in Lviv. Which was, to me, I was so proud, because I knew that that was a vision that I had, that these guys need this, and that was recognized.

Dr. Madden: You should be incredibly proud. I’m having this moment right now thinking about, you truly already have so many points to know that you’ve made a difference. And you certainly are helping the Society continue to make a difference.

Dr. Rudy: Thank you. From there, SCCM knows, and they’re sending teams to train the trainers. There was a team that actually went and trained some of the frontline physicians to continue the training. That’s really wonderful and empowering. Then we went a third time, also part of a training-the-trainer kind of course.

Dr. Madden: I’m sitting here just trying to think, I love the opportunities that I have outside of my comfort zone to go to other environments and feel that maybe I made a little bit of a difference. And I always learn something more, I think, from the people I get to engage with outside of my environment. But I’m thinking about, could I do what you did? As you said, maybe because you didn’t really know what you were getting into. But tell me how that has impacted your vision of continuing to get more advanced practice providers engaged in this. Tell me how you think they can become part of that or just grow, or figure out how do you do this between academics and clinical work and your personal life? How do you make it all work?

Dr. Rudy: Well, it’s difficult, you know, you have to have some flexibility. I’ve actually personally had to make some changes in my professional career to be able to address that passion, because that, to me, I’ve always been drawn to humanitarian work. It’s difficult when you’re trying to maintain a full-time job and have any semblance of a family or professional career, you’re trying to balance it, is a good way to put it.

I’ve had to make some personal changes in my professional career, making some changes so that I have more flexibility to do at least some humanitarian work once or twice a year. But for people who are interested in getting involved, every state has a national disaster medical assistance team. I encourage people to look into that. There are federally funded programs, disaster management courses that you can go to. Department of Homeland Security and the Center for Domestic Preparedness in Anniston, Alabama, has free courses. They’re fantastic.

If you want to learn about nuclear radiation, you can go out to the Nevada test site and do that. If you want to learn how to handle chemical biological agents, you go to Anniston, Alabama. And there are short trips that you can do, but the connections are getting into that federal emergency management assistance division kind of thing. Which brings me to talk a little bit about New York. I also went to New York during COVID. As we all know, in March of 2020, again, March seems like a bad month, New York probably had the highest per capita cases and deaths in the whole country.

Dr. Madden: I live right outside of New York City, so I have some sense, but again, when we initially introduced ourselves, pediatric person, so my perspective and experiences were different in my clinical world. Tell me about what you jumped into.

Dr. Rudy: New York, again, the reason why they contacted me about this was through connections. They knew I’d had previous experience doing this emergency management, DMAT stuff, and they needed a provider to manage all the EMS that was coming to the Bronx, they were going to be stationed in the Bronx. Remember, March is when everything exploded in a period of a week, like the cases tripled and 500 ambulances and 1600 providers were coming to New York and New Jersey to handle all the five boroughs there.

Everybody was stationed in the Bronx and they had 1600 EMS providers. We had to set up a medical. I was tasked with being sort of the medical officer doing that. I had nursing and I had psychological support counseling. Because there was no formal system, we didn’t have anything formally in place. We created it on the fly. We created a medical tent to handle emergencies, but how we did it is, basically, before every shift they had to come and see us in medical. We had to check them for symptoms, check their temperature, talk with them, make sure they’re psychologically and emotionally okay to be able to handle a 12-hour day of nothing but running.

It was physically and emotionally difficult for all of them, but that’s what we did. I did it for two weeks, and then I had another provider come in and take over for me for two weeks, but it was pretty nonstop 24 hours a day that we did that.

Dr. Madden: Then how do you just go back to what’s, quote unquote, your normal life?

Dr. Rudy: Boring life?

Dr. Madden: No, I’m just saying the normal or the everyday.

Dr. Rudy: Well, I went back, but you always think about it. For me, I personally would have loved to stay longer, but I had responsibilities, academic responsibilities that I had to get back to. But I was really proud to be able to support that. What’s interesting is that my great-grandmother was a nurse during the great influenza and she worked for the Red Cross, so it’s in the family.

Dr. Madden: It’s in your blood already is what that is. Unfortunately, we’re really out of time. I anticipated when we first were starting that we wouldn’t have enough time to explore all this. I think you’re an amazing individual and I want to give you a lot of gratitude for the things that you just go and do because you’re more concerned about how you can help than your own necessarily personal safety at times. Other people may go, she’s crazy, but you’re intriguing to so many other people.

Hopefully that’s more the lead and that we can encourage APPs to see that there are windows of so many ways to get involved and shape critical care medicine, help to educate and move on. Before we conclude, I just want to ask if there’s anything else that you really wanted to have the opportunity to say.

Dr. Rudy: Thank you very much for taking the time to talk with me. I want to use this last couple minutes just to encourage anybody who’s interested in point-of-care ultrasound, just to carpe diem, seize the day, do it, come to these courses, take the opportunities and then take it back and start using it. It is going to be instrumental and fundamental to your professional practice in the future.

Either you learn it now or you’re going to end up having to learn it later. I recommend learning it now. SCCM has been so supportive and they will embrace you, welcome you to their courses. Then if you’re interested in the Ultrasound Committee, adult and pediatric, we welcome you. There’s room for junior faculty and we’d love to have you.

Dr. Madden: That’s so wonderful. Thank you, Dr. Rudy, Susanna.

Dr. Rudy: Thank you.

Dr. Madden: This concludes another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. You also know that Susanna is a member of the Society, so if you know how to go through and find a member, you’ll find her, so please reach out. I know that I’ll be doing that. For the Society of Critical Care Medicine Podcast, I’m Maureen Madden.

Announcer: Maureen A. Madden, DNP, RN, CPNC-AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the pediatric intensive care unit at Bristol-Myers Squibb Children’s Hospital in New Brunswick, New Jersey.

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