Ultrasound Handoff

This rotation is what you make it. The ultrasonographers have full-day schedules and are happy to teach you, but you’ll need to show initiative.

• •With Irene in 1J doing pelvic US — particularly to get more early TVUS exposure.
• •Don’t need to prep beforehand — she’ll go over each patient’s indication with you before the scan.
• •Lets you do the whole scan; will hand-over-hand as needed.
• •Ask questions! She loves to teach.
• •Mostly GYN US, a few EPAC scans scattered in.

Working with Joanne on whatever antepartum / active / triage scans are ordered. Mostly growths and BPPs. You’ll get to do a decent amount of scanning depending on how busy it is and the difficulty / type of scan.

Joanne also loves to teach and will go over images with you for anything you want to review (fetal anatomy, cervical and/or placental eval, dopplers, etc.).

• •Arrive 8:15–8:30.
• •She’ll usually text if she’s getting pulled to help in the AM at DPC for scans.
• •Done 4:30–5:30 depending on day.

• •In the workroom there’s a list on the whiteboard of all patients of the day and the time.
• •Write your name next to patients so sonographers know who you’ll see.
• •Give them a “goal for the day” — one thing to learn (e.g., femur length).
• •Mayda is the most experienced ultrasonographer there. There’s been some turnover in this office so you might see new faces.

Most of our class agrees the best teaching happens here. Mary, Raven, and Julie are great teachers.

• •Goal is to go to shadow one genetics appointment a week with a geneticist — Amanda and Erin.
• •Nice to go to a patient’s ultrasound and then follow them for their genetics appointment after.

• •Get to HROB by 12:10 PM on the first day — get oriented to clinic + MAs.
• •You'll have your own patients assigned to you, ~10 max.

EPIC Context: Duke Perinatal Durham Clinic

Dot phrases: .mfmmasterlist (select postpartum) and .hrobppplans

Workflow:

• •Stop at front desk to be let into the back workroom.
• •You'll be with the Outpatient resident and 1 attending preceptor; 1 MA assigned to you for the afternoon.
• •Let MA know if contraception known in advance, fetal death (ask to room far away from seeing lots of babies).
• •MA will give you vitals, name of pt, and any concerns before seeing patient.
• •Pay extra special attention to BP, especially if HTN disease.
• •Write down GsPs, when delivered, modality, comorbidities needing follow-up (gDM with medication or pre-gDM, HTN disorder of pregnancy, did they go to 3-day BP appt?), sub-specialist follow-up, PP bleeding or depression, contraception.
• •They have someone on site for mental health for patients to talk to (Julia Tarr — see below).
• •Mostly work with MAs and nursing assistants here — communicate everything you need from them (meds, orders, tests, labs, contraception).
• •The attending doesn't have patients — you have your own panel and see all of them. Will be present for all procedures. Route all notes to the attending on the “Wrap Up” tab. Stay until you finish all notes ideally, but can finish from home.
• •Most visits are routine PP, lots of IUD / Nexplanon placements.

Documentation / Appointment Talking Points:

• •Summarize labor course, IOL, complications, PP hemorrhage, vaginal laceration, STAT C/S, baby that died (highlight red/bold), baby in NCU (highlight in yellow). Get it from the discharge summary for intrapartum course.
• •Follow up with patients on traumatic, difficult events.
• •Note medications continued/discontinued + impact on breastfeeding (Lactmed.com).
• •Wound vac, etc. that needs changing or evaluation.
• •PP contraception: given before discharge or not? Counsel that not using contraception = increased risk of uterine rupture in first 18 mo following pregnancy and increased risk of preterm birth (not something they have to do, but a known risk).
• •Confirm if patients want bridge contraception until ultimate management (e.g., vasectomy). May need UPT (urine pregnancy test) if getting BC.
• •Still on anticoagulation? Stopped prematurely? Explain why anticoag is important.
• •Follow up with PCP / sub-specialists.

Exams:

• •C/S: no vaginal exam, examine scar.
• •SVD: offer vaginal exam if laceration → ask attending to join to evaluate.
• ◦Up to 2nd degree: don't need to look at it.
• ◦2nd degree bothering them: look at it.
• ◦Greater than 2nd: should evaluate.
• •Post-placental IUD: string check, bedside U/S if don't see strings.

Responsible for In Basket — call/message patients back with results, answer questions.

Pearls:

• •Look up breastfeeding interactions with meds and any unfamiliar morbidities.
• •In-person interpreter for all Spanish-speaking patients: Ana.
• •For fetal death, still review milestones — sex, period resumed, expelling clots.
• •Depression screen (EDPS) → if above 10 or SI positive, dig into mood. If blue ribbon, no EDPS. Julia Tarr is social worker.
• •When people get tearful → stabilize: let them know we'd like to continue the conversation and have resources to help after the visit.
• •No contraception for self-pay → give them info to Health Department for LARC at sliding scale. Warn them even Pap smear is $200.

Weekend swing call as listed on the rotation grid. Workflow follows the standard DUH night-call expectations.