Press Your Luck: Point-of-Care Ultrasound Video Trivia
Attendees at this SHM Converge 2025 workshop pulled up a chair, grabbed a pen (and maybe a pint…of coffee, that is), and braced themselves for a morning of high-stakes, low-stress competition. Hosted by Brandon Boesch, DO, SFHM, medical director for hospital and support services at Cottage Health in Santa Barbara, Calif., and a merry band of ultrasound-savvy colleagues, this pub trivia-style session tested attendees’ point-of-care ultrasound (POCUS) skills through quick image interpretation, clinical puzzles, and just enough friendly rivalry to keep things spicy.
Participants split into teams with clever (and yes, ChatGPT-generated) names like “Echo Chamber of Secrets,” “The Pleural Effusionaries,” and “It’s Not All About the IVC.” After a quick refresher on ultrasound terminology and a reminder that “one view is no view,” illustrated by a photograph of a lioness appearing to eat a cub but from another camera angle revealing a mother carrying her cub unharmed, the games began. A warm-up case featured a patient with abnormal liver function tests, low platelets, and a distended abdomen. The corresponding POCUS clip showed finger-like gray projections floating in a black, anechoic sea. Everyone correctly called it: ascites. The early confidence boost was short-lived.
Round One: Cardiac quandaries
Gigi Liu, MD, MSc, the director of POCUS education at the Osler internal medicine residency program at Johns Hopkins University School of Medicine in Baltimore, kicked off the first official round with parasternal long-axis views of the heart. Teams had to judge whether the left ventricular (LV) systolic function was normal, severely reduced, or hyperdynamic. For bonus points, they could identify sneaky findings that might throw off interpretation. The first clip—with a flaccid left ventricle, a giant left atrium, and barely twitching mitral valve leaflets—was a slam dunk for “severely reduced.”
But then things got murky. Tachyarrhythmias created beat-to-beat variability that could trick the eye into overestimating LV function. Mitral stenosis blunted the excursion of the anterior leaflet in one case, and a dilated aortic root hinted at aortic insufficiency in another, both making the maybe not-so-trusty end-point septal separation (EPSS) measurement an unreliable indicator of LV function. At the end of the round, “Echo Chamber of Secrets” opened a narrow lead with eight points, followed by “The Pleural Effusionaries” with six and “Hepatorenal Hotshot” with five.
Round Two: Lungs, lines, and lies
Next up: Thoracic imaging. The “mirror artifact” made the normal lung look deceptively consolidated—a fitting mirage for Las Vegas. The giveaway? The spine was visible below the diaphragm through the liver or spleen, but vanished above it. True consolidation would have revealed the spine throughout. The “shred sign”—also known as subpleural consolidation—was reviewed as more sensitive than chest radiography for diagnosing pneumonia. And those bright, worm-like, dynamic air bronchograms? A reliable clue for consolidation.
When pleural effusions showed with internal septations, the message was clear: don’t waste time with a simple diagnostic thoracentesis. Go straight to tube thoracostomy and fibrinolytics. Several teams nailed this round with perfect scores, but “Echo Chamber of Secrets” still held its lead.
Round Three: Abdominal adventures
In the abdominal round, most of the players easily recognized large, black, anechoic cysts filling the kidneys as classic polycystic kidney disease. Fewer teams earned bonus points by recalling the Bosniak classification system of renal cysts to characterize their risk of malignancy.
Then came the curveballs. A-lines—usually seen in lung scans—were in the abdomen? Was it pneumoperitoneum? Or just a gassy bowel from ileus abutting the peritoneum? An abdominal X-ray revealed the latter and proved that plain radiography is still relevant in a POCUS world. When it came to gallbladder imaging, teams were cautioned not to mistake innocent artifacts like edge refraction or posterior acoustic enhancement for true pathology such as gallstones.
“It’s Not All About the IVC” scored a perfect round, but “Echo Chamber of Secrets” refused to be caught.
Round Four: Right heart riddles
Back to the heart, but this time, Dr. Liu served up apical four-chamber views to test players’ assessment of right ventricular (RV) systolic function. Attendees learned to spot McConnell’s sign—paradoxical bulging of the RV free wall during systole—as a clue to reduced RV function. One clip looked all wrong because it was. A flipped transducer reversed the usual left-right orientation, sending several teams into temporary disarray. The left ventricular outflow tract visible on the wrong side of the interventricular septum was the clue.
And then came the tricuspid annular plane systolic excursion, or TAPSE, a marker of RV function that’s easily overinterpreted. In cases like tamponade or severe tricuspid regurgitation, normal TAPSE may belie RV dysfunction.
Lightning Round: A potpourri of pitfalls
In the final round, attendees had to spot dual effusions in the pericardial and pleural spaces, recognize off-axis views of the inferior vena cava, and identify sonographic findings of tamponade. Teams leaned in. Pens scribbled. But when the dust settled, “Echo Chamber of Secrets” emerged victorious with 40 points. “The Pleural Effusionaries” and “It’s Not All About the IVC” followed close behind with 37 and 36 points, respectively. While only one team earned the grand prize trophy, everyone walked away with sharper skills, better eyes, and a reminder that even the best ultrasound clips can be full of surprises.
Key Takeaways
- A single ultrasound view is often insufficient for accurate diagnosis. Clinicians should obtain multiple imaging planes to better answer clinical questions and avoid over-reliance on any one sonographic finding.
- Subpleural consolidation on lung POCUS is more sensitive than chest radiography for diagnosing pneumonia. In contrast, reverberation artifacts at tissue-air interfaces may not differentiate intraluminal gas in distended bowel loops abutting the peritoneum from extraluminal peritoneal free air; abdominal radiography can help clarify the diagnosis.
- Off-axis imaging of cylindrical structures can lead to an underestimation of their diameter. When imaged properly, wall borders appear crisp and white, not blurred or gray.
Dr. Goldstein is a family medicine hospitalist and associate professor at the University of New Mexico School of Medicine in Albuquerque and the physician lead for clinical documentation integrity at the University of New Mexico hospitals, and serves on SHM’s Family Medicine Hospitalists Advisory Council.