Dear Editor,
I would like to thank Dr McNamara for his useful comments about my
paper. It is quite clear from his letter, however, that his degree of
development of the skill of echocardiography is way beyond that required
by a neonatologist. This needs to be emphasised lest neonatologists are
put off for fear of having to go for formal retraining to achieve the
obviously very advanced level of scanning like Dr McNamara’s. He lists
“novel echocardiographic methods” like acoustic quantification, three
dimensional echo, and tissue Doppler [2] in his repertoire. These are not
standard echocadiographical techniques even for the paediatric
cardiologist in the UK and the neonatologist need not worry about the cost
to acquire such equipment nor the expertise to use it. One does not need
such a sophisticated machine to scan neonates, and for less than £50,000-
00 one can acquire a respectable 2D machine with colour and Doppler [1]
that will do all that is required for good up-to-date neonatal
cardiological studies. Some very good short Echocardiography courses are
available in the UK for the non-cardiologist and if these are followed by
frequent scanning using the disciplined method of “sequential chamber
localisation”[3], then one will soon make progress. Like Dr McNamara I
found that frequent scanning enhanced my skills during the earlier days.
I agree with Dr McNamara about the need to recognise one’s
limitations and the need to involve the paediatric cardiologist early.
This is mentioned several times in my article. The availability of
Telemedicine makes it even easier to consult [1,4,5,6]. A recent
experience on our unit demonstrates this very well, as described below.
After a very long and tiring joint cardiology clinic with a
paediatric cardiologist from a tertiary centre, I tried to sneak into my
office at about 1830hrs without being noticed as I was not on call that
night. This was wishful thinking, however, as my presence got noticed by
one of our Senior Staff Nurses who immediately made off very rapidly in
the opposite direction. She returned just as rapidly with a Staff Grade
Paediatrician, an SHO, and two Medical Students in tow. Breathlessly she
pronounced that they had a “blue baby” and could I have a look. The senior
on call that night was on his way in and I knew that he would not mind my
intrusion, as he could not scan. I soon discovered the atretic pulmonary
artery, intact ventricular septum and the barely patent ductus arteriosus.
I was ordering a prostin (Dinoprostone) infusion when my deeply relieved
colleague walked in. I made video recording of my findings and left for
home. My colleague subsequently transmitted the pictures to the paediatric
cardiologist via telelink at the tertiary centre. In the event the infant
was saturating normally on self-ventilation in air, had normal gases and
blood pressure by the time of transmission. During the ensuing discussion
with the cardiologist the diagnosis was confirmed and it was agreed that
the infant be transferred electively the following morning. Telemedicine
will enhance the safety of this skill being performed by the non-
cardiologist because of the ease of consultation. Availability of this
facility should go a long way towards satisfying even the most hardened
doubters.
Dr McNamara also revisits the issue of “working in the dark” while
managing neonatal haemodynamic problems. I do not think that
neonatologists can resist, or indeed continue to denigrate the acquisition
of echocardiographic skills for much longer. The case for acquiring the
skill by at least one in-house neonatologist at NICUs that manage the very
preterm neonate is overwhelming.
I am encouraged to hear that neonatologists form other parts of the
world, like Dr McNamara originally from Belfast and now in Toronto,
Canada, are developing this skill which can only be good for the neonate.
Jasper Katumba-Lunyenya
Paediatrician
References
(1) Katumba-Lunyenya JL. Neonatal/infant echocardiography by the non-
cardiologist: a personal practice, past, present, and future. Arc Dis
Child Fetal Neonatal Ed 2002:86 F55-F57.
(2) Patrick J McNamara. The Forgotten Organ on NICU. ELetters ADC 7th
February 02.
(3) Skinner J, Alverson D, Hunter S: Echocardiography for the
neonatologist. Edinburgh: Churchill-Livingstone, 2000:174-9.
(4) Casey FA. Telemedicine in paediatric cardiology. Arch Dis Child
1999; 80:497-9.
(5) Rundolph GR, Hagler DJ, Khanderina BK, et al. Remote telemedical
interpretation of neonatal echocardiograms: impact on clinical management
in a primary setting. J Am Coll Cardiol 1999; 34:241-5.
(6) Mulholland HC, Casey F, Brown D, et al. Application of a low cost
telemdicine link to the diagnosis of congenital heart defects by remote
consultation. Heart 1999; 82:217-21.
Dear Editor,
I would like to thank Dr McNamara for his useful comments about my paper. It is quite clear from his letter, however, that his degree of development of the skill of echocardiography is way beyond that required by a neonatologist. This needs to be emphasised lest neonatologists are put off for fear of having to go for formal retraining to achieve the obviously very advanced level of scanning like Dr McNamara’s. He lists “novel echocardiographic methods” like acoustic quantification, three dimensional echo, and tissue Doppler [2] in his repertoire. These are not standard echocadiographical techniques even for the paediatric cardiologist in the UK and the neonatologist need not worry about the cost to acquire such equipment nor the expertise to use it. One does not need such a sophisticated machine to scan neonates, and for less than £50,000- 00 one can acquire a respectable 2D machine with colour and Doppler [1] that will do all that is required for good up-to-date neonatal cardiological studies. Some very good short Echocardiography courses are available in the UK for the non-cardiologist and if these are followed by frequent scanning using the disciplined method of “sequential chamber localisation”[3], then one will soon make progress. Like Dr McNamara I found that frequent scanning enhanced my skills during the earlier days.
I agree with Dr McNamara about the need to recognise one’s limitations and the need to involve the paediatric cardiologist early. This is mentioned several times in my article. The availability of Telemedicine makes it even easier to consult [1,4,5,6]. A recent experience on our unit demonstrates this very well, as described below.
After a very long and tiring joint cardiology clinic with a paediatric cardiologist from a tertiary centre, I tried to sneak into my office at about 1830hrs without being noticed as I was not on call that night. This was wishful thinking, however, as my presence got noticed by one of our Senior Staff Nurses who immediately made off very rapidly in the opposite direction. She returned just as rapidly with a Staff Grade Paediatrician, an SHO, and two Medical Students in tow. Breathlessly she pronounced that they had a “blue baby” and could I have a look. The senior on call that night was on his way in and I knew that he would not mind my intrusion, as he could not scan. I soon discovered the atretic pulmonary artery, intact ventricular septum and the barely patent ductus arteriosus. I was ordering a prostin (Dinoprostone) infusion when my deeply relieved colleague walked in. I made video recording of my findings and left for home. My colleague subsequently transmitted the pictures to the paediatric cardiologist via telelink at the tertiary centre. In the event the infant was saturating normally on self-ventilation in air, had normal gases and blood pressure by the time of transmission. During the ensuing discussion with the cardiologist the diagnosis was confirmed and it was agreed that the infant be transferred electively the following morning. Telemedicine will enhance the safety of this skill being performed by the non- cardiologist because of the ease of consultation. Availability of this facility should go a long way towards satisfying even the most hardened doubters.
Dr McNamara also revisits the issue of “working in the dark” while managing neonatal haemodynamic problems. I do not think that neonatologists can resist, or indeed continue to denigrate the acquisition of echocardiographic skills for much longer. The case for acquiring the skill by at least one in-house neonatologist at NICUs that manage the very preterm neonate is overwhelming.
I am encouraged to hear that neonatologists form other parts of the world, like Dr McNamara originally from Belfast and now in Toronto, Canada, are developing this skill which can only be good for the neonate.
Jasper Katumba-Lunyenya
Paediatrician
References
(1) Katumba-Lunyenya JL. Neonatal/infant echocardiography by the non- cardiologist: a personal practice, past, present, and future. Arc Dis Child Fetal Neonatal Ed 2002:86 F55-F57.
(2) Patrick J McNamara. The Forgotten Organ on NICU. ELetters ADC 7th February 02.
(3) Skinner J, Alverson D, Hunter S: Echocardiography for the neonatologist. Edinburgh: Churchill-Livingstone, 2000:174-9.
(4) Casey FA. Telemedicine in paediatric cardiology. Arch Dis Child 1999; 80:497-9.
(5) Rundolph GR, Hagler DJ, Khanderina BK, et al. Remote telemedical interpretation of neonatal echocardiograms: impact on clinical management in a primary setting. J Am Coll Cardiol 1999; 34:241-5.
(6) Mulholland HC, Casey F, Brown D, et al. Application of a low cost telemdicine link to the diagnosis of congenital heart defects by remote consultation. Heart 1999; 82:217-21.