Bedside ultrasound survey

[miacomet]

This is for the attendings out there-

How much do you use it?
What practice setting are you in?
What do you find ultrasound useful for?
What do you find it not so useful for?
Do you think it increases throughput?

---

Members don't see this ad.

 

[MechEDoc]

Most every shift. I do DVT, basic biliary studies, FAST, E-FAST, pulmonary, soft tissue (abscess vs phelgmon, etc), transabdobminal for early pregnancy, peripheral and central venous access, occular (several times per year), occasional tendons, and cardiac (effusion? right heart strain?). I think it increases throughput and improves outcomes.

 

[RustedFox]

Intra-resuscitatively and for central line placement only.
The rest can and should be done by an ultrasound tech while I do other things.

 

[RoyBasch]

Intra-resuscitatively and for central line placement only.
The rest can and should be done by an ultrasound tech while I do other things.

Me to, will use it for peripheral IVs to. Sometimes to decide if a borderline soft tissue infection needs I&D.

 

[RustedFox]

Me to, will use it for peripheral IVs to. Sometimes to decide if a borderline soft tissue infection needs I&D.

Oh yeah, me too. Forgot about that.

 

[Zebra Hunter]

I use it once every third or fourth shift. I do way less central lines and US guided PIV placement as an attending. I'll occasionally use it to eval for retinal detachment. I'll use it to reassure pregnant women who have already had confirmed IUP that their babies heart is still beating. I'll occasionally look for pericardial effusion on someone with a good story for pericarditis. I use it occasionally for the questionable abscess vs cellulitis. Other than that, I really don't use it.

 

[GonnaBeADoc2222]

Community:
-POS u/s machine, barely passable
-Use it about 5% of the time that I used it in residency (heavy u/s program...almost every CP patient got a bedside cardiac u/s...yeah.)
-Most commonly use it for IV access (peripheral >>> central)
-Peri-code and intra-code patients to assess for effusion, PTX, AAA (abdominal pain + hypotension)
-Ocular for obvious retinal detachment in the 3 times a year I need to do it
-Abscess vs phlegmon if unsure
-Unstable trauma
-Never for stable trauma...why do this? Just slows down getting to CT.
-OB, renal, RUQ --> formal always, time waster to do bedside
-Never for silliness such as tendon, bone for fracture, SBO, pneumonia

Extremely useful in certain settings (Peripheral IVs FTW...although RNs need to be trained in this...this is not a doctor job), extreme time waster in most settings

 

[deleted245139]

Most every shift. I do DVT, basic biliary studies, FAST, E-FAST, pulmonary, soft tissue (abscess vs phelgmon, etc), transabdobminal for early pregnancy, peripheral and central venous access, occular (several times per year), occasional tendons, and cardiac (effusion? right heart strain?). I think it increases throughput and improves outcomes.

Similar... Minus DVT, time dependent. I like it for some fractures (sternum, ribs) and dislocation reduction confirmation in shoulders sometimws

 

[GonnaBeADoc2222]

Similar... Minus DVT, time dependent. I like it for some fractures (sternum, ribs) and dislocation reduction confirmation in shoulders sometimws

Really?

Sternum and rib fractures? If you're not getting a CT on this level of trauma, you're nuts. And if you are, you're wasting time with the u/s.

Dislocation reduction? Should be pretty obvious on clinical exam, and again, need XR post (standard of care), waste of time.

Do you have residents doing all your stuff?

 

[Paperman]

Similar to RF.

Community setting.

FAST, central access, quick pneumothorax evaluation, abscess/cutaneous/foreign bodies, thoracentesis/paracentesis and ophthalmic.

The rest is within my capability but frankly is generally too time consuming and I would rather allocate time to other patients/matters and my hospital agrees.

I think it SLOWS down my throughput tremendously which is why I have US techs do the rest. Technically easy, but still time consuming. In residency it was fun as throughput was not as much of an issue....

Our residency had a pretty intense US training program and I think that US fellowship is generally superfluous for most recent EM trained docs.

TPM

 

[miacomet]

Most every shift. I do DVT, basic biliary studies, FAST, E-FAST, pulmonary, soft tissue (abscess vs phelgmon, etc), transabdobminal for early pregnancy, peripheral and central venous access, occular (several times per year), occasional tendons, and cardiac (effusion? right heart strain?). I think it increases throughput and improves outcomes.

Are you in the community? Academia?

 

[deleted245139]

Really?

Sternum and rib fractures? If you're not getting a CT on this level of trauma, you're nuts. And if you are, you're wasting time with the u/s.

Dislocation reduction? Should be pretty obvious on clinical exam, and again, need XR post (standard of care), waste of time.

Do you have residents doing all your stuff?

No I am.
Single scanner at a level one trauma center
US and a chole means a quicker call to surgery.
Sternal fx pushes a trauma CS with additional imaging.
US can serve as a great tool to triage is what I'm saying.
Also.... US a shoulder on a sedated patient is way easier than waiting XR after an attempt if you're not sure. I find it faster. If you're telling me you're 100 percent on reductions and have never had a tough one where you weren't sure and needed a second attempt, you're a better doctor than me.
And you're right... They need that post reduction XR.
I should have been more clear. The times to use it in those situations is super limited. But there is occasional utility

 

[WilcoWorld]

I use it every shift.

For me, it speeds up dispo on DVT and ectopic rule outs. I also like it for deciding whether to I&D something that I'm on the fence about. And for procedural guidance it's very useful (mainly neck lines). IMO, most other ED applications are overstated.

But this fails to cover it's biggest use: patient reassurance. When I have a low clinical suspicion for something, but I get the feeling that the patient thinks they need a TEST to have been properly evaluated I wheel in the fancy US machine, show the patient the nice reassuring pictures...aaaand discharge! Everyone's happy.

 

[gro2001]

How much do you use it?
At least 3-4 times every day.

What practice setting are you in?
Academia. I work exclusively in the resus bay of a large, extremely busy emergency department.

What do you find ultrasound useful for?
Guiding resuscitation in undifferentiated, critically ill patients. Nothing like a RUSH exam for undifferentiated shock.
Especially:
-Cardiac US to r/o tamponade
-IVC to guide volume resus
-Procedural (central lines, arterial lines, thoracentesis, paracentesis, etc)

What do you find it not so useful for?
Anything where an official study is available and/or the diagnosis can wait. Sometimes I take a quick look at a gallbladder out of curiosity, but most of the time things like gallbladder scans and DVT scans get official imaging only.

Do you think it increases throughput?
Less of a concern in my practice setting. When I worked non-resus shifts, they occasionally did, but most of the time not so much.

 

[Rendar5]

]How much do you use it?
Every 3-4 shifts.

What practice setting are you in?
Suburban community hospital level 1 trauma center that does serve as a secondary site for a residency program (1/3 of shifts)

What do you find ultrasound useful for?
To determine abscess vs Phlegmon (common)
IJ central lines (occasional)
retinal detachment if I can’t get a good exam (occasional)
Check for pericardial effusion (rare)
Check a gallbladder if ultrasound or ct is backed up and I want to know which formal study to order (very rare)
Check for free fluid (rare, I don’t use it for trauma but rather medical)
Check for AAA in sick patients

What do you find it not useful for?
Pneumothorax
Bones
Tendons
DVT
Trauma (or at least extremely overrated. People waste so much time on FAST in stable patients or those with clear indications for OR. I see maybe one patient a year who actually warrants a FAST)

 

[turkeyjerky]

My practice is similar to most of the above, although I never use it on MSK--not really well trained on this application and don't see much clinical utility) or DVT--I like a formal report in the chart, seems high liability since what happens when the patient when the patient bounces back from with an (unrelated) PE in 3 months. Plus, getting the patient positioned is a time-suck.

I do use it a fair amount for GB--this is the major time I think it improves throughput, since it's an instant discharge vs waiting for 2+ hrs to get a formal sometimes.

 

[Hamhock]

]
Trauma (or at least extremely overrated. People waste so much time on FAST in stable patients or those with clear indications for OR. I see maybe one patient a year who actually warrants a FAST)

Yes, I think this is due to the FAST being poorly understood and poorly taught. Everyone gets a FAST during residency for training purposes. However, the traditional FAST is really only for unstable patients with uncertain OR vs. CT vs. IR and to assist the surgeon in decision making.
(also, in multi-trauma activations, the stable patient with free fluid gets the CT before the other stable patients)

That said, although useful and acceptable, I feel the framework I just described above is outdated.
It amazes me with all of these UTS-fellowship trained attendings and UTS programs in residency that we still train residents on the FAST.

Rather, a modified E-FAST is what should be taught. In the unstable polytrauma patient, I initially don't care at all if there is free fluid in Morrison's or around the bladder. There's nothing we can do about that in the ED.

However, if there is PTX or HTX (especially large) or a pericardial effusion, there's a lot I can do about that. If I don't rapidly diagnose and intervene, these "salvageable" patients may die.

The unstable polytrauma patient doesn't need an immediate look for peritoneal free fluid; this patient needs a quick look anteriorly for PTX and a look at both costophrenic angles. Then, if the doc want to slide down to spleno-renal or Morrison's vs. quick echo -- well, that's dealer's choice. Then you are back to the "traditional FAST" framework and indications as I described above.

So, the number of mE-FAST exams per year, I believe, is equal to the number of unstable trauma patients you see.
But, I also agree that the number of traditional FAST exams is probably very small indeed (see indications above).

I also I think -- and here is the controversial part, I know -- the lack of understanding regarding FAST vs mE-FAST is another indicator of the lack of understanding about trauma (especially ED intervention vs. IR vs. OR vs. CT) that is a sad product of the EM world believing trauma is just cookbook and ATLS is sufficient. This is a shame the EM world has yet to acknowledge.

HH

 

[Zebra Hunter]

Yes, I think this is due to the FAST being poorly understood and poorly taught. Everyone gets a FAST during residency for training purposes. However, the traditional FAST is really only for unstable patients with uncertain OR vs. CT vs. IR and to assist the surgeon in decision making.
(also, in multi-trauma activations, the stable patient with free fluid gets the CT before the other stable patients)

That said, although useful and acceptable, I feel the framework I just described above is outdated.
It amazes me with all of these UTS-fellowship trained attendings and UTS programs in residency that we still train residents on the FAST.

Rather, a modified E-FAST is what should be taught. In the unstable polytrauma patient, I initially don't care at all if there is free fluid in Morrison's or around the bladder. There's nothing we can do about that in the ED.

However, if there is PTX or HTX (especially large) or a pericardial effusion, there's a lot I can do about that. If I don't rapidly diagnose and intervene, these "salvageable" patients may die.

The unstable polytrauma patient doesn't need an immediate look for peritoneal free fluid; this patient needs a quick look anteriorly for PTX and a look at both costophrenic angles. Then, if the doc want to slide down to spleno-renal or Morrison's vs. quick echo -- well, that's dealer's choice. Then you are back to the "traditional FAST" framework and indications as I described above.

So, the number of mE-FAST exams per year, I believe, is equal to the number of unstable trauma patients you see.
But, I also agree that the number of traditional FAST exams is probably very small indeed (see indications above).

I also I think -- and here is the controversial part, I know -- the lack of understanding regarding FAST vs mE-FAST is another indicator of the lack of understanding about trauma (especially ED intervention vs. IR vs. OR vs. CT) that is a sad product of the EM world believing trauma is just cookbook and ATLS is sufficient. This is a shame the EM world has yet to acknowledge.

HH

Not sure when or where you did residency, but the modified E-FAST has been taught for years across the country as the more appropriate study for unstable traumas. Also, just look at any online EM education resources regarding trauma and you will see countless discussing how ATLS alone is not sufficient. There is a lot to mock regarding EMs ultrasound education in general, but I think you’re a bit off on the point you’re trying to make.

What I will agree on, however, is that many EM docs forget the indication for E-FAST exams. Also, I get annoyed when a mid-level or nurse asks me to perform a FAST exam on a stable patient. The annoyance is mainly because some other doc taught them that all traumas need to have a FAST exam, and we even have it on our trauma flowsheets as a requirement for any trauma activation. I still don’t do it, but it’s annoying to have the same discussion every single time.

 

[Paperman]

Not sure when or where you did residency, but the modified E-FAST has been taught for years across the country as the more appropriate study for unstable traumas. Also, just look at any online EM education resources regarding trauma and you will see countless discussing how ATLS alone is not sufficient. There is a lot to mock regarding EMs ultrasound education in general, but I think you’re a bit off on the point you’re trying to make.

What I will agree on, however, is that many EM docs forget the indication for E-FAST exams. Also, I get annoyed when a mid-level or nurse asks me to perform a FAST exam on a stable patient. The annoyance is mainly because some other doc taught them that all traumas need to have a FAST exam, and we even have it on our trauma flowsheets as a requirement for any trauma activation. I still don’t do it, but it’s annoying to have the same discussion every single time.

Ugh. Nursing trauma checklists.

But not sure where you're going on initial paragraph. Where I trained, EM ultrasound education was rigorous and longitudinal and complete overkill for what I do clinically.

Let's be honest, US is extremely easy to master and doesn't require an MD/DO degree. Which is why I generally have techs do it. My wife works in a corporate field and we played around with it during residency and I taught her a reliable e-FAST, biliary exam, echo and pulmonary exam. She can still perform them reliably well today.

 

[WilcoWorld]

Yes, I think this is due to the FAST being poorly understood and poorly taught. Everyone gets a FAST during residency for training purposes. However, the traditional FAST is really only for unstable patients with uncertain OR vs. CT vs. IR and to assist the surgeon in decision making.
(also, in multi-trauma activations, the stable patient with free fluid gets the CT before the other stable patients)

That said, although useful and acceptable, I feel the framework I just described above is outdated.
It amazes me with all of these UTS-fellowship trained attendings and UTS programs in residency that we still train residents on the FAST.

Rather, a modified E-FAST is what should be taught. In the unstable polytrauma patient, I initially don't care at all if there is free fluid in Morrison's or around the bladder. There's nothing we can do about that in the ED.

However, if there is PTX or HTX (especially large) or a pericardial effusion, there's a lot I can do about that. If I don't rapidly diagnose and intervene, these "salvageable" patients may die.

The unstable polytrauma patient doesn't need an immediate look for peritoneal free fluid; this patient needs a quick look anteriorly for PTX and a look at both costophrenic angles. Then, if the doc want to slide down to spleno-renal or Morrison's vs. quick echo -- well, that's dealer's choice. Then you are back to the "traditional FAST" framework and indications as I described above.

So, the number of mE-FAST exams per year, I believe, is equal to the number of unstable trauma patients you see.
But, I also agree that the number of traditional FAST exams is probably very small indeed (see indications above).

I also I think -- and here is the controversial part, I know -- the lack of understanding regarding FAST vs mE-FAST is another indicator of the lack of understanding about trauma (especially ED intervention vs. IR vs. OR vs. CT) that is a sad product of the EM world believing trauma is just cookbook and ATLS is sufficient. This is a shame the EM world has yet to acknowledge.

HH

Not sure when or where you did residency, but the modified E-FAST has been taught for years across the country as the more appropriate study for unstable traumas. Also, just look at any online EM education resources regarding trauma and you will see countless discussing how ATLS alone is not sufficient. There is a lot to mock regarding EMs ultrasound education in general, but I think you’re a bit off on the point you’re trying to make.

What I will agree on, however, is that many EM docs forget the indication for E-FAST exams. Also, I get annoyed when a mid-level or nurse asks me to perform a FAST exam on a stable patient. The annoyance is mainly because some other doc taught them that all traumas need to have a FAST exam, and we even have it on our trauma flowsheets as a requirement for any trauma activation. I still don’t do it, but it’s annoying to have the same discussion every single time.

If someone wants to do an unnecessary FAST or EFAST on a stable patient, I don't really care. What gets my hackles up is when I hear someone recommend using FAST to rule out intraabdominal injury. It was not designed for that and it does not do that.

Learners: please do not let the FAST exam give you a false sense of security. If a stable trauma patient has significant abdominal tenderness, a FAST exam does not settle your important questions.

 

[Groove]

I'm a fan of US and use it frequently. I think it's relevant to our specialty and feel that we should aim for proficiency in the modality as it's perfectly suited for the ED. That being said, I totally hear the people that argue for formal studies and don't like to do bedside studies because it slows them down. I get it. Personally, if I have a high pre-test prob for acute path, I will more than likely order a formal study. However, for path that I have low pre-test prob or when there is a delay with formal, I think it's very useful to do a limited bedside study. Plus, you can bill for these!

Mainly... FAST, eFAST, cardiac, regional blocks, line placement, MSK, biliary, ovarian/testicular power doppler, renal, aorta, ~CVP, very infrequent ocular (lens, retina, FB, etc..), occasional measurement of optic nerve for ICP, phlegmon/abscess, PIVs, OB, etc..

Again, if I'm really worried about something, then I probably am ordering a formal study (torsion, etc..).

Sometimes, it really can make a difference in management. Perfect example was a young guy I sniped from fast track last week that had a large splinter from a wooden pole at work penetrate his thenar eminence. He pulled it out but came in due to swelling and pain. I noticed that he had a lot of pain on FPL testing. XR seemed to suggest FB but on US I could clearly see a 2cm FB perpendicular to and penetrating the FPL tendon of the thumb. I'm not saying I needed it to ultimately disposition the guy but it greatly helped speed things up and made my discussion with the hand surgeon that much easier.

All that being said, I def go through phases. If it's a super busy shift then I'm probably doing less of these because it's just easier to order formal studies and go see another pt. It all depends on how much time I have during the shift.

 

[thegenius]

But this fails to cover it's biggest use: patient reassurance. When I have a low clinical suspicion for something, but I get the feeling that the patient thinks they need a TEST to have been properly evaluated I wheel in the fancy US machine, show the patient the nice reassuring pictures...aaaand discharge! Everyone's happy.

Oh yea done this numerous times! It's fantastic! Then I tell them "I'll even give you two for the price of one. Let's look at your heart!"

 

[thegenius]

I see 20-25 pts a shift.

I am not a big fan of US...mostly because our machine is big, difficult to maneuver, it takes ~5 minutes to set up, clean, boot up, select the right patient, and positioning the patient properly, before doing the scan.

I hate cleaning gel off a patient.

That being said....I use it regularly to
- scan skin shiit to look for abscesses / purulent cellulitis
- transabd US for IUP
- gallbladder stuff

I use it infrequently to
- cardiac US
- vascular stuff
- FAST

I use it 100% of the time for central lines. I have never placed one blindly (except during CPR)

I really don't understand all the hub-bub is over using it for detecting pulmonary edema and pneumothorax. You either can determine these with a good history and physical, or you have time and don't need to know instantly. Why do you have to know in 1 minute if your guy has CHF?



Re: trauma. If an unstable polytrauma comes in with HR 130, BP 70/30 and there is obvious chest trauma, that guys gets a chest tube. Why are people futzing around with US? Put the damn chest tube in.


Oh...and lastly US does slow me down overall. For all comers.

 

[Paperman]

I think ED physicians should have MASTERY of:

-very difficult airway situations
-difficult central venous access procedures
-reduction of complex fracture/dislocations
-pneumothorax-thoracosctomy techniques
-paracentesis
-arterial lines (yawn, and infrequent)
-US (again, over-emphasized in residency)

Most importantly:
-Quick, decisive, emergent clinical decision making. Our absolute best skill. Very under appreciated, very hard to measure, very difficult to interpret. The reason so many PC docs incorrectly think they could "do what we do." We're damn good at this. Really only appreciate as an attending at a high-volume/high-acuity shop. The training just shines. You just smile.

Procedures should be chased, fawned over and perfected during residency. But that won't be what separates you as an attending.

US? Necessary, but now normal part of physical exam for EM docs. Do we really even need US threads?

TPM

 

[RoyBasch]

What practice setting are you in?
Academia. I work exclusively in the resus bay of a large, extremely busy emergency department.

Side bar to the actual US discussion: But how is this type of job? How did you find it? This is the type of thing at some point I would like to do (very interested in CCM, almost did the fellowship, but for logistical reasons just went into general ER practice).

 

[deleted109597]

I use it a couple of times a week in a freestanding setting.
Almost universally for abscesses and IUPs. Everything else, the tech gets called in. I have more important things to do.

 

[miacomet]

I think ED physicians should have MASTERY of:

-very difficult airway situations
-difficult central venous access procedures
-reduction of complex fracture/dislocations
-pneumothorax-thoracosctomy techniques
-paracentesis
-arterial lines (yawn, and infrequent)
-US (again, over-emphasized in residency)

Most importantly:
-Quick, decisive, emergent clinical decision making. Our absolute best skill. Very under appreciated, very hard to measure, very difficult to interpret. The reason so many PC docs incorrectly think they could "do what we do." We're damn good at this. Really only appreciate as an attending at a high-volume/high-acuity shop. The training just shines. You just smile.

Procedures should be chased, fawned over and perfected during residency. But that won't be what separates you as an attending.

US? Necessary, but now normal part of physical exam for EM docs. Do we really even need US threads?

TPM

I wasn't asking if people should be trained in it, but if people used it regularly. Considering that use of US varies widely in the answers, yes, I think it's a reasonable question. ABEM clearly thinks so, too, as they don't include US on the ConCert.

 

[gro2001]

Side bar to the actual US discussion: But how is this type of job? How did you find it? This is the type of thing at some point I would like to do (very interested in CCM, almost did the fellowship, but for logistical reasons just went into general ER practice).

I work overseas in an ER that sees 1500 patients/day and has a 12 bed ICU area. The ICU area gets all the super sick patients, adults and kids, except major trauma, which goes to a separate Trauma Resuscitation Unit, which is run by trauma surgery (though we occasionally get overflow). I only do shifts in the ICU area. I love the set up. I work about 24 hours/week clinically, but have a big academic workload.

It seems jobs like this back in the US are out there, but somewhat rare. It seems that to get a job like this, several things would have to happen:
1) the ER would need to be very large to have an ICU area with dedicated attending staffing
2) you would need to convince the department that it makes sense for you to only work in that area and not in other areas.

I think most of the time you would need to either do a fellowship to justify working in just the resus bay, or alternatively have a lot of protected time due to academic commitments (which is my situation). Or you would have to have some other thing you could negotiate with. Do only nights? Do lots of weekends? Either way, if an ER had a resus bay, lots of the other attendings in the department would want to work a lot of shifts there, so you would have to be bringing something to the table that the other attendings were not. I think doing a fellowship would probably be the most straightforward pathway. But maybe if anyone here has a job like that in the US and can chime in?

 

[Tiger26]

About me--work at a 40,000 visit community ED 90% of the time, a critical access hospital 5% of the time, and in the academic site the remaining 5%

Did an ultrasound fellowship.

I can go months without using the machine and then use it 5 times in a shift.

As has been said, I really mainly use it when I need to make a critical decision emergently or for procedures. Otherwise, I have the tech do it.

Also, has been said, I haven't done a meaningful FAST in years. Our CT scanner is 15 feet away from our resus rooms. I think even many EPs don't appreciate that the FAST is not a rule-out test

 

[miacomet]

I work overseas in an ER that sees 1500 patients/day and has a 12 bed ICU area. The ICU area gets all the super sick patients, adults and kids, except major trauma, which goes to a separate Trauma Resuscitation Unit, which is run by trauma surgery (though we occasionally get overflow). I only do shifts in the ICU area. I love the set up. I work about 24 hours/week clinically, but have a big academic workload.

It seems jobs like this back in the US are out there, but somewhat rare. It seems that to get a job like this, several things would have to happen:
1) the ER would need to be very large to have an ICU area with dedicated attending staffing
2) you would need to convince the department that it makes sense for you to only work in that area and not in other areas.

I think most of the time you would need to either do a fellowship to justify working in just the resus bay, or alternatively have a lot of protected time due to academic commitments (which is my situation). Or you would have to have some other thing you could negotiate with. Do only nights? Do lots of weekends? Either way, if an ER had a resus bay, lots of the other attendings in the department would want to work a lot of shifts there, so you would have to be bringing something to the table that the other attendings were not. I think doing a fellowship would probably be the most straightforward pathway. But maybe if anyone here has a job like that in the US and can chime in?

That's very cool. Did you train in the US? Is this setup common in said country? Which country? How is ultrasound training there?

 

[RoyBasch]

I work overseas in an ER that sees 1500 patients/day and has a 12 bed ICU area. The ICU area gets all the super sick patients, adults and kids, except major trauma, which goes to a separate Trauma Resuscitation Unit, which is run by trauma surgery (though we occasionally get overflow). I only do shifts in the ICU area. I love the set up. I work about 24 hours/week clinically, but have a big academic workload.

It seems jobs like this back in the US are out there, but somewhat rare. It seems that to get a job like this, several things would have to happen:
1) the ER would need to be very large to have an ICU area with dedicated attending staffing
2) you would need to convince the department that it makes sense for you to only work in that area and not in other areas.

I think most of the time you would need to either do a fellowship to justify working in just the resus bay, or alternatively have a lot of protected time due to academic commitments (which is my situation). Or you would have to have some other thing you could negotiate with. Do only nights? Do lots of weekends? Either way, if an ER had a resus bay, lots of the other attendings in the department would want to work a lot of shifts there, so you would have to be bringing something to the table that the other attendings were not. I think doing a fellowship would probably be the most straightforward pathway. But maybe if anyone here has a job like that in the US and can chime in?

The hospital I was a medical student at had very large ER (I assume 100-150k visits/yr) and had a resuscitation pod. Working in that pod was a "shift." However, I didn't know if any of the staff exclusively worked that shift in addition to shifts in the different regular medical/medium acuity pods.

What country do you work in? I always assumed based on your posts you were/are in the US.

Anyways, sounds cool.

 

[RoyBasch]

Also, has been said, I haven't done a meaningful FAST in years. Our CT scanner is 15 feet away from our resus rooms. I think even many EPs don't appreciate that the FAST is not a rule-out test

I think many do, which is why they are rarely done in the community. I had stopped doing a FAST in 98% of trauma patients (work at a community level II trauma center) until the trauma clipboard nurses told us they are "required."

I agree with Hamhock above, the true utility of the FAST in trauma is not really taught in residency. I think its fairly useless in stable patients, just get the CT which has superior sensitivity, specificity, and characterization of specific injuries. It is helpful to confirm decision making about performing a truly emergent resuscitative procedure in a crashing trauma. e.g. undifferentiated hypotensive penetrating trauma pt, FAST pericardial window shows effusion, go for pericardiocentesis, or poor lung slide, go for needle decompression vs. chest tube.

 

[thegenius]

I don't really do FAST where I work at a community setting because the trauma surgeon decides what to do with the patient. If they want CT they go to CT. If they want OR they go to OR. If they want a coffee with cream and sugar, they get a coffee with cream and sugar (but not from me).

 

[gro2001]

The hospital I was a medical student at had very large ER (I assume 100-150k visits/yr) and had a resuscitation pod. Working in that pod was a "shift." However, I didn't know if any of the staff exclusively worked that shift in addition to shifts in the different regular medical/medium acuity pods.

What country do you work in? I always assumed based on your posts you were/are in the US.

Anyways, sounds cool.

I was, but now I work in Qatar.

 

[BoardingDoc]

I was, but now I work in Qatar.

Sidetracking from the original conversation, but why/how did you go about doing that? No personal interest in doing anything remotely similar, but sounds like an interesting story.

 

[deleted547339]

Busy academic hospital. Every IJ, most fem lines. Essentially every code. Most patients in shock or peri-intubation. PIVs. Pregnancy to document IUP/fetal heart rate. Trauma for fast. If the RV looks big and I think patient may die from PE, I may check the femoral veins quickly. Thora/paras. PIVs. Post foley placement with minimal UOP.

Never biliary. Never ocular. Never appy. Never isolated DVT. Never chest pain unless super sick/concern for tamponade. Almost never msk. Never LP. Almost never abscess. Never kidney stone.

 

[emergentmd]

Am I such an outlier on U/S? I never use an US.

I do my central lines by landmarks as I can do it much faster. Some do use it, and seems like a lot of time setting it up which maybe user dependent. One U/S doc did help me with an U/S guided IJ but we couldn't get it after a good 45 minutes of work. I popped in a femoral in 10 minutes and out the door. They all switch to PICC lines upstairs anyhow. No one has ever complained that I put in a Fem Line.

NO one in any of my hospitals routinely use U/S for anything else. It may start from the sounds of this thread but hopefully I will be retired by then.

 

[TheComebacKid]

For determination of IUP in pregnancy, it's the standard of care. If you want to farm it out to an US tech to do it, that's fine, but US definitely required in this case.

I use it routinely for abscesses. There are many people who have lots of induration and concern for abscess but when you put a probe on them there is no definitive fluid collection. It saves these patients an unnecessary I&D and they can go home on antibiotics for cellulitis. Extremely easy to do.

I haven't been trained on placing an IJ without US, so I use it for all of those lines. It's useful for femoral but not required. I also like using it for arterial lines. If you are placing crash lines though, agreed it takes too much time to set up and better to go off just anatomy.

I use it routinely for hypotensive patients to determine whether they are primarily in cardiogenic or distributive shock. It takes two seconds to put a probe on someone's chest and determine their cardiac contractility. While IVC collapsibility has not really panned out, sometimes I still do it since it's easy to obtain on a subxiphoid view of the heart. I won't really use it to truly guide my resuscitation though

I personally think FAST is absolutely worthless if you work at a trauma center. Zero utility for penetrating trauma. For blunt abdominal trauma that is stable they go straight to CT. For blunt abdominal trauma but they are unstable, in theory it doesn't matter what the hell the FAST shows, if they are hypotensive they should go to the OR directly. The problem is that most surgeons are reluctant to take any patient to the OR without imaging, irrespective of how unstable they are. A FAST gives you a little more ammunition, but I have still found that despite the studies that show 98% specificity for free fluid, surgeons don't same to care.

At academic centers, the mental masturbation that is exhibited with US has gotten a little ridiculous. US while it has it's uses, sometimes just isn't warranted and you should just get the damn CT scan. Also, all this stuff about using an US for a subclavian line is just ridiculous, as the whole point of that line is to get it in fast using only anatomy. Drives me crazy when people start bringing up these points on podcasts and the like.

 

[emergentmd]

I use it routinely for abscesses. There are many people who have lots of induration and concern for abscess but when you put a probe on them there is no definitive fluid collection. It saves these patients an unnecessary I&D and they can go home on antibiotics for cellulitis. Extremely easy to do. - I can tell most of the time if they have an abscess and if I have any concerns, I just put a needle in.

I haven't been trained on placing an IJ without US, so I use it for all of those lines. It's useful for femoral but not required. I also like using it for arterial lines. If you are placing crash lines though, agreed it takes too much time to set up and better to go off just anatomy. - None of my community sites put an Art line in. I can put a Fem line in quick, they get their line and meds, they go upstairs where they change it for a PICC. Haven't had any pushbacks in 18yrs and the ICU docs are just happy I put a line in.

I use it routinely for hypotensive patients to determine whether they are primarily in cardiogenic or distributive shock. It takes two seconds to put a probe on someone's chest and determine their cardiac contractility. While IVC collapsibility has not really panned out, sometimes I still do it since it's easy to obtain on a subxiphoid view of the heart. I won't really use it to truly guide my resuscitation though - Again, I have never done this and never asked by the ICU docs. We treat with IV fluids, pressors, and let them figure out upstairs.

I personally think FAST is absolutely worthless if you work at a trauma center. Zero utility for penetrating trauma. For blunt abdominal trauma that is stable they go straight to CT. For blunt abdominal trauma but they are unstable, in theory it doesn't matter what the hell the FAST shows, if they are hypotensive they should go to the OR directly. The problem is that most surgeons are reluctant to take any patient to the OR without imaging, irrespective of how unstable they are. A FAST gives you a little more ammunition, but I have still found that despite the studies that show 98% specificity for free fluid, surgeons don't same to care. - I have not seen anyone do a Fast exam in the community or even Level 1 I have worked at. The Trauma docs also have stopped doing them, just CT.

At academic centers, the mental masturbation that is exhibited with US has gotten a little ridiculous. US while it has it's uses, sometimes just isn't warranted and you should just get the damn CT scan. Also, all this stuff about using an US for a subclavian line is just ridiculous, as the whole point of that line is to get it in fast using only anatomy. Drives me crazy when people start bringing up these points on podcasts and the like. - I was taught subclavian in Residency and will go here if we could not get a femoral. A recent doc using U/S could not get his IJ. I got a Subclavian via landmarks

I know EM docs will get on their soapbox all the amazing things they can do with U/S. Gallbladders, Ectopic, Appendicits (really?), Joint reduction, fractures. I just don't get it. These pts are typically stable, they can wait for a CT/US. And if it requires a stat one for an ectopic, I just get the Tech to drop everything and come do it. just as fast.

 

[Rendar5]

Agree with most of above except for skin abscesses. I’ve seen data that shows clinical exam is ~50% accurate for determination of abscess vs phlegmon

 

[Hamhock]

I personally think FAST is absolutely worthless if you work at a trauma center.

See my post above. The traditional FAST may indeed be mostly useless; but, in the unstable trauma patient, the thoracic portion is very useful about 1 in 20 times and it is essential about 1 in 100 times. This exam frequently enough gets the patient to IR for intra-abdominal hemorrhage after correction with a chest tube, when "traditional" trauma management would require mucking around in the ED with massive transfusion and likely a trip to the OR for an unnecessary and inferior laparotomy (then delayed trip to IR!).

Pevlis xrays, on the other hand -- my god!

CXRs in stable patients headed to CT? Less useful than an abdominal FAST.

At academic centers, the mental masturbation that is exhibited with US has gotten a little ridiculous.

Agreed! ...but your example of this I think is a poor one.

Also, all this stuff about using an US for a subclavian line is just ridiculous, as the whole point of that line is to get it in fast using only anatomy. Drives me crazy when people start bringing up these points on podcasts and the like.

The whole point of a subclavian is not always to be "fast". In crashing trauma or arrest? Yes, blind subclavian.

However, especially for recent grads and in academic centers with a bit of extra time, the ultrasound-guided subclavian is -- and I know this is still a bit debatable -- safer, cleaner, and more comfortable than an IJ. If I have a bit of time, I don't even consider an IJ anymore (except severe coaguloapathy or poor view when I "glance" just before draping). If I have enough time to drape, I am going in the subclavian space. And, if I don't have enough time to drape, I am still going subclavian!

That said, I no longer take shifts in community EDs (still reached for subclavians when I did, however) and I have never worked where there was not an acceptable ultrasound, like some posters above seem to describe.

The benefit if the mental masturbation and podcasts is that it makes us re-consider things like this. Maybe not all of it turns out to be a good idea or applicable to all EDs, but some of it has greatly improved care and often become the standard of care.

It wasn't too long ago that an ultrasound-guided IJ was considered "cutting edge" and unnecessary by every ED doc older than 50. Now it's almost standard of care and it's easy to find recent residency grads with less than five blind IJs.

HH

 

[thegenius]

Agree with most of above except for skin abscesses. I’ve seen data that shows clinical exam is ~50% accurate for determination of abscess vs phlegmon

Agree...and often "purulent cellulitis" does better if you give a conduit for the pus to come out. e.g. I&D

There is no abscess below. but I would I&D this. Squeeze pus out and put in some packing, and tell the patient to take it out in a few days:

 

[Apollyon]

There is no abscess below. but I would I&D this. Squeeze pus out and put in some packing, and tell the patient to take it out in a few days:

This is confusing; if there is pus, that's an abscess. That is by definition. If you "squeeze pus out of it", that's an abscess.

 

[thegenius]

There is
- non-purulent cellulitis
- purulent cellulitis
- phlegmon / abscess

and sometimes you have a combo of those above.

I consider an abscess a discrete pocket of pus. I consider purulent cellulitis when you have little bits of pus invaginating into tissue planes.

This is an abscess:

 

[gro2001]

Sidetracking from the original conversation, but why/how did you go about doing that? No personal interest in doing anything remotely similar, but sounds like an interesting story.

I went to medical school there, so the how was easy for me. Called up my former professor who is now an associate dean and got the job.
As to the why, there were a number of factors, but determining one was that I was in the US on a J1 visa, which requires you to go back from whence you came for 2 years.

 

[RoyBasch]

I was, but now I work in Qatar.

Cool sounds like a great gig.

 

[res1cue]

Hey late to the conversation, but a few weeks ago as a brand new attending, my answer is similar to most of you: couple times a shift at most, mostly soft tissue or fasts, sometimes a quick transabdominal OB for quick dispo. Almost never cardiac, gallbladders, unlike in residency.



Then, I purchased a wireless pocket US probe (not butterfly, which I am still waiting on) and everything changed

I US over half my patients. I am talking to them anyways, and scribe carries gel and towel. Does not slow me down at all, most the time it doesn’t help my clinical decision making, but it does help my ultrasound skills immensely. I am taking a shot at all potential appys, alot of lung and MSK, a few aortas, a lot of weird stuff that I never would ultrasound otherwise.

Patients LOVE it, and it makes my shifts a whole lot more enjoyable and also helps me improve my ultrasound skills

Still havent done a LP since I got it, but cant wait to try sticking it into a sterile glove and using it for guidance and seeing how that works

 

[RustedFox]

Hey late to the conversation, but a few weeks ago as a brand new attending, my answer is similar to most of you: couple times a shift at most, mostly soft tissue or fasts, sometimes a quick transabdominal OB for quick dispo. Almost never cardiac, gallbladders, unlike in residency.



Then, I purchased a wireless pocket US probe (not butterfly, which I am still waiting on) and everything changed

How much did this toy cost you?

 

[res1cue]

$0

But it did take 1400 out of my CME!

It is made by some chinese company SonoStar Med, but there were some youtube reviews including one by a missionary gen surgeon, so I decided if I was gambling with CME money, with 18 month warrantee, and 30 day return policy, it would be an acceptable risk.

I kind of wish I got the double headed one for $2400, also seriously considering the qsono one too.

I think I will just wait till butterfly comes out and see if the wire is an acceptable tradeoff to the better quality

Also, major plus for this device is boot up time: from pulling it out of my scrubs to scanning under 10 sec

 

[thegenius]

$0

But it did take 1400 out of my CME!

It is made by some chinese company SonoStar Med, but there were some youtube reviews including one by a missionary gen surgeon, so I decided if I was gambling with CME money, with 18 month warrantee, and 30 day return policy, it would be an acceptable risk.

I kind of wish I got the double headed one for $2400, also seriously considering the qsono one too.

I think I will just wait till butterfly comes out and see if the wire is an acceptable tradeoff to the better quality

Also, major plus for this device is boot up time: from pulling it out of my scrubs to scanning under 10 sec

Dude tell us more. What is the link to the product you bought? Does it interface with your mobile phone? Battery life? how good is quality? I want to know more about this.

if I buy this it's a business expense and I get to save like ~30-40%.