Any good data on how POCUS has changed outcomes?

[MedicineZ0Z]

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In an ED or really any acute setting (ICU, inpatient etc). We're using POCUS everywhere now and I'm really curious if we've looked into how it's improved outcomes if at all.

 

[RustedFox]

Hocus Pocus, I need unsafe amounts of caffeine to focus.

 

[lymphocyte]

In an ED or really any acute setting (ICU, inpatient etc). We're using POCUS everywhere now and I'm really curious if we've looked into how it's improved outcomes if at all.

There are data that it actually might cause harm with delays in care. All the usual caveats for observational studies apply.

You could ask a similar question about stethoscopes. I'd argue U/S is infinitely more useful but only with a lot of humility and training.

Impact of Point-of-Care Ultrasound in the Emergency... : Critical Care Explorations

tment patients in two academic emergency departments. All emergency department patients admitted to the intensive care unit or that die in the emergency department were entered prospectively into a registry. Setting: Two academic emergency departments. Patients: All adult (> 18 years old)...

journals.lww.com

 

[AlmostAnMD]

I call codes much faster

Pretty much all I use it for

Related, but also helps when a nurse is feeling for a fem pulse during a pulse check and they're like, I FEEL A PULSE

then I look at zero cardiac activity on US and I'm like

lol

no you don't

he dead

 

[bougiecric]

In an ED or really any acute setting (ICU, inpatient etc). We're using POCUS everywhere now and I'm really curious if we've looked into how it's improved outcomes if at all.

I'd cynically argue that it's in academics where POCUS is used "everywhere now," chiefly to justify the careers of its proponents. Community docs will use it as indicated, but the vast majority of bedside ultrasound studies you do in academics are either irrelevant or make more sense to be done by an ultrasound tech.

 

[Angry Birds]

I'm taking a review course to earn my CME's and I notice how much POCUS is mentioned... I myself trained when it was just being introduced in the field, so I confess that I haven't really developed the skill aside from something like central line placement. But, all I know is that in the community setting I'll be damned if any consultant would act on a reported ultrasound finding without a CT scan. I can't see how it would actually change anything, and I do think it would actually slow things down. In the very rare case that the patient is vitally unstable then it's the physical exam alone that would cause me to pull the trigger early to transfer, but even then, I'm often taking the patient to CT scan while the transport is on the way...

Admittedly, I have a bias here since I naturally want to downplay a technology I am not adept at. So take it with a grain of salt. But, for me, it's still hocus pocus.

The other problem is that I'm lazy. Lugging around that ultrasound seems like a lot of work. I'd rather eat a sandwich while the patient is in scan.

 

[Jabbed]

I would expect that the data showing how POCUS has changed outcomes is similar to the data showing mortality outcomes between mid levels and physicians.

It probably isn’t there, but that does not necessarily mean that there is no difference between your US fellowship trained pro vs the dinosaur that can only place blind fem lines.

@Angry Birds I’ve had community consultants act on bedside ultrasound findings several times, but there has to be a reason why my bedside ultrasound study is the preferred study in these situations. Normally that is because the patient has a life threatening pathology (tamponade, ruptured ectopic, hemoperitoneum) AND is truly too unstable to go to scanner (ie, MTP). They may not necessarily believe me 100%, but it’s much more difficult to turn someone down when you say “I need your help. I’ve got a patient with abc pathology, and they need xyz procedure. You need to come in/down.”

 

[Angry Birds]

It probably isn’t there, but that does not necessarily mean that there is no difference between your US fellowship trained pro vs the dinosaur that can only place blind fem lines.

Roar!

@Angry Birds I’ve had community consultants act on bedside ultrasound findings several times, but there has to be a reason why my bedside ultrasound study is the preferred study in these situations. Normally that is because the patient has a life threatening pathology (tamponade, ruptured ectopic, hemoperitoneum) AND is truly too unstable to go to scanner (ie, MTP). They may not necessarily believe me 100%, but it’s much more difficult to turn someone down when you say “I need your help. I’ve got a patient with abc pathology, and they need xyz procedure. You need to come in/down.”

I gotcha. You're probably right.
I just work at a rural shop without a single consultant who would come in for anything at all. If the situation was so emergent that they would need to come in, it would be an immediate transfer or life flight.

Anyways, I wish I had learned ultrasound in residency. But I was overwhelmed during that time and it was a new technology... I guess I should sign up for some course somewhere but I'm a dinosaur now.

 

[Janders]

LIke so many things, I come down in the middle of the road on POCUS.

I do love it as a procedure-assist; certainly I can place a blind CVL with a hand behind my back, but I strongly prefer to see the anatomy on US. I place a LOT of PIVs with it, and patients like that. It likely prevents a few downstream DVT/CLABSIs but you’d need a lot of numbers to prove it. I like it for some nerve blocks, to look a joints for aspiration, and sometimes to look at abscesses. It isn’t required for any of these, but I find it personally helpful.

Diagnostically, I mostly like it for people who are critically ill. The quick echo-pulse check / rule out tamponade is a mainstay (we find a tamponade once every year or two…). I just think codes seem more formal and concrete if I can do 1-2 echo checks. Uncommonly I do get people stat transferred or right to the OR from POCUS (the classic unstable ruptured ectopic with massive blood in the belly, a ruptured spleen with a classic story and severe instability). We don’t have overnight formal US, so I’ve personally acted on positive DVT and RUQ studies many times, and certainly had our surgeons admit acute chole based on review of my images (they might get a formal US in the AM before the OR, but hey at least we got the patient admitted).

Most recent example, partner had an older lady come in with dyspnea/severe hypoxia (middle of a covid wave) who progressed to respiratory->cardiac arrest about 2 minutes after arrival, before anyone got access or labs or an EKG even. So we start to code her, he’s tubing her, we see her leg is swollen. After IO + epi, while he passes the tube, I put the probe on her groin… incompressible fem, +DVT. 2 minutes into the code, pulse check, slap the probe on her chest and she has pseudo-ROSC (i.e. solid cardiac activity, but hypotensive with minimally palpable central pulses) with massive dilated RV. We’re like “this is a huge PE, has to be” so slam TPA in… 4 minutes later excellent ROSC with minimal pressor need. CTA thereafter confirmed residual bilateral PE.

Might we have gone off the swollen left leg alone, and her arrest, and eventually given TPA? Maybe. But being able to visually confirm DVT and RH Strain in seconds really took all the uncertainty off the table, and made us move more quickly and aggressively.

But the thing is, these cases ARE uncommon… its not like I’m saving lives and massively changing management every shift with my probe.

As well, when formal US is readily available, I defer DVT and RUQ studies to them so I can spend my time doing other things, unless the patient is so sick I’m in the room anyway.

 

[MedicineZ0Z]

There are data that it actually might cause harm with delays in care. All the usual caveats for observational studies apply.

You could ask a similar question about stethoscopes. I'd argue U/S is infinitely more useful but only with a lot of humility and training.

Impact of Point-of-Care Ultrasound in the Emergency... : Critical Care Explorations

tment patients in two academic emergency departments. All emergency department patients admitted to the intensive care unit or that die in the emergency department were entered prospectively into a registry. Setting: Two academic emergency departments. Patients: All adult (> 18 years old)...

journals.lww.com

I should have clarified that this is excluding its use for procedures.

Only uses I've seen so far in has been identifying a pneumo, volume status and intra code use (and I actually use it a lot). I've certainly founds loads of other things on there but the diagnosis was either known already or almost certain. Even volume status is a bit iffy since it's uncommon to cause major changes in the plan.

 

[dadaddadaBATMAN]

I should have clarified that this is excluding its use for procedures.

Only uses I've seen so far in has been identifying a pneumo, volume status and intra code use (and I actually use it a lot). I've certainly founds loads of other things on there but the diagnosis was either known already or almost certain. Even volume status is a bit iffy since it's uncommon to cause major changes in the plan.

Things it’s kind of helpful for
Ruptured ectopic
Is this unconscious/drugged out lady just Fat or gravid (not helpful unless late)
Pulmonary edema and ptx
Aaa in unstable
Tamponade/effusion eval

Things I do to appease people/put on a show but don’t keep images of or mention in my mdm: gall bladder, echo, abscess

Not an exhaustive list, but I’m not doing gall bladder, dvt, tvus or other high risk studies on my own often if they are actual possibilities

 

[SpacemanSpifff]

There are data that it actually might cause harm with delays in care. All the usual caveats for observational studies apply.

You could ask a similar question about stethoscopes. I'd argue U/S is infinitely more useful but only with a lot of humility and training.

Impact of Point-of-Care Ultrasound in the Emergency... : Critical Care Explorations

tment patients in two academic emergency departments. All emergency department patients admitted to the intensive care unit or that die in the emergency department were entered prospectively into a registry. Setting: Two academic emergency departments. Patients: All adult (> 18 years old)...

journals.lww.com

I would revise the bolded to read there is at least one paper suggesting association with increased mortality. Here’s a separate study which associated a bedside echo in patients with undifferentiated shock with improved mortality, less AKI: Limited echocardiography–guided therapy in subacute shock is associated with change in management and improved outcomes

The need to associate a diagnostic study with outcomes has always confused me. If you interpret any diagnostic study inaccurately, it isn’t going to help the patient. We don’t do the same for ECG’s, CBC’s, or chest radiography, why is ultrasound different? I suppose if you want to justify the purchase of a machine that costs tens of thousands of dollars to a group.

My bias is towards using ultrasound in certain situations, specifically undifferentiated shock, as I trained in a program with a solid division. At this point in my training (critical care) I use echo more frequently than any other study, and find it changes my management frequently. That said, I have spent a lot of time learning image acquisition and interpretation, since it is more frequently pertinent in the ICU.

I empathize with those who can’t get consultants to do anything without a “formal” and don’t begrudge them the subsequent lack of interest. It doesn’t make sense to do a study if you know your consultant is going to request another one.

 

[CoolDoc1729]

I'm taking a review course to earn my CME's and I notice how much POCUS is mentioned... I myself trained when it was just being introduced in the field, so I confess that I haven't really developed the skill aside from something like central line placement. But, all I know is that in the community setting I'll be damned if any consultant would act on a reported ultrasound finding without a CT scan. I can't see how it would actually change anything, and I do think it would actually slow things down. In the very rare case that the patient is vitally unstable then it's the physical exam alone that would cause me to pull the trigger early to transfer, but even then, I'm often taking the patient to CT scan while the transport is on the way...

Admittedly, I have a bias here since I naturally want to downplay a technology I am not adept at. So take it with a grain of salt. But, for me, it's still hocus pocus.

The other problem is that I'm lazy. Lugging around that ultrasound seems like a lot of work. I'd rather eat a sandwich while the patient is in scan.

I think a lot depends on your practice setting too. At my single coverage 65k main gig with 24/7 us coverage it would be asinine for me to do any US besides procedure assist and calling the codes. The us tech is 110% always less busy than I am. At my 10k freestanding with no night US coverage it would be much more useful. Would my consultants pay any attention to my findings ? Hopefully if it’s a +ucg with hemoperitoneum etc…

 

[alpinism]

I think a lot depends on your practice setting too. At my single coverage 65k main gig with 24/7 us coverage it would be asinine for me to do any US besides procedure assist and calling the codes. The us tech is 110% always less busy than I am. At my 10k freestanding with no night US coverage it would be much more useful. Would my consultants pay any attention to my findings ? Hopefully if it’s a +ucg with hemoperitoneum etc…

You see 65K with single coverage?

I hope they’re paying 300/hr minimum.

 

[lymphocyte]

I would revise the bolded to read there is at least one paper suggesting association with increased mortality. Here’s a separate study which associated a bedside echo in patients with undifferentiated shock with improved mortality, less AKI: Limited echocardiography–guided therapy in subacute shock is associated with change in management and improved outcomes

The need to associate a diagnostic study with outcomes has always confused me. If you interpret any diagnostic study inaccurately, it isn’t going to help the patient. We don’t do the same for ECG’s, CBC’s, or chest radiography, why is ultrasound different? I suppose if you want to justify the purchase of a machine that costs tens of thousands of dollars to a group.

My bias is towards using ultrasound in certain situations, specifically undifferentiated shock, as I trained in a program with a solid division. At this point in my training (critical care) I use echo more frequently than any other study, and find it changes my management frequently. That said, I have spent a lot of time learning image acquisition and interpretation, since it is more frequently pertinent in the ICU.

I empathize with those who can’t get consultants to do anything without a “formal” and don’t begrudge them the subsequent lack of interest. It doesn’t make sense to do a study if you know your consultant is going to request another one.

I revise nothing. This is the emergency medicine sub-forum, right? That paper is from the intensive care setting. Different beast. Patient population is different. Priorities are different. Nobody's really making nuanced decisions about volume status +/- starting dobutamine when the line is out the door and there's more coming in.

Doesn't even matter though. I got papers for your papers. The point is that POCUS is at best chaotic good. It's great if you know how to do it correctly. Just like interpreting a d-dimer or taking a chest pain history. Yes, undifferentiated shock probably merits a skilled and focused US. But the key words are "skilled" and "focused." If that's you, that's great. But I've seen plenty of **** ups, which is probably more common than we'd like to think.

And then there's the question of liability. Which is a question that is roughly the size of a massive elephant turd. When the chips are down and the call really matters and a formal study is just a phone call away, 9.9 times out of 10 the response will be, "let's just get a formal."

 

[CoolDoc1729]

You see 65K with single coverage?

I hope they’re paying 300/hr minimum.

We are single doc coverage at night (I’m a nocturnist) I have a pa from 2200-0200, then alone 0200-0600. Our CMG is kind enough to provide productivity spreadsheets each month that say I only average 1.2 pph, so it’s clearly not that bad, maybe I should get an MBA so I can learn that kind of math ! No 300/h.

(If only my husband was not super attached to the area for no discernible reason .. or I guess if only I wasn’t super attached to him 🤣)

 

[EctopicFetus]

I trained with it. Minimal utility but it’s there. Procedures as noted above for sure. But pushing it for dvts and other stuff is either purely academic or you aren’t busy enough. I would argue much like placing ivs our time is better spent caring for people and not doing things “cheaper” labor can do.
codes sure, trauma fast meh Maybe, retinal detachments yep, procedures totally but dvts gall bladders Ob / GYN us nope. Waste of time. If you are there to learn or see something cool. Sure. But for flow and patient care nope.

 

[lucid_leprechaun]

I trained with it. Minimal utility but it’s there. Procedures as noted above for sure. But pushing it for dvts and other stuff is either purely academic or you aren’t busy enough. I would argue much like placing ivs our time is better spent caring for people and not doing things “cheaper” labor can do.
codes sure, trauma fast meh Maybe, retinal detachments yep, procedures totally but dvts gall bladders Ob / GYN us nope. Waste of time. If you are there to learn or see something cool. Sure. But for flow and patient care nope.

I would argue that bringing an ultrasound in for pregnant patients actually shortens dispo in my hospitals. If quick pregnancy localization that looks reassuring a lot of first trimester bleeding, pain, etc patients are ready to leave. Especially if known rH +.

 

[Mount Asclepius]

I would argue that bringing an ultrasound in for pregnant patients actually shortens dispo in my hospitals. If quick pregnancy localization that looks reassuring a lot of first trimester bleeding, pain, etc patients are ready to leave. Especially if known rH +.

Our radiologists tell me they hate reading OB ultrasounds due to the higher liability. Granted, I think this is more likely related to later term ultrasounds where defects or abnormalities that affect pregnancy that aren’t detected become more problematic. Regardless, a slightly shorter time to dispo for me isn’t worth the liability trade off.

If you aren’t billing and recording images (increased liability by doing so) for these, then you might be losing money by doing them instead of just ordering the formal US and seeing an extra patient.

 

[Angry Birds]

I prefer to side with studies that reinforce my own practice patterns and limitations.

 

[MedicineZ0Z]

I would argue that bringing an ultrasound in for pregnant patients actually shortens dispo in my hospitals. If quick pregnancy localization that looks reassuring a lot of first trimester bleeding, pain, etc patients are ready to leave. Especially if known rH +.

the liability aspect though?

 

[EctopicFetus]

I would argue that bringing an ultrasound in for pregnant patients actually shortens dispo in my hospitals. If quick pregnancy localization that looks reassuring a lot of first trimester bleeding, pain, etc patients are ready to leave. Especially if known rH +.

You are doing transvag us? Also idk but many of our patients are rh unknown and the 2 main sites I work at deliver a ton of babies.

 

[EctopicFetus]

Our radiologists tell me they hate reading OB ultrasounds due to the higher liability. Granted, I think this is more likely related to later term ultrasounds where defects or abnormalities that affect pregnancy that aren’t detected become more problematic. Regardless, a slightly shorter time to dispo for me isn’t worth the liability trade off.

If you aren’t billing and recording images (increased liability by doing so) for these, then you might be losing money by doing them instead of just ordering the formal US and seeing an extra patient.

Also I would argue you better save those images for med mals sake.

 

[DeadCactus]

I revise nothing. This is the emergency medicine sub-forum, right? That paper is from the intensive care setting. Different beast. Patient population is different. Priorities are different. Nobody's really making nuanced decisions about volume status +/- starting dobutamine when the line is out the door and there's more coming in.

Doesn't even matter though. I got papers for your papers. The point is that POCUS is at best chaotic good. It's great if you know how to do it correctly. Just like interpreting a d-dimer or taking a chest pain history. Yes, undifferentiated shock probably merits a skilled and focused US. But the key words are "skilled" and "focused." If that's you, that's great. But I've seen plenty of **** ups, which is probably more common than we'd like to think.

And then there's the question of liability. Which is a question that is roughly the size of a massive elephant turd. When the chips are down and the call really matters and a formal study is just a phone call away, 9.9 times out of 10 the response will be, "let's just get a forma

I don't think anyone would dispute that the optimal use cases for point-of-care ultrasound are very narrow. That's exactly why I find a retrospective cohort study in a large academic ED to be lackluster evidence; it's exactly the setting ultrasound is least useful in. Ultrasound should be compared to other diagnostic modalities to validate it as an equivalent to other modalities when they are not available or inferior. All this shows is that patients who had an unclear need for an intervention got more diagnostic studies before getting the intervention. I also find it a red flag that a paper coming out of the home of a major ultrasound fellowship does not seem to have a single ultrasound faculty member on it and even the EM authors seem to be EM-CC rather than full-time EM.

 

[Radetzky]

I use bedside echo in the ICU which changes my management a lot but I have devoted ALOT of time and training to get good with it. I think there is a real danger to “dabbling” with POCUS and I see overconfident conclusions a lot.

Case in point- anyone claiming to assess “volume status” with POCUS- there is no ultrasound finding that tells you “volume state”

 

[RustedFox]

I use bedside echo in the ICU which changes my management a lot but I have devoted ALOT of time and training to get good with it. I think there is a real danger to “dabbling” with POCUS and I see overconfident conclusions a lot.

Case in point- anyone claiming to assess “volume status” with POCUS- there is no ultrasound finding that tells you “volume state”

So yeah; I caught myself thinking about this the other day. How does one determine "fluid overload" versus "poor EF in the setting of normovolemia" vs. all the other combinations thereof? You can't.

 

[MedicineZ0Z]

So yeah; I caught myself thinking about this the other day. How does one determine "fluid overload" versus "poor EF in the setting of normovolemia" vs. all the other combinations thereof? You can't.

I just consider it a tool as part of the exam. IVC, looking at the IJ etc combined with my exam and history. In the ICU setting obviously the history component falls off. But I do find it useful when combined with everything else especially for the obese patients.

 

[turkeyjerky]

the liability aspect though?

Where’s the liability? Pt w/ known 1st tri IUP comes in for bleeding. You do an US to reassure, emphasize the fact that she could still miscarry tomorrow and dc.

 

[RustedFox]

I just consider it a tool as part of the exam. IVC, looking at the IJ etc combined with my exam and history. In the ICU setting obviously the history component falls off. But I do find it useful when combined with everything else especially for the obese patients.

So:

1.) You're right.

2.) In this weird thought process of mine, I really did put myself in the situation of interpreting the ultrasound of the "universal patient" (if that makes sense), where you were interpreting only the US images and ignoring the history/physical/etc. Like; basically looking for a highly specific "US finding" that indicated "condition X". Like, "seeing a noncompressible section of the femoral vein with hyperechoic irregularities in the lumen indicates DVT".

Is it overly simplistic? Yes. Was I trying to start somewhere? Yes. Did it work out the way I wanted it to? No. Did it entertain my ADHD brain while I found more caffeine and chanted "hocus pocus focus" again? Yes.

3. "...especially for the obese patients"
- So, all of the patients. Lol.

 

[lucid_leprechaun]

Our radiologists tell me they hate reading OB ultrasounds due to the higher liability. Granted, I think this is more likely related to later term ultrasounds where defects or abnormalities that affect pregnancy that aren’t detected become more problematic. Regardless, a slightly shorter time to dispo for me isn’t worth the liability trade off.

If you aren’t billing and recording images (increased liability by doing so) for these, then you might be losing money by doing them instead of just ordering the formal US and seeing an extra patient.

Agree my only role in early pregnancy is finding an IUP +/- FHR depending on gestational age. And definitely must post images on chart, otherwise could be a malpractice nightmare. I also bill for them. My shop only has a trans abdominal probe so I have to order consultative ultrasounds if I’m not able to confirm uterine pregnancy.

 

[dadaddadaBATMAN]

Where’s the liability? Pt w/ known 1st tri IUP comes in for bleeding. You do an US to reassure, emphasize the fact that she could still miscarry tomorrow and dc.

Mostly if you’re wrong. I’m not going to pretend I trace the uterus down to the cervix on every case.

Considering I have ultrasound in house and this is one of the highest risk areas of er I’m not doing these.

 

[Radetzky]

So yeah; I caught myself thinking about this the other day. How does one determine "fluid overload" versus "poor EF in the setting of normovolemia" vs. all the other combinations thereof? You can't.

no you cant
IVC is useless- might as well go back to measuring CVP
EDV/LV size- you have no idea what’s normal/baseline for any individual
EF/function depends more on after load conditions than anything else
The closest you can get is LVOT VTI and measure changes post fluid but even this is fraught with difficulty

 

[Rekt]

Where’s the liability? Pt w/ known 1st tri IUP comes in for bleeding. You do an US to reassure, emphasize the fact that she could still miscarry tomorrow and dc.

Known IUP with previous formal ultrasound is much different than undifferentiated vaginal bleeding/pain with only a positive test. If you're doing a bedside TAUS on the latter and discharging then you're making a very poor decision.

 

[Siggy]

Do I generally see a role for things like comprehensive echos in terms of POCUS?

No.

I have no doubt, though, that timely complaint directed echos, sometimes with simple measurements (i.e. IVC variation or FS measurement for EF) improves outcomes. Knowing immediately after a cardiac arrest that there's tamponade is helpful. Knowing fluid responsive status (IVC) can be helpful. Catching a tachycardia induced cardiomyopathy on US on a thyrotoxic patient, so you go with esmolol over propranolol is helpful.

Most of the mental self flagellation with POCUS echos? Yea... ain't got time to see 20+ ICU patients and grab serial aortic outflow track dopplers on apical 5 chamber views that can be used with the aortic diameter from parasternal long to calculate cardiac outputs.

 

[pollyspockets]

Known IUP with previous formal ultrasound is much different than undifferentiated vaginal bleeding/pain with only a positive test. If you're doing a bedside TAUS on the latter and discharging then you're making a very poor decision.

I disagree. Trans ab with IUP clearly in the uterus with + FHT and a good counseling is sufficient for me

 

[SpacemanSpifff]

I revise nothing. This is the emergency medicine sub-forum, right? That paper is from the intensive care setting. Different beast. Patient population is different. Priorities are different. Nobody's really making nuanced decisions about volume status +/- starting dobutamine when the line is out the door and there's more coming in.

Doesn't even matter though. I got papers for your papers. The point is that POCUS is at best chaotic good. It's great if you know how to do it correctly. Just like interpreting a d-dimer or taking a chest pain history. Yes, undifferentiated shock probably merits a skilled and focused US. But the key words are "skilled" and "focused." If that's you, that's great. But I've seen plenty of **** ups, which is probably more common than we'd like to think.

And then there's the question of liability. Which is a question that is roughly the size of a massive elephant turd. When the chips are down and the call really matters and a formal study is just a phone call away, 9.9 times out of 10 the response will be, "let's just get a formal."

Sure sure. The paper supplied was meant to add something to the OP's original question, i.e. data from an acute care setting, not suggest that echo is the key to shock evaluation. I wouldn't claim that US has the best evidence base, hence all the added context in my post.

 

[SpacemanSpifff]

So:

1.) You're right.

2.) In this weird thought process of mine, I really did put myself in the situation of interpreting the ultrasound of the "universal patient" (if that makes sense), where you were interpreting only the US images and ignoring the history/physical/etc. Like; basically looking for a highly specific "US finding" that indicated "condition X". Like, "seeing a noncompressible section of the femoral vein with hyperechoic irregularities in the lumen indicates DVT".

Is it overly simplistic? Yes. Was I trying to start somewhere? Yes. Did it work out the way I wanted it to? No. Did it entertain my ADHD brain while I found more caffeine and chanted "hocus pocus focus" again? Yes.

3. "...especially for the obese patients"
- So, all of the patients. Lol.

Junior trainees use this cognitive structure frequently, outside of the thought exercise you created, and that's where the chaos that @lymphocyte mentioned comes from. Big RV on an echo? Must be a PE. Plethoric IVC? Must be volume overloaded. etc.

 

[RoyBasch]

Where’s the liability? Pt w/ known 1st tri IUP comes in for bleeding. You do an US to reassure, emphasize the fact that she could still miscarry tomorrow and dc.

I think the liability is more in the case where the patient has not had an US at all yet, and there is no confirmed IUP. The majority of these patients have no prenatal care (the ER is their prenatal care) and the first time they see a OB is when they ROM/start labor. The risk early on is going to be missed ectopic or hetero-ectopic (very rare I know) and later on its going to be missed birth defects with inadequate counseling and referral to appropriate pediatric and maternal fetal specialists.

 

[The Knife & Gun Club]

Situations where US seems to be legitimately beneficial:

1) acute resuscitation - protocols like rush and fast can give you a decent amount of information and be done in 1-2 in an appropriately trained provider. Things like rapidly ruling in or out pneumo, pulmonary edema, tamponade, volume status with ICU gets my resus going in the right direction way faster

2) occular US - I can’t do a reliable slit lamp exam to save my life and I’d imagine most of you all are the same. But I can diagnose/rule out vitreous hemorrhage and retinal detachment in under 30 seconds per eye. Can be useful in differentiating a focal stroke from primarily optho pathology as well

3) line placement - obviously we should all be proficient in this

4) therapeutic - for those patients that psychologically benefit from non-indicated imaging

 

[Tiger26]

I think the liability is more in the case where the patient has not had an US at all yet, and there is no confirmed IUP. The majority of these patients have no prenatal care (the ER is their prenatal care) and the first time they see a OB is when they ROM/start labor. The risk early on is going to be missed ectopic or hetero-ectopic (very rare I know) and later on its going to be missed birth defects with inadequate counseling and referral to appropriate pediatric and maternal fetal specialists.

In the absence of hetero topic risk factors, I'm not really seeing the risk in 1st trimester bleeding when you have a bedside ultrasound showing an IUP with a HR, but maybe in missing something. They can have a formal ultrasound done later on in clinic, but there's nothing to be done from an EM standpoint.

 

[Zebra Hunter]

Agree with the few saying there is almost zero liability in a first trimester bleeding/pain who already has confirmed IUP. Just put an US on their belly and discharge them. That is a zero risk situation. They technically don't even need an US if they already have a confirmed IUP, just OB follow-up. Slightly more risk with no prior US, but I still think it is reasonable if they have good follow-up.