ED Ultrasound: When is it useful?

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Zebra Hunter

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This is a spin-off of the pelvic exam thread. It seems most med students and many of my fellow residents and faculty seem to be in love with the ultrasound in the ER; however, I do not share this love affair with it. I think it is great to learn, I think it undoubtedly has its place, but I think it's benefits are largely overstated.

So let's talk about when U/S actually is useful, and by useful I mean, actually has meaningful difference in procedure success, disposition of the patient, or changes management of the patient that could not be duplicated by an alternative imaging modality or a formal ultrasound.
 
FAST in the appropriate setting and interpretation
Undifferentiated hypotension
CVC placement (and post line pneumo check)
Bleeding in pregnancy
Maybe renal if you see hydronephrosis on a patient with known stones you can save them the radiation
Intussusception in kiddos
Might think of more...
 
pollyspockets said:
FAST in the appropriate setting and interpretation
Undifferentiated hypotension
CVC placement (and post line pneumo check)
Bleeding in pregnancy
Maybe renal if you see hydronephrosis on a patient with known stones you can save them the radiation
Intussusception in kiddos
Might think of more...
Click to expand...

I was with you until Intussusception....
 
1. Cardiac activity - "pulse check" - during codes.
2. Central lines, yo. All day long.
3. First trimester bleeding.
4. FAST exam.
5. Gallbladder.


That's pretty much what I use it for.
 
Agree with initial post. Ultrasound is cumbersome and time consuming. It's useful in only a handful of situations, like central line placement and cardiac activity.

But FAST? Waste of time. I did residency at a trauma center and we did this useless exam every time and not once did it change management.

And then you spend ages trying to upload the images so you can bill for it. What a time suck. Just cleaning the damn probe is annoying enough.
 
Angry Birds said:
But FAST? Waste of time. I did residency at a trauma center and we did this useless exam every time and not once did it change management.
Click to expand...
I agree. It's hard enough to get the trauma guys to do what ATLS says when they're in the room watching you do it. In a community hospital? They won't trust you for anything. Either they'll accept the hypotensive pt because of an agreement, or they'll make you scan it. Either way, the FAST doesn't help the pt, even if it makes you feel better.
And don't get me started on doing it on the normotensive pt.
 
Once did a FAST on a lady with a mildly distended belly, no trauma. Fluid in Morrison's. INR came back at 15. Turned out she continued to take her Coumadin for two weeks while out of the country on vacation but also having NVD, and she started to bleed out.
 
Dr.McNinja said:
I agree. It's hard enough to get the trauma guys to do what ATLS says when they're in the room watching you do it. In a community hospital? They won't trust you for anything. Either they'll accept the hypotensive pt because of an agreement, or they'll make you scan it. Either way, the FAST doesn't help the pt, even if it makes you feel better.
And don't get me started on doing it on the normotensive pt.
Click to expand...


I'll push your start button. I dont disagree, but I want you to speak.
 
tkim said:
Once did a FAST on a lady with a mildly distended belly, no trauma. Fluid in Morrison's. INR came back at 15. Turned out she continued to take her Coumadin for two weeks while out of the country on vacation but also having NVD, and she started to bleed out.
Click to expand...

Not to sound too snarky, but then should we be doing a FAST on all patients based on the idea that occasionally it will show a positive finding? In the case you described, did you end up ordering a CT scan? I'm gonna guess yes.

Ultrasound is one of those things where you have to convince yourself it's useful.
 
RustedFox said:
I'll push your start button. I dont disagree, but I want you to speak.
Click to expand...
The indication for FAST is to where to take the hypotensive trauma patient. If it's positive, they're supposed to go to the OR or get pericardiocentesis. If it's negative, you're supposed to figure out why.
If they're not hypotensive, they're going to get a CT all of the time. FASTing them actually makes things SLOWer.
algorithm.jpg
 
I'll tell you one of the major reasons I hate ultrasound. There is a direct correlation between ER docs and especially residents having the capability to do ultrasound guided peripheral IV's and nursing failure rate in IV access successs.

In residency, nurses on every shift couldn't get IV access and would ask for a resident to waste fifteen minutes of time (and often more than that) mucking around with the ultrasound to get an IV in. Now I work at a shop without ultrasound--or at least nobody uses it for this propose--and suddenly nurses have success 99 percent of the time.

The worst was when a nurse in residency would come up to us and say, "the patient is a really hard stick. Should I even try or do you just want to use the ultrasound?" My head would explode when I heard this. Of course when you say for them to try, they do two weak attempts just stabbing random places and then say that the patient refused further attempts and wants it done by ultrasound.

The ultrasound is a huge time suck.
 
Dr.McNinja said:
The indication for FAST is to where to take the hypotensive trauma patient. If it's positive, they're supposed to go to the OR or get pericardiocentesis. If it's negative, you're supposed to figure out why.
If they're not hypotensive, they're going to get a CT all of the time. FASTing them actually makes things SLOWer.
algorithm.jpg
Click to expand...

I would always tell the intern to do the SLOW exam because that's what it should be renamed.
 
I feel blasphemous (having completed an US fellowship), but agree with all the above.

FAST exam? Had a positive finding the other day. You know what the next step was? CT. Over 3 years of residency, 1 of fellowship, and more than that as an attending, I've never seen one positive FAST go to the OR. They ALL go to CT.

Maybe I'm being too extreme. Did have one stab wound to the chest get an emergent OR thoracotomy directly after visualizing hemopericardium on US.

I already started, so now I'm going to get really blasphemous. The vast majority of bedside ED ultrasounds can be done by radiology. In the truly, truly emergent cases, it's helped guide management. But these cases are so rare that it's hard for me to justify the overall resources devoted to it.

First trimester vag bleeder? Radiology US. Cholelithiasis/cholecystitis? Radiology US. DVT? Radiology US. Etc, etc. No consultant anywhere cares about our bedside US. It might as well be done by radiology, in the PACS, with a formal read.

My biggest pet peeve is pulmonary US. Yes, it actually works quite well. Edema is readily diagnosable via B lines. Pleural effusion is easy. Pneumonia pretty decent (as more and more studies are showing). Many are proclaiming it better than CXR (which it very well may be). If this is so, then why do I have to be the one to do it? Why can I not order a pulmonary US via radiology?

Unless the patient is in extremis and about to die, it is a much better use of my time to defer to our radiology colleagues and try to move the department.
 
I have had all of one FAST exams go to the operating room. It was in the hypotensive pregnant patient, who had already been told by an outside facility that she may have an ectopic. If anything else, the FAST exams are useful for documenting in the chart, "FAST negative," but really serve no other purpose.

I definitely use ultrasound on all of my central line placements to confirm needle insertion and guide wire location prior to dilation. I also like performing bedside echocardiograms during codes and occasionally during chest pain workups to evaluate contractility and to see if there is a pericardial effusion. And as crazy as it may sound, ocular ultrasounds have been useful on a few occasions for diagnosing retinal tears and vitreous hemorrhages. The ophthalmologists do seem to take our word on whatever we find via ultrasound. The end result is that the specialist will still tell me, "That's great. Have the patient follow-up with me tomorrow in clinic."

I will occasionally perform quick right upper quadrant abdominal scans of someone's gallbladder or kidney if the history and physical are nonspecific for any one particular disease. The reason I do that is more to figure out what kind of imaging study comes next: formal ultrasound to look for cholelithiasis, noncontrast abdominal CT look for renal stones, or contrast enhanced CT because I have no idea really what I'm looking for.

For everything else, the patient goes to the radiology department.
Pelvic ultrasound? Better performed by experienced radiology tech.
DVT study? There is no reason I need the answer right now in the emergency department.
Pulmonary ultrasound? I have never been able to diagnose pneumothorax, pneumonia, or effusion with ultrasound. I will let the chest x-ray and possibly chest CT take care of that for me.
Intussusception? Appendicitis? Small bowel obstruction? I'd have no idea what I'm looking for. And on top of that, the surgeon is going to want a formal study anyway.
 
Have seen many +FAST go directly to OR (though we see A LOT of penetrating trauma). Have had surgery accept a patient without a formal GB US after reviewing my images (doesn't usually happen, but when its convincing enough). Have caught peripartum cardiomyopathy (at least made dispo at lot easier and quicker) and massive pericardial effusion (went direct to IR for a drain). I've NEVER ordered a formal RUQ US if the bedside one was negative. We have caught ruptured ectopics and gyn has gone to OR after reviewing our images when the patient was unstable. We US preg vag bleeders all the time; if IUP --> home w/ ob/gyn f/u, no formal US. Lung US is helpful in the COPD vs CHF pt., and when not sure if I'm seeing an infiltrate or effusion on CXR. At one community site, I'm more than happy to have radiology do certain scans, but I still do my own frequently.

I don't expect things like this to happen in the community, really, and I'm sure my practice will adjust accordingly.
 
I really think this ultrasound trend has to do with a couple factors, none of which justify its use:

(1) We can. We can now ultrasound an elbow to see if there is a fracture. Why the f*** would we do this (instead of getting an x-ray)? Because we can.

(2) It's something new and neat.

(3) It's a specialized skill that emergency physicians can pioneer.

I think #3 is the major reason for this push toward ultrasound. We hate being the jack of all trades master of none, and this will allow us to do something (2) new and neat that (1) we can do and that nobody else does.

But, like I said, it's a big time suck. Order the x-ray and go see three other patients in the time it would take you to do an ultrasound.
 
Angry Birds said:
I really think this ultrasound trend has to do with a couple factors, none of which justify its use:

(1) We can. We can now ultrasound an elbow to see if there is a fracture. Why the f*** would we do this (instead of getting an x-ray)? Because we can.

(2) It's something new and neat.

(3) It's a specialized skill that emergency physicians can pioneer.

I think #3 is the major reason for this push toward ultrasound. We hate being the jack of all trades master of none, and this will allow us to do something (2) new and neat that (1) we can do and that nobody else does.

But, like I said, it's a big time suck. Order the x-ray and go see three other patients in the time it would take you to do an ultrasound.
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As a rads resident, I think number three is funny because in the early stages of ultrasound, the radiologist would do the exam, they'd call themselves ultrasonologists, they had fellowships in Ultrasound.

They soon realized that it's a huge waste of time to actually acquire all of the images and delegated the task to a sonographer so they could read multiple other studies instead.

I'm curious to see if there is the same boom bust cycle of ER ultrasound that happened with radiologists.
 
I found a few bot flies underneath a patient's skin with ultrasound. I wish I would have saved the images because they were actually pretty cool.

That said: FB, lines, pulse check, pneumo, pericardiocentesis, thoracentesis, paracentesis, FAST, gallbladder, kidney stones, normal babies, babies where they aren't supposed to be babies, DVT, arterial occlusion.

Ultrasound is just a tool. I don't use it on every patient or even every shift but when I use it I only use it to perform a useful task or obtain useful information in a timely manner. I just treat it like a laryngoscope, a scalpel or my dilaudid macro, just another tool in my get the hell out of my ER box.
 
True, I forgot about skin examinations. Before I even consider performing an incision and drainage, I always check with the ultrasound to see how deep the abscess goes, or even if there is a drainable abscess at all versus heavy cellulitis. I checked a few times for foreign bodies, but haven't had luck in finding any.
 
I find it useful to get ooh's and ahh's from family members. When I do slap on the ultrasound and point to the mitral valve and tell them what it is it really gets the "wow all I see is fuzzy stuff". Granted I could tell them it's the corpus cavernosum and they wouldn't know the difference but they will still think; man that doc is good. Really though patients love to see their heart beating. The pregnant patient LOVES to see their baby and once in a while I need to pull it out because the nurse can't get FHT's on an early pregnancy. Past that I use it for central lines and pushing it around at the end of my shift so it looks like I'm busy and can't pick up the multiple medical complaints before my college comes in.
 
Always:

Echo, IVC, lungs on undifferentiated shocked patients

All IJ CVLs, paras and thoras

E Fast on hypotensive trauma patients (our surgeons are starting to operate on these without CT)

Abscess vs cellulitis

Foreign body removal

Proximal median nerve block

PIVs

Codes

Never: RUQ, renal for stone, tendon rupture, intussusception, appy, FAST in stable trauma
 
My list (roughly in order of frequency) of bedside exams from a community shop that has 24/7 in-house US techs:
1) Soft tissue - abscess vs. cellulitis
2) Confirming late 1st trimester pregnancy (mechanics of cleaning endocavitary probe derailed transvag utility)
3) Central lines
4) Hypotensive patients that aren't clearly septic - FAST, aortic imaging, check for PTX
5) Endocavitary probe for determining presence or absence of PTA

There is one advantage to doing a FAST exam on hemodynamically stable trauma patients in the community. The newest generation of surgeons trained in places where the ED had already thrown the probe on the traumatized patient regardless of clinical scenario. They also trained in places where their recollection of how fast imaging was acquired is deeply skewed. This means that the stable MVC with a tender belly that you order a CT on and the read comes back 3 hrs later may get you a letter from peer review, if the patient's pressure starts dropping prior to the surgeon evaluating the patient. A FAST helps buff the chart because most surgeons will accept that a negative FAST means that you considered the possibility of internal hemorrhage and risk stratified the patient to be able to wait behind all the CT Brains for vague neuro symptoms that jump the line because you're in a Stroke Center. Not doing a FAST usually means there's no documentation of thought process between initial eval and decompensation which looks bad if there's a significant delay in the radiologist reading your scan (Protip #1: there's always a delay). Of course if you advocate aggressively for getting the CT and you're decent at picking up solid organ injury and mod/large free fluid on your own wet read then you don't have to worry about this.

Which actually reminds me of another law of peer review:
If a patient decompensates between your last documented exam and your consultant/admitting physician's first exam, your exam was inaccurate/inadequate.
 
Zebra Hunter said:
This is a spin-off of the pelvic exam thread. It seems most med students and many of my fellow residents and faculty seem to be in love with the ultrasound in the ER; however, I do not share this love affair with it. I think it is great to learn, I think it undoubtedly has its place, but I think it's benefits are largely overstated.

So let's talk about when U/S actually is useful, and by useful I mean, actually has meaningful difference in procedure success, disposition of the patient, or changes management of the patient that could not be duplicated by an alternative imaging modality or a formal ultrasound.
Click to expand...

I agree with a lot of the above. I largely consider myself an ultrasound agnostic. Still, there are a couple of things I find US to be useful:

1) Resus. Not trauma/FAST but rather the undifferentiated hypotensive patient. Occasionally you find something like a ginormous effusion, or dilated RV, poor global contractility, flat or plump IVC, etc that even if it does not in the moment change your management, helps you better understand the patient in front of you and guide their further care.

2) Lines. I find we do fewer central lines thanks to IOs, but if someone needs a central line, my preference (barring special circumstances like a code) would be to place an US guided IJ. Yes, yes, I like feeling like a cowboy and dropping blind subclavians. But in your heart of hearts, do you think that is the best possible line?

3) Skin. Double checking for radiolucent foreign bodies before suturing a lac, double checking that this is/is not actually an abscess, etc.

4) Codes. Makes everyone feel better to see no cardiac activity.
 
Angry Birds said:
Agree with initial post. Ultrasound is cumbersome and time consuming. It's useful in only a handful of situations, like central line placement and cardiac activity.

But FAST? Waste of time. I did residency at a trauma center and we did this useless exam every time and not once did it change management.

And then you spend ages trying to upload the images so you can bill for it. What a time suck. Just cleaning the damn probe is annoying enough.
Click to expand...


The FAST exam literally takes 90 seconds to do once you've learned it. Don't even plug in the U/S.

Unstable patients with +FAST go to OR, at least if your trauma surgeon is any good.

I have had it change management at least 4 times and I am only a resident.
 
Angry Birds said:
I'll tell you one of the major reasons I hate ultrasound. There is a direct correlation between ER docs and especially residents having the capability to do ultrasound guided peripheral IV's and nursing failure rate in IV access successs.

In residency, nurses on every shift couldn't get IV access and would ask for a resident to waste fifteen minutes of time (and often more than that) mucking around with the ultrasound to get an IV in. Now I work at a shop without ultrasound--or at least nobody uses it for this propose--and suddenly nurses have success 99 percent of the time.

The worst was when a nurse in residency would come up to us and say, "the patient is a really hard stick. Should I even try or do you just want to use the ultrasound?" My head would explode when I heard this. Of course when you say for them to try, they do two weak attempts just stabbing random places and then say that the patient refused further attempts and wants it done by ultrasound.

The ultrasound is a huge time suck.
Click to expand...


The problem is that it takes you 15 minutes to do a PIV with an U/S.......
 
Zebra Hunter said:
This is a spin-off of the pelvic exam thread. It seems most med students and many of my fellow residents and faculty seem to be in love with the ultrasound in the ER; however, I do not share this love affair with it. I think it is great to learn, I think it undoubtedly has its place, but I think it's benefits are largely overstated.

So let's talk about when U/S actually is useful, and by useful I mean, actually has meaningful difference in procedure success, disposition of the patient, or changes management of the patient that could not be duplicated by an alternative imaging modality or a formal ultrasound.
Click to expand...


U/S is a great tool. It just takes a lot of time and practice to get good at it.

Most residents I know do not want to spend that time, so they are really not that good at it.

Then everyone complains that it just takes too long.......translation......they suck at it.

U/S pneumo..........I dont even listen to my trauma patient's anymore, takes 10 seconds and I r/o pneumo, more sensitve that Xray

U/s for PIV

U/S for pregnancy......patient's love this, they love to see their baby

U/s for central line

U/s in a code.

There are a ton more. But they all take lots and lots of time and practice to get good at, and most people just don't want to put in the effort.
 
Ahh, the residents. I enjoy their idealism.
Realize that a significant number of EDs out there won't have US, or at least not one with anything more than a linear probe.
If you go somewhere that doesn't have a formal PACS upload QI process, and you start sending home negative anything, or calling for positive anything, prepare to get peer reviewed.
In my experience, there are fewer new surgeons than there are new EPs (n=8 hospitals now). And apart from the trauma center, none of my surgeons even listens to me describe a FAST exam.

Also, ad hoc ergo propter hoc doesn't apply for the "wait for positive CT" thing, as I've had more than a handful of negative FASTs that have a delay in CT, then show fluid, and the FAST becomes positive. FASTs are dynamic, just like EKGs. Only difference is, a positive one stays positive. And while it's not a long amount of time to fire up the machine, go in the room, acquire the images, print them if it's not wireless uploading them, clean the patient, clean the probe, and come back out, it's way more time than it takes to ask the nurse for another EKG.

Don't get me wrong, I love it for eyes and central lines, as well as scattered other things. But to have it replace the stethoscope means every exam is going to take longer. Also, you don't see any stethoscope fellowship trained docs out there, so the field is planning it's own educational obsolescence by making everyone facile in it.
 
FAST exams have their place if used correctly and you have good surgeons available.

Doing it on literally every trauma patient however is of course a waste of time and resources.

Besides that - RUSH exams, resuscitations, codes, lines, nerve blocks, joint aspirations, abscess drainages, and foreign body evaluations.

As others have said, exams involving the eyes, lungs, gallbladder, testicles, and pelvis may or may not be helpful depending on where you work.
 
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Us is a great tool. It takes a lot of time to get good at the individual studies.
Even if you are good, it still takes a lot of time to do a complete study and save and document all of your findings.

If you end up working in the community, most of this will end up seeming like a gigantic waste of time.

I'm sure i could figure out how to shoot X-rays or run the ct scanner.

No way I'd waste my time doing that either.

If I want an us, I get a tech to do it and I go see another patient.

Personal use is limited to line placement, looking at an occasional heart in a code, maybe looking at cellulitis vs abscess.

And this is coming from someone who loved us and considered a fellowship at one point.
 
We see lots of early pregnancy stuff, so it's very useful for documenting IUP.

I hate ultrasound guided IVs with a passion. They started teaching nursing how to do them here, but that rapidly tapered off (I think after nursing figured out how much work they were). I agree that as soon as US IVs are available, it becomes an easy default. I worked at a place where most docs didn't use ultrasound and the nurses were pretty magic with IVs!! It was across town from another place I had worked, and I noticed that patients who ALWAYS "needed" US IVs at the other place magically got peripherals placed by nursing at this place!

I hate FAST exams. They are pointless. And a waste of time. And I've seen at least a few "equivocal" exams done for no real reason that resulted in unnecessary imaging.
 
everything above plus we have a peds protocol for u/s appy. written by peds surgery, no ct until seen by surgeon. also IVC check for sepsis
for the nursing staff we got 2.5in IV w built in guidewires to place u/s iv's.
 
Angry Birds said:
I'll tell you one of the major reasons I hate ultrasound. There is a direct correlation between ER docs and especially residents having the capability to do ultrasound guided peripheral IV's and nursing failure rate in IV access successs.

In residency, nurses on every shift couldn't get IV access and would ask for a resident to waste fifteen minutes of time (and often more than that) mucking around with the ultrasound to get an IV in. Now I work at a shop without ultrasound--or at least nobody uses it for this propose--and suddenly nurses have success 99 percent of the time.

The worst was when a nurse in residency would come up to us and say, "the patient is a really hard stick. Should I even try or do you just want to use the ultrasound?" My head would explode when I heard this. Of course when you say for them to try, they do two weak attempts just stabbing random places and then say that the patient refused further attempts and wants it done by ultrasound.

The ultrasound is a huge time suck.
Click to expand...
Our nurses (I'm a resident) do US guided IVs if they can't get peripheral.
 
TooMuchResearch said:
Our nurses (I'm a resident) do US guided IVs if they can't get peripheral.
Click to expand...
Ours, and the overwhelming majority of them out there can't.
Unless they're the PICC nurses, in which case they can.
Not everything is as nice and shiny as it is in residency, and not every residency has the same amount of support.
 
So in the community where I have ZERO U/S from 10pm-->8am, not even on call, in kinda-order of importance to me:

(1) Cardiac U/S in codes, I really like it instead of pulse checks
(2) Undifferentiated shock where you really don't know what is going on.... I don't do it every time, but sometimes its a big save
(3) Severe dyspnea, where in the first 30s you aren't sure if its CHF or not. Pop the probe on... B lines everywhere? find the nitro!
(4) Placing lines, both Cvl and PIV (i've taught some nurses to do the PIV so they don't bother me that much)
(5) RUQ during the overnight. Why irradiate someone with CT, or defer U/S for 9 hours, when I can just see the stones now...
(6) Random soft tissue stuff... Is that an abscess? Is there a FB? Oh look a worm!
(7) Good story for a spontaneous pneumo? why wait 10 minutes for X-ray, lets look right now I hate waiting...
(8) The other day I had a guy who's urinary stream stopped mid-stream. Suddenly. He felt like the proximal penis was "clogged". Rapid bedside u/s by yours truly showed an fully occlusive uretheral stone about 1/3 the way down the penis. Even the urologist thought that was cool to see 😉
(9) Say hi to the healthy baby! Look it moves and its heart beats! yay!
 
Community non-trauma center attending here with 24/7 US capabilities.

I use ultrasound for (in this order):

Codes. Usually to call it because there is cardiac standstill but some residual electrical activity.
Central Lines.
Occasionally to look at abscess vs cellulitis to see if it's worth draining.
Retinas. I LOVE u/s for retinal detachment, mostly because I admit I suck at fundoscopy and it's an awesome super-easy scan.
Occasionally to look at a baby, assuming I have a little downtime to indulge mom or I need to know that the head is down and yes, the baby is big. Don'tpushdontpushdontpush! Assuming baby isn't already on the way out, it's a huge patient satisfier, especially if they haven't felt baby move (and I already know there are present FHT. Diagnosing fetal demise at bedside is pretty sucky.)
 
Angry Birds said:
Not to sound too snarky, but then should we be doing a FAST on all patients based on the idea that occasionally it will show a positive finding? In the case you described, did you end up ordering a CT scan? I'm gonna guess yes.

Ultrasound is one of those things where you have to convince yourself it's useful.
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In this case, my US and then the subsequent INR of 15 and H/H 6/18 was convincing enough that the ED doc at the mecca took it without waiting for a CT. She survived after reversal and IR did some repair but I don't recall which vessel let go. The family donated some money in my name to the hospital. Not a wing or anything but it was a nice touch.

So, this is coming from a guy who did the 'ultrasound track' at my residency, and if I choose to, could sit for the ARDMS ultrasonographer exam but I doubt I ever will. It's got it's uses, but it's not the be all end all. I use it for central lines, retinal detachment, locating FB, but for other things, if the US tech is in house, I just put the order in and see another patient.

I will say that the one thing that I wished I learned in residency is US-guided nerve blocks.
 
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I only see two main categories of practical use:

1) Procedural assistance

2) Additional diagnostic information in a patient too unstable to go to radiology

Everything else is nice academically if you have the time.
 
DVT studies with 2 point compression U/S anyone? Especially after hours where ultrasound requires calling in a tech who will take like 1-2 hours to get there, then acquire the images, then send the images to India or wherever the after hours images are read.

Versus: order the D dimer, Walk into the room, perform that study in all of about three minutes, patient gets dispoed with either their 1 week repeat us script or their return precautions. Huge time savings


As some have mentioned before, the placebo effect goes a long way too. A moving baby can assuage the "I feel funny" pregnant chick (though this can backfire and many of them return frequently because they want to see their baby and have nothing better to do on a Tuesday night), or for the undifferentiated nothing-is-wrong-with-you fibromyalgia abdominal pain s/p resection of every abdominal organ you have to look and show "oh good no fluid in your abdomen! You're good to go!"
 
This is kind of a sad thread.

I have worked pretty hard in residency to try to get good at ultrasound but it sounds as though in real life community practice its not really that helpful. Is that correct?
 
Lots of hate for US here. There's no doubt in the right hands it's extremely useful as a diagnostic tool. Most ER docs overall are pretty ****ty with ultrasound, barring those out in recent years. My main barrier to its use is that it's a pain in the ass - cords, gel, login screens, dead battery, rolling it around, wtf. But I diagnose all kinds of cool **** with it and save a lot of time waiting for formal studies when I have a slam dunk finding. Had a guy yesterday with colicky left flank pain, hematuria, sonod his aorta normal and had left hydro and dcd him home in 5 minutes. Normally takes a long ass time to get a formal or a CT. I would use it more in private practice if the hardware, software, and technology were more practical (hopefully soon).
 
I was trained heavily in ultrasound during residency. It has helped my practice with a few things as noted above.

1) RUQ abdominal pain overnight when ultrasound tech is not there and would take around an hour to call them in and get it done. I can just dispo with mine and not wait.

2) SOB when determining COPD vs CHF (a ton of people have both) It's quick and easy.

3) Overnight determination of IUP, same with RUQ. My dispo is extremely fast with this and gets patients moving.

**I actually had a young female patient today show up with pelvic pain before our tech could arrive (2 hours before). + urine HCG and + fast for blood in her belly and the OB took her to the OR within an hour and she had a ruptured ectopic with over a liter of blood in her belly. Who knows what would have happened if it took an hour for the tech to come in and get it done and then longer for dispo.

Overall I completely agree with US PIVs. Don't tell nurses you can do it or they all suddenly "tried and can't get one"
 
mauricekenter said:
I was trained heavily in ultrasound during residency. It has helped my practice with a few things as noted above.

1) RUQ abdominal pain overnight when ultrasound tech is not there and would take around an hour to call them in and get it done. I can just dispo with mine and not wait.

2) SOB when determining COPD vs CHF (a ton of people have both) It's quick and easy.

3) Overnight determination of IUP, same with RUQ. My dispo is extremely fast with this and gets patients moving.

**I actually had a young female patient today show up with pelvic pain before our tech could arrive (2 hours before). + urine HCG and + fast for blood in her belly and the OB took her to the OR within an hour and she had a ruptured ectopic with over a liter of blood in her belly. Who knows what would have happened if it took an hour for the tech to come in and get it done and then longer for dispo.

Overall I completely agree with US PIVs. Don't tell nurses you can do it or they all suddenly "tried and can't get one"
Click to expand...

I dunno about the IV thing - I think entirely depends on the culture of the nursing staff. I'm a graduating resident. Our nurses put in US guided IVs. They know I can get access on anyone with US. I have been asked exactly once in the past 6 months to place a PIV.
 
Sad commentary here. I used to be dope with the ultrasound in residency. Get a PIV, look for ectopics, do it all. Then, I became a real boy, Gepetto. Radiology got pissy for not being able to bill for the studies, and HCA mouthbreathers told me to stop and order the formal study; nevermind that we didn't have US in house after 6pm.

Now, I don't know my way around an abdomen/pelvis with an ultrasound, and I'm all central lines, cause they're waaay faster.
 
Dr.McNinja said:
Ahh, the residents. I enjoy their idealism.
Realize that a significant number of EDs out there won't have US, or at least not one with anything more than a linear probe.
If you go somewhere that doesn't have a formal PACS upload QI process, and you start sending home negative anything, or calling for positive anything, prepare to get peer reviewed.
In my experience, there are fewer new surgeons than there are new EPs (n=8 hospitals now). And apart from the trauma center, none of my surgeons even listens to me describe a FAST exam.

Also, ad hoc ergo propter hoc doesn't apply for the "wait for positive CT" thing, as I've had more than a handful of negative FASTs that have a delay in CT, then show fluid, and the FAST becomes positive. FASTs are dynamic, just like EKGs. Only difference is, a positive one stays positive. And while it's not a long amount of time to fire up the machine, go in the room, acquire the images, print them if it's not wireless uploading them, clean the patient, clean the probe, and come back out, it's way more time than it takes to ask the nurse for another EKG.

Don't get me wrong, I love it for eyes and central lines, as well as scattered other things. But to have it replace the stethoscope means every exam is going to take longer. Also, you don't see any stethoscope fellowship trained docs out there, so the field is planning it's own educational obsolescence by making everyone facile in it.
Click to expand...
Only stethoscope trained fellows can hear the mythical grade I/VI murmur.
 
Tenk said:
Only stethoscope trained fellows can hear the mythical grade I/VI murmur.
Click to expand...
The dean of our school (cardiologist) lectured us during our preclinical years on heart murmurs. "Grade I/VI means I can hear it, you can't."

Edit: apparently autocorrect likes I/V better than I/VI.

Sent from my SM-G930V using Tapatalk
 
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Angry Birds said:
I'll tell you one of the major reasons I hate ultrasound. There is a direct correlation between ER docs and especially residents having the capability to do ultrasound guided peripheral IV's and nursing failure rate in IV access successs.

In residency, nurses on every shift couldn't get IV access and would ask for a resident to waste fifteen minutes of time (and often more than that) mucking around with the ultrasound to get an IV in. Now I work at a shop without ultrasound--or at least nobody uses it for this propose--and suddenly nurses have success 99 percent of the time.

The worst was when a nurse in residency would come up to us and say, "the patient is a really hard stick. Should I even try or do you just want to use the ultrasound?" My head would explode when I heard this. Of course when you say for them to try, they do two weak attempts just stabbing random places and then say that the patient refused further attempts and wants it done by ultrasound.

The ultrasound is a huge time suck.
Click to expand...

Totally agree
 
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