U/S in the ER

[deleted109597]

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Anyone in community EM feel US slows you down enough to make it impractical?

For certain things. It is still incredibly practical in others.

Depends on the machine as well. My community job had a ****ty sonosite or a terrible ex-OB monster that took 5 minutes to boot. Would have preferred neither.

 

[Apollyon]

EM/IM/CC is 6 years at 3 of the EM/IM programs out there.

Post #34.

 

[Groove]

Anyone in community EM feel US slows you down enough to make it impractical?

Yes, it always slows me down and I find myself ordering many more formal studies or finding ways to avoid having to break it out to do something unless I absolutely need it. Sometimes, it comes in handy...equivocal CT's where radiology hedges on eval of GB. Regardless, I find myself using it MUCH less frequently compared to residency when I was all excited about using it. We see 90K a year and I find myself just unable to slow down and play with it unless it's a very rare lull during a night shift.

 

[TooMuchResearch]

Sure, turn a 5 minute procedure into a 1 hour one. Once you get good doing an L-P is easy. I can get CSF from anyone including a 90 year old hunch back with a lumbar fusion.
I also prefer to use a 22 gauge whitacre needle on all the patients under the age of 60 to minimize the incidence of headache.

I don't think it's designed for routine use.

 

[Rendar5]

I only use u/s for eyes, FB visualization (though doesn't aid me in removal), IJ placement, and abscess evaluation for I&D. It's much faster to order a formal study and get it and see another pt than it is to bring it to the room, boot it up, and obtain gallstone pics. I've only done a FAST exam once in the last year (we're not a trauma hospital), and that was for a quick check on a accidental 14yo self-stabbing before sending him to the children's hospital for wound exploration

 

[Tiger26]

The biggest thing with ultrasound is the workflow. At my current gig, I rarely use it on my shifts even though I'd like to more, since I'm supervising multiple residents.

In residency, I spent a month with one of the guys who started the first EM ultrasound fellowship (now working at an academic place without residents). Because it's such an effecient ED, he is able to have the techs set up the machine before he sees the patient, so he walks in, does his H&P, and checks out any relevant pathology. He ultrasounds probably 75% of the patient's he sees this way.

It's the same as having to get supplies and setup everything for a laceration repair vs a tech getting everything together and washing the wound before you walk in and throw a few sutures.

 

[Apollyon]

(now working at an academic place without residents)

What is that? Just attendings doing research? I mean, what is academic if not teaching?

 

[Tiger26]

What is that? Just attendings doing research? I mean, what is academic if not teaching?

All the other services have residents except the ED, which is mainly attending staffed

 

[Venko]

I have worked at places without easy access to radiology comprehensive ultrasound and found my own skills much more useful. Now I work in an institution with more resources than almost anywhere in the world. In this setting its still very useful for the right patient encounter. Here are a few ways I still feel it makes me a better doctor than without it even in the most efficient and resource heavy situations...

1. Undifferentiated shock / hypotension
- If IVC is big then I check pericardial window, and lung windows
- If IVC is small, then I do a FAST, and aortic ultrasound

2. Patients with tachycardia and hypertension
- If I am trying to differentiate hyperthyroidism from cocaine / sympathomimetic toxicity, I ultrasound the thyroid for hypervascularity

3. Patients with epigastric / RUQ pain but still have their gallbladder
- If my POC ultrasound shows thickening, pericholy fluid, wall edema, wall-echo-shadow, etc, I get a radiology ultrasound; if its quite normal then I order the CT

4. Ocular scanning for retinal detachment, lens dislocation

5. dyspnea in dialysis patients, I scan the heart

6. IJ CVC insertion

and a few other select reasons.

Before, at the county hospital and VA environments I worked in, I used it much more consistently and for many more indications.

TL