Ultrasounds for Epigastric Pain vs Cholecystits

[suckstobeme]

I mean Dysepsia vs Cholecystitis

My question is do you get a formal ultrasound (ie done by radiology) for this patient? Do you get it emergently in the ER or do you try to schedule it as an outpatient?

35 y/o male no PMH two days of burning epigastric pain occurring about 20 min after eating. Sometimes worse with spicy foods, he's not sure if it's worse with greasy or fatty foods. Nauseous, one episode of non-bilious vomitting yesterday. No fever or chills. No other symptoms. No history of EtOH, illicits, smoking. On exam, epigastric tenderness, no Murphy, other exam is normal including vitals. You give him a GI cocktail and he feels better in about 30 min. You sent off some labs and everything is normal including chemistry, lipase, LFTs, CBC.

1) So, do you stop there and call it gastritis/dyspepsia and send him home with appropriate meds? Does it change if the patient were a woman?
2) Let's say you decide to take a quickk look with an U/S. The patient is chubby and has some bowel gas, so not a great exam, but no raging obvious cholecystits. Do you get a formal ultrasound?

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[DrMom]

If we order a formal US, we definitely do outpatient. Kinda case-by-case and attending specific as to whether we do a formal or not. I don't think we'd be likely to order one on a patient like you described.

 

[emergiQ]

I mean Dysepsia vs Cholecystitis

My question is do you get a formal ultrasound (ie done by radiology) for this patient? Do you get it emergently in the ER or do you try to schedule it as an outpatient?

35 y/o male no PMH two days of burning epigastric pain occurring about 20 min after eating. Sometimes worse with spicy foods, he's not sure if it's worse with greasy or fatty foods. Nauseous, one episode of non-bilious vomitting yesterday. No fever or chills. No other symptoms. No history of EtOH, illicits, smoking. On exam, epigastric tenderness, no Murphy, other exam is normal including vitals. You give him a GI cocktail and he feels better in about 30 min. You sent off some labs and everything is normal including chemistry, lipase, LFTs, CBC.

1) So, do you stop there and call it gastritis/dyspepsia and send him home with appropriate meds? Does it change if the patient were a woman?
2) Let's say you decide to take a quickk look with an U/S. The patient is chubby and has some bowel gas, so not a great exam, but no raging obvious cholecystits. Do you get a formal ultrasound?

If patient was over 40 and/or any risk factors: I'd make sure to get an ECG and not miss any cardiac -- ... and if there was ANY suggestion on history that this guy had the symptoms accompanied by diaphoresis/shortness of breath, or a reliable history of exertional component, I'd rule him out with a stress test even at this age.

It seems like his pain is reliably related to food intake, so that certainly makes aortic dissection/pancreatitis less likely (and you said he doesn't drink alcohol). So yes, this points to chole/gastritis/gastric ulcer (remember: gastric ulcers are WORSE with food, duodenal typically better). Also: intestinal ischemia can rear its head after food (effectively an anginal equivalent) but probably too young for ischemia.

Bottom line: When I worked in academia, I probably would have perseverated about whether to/not to ultrasound and it would take AGES if I did the u/s; Now that I'm in the real world .... and things are optimized for my throughput, I'd ultrasound this guy (he was chubby!) and have some sort of answer.

The astute among you would probably ask: "Why!? Does ultrasound change your management?"

I would say yes:

He still gets discharged either way pending no evolution of symptoms (and hopefully better after some antiemetic and fluids) but now I have some justification for referring either to his primary PCP (if negative) or a surgeon if positive. Last note: I make sure he has damn good instructions to follow should his symptoms evolve and suggest a dangerous diagnosis in particular (missed appy/cardiac/systemic illness indicating fulminant chole or intestinal catastrophe, etc).

 

[BADMD]

If he feels better with a GI cocktail and otherwise has normal vital sign, it is unlikely to be cholecystitis. It may be billiary cholic, but that is not something that needs prompt surgical care and can be handled as an outpatient. If I suspect cholecystitis, I may do bedside U/S myself and make decisions accordingly.

 

[Seaglass]

2) Let's say you decide to take a quickk look with an U/S. The patient is chubby and has some bowel gas, so not a great exam, but no raging obvious cholecystits. Do you get a formal ultrasound?

If that was all you saw then you did a half-assed exam and yeah, you would have to get a formal one. The RUQ US exam is not complete unless you see and measure the CBD.

As for your primary question, I would send the guy home with PCP follow up with no other testing.

 

[roja]

If that was all you saw then you did a half-assed exam and yeah, you would have to get a formal one. The RUQ US exam is not complete unless you see and measure the CBD.

As for your primary question, I would send the guy home with PCP follow up with no other testing.

I really hate that term formal and think that EP's credentialed in U/S should not use it. The exam that is being done by an EP credentialed in the ED is formal. Just like our exam. What the exam is is LIMITED. (there is coding for billing vs comprehensive).

The term formal vs informal is easily interpreted by patients. And sometimes residents. Limited makes it very clear that one was looking for something very specific.

/soapbox.


To the O/P. I often use U/S in pts. I look a the GBW and the CBD and see if there are stones. If no, then I am done (assuming there is nothing else in your Diff. Dx)

 

[bulgethetwine]

If he feels better with a GI cocktail and otherwise has normal vital sign, it is unlikely to be cholecystitis. It may be billiary cholic, but that is not something that needs prompt surgical care and can be handled as an outpatient. If I suspect cholecystitis, I may do bedside U/S myself and make decisions accordingly.

Are you credentialed in ultrasound? It matters.

Either way, 9/10 (probably more) you'll be right no matter what you do -- he'll have nothing going on.

But there's more here than just chole in your differential. The task here isn't to make the diagnosis of chole or not -- the task is to consider all the dangerous things, discuss with pt and document accordingly. Then you can get 'em out the door.

 

[kungfufishing]

I agree with the above regarding EM and RUQ ultrasound. It just isnt that hard to see the specific things we are looking for. Sometimes you need a tech and their machine, but not all that often.

 

[BADMD]

Are you credentialed in ultrasound? It matters.

Credentialling really only matters if I choose to bill for the procedure. If I am confident in what I see and it fits the scenario, then I'm happy to make decisions based on my US. If it becomes an issue, I'll have to defend myself in court. But then again, I'd have to do that if I just cut him loose too.

But there's more here than just chole in your differential. The task here isn't to make the diagnosis of chole or not -- the task is to consider all the dangerous things, discuss with pt and document accordingly.

The question was dypepsia versus cholecystitis. I didn't think I needed to include an entire differential diagnosis and evaluation plan for each.

 

[Schnoffle]

My question is do you get a formal ultrasound (ie done by radiology) for this patient? Do you get it emergently in the ER or do you try to schedule it as an outpatient?

The only reason I would think to get it emergently taken to the ER was if he were showing signs of an acute abdomen and possible ruptured gall bladder. If he is too large for an U/S to show any definitive proof of stones or wall thickening, then follow symptoms through outpatient (maybe even an ERCP on a later date? probably over kill at the moment, but may be suggested later by PCP/surgeon).

The problem with our ER is that anyone coming in with possible gall bladder symptoms gets admitted and C/Sed to the surgery team, even without a good U/S. It gets pretty frustrating sometimes...

 

[southerndoc]

Credentialling really only matters if I choose to bill for the procedure. If I am confident in what I see and it fits the scenario, then I'm happy to make decisions based on my US. If it becomes an issue, I'll have to defend myself in court. But then again, I'd have to do that if I just cut him loose too.

Perhaps in an academic setting, but in the community, a physician may only perform procedures in which he/she is credentialed.

I just recently got credentialed for FAST, vascular access, and AAA screening, so I can now perform those.

 

[BADMD]

Perhaps in an academic setting, but in the community, a physician may only perform procedures in which he/she is credentialed.

I just recently got credentialed for FAST, vascular access, and AAA screening, so I can now perform those.

So if you had difficulty obtain central line access, you are forbidden from using an U/S unless someone else signs off? That sure doesn't seem to apply to any other medical specialty. And there are an awful lot of people out there using informal ultrasound then.

Too bad when I got a board question that had an ultrasound in it, I just didn't write in "I'm not credentialed for this."

 

[deleted65604]

The problem with our ER is that anyone coming in with possible gall bladder symptoms gets admitted and C/Sed to the surgery team, even without a good U/S. It gets pretty frustrating sometimes...

So, every vague epigastric pain, with normal labs gets admitted to surgery? That sounds funny. Maybe I misunderstood. What does C/Sed mean?

The problem with doing your own ultrasounds, is that you can't upload them on the pax system and let future physicians see what you saw. It would be dificult for somebody to track down those images. RUQ can be difficult in some people and you might get stuck standing there for 20 minutes angling this way and that, trying to get the perfect "Mickey-mouse sign", trying to decide if that is the common bile duct or not, and praying the gas bubble moves out of the way.

It is also a patient satisfaction issue. You tell them that they may have gallstones, and that you could order a definitive study that would rule it out, but don't want to wake up the US tech because you are a nice person, the patient is going to be a little pissed.

I saw a healthy 26 year old patient in the ER that presented for the second time with epigastric pain. The first time in the ER, he was given a GI cocktail which cured the symptoms and was sent home with some prilosec or something. He came to me with the same symptoms, but didn't get relief with a GI cocktail. He refused labs, and said, "what do you think it is?" He said, "just treat me for what you think is most likely and don't do any imaging or labs." I said it sounded like GERD or ulcers, and sent him home with sucralfate, doubled the dose of PPI, and added maalox PRN to regimen.

He came back a 3rd time, still asking for no labs.

A fourth time, the ER doc went all out. AST was about 5 above normal and white count was normal. CT to eval for perfed ulcer was normal. Ultrasound showed gallstones and slight GB thickening.

Surgery took out gall-bladder and it was very nasty, filled with puss, just waiting to burst, or cause ascending cholangitis.

With only slightly abnormal labs 1 week after I saw him, I'm sure labs would have been normal had I checked them.

We wasted so much money in ER visits (3 visits before getting the real diagnosis), that an US would have been cost effective, would have given immediate answer, and would have saved him a world of pain.

If it is daytime, I now just US them. If it is 12-6 in the morning, (provided their symptoms are resolved, and labs normal) I give them the option of getting it now, or giving them an out-patient prescription and following up with their doctor for the results.

Long-winded answer for... Just get an ultrasound. If you are credentialed and feel comfortable, do it yourself. We do a lot of testing for much weaker reasons than, "They might have gallstones."

 

[deleted65604]

So if you had difficulty obtain central line access, you are forbidden from using an U/S unless someone else signs off? That sure doesn't seem to apply to any other medical specialty. And there are an awful lot of people out there using informal ultrasound then.

Too bad when I got a board question that had an ultrasound in it, I just didn't write in "I'm not credentialed for this."

My understanding is that you don't need credentialling for using US in helping you do any procedure, whether that is drainage of abscess, or central line access. My understanding is that you still need credentialling, even though you aren't charging for it.

For example, the attending OBs in my training hospital weren't all credentialled in first trimester ultrasound, and none of the OB residents were. The official position of the hospital was that OB residents and attendings not credentialled in first trimester, could not use our US machine and do informal studies in the ER. This seems assinine since they do them in clinic all the time and are completely competent. However, they have not gone through the official credentialling process yet.

So yes, when we have a presumed ectopic, with blood in the belly, "officially" the OB/Gyn has to get a formal study if they want to confirm for themselves.

Credentialing also varies hugely from institution to institution. I've been given the green light to do whatever US I feel like doing in my institution with no formal credentialling process other than requesting to be able to do the study. (My boss and ER director is on the credentialling commitee).

I want to say that my attendings in residency had to perform something like 20 Ultrasounds with the images being reviewed and confirmatory official imaging to check the results. (20 US per study whether RUQ, first trimester, AAA, etc.)

If you get a radiologist on your credentialling commitee, forget about it. They will require like 100 US and reimbursement to the radiology deparment for lost revenue (just kidding...kind of).

 

[Seaglass]

Credentialling really only matters if I choose to bill for the procedure. If I am confident in what I see and it fits the scenario, then I'm happy to make decisions based on my US. If it becomes an issue, I'll have to defend myself in court. But then again, I'd have to do that if I just cut him loose too.



The question was dypepsia versus cholecystitis. I didn't think I needed to include an entire differential diagnosis and evaluation plan for each.

You'll also have to defend yourself to your hospitals credentialing committee.

 

[bulgethetwine]

If it becomes an issue, I'll have to defend myself in court

I was mistaken. You *DID* get the point

Truth is, I think we'd all LIKE to do what you suggest in your post, but this day and age, I'm not risking my license. If that backs up the medical system, then too bad, the only thing worse than being an accomplice to the backlog is to be unemployed.

 

[southerndoc]

So if you had difficulty obtain central line access, you are forbidden from using an U/S unless someone else signs off? That sure doesn't seem to apply to any other medical specialty. And there are an awful lot of people out there using informal ultrasound then.

Too bad when I got a board question that had an ultrasound in it, I just didn't write in "I'm not credentialed for this."

Except in emergent (life or death) situations, I am forbidden from doing things which I am not credentialed.

This is not my hospital, this is the standard across all hospitals in the nation. Do something in which you are not credentialed, and you not only face suspension of your medical staff privileges, but you also face legal risks. Your malpractice insurer will only cover you for things which you are credentialed.

As simple as ultrasound may seem, other things that are simple also require credentialing: suturing, incision and drainage, etc. If a hospital doesn't credential you in these simple procedures, then you are not entitled to perform them. I was specifically credentialed for reading plain film x-rays, but I don't bill for them. Credentialing and billing rights are not synonymous.

 

[BADMD]

I find this all very interesting, and maybe it is because I work in the world of academia, that I'm somewhat surprised. A significant number of the people I work with will drop an US on the patient without even thinking about. I can't think of the number of fast exams that have been performed without anyone having a formal process (although that is changing).

I pulled out my credentialing paperwork and I noted an interesting line in my privileges that was essentially "but not limited to" and then a list of the standard skill set of an EP. I wonder if that is the unofficial shield.

 

[southerndoc]

I pulled out my credentialing paperwork and I noted an interesting line in my privileges that was essentially "but not limited to" and then a list of the standard skill set of an EP. I wonder if that is the unofficial shield.

I had to credential for everything -- laceration repair, IM injections, SQ infiltration, x-ray interpretation, emergent thoracotomy, emergent trachs, intubation/RSI, conscious sedation, etc.

The point of credentialing is not to allow you to bill for procedures. It allows the hospital to determine if you are competent to perform the procedure. This is the primary purpose of credentialing. However, many hospitals also use credentialing to limit the practice of physicians (i.e., doing ultrasounds and treading on the turf of the radiologists). The Joint Commission and many state laws require hospitals to credential physicians. Credentialing has nothing to do with billing as insurers determine what you are allowed to bill for. This isn't a formal process but is a simple "yes, we'll pay" or "nope, not going to pay for it" type situation after you submit the bill.

There is a clause that states "Credentialed procedures shall not be all inclusive in cases of life or death emergencies where performing a procedure in which the physician or mid-level provider is not credentialed shall have a possible benefit to the patient."

So in a hypotensive patient, I could use an ultrasound to check for pericardial effusion and perform a pericardiocentesis. However, I can't use an ultrasound to look at a gallbladder to see if there are stones. (Quite frankly I don't want to. Although it might speed patient disposition, it slows me down, and in a fee-for-service situation, I can see an additional patient in the amount of time it takes me to setup the ultrasound machine, do the procedure, and roll the machine back to its place.)

 

[BADMD]

The disclaimer in mine isn't nearly that long and is far more open ended. And as I'm not pure fee for service, speeding up disposition is definitely a plus.

 

[spyderdoc]

Although it might speed patient disposition, it slows me down, and in a fee-for-service situation, I can see an additional patient in the amount of time it takes me to setup the ultrasound machine, do the procedure, and roll the machine back to its place.)

To play devil's advocate, we are FFS as well, and I (as well as a good number of us in the group) prefer to do bedside u/s. We bill for a LTD study (not much $, but something). I think that if I can speed up the dispo time and get the patient out of the room instead of waiting for the formal U/S (place order, wait for test to be done, wait for reading), I can see more patients in that room that I cleared out sooner....This is especially helpful after 1700hrs since there is no in-house tech, so when we call themin, it is usually a half hour or so before they come in...

To save a bit of time, I turn the power on as I am rolling the machine to the room (Sonosite machine), so it is ready to go as I walk in the room. Instead of entering all the patient's demographics info into the U/S, I print out the images and place their name stickers on the images and attach them to a progress note. I tend to leave the machine near my work station since I use it so much....

 

[southerndoc]

This is especially helpful after 1700hrs since there is no in-house tech, so when we call themin, it is usually a half hour or so before they come in...

Maybe I'm spoiled because I have an ultrasound tech in-house 24/7.

 

[spyderdoc]

Maybe I'm spoiled because I have an ultrasound tech in-house 24/7.

Nice! That definetly helps. Ours are on call and must be in within 30 min of call, and they don't mind getting called since they get a ridiculous amount of money to come in at 3AM. Nonetheless, it is still painful to have to call them and wait.....

 

[deleted65604]

I agree with Southerndoc, in that I can't be bothered to do a non-emergent US myself. Sure, I wait for 30 minutes for the tech to come in, but, chances are, I'm going to be waiting for labs in addition to the lab tech. For example, someone comes in with RUQ, or epigastric pain, I'm going to order Complete metabolic panel, CBC, lipase, and sometimes, an h.pylori. I don't just want to rule out gall stones, I want to rule out hepatitis, anemia from a chronically bleeding ulcer, pancreatitis, pancreatic mass causing increased bilirubin, etc. Chances are, if I will have ultrasound report back even before the labs are back. I rarely have time on shift to chart on patients, and I would much rather spend any free time charting, rather than hemming and hawing over gallbladder wall thickness, and common bile duct measurements.

I have heard the argument again and again, that US speeds up dispostion. I'm sure there are ERs out there that are so gridlocked that you have to maximize the turn-over of a particular room. I don't work at an ER where that is true. My ability to see more patients is more to do with getting nursing to carry out orders, and lab to complete lab testing. If I did ultrasound right now, it would take me away from seeing patients and the department would slow down. When I order an ultrasound, it takes me one second to check the box. When I do it myself, it would take me from 20 minutes to as much as 60 minutes to get good RUQ images. I am not good at seeing pancreas, and certainly, the patient is going to get a superior scan both in terms of expertise and better equipment from a formal scan.

I don't see a reason to do your own scan unless you are going to bill for it. I think that there is a bit of an ethical dilemma going on there. How much do I bill? The patient is going to get an inferior study if they get it from me. So, I don't think that I should be telling them to fork over the cash. I have seen techs labor over a scan for 45 minutes, where if I would do it, I would look around for 10 minutes and then give up and call it a limited study due to body habitus so that I could get back to seeing patients.

I think that there are some ER attendings out there that are just as good, if not better than a tech. I don't think that doing the average ER residency gets you to that level without a fellowship in ultrasound. I think that there is enough to learn in residency without wasting time on non-emergent ultrasound skills such as RUQ. I think that if you want to bill at the same level and do the same scans as an ultrasound tech, that you should get at least as much training as they do (one year minimum of dedicated 40 hour/week experience doing scans).

I think that there is some liability incurred when doing your own scans. If I miss something, and they get another scan in a few days, I think I would be in a legal bind and open to lawsuits if I am doing my own non-emergent scans, and telling the patient that nothing is wrong with them.

I think I am in an ethical dilemma when I do the scan, charge them, and then tell them to get a formal scan and have them get charged again.

My overblown, paranoid, nightmare ultrasound scenarios:

1. RUQ pain- normal labs, miss subtle liver lesions which is picked up by repeat US in one month and patient diagnosed with metastatic colon cancer.

2. Vag bleed, pregnant- HCG is 1000. My ultrasound normal, repeat in 2 days shows obvious adnexal mass (in addition to free fluid in abdomen from ruptured ectopic). Lawyer sues me for not diagnosing ectopic and adnexal mass. I have one tenth of the experience of US tech on call, who would have had a better chance, given experience and better machine at picking up the adnexal mass.

3. Flank pain- blood in urine, symptoms of kidney stone. I Ultrasound and see no hydro, diagnose kidney stone, and miss the subtle kidney lesion that is picked up on abdominal CT 9 months later and is diagnosed as metastatic renal cell carcinoma. I get sued by lawyer who claims that I could have easily diagnosed the cancer earlier either by having a formal US, or getting the CT of the belly. Lawyer tracks down tech on call that day, who is a seasoned 10 year veteran and asks her (no I've never seen a male) on the stand how many retroperitoneal US she has done in her career and she says 3,000. Lawyer asks you to show documentation of how many you have done. You pull out your residency log book and show them 25, or 90, or 150, or whatever, and then asks the jury to decide for themselves, who is better qualified to do ultrasounds.

4. signs/symptoms of DVT- I ultrasound and send home. Patient dies of PE. Lawyer to me on the stand, "Why didn't you get a formal study?" Me,"well, I was trying to increase my billing, and get the patient out of the ER faster, so I just did it myself."

I'll grant that the above scenarios are a reach, and you could argue that malpractice didn't occur, but, I think a good lawyer could make you look like a real tool.

I've heard it argued that we will use ultrasound in the future just like a stethoscope. I think it is a great dream, but the difference is that you don't charge people a separate bill for listening to their heart, and you don't have a stethoscope tech waiting to come in, who is much better at listening to hearts than you are. I think the current ultrasound vogue and hype throughout residency puts too much pressure on ER residents to waste time on non-emergent US skills in the hopes that their future employer will love them because they do their own RUQ, DVT, or Pelvic US. That question never even came up when I was interviewing for jobs.

I think this US mania is perpetuated by academic programs who are desperate for attendings with credentialling to do FAST scans, and teach residents ultrasound. It creates fellowships dedicated to teaching non-emergent ultrasound skills which are only needed in residency to teach ultrasound (a self serving niche that only exists to preserve its niche).

I work at a very small ER (16,000 annual volume), in a very small hospital (99 bed) in a very small city (20,000). I have 24/7 ultrasound coverage and I see absolutely no reason to do non-emergent ultrasound.

FAST, limited cardiac, AAA-very helpful.

Retroperitoneal, RUQ, DVT, pelvic, time consuming, and I'd rather be charting.

 

[southerndoc]

I'll grant that the above scenarios are a reach, and you could argue that malpractice didn't occur, but, I think a good lawyer could make you look like a real tool.

A reach? Not really.

The DVT situation you described is in trial right now. I probably shouldn't say this, but I once dated the enemy. My ex is a medical malpractice attorney and is currently litigating the DVT case right now. Will be interesting to see the outcome.

 

[Seaglass]

From the US proponent position, the bad things happen only when you tell the patient "everything is fine" after a limited study and fail to tell them they need follow up testing. For example, in all the pregnant vag bleeding protocols I know of patients with a low quant and no IUP will need 48 hour scheduled follow up at the minimum if not a complete pelvic US during that visit. In the case of your RUQ US you tell the patient "Your US did not show and signs of gallbladder problems but if your pain persists you may need additional testing that your PCP can arrange." I would note that metastatic cancer is not an emergent condition. Regarding DVT, the purpose of an ER US is to decide whether or not the patient needs lovenox until they can have an outpatient duplex scan arranged by their doc. Anyway, I think a lot depends on how you handle it with the patient and what you are actually trying to do with the US.

 

[Seaglass]

In the malpractice side, there was an abstract at ACEP a year ago that showed all the malpractice claims related to EUS, there was only one judgement against a physician and that was for failure to do the US when it was indicated.

 

[Schnoffle]

So, every vague epigastric pain, with normal labs gets admitted to surgery? That sounds funny. Maybe I misunderstood. What does C/Sed mean?

I may have been over exagerating at this point. C/S just means consult. It seems that when a patient comes into the ER, if they complain of symptoms of gall bladder disease, they will get consulted to the surgery team prior to receiving any labs or U/S results. The major issue here is that many of our "minor" ER patients are seen by hospitalists and PA's, and they tend to pass off the responsibility to other people without putting much thought into it. It's a frustrating situation.

 

[bulgethetwine]

I may have been over exagerating at this point. C/S just means consult. It seems that when a patient comes into the ER, if they complain of symptoms of gall bladder disease, they will get consulted to the surgery team prior to receiving any labs or U/S results. The major issue here is that many of our "minor" ER patients are seen by hospitalists and PA's, and they tend to pass off the responsibility to other people without putting much thought into it. It's a frustrating situation.

Really? And just how much experience do you have in this ER as a medical student?

Most of the medical students I've worked with, even the conscientious ones, wouldn't know sh hit when it comes to what really happens, day after day, in the ER. Most of intern year of an ER residency is spent determining what is sick/not sick... I don't know if you have the clout to talk down to the hospitalists and PAs and suggest they don't and you do.

 

[Schnoffle]

Really? And just how much experience do you have in this ER as a medical student?

Most of the medical students I've worked with, even the conscientious ones, wouldn't know sh hit when it comes to what really happens, day after day, in the ER. Most of intern year of an ER residency is spent determining what is sick/not sick... I don't know if you have the clout to talk down to the hospitalists and PAs and suggest they don't and you do.

I may not be working in the ER as much as you guys as a student, but when the Surgery/Psych/IM depts all have to file complaints to their heads of staff, that usually says something. I am not saying I know more than them, or am I "talking down" to them. I know they have more experience than me. I am just speaking of an isolated incident at my specific hospital, not in general. The topic was on U/S and the use of it in determing gallbladder disease, and when do you emergently take them to surgery. That's all my focus was on in regards to the types of consults we receive. Relax

 

[roja]

I agree with Southerndoc, in that I can't be bothered to do a non-emergent US myself. Sure, I wait for 30 minutes for the tech to come in, but, chances are, I'm going to be waiting for labs in addition to the lab tech. For example, someone comes in with RUQ, or epigastric pain, I'm going to order Complete metabolic panel, CBC, lipase, and sometimes, an h.pylori. I don't just want to rule out gall stones, I want to rule out hepatitis, anemia from a chronically bleeding ulcer, pancreatitis, pancreatic mass causing increased bilirubin, etc. Chances are, if I will have ultrasound report back even before the labs are back. I rarely have time on shift to chart on patients, and I would much rather spend any free time charting, rather than hemming and hawing over gallbladder wall thickness, and common bile duct measurements.

I have heard the argument again and again, that US speeds up dispostion. I'm sure there are ERs out there that are so gridlocked that you have to maximize the turn-over of a particular room. I don't work at an ER where that is true. My ability to see more patients is more to do with getting nursing to carry out orders, and lab to complete lab testing. If I did ultrasound right now, it would take me away from seeing patients and the department would slow down. When I order an ultrasound, it takes me one second to check the box. When I do it myself, it would take me from 20 minutes to as much as 60 minutes to get good RUQ images. I am not good at seeing pancreas, and certainly, the patient is going to get a superior scan both in terms of expertise and better equipment from a formal scan.

I don't see a reason to do your own scan unless you are going to bill for it. I think that there is a bit of an ethical dilemma going on there. How much do I bill? The patient is going to get an inferior study if they get it from me. So, I don't think that I should be telling them to fork over the cash. I have seen techs labor over a scan for 45 minutes, where if I would do it, I would look around for 10 minutes and then give up and call it a limited study due to body habitus so that I could get back to seeing patients.

I think that there are some ER attendings out there that are just as good, if not better than a tech. I don't think that doing the average ER residency gets you to that level without a fellowship in ultrasound. I think that there is enough to learn in residency without wasting time on non-emergent ultrasound skills such as RUQ. I think that if you want to bill at the same level and do the same scans as an ultrasound tech, that you should get at least as much training as they do (one year minimum of dedicated 40 hour/week experience doing scans).

I think that there is some liability incurred when doing your own scans. If I miss something, and they get another scan in a few days, I think I would be in a legal bind and open to lawsuits if I am doing my own non-emergent scans, and telling the patient that nothing is wrong with them.

You bring up some good points. It comes down to your own experience and comfort level. I do not send labs on every patient with epigastric pain. I will often do a quick RUQ scan (which takes me about 5 minutes) to check for stones, thickened GBW, CBD and presence of pericholecystic fluid. If negative, gi cocktail and reassess in 20 minutes. I inform patients that my scan is a LIMITED scan, meaning I am only checking for a few things. (this is the core point of ALL EUS... we do LIMITED exams and this must be communicated to the patient and any other health care providers) Pt all better- out the door. I bill for a LIMITED exam (there are cpt codes for limited vs comprehensive.) As will all procedures, one must know their limits of knowledge and experience. I have over 1500 emergency ultrasounds and I am pretty comfortable with those limited scans that I do.

I think I am in an ethical dilemma when I do the scan, charge them, and then tell them to get a formal scan and have them get charged again.

My overblown, paranoid, nightmare ultrasound scenarios:

1. RUQ pain- normal labs, miss subtle liver lesions which is picked up by repeat US in one month and patient diagnosed with metastatic colon cancer.

2. Vag bleed, pregnant- HCG is 1000. My ultrasound normal, repeat in 2 days shows obvious adnexal mass (in addition to free fluid in abdomen from ruptured ectopic). Lawyer sues me for not diagnosing ectopic and adnexal mass. I have one tenth of the experience of US tech on call, who would have had a better chance, given experience and better machine at picking up the adnexal mass.

3. Flank pain- blood in urine, symptoms of kidney stone. I Ultrasound and see no hydro, diagnose kidney stone, and miss the subtle kidney lesion that is picked up on abdominal CT 9 months later and is diagnosed as metastatic renal cell carcinoma. I get sued by lawyer who claims that I could have easily diagnosed the cancer earlier either by having a formal US, or getting the CT of the belly. Lawyer tracks down tech on call that day, who is a seasoned 10 year veteran and asks her (no I've never seen a male) on the stand how many retroperitoneal US she has done in her career and she says 3,000. Lawyer asks you to show documentation of how many you have done. You pull out your residency log book and show them 25, or 90, or 150, or whatever, and then asks the jury to decide for themselves, who is better qualified to do ultrasounds.

4. signs/symptoms of DVT- I ultrasound and send home. Patient dies of PE. Lawyer to me on the stand, "Why didn't you get a formal study?" Me,"well, I was trying to increase my billing, and get the patient out of the ER faster, so I just did it myself."

I'll grant that the above scenarios are a reach, and you could argue that malpractice didn't occur, but, I think a good lawyer could make you look like a real tool.

I've heard it argued that we will use ultrasound in the future just like a stethoscope. I think it is a great dream, but the difference is that you don't charge people a separate bill for listening to their heart, and you don't have a stethoscope tech waiting to come in, who is much better at listening to hearts than you are. I think the current ultrasound vogue and hype throughout residency puts too much pressure on ER residents to waste time on non-emergent US skills in the hopes that their future employer will love them because they do their own RUQ, DVT, or Pelvic US. That question never even came up when I was interviewing for jobs.

I think this US mania is perpetuated by academic programs who are desperate for attendings with credentialling to do FAST scans, and teach residents ultrasound. It creates fellowships dedicated to teaching non-emergent ultrasound skills which are only needed in residency to teach ultrasound (a self serving niche that only exists to preserve its niche).

I work at a very small ER (16,000 annual volume), in a very small hospital (99 bed) in a very small city (20,000). I have 24/7 ultrasound coverage and I see absolutely no reason to do non-emergent ultrasound.

FAST, limited cardiac, AAA-very helpful.

Retroperitoneal, RUQ, DVT, pelvic, time consuming, and I'd rather be charting.

You are not double charging them. If you feel that a patient needs a comprehensive exam, then that is a different study. It is not limited and it addresses different clinical questions.

The clinical situations you give are not appropriate scenarios for u/s. (pos beta, 'nl' exam = ectopic.) (kidney stone= no data to support use in kidney stone. very useful in looking at the aorta) (dvt= don't do it)(RUQ= gallstones only, hence limited exam)


Like all tools, eus has great uses, academic (for education) and extremely limited.

 

[southerndoc]

It comes down to your own experience and comfort level. I do not send labs on every patient with epigastric pain.

I used to be very Osler-like during residency and would only order select labs and only when needed. Ordering a single troponin without a CBC or CMP, a d-dimer only with a creatinine (in case they get scanned), etc.

However, since coming to the community world where the vast majority (90+%) of my patients are insured, many of them expect labs to be drawn.

I will just say this: I have been surprised at the number of people I think do not need labs that have something seriously wrong with them... Weakness being secondary to hyperkalemia and/or acute renal failure, epigastric pain being secondary to pancreatitis, etc.

The vast majority of labs are normal (as one would expect), but I have been surprised by the number of abnormals I've found. The yield is low, but for the person who you tell you have a definitive cause of their abdominal pain instead of just telling them that they have gastritis it makes a lot of difference.

Then again, I practice in a hospital where labs usually take 30 minutes for turnaround times, and this will be getting even less in coming months as we implement point-of-care testing.

 

[DrMom]

You bring up some good points. It comes down to your own experience and comfort level. I do not send labs on every patient with epigastric pain. I will often do a quick RUQ scan (which takes me about 5 minutes) to check for stones, thickened GBW, CBD and presence of pericholecystic fluid. If negative, gi cocktail and reassess in 20 minutes. I inform patients that my scan is a LIMITED scan, meaning I am only checking for a few things. (this is the core point of ALL EUS... we do LIMITED exams and this must be communicated to the patient and any other health care providers) Pt all better- out the door.

This is essentially how we do it at my program.

 

[docB]

I think that there is some confusion here over the word "credentialed." I think that the credentialing Southerndoc is referring to is called “privileging” in my hospitals. Privileging is the process of having the hospital grant you the privilege of doing specific procedures in their facility. For EPs that includes suturing, central lines, intubation, etc. I never had to demonstrate competency on these. I certainly never took a suturing evaluation for the chief of staff or anything like that. What SD is saying about only being able to do certain procedures routinely but being able to do anything emergently sounds just like my hospital privileging.

I am now going through the process of getting credentialed in ultrasound. In my hospitals that will mean going through the process of doing 150 over read studies in 6 areas to show competency as set forth by the departments of EM and Rads. Then I'll be credentialed.

 

[Seaglass]

I am now going through the process of getting credentialed in ultrasound. In my hospitals that will mean going through the process of doing 150 over read studies in 6 areas to show competency as set forth by the departments of EM and Rads. Then I'll be credentialed.

So essentially that is what the departments of EM and Rads have decided will be necessary for the "privilege" of Emergency room US at your hospital. As a clarification I would point out that there is no national credential/certification in emergency ultrasound - it is defined hospital by hospital.

 

[docB]

So essentially that is what the departments of EM and Rads have decided will be necessary for the "privilege" of Emergency room US at your hospital. As a clarification I would point out that there is no national credential/certification in emergency ultrasound - it is defined hospital by hospital.

You're right but this is a new one for us. There is no other procedure where we are asked to show proficiency byond our board certification. We are trying to mirror our process to the ACEP process although that's still in the works (looks like it'll hit the council floor in 2009).

So in my mind one of the big issues about being "credentialed" vs. not was billing. We have been told that we can't bill until we are "credentialed." I agree with that but Seaglass brings up a good point: If getting "credentialed" is purely at the whim of the hospital priveledges comittee does it really have any bearing on billing?

 

[southerndoc]

I think that there is some confusion here over the word "credentialed." I think that the credentialing Southerndoc is referring to is called "privileging" in my hospitals. Privileging is the process of having the hospital grant you the privilege of doing specific procedures in their facility. For EPs that includes suturing, central lines, intubation, etc. I never had to demonstrate competency on these. I certainly never took a suturing evaluation for the chief of staff or anything like that. What SD is saying about only being able to do certain procedures routinely but being able to do anything emergently sounds just like my hospital privileging.

Perhaps there are wording differences, but in my hospital, I did have to demonstrate competency to perform the procedures. This was not done in direct observation, but in my residency program director signing off that I am competent in procedures. In fact, I had to submit residency procedure log summaries for total laceration repairs, thoracotomies, etc. to all three hospitals I credentialed. I didn't document enough conscious sedations during residency (did them, but didn't document them), and therefore had to be observed for the first few conscious sedations until I was credentialed to perform them without supervision.

 

[bulgethetwine]

I agree with Southerndoc, in that I can't be bothered to do a non-emergent US myself. Sure, I wait for 30 minutes for the tech to come in, but, chances are, I'm going to be waiting for labs in addition to the lab tech. For example, someone comes in with RUQ, or epigastric pain, I'm going to order Complete metabolic panel, CBC, lipase, and sometimes, an h.pylori. I don't just want to rule out gall stones, I want to rule out hepatitis, anemia from a chronically bleeding ulcer, pancreatitis, pancreatic mass causing increased bilirubin, etc. Chances are, if I will have ultrasound report back even before the labs are back. I rarely have time on shift to chart on patients, and I would much rather spend any free time charting, rather than hemming and hawing over gallbladder wall thickness, and common bile duct measurements.

I have heard the argument again and again, that US speeds up dispostion. I'm sure there are ERs out there that are so gridlocked that you have to maximize the turn-over of a particular room. I don't work at an ER where that is true. My ability to see more patients is more to do with getting nursing to carry out orders, and lab to complete lab testing. If I did ultrasound right now, it would take me away from seeing patients and the department would slow down. When I order an ultrasound, it takes me one second to check the box. When I do it myself, it would take me from 20 minutes to as much as 60 minutes to get good RUQ images. I am not good at seeing pancreas, and certainly, the patient is going to get a superior scan both in terms of expertise and better equipment from a formal scan.

I don't see a reason to do your own scan unless you are going to bill for it. I think that there is a bit of an ethical dilemma going on there. How much do I bill? The patient is going to get an inferior study if they get it from me. So, I don't think that I should be telling them to fork over the cash. I have seen techs labor over a scan for 45 minutes, where if I would do it, I would look around for 10 minutes and then give up and call it a limited study due to body habitus so that I could get back to seeing patients.

I think that there are some ER attendings out there that are just as good, if not better than a tech. I don't think that doing the average ER residency gets you to that level without a fellowship in ultrasound. I think that there is enough to learn in residency without wasting time on non-emergent ultrasound skills such as RUQ. I think that if you want to bill at the same level and do the same scans as an ultrasound tech, that you should get at least as much training as they do (one year minimum of dedicated 40 hour/week experience doing scans).

I think that there is some liability incurred when doing your own scans. If I miss something, and they get another scan in a few days, I think I would be in a legal bind and open to lawsuits if I am doing my own non-emergent scans, and telling the patient that nothing is wrong with them.

I think I am in an ethical dilemma when I do the scan, charge them, and then tell them to get a formal scan and have them get charged again.

My overblown, paranoid, nightmare ultrasound scenarios:

1. RUQ pain- normal labs, miss subtle liver lesions which is picked up by repeat US in one month and patient diagnosed with metastatic colon cancer.

2. Vag bleed, pregnant- HCG is 1000. My ultrasound normal, repeat in 2 days shows obvious adnexal mass (in addition to free fluid in abdomen from ruptured ectopic). Lawyer sues me for not diagnosing ectopic and adnexal mass. I have one tenth of the experience of US tech on call, who would have had a better chance, given experience and better machine at picking up the adnexal mass.

3. Flank pain- blood in urine, symptoms of kidney stone. I Ultrasound and see no hydro, diagnose kidney stone, and miss the subtle kidney lesion that is picked up on abdominal CT 9 months later and is diagnosed as metastatic renal cell carcinoma. I get sued by lawyer who claims that I could have easily diagnosed the cancer earlier either by having a formal US, or getting the CT of the belly. Lawyer tracks down tech on call that day, who is a seasoned 10 year veteran and asks her (no I've never seen a male) on the stand how many retroperitoneal US she has done in her career and she says 3,000. Lawyer asks you to show documentation of how many you have done. You pull out your residency log book and show them 25, or 90, or 150, or whatever, and then asks the jury to decide for themselves, who is better qualified to do ultrasounds.

4. signs/symptoms of DVT- I ultrasound and send home. Patient dies of PE. Lawyer to me on the stand, "Why didn't you get a formal study?" Me,"well, I was trying to increase my billing, and get the patient out of the ER faster, so I just did it myself."

I'll grant that the above scenarios are a reach, and you could argue that malpractice didn't occur, but, I think a good lawyer could make you look like a real tool.

I've heard it argued that we will use ultrasound in the future just like a stethoscope. I think it is a great dream, but the difference is that you don't charge people a separate bill for listening to their heart, and you don't have a stethoscope tech waiting to come in, who is much better at listening to hearts than you are. I think the current ultrasound vogue and hype throughout residency puts too much pressure on ER residents to waste time on non-emergent US skills in the hopes that their future employer will love them because they do their own RUQ, DVT, or Pelvic US. That question never even came up when I was interviewing for jobs.

I think this US mania is perpetuated by academic programs who are desperate for attendings with credentialling to do FAST scans, and teach residents ultrasound. It creates fellowships dedicated to teaching non-emergent ultrasound skills which are only needed in residency to teach ultrasound (a self serving niche that only exists to preserve its niche).

I work at a very small ER (16,000 annual volume), in a very small hospital (99 bed) in a very small city (20,000). I have 24/7 ultrasound coverage and I see absolutely no reason to do non-emergent ultrasound.

FAST, limited cardiac, AAA-very helpful.

Retroperitoneal, RUQ, DVT, pelvic, time consuming, and I'd rather be charting.

I don't know how I missed this post. Fantastic. Sums up my feelings completely about the (mis) use of ultrasound in residency education in academic settings.