Use of ED ultrasound

[msgsk]

I wanted to 'poll the audience' to see what others think about use of US in the ED. Of course it's helpful for the quick FAST or to place a central line, but I mean beyond that. I trained at a time when it was just on the up and up but they're now using teaching ER doctors to do the full gallbladder, DVT, and all pelvic scans on their own (amongst others). While it's not beyond our level of comprehension or particularly complex, I do hesitate to
a) take the time to do a full scan when I'm pushed to move volume faster and
b) take the liability of performing a full diagnostic scan when their are trained US techs and radiologists available and
c) perform a test that's not reimbursable (this one's not as important but feeds into 'b')
What do you guys think? In a hospital where techs and radiologists are readily available, but so is a decent portable ultrasound machine - how much do you use it? Will you do a full gallbladder scan in a patient with right upper quadrant pain or just order the labs and ultrasound and move on until results are back?
It's my understanding that unless a recorded copy of the ultrasound is included with the patient's chart (which in our hospital it never would be) then it's impossible to be reimbursed for it. Which would tell me it's high liability to make major decisions based on it.

Edit: in a non-academic community center

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[Groove]

I did a lot of US my last year of training and although it's nice having the skills, I haven't particularly found it very useful a few years out. Ultimately, it slows you down and increases your liability. Why perform it yourself when you can see another pt and order the study with a radiologist who's going to give you a formal read? It's a no brainer. I can see 2 more patients in the time it's taken me to wheel in the US machine and do a limited abd study. I probably use it more these days for peripheral US guided deep brachial cannulations on those difficult stick pts along with eFASTs. Oh and lines.

 

[RustedFox]

I seriously only use it for central line placement and during codes (cardiac ultrasound).

 

[emergentmd]

IMO, U/S is only useful for lines and I don't even use them for that. I know I am an old Fart, but I was never trained to use it and got by the 1st 10 yrs fine without using it.

Other than that, I don't see any other real reason. I would NEVER do a radiological test and be the final say. Way too much liability and too much time. Plus, There is expertise in repetition.

 

[brk81144]

I would echo the above sentiments. We did all varieties of studies in residency but I only find myself using it to place lines, cardiac us during a code and bedside confirmation of IUP or fetal heart rate via abdominal us only. The rest seems to be a waste of time when I can see another 1-2 patients in that same time.

 

[namethatsmell]

A factor I didn't anticipate was how long a crappy us machine takes to boot up. In residency we had solid machines. At my current gig it literally takes 2-3 minutes for the machine to just to turn on and it dies immediate if unplugged. It feels like an eternity.


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[alpinism]

I'll offer a dissenting opinion since I'm training at a very US heavy program.

Obviously your use of US will vary depending on your prior training and how comfortable you are doing scans. That being said IMO every critical/unstable patient should get a scan (focused cardiac/pulmonary/IVC/RUSH/FAST). If not already this is rapidly becoming the new standard of care in EM. With practice you can quickly do these scans upon arrival while the nursing staff is obtaining IV access and drawing labs. In the past month alone I've diagnosed 3 PEs and 1 tamponade on US within 5min of the patient arriving in the resuscitation bay. Without US directed care those patients would have likely died or had a much worse outcome.

Besides the above exams we also use US on a daily basis for peripheral lines, central lines, arterial lines, nerve blocks, abscess drainage, and pregnancy evals.
Gallbladder, renal, and aorta scans are also done on a regular basis but they are more for educational purposes and really change management for most patients.
As far as liability we always document our scans as a focused emergency exam and specifically mention that it does not replace the need for a formal exam if indicated.

 

[filhodeinferno]

I wanted to 'poll the audience' to see what others think about use of US in the ED. Of course it's helpful for the quick FAST or to place a central line, but I mean beyond that. I trained at a time when it was just on the up and up but they're now using teaching ER doctors to do the full gallbladder, DVT, and all pelvic scans on their own (amongst others). While it's not beyond our level of comprehension or particularly complex, I do hesitate to
a) take the time to do a full scan when I'm pushed to move volume faster and
b) take the liability of performing a full diagnostic scan when their are trained US techs and radiologists available and
c) perform a test that's not reimbursable (this one's not as important but feeds into 'b')
What do you guys think? In a hospital where techs and radiologists are readily available, but so is a decent portable ultrasound machine - how much do you use it? Will you do a full gallbladder scan in a patient with right upper quadrant pain or just order the labs and ultrasound and move on until results are back?
It's my understanding that unless a recorded copy of the ultrasound is included with the patient's chart (which in our hospital it never would be) then it's impossible to be reimbursed for it. Which would tell me it's high liability to make major decisions based on it.

Edit: in a non-academic community center

Just finished an ultrasound month during 3rd year residency, and after that month here's what I decided I'll use the U/S machine for in my community job next year:

-FAST
-IJ central lines
-Cardiac/IVC in patients with undifferentiated shock...and I'm talking cardiac like checking for effusion, eyeball EF, quick IVC, none of that fancy stuff
-Cardiac in coding patients
-Occasional GB ultrasound if I have low suspicion and wanna make myself feel better (and this is a stretch)

Anything beyond this I just couldn't see the practicality of it as a community doc with plenty of imaging resources available 24:7 and the need to move people along.

 

[WilcoWorld]

I'll make clinical decisions based on the following US findings (in rough order of utility):

+ IUP in r/o ectopic
+ fluid collection when thinking of draining a skin infection
+ urinary retention on PVR-->MRI for cauda equina in a back pain patient
+ FAST (who am I kidding? the surgeon wants a CT anyway)
+ vs (-) abscess on pharyngeal US when deciding CT neck vs empiric drainage and dc w/o CT
+ vs (-) ascites when deciding whether to tap for SBP
+ RV dilation and + DVT in an unstable patient
(-) GB study in a vague upper and pain with (-) labs (I could probably make this decision 9/10 times w/o a probe in my hand)
+ PTX in a poly trauma patient (I could probably make this decision 19/20 times w/o a probe in my hand)

 

[e30ftw]

I use ED BS U/S for the following:

CVL placement.

PIV placement. (more common)

Critical patients (echo, lung, fast)

Abscesses if there's swelling w/ cellulitis but not frank purulence.

Negative GB studies in low risk patients.

Verifying IUP in low risk 1st trimester patients (saves time). Making later pregnancy patients feel good.

Bladder scan for urinary retention to help determine the appropriateness of foley placement.

And to placate numerous low risk complaints and make patients happy at bedside.

Ultrasound is useful and I'm glad we have it. I don't bill and am not ARDMS certified but it is helpful at bedside. I rarely spend more than a minute performing the ultrasound and it takes maybe 15 seconds to cart it to bedside and boot up, so in my mind, time well spent even in a busy community ED.

 

[GonnaBeADoc2222]

Graduating from a very ultrasound heavy program where we have NASA grade machines. We sell it hardcore to the junior residents and medical students...so much so that I think their other clinical skills deteriorate and are sometimes not up to par. I plan on using it for the following next year in the community:

-FAST
-RUSH/ECHO in unstable patient. Shockingly, not every patient who possesses a heart and has chest pain/dyspnea requires a bedside Echo.
-Central lines
-Peripheral Lines
-Simple cellulitis vs abscess
-Bladder for retention
-Maybe nerve blocks
-1st trimester vaginal bleeding / abdominal pain for IUP and FHR measurement
-Believe it or not, throwing probe on to take a quick look for intussusecption is pretty easy (much easier than appendix)
-Maybe occular if I'm really concerned for detachment since it's kinda easy/quick and could convince ophthalmologist to come in

Most other applications (DVT, biliary, renal, pulmonary for pneumonia (really?), transpelvic, appendix) I consider to be a waste of time as commented on above. I also consider many of these exams (DVT, transpelvic, appendix) to really be out of the scope of many EPs, unless you've done maybe 100+ supervised exams.

 

[Tenk]

Codes, Lines, IV, blood draws in drug addicts with no veins, certain tachycardias, codes, pregnancy, ruq abdominal pain when I don't think it's actually gallstones and don't wanna wait to get a formal, pneumo, abscess, foreign body.

I think that's it. I prolly use it once every other shift or so. I think on these things it saves time so I can either get blood or access faster than my staff or not have to wait on a formal ultrasound. If it won't save time I don't get it.

Our ultrasound has a docking station and boots in about 30 seconds so it's not a time sink.

 

[deleted109597]

That being said IMO every critical/unstable patient should get a scan (focused cardiac/pulmonary/IVC/RUSH/FAST). If not already this is rapidly becoming the new standard of care in EM. With practice you can quickly do these scans upon arrival while the nursing staff is obtaining IV access and drawing labs. In the past month alone I've diagnosed 3 PEs and 1 tamponade on US within 5min of the patient arriving in the resuscitation bay. Without US directed care those patients would have likely died or had a much worse outcome.

Hardly. Yes, if you've got an instant on machine, and enough of them that every doc literally has one at arm's length, sure. I'm sure my nurses would "write me up" for trying to US while they were doing the EKG/Foley/failing at IVs. It isn't standard of care. It never will be, because not every department has an US. Just like VL vs DL, this is a haves vs have nots argument. You can't invent **** out of thin air.

Besides the above exams we also use US on a daily basis for peripheral lines

Sadly, yes

central lines

Of course, if you have one

arterial lines

Not an ER procedure. They don't change my management any, and if the admitting team wants one, then they can put it in.

nerve blocks

Agree it's a great skill. It's just hard to get buy in from the director on something like this, and surgery throws fits about "not being able to detect compartment syndrome"

abscess drainage

I'll run it over every now and then, but the number of abscesses I couldn't feel was pretty low. And if it's super deep, I'm not going for it, and surgery will want the CT anyway

pregnancy evals

Transabd only, and even then, if I'm worried about ectopic or abruption, a radiologist is reading it, not me.

Gallbladder, renal, and aorta scans are also done on a regular basis but they are more for educational purposes and really change management for most patients.
As far as liability we always document our scans as a focused emergency exam and specifically mention that it does not replace the need for a formal exam if indicated.

I actually use it on kidneys for hydro in known stones, and gallbladders for the same reason.
Truly, this is one of those things that has gotten ridiculous. Yes, I can determine SpO2, ETT placement, religion, sexual orientation, and last meal time using an US. But I could also see another 10 patients per shift.

 

[deleted245139]

Love it for ocular stuff along with the usual suspects. Also good for cognitive offloading in the sick hypotensive patient which I always appreciate

 

[filhodeinferno]

Graduating from a very ultrasound heavy program where we have NASA grade machines. We sell it hardcore to the junior residents and medical students...so much so that I think their other clinical skills deteriorate and are sometimes not up to par. I plan on using it for the following next year in the community:

-FAST
-RUSH/ECHO in unstable patient. Shockingly, not every patient who possesses a heart and has chest pain/dyspnea requires a bedside Echo.
-Central lines
-Peripheral Lines
-Simple cellulitis vs abscess
-Bladder for retention
-Maybe nerve blocks
-1st trimester vaginal bleeding / abdominal pain for IUP and FHR measurement
-Believe it or not, throwing probe on to take a quick look for intussusecption is pretty easy (much easier than appendix)
-Maybe occular if I'm really concerned for detachment since it's kinda easy/quick and could convince ophthalmologist to come in

Most other applications (DVT, biliary, renal, pulmonary for pneumonia (really?), transpelvic, appendix) I consider to be a waste of time as commented on above. I also consider many of these exams (DVT, transpelvic, appendix) to really be out of the scope of many EPs, unless you've done maybe 100+ supervised exams.

I wish I learned how to do PIVs better under US. That's one place I don't use it that I wish I could. At my residency the nurses are trained to do U/S guided PIVs, so I just haven't had to learn them because there's no necessity. Wonder if that will end up being a skill that I wish I had down the line.

 

[sonofva]

I am glad to have the skill for the military where i will be deployed with fewer resources available. I anticipate not using it much in future civilian practice.

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[Zebra Hunter]

I wish I learned how to do PIVs better under US. That's one place I don't use it that I wish I could. At my residency the nurses are trained to do U/S guided PIVs, so I just haven't had to learn them because there's no necessity. Wonder if that will end up being a skill that I wish I had down the line.

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

 

[Angry Birds]

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

Thanks for the advice. Basilic vein above or below the elbow? Before, right? Before it bifurcates?

 

[Zebra Hunter]

Thanks for the advice. Basilic vein above or below the elbow? Before, right? Before it bifurcates?

I always do above the elbow where it is nice and fat, but you are going to need a long angiocath, not just to reach it, but to ensure that at least half or more of the cath is in the vein.

 

[justaregularmed]

You can get 2 inch 18's but the 2 inch 20's are where its at for PIV's you can put them in anything. In a pinch you can use an aline kit (usually 20's) but its not quite as long.

 

[gman33]

I loved US in training, now i think it's largely a waste of time.
But I work at a place when I can get a formal US or CT on anyone pretty quickly if I'm really concerned.
Doing high quality studies takes time. Time that I can spend doing other stuff.
I will take a quick look at a few things if I have the US handy.
I will use it for lines, both central and peripheral.

Outside of that, I just don't use it.
I'd rather see other patients.

I'm sure I could figure out how to do a CT or X-ray, but that's why we have techs.

 

[TheComebacKid]

As a medical student I kept hearing all the hullabaloo about ultrasound in the ED. "It's a game changer!" they said. Now as a resident, I get the sense that it's really overrated, and sometimes when I see people ultrasounding stupid things, I get the feeling like ED people just needed something new, up and coming, that they could get excited about.

And lets address the elephant in the room. Our consultants really don't care, nor do they trust our ability to ultrasound things properly. I spent a lot of time learning how to do RUQ ultrasounds looking at the gallbladder during residency. Many times I would find stones, pericholecystic fluid, thickened anterior wall, dilated common bile ducts etc. I would show this to consulting surgeon. "Look, look, look what I found! Cholecystitis! We have the diagnosis mwahahahahaha". To which they would respond, "did you get a formal study?". If I tried to convince a surgeon that a patient had appendicitis based on an ultrasound without a CT, they would probably laugh in my face. Despite what you hear about FAST exams for hypotensive blunt trauma patients, I have never seen a patient go directly to the OR based just on a FAST scan. Nobody cares that you see absence of lung sliding, they want the chest x-ray. That's just how it works at my institution.

So the question, does ultrasound REALLY change management? For certain things, it does. Ultrasound is absolutely vital for line placement (central, peripheral, arterial). I use it ton for that. I also think it's basically mandatory for diagnosing an intrauterine pregnancy. In terms of cardiac ultrasound, it's probably useful to diagnose an effusion or tamponade physiology. But all the other stuff we use it for like identifying right heart strain, ankle effusions, gallbladders, DVTs, IVCs etc. I just don't think we are at a point where we can efficiently and reliably make diagnoses that we can act on and our consultants will feel good about.

 

[BoardingDoc]

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

I don't disagree that it CAN be easy. I certainly think it's easy now. That said, I had a hard as hell time doing them when I first started. Either I wouldn't be able to get them, or they'd blow shortly after placement. A helpful tip I've found:

Place them in LONG view. This is counter to how most people place IJs in that they just use the trans view. The benefit of long view is that you can see the needle enter the vein, and then you can advance the needle a cm or so and watch it stay in the vessel before you advance the catheter. This has dramatically decreased my rate of blown PIVs.

Also, I agree with the above posts. Unless the vessel is within 0.5cm of the surface, you should be using a long IV, not a standard one.

 

[TheComebacKid]

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

I completely disagree with your statement that it's easy. Ultrasound guided peripheral IV's are arguably one of the hardest if not the hardest skill to learn in the ED. It is absolutely nothing like putting in a central line. An IJ is usually a humongously fat and plump vessel with a relatively predictable course. A peripheral vein is like trying to land a 20 gauge IV on top of a piece of spaghetti that is curving all over the place. In addition, the majority of patients have a reasonable IJ that you can hit. A lot of them have crap veins.

I agree that the basilic vein is the best target.

People will tell you all kinds of BS and different techniques they use to land peripheral IV's. In reality, there is only ONE thing you need to do: find the god damn needle tip. If you can see the needle tip on the screen (which is much, much harder than you think, especially when you are just starting out), and you can master the technique of advancing the probe and the needle tip simultaneously, you can hit most IV's. And even then, you'll miss a bunch.

I thought putting femoral and neck central lines were child's play after I spent a month on an ultrasound rotation just doing peripheral IV's all day.

Peripheral IV's are a great skill to have.

 

[Zebra Hunter]

I completely disagree with your statement that it's easy. Ultrasound guided peripheral IV's are arguably one of the hardest if not the hardest skill to learn in the ED. It is absolutely nothing like putting in a central line. An IJ is usually a humongously fat and plump vessel with a relatively predictable course. A peripheral vein is like trying to land a 20 gauge IV on top of a piece of spaghetti that is curving all over the place. In addition, the majority of patients have a reasonable IJ that you can hit. A lot of them have crap veins.

I agree that the basilic vein is the best target.

People will tell you all kinds of BS and different techniques they use to land peripheral IV's. In reality, there is only ONE thing you need to do: find the god damn needle tip. If you can see the needle tip on the screen (which is much, much harder than you think, especially when you are just starting out), and you can master the technique of advancing the probe and the needle tip simultaneously, you can hit most IV's. And even then, you'll miss a bunch.

I thought putting femoral and neck central lines were child's play after I spent a month on an ultrasound rotation just doing peripheral IV's all day.

Peripheral IV's are a great skill to have.

Agree to disagree. The skills you use to put in a central line are the exact same for peripheral line placement. Your explanation for why it is harder than a central line just demonstrates my point. You are describing trying to place a line in an antecubital vein. People always try to dick around with antecubital veins when they first learn the skill, which have a terribly unpredictable course and are usually tiny veins. The basilic vein has a very predictable course and is plump. Since making this realization, I've never missed a peripheral line, and can't remember the last time I did not get it on the first attempt.

 

[GonnaBeADoc2222]

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

People will tell you all kinds of BS and different techniques they use to land peripheral IV's. In reality, there is only ONE thing you need to do: find the god damn needle tip. If you can see the needle tip on the screen (which is much, much harder than you think, especially when you are just starting out), and you can master the technique of advancing the probe and the needle tip simultaneously, you can hit most IV's. And even then, you'll miss a bunch..

Definitely not an easy procedure. I would argue that it's probably the toughest of our toolbox to master. I am extremely proficient in them now and it's a rarity for me to miss, but it took probably 20-30 (or more) failures during 1st-2nd year before I finally figured it out. Basilic is key as it is usually bigger and SOMETIMES more predictable. But I've seen that damn thing dive up and down like a roller coaster, split in wacky ways and in same weird vasculopaths just disappear completely as I attempt to track it. Keeping needlepoint in view at all times is also pro advice. I think the most important thing with this procedure (and especially central access, as this is higher stakes) is to be honest and recognize when you are failing and abort. I've seen too many instances where someone thinks they're in the peripheral vessel, but really they're through and through, have created a small hematoma, and assume they are in the vessel because they are able to negatively aspirate the hematoma blood.

 

[GonnaBeADoc2222]

And lets address the elephant in the room. Our consultants really don't care, nor do they trust our ability to ultrasound things properly. I spent a lot of time learning how to do RUQ ultrasounds looking at the gallbladder during residency. Many times I would find stones, pericholecystic fluid, thickened anterior wall, dilated common bile ducts etc. I would show this to consulting surgeon. "Look, look, look what I found! Cholecystitis! We have the diagnosis mwahahahahaha". To which they would respond, "did you get a formal study?". If I tried to convince a surgeon that a patient had appendicitis based on an ultrasound without a CT, they would probably laugh in my face. Despite what you hear about FAST exams for hypotensive blunt trauma patients, I have never seen a patient go directly to the OR based just on a FAST scan. Nobody cares that you see absence of lung sliding, they want the chest x-ray. That's just how it works at my institution.

So the question, does ultrasound REALLY change management? For certain things, it does. Ultrasound is absolutely vital for line placement (central, peripheral, arterial). I use it ton for that. I also think it's basically mandatory for diagnosing an intrauterine pregnancy. In terms of cardiac ultrasound, it's probably useful to diagnose an effusion or tamponade physiology. But all the other stuff we use it for like identifying right heart strain, ankle effusions, gallbladders, DVTs, IVCs etc. I just don't think we are at a point where we can efficiently and reliably make diagnoses that we can act on and our consultants will feel good about.

It depends at my institution (large academic). I find that general surgery is far less likely to take chole / appy to OR without formal study - and I think that's appropriate. I've seen a positive FAST go both ways - more commonly favoring the CT route and not the direct to OR route - and I'm not quite sure what decision criterion is being used here. If there's a solitary discrete bleeder (especially in peds nowadays), IR is used more and more and is likely better for the patient rather than an ex-lap.

I have seen vascular surgery and cardiovascular surgery take a patient directly to the OR based on an bedside u/s showing unstable large AAA or an ascending thoracic dissection.

For pneumothorax, if stable I will wait for the CXR, if unstable/peri-unstable I am decompressing without consultant input.

In my n=1 experience, I have seen OBGYN act very expediently on a young, hypotensive, HCG(+) patient with a bedside positive FAST.

 

[WilcoWorld]

As a medical student I kept hearing all the hullabaloo about ultrasound in the ED. "It's a game changer!" they said. Now as a resident, I get the sense that it's really overrated, and sometimes when I see people ultrasounding stupid things, I get the feeling like ED people just needed something new, up and coming, that they could get excited about.

And lets address the elephant in the room. Our consultants really don't care, nor do they trust our ability to ultrasound things properly. I spent a lot of time learning how to do RUQ ultrasounds looking at the gallbladder during residency. Many times I would find stones, pericholecystic fluid, thickened anterior wall, dilated common bile ducts etc. I would show this to consulting surgeon. "Look, look, look what I found! Cholecystitis! We have the diagnosis mwahahahahaha". To which they would respond, "did you get a formal study?". If I tried to convince a surgeon that a patient had appendicitis based on an ultrasound without a CT, they would probably laugh in my face. Despite what you hear about FAST exams for hypotensive blunt trauma patients, I have never seen a patient go directly to the OR based just on a FAST scan. Nobody cares that you see absence of lung sliding, they want the chest x-ray. That's just how it works at my institution.

So the question, does ultrasound REALLY change management? For certain things, it does. Ultrasound is absolutely vital for line placement (central, peripheral, arterial). I use it ton for that. I also think it's basically mandatory for diagnosing an intrauterine pregnancy. In terms of cardiac ultrasound, it's probably useful to diagnose an effusion or tamponade physiology. But all the other stuff we use it for like identifying right heart strain, ankle effusions, gallbladders, DVTs, IVCs etc. I just don't think we are at a point where we can efficiently and reliably make diagnoses that we can act on and our consultants will feel good about.

I agree that our consultants are unlikely to act on the ED's US alone. That's why, if you look at my list below, you'll see that I find US most useful for making (a limited number) of my own decisions. Bound up in this utility is the internal ability to evaluate your image quality and say, "I am confident in this finding" vs "I can't get a good scan, so this is not actionable data."

I'll make clinical decisions based on the following US findings (in rough order of utility):

+ IUP in r/o ectopic
+ fluid collection when thinking of draining a skin infection
+ urinary retention on PVR-->MRI for cauda equina in a back pain patient
+ FAST (who am I kidding? the surgeon wants a CT anyway)
+ vs (-) abscess on pharyngeal US when deciding CT neck vs empiric drainage and dc w/o CT
+ vs (-) ascites when deciding whether to tap for SBP
+ RV dilation and + DVT in an unstable patient
(-) GB study in a vague upper and pain with (-) labs (I could probably make this decision 9/10 times w/o a probe in my hand)
+ PTX in a poly trauma patient (but I could probably make this decision 19/20 times w/o a probe in my hand)

And, to prove your point, I'll refer you to my parenthetical statement about the FAST exam.

 

[DrBowtie]

I agree that our consultants are unlikely to act on the ED's US alone. That's why, if you look at my list below, you'll see that I find US most useful for making (a limited number) of my own decisions. Bound up in this utility is the internal ability to evaluate your image quality and say, "I am confident in this finding" vs "I can't get a good scan, so this is not actionable data."



And, to prove your point, I'll refer you to my parenthetical statement about the FAST exam.

Rads resident here. Do you think part of this dismissiveness by the consultants relates to the storage and availability of images/reports?

 

[WilcoWorld]

Rads resident here. Do you think part of this dismissiveness by the consultants relates to the storage and availability of images/reports?

Yes, but I think it's tangentially related.

I suspect that if we established a track record of ED studies getting stored and verified by Radiology, then the culture would change. But I think that change would occur slowly.

I'll add that I sympathize with consultants' reluctance. Some docs are great at US, and if they say that there's an intussusception, then you can believe them (I am not one of those docs). But there are other docs who don't know that they don't know, and many of them will speak with just as much confidence as the former group. It's hard for a consultant to know who's who. Your suggestion would go part of the way towards addressing this ambiguity.

 

[DrBowtie]

Yes, but I think it's tangentially related.

I suspect that if we established a track record of ED studies getting stored and verified by Radiology, then the culture would change. But I think that change would occur slowly.

I'll add that I sympathize with consultants' reluctance. Some docs are great at US, and if they say that there's an intussusception, then you can believe them (I am not one of those docs). But there are other docs who don't know that they don't know, and many of them will speak with just as much confidence as the former group. It's hard for a consultant to know who's who. Your suggestion would go part of the way towards addressing this ambiguity.

I think the ED guys here use US fairly robustly but I have never seen any of the images. They aren't stored in PACS nor are they linked with the EMR. We often get requests with very specific indications such that I know a bedside has been done but have no way of seeing anything. They can't be used for older comparison. We have the same complaint with our vascular lab.

 

[filhodeinferno]

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

Thanks for the advice. I guess residency isn't over yet...maybe I'll put the effort into doing some of them when I've got the time.

 

[WilcoWorld]

I think the ED guys here use US fairly robustly but I have never seen any of the images. They aren't stored in PACS nor are they linked with the EMR. We often get requests with very specific indications such that I know a bedside has been done but have no way of seeing anything. They can't be used for older comparison. We have the same complaint with our vascular lab.

I've worked in 2 US-heavy ED's now and I am surprised at how difficult image integration into the EMR seems to be. I'm sure it must be frustrating on your end as well.

 

[Arcan57]

I've worked in 2 US-heavy ED's now and I am surprised at how difficult image integration into the EMR seems to be. I'm sure it must be frustrating on your end as well.

There are programs that integrate well and allow for robust QI. The problem is that the cost of licensing them are about equivalent to what you get for billing at places that aren't performing superfluous US just for education. Still shaking my head at the speaker at ACEP that was trying to convince me that scanning B legs for DVT added significantly to the use of U/S in undifferentiated shock.

 

[Janders]

I DO use the U/S just about every shift in a community based practice. We are still unable to store and bill these, so $ does not impact my decision to use this tool.

Things I do:
(1) CVL-- Not universally, but the great great majority.
(2) PIV-- I usually just place an EJ if RNs fail. PIVs annoy me (time sink). But sometimes you need them. I'd rather train the RN staff to place PIV under U/S guidance-- I think this inside their practice limits, and would free me up.
(3) Lung Scan-- I didn't learn this in residency. But I think it is fairly nice when you have a sick, dyspneic patient and due to habitus CHF/COPD are hard to differentiate. I also like it if I think pneumothorax is high on the ddx. I can have an answer 5 minutes faster than portable chest X-ray.
(4) Cardiac-- all codes. Patients who I think have a solid chance of cardiac tamponade as source of illness. Critically ill patients who aren't responding to initial fluid resus and levophed typically get a "shock" u/s from me to make sure we aren't missing something. I do NOT echo all chest pains, or all dyspneas, or all hypotension.
(5) After-hours, I do DVT scans and Gall bladder scans if I think they are clinically relevant as we don't have U/S available from 10pm 'til 8am. If its a classic cholecystitis, I can show the surgeon myself and skip the unneeded, insensitive CT scan. I do hedge my bets on these, and do inform negative DVT patients they need a formal U/S next day as an outpatient, etc.
(6) Procedural-- Sometimes I look for abscesses, but 90% of the time I just cut. I do use it for nerve blocks occasionally. I do use it to find deep FB a few times a year (huge thorn, long needle, very long sliver of glass). I see a fair amount of cirrhotics, so I'll use it for paracentesis as well (most of the time...).
(7) Trans-abdominal pelvic-- Just to check FHTs and fetal movement.
(8) Bladder- We get a ton of old guys with urinary retention. I do typically check a 10s bladder u/s prior to placing the foley, if I can't palpate the bladder due to habitus.

I don't do a ton of renal, but occasionally will looking for unilateral hydro from a stone. We don't have an endocavitary probe. I don't know how to do testicular U/S (would be useful overnight). I have played with ocular, but don't feel all that comfortable that a negative study in my hands is enough until I have practiced more. We are not a trauma center, so while I've done a billion FASTS in my life, I actually rarely do them now. Generally the patient is stable enough to get the CT they actually need for their blunt trauma.

Most of the scans I do take <1 minute and give a big yes/know answer. I find that patients like the scans a lot; it can be fun to give them and the family a brief tour of their anatomy. As such it can be a valuable communication and satisfaction tool.

 

[Gastrapathy]

I just had a US fellowship trained ED attending get mad at me for not believing his "cholodocholithiasis" finding enough to take a currently asymptomatic patient with mildly elevated liver tests to ERCP. It is definitely a problem that we can't see the images. In this case, by the time the MRCP was completed, the stone must have passed spontaneously.

 

[Angry Birds]

I just had a US fellowship trained ED attending get mad at me for not believing his "cholodocholithiasis" finding enough to take a currently asymptomatic patient with mildly elevated liver tests to ERCP. It is definitely a problem that we can't see the images. In this case, by the time the MRCP was completed, the stone must have passed spontaneously.

I gave you a Like and then took it right back when I realized you're a GI guy.

 

[alpinism]

Hardly. Yes, if you've got an instant on machine, and enough of them that every doc literally has one at arm's length, sure. I'm sure my nurses would "write me up" for trying to US while they were doing the EKG/Foley/failing at IVs. It isn't standard of care. It never will be, because not every department has an US. Just like VL vs DL, this is a haves vs have nots argument. You can't invent **** out of thin air.


Sadly, yes

Of course, if you have one

Not an ER procedure. They don't change my management any, and if the admitting team wants one, then they can put it in.

Agree it's a great skill. It's just hard to get buy in from the director on something like this, and surgery throws fits about "not being able to detect compartment syndrome"

I'll run it over every now and then, but the number of abscesses I couldn't feel was pretty low. And if it's super deep, I'm not going for it, and surgery will want the CT anyway

Transabd only, and even then, if I'm worried about ectopic or abruption, a radiologist is reading it, not me.

I actually use it on kidneys for hydro in known stones, and gallbladders for the same reason.
Truly, this is one of those things that has gotten ridiculous. Yes, I can determine SpO2, ETT placement, religion, sexual orientation, and last meal time using an US. But I could also see another 10 patients per shift.

We've got 2 brand new ZONARE units in the resuscitation bay and another 3 stationed around the department. So yes we are spoiled in that regard.

I usually tell the nurses to pick a side of the patient and I'll take the other side. If they need both arms I'll just go ahead and do it from the head of the bed.

BTW its a little known fact that ultrasounds were made to piss off the nurses. One of my favorite pastimes is leaving gel all over the place then throwing towels at them until they clean up the mess. Extra points if its right before the ECG and none of the leads will stick to the skin. UMMMMMMMM EXCUSE ME NURSE ... Why the hell is my 12 lead taking so long???

 

[alpinism]

Dude, it's easy. If you can do a central line, you can do an u/s guided peripheral IV. Grab a long angiocath (preferably one that is about 2 inches long or more), don't bother with any other vein other than the basilic vein, throw it in like you would for a central line, walk away 2 minutes later because it is that easy. I never have to do them anymore after teaching the nurses at my hospital to stop dicking around with antecubital veins when trying to place a u/s guided IV, and just go straight for the basilic.

The deep basilic vein is great in most patients. However, I'd caution anyone from just throwing IVs in it without any formal supervised training. In some patients the nerve sits right above the vein and in many its right next door. Nerves can be tricky to find in some people and you need to know how to identify them on ultrasound. Most patients will let you know if you hit the nerve (maybe even by smacking you in the face) but if they're unresponsive or altered you can cause permanent nerve damage.

 

[Gastrapathy]

I gave you a Like and then took it right back when I realized you're a GI guy.

Aww. I even ordered the MRCP just because he was sooo sure the stone was there. That's more than most (all) of my partners would have done.

 

[shoal007]

I DO use the U/S just about every shift in a community based practice. We are still unable to store and bill these, so $ does not impact my decision to use this tool.

Things I do:
(1) CVL-- Not universally, but the great great majority.
(2) PIV-- I usually just place an EJ if RNs fail. PIVs annoy me (time sink). But sometimes you need them. I'd rather train the RN staff to place PIV under U/S guidance-- I think this inside their practice limits, and would free me up.
(3) Lung Scan-- I didn't learn this in residency. But I think it is fairly nice when you have a sick, dyspneic patient and due to habitus CHF/COPD are hard to differentiate. I also like it if I think pneumothorax is high on the ddx. I can have an answer 5 minutes faster than portable chest X-ray.
(4) Cardiac-- all codes. Patients who I think have a solid chance of cardiac tamponade as source of illness. Critically ill patients who aren't responding to initial fluid resus and levophed typically get a "shock" u/s from me to make sure we aren't missing something. I do NOT echo all chest pains, or all dyspneas, or all hypotension.
(5) After-hours, I do DVT scans and Gall bladder scans if I think they are clinically relevant as we don't have U/S available from 10pm 'til 8am. If its a classic cholecystitis, I can show the surgeon myself and skip the unneeded, insensitive CT scan. I do hedge my bets on these, and do inform negative DVT patients they need a formal U/S next day as an outpatient, etc.
(6) Procedural-- Sometimes I look for abscesses, but 90% of the time I just cut. I do use it for nerve blocks occasionally. I do use it to find deep FB a few times a year (huge thorn, long needle, very long sliver of glass). I see a fair amount of cirrhotics, so I'll use it for paracentesis as well (most of the time...).
(7) Trans-abdominal pelvic-- Just to check FHTs and fetal movement.
(8) Bladder- We get a ton of old guys with urinary retention. I do typically check a 10s bladder u/s prior to placing the foley, if I can't palpate the bladder due to habitus.

I don't do a ton of renal, but occasionally will looking for unilateral hydro from a stone. We don't have an endocavitary probe. I don't know how to do testicular U/S (would be useful overnight). I have played with ocular, but don't feel all that comfortable that a negative study in my hands is enough until I have practiced more. We are not a trauma center, so while I've done a billion FASTS in my life, I actually rarely do them now. Generally the patient is stable enough to get the CT they actually need for their blunt trauma.

Most of the scans I do take <1 minute and give a big yes/know answer. I find that patients like the scans a lot; it can be fun to give them and the family a brief tour of their anatomy. As such it can be a valuable communication and satisfaction tool.

yuck. i wouldnt want that liability. i work in a small shop 30k/yr and we have 24/7 us. no excuse if that size.

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[cofcemt]

yuck. i wouldnt want that liability. i work in a small shop 30k/yr and we have 24/7 us. no excuse if that size.

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Apparently I'm working at the wrong places. Split my time 50/50 between a 120k lvl 1 and a 34k community site.

The big house has general US 24/7, but at night takes 2-3 hours to get a read and no DVT from 8p-7a.

The community site has no US or DVT from 4:30p-7a.

So that being said, I do RUSH on hypotensives, tons of PIVs (currently training a bunch of nurses), CVCs, gallbladders/DVTs at night, Transabd preg, ocular when needed and abscesses (esp Peds gluteal). If I can't hit the aline without the US, it's not getting done. Otherwise, the rest are only utilized with resident teaching.

I have had our OB group take 3 ruptured ectopics straight to the OR (2 were older colleagues patients that suspected). Showed them at the bedside the images, they were grateful and provided nice collegial interaction between the ED and the consultant.

 

[The White Coat Investor]

I was really interested in US as a resident, although wasn't at a program where it was very big at the time. It got bigger as I went through residency and I actually went away and did a one month rotation at UC Irvine with Christian Fox. So although I didn't do a fellowship, I certainly knew my way around an ultrasound machine by graduation and in fact worked at places without 24/7 US back-up including a busy level 2 trauma center.

I'm now 10 years out with 24/7 US coverage. I routinely use the US for (and bill for) the following:

1. When I call a code to check for cardiac motion
2. A rare FAST (true indications for FAST are very rare, especially in a level 3 trauma center like mine). Probably do it more looking for non-traumatic ascites and pericardial effusions.
3. US guided procedures- central line, LP, paracentesis, thoracentesis, PTA drainage
4. Abscess vs Cellulitis
5. 1st trimester vag bleed/pelvic pain- I only rule in IUP. If I can't see an IUP, I order an US.
6. 2nd/3rd trimester assessment of fetal viability and fluid assessment
7. Bladder volume assessment- post-void residuals mostly

I feel pretty comfortable doing a GB US and a DVT US but usually let radiology do those. I don't feel very comfortable with ocular, IVC volume status assessment, appy, ovaries, testicles.

All our techs and nurses are better than me at peripheral IVs, both with and without an US.

 

[Janders]

yuck. i wouldnt want that liability. i work in a small shop 30k/yr and we have 24/7 us. no excuse if that size.

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My shop is low 30k / year. Still no U/S for half the day, basically. Want to convince them otherwise? I've tried

Anyway, like I say I hedge my bets with DVT-- You can use DDimer to help. Some people come in with an obvious calf strain, and a bedside U/S can make them feel better and show no clot. Some people come in with multiple risk factors, a +ddimer, and a negative bedside U/S. They might get a dose of lovenox and a repeat visit the next day.

 

[shookwell]

Bedside ultrasound is also the best test for pulmonary edema. More sensitive and more specific than labs or CXR. Very useful when in the undifferentiated dyspneic patient if you are not sure clinically whether they have pulmonary edema or just bronchospasm.

I do my own DVT studies, if they are positive no need to call in a tech I just treat. If mine is negative then I get the formal study to confirm since they do a much more extensive sono.

That's in addition to transvag for IUP, RUQ, soft tissue for abscess, kidney for hydro, FAST, echo, and venous access

Regarding peripheral access, if the patient is kind of sick and needs access quick I often just put a central line catheter into the basilic vein. I use the small 2 lumen CVC kits that they stock in pediatric. Better than messing with a peripheral IV that's going to blow in an hour.

 

[Arcan57]

Bedside ultrasound is also the best test for pulmonary edema. More sensitive and more specific than labs or CXR. Very useful when in the undifferentiated dyspneic patient if you are not sure clinically whether they have pulmonary edema or just bronchospasm.

The best test for clinically significant pulmonary edema is a history and physical. The undifferentiated dyspneic patient gets tossed around almost as much as the undifferentiated hypotensive patient as the killer app for bedside U/S in the community ED. My problem with this is 2-fold: 1) truly undifferentiated dyspnea where the initial treatment is going to be both disease specific and has serious potential side effects is rare and 2) all the studies that talk about how U/S is the best thing ever for diagnosing x,y, and z are small and I'm not convinced it's anywhere near as specific as the literature claims.

Both bronchospasm and pulmonary edema of sufficient severity are going to get ventilatory support. In someone with a history of CHF and COPD who is wheezing with almost no air movement, are you going to hold off on Beta-agonists because of B-lines? Are you going to let a 290/180 BP ride in someone with severe distress because you're not seeing "enough" B-lines? Are you going to stop the eval if there are some B-lines but story could be consistent with PE? How do you factor in that pulmonary fibrosis and other interstitial lung diseases also causes B-lines?

If you need findings on bedside U/S to give you permission to rapidly initiate treatment or your sense of efficacy at work derives from not "shotgunning" initially on critically ill patients then go for it.

 

[shookwell]

Some patients have sufficient findings on their history and physical to differentiate CHF and COPD, but not all. And I agree that the really sick patient will get ventilatory support regardless. But there are still plenty of patients in between that benefit from bedside ultrasound.

There was a really good meta-analysis I read recently that supports the use of bedside ultrasound in this setting: https://www.ncbi.nlm.nih.gov/pubmed/26910112