Where is U/S being used for more than FAST?

[ERresponsible]

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Anyone know residency programs that are teaching Residents how to use U/S for non-trauma stuff? Any examples?

I'm hoping to find a program this year that can teach more than FAST and has been able to incorporate U/S such that the time involved and billing make economic sense.

 

[Seaglass]

AFAIK all the NC programs do at least the core AAA, TV-US, FAST, Simple cardiac. Here we do more, at my last shop we also did more than that.

 

[BADMD]

Anyone know residency programs that are teaching Residents how to use U/S for non-trauma stuff? Any examples?

I'm hoping to find a program this year that can teach more than FAST and has been able to incorporate U/S such that the time involved and billing make economic sense.

I diagnosed a pneumothorax and hydrothorax a few days ago with U/S. If I really suspect to see something in the biliary tree, I put the ultrasound down. Most of the residency programs I've seen in Detroit have an ultrasound elective and go beyond the FAST exam.

 

[EM_Rebuilder]

I am still a few years away from my more intense U/S training, but we have time dedicated to it that goes much further than FAST exams... and we have one of the pioneers of U/S teaching it.

 

[c.bear]

Our program is teaching and really pushing for us to use it for everything even if we f/u our US with an offical US. Just to name a few: obgyn, dvt, AAA, gall bladder dz, kidney, lung, IJ placement, pericardiocentesis....Oh and the other day my attending stuck a pt's foot in a bucket of water to use the US to evaluate for a foreign body (glass).

 

[ditch doctor]

Most of our staff are pretty ultrasound happy for anything that is remotely ultrasoundable and love to teach, which is nice.

Although, the FAST they are not so crazy about... Both schools where I did rotation as a MSIV would FAST any trauma almost as "F" in the primary survey. Where I'm at now they only like the FAST when it is indicated; unstable blunt trauma. They are very adamant about timely definitive treatment/dispo and don't want to slow down a trip to the CT or whatever. Even for the 1 minute it takes for the FAST. Of course they don't care if we want to FAST a non-serious trauma, but we are always told the same thing, "Yeah, sure if you want the practice; but what are the indications for a FAST exam???" "yeah, yeah, we know..."

 

[FoughtFyr]

We use it for everything but bill for (and attendings are credentialled for) IUP - both trans abd and trans vag, FAST, aorta, line placement and echo during codes.

- H

 

[southerndoc]

We are researching Extended-FAST's (E-FAST), so every modified and full trauma response gets an E-FAST exam, which includes lung windows.

Other than that, we have two fellowship-trained ultrasonographers as well as two fellows. All attendings are experienced in ultrasound and need to perform a number of ultrasounds per year to remain part of the faculty. We routinely do OB/gyn, gallbladder, AAA, DVT, transthoracic echos, retinal detachment, abscess, as well as procedural stuff (paracentesis, thoracentesis, IJ central lines, peripheral IV's when there is difficulty obtaining access, etc.). Ultrasound is definitely one of the strongest components of my program.

 

[dchristismi]

We have 2 fellowship-trained attendings, an old-school expert who's been running the program for ages, and a new u/s fellowship at ORMC. We do use it in trauma, although our surgeons are now so indoctrinated they will try to beat us to the FAST. 🙂 U/S guided procedures are the norm. My personal favorite is scanning for retinal detachments/vitreous hemorrhage. We also use it to help guide code rescucitations. Just got a lecture the other day about using it to verify tendon injuries, as well, so needless to say, we ultrasound a lot too.

I think you'll find that most programs are really exploring ultrasound as a versatile tool these days beyond the typical trauma applications.

 

[turtle md]

Christiana

We use it for almost everything mentioned above. Peski is our director and can elaborate more, but as a resident, I feel we get more than adequate exposure to non-trauma u/s.

 

[Jeff698]

FAST scans seem to almost be a minority of what I use the US for. I do a ton of TV for IUP detection. I also try to use it for all my lines. I use it on all codes, will do RUQs for education value and often take a look at abscesses before I&D. I'm sure I'm missing some but that's the majority for sure.

I think that as we (the specialty) get more experience with US, FASTs will likely be the minority of scans we do.

Take care,
Jeff

 

[EctopicFetus]

FAST scans seem to almost be a minority of what I use the US for. I do a ton of TV for IUP detection. I also try to use it for all my lines. I use it on all codes, will do RUQs for education value and often take a look at abscesses before I&D. I'm sure I'm missing some but that's the majority for sure.

I think that as we (the specialty) get more experience with US, FASTs will likely be the minority of scans we do.

Take care,
Jeff

Same here.

 

[Febrifuge]

My beloved erstwhile workplace has multiple machines rolling around the department. I used to be able to stash one of the "good ones" in the trauma room and still have one for OB stuff, one for general abdominal or cardiac, and another for random "let's show the student something cool" stuff. U/S guided placement of really tricky IVs is one popular example.

 

[peksi]

Ok Turtle, I will reply. Beyond the basics and advanced for our 7,000+ EUS per year including ocular, vascular, thoracic and testicular (which we have researched and pioneered) we are the only ED program performing therapeutic ultrasound for stroke or thrombolysis at this time.
The next venue of EUS is therapeutic ultrasound for which we are leading the pack!!!

Paul

 

[southerndoc]

Ok Turtle, I will reply. Beyond the basics and advanced for our 7,000+ EUS per year including ocular, vascular, thoracic and testicular (which we have researched and pioneered) we are the only ED program performing therapeutic ultrasound for stroke or thrombolysis at this time.
The next venue of EUS is therapeutic ultrasound for which we are leading the pack!!!

Paul

This sounds cool. What are you doing with ultrasound in stroke patients?

 

[ERMudPhud]

This sounds cool. What are you doing with ultrasound in stroke patients?

Type "therapeutic ultrasound stroke" into pubmed and you'll see a few dozen article on focused ultrasound being used to enhance the efficacy of thrombolytics. Think of it as lithotripsy for clots. "thrombotripsy?"

 

[dlung]

ha! figured out something no one mentioned yet--peripheral nerve blocks...

 

[peksi]

Not to hijack the thread, but knowing that US is a mechanical pressure wave, its bioeffects are being sudied in specific disease states both alone and in conjunction with existing and newer therapies, its therapeutic uses are expaning from cleaning jewelry to now enhancing clot lysis, increasing chemotherapeutic delivery, to targeting. Our study, US and 5 other countries uses TCD, TPA and nanobubble technology. The CLOTBUST trial by Andrei Alexandrov demonstrated the addative effect of low freq TCD with TPA in AIS without increasing the symptomatic blead rate.

Now significant evidence exists related to how ultrasound modulates cell membranes and this has opened a full field of therapeutic ultrasound...

Paul

 

[southerndoc]

Type "therapeutic ultrasound stroke" into pubmed and you'll see a few dozen article on focused ultrasound being used to enhance the efficacy of thrombolytics. Think of it as lithotripsy for clots. "thrombotripsy?"

That's what I thought you were talking about, but wasn't sure. IR recently did this on an 18-year-old I admitted with a subclavian thrombosis secondary to thoracic outlet syndrome. They lysed him and used therapeutic ultrasound to facilitate lysis.

 

[ERMudPhud]

Not to hijack the thread, but knowing that US is a mechanical pressure wave, its bioeffects are being sudied in specific disease states both alone and in conjunction with existing and newer therapies, its therapeutic uses are expaning from cleaning jewelry to now enhancing clot lysis, increasing chemotherapeutic delivery, to targeting. Our study, US and 5 other countries uses TCD, TPA and nanobubble technology. The CLOTBUST trial by Andrei Alexandrov demonstrated the addative effect of low freq TCD with TPA in AIS without increasing the symptomatic blead rate.

Now significant evidence exists related to how ultrasound modulates cell membranes and this has opened a full field of therapeutic ultrasound...

Paul

So now that we know that US has all these bioeffects down to the molecular level. How soon until we start finding that perhaps its not 100% safe in pregnancy. I'm especially curious given the recent appearance of these ultrasound boutiques for rich parents to get whole photo albums in utero.

Sorry for the double hijack

 

[roja]

We have 3 U/S trained faculty, our PD is RDMS, and we have two-three fellows a year. Several of our residents have graduated RDMS eligable (myself included)

We use it for all the above.

 

[crewmaster1]

Just used it today to find a small abdominal wall abscess and to eval a patient for hydronephrosis.

 

[WilcoWorld]

I'm at Christ.

I found a heterotopic pregnancy on bedside US last week. That was probably the most satisfying scan of my short career.

Here we are encouraged to use it for whatever we like. We all do an US rotation with Mike Lambert, who is a great teacher - especially when it comes to US. We also have a fellowship and several attendings who are certified, so more often than not you can find someone working who can help you with a scan. I try to do at least 2 scans per shift, but usually get in about 4. I'm hoping to get in my 300 scans before graduation & it looks like that's going to happen. At the moment I'm comfortable with the following scans:

FAST
Biliary
Trans abd / trans vag pregnancy location
Aorta
Central line guidance
Abscess & foreign body localization
LE DVT study
Pericardial effusions
Gross myocardial wall motion abnormalities
visualizing a pleural effusion


Haven't tried nerve blocks yet, but Lambert just gave us a lecture on it & I'm looking forward to trying it.

 

[RockfordWF]

Anyone know residency programs that are teaching Residents how to use U/S for non-trauma stuff? Any examples?

I'm hoping to find a program this year that can teach more than FAST and has been able to incorporate U/S such that the time involved and billing make economic sense.

I've used ultrasound for medical conditions at both programs I have rotated at (Oklahoma City, OK and Temple, TX).

We look at all pregnant patients for OB exams, I've looked at several aortas, and a few gallbladders.

 

[bulgethetwine]

I've used ultrasound for medical conditions at both programs I have rotated at (Oklahoma City, OK and Temple, TX).

We look at all pregnant patients for OB exams, I've looked at several aortas, and a few gallbladders.

With all due respect to Peksi whom I respect very much, I think that ultrasound is actually overused (edit: I mean to say it is overemphasized to residents). That's not to say that I don't use it -- I do! See below... but there is a very disturbing trend, at least from my academic experience, that considerable time is being used for things that u/s just isn't really good at or for which an already good test exists.

Here's what I use ultrasound for:

Central line placement
Deep brachials
OB (both transab and transvag)
FAST scans - but I have to say, I find this very LOW utility (really)
GB (pretty reliable)
Cardiac (I can get good pictures and can often get a good indication of an estimated EJ%, but to be honest, it's never changed my management ... but certainly would if I saw an effusion. Oh, and I've often used it at the end of a code)

What I DON'T USE ULTRASOUND FOR

AAA. If I suspect AAA, I often suspect dissection. Very low utility.
Renal. This has never changed my management.
Pneumothorax. This, in my opinion, is f*&^ing ridiculous. It's not sensitive enough *in certain circumstances* (i.e. depending on location of the pneumo) and by God, does it really take that long to get a portable chest? Besides, if it's really big, it should be picked up on physical exam.
Ocular. I leave this to the subspecialists, but that's just me. I bet Peksi's good at it, and imagine it might change management if I was equally as good.


What I *might* use ultrasound for more often:

LP on a high BMI person

Just my .02, but I feel like the EM world needs a little bit of push back in the ultra-sound happy environment...

 

[RockfordWF]

With all due respect to Peksi whom I respect very much, I think that ultrasound is actually overused. That's not to say that I don't use it -- I do! See below... but there is a very disturbing trend, at least from my academic experience, that considerable time is being used for things that u/s just isn't really good at or for which an already good test exists.

Here's what I use ultrasound for:

Central line placement
Deep brachials
OB (both transab and transvag)
FAST scans - but I have to say, I find this very LOW utility (really)
GB (pretty reliable)
Cardiac (I can get good pictures and can often get a good indication of an estimated EJ%, but to be honest, it's never changed my management ... but certainly would if I saw an effusion. Oh, and I've often used it at the end of a code)

What I DON'T USE ULTRASOUND FOR

AAA. If I suspect AAA, I often suspect dissection. Very low utility.
Renal. This has never changed my management.
Pneumothorax. This, in my opinion, is f*&^ing ridiculous. It's not sensitive enough *in certain circumstances* (i.e. depending on location of the pneumo) and by God, does it really take that long to get a portable chest? Besides, if it's really big, it should be picked up on physical exam.
Ocular. I leave this to the subspecialists, but that's just me. I bet Peksi's good at it, and imagine it might change management if I was equally as good.


What I *might* use ultrasound for more often:

LP on a high BMI person

Just my .02, but I feel like the EM world needs a little bit of push back in the ultra-sound happy environment...

It really depends on where you work. It there will be a long wait time for a radiologic scan, and your U/S can help guide the diagnosis, it is often much more time effective. If you don't feel you are competent in it, do an extra elective in ultrasound if your residency doesn't already require it.

 

[bulgethetwine]

It really depends on where you work. It there will be a long wait time for a radiologic scan, and your U/S can help guide the diagnosis, it is often much more time effective. If you don't feel you are competent in it, do an extra elective in ultrasound if your residency doesn't already require it.

Fair point. But that's really the gist behind my what-I-use-it-for and what-I-don't list. And not to pull the your-a-medical-student card, but I've got lots of experience *with* ultrasound... except I could get some more training in the ocular issue.

By all means, though, as a student, you are totally right -- do the ultrasound, and decide what utility it has for you.

 

[hurricanemd]

I've seen it used to place quite a few IJ central lines.

 

[Northeaster]

I find the pneumothorax u/s useful. I don't understand the comment "if it is that big it should be picked up on physical exam."

 

[bulgethetwine]

I find the pneumothorax u/s useful. I don't understand the comment "if it is that big it should be picked up on physical exam."

Sorry. I should have clarified.

What I meant was that a pneumo is either so big that it is obvious on clinical exam and thus the chest tube should be put in prior to any study -- chest xray or otherwise -- OR

The pneumo isn't evident on physical exam (i.e. it's not tension) but if you have concern based on mechanism, etc. the chest xray is the study of choice. It's already a fast exam (even if you claim that you can do a complete ultrasound of the chest faster than get a chest xray -- which might be true -- it certainly isn't loads of time faster). In addition, the chest xray has better sensitivity than ultrasound ever would due to the limitations of ultrasound on identifying the pneumo in certain parts of the lung, and, perhaps most importantly, the chest xray gives me some information relevant for my management plan too because it gives me an idea of how large it is, i.e. can I pursue conservative management or do I need a chest tube (if it's > 20% or whatever your arbitrary cut off is).

I think that using an ultrasound for the diagnosis of pneumothorax is the most outlandishly useless supposed indication. Just because you CAN use ultrasound to diagnose a pneumo doesn't mean you should... if there's a better, already cheap and fast alternative.

 

[GeneralVeers]

Every program should at least teach residents FAST, gallbladder, AAA, renal, and obstetric evaluations.

 

[bulgethetwine]

Every program should at least teach residents FAST, gallbladder, AAA, renal, and obstetric evaluations.

Teach it, sure. I'd add vascular access (central lines and deep brachial), too. But FAST scans are largely of academic interest and renal scans rarely changed the management of any of my patients or of my colleagues.

 

[Northeaster]

Sorry. I should have clarified.

What I meant was that a pneumo is either so big that it is obvious on clinical exam and thus the chest tube should be put in prior to any study -- chest xray or otherwise -- OR

The pneumo isn't evident on physical exam (i.e. it's not tension) but if you have concern based on mechanism, etc. the chest xray is the study of choice. It's already a fast exam (even if you claim that you can do a complete ultrasound of the chest faster than get a chest xray -- which might be true -- it certainly isn't loads of time faster). In addition, the chest xray has better sensitivity than ultrasound ever would due to the limitations of ultrasound on identifying the pneumo in certain parts of the lung, and, perhaps most importantly, the chest xray gives me some information relevant for my management plan too because it gives me an idea of how large it is, i.e. can I pursue conservative management or do I need a chest tube (if it's > 20% or whatever your arbitrary cut off is).

I think that using an ultrasound for the diagnosis of pneumothorax is the most outlandishly useless supposed indication. Just because you CAN use ultrasound to diagnose a pneumo doesn't mean you should... if there's a better, already cheap and fast alternative.

I didn't know of studies that showed CXR is more sensitive than U/S to diagnose pneumothorax. I wasn't sure so I did a ten second search and all the studies I looked at point to sensitivities being equal or better with ultrasound (links below).

American Journal of Roentgenology. 188(1):37-41, 2007 Jan. - 285 patients, 8 with pneumothorax, ultrasound 100%, CXR 87.5% - missed one
European Journal of Radiology. 53(3):463-70, 2005 Mar.- 53 patients, again ultrasound 100% sensitive, CXR missed one
American Journal of Respiratory & Critical Care Medicine. 164(3):403-5, 2001 Aug 1, ultrasound 100% sensitive
J Trauma. 50(4):750-2, 2001 Apr. - case report of diagnosis of ptx with cxr that was non-diagnostic

 

[bulgethetwine]

The above studies have several important flaws. Notably that they don't define what is clinically significant vs. insignificant pneumos, nor do they account for operator experience. The study needs to be on a population of physicians who are non-fellowship trained. Take your average EM docs, give them "reasonable" training, then do the study. Also, the studies don't have enough 'n', especially for those pneumos in hard to image areas of the thorax (with ultrasound) which are fairly easy to see on a CXR with adequate penetration.

Plus, you don't need a study to show that CXR has better sensitivity than ultrasound -- it's already the gold standard. Show me the study in EM-trained, ultrasound-experienced (but not fellowship-trained) physicians, with large "N", that shows that u/s has better sensitivity than the current gold standard. Then I'll be excited. Until then, it's all voodoo. Kind of reminds me of days long ago when the chiropractors used to claim new utility for spinal manipulation every month.

That's why ACEP clearly defines the 6 relevant ultrasound indications for EM.

But once again, I encourage you (and any newbies) to continue to try. If it works for you, then more power to you -- I just think the enthusiasm for this technology needs to be tempered. A little.😉

Good luck.

 

[GeneralVeers]

Teach it, sure. I'd add vascular access (central lines and deep brachial), too. But FAST scans are largely of academic interest and renal scans rarely changed the management of any of my patients or of my colleagues.

I forgot the vascular applications.......although REAL residents don't need ultrasound for a central line.

The only ED U/S that truly changes my management is the OB U/S. If I can see baby with heart beat, the workup is done, no formal imaging required.

 

[roja]

Here are the things that I use it for on a very regular basis:

RUQ for cholecystitis/biliary colic
IUP
vascular access
FAST in trauma
Cardiac to look for pericardial effusion
Abdominal pericentesis (somewhat academic but you can use it to find the largest 'pockets' of fluid)
Cellulitis vs abscess

I use it for PTX but at this point it is still fairly academic. You can increase your sensitivity by looking in more than one area for the PTX. You can also have them sit up for a little before you do the ultrasound and look in the apices. For those that are interested, take a look here: http://www.trauma.org/archive/radiology/FASTthoracic.html

You can see both a negative and positive u/s for ptx side by side

 

[Seaglass]

I forgot the vascular applications.......although REAL residents don't need ultrasound for a central line.

The only ED U/S that truly changes my management is the OB U/S. If I can see baby with heart beat, the workup is done, no formal imaging required.

You mean if you can see a baby in the uterus with a heart beat I think.

 

[Jeff698]

You mean if you can see a baby in the uterus with a heart beat I think.

No, Roja is REALLY into U/S. She does a cardiac echo on all of her pediatric patients. 🙂

Take care,
Jeff

 

[roja]

Only the jealous ones mock. 😉


Actually, I prefer to do in-utero fetal echos. Its really very simple. 😀


*snort*

 

[GeneralVeers]

You mean if you can see a baby in the uterus with a heart beat I think.

Naww, any baby will do. In utero, or 10 months old.

 

[DelawareEMIM]

The above studies have several important flaws. Notably that they don't define what is clinically significant vs. insignificant pneumos, nor do they account for operator experience. The study needs to be on a population of physicians who are non-fellowship trained. Take your average EM docs, give them "reasonable" training, then do the study. Also, the studies don't have enough 'n', especially for those pneumos in hard to image areas of the thorax (with ultrasound) which are fairly easy to see on a CXR with adequate penetration.

Plus, you don't need a study to show that CXR has better sensitivity than ultrasound -- it's already the gold standard. Show me the study in EM-trained, ultrasound-experienced (but not fellowship-trained) physicians, with large "N", that shows that u/s has better sensitivity than the current gold standard. Then I'll be excited. Until then, it's all voodoo. Kind of reminds me of days long ago when the chiropractors used to claim new utility for spinal manipulation every month.

That's why ACEP clearly defines the 6 relevant ultrasound indications for EM.

But once again, I encourage you (and any newbies) to continue to try. If it works for you, then more power to you -- I just think the enthusiasm for this technology needs to be tempered. A little.😉

Good luck.

As a small note, the GOLD standard for picking up pneumothoraces is not the CXR, it is a CT of the Chest.