EM Res Podcast Episode 12: US Rants and Ramblings

by Bob Stuntz

In this episode of the podcast, I talk about a few things I have been wanting to discuss related to recent doings in the world of Point of Care Ultrasound.  I talk about the following topics: 

1.  Diagnostic versus resuscitative ultrasound, and where we should really focus our educational efforts.  Our residents should be able to answer the basic yes or no questions of point of care diagnostic ultrasound, but the most important use of ultrasound in the point of care setting and where we should really focus our efforts is in resuscitative ultrasound.  I wish every Emergency Department let their physicians perform biliary ultrasound, but it is not the case.  And lets be honest: most community docs will not be doing US for pediatric skull fractures.  If we push for too much advanced diagnostic ultrasound early on in their training, we risk losing people who may otherwise be interested in the basics.  Lets make experts in resuscitative point of care ultrasound, and if our residents are interested in learning diagnostic applications beyond the basic yes or no questions, then more power to them.  

2. Can you spend too much time doing US?  We hear this a lot.  "That resident could have seen 2 patients in the time it took her to do that echo.  She is ultrasounding too much."  Yes, it should not take 45 minutes to do a basic study.  But remember, there is a learning curve with everything.  Central lines and lacerations take longer for an intern than they do for an experienced upper level, and the same goes for ultrasound.  Give them some time.  Remember, becoming proficient in ultrasound allows you to make earlier diagnoses and dispositions, making you faster and taking better care of your patients.     

3.  Is the US the new stethoscope?  No.  Not every person I see deserves an echo, and  the stethoscope is still one of the few personal connections we have to patients in an age of technology separating us from our patients.  Does it provide a ton of information?  No, it is more of a screening tool at this point (murmurs, wheezing, etc).  But I'm not doing 30 normal echo's a shift.  

4.  Is US just an extension of the physical exam?  No.  US is a diagnostic study.  Learning to become a proficient sonologist is a specific skill that requires training and practice to use safely and effectively.  Calling it physical exam also has implications on billing (I do not go in to this on the podcast, but it is important nonetheless).  US is integral to my evaluation of patients, but it is a separate skill and diagnostic study with respect to your exam.   

5.  FAST exams in stable trauma patients?  Yes.  I want to know about free fluid in the peritoneum, pleural space, pericardium, or pneumothohorax before they crump.  And if you don't use it, you lose it.  Practicing on the non-crashing patient gives you the skill to do it when the wheels are coming off.  

I'd love to hear your feedback, and I recognize some will disagree.  And now, the podcast.