I decided to post about a case that did not happen while I was on shift, or while any of my residents or students were on shift, but while I was sitting at the bedside of my family member who was in their regional emergency department…..ok, I’ll start out by admitting that this post is biased – to the extent that I want the best for my family and expect that all available resources be utilized for them, as well as being biased toward the use of the bedside technical God (aka ultrasound machine, if that wasn’t obvious) that answers the questions I need answered quickly – when it counts. I recently commented on a post from the LITFL “Ultrasound Training Rant” about this case, and it deserves mention again. I couldnt agree more with the point that the physician has to be able to “inspect, palpate, percuss, auscultate, ultrasound and cogitate….” — and I wish they would do them all correctly.
I was at the ED with my elderly family member who has a history of hypertension, high cholesterol, and neuromuscular disease who was nauseated, feeling weak and had epigastric pain, with a heart rate in 110s and SBP in 110s. he also had some loose bowel movements, but no fevers, and was coughing more, nonproductive, feeling near syncopal just prior to arrival – which is when he thought “This isnt good, I think I need someone to check me inside and out.” Interesting choice of words actually – “inside and out” – that means so much more to me now and defines an expectation from the patient. If the patient (especially an elderly male with that history) doesn’t feel good, we need to check them inside and out. The “out” is what we all trained to do well and correctly. The “inside” was always difficult given the physical exam limitations and we can always defer to a CT, but what if they were unstable? What if you needed to know quickly? What if there isnt a CT scanner?
Well, let’s start from the beginning of this case: the nurse had 5 IV attempts (yup, F-I-V-E….and this is after he said to them “Ill need to warn you, people always have a hard time getting an IV in me” – which to me is clue for “get the ultrasound machine”), until the miraculous 6th came through (so no ultrasund to do an USG Peripheral IV). Then, before fluids were ordered, they did orthostatics which showed an INCREASE in his HR AND BP when standing to120s (let’s not discuss the sensitivity of orthostatics at this time, as that would take me a much longer time). So, they wanted to hold off on the fluids, but I let them know of my disagreement (yup, I was THAT “relative who was a doctor”) and they gave him fluids (no ultrasound to see the IVC). They did an abdominal exam ….with him sitting up….and when I say “abdominal exam” I mean pressed on his abdomen kinda sorta while asking him questions. I couldn’t help myself anymore, I finally asked if they had a bedside ultrasound machine to quickly check to make sure he didnt have an abdominal aneurysm or decline in contractility of his heart, and I suppose I already knew the answer: “No….but we can wait for the H/H to come back in about an hour and see if his chest XR shows anything.” His H/H was stable, thankfully, and his Creatinine was a bit elevated. He got 2 Liters of normal saline bolus, felt better and was discharged….HR 94. Look, I get it, they weren’t impressed, their abdominal exam did not impress them either, and I didn’t want to push and be “THAT relative who was a doctor” anymore. Plus, I wanted to also believe that all he had was dehydration.
When we got back to his home, I took out the hand-held scanner I had in my bag and took a look at his “inside” myself – - aorta, negative – phew! – - his heart, a moderate sized pericardial effusion. I called his doctor and he got admitted to cardiology…. from home (yup, still that “relative who is a doctor”). He was in the ED for 5 hours and only an ultrasound could have quickened his stay, potentially decreased his medical cost, definitely increased his (and my) satisfaction, and made his diagnosis and ultimate disposition decision. And, his “inside and out” would have been evaluated. Now, I cannot blame the treating team, the doctors did only what they knew how to do, and they were all very nice — Ill give them that, but medicine is changing, it always will. We need to change with it.
This is only one case, but there are plenty of others that I could list where bedside ultrasound has expedited the management and diagnosis, not to mention save a life. Iv’e actually posted about them on this site – whether it’s the altered elderly patient in shock who was diagnosed with a AAA in 5 minutes and went to the OR, or the young female patient who had abdominal pain and found to have a positive FAST scan from a ruptured ectopic pregnancy who went straight to the OR before declining. If I were to list the ultrasound guided procedures that should be done, I’d add about 10 more lines here…. so just take my word for it. There is a good (no wait, GREAT) reason for it’s use.
Medicine is changing, our resources are increasing, our patient volumes are increasing, our hospitals are filling up, and their expectations are increasing. Ultrasound training should be incorporated into the medical schools, it should be in all residency training programs (as it’s not just applicable to emergency and critical care anymore) For those who are out of training, you should attend the workshops, practice it’s use, learn about it’s strengths and it’s limitations, and compare your bedside results to any confirmatory test until you are savvy to make that decision on your own. Some applications don’t require too many of those practice runs, but some require even more than what ACEP guidelines are currently.
As much as I cannot imagine my life without my smartphone, I cannot imagine my work without my ultrasound. I can know what a patient has, or (even better sometimes) what a patient does not have in 5 minutes. Physical exam has its limitations too, and there are few doctors I see actually do a physical exam completely and correctly anymore, let’s not forget that…..
The more we have at our hands…. that could give more information…. about their “inside and out”, let’s use it.