Sunday, March 3, 2013

Better than a stethoscope...

This is the first post by Michelle Schroeder, a senior resident and soon to be Emergency Ultrasound Fellow...

Okay…. So it’s July 1st and you are on your first shift of your all-important Emergency Medicine “audition” rotation.   The first patient you go to see is a 73 yo female is sent in from a nursing home for altered mental status. Unfortunately for you, she’s never been to your ED (so no help from the EMR), and the patient has baseline dementia and is altered beyond that (so no history from the patient); all you have to go on is the nursing home problem list, which includes heart failure and recurrent aspiration pneumonia.  Her blood pressure is 80/40 and her oxygen saturation is 85% on Room Air, now up to 95% on nasal cannula, and she has crackles in both lungs.

She is clearly sick and you are going to go get some help from your resident or attending, but you want to wow them with a plan of action.  So is this an exacerbation of her heart failure that needs diuresis? Or is this pneumonia and sepsis requiring aggressive fluid resuscitation? It’s a big difference and you don’t want to make her worse?

You tell your supervisor there is a sick patient in bed 13 and bring the ultrasound machine to the bedside.  You see that her ventricles are squeezing overtime and her IVC is collapsed - this isn’t heart failure. So you put septic shock #1 on your differential and begin aggressive fluid resuscitation, broad spectrum antibiotics, and you look like a superstar.
Alright, so it sounds like something out of an “ER” re-run, but this sort of diagnostic conundrum happens all the time in the ED.  Ultrasound can be your saving grace, especially for patients who are too sick to go for advanced imaging.
Not a believer yet?  What would you rather do for the hypotensive 20 yo female who syncopized and has lower abdominal pain? Bedside ultrasound showing a positive FAST and off to the OR she goes or trying to keep her stable while you argue with OB and wait for a formal ultrasound.  

How about the 65 yo dialysis patient with hypotension and tachycardia? Quick bedside ECHO shows a huge uremic pericardial effusion, easily a diagnosis that could have been delayed without ultrasound.  

And although the greatest benefit of ultrasound may be in critical care, it’s essential for non-critical care as well. Pregnant woman with ankle fracture? Ultrasound guided peripheral nerve block obviates the need for conscious sedation. Want to map out that carotid artery before you drain a peritonsillar abscess? Endocavitary probe to the rescue!

I could go on (and on), but suffice it to say, ultrasound is an indispensable extension of our physical exam, as necessary as a stethoscope (and way cooler) allowing direct visualization of anatomy at the bedside.

So get involved, start using ultrasound now, be as comfortable with the machine as you are with your cardiac exam; be as facile at scanning as you are at texting on your iPhone.  

It’s no longer the wave of the future, folks, it’s here, it’s now, and it’s awesome.

- Michelle Schroeder

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