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Ilene and Dina discuss using ultrasound to speed up diagnoses in the ED. How DO you identify apendicitis on an ultrasound that looks like a bunch of grayish blobs?
Thank you for bringing increased exposure to the diagnosis of appendicitis by ultrasound. I find that surgeons are increasingly taking these kids to the OR, without the need for CT. I always feel like I've done the patient a service when I can get them diagnosed without a dose of radiation.
However, I'm going to go against the grain here a bit (as EP who's completed an ultrasound fellowship), and make the radical statement (to those in the bedside US community) that this really isn't something an ER doc needs to be doing.
Bedside US initially started in the ED to answer yes/no questions on life threatening diagnoses (see: pericardial effusion/tamponade, intraperitoneal hemorrhage in trauma/ectopic, ruptured AAA). In the academic world, it has slowly creeped toward diagnosing non-life threatening conditions or those better done with US techs or radiography (see: appendicitis, gallbladder, DVT, SBO, pneumoperitoneum, diastolic HF, pneumonia...).
I understand how it is. I've been there. In academics, you have ample opportunity to do and experiment with ultrasound, as you have residents doing all the documenting/ordering/calling. I myself have picked up appendicitis at the bedside (which the surgeon, of course, made me confirm with a radiology study).
But in the community, this isn't and never will be reasonable. It's wholly inefficient. There is no reason for an EP to do a tech's job when a tech is available. Just as there is no reason for us to place IVs, draw blood, push patients, clean rooms. I can't speak for for other docs, but at the hospital I work at, there is always another patient to be seen, and it much more efficient for me to see them than do a bedside appendicitis US.
Don't get the wrong impression: I love bedside US. I use it daily in my practice both for diagnostics and procedures. But we have to choose our battle wisely. Most academic attendings (other than those trained or with a unique interest) and community docs are US naive and have no true interest in learning esoteric applications. I think trying to convince EPs to do this at the bedside is the wrong route, especially when most aren't even doing the core scans.
Thank you so much for this episode! I'm an intern at a hospital that has never had residents before, so listening to these podcasts tends to bring up a lot of new discussions. On my peds rotation, I got called down to look at a 2 yo M with vomiting, some non-descript "colicky" type pain, and (the dreaded) lethargy. Abdominal films we're read as neg. Having listened to this podcast (twice), I felt like it was worth a shot to put a probe on this kid, knowing that since we don't have a radiology department that reads peds ultrasound on a regular basis, I may have to interpret it. After about 5 min of scanning, I got a great target sign, which I then showed to the radiologist, who said that she didn't think this could be intussusception. We decided to ship the kid to a peds hospital anyway where he was diagnosed and treated for intussusception!
Thanks for giving this intern the confidence to make this diagnosis.
I am looking to incorporate MRI into our pediatric appendicitis evaluation. Does anyone have a copy of the 10 minute MRI protocol mentioned in this segment?
Very wise words from Todd C.
I to am a big proponent of point of care ultrasound and have been teaching workshops for years. But I also am concerned about the creep of ED ultrasound in to the relm of imaging that should really be done by formal sonographers. Time critical bedside scans are great for patient care. Lung ultrasound or bedside echo in the crashing patient even better. Ultrasound guided line placement... mandatory.
But bedside ultrasound for appendicitis... probably a wast of time. Lets face it, even the sonographers who have been doing this for years struggle with this application. I doubt you would find a surgeon who would act upon the result of an ED bedside ultrasound. They would very likely be wise to get a formal study.
I love point of care ultrasound... but lets focus on the important & useful applications.
What you do matters.