4 ms·

TLDR: Yes. An inordinate amount of time is spent teaching auscultation (using a stethoscope) to doctors. The diagnostic performance isn’t that great even under

by Gatsky 4y ago

TLDR: Yes. An inordinate amount of time is spent teaching auscultation (using a stethoscope) to doctors. The diagnostic performance isn’t that great even under ideal conditions. Having bedside ultrasound would really improve things for patients, and save money on unnecessary tests and treatments.

haldujai 4y ago
Thats a very generous view on the current state of POCUS. I don't believe this has been studied yet but the % of patients who undergo POCUS in the ED (which is billed for) and leave without formal imaging in the radiology department (also billed for) is probably in the single digits. Irrespective of their findings, clinicians are not yet confident enough to discharge their patient on the basis of their negative POCUS nor are surgeons confident enough in the clinician skills to operate on positive POCUS findings (except FAST). Hopefully this will slowly improve over time, particularly if AI can play a role in procuring adequate images, but ultrasound is a hard skill to master (sonographers do this day in and day out, a lot more skillful than myself as a radiologist let alone a clinician with an underpowered POCUS). Conversely, there is a non-trivial amount of unnecessary imaging generated as a result of POCUS findings (perhaps most significantly for aortic dissection which is a high dose CT scan). Out of ~100 CT studies I've reported that come with the history 'dissection/intimal flap on POCUS' 0 have been positive, and had the clinician gone purely on the clinical picture + labs they would have probably not ordered the CT in most of these cases. Also ultrasound can't penetrate lungs.
- unwind 4y ago
  Here, POCUS = point of care ultrasound.
  - philiplu 4y ago
    Thanks for that. So what does ED refer to? Emergency Department? Synonym for ER?
    - haldujai 4y ago
      Sorry I should have explained to the acronyms I was using, bad habit. Yeah exactly. Apologies I use them inconsistently and interchangeably, Epic’s electronic medical record system changed it to ED for some reason.
- Gatsky 4y ago
  All good points, but you would surely agree that despite that it is better than the stethoscope? Particularly in ambulatory care rather than ED, where there isn’t a CT scanner down the corridor. ED docs are forever trying to diagnose aortic dissection for some reason… I thought POCUS was useful for pleural effusion and consolidation, but you’d know better than I do.
  - haldujai 4y ago
    If you need imaging for pneumonia / consolidation it’s definitely better to X-ray (very accessible), you may get lucky and see a peripheral pneumonia if it’s dense enough but the negative predictive value isn’t there as you have very little depth of penetration. Pulmonary edema is presently still X-ray preferred as it’s easier to compare cardiomegaly and pulmonary vasculature with priors, as opposed to US images which are operator dependent and likely not saved. There is increasing research on cardiac/caval measurements as surrogates for CHF but the standard measurements haven’t been fully developed to be clinically ready as the sole investigation, I expect one day in the not too distant future this will change. Pleural effusions go either way, as an initial investigation you’ll usually still want the X-ray to evaluate for parenchymal disease and CHF so why do two tests. With that said we drain effusions under US guidance so if that’s your only clinical question for sure POCUS is great, I would say that’s an uncommon scenario though unless the patient is known for chronic/malignant effusions and you may only be assessing for reaccumulation and planning drainage. Pneumothoraces on US still need X-ray confirmation and to accurately assess size as the sliding sign isn’t that reliable yet. Given how broad most differentials are for dyspnea it’s hard to find a patient where US (either in radiology or POCUS) is satisfactory as a single investigation when concerned about lung/pleural disease. It’s awesome for cardiac stuff like wall motion abnormalities and gross dilatation/dysfunction in the acute setting, but you’ll still want a formal echo for accurate size measurements. At my institution we still have echocardiographers on backup call for the cardiology fellows, although they’re being called in less and less. Abdominal imaging is way more of a crapshoot. Acutely presenting patients are often unwell, have large body habitus, and acquiring adequate images is hard even for us. If you’re in a place without emergent/urgent US access it’s certainly better than nothing. You would certainly never diagnose malignancy or workup a mass based on POCUS, this can be really hard even for radiologists + sonographers. Personally, I hope clinician skills reach the point where I don’t do (or do significantly less) acute US studies so this isn’t gatekeeping at all. I would gladly give up the work. A lot of the issues stem from how POCUS was implemented, currently it is very unstandardized and you can get certified after a weekend course in some places and are being taught by other clinicians. It would be better if they rotated with our sonographers to learn the skills in my opinion. Edit: I don’t disagree re: stethoscope but it’s already been replaced by X-ray in any facility with one (which is most places), chest imaging is a bad example of where POCUS will be useful for the above reasons. Increased skills at biliary, renal and testicular pathology as well as echo are way better examples and instances where stethoscopes are already outdated. When I was an intern 5 years ago we had already moved past auscultating murmurs, which are generally not acute, and you would still get a formal outpatient echo for accurate measurements (these take a while and you need to be really good at measuring, slight obliquely can significantly alter values).

by Gatsky 4y ago

haldujai 4y ago

Thats a very generous view on the current state of POCUS. I don't believe this has been studied yet but the % of patients who undergo POCUS in the ED (which is billed for) and leave without formal imaging in the radiology department (also billed for) is probably in the single digits. Irrespective of their findings, clinicians are not yet confident enough to discharge their patient on the basis of their negative POCUS nor are surgeons confident enough in the clinician skills to operate on positive POCUS findings (except FAST). Hopefully this will slowly improve over time, particularly if AI can play a role in procuring adequate images, but ultrasound is a hard skill to master (sonographers do this day in and day out, a lot more skillful than myself as a radiologist let alone a clinician with an underpowered POCUS). Conversely, there is a non-trivial amount of unnecessary imaging generated as a result of POCUS findings (perhaps most significantly for aortic dissection which is a high dose CT scan). Out of ~100 CT studies I've reported that come with the history 'dissection/intimal flap on POCUS' 0 have been positive, and had the clinician gone purely on the clinical picture + labs they would have probably not ordered the CT in most of these cases. Also ultrasound can't penetrate lungs.

unwind 4y ago
Here, POCUS = point of care ultrasound.
- philiplu 4y ago
  Thanks for that. So what does ED refer to? Emergency Department? Synonym for ER?
  - haldujai 4y ago
    Sorry I should have explained to the acronyms I was using, bad habit. Yeah exactly. Apologies I use them inconsistently and interchangeably, Epic’s electronic medical record system changed it to ED for some reason.
Gatsky 4y ago
All good points, but you would surely agree that despite that it is better than the stethoscope? Particularly in ambulatory care rather than ED, where there isn’t a CT scanner down the corridor. ED docs are forever trying to diagnose aortic dissection for some reason… I thought POCUS was useful for pleural effusion and consolidation, but you’d know better than I do.
- haldujai 4y ago
  If you need imaging for pneumonia / consolidation it’s definitely better to X-ray (very accessible), you may get lucky and see a peripheral pneumonia if it’s dense enough but the negative predictive value isn’t there as you have very little depth of penetration. Pulmonary edema is presently still X-ray preferred as it’s easier to compare cardiomegaly and pulmonary vasculature with priors, as opposed to US images which are operator dependent and likely not saved. There is increasing research on cardiac/caval measurements as surrogates for CHF but the standard measurements haven’t been fully developed to be clinically ready as the sole investigation, I expect one day in the not too distant future this will change. Pleural effusions go either way, as an initial investigation you’ll usually still want the X-ray to evaluate for parenchymal disease and CHF so why do two tests. With that said we drain effusions under US guidance so if that’s your only clinical question for sure POCUS is great, I would say that’s an uncommon scenario though unless the patient is known for chronic/malignant effusions and you may only be assessing for reaccumulation and planning drainage. Pneumothoraces on US still need X-ray confirmation and to accurately assess size as the sliding sign isn’t that reliable yet. Given how broad most differentials are for dyspnea it’s hard to find a patient where US (either in radiology or POCUS) is satisfactory as a single investigation when concerned about lung/pleural disease. It’s awesome for cardiac stuff like wall motion abnormalities and gross dilatation/dysfunction in the acute setting, but you’ll still want a formal echo for accurate size measurements. At my institution we still have echocardiographers on backup call for the cardiology fellows, although they’re being called in less and less. Abdominal imaging is way more of a crapshoot. Acutely presenting patients are often unwell, have large body habitus, and acquiring adequate images is hard even for us. If you’re in a place without emergent/urgent US access it’s certainly better than nothing. You would certainly never diagnose malignancy or workup a mass based on POCUS, this can be really hard even for radiologists + sonographers. Personally, I hope clinician skills reach the point where I don’t do (or do significantly less) acute US studies so this isn’t gatekeeping at all. I would gladly give up the work. A lot of the issues stem from how POCUS was implemented, currently it is very unstandardized and you can get certified after a weekend course in some places and are being taught by other clinicians. It would be better if they rotated with our sonographers to learn the skills in my opinion. Edit: I don’t disagree re: stethoscope but it’s already been replaced by X-ray in any facility with one (which is most places), chest imaging is a bad example of where POCUS will be useful for the above reasons. Increased skills at biliary, renal and testicular pathology as well as echo are way better examples and instances where stethoscopes are already outdated. When I was an intern 5 years ago we had already moved past auscultating murmurs, which are generally not acute, and you would still get a formal outpatient echo for accurate measurements (these take a while and you need to be really good at measuring, slight obliquely can significantly alter values).