4 ms·

Ultrasound can't penetrate lungs (bags of gas) so probably not, you can see things like effusions, pneumothoraces, and maybe a peripheral consolidation. Regard

Ultrasound can't penetrate lungs (bags of gas) so probably not, you can see things like effusions, pneumothoraces, and maybe a peripheral consolidation. Regardless, the stethoscope has (for better or worse) already been replaced for a while, at least for in-hospital care at larger US/Canadian community/academic settings, by chest x-ray and/or the increasing straight jump to CT pulmonary angiography. The amount of patients with respiratory complaints presenting acutely that leave hospital without radiology department imaging is probably <10% today. Physical exam skills as a whole are dying, abdominal pain is similarly a straight jump to CT or US these days, often before a physical exam is even documented (was it even done?). Even more true for gynaecological concerns (not debating whether or not this more ethical, but it's very rare to see ER physicians perform a vaginal exam these days before ordering ultrasound). In terms of the utility of POCUS, the heterogeneity in training has been a barrier to adoption by clinicians in Canada (I imagine similarly in the US). While POCUS is performed by ER/internal medicine, patients are still being sent to radiology for formal imaging before definitive management takes place, even for more straightforward cases like gallstones and kidney stones. Presently, very few POCUS studies are formally uploaded to a patient's record in my current hospital (largest institution in Canada) although that is increasing and clinician competence at POCUS is slowly rising. The FAST exam in trauma settings is probably one of the only reliable POCUS uses at the moment, and echocardiography.

n8henrie 4y ago
Was mostly with you until comments about FAST. What?! Only validated in shock, I'd say one of the least sensitive and least important tests we do for questionable reasons, since every trauma goes to the donut of truth anyway. I would say biliary, echo, ocular, peritonsillar, procedural (CVC, paracentesis, thora), soft tissue, early obstetric all highly reliable in my practice environment. Then again, our small department is almost all recently trained and we have very limited radiology options so we get a lot of practice.
- haldujai 4y ago
  I’m impressed by your comfort level and curious about the specific indications you’re doing, would appreciate your perspective as I’m in a tertiary care/level 1 centre so POCUS practitioners aren’t as skilled here imo. The training in Canada is also very heterogeneous (some do a 1 year fellowship while others do a weekend course with standardized patients). One of the issues to keep in mind with POCUS is monitoring outcomes / comparing with gold standards (whether that’s formal imaging or operative reports). In radiology we very often get feedback in addition to M&M + multidisciplinary rounds to maintain quality, anecdotally I’ve found this to be more variable in POCUS-heavy practices. 1. Regarding FAST There is a certain amount of variation by centre, but it is definitely not true that every trauma goes to CT first, most do but it’s not infrequent (forgive my usage of this) to go straight to OR for damage control lap and CT after, particularly with penetrating trauma or non-responding hemodynamically unstable patients. At my hospital (level 1 trauma) a positive FAST + instability generally goes straight to OR, you may argue the FAST is noncontributory and these patients should go straight to OR anyway but it’s certainly routinely performed. 2. Procedural - completely agree, should be highly reliable for all physicians. It’s arguably malpractice to do procedures blind these days. 3. Early OB - are you performing TVUS? This is uncommon, and if you are that’s phenomenal. Are you just doing r/o ectopic or formal dating US? CRL and MSD can be challenging to measure accurately, but if you’re doing a lot and getting followup from rads/OB it’s certainly possible to be reliable at this. 4. Soft tissue - as in abscess or MSK? MSK ultrasound is very challenging and I would be enormously impressed if you are doing tendon tears reliably (other than full thickness) as many radiologists are uncomfortable with these today. Do you have MR or formal radiology follow up reads to assess your sens/spec? 5. Biliary - Assuming you mean cholecystitis and gross bil dil, glad to hear this is becoming comfortable for POCUS practitioners. My centre has a formal POCUS fellowship but the surgeons don’t rely on their reads, they will see in consult based on POCUS but always demand a radiology examination prior to operating. I hope that this will change in the near future for chole. I’d be hesitant as a patient getting scanned for focal bil dil (aka ?cholangio) or PSC by POCUS, but I doubt that’s a common indication for you. 6. Echo - Assuming you mean for ER indications? Are you still sending for formal echos or comfortable ruling out all valvular disease? Our cardiology fellows who do bedside echo in CCU still seem to get formal reads. 7. Peritonsillar - I can’t even remember the last time I’ve reported one of these, we have dedicated ER CT scanners 24/7 so they always go straight to CT. Is this an accurate test? Overall happy to hear POCUS is more reliable in some places, I dream of the day I can stop reporting acute care US.
- rscho 4y ago
  > every trauma goes to the donut of truth anyway Yes, and that's also not supposed to work like that. ATLS says FAST+ -> OR without donut. As an anesthesiologist, I can tell you it's very frustrating to lose patients because you spent an hour and a half in the ER because the trauma surgeon doesn't have the balls to open the patient without a CT. Lost a 20 yo, probably in good part due to that.
  - n8henrie 4y ago
    > ATLS says FAST+ -> OR without donut > you spent an hour and a half in the ER because the trauma surgeon doesn't have the balls to open the patient without a CT. Lost a 20 yo, probably in good part due to that. Rough case, sorry to hear about that. I imagine the logic of blindly following ATLS probably depends on circumstances; where I trained the CT scanners were basically in the trauma bay, whereas the OR might as well have been a mile away. I imagine estimating the cumulative harms of opening a patient for a false-positive FAST (ascites, physiologic pelvic fluid in a reproductive age female) every once in a while vs the harm of spending an extra 5-10 minutes for CT (when it takes longer than that to get to the OR) is some complex math. Of course the farther away the OR is, it would taken even longer to get CT and then get there...
n8henrie 4y ago
Also, I'd say respiratory complaint with acute presentation (meaning to ED) less than 1% don't get imaging. Maybe 10% if you include urgent care or clinics.
- haldujai 4y ago
  Haha I was being a bit conservative, but my centre has UC in the tertiary care hospitals and I don’t see many asthma indications so I assume that population is not getting imaged routinely.
maxerickson 4y ago
Is that maybe partly because the billing on CTs is completely out of step with the apparent cost? To the extent that there are regulatory hurdles to buying and operating a CT suite (and there are such hurdles in many states), there should be regulation that ensures that the billing is reasonable. Instead, you pay like a whole number percentage of the cost of running the damn thing for a year.
- haldujai 4y ago
  I can’t speak to US billing practices on the facility fee side, in general though Canadian fee codes for the professional fee/reporting component are higher than the US. The tendency to proceed to CT early is largely because: 1. A lot of ED centres are financially rewarded if they keep time to disposition within target (either directly in Canada or for throughput in US). If the CT identifies a cause for admission and a service is consulted that patient is officially “discharged” from ED even if they are physically still there waiting for the specialty consultation / admission. 2. Generally unjustified malpractice fears in both US/CAN, the theoretical risk of cancer down the line is impossible to tie to an individual imaging study, but there is a lot of fear for missed diagnosis. Despite risk scoring systems for things like pulmonary embolism I see a lot of patients with pneumonia on X-ray (I.e. an explainable cause for chest pain) getting these studies “just to be safe”. Overalll positivity rates on these studies is 1-2%, despite how much this imaging has become utilized (something like 10-20x increase over the last 10 years) we have not seen corresponding reductions in mortality suggesting overimaging, but research is ongoing. As a radiologist I try my best to reject unnecessary scans, but it’s difficult to do so when a clinician is telling you “I’m scared about deadly condition x”. When they’re younger I can apply the radiation risk consideration and suggest shared decision making, in some outlandish requests (I was asked to CT an 18 year old male with a fever, negative blood work and zero risk factors for PE, so likely viral illness or asthma) I outright refuse but those cases are few unfortunately as most presentations are elderly patients.
  - maxerickson 4y ago
    The radiologist interpretation fee is almost always like $20 straight up, that part of it seems to be working just fine.
cperciva 4y ago
Regardless, the stethoscope has (for better or worse) already been replaced for a while, at least for in-hospital care at larger US/Canadian community/academic settings, by chest x-ray and/or the increasing straight jump to CT pulmonary angiography. In hospitals, sure, but GPs don't have access to those. At least in my experience "is this a bad cold or is it bronchitis" gets answered with a stethoscope.
ayewo 4y ago
For other similarly confused readers as I was: - POCUS = Point Of Care Ultrasound 1: Thanks to https://news.ycombinator.com/item?id=34464971 https://news.ycombinator.com/item?id=34464971

n8henrie 4y ago

Was mostly with you until comments about FAST. What?! Only validated in shock, I'd say one of the least sensitive and least important tests we do for questionable reasons, since every trauma goes to the donut of truth anyway. I would say biliary, echo, ocular, peritonsillar, procedural (CVC, paracentesis, thora), soft tissue, early obstetric all highly reliable in my practice environment. Then again, our small department is almost all recently trained and we have very limited radiology options so we get a lot of practice.

haldujai 4y ago
I’m impressed by your comfort level and curious about the specific indications you’re doing, would appreciate your perspective as I’m in a tertiary care/level 1 centre so POCUS practitioners aren’t as skilled here imo. The training in Canada is also very heterogeneous (some do a 1 year fellowship while others do a weekend course with standardized patients). One of the issues to keep in mind with POCUS is monitoring outcomes / comparing with gold standards (whether that’s formal imaging or operative reports). In radiology we very often get feedback in addition to M&M + multidisciplinary rounds to maintain quality, anecdotally I’ve found this to be more variable in POCUS-heavy practices. 1. Regarding FAST There is a certain amount of variation by centre, but it is definitely not true that every trauma goes to CT first, most do but it’s not infrequent (forgive my usage of this) to go straight to OR for damage control lap and CT after, particularly with penetrating trauma or non-responding hemodynamically unstable patients. At my hospital (level 1 trauma) a positive FAST + instability generally goes straight to OR, you may argue the FAST is noncontributory and these patients should go straight to OR anyway but it’s certainly routinely performed. 2. Procedural - completely agree, should be highly reliable for all physicians. It’s arguably malpractice to do procedures blind these days. 3. Early OB - are you performing TVUS? This is uncommon, and if you are that’s phenomenal. Are you just doing r/o ectopic or formal dating US? CRL and MSD can be challenging to measure accurately, but if you’re doing a lot and getting followup from rads/OB it’s certainly possible to be reliable at this. 4. Soft tissue - as in abscess or MSK? MSK ultrasound is very challenging and I would be enormously impressed if you are doing tendon tears reliably (other than full thickness) as many radiologists are uncomfortable with these today. Do you have MR or formal radiology follow up reads to assess your sens/spec? 5. Biliary - Assuming you mean cholecystitis and gross bil dil, glad to hear this is becoming comfortable for POCUS practitioners. My centre has a formal POCUS fellowship but the surgeons don’t rely on their reads, they will see in consult based on POCUS but always demand a radiology examination prior to operating. I hope that this will change in the near future for chole. I’d be hesitant as a patient getting scanned for focal bil dil (aka ?cholangio) or PSC by POCUS, but I doubt that’s a common indication for you. 6. Echo - Assuming you mean for ER indications? Are you still sending for formal echos or comfortable ruling out all valvular disease? Our cardiology fellows who do bedside echo in CCU still seem to get formal reads. 7. Peritonsillar - I can’t even remember the last time I’ve reported one of these, we have dedicated ER CT scanners 24/7 so they always go straight to CT. Is this an accurate test? Overall happy to hear POCUS is more reliable in some places, I dream of the day I can stop reporting acute care US.
rscho 4y ago
> every trauma goes to the donut of truth anyway Yes, and that's also not supposed to work like that. ATLS says FAST+ -> OR without donut. As an anesthesiologist, I can tell you it's very frustrating to lose patients because you spent an hour and a half in the ER because the trauma surgeon doesn't have the balls to open the patient without a CT. Lost a 20 yo, probably in good part due to that.
- n8henrie 4y ago
  > ATLS says FAST+ -> OR without donut > you spent an hour and a half in the ER because the trauma surgeon doesn't have the balls to open the patient without a CT. Lost a 20 yo, probably in good part due to that. Rough case, sorry to hear about that. I imagine the logic of blindly following ATLS probably depends on circumstances; where I trained the CT scanners were basically in the trauma bay, whereas the OR might as well have been a mile away. I imagine estimating the cumulative harms of opening a patient for a false-positive FAST (ascites, physiologic pelvic fluid in a reproductive age female) every once in a while vs the harm of spending an extra 5-10 minutes for CT (when it takes longer than that to get to the OR) is some complex math. Of course the farther away the OR is, it would taken even longer to get CT and then get there...

n8henrie 4y ago

Also, I'd say respiratory complaint with acute presentation (meaning to ED) less than 1% don't get imaging. Maybe 10% if you include urgent care or clinics.

haldujai 4y ago
Haha I was being a bit conservative, but my centre has UC in the tertiary care hospitals and I don’t see many asthma indications so I assume that population is not getting imaged routinely.

maxerickson 4y ago

Is that maybe partly because the billing on CTs is completely out of step with the apparent cost? To the extent that there are regulatory hurdles to buying and operating a CT suite (and there are such hurdles in many states), there should be regulation that ensures that the billing is reasonable. Instead, you pay like a whole number percentage of the cost of running the damn thing for a year.

haldujai 4y ago
I can’t speak to US billing practices on the facility fee side, in general though Canadian fee codes for the professional fee/reporting component are higher than the US. The tendency to proceed to CT early is largely because: 1. A lot of ED centres are financially rewarded if they keep time to disposition within target (either directly in Canada or for throughput in US). If the CT identifies a cause for admission and a service is consulted that patient is officially “discharged” from ED even if they are physically still there waiting for the specialty consultation / admission. 2. Generally unjustified malpractice fears in both US/CAN, the theoretical risk of cancer down the line is impossible to tie to an individual imaging study, but there is a lot of fear for missed diagnosis. Despite risk scoring systems for things like pulmonary embolism I see a lot of patients with pneumonia on X-ray (I.e. an explainable cause for chest pain) getting these studies “just to be safe”. Overalll positivity rates on these studies is 1-2%, despite how much this imaging has become utilized (something like 10-20x increase over the last 10 years) we have not seen corresponding reductions in mortality suggesting overimaging, but research is ongoing. As a radiologist I try my best to reject unnecessary scans, but it’s difficult to do so when a clinician is telling you “I’m scared about deadly condition x”. When they’re younger I can apply the radiation risk consideration and suggest shared decision making, in some outlandish requests (I was asked to CT an 18 year old male with a fever, negative blood work and zero risk factors for PE, so likely viral illness or asthma) I outright refuse but those cases are few unfortunately as most presentations are elderly patients.
- maxerickson 4y ago
  The radiologist interpretation fee is almost always like $20 straight up, that part of it seems to be working just fine.

cperciva 4y ago

Regardless, the stethoscope has (for better or worse) already been replaced for a while, at least for in-hospital care at larger US/Canadian community/academic settings, by chest x-ray and/or the increasing straight jump to CT pulmonary angiography. In hospitals, sure, but GPs don't have access to those. At least in my experience "is this a bad cold or is it bronchitis" gets answered with a stethoscope.

ayewo 4y ago

For other similarly confused readers as I was: - POCUS = Point Of Care Ultrasound 1: Thanks to https://news.ycombinator.com/item?id=34464971 https://news.ycombinator.com/item?id=34464971