5 ms·

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

by 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).
slaw3 4y ago
I use a stethoscope to listen for airflow in the lungs and murmurs of the heart. In both cases I would still order more imaging before finalizing a treatment plan unless it is for something emergent. Ultrasound cannot assess airflow well so I don't see it replacing the stethoscope in that regard. My unpopular opinion is that point of care ultrasound is a fad and will eventually be phased out of physician workflows. This is because I haven't seen it actually change someone's medical decision making. More often, people use it as a means to justify why they haven't actually made a treatment decision yet. The only way I could see it have adoption is if actual radiologists (which as of now are the only physicians that went through standardized examination confirming competency in reading ultrasound studies) started doing rounds in the ER and on the wards.
- haldujai 4y ago
  Abstractly I wouldn’t mind that, but it would take massive system level changes to make this feasible. We used to do ICU rounds are my institution but we’re struggling to keep up with the ever increasing volume of cross sectional imaging studies. Our outpatient X-rays are going unreported for > 1 month. Even some routine MRs embarrassingly. Volumes are getting insane, in some places I’ve worked I’ve had to keep up with 80+ CTs and 100 x-rays on an 8 hour evening ER/inpatient shift (never leave at 8 hours).
- Gatsky 4y ago
  Frankly, the average diagnostic performance of the stethoscope doesn’t justify this approach [1]. The real world performance will be even worse. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192898/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192898/

by Gatsky 4y ago

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).

slaw3 4y ago

I use a stethoscope to listen for airflow in the lungs and murmurs of the heart. In both cases I would still order more imaging before finalizing a treatment plan unless it is for something emergent. Ultrasound cannot assess airflow well so I don't see it replacing the stethoscope in that regard. My unpopular opinion is that point of care ultrasound is a fad and will eventually be phased out of physician workflows. This is because I haven't seen it actually change someone's medical decision making. More often, people use it as a means to justify why they haven't actually made a treatment decision yet. The only way I could see it have adoption is if actual radiologists (which as of now are the only physicians that went through standardized examination confirming competency in reading ultrasound studies) started doing rounds in the ER and on the wards.

haldujai 4y ago
Abstractly I wouldn’t mind that, but it would take massive system level changes to make this feasible. We used to do ICU rounds are my institution but we’re struggling to keep up with the ever increasing volume of cross sectional imaging studies. Our outpatient X-rays are going unreported for > 1 month. Even some routine MRs embarrassingly. Volumes are getting insane, in some places I’ve worked I’ve had to keep up with 80+ CTs and 100 x-rays on an 8 hour evening ER/inpatient shift (never leave at 8 hours).
Gatsky 4y ago
Frankly, the average diagnostic performance of the stethoscope doesn’t justify this approach [1]. The real world performance will be even worse. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192898/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192898/