3 ms·

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 questionab

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.
- n8henrie 4y ago
  Thanks for your kind words. As a preface for the below (so I don't have to repeat it), I'm privileged to be a salaried US federal employee protected by FTCA in a rural and baseline non-litigious community. We get to provide care with "what we think is right" being the 1st, 2nd, and 3rd concerns, with billing, medical-legal risk, and productivity having minimal influence. It's fantastic. We have no overnight or on-the-weekend US availability, no echo whatsoever, and for the last several years we can rarely transfer a patient anywhere less than 100 miles away. My POCUS practice and scope reflects the above, is strictly limited to focused questions and clinical decision making in the ED. For example with OB I'm not terribly interested at becoming an expert on e.g. CRL, but would love to get better at evaluations at rule-in torsion. > One of the issues to keep in mind with POCUS is monitoring outcomes / comparing with gold standards Yes, establishing a QA process has been challenging. > There is a certain amount of variation by centre, but it is definitely not true that every trauma goes to CT first I'm sure it's very institution dependent. I trained at L1TS where the OR was much, much farther away than CT. CT was basically in the trauma bay, multiple scanners so almost always 1 open, so I don't recall a single case going straight to OR. CT usually only took a few minutes longer than an intern's FAST honestly. I'm sure there were a few that went without CT, but I don't remember any. In my current L4TS our surgeons won't take trauma, so it's usually a multi-hour process just to get the patient accepted for transfer somewhere, during which they also always get scanned (or die if they're never stable enough). > 3. Early OB - are you performing TVUS? Yes, frequently. My wife is the chair of our Ob/Gyn department, so I have a bit of a leg up. Yes mostly eval for IUP / rule-in ectopic. Tremendous number of patients presenting late for prenatal care so will occasionally estimate a CRL / BPD / femur length, but only as a ballpark when communicating with colleagues -- rarely much time pressure on these so can be formalized as outpatient. > Soft tissue - as in abscess or MSK? Not MSK. Abscess, cellulitis (high burden of NSTI but don't want to scan them all). MSK mostly limited to joint effusions / shoulder dislocations in the obese. Occasionally for fracture reductions -- we have no C-ARM). > 5. Biliary - Assuming you mean cholecystitis and gross bil dil Yes, this. Lots of these, very high burden of alcoholism and gallbladder disease here (as many as 5 acute choles in 1 morning between 8 AM and noon, all confirmed in the OR), so lots of abnormal LFTs, belly pain, and vomiting. POCUS critical here! Many of our surgeons hesitant, but the sensitivity seems to be pretty good and helpful for making overnight dispos in people with clearly normal studies (esp in the context of labs, vitals, exam -- which admittedly bias our interpretation of the study). > 6. Echo - Assuming you mean for ER indications? Yes -- mostly wall motion, severe acute CHF, gross RV dilation, large effusion, gross valvular incompetence. Can get formal studies later for the details, this is mostly for "does this seem to be a likely cause of this patient's critical illness?" > 7. Peritonsillar Tons of PTAs here. Yes, useful -- both for Dx as well as "where to aim the needle / scalpel." I forgot to add DVT -- we do lots of those.
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...

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.

n8henrie 4y ago
Thanks for your kind words. As a preface for the below (so I don't have to repeat it), I'm privileged to be a salaried US federal employee protected by FTCA in a rural and baseline non-litigious community. We get to provide care with "what we think is right" being the 1st, 2nd, and 3rd concerns, with billing, medical-legal risk, and productivity having minimal influence. It's fantastic. We have no overnight or on-the-weekend US availability, no echo whatsoever, and for the last several years we can rarely transfer a patient anywhere less than 100 miles away. My POCUS practice and scope reflects the above, is strictly limited to focused questions and clinical decision making in the ED. For example with OB I'm not terribly interested at becoming an expert on e.g. CRL, but would love to get better at evaluations at rule-in torsion. > One of the issues to keep in mind with POCUS is monitoring outcomes / comparing with gold standards Yes, establishing a QA process has been challenging. > There is a certain amount of variation by centre, but it is definitely not true that every trauma goes to CT first I'm sure it's very institution dependent. I trained at L1TS where the OR was much, much farther away than CT. CT was basically in the trauma bay, multiple scanners so almost always 1 open, so I don't recall a single case going straight to OR. CT usually only took a few minutes longer than an intern's FAST honestly. I'm sure there were a few that went without CT, but I don't remember any. In my current L4TS our surgeons won't take trauma, so it's usually a multi-hour process just to get the patient accepted for transfer somewhere, during which they also always get scanned (or die if they're never stable enough). > 3. Early OB - are you performing TVUS? Yes, frequently. My wife is the chair of our Ob/Gyn department, so I have a bit of a leg up. Yes mostly eval for IUP / rule-in ectopic. Tremendous number of patients presenting late for prenatal care so will occasionally estimate a CRL / BPD / femur length, but only as a ballpark when communicating with colleagues -- rarely much time pressure on these so can be formalized as outpatient. > Soft tissue - as in abscess or MSK? Not MSK. Abscess, cellulitis (high burden of NSTI but don't want to scan them all). MSK mostly limited to joint effusions / shoulder dislocations in the obese. Occasionally for fracture reductions -- we have no C-ARM). > 5. Biliary - Assuming you mean cholecystitis and gross bil dil Yes, this. Lots of these, very high burden of alcoholism and gallbladder disease here (as many as 5 acute choles in 1 morning between 8 AM and noon, all confirmed in the OR), so lots of abnormal LFTs, belly pain, and vomiting. POCUS critical here! Many of our surgeons hesitant, but the sensitivity seems to be pretty good and helpful for making overnight dispos in people with clearly normal studies (esp in the context of labs, vitals, exam -- which admittedly bias our interpretation of the study). > 6. Echo - Assuming you mean for ER indications? Yes -- mostly wall motion, severe acute CHF, gross RV dilation, large effusion, gross valvular incompetence. Can get formal studies later for the details, this is mostly for "does this seem to be a likely cause of this patient's critical illness?" > 7. Peritonsillar Tons of PTAs here. Yes, useful -- both for Dx as well as "where to aim the needle / scalpel." I forgot to add DVT -- we do lots of those.

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...