RESIDENT PORTFOLIOS

Emergency Department Ultrasound:A Resident’s Perspective

I remember the day I first became fascinated withultrasound as vividly as I remember the day I fell inlove with emergency medicine. It was early in my

fourth year of medical school and was 11:00 PM at night. Iwill never forget the look on the young mother’s facewhen she saw the heartbeat on the screen and knew herbleeding was not another miscarriage but a threatenedabortion. Sure, my diagnosis did not change her out-come, but I see our job as one of relieving suffering, andthe anguish I prevented her from experiencing whilewaiting for a consultative ultrasound in the morning wasvery important to the both of us. Having the evidence tosupport my decision gave me the ability to immediatelysend her home to take care of her other children.1

Later, my initial fascination with ultrasound grew intoa deep respect and admiration as I diagnosed things suchas cardiac tamponade and ascending aortic dissection ina patient who presented only with syncope and a suddendrop in blood pressure. It gives me great pride to be ableto tell the grizzled trauma surgeon that this traumapatient’s hypotension is in fact not due to a pneumotho-rax or tamponade, but the FAST is positive and thepatient should go to the operating room. And yes, I haveevidence to back up our decision to make these criticaldiagnoses with ultrasound alone.2,3 It also gives me greatsatisfaction to know that I was around 34% more success-ful in placing central lines in residency due to my routineuse of ultrasound for the procedure.4 I have seen some ofmy attendings place these lines blindly, and while I havetremendous respect for their experience and amazingclinical abilities, I am very thankful for ultrasound and thedirect visualization it provides. Having reviewed studiesdescribing the significant percentage of cases where thefemoral artery is positioned directly over the vein, I knowthat as a resident I do not have the experience or skill toblindly determine when this is occuring.5

Perhaps where my respect and admiration for ultra-sound truly blossomed into love, though, was when I firststarted moonlighting in community and rural emergencydepartments (EDs) as a senior resident. Having the skilland confidence to take care of patients who needed ultra-sounds at night when no ultrasound techs, radiologists,or consultants were available is what I felt really sepa-rated me from clinicians who did not have this ability.Having this skill certainly did not take away from myability to make decisions otherwise. It simply gave me

another tool that has been proven to affect patient out-comes.6 I can confidently call the surgeon when my ultra-sound reveals acute cholecystitis or not call when I ruleout abdominal aortic aneurism and find that my patientreally does just have renal colic. Another benefit in thecommunity is added efficiency. While I am no expert inED operations, the ability to call the surgeon about cho-lecystitis or abdominal aortic aneurism without wait-ing hours for a consultative study, or sending the patientwith intrauterine pregnancy home instead of stayingovernight for a comprehensive exam, seems more effi-cient and beneficial in terms of throughput.7

Recently, I was shocked to read an editorial that notedthat only 19% of community EDs had ultrasound capabil-ity.8 I quickly realized, however, that these data camefrom a survey done 5 years ago, were outdated, and assuch, were likely a gross underestimation.9 But even if itwas close to the truth it left me very concerned. Theseare the exact settings in which ultrasound is so importantand potentially life-saving. These amazing communityED physicians are precisely the people who need theresources and ability to perform these examinations, dueto their lack of backup and limited imaging resources. Asshocked as I was, though, I am confident this is changingrapidly. I enjoy hearing the stories from my attendings ofhow when they first came out into practice, one of theirmain concerns was whether they would be allowed tointubate or not in the ED they were applying to. This ismy favorite example they give of the countless obstacleswe have had to overcome in emergency medicine for thebenefit of our patients. Sure, there are going to be thosewho do not understand what we do and those who arenot comfortable with new technology. But emergencymedicine is a dynamic specialty filled with progressivethinkers and clinicians who will stop at nothing to makesure our patients get the best possible care. That realiza-tion is what caused me to fall in love with emergencymedicine early in my fourth year of medical school, andthat truth is what will continue to propel ultrasound andsolidify it as being fundamental to our clinical practice.

Matthew Dawson, MD(msdaws2@gmail.com)

Michael Mallin, MDDivision of Emergency MedicineUniversity of UtahSalt Lake City, UTSupervising Editor: Carey Chisholm, MD.

ª 2011 by the Society for Academic Emergency Medicine ISSN 1069–6563doi:10.1111/j.1553-2712.2010.00974.x PII ISSN 1069–6563583 307

Related commentaries appear on pages 309.

References

1. McRae A, Murray H, Edmonds M. Diagnostic accu-racy and clinical utility of emergency departmenttargeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematicreview. CJEM. 2009; 11:355–64.

2. Tayal VS, Kline JA. Emergency echocardiography todetect pericardial effusion in patients in PEA andnear-PEA states. Resuscitation. 2003; 59:315–8.

3. Wilkerson RG, Stone MB. Sensitivity of bedsideultrasound and supine anteroposterior chest radio-graphs for the identification of pneumothorax afterblunt trauma. Acad Emerg Med. 2010; 17:11–17.

4. Milling TJ Jr, Rose J, Briggs WM, et al. Randomized,controlled clinical trial of point-of-care limited ultra-sonography assistance of central venous cannulation:the Third Sonography Outcomes AssessmentProgram (SOAP-3) Trial. Crit Care Med. 2005; 33:1764–9.

5. Hopkins JW, Warkentine F, Gracely E, Kim IK. Theanatomic relationship between the common femoral

artery and common femoral vein in frog leg positionversus straight leg position in pediatric patients.Acad Emerg Med. 2009; 16:579–84.

6. Melniker L, Leibner E, Mckenney M, Lopez P, BriggsW, Mancuso CA. Randomized controlled clinical trialof point-of-care, limited ultrasonography for traumain the emergency department: the first sonographyoutcomes assessment program trial. Ann EmergMed. 2006; 48:227–35.

7. Blaivas M, Sierzenski P, Plecque D, Lambert M. Doemergency physicians save time when locating a liveintrauterine pregnancy with bedside ultrasonogra-phy? Acad Emerg Med. 2000; 7:988–93.

8. Welch S. Bedside ultrasound: a wrong turn some-where? Emerg Med News. March 2010.

9. Moore CL, Molina AA, Lin H. Ultrasonography incommunity emergency departments in the UnitedStates: access to ultrasonography performed byconsultants and status of emergency physician-performed ultrasonography. Ann Emerg Med. 2006;47:147–53.

308 RESIDENT PORTFOLIOS