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Ultrasound in the ED can mean dramatic improvement in care, research shows

March 1, 2001

Ultrasound in the ED can mean dramatic improvement in care, research shows

Warning: You'll confront resistance to this diagnostic tool

When an elderly man came to the ED at Doctor’s Hospital in Columbus, OH, screaming in pain, an abdominal aortic aneurysm (AAA) was suspected immediately, recalls Robert Jones, DO, FACEP, emergency ultrasound coordinator. However, the vascular surgeon remained unconvinced, says Jones. "He stood at the bedside and asked the staff to call him only after a CT scan was done," Jones says. "But when we put the probe on the patient, the surgeon was able to visualize the AAA. He began barking out orders himself to get things moving."

On another occasion, Jones felt strongly that a woman had a ruptured ectopic pregnancy, but the obstetrician attending felt otherwise — until she saw the ultrasound results.

These two scenarios illustrate the dramatic impact ultrasound can have on the care patients receive in the ED, argues Jones. "You can tell specialists until you are blue in the face that you think a patient is really sick, although the vitals aren’t unstable at that point," he says. "A picture is worth a thousand words."

Ultrasound results also can affect care the patient receives by ED staff, Jones acknowledges. "A trauma patient may not look too bad, so while the team is moving at a quick pace, they don’t appreciate what is going on internally," he says. "When they see evidence of internal bleeding, suddenly everyone is moving at a double pace and hovering around the bedside."

The practice of ultrasound in the ED is a quickly growing trend, Jones reports. "The number of centers doing this is going up exponentially. This is going to become standard of care in the ED in the very near future," he predicts. (See "How should you train staff in ultrasound," in this issue.)

Determine exactly which ultrasound applications will be performed in your ED and under what circumstances, emphasizes Michael Blaivas, MD, RDMS, director of emergency ultrasound at North Shore University Hospital in Manhasset, NY. "In general, ultrasound should be used to help treat, diagnose, or triage patients with potentially emergent conditions," Blaivas says. The particular applications will vary among settings, he says. "They will depend on what void is left by radiology and what pathology commonly presents at one’s doorstep," he adds.

Here are items to consider when implementing ultrasound use in the ED:

• Use ultrasound to answer specific questions. The modern ultrasound machine is really an extension of the emergency physician’s stethoscope, says Blaivas. "The ultrasound probe should be used to answer the questions an ED physician has, after the physical examination," he explains. Blaivas offers the following examples:

  • If there is pain in the right upper quadrant, then the physician can visualize the gallbladder immediately.
  • If the heart sounds appear muffled and the patient has low blood pressure, then a pericardial effusion can be ruled out right away.
  • If the patient has unilateral leg swelling and risk factors for deep venous thrombosis (DVT), the ED physician can quickly diagnose or rule out DVT.

• Consider use for lower-extremity DVT. Blaivas notes that many departments are now exploring the use of bedside ultrasound for rapid diagnosis of lower-extremity DVT in the ED. "Many EDs do not have vascular laboratory coverage after business hours and on weekends, and are forced to empirically treat and possibly admit patients with suspected DVT," he explains.

• Explain how ultrasound will be used. Radiologists might feel as if you’re intruding on their "turf," warns Jones. "Explain that if we work together as departments and follow guidelines, we can institute this and benefit patient care," he advises. "Tell them that you are doing it as a limited study to answer simple yes/no questions about life-threatening emergencies." Examples of this include intra-abdominal or intrathoracic traumas, abdominal aortic aneurysm, and suspected ectopic pregnancies, says Jones.

"These are all life-threatening conditions when you need an answer, even at 2 in the morning," says Jones. "The problem is, most hospitals do not have the resources to bring an ultrasonographer in within a 10-minute time frame. So the onus falls on us to make these diagnoses rapidly."

• Decide how ultrasound will be used based on evidence that it benefits patient care. Using ultrasound in the ED is potentially life-saving, stresses Jones. "If a patient has a leaking AAA, you don’t want to spend 40 minutes getting a CT scan. The patient may deteriorate in that amount of time," he says. "If you rule out an AAA, you can pursue other diagnoses. If you find it, you can mobilize the resources that you need."

As more literature emerges on the topic, it is becoming clear that ED physicians are able to considerably decrease the length of stay for patients receiving bedside emergency ultrasonography in the ED, says Blaivas. In addition, use of ultrasound in the ED has been shown to decrease morbidity and mortality, says Blaivas. Using ultrasound also improves some simple tasks such as the placement of peripheral or central lines in patients who have poor vascular access, or locating subcutaneous foreign bodies, says Blaivas.

There is increased interaction with the patients and satisfaction with the visit tends to improve, Blaivas adds. "This improved satisfaction comes from a sense of a more complete ability to diagnose and treat one’s own patients," he says. "Further, there is the sense of increased competence and mastery as one can rapidly make diagnosis, which were once only in the hands of a radiologist."

• Assess the gaps in ultrasound availability, and fill them. Determine specific needs when lobbying for ultrasound capability in the ED, Jones recommends. "Tell them that in the past three months, you’ve had X number of cases in the off hours that required ultrasound, and you were unable to get it," he says.

If you document a clear unmet need for ultrasound, other departments might have to concede the ED should provide the service, says Jones. "They have to throw up their hands and say, Since we’re not able to meet the demand, we reluctantly have to agree,’" he says. (See "Here's how to get buy-in for ultrasound," in this issue.)

Do your homework and determine the current weaknesses in the services provided by radiology, advises Blaivas. "Perhaps the ED receives many cardiac arrests. Can radiology be available to perform a basic ultrasound to evaluate the heart and aorta in a coding patient on 30-second notice?" he asks. "It is very unlikely they could." He recommends asking the following questions:

  • Are patients with first-trimester pregnancy complications waiting for hours to be scanned when 70% of them could be quickly diagnosed with a live intrauterine pregnancy by the ED physician and sent home?
  • Is any group of patients waiting for hours to get an ultrasound study?
  • Is vascular surgery happy that patients with potential deep venous thrombosis are not being scanned after hours or on weekends?

Once areas of potentially improved service with bedside ED ultrasound are identified, the next step is to seek support from other departments, Blaivas suggests. "For instance, if OB/GYN would like their patients scanned right away and not wait, they may help convince the hospital executive board to allow the purchase of such equipment," he suggests. "Now add in the available literature regarding decreased length of stay, decreased morbidity or mortality, and increased satisfaction, and the argument is set," he says.

Sources

For more information about ultrasound use in the ED, contact:

• Michael Blaivas, MD, RDMS, Department of Emergency Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Telephone: (516) 562-2927. Fax: (516) 562-2828. E-mail: blaivas@pyro.net.

• Robert Jones, DO, FACEP, Emergency Medicine Residency Program, Doctor’s Hospital, 1087 Dennison Ave., Columbus, OH 43201. Telephone: (614) 297-4008. Fax: (614) 297-4329. E-mail: Jones8673@aol.com.

Resources

Gulfcoast Ultrasound Institute offers continuing education ultrasound programs. A course on emergency ultrasound will be held March 21-23 and Sept. 12-14. The cost is $850. A three-part videotape series titled Emergency Medicine Ultrasound is available for $299. For more information, contact: Gulfcoast Ultrasound Institute, P.O. Box 66708, St. Pete Beach, FL 33736. Telephone: (800) 619-1900 or (727) 363-4500. Fax: (727) 363-0811. E-mail: learn@gcus.com.

The American College of Emergency Physicians (ACEP) has a two-day skills course, Module I: Introduction to Emergency Medicine Ultrasound. The course includes lab sessions with live models for abdominal, obstetrical, and echocardiology; case studies; and an Ultrasound Clinical Skills Assessment Lab. The course will be held March 17-18 in San Diego, and May 3-4 in Chicago. For more information, contact: American College of Emergency Physicians, 1125 Executive Circle, Irving, TX 75038-2522. Telephone: (800) 798-1822 ext. 6 or (972) 550-0911. Fax: (972) 580-2816. E-mail: customerservice@acep.org. Web: www.acep.org.

ACEP has a Section on Emergency Ultrasound that meets twice a year at the ACEP Scientific Assembly and the Society for Academic Emergency Medicine annual meeting and publishes a regular newsletter. The section aims to help EDs establish ultrasound capacity by compiling information about how EDs have implemented ultrasound, providing key liaisons, and encouraging educational efforts. For more information, call (800) 798-1822, Ext. 3242.

The South Carolina College of Emergency Physicians offers The Emergency Ultrasound Course. The course includes training in ultrasound physics, abdominal vasculature, gynecology and obstetrics, biliary ultrasound, trauma ultrasound, emergency cardiac ultrasound, program development, and training labs. Upcoming courses will be held May 19-20 in Philadelphia; Sept. 15-16 in Columbia, SC; and Nov. 10-11 in Charlotte, NC. For more information, e-mail registration@emergencyultrasound.com.

The Web site www.Emedhome.com (click on "Ultrasound") features an introduction to ED ultrasound, sample video cases, policy statements, information on courses, and links to sites that address ultrasound use.