Keeping Up With Emergency Department Ultrasound

Ibegan my emergency medicine (EM) residency training just over 10 years ago. I trained at a time when ultrasound was just beginning its rise in popularity and found myself just as enamored as the rest of my colleagues. At times I felt like I was cheating the system—not waiting for the ultrasound to confirm pregnancy, finding the inflamed gallbladder or the free fluid indicative of the ruptured ectopic in a young woman who presented with syncope. My excitement stemmed mainly from witnessing the perceived facilitation of my patients’ care, as I was able to take control over diagnostic studies that were ordinarily not within my purview. Later, I found that ultrasound could assist me in placing hard-to-find peripheral access as well as more reliably find the vessel for central venous access. As a residency educator, I believe I fall into the group of the somewhat older physician, but certainly not the type who is unable or unwilling to learn new things. Recently, I found myself asking my residents to help guide me through ultrasound procedures such as evaluating for deep vein thrombosis or diagnosing retinal detachments, both of which have become “core emergency ultrasound applications.”¹ I found myself somewhat uncomfortable, not because my residents were more knowledgeable than I or that I was concerned technology had passed me by. Rather, I was struck with the recognition that the most inexperienced person in the department was, in some way, guiding the care of the patient without the benefit of the attending. Why were we as attendings willing to accept this backseat role to residents whose ultrasound skills were better than ours? I could think of no other area in which this would be acceptable.

Use of bedside emergency department (ED) ultrasound continues to generate heated debate, both from critics such as Welch² and supporters such as Chiricolo and Noble.³ It was not surprising for me to find that Dr. Welch has been in practice for over 20 years and Drs. Chiricolo and Noble both less than 10. This is not a criticism of older physicians, but simply a statement that younger practioners are more likely to be wooed by the newness of technology and innovation. A recent commentary entitled “All that glistens is not gold”⁴ discussed the difference between early and late adopters. In general, emergency physicians are more likely to be early adopters. We are the group who are more willing to try new devices or use new drugs, often as a “trial” in hopes they will benefit our patients or ourselves in our ever-crowded, overwhelmed system. Of all emergency physicians, the more junior physician is the most susceptible. This is the opposite of the well-known adage about old dogs and new tricks—our residents and new graduates are the playful “puppies,” if we are to stay on theme, who are excited and willing to try new things. For junior physicians, there is little “standard practice” already ingrained, and as such they often have no clear practice pattern that needs to be changed. In addition, they often have no experience with unanticipated side effects or bad outcomes associated with using new drugs or devices. They are the least likely to be gun-shy and the most likely to be the least educated. One could imagine where this perfect storm could lead.

As I read this article, it was clear that the authors are enamored with ultrasound. [The Resident Portfolio is written in the singular, but is co-authored by two chief residents—Ed.] They freely admit that their initial emotion of fascination with ultrasound only later, with time and experience, grew into respect and admiration. This fascination is what we in medical education often describe as “the spark” that grabs a resident and often leads to a career choice. Fascination can be a powerful sentiment, especially when the object (in this case ultrasound) allows one to provide not only medical care but to gain the proverbial “upper hand” with the grizzled trauma surgeon. Ultrasound, however, is the only area I can think of where the object of fascination is not simply knowledge of a certain topic, such as toxicology, or a niche, such as disaster relief, but an actual concrete thing. Residents do not become fascinated with the procedural skill of putting in an IV, tapping a joint, or inserting a chest tube. No one makes their career solely around such skills. Ultrasound as a “field” encompasses not just the technical skill, but the knowledge of how and when to incorporate that skill into daily practice. I have witnessed fascination with ultrasound impede residents from achieving efficiency. I have witnessed them rely on questionable literature and their own noncredentialed skills as support for not pursuing further imaging. These instances have given me concern. I wonder at their ability to differentiate motivation linked to the allure of ultrasound, from motivation linked to evidence.

Please do not misunderstand me—I am by no means implying that ultrasound is a useless bandwagon without evidence to support its use. I will state openly that I use it daily. I will also state that I work at a Level I trauma center where I do not need a confirmatory study for my FAST, but where most of my patients go to CT anyway. I do not bill for my ultrasounds, and although there is no clear policy stating so, I know that I am encouraged to get that “confirmatory” study. So, do I grab the ultrasound machine to find cholecystitis when I know my patient will need to get an official study anyway? Not often. When I do, it is usually for the purposes of teaching. The residents state that they were shocked to find that only 19% of community EDs have ultrasound capability.⁵ I am not sure why. Even I, with multiple ultrasound machines at my fingertips, choose to forego doing the study myself when I know it will need to be performed in an official capacity. Less than a third of respondents from the paper cited above state that they do not need a confirmatory study and so, if my patient is obligated to wait to find out if they have a deep vein thrombosis, would my time not be better spent seeing the next patient? I agree that rapid diagnosis of findings can help facilitate patient flow and disposition; however, most EDs are not prepared to allow this. Clearly, liability is the main concern. I think the very detailed policy statement created by the American College of Emergency Physicians (ACEP) is, in fact, very detailed for a reason. Rigorous training, immaculate documentation, and quality control are all musts if liability is to remain near nonexistent for emergency practitioners using ultrasound. The question is can we meet this standard?

The biggest barrier I see in meeting this standard is training. The challenges within training are different based on the physician group one considers. The rigorous training of residency is useful only for the ultrasound indications available at that time and credentialing for new indications will rely heavily on the continuing lifelong training we try to instill in our residents. I, as a residency-trained emergency physician who actually likes ultrasound and uses it frequently, have trouble meeting the practice-based pathway (the pathway for physicians having already completed residency) laid out in ACEP’s policy statement on emergency ultrasound guidelines.¹ Is it realistic to expect that experienced physicians who are unfamiliar with new applications will perform 25–50 reviewed scans after first completing a didactic training? When the new intraosseous drill came to my department, I simply went to an “in-service” and practiced on a hard-boiled egg for 5 minutes.

The other group of physicians, not the eager young trainees or new graduates, but the older, more experienced group, many of whom are not trained in EM, are a different challenge altogether. For many non-EM–trained physicians who staff community EDs, as well as EM residency graduates who are not familiar with new indications for ultrasound, training is the biggest hurdle. Only 9% of community EDs surveyed about their use of ultrasound had 100% of their staff made up of EM residency–trained providers. This is the group of doctors who place subclavian lines blindly, a skill, I will add, many of my residents are not comfortable with. Given the choice, they will always choose a line where they can “see” the vessel. I have no doubt that these visualized lines are more successful; however, when our residents leave and go to an ED without an ultrasound, have we done them a disservice by allowing them to only practice with a crutch, particularly when we have very good data to support that many of our community-bound residents will not have this luxury?

And what about those many times when technology fails? Machines break, parts need to be replaced. Even worse, someone else is using it. I had a resident tell me the other day that we needed another ultrasound machine, in addition to the two we already have. (Granted, one of them is oversized and often broken!) He told me that he had waited 40 minutes for the ultrasound so that he could look for a peripheral vein for an intravenous line. I was shocked. In those 40 minutes, was there no other “plan B” that he could use? The mental reliance on technology in our recently trained physicians becomes more apparent to me every day, leaving me apprehensive about their functionality in the future. I have no doubt my resident was procedurally capable of moving forward; rather, he seemed mentally impeded by his reliance on technology.

And so, where does that leave us? I am cautiously hopeful that our dynamic specialty of progressive thinkers can balance the desire for innovation with the need to be realistic. I am fully in support of solidifying ultrasound as a fundamental skill within our practice. I also believe that understanding the limitations and varied challenges facing department leaders, providers, and our field will serve us well as we work together to find the right balance. Simply because we can, does not necessarily mean that we should. And so, for now, I continue to try to stay up to speed in the rapidly growing field of ultrasound. I remain attentive to what I can learn from my residents and hope they, too, can remain attentive when I remind them that all that glitters is, indeed, not gold.