Emergency Department Ultrasound: A Resident’s Perspective

I remember the day I first became fascinated with ultrasound as vividly as I remember the day I fell in love with emergency medicine. It was early in my fourth year of medical school and was 11:00 pm at night. I will never forget the look on the young mother’s face when she saw the heartbeat on the screen and knew her bleeding was not another miscarriage but a threatened abortion. Sure, my diagnosis did not change her outcome, but I see our job as one of relieving suffering, and the anguish I prevented her from experiencing while waiting for a consultative ultrasound in the morning was very important to the both of us. Having the evidence to support my decision gave me the ability to immediately send her home to take care of her other children.¹

Later, my initial fascination with ultrasound grew into a deep respect and admiration as I diagnosed things such as cardiac tamponade and ascending aortic dissection in a patient who presented only with syncope and a sudden drop in blood pressure. It gives me great pride to be able to tell the grizzled trauma surgeon that this trauma patient’s hypotension is in fact not due to a pneumothorax or tamponade, but the FAST is positive and the patient should go to the operating room. And yes, I have evidence to back up our decision to make these critical diagnoses with ultrasound alone.^2,3 It also gives me great satisfaction to know that I was around 34% more successful in placing central lines in residency due to my routine use of ultrasound for the procedure.⁴ I have seen some of my attendings place these lines blindly, and while I have tremendous respect for their experience and amazing clinical abilities, I am very thankful for ultrasound and the direct visualization it provides. Having reviewed studies describing the significant percentage of cases where the femoral artery is positioned directly over the vein, I know that as a resident I do not have the experience or skill to blindly determine when this is occuring.⁵

Perhaps where my respect and admiration for ultrasound truly blossomed into love, though, was when I first started moonlighting in community and rural emergency departments (EDs) as a senior resident. Having the skill and confidence to take care of patients who needed ultrasounds at night when no ultrasound techs, radiologists, or consultants were available is what I felt really separated me from clinicians who did not have this ability. Having this skill certainly did not take away from my ability to make decisions otherwise. It simply gave me another tool that has been proven to affect patient outcomes.⁶ I can confidently call the surgeon when my ultrasound reveals acute cholecystitis or not call when I rule out abdominal aortic aneurism and find that my patient really does just have renal colic. Another benefit in the community is added efficiency. While I am no expert in ED operations, the ability to call the surgeon about cholecystitis or abdominal aortic aneurism without waiting hours for a consultative study, or sending the patient with intrauterine pregnancy home instead of staying overnight for a comprehensive exam, seems more efficient and beneficial in terms of throughput.⁷

Recently, I was shocked to read an editorial that noted that only 19% of community EDs had ultrasound capability.⁸ I quickly realized, however, that these data came from a survey done 5 years ago, were outdated, and as such, were likely a gross underestimation.⁹ But even if it was close to the truth it left me very concerned. These are the exact settings in which ultrasound is so important and potentially life-saving. These amazing community ED physicians are precisely the people who need the resources and ability to perform these examinations, due to their lack of backup and limited imaging resources. As shocked as I was, though, I am confident this is changing rapidly. I enjoy hearing the stories from my attendings of how when they first came out into practice, one of their main concerns was whether they would be allowed to intubate or not in the ED they were applying to. This is my favorite example they give of the countless obstacles we have had to overcome in emergency medicine for the benefit of our patients. Sure, there are going to be those who do not understand what we do and those who are not comfortable with new technology. But emergency medicine is a dynamic specialty filled with progressive thinkers and clinicians who will stop at nothing to make sure our patients get the best possible care. That realization is what caused me to fall in love with emergency medicine early in my fourth year of medical school, and that truth is what will continue to propel ultrasound and solidify it as being fundamental to our clinical practice.