This patient presented with right upper quadrant abdominal pain. There was RUQ tenderness on exam, but no fever, rebound or Murphy sign. A point-of-care ultrasound was performed to assess for signs of cholecystitis and the following image was obtained. This prompted the operator to ask, “What the heck?”
To image something which moves, you must remain still. To image something which is still, you must move.
If you think on this long enough, the point is self-evident and requires no explanation. Or, just see some examples below.
We are pretty well adapted to seeing three dimensions at a time. Thus when imaging a moving structure like the heart, we hold the probe in a fixed position to obtain standard views. This allows us to focus on the movement, and cardiac presets optimize temporal resolution at the expense of spatial resolution. We are then seeing two spatial dimensions and one temporal dimension (heart moving in time).
It is very difficult to appreciate the anatomy and function of the heart, for example, when the probe is moving.
In contrast, imaging the right upper quadrant for fluid in Morison’s pouch requires a slow fan through the liver, diaphragm, and kidney. This allows us to appreciate the entire potential space where fluid can collect. Abdominal imaging is optimized for spatial resolution at the expense of temporal resolution, so be sure to move the probe slowly. Fanning through the entire structure of interest will often reveal pathology which was missed with a single-plane scan. Small gallstones, small amounts of peritoneal or pleural fluid, saccular aneurysms, and other maladies can fool a novice sonographer who isn’t thorough. In this case we are seeing three spatial dimensions.
So, keep your audience in mind when you are creating scans. Should you fan through the static anatomy, or let the movement of the structures speak for themselves?
Is ultrasound the stethoscope of the future? Is it an extension of the physical examination? Will it replace the physical exam?
Point-of-care ultrasound is a diagnostic test. It is a rapid, bedside, noninvasive, accurate, diagnostic test, but still a diagnostic test. It can certainly augment data obtained through physical examination and medical interviews, and adds to information obtained by blood assays and radiology studies.
It is performed using FDA-approved medical devices by clinicians with specialized training. Images used for medical decision-making may be archived and shared with colleagues from multiple specialties. Quality assurance programs improve clinician accuracy and accountability. These are not physical examination characteristics. These are qualities of good diagnostic tests.
There is and will continue to be debate about this issue. Whether we think about point-of-care ultrasound as a diagnostic test or part of the physical examination has ramifications for training, documentation, archiving, and billing.
We recommend checking the guidelines relevant to your specialty and making up your own mind on this issue. In either camp some things remain constant: train well and use ultrasound to enhance the care you provide your patients.
They offer an enormous amount of information for providers at all levels; from the first time Sonographer to the Ultrasound Director and offer forums and support for all your Ultrasound-related endeavors.
Please visit the following websites for more information and/or follow them on twitter to interact with them in real time. We have included links to student, resident, or fellow membership options where applicable. Be sure to check out special rates, courses, and benefits in all of these organizations designed tom promote inclusion of providers at all levels!
The Mount Sinai School of Medicine recently welcomed its incoming first-year class in its traditional White Coat Ceremony. In a day filled with inspirational talks by prominent faculty and medical leaders, students don their new white coats and receive a stethoscope at a special ceremony attended by family, friends and faculty members.
This year, Sinai’s medical students were also introduced to a new curriculum in point-of-care ultrasound:
“First-year medical students traditionally learn about the human body by dissecting the cadavers and eventually by examining the patients, and the examination ranges from inspection and palpation to listening with the help of a stethoscope and interpreting the sounds of the heart, lungs and blood vessels,” says Jagat Narula, MD, PhD, who is the principal investigator of this research study and the director of the cardiovascular imaging program at Mount Sinai School of Medicine. “With handheld ultrasound, our medical students will have the ability to see live images of inside the body projected onto a handheld screen in real time. It’s an innovative educational concept that can modernize medical education.”
As part of an educational research study, GE Vscan ultrasound machines will be distributed to groups of medical students who will learn to use the technology to image the heart, lungs, and abdomen. Mount Sinai is the first school in New York to initiate such a curriculum.
David Muller, MD, dean of medical education at Mount Sinai School of Medicine, says of the research study, “First-year medical students will learn how to identify and assess the anatomical structures within cardiac, thoracic and abdominal applications. We are excited to incorporate the portable ultrasound in our curriculum as we strive to revolutionize the way medicine is taught.”
The curriculum will augment what is being taught in the Art and Science of Medicine course, which is the students’ introduction to physical examination.
Bret Nelson, MD, RDMS, FACEP, associate professor and director of emergency ultrasound in the department of emergency medicine at Mount Sinai, will be leading the new curriculum with Dr. Narula. Says Dr. Nelson, “Point-of-care ultrasound represents a distinct skill set beyond physical examination. Te increased penetration of sonography through a variety of clinical practice environments means students will need to understand this technology to excel in patient care through their careers.”
“Today, we are thrilled to play a part in this important research project by providing Mount Sinai’s first-year medical students with the power of portable ultrasound technology, as they take the first step towards becoming our next generation of doctors,” says Tom Gentile, president and CEO of GE Healthcare Systems. “Tools like Vscan have the ability to help transform the physical exam and today’s announcement reaffirms GE Healthcare’s commitment to research and improving patient care by helping enhance the physician’s ability to quickly and accurately diagnose patients.”
For the full story, please check out the October 1 edition of Inside Mount Sinai.
Although we tend to suspect torsion only in cases where there is ovarian enlargement, cyst, etc., there are a number of studies that show these are not reliable (sensitive or specific) indicators of torsion. Radiology reports often seem to hedge and note that ovarian torsion is a clinical diagnosis because the test characteristics of ultrasound are not that great even when you include flow, adnexal size, free fluid, and other factors in combination.
Children (<15 years old) are at greater risk of torsing normal ovaries (up to 50% of torsion cases), but even in women of childbearing age 8-19% of cases are associated with normal ovaries. Doppler flow has demonstrated great sensitivity and specificity for torsion by some authors but was much less valuable in this retrospective study.
In this recent study, abnormal ovarian location, abnormal flow and free fluid were the best predictors of torsion; ovarian mass or cyst actually didn’t help rule in or out the diagnosis.
Bottom line: normal ovaries do not rule out torsion. Doppler flow may not be sensitive or specific enough either. So use (dare we say it?) clinical judgement.
Many of our lectures reference the same pantheon of literature on ultrasound in the acutely hypotensive patient. For ease of reference here they are, with appropriate links to the original publications:
- UHP protocol
- Rose JS et al, Am J Emerg Med 2001 (PMID: 11447518)
- Trinity Protocol
- Bahner D, JDMS 2002
- RCT of ultrasound in hypotension
- Jones AE et al, Crit Care Med 2004 (PMID: 15286547)
- FATE:Focused Assessed Transthoracic Echocardiography
- Jensen et al, Eur J Anaesthesiol 2004 (PMID: 15595582)
- FEER:Focused Echocardiographic Evaluation in Resuscitation
- Breitkreutz et al, Crit Care Med 2007 (PMID: 17446774)
- CAUSE:Cardiac Arrest Ultrasound Exam
- Hernandez et al, Resuscitation 2008 (PMID: 17822831)
- RUSH: Rapid Ultrasound in Shock and Hypotension
- ACES:Abdominal and Cardiac Evaluation with Sonography in Shock
- Atkinson et al, Emerg Med J 2009 (PMID: 19164614)
- RUSH: Rapid Ultrasound in Shock
- Perera P et al, Emerg Med Clin N Am 2010 (PMID: 19945597)