The issue about emergency ultrasound lies in the fact that is a rule in,
NOT a rule out tool. I personally favour a rapid, non-invasive test that
will immediately alter my management. If the emergency scan is negative,
merely treat the patient as if you did not not have a scan. In this
scenario, if ED ultrasound negative consider departmental scan, as it is
more sensitive.
Alistair
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of Dunn Matthew Dr. (RJC) A
& E - SwarkHosp-TR
Sent: 27 August 2004 20:33
To: [log in to unmask]
Subject: Re: UTI's, abdo pain and early pregnancy
> "This is another reason why it is pretty difficult to defend
> running an ED
> without a scanner these days. Ultrasound is cheap and safe.
> Why not do it?"
>
> Matt, are you really serious about this? I'll tell you why
> not to do it. I
> and neither of my colleagues have the expertise to do it.
I'm kind of serious about it. I don't think it's practical at present to do
it except maybe in a few departments. Not doing it myself at present.
Nonetheless, I do think it is one of these things that will be practical in
a few years time. Lack of expertise is a reason not to do it of course.
However, if that's your only reason you should look to acquiring the
expertise unless there's a reason not to.
If you come across a copy, Ma and Mateer's "Emergency Ultrasound" covers
(quite apart from the physics and practical details) the arguments and
practicalities around PLUS, and makes a good read.
> We
> have such low
> staff levels that there is no way we could provide this
> service 12 hours a
> day never mind 24 hours. Our middle grades are often locums
> with varying
> degrees of experience and ability. It's safer not to do it
> than to do it
> from a clinical governance point of view.
>
Middle grades being locums is of course a problem. (In fact, this is one of
the problems the speciality has- it is not uncommon for people who are
basically surgeons to do middle grade locums in A and E, but it is a lot
less common for A and E docs to do middle grade locums in surgery). Means
you may well have to pass on most of these cases to O and G. From the
clinical governance point of view it's not too much of a problem provided
everyone knows their own limitations. It doesn't take a huge amount of
training to be able to spot a yolk sac with high specificity (but lower
sensitivity) on abdominal US- although it does take more training and
expertise to be happy with the more subtle signs. Depending on expertise,
you'll miss a lot of intrauterine pregnancies, but if you treat every
equivocal scan as "no pregnancy seen" and get another opinion it is safe.
The point being that it is a safe, simple and non invasive investigation
that adds something to your clinical judgement
> I'm quite sure I could be trainned to do scans initially but
> I'm not sure
> that there is enough scannable patholgy coming through the
> department for me
> and my colleagues (and the fictional 24 hour middle grade
> cover) to maintain
> our skills. I know these are all old arguments but in some
> departments they
> are genuine problems and blanket statements like yours do not
> help those of
> us doing our best with the limited resources we have.
OK. Sorry for my statement. Actually pretty easy to defend running a
department without a scanner at present. Should have toned it down to "It is
likely that availability of Point of care Limited Ultrasound in A and E is a
cost effective way of improving patient care."
There's probably more pathology around than you think. How many pregnancy
tests are you doing? Why aren't these patients having ultrasounds? In
general, a lot of A and E patients come in with cardiac symptoms, soft
tissue injury, abdominal pain and injury, problems in pregnancy, testicular
pain and need for vascular access. All good indications for emergent
ultrasound.
> However, I feel that a distinct difference is
> developing in the EM practised in well staffed, often central
> hospitals, and
> the less well staffed, often district hospitals and it
> doesn't help if one
> appears to think it is better than the other.
Why shouldn't I think my department is better than one in a well staffed
central hospital?
> One size does not fit all and never will. Sensible local
> solutions with realistic, practical national guidance is the
> way forward.
I agree. What can I say? Hobby horse, I like ultrasound, I see it as part of
the way forwards (as part of EP consultant- with roles expanded outside the
current core curriculum- delivered care of all the sicker and more complex
cases). I also reckon that as we seniorise A and E, it makes sense that we
expand what we do. (A consultant delivered ED service should be very
different to a SHO delivered one.) Try to slip it into any discussion if it
is even peripherally relevant, and this seemed an appropriate one. Got to
say not as much evidence as I'd like to support my view, and in the short
term it probably isn't for every department. However, I think a lot of
people who are not moving towards PLUS are doing so because they're worrying
inappropriately. PLUS is an extension of clinical examination. An ultrasound
scanner should be no scarier (and have no more concerns about difficulty
acquiring and retaining skills) than a stethoscope, which is a much trickier
instrument to use properly. I post things like this and present an extreme
view in the hope of stimulating thought and debate rather than in the belief
that I'm necessarily right.
Never seen a realistic, practical national guidance myself so can't comment
on them, but in the absence of evidence to the contrary I'll take your point
that if I see one I should adopt and cherish it.
Matt Dunn
Warwick
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