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Do your consultants believe your scans?

November 8, 2015 4 Comments

no doubt

I would like a show of hands, or emoji hands, as to how many of you have consultants who will act on your findings without further imaging.

There is a learning curve and a trust that has to evolve in most consultative processes.  You get enough calls correct and the trust hopefully begins to grow.  But there is also the comfort of the familiar way of doing things which may resist embracing good POCUS calls.

For me it started with unstable abdominal aneurysms.  Making the diagnosis within minutes of patient arrival and getting them off to vascular surgery with no other imaging required some persuading in the early years of POCUS.  But now it happens almost without question.  I even get asked as to anatomic location of the lesion.

Other more advanced POCUS applications have taken longer to establish POCUS-only referrals however.  I used to require 100% rescans of ectopics found at the bedside, but when I can show a quality image to the gynaecologist I have had them occasionally take cases to the OR or clinic without further proof.  I have convinced the hematologist we should thrombolyze a massive PE based on bedside findings of acute RV dilation and severe hypotension.  Our internists are more willing to act on our cardiac and pulmonary scans than ever before.  It has been known to happen that I will arrange follow up for biliary colic based on the POCUS and get a follow up scan through the ultrasound department later.  These small victories add up over time in the culture of referrals.

But I had two cases on my last shift that demonstrated that we have come a long way but there is still a ways to go.

Patient one was in his 40s with left flank pain and microscopic hematuria.  Previous renal colic 4 years ago.  Normal physical exam, pain was settling with NSAIDs and the bedside scan showed no AAA, no FF, no bowel obstruction, but did show this:


Straightforward. Mild-moderate hydronephrosis on the affected side.  Patient was discharged home with arrangements to follow up with urology.  But…the consultant wanted to get an outpatient CT scan anyway despite the literature showing this doesn’t change management in these simple cases.

Second case was a 12 year old male with RLQ pain and elevated WBC.  My scan showed this:

A huge appendix measuring 1.4cm in diameter.  You can see both the blind end and the cecal junction.  The surgeon was contacted in the morning and agreed that the patient should be booked for surgery before any further imaging was done.  Another child spared the CT scanner, yay!

I know some departments, particularly in the USA, do the initial DVT scan and thrombosis clinics will accept the referral.  Can’t say we are there yet in my neck of the woods.

I have had some testicular torsions identified by POCUS and taken right to the OR, but a colleague has had the opposite experience, where the trip to the OR got delayed by hours as an ultrasound tech was called in after hours to repeat the scan and confirm the lack of flow demonstrated on the ED scan.

I get it.  Surgical intervention is a high stakes game and if the consultant doesn’t have faith in your call they are going to get further confirmation.  The question is: At what point do we earn that trust and improve time to definitive care and elimination of unnecessary radiation or delay?  There is the danger of a persistent culture of doing things the old way when a better method has developed right in front of  one’s eyes.

How are you working to change this culture?





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Comments (4)

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  1. Gen says:

    Hi Greg and gang!

    Just had to comment on this thread as we have recently seen an increased interest by radiology regarding POCUS ever since the chief of surgery has been on their backs for CT-scanning first most query appys…

    This started when I sent an ‘older’ patient as per their standards (my age… 37!) for a confirmatory scan in the morning after printing and leaving clear diagnostic images of an appendicitis in the patient’s chart. It was systematically and unilaterally changed into a CT scan study by radiology. Chief of surgery who was on call the next day went to see the radiologist in question and started arguing wih him… Finally admitting that there were beautiful pictures of a juicy appy in the chart and it’d be ridiculous to submit patient to radiation for naught.. That piqued radiology curiosity to say the least! As they didn’t even know POCUS existed, they were very surprised to learn what some of us were capable of doing. And what an endorsement from our chief of surgery who is usually quite grumpy and suspicious of our work !

    We are thus meeting with radiology this week to explain what we do. It’s easier now than 10 years ago as there are so many more of us. We’ll see how it goes. I think they understood through our preliminary discussions the very clinical, rule-in nature of our art and now see that our 2 types of US can co-exist.

    This trust was built over 10 years of having an active basic applications POCUS program and 4 years of my doing advanced applications and 2 years of training a few motivated colleagues who now have excellent chops.

    Urology has been more reticent in going straight to OR (without CT) for a few patients in ongoing urosepsis with poor response to antibitotics with POCUS findings of unilateral severe hydro…

    I guess they don’t know our skills well enough to decide to operate on our findings and we’ve had less chance for proving ourselves to them.

    Same with clear torsion with whirlpool sign…

    Orthopods have told the few of us who do advanced nerve blocks that they prefer us doing them because they seem to ‘work better’. Most of our anesthesiologists still go blind at our shop !
    And they love dealing with a comfortable, non-delirious patient in the morning to obtain consent for hip surgery. Makes their life easier. They even support me doing shoulder scans and are very happy for us tapping all sorts of joints by ourselves without their help.

    Recently gained major brownie points with cardiology for sending to cath lab (a 20min ambo transfer for us)a patient post ROSC with a non-diagnostic ECG but with clear WMA in the LAD territory thus pinpointing the lesion and having the cathlab call back to ‘congratulate’ us on our fine POCUS skills! They’ve always been huge supporters of the few of us who are doing advanced stuff and have been a great big wind beneath our wings. There’s even an opening for TEE supervision from a newbie cardiologist (who did his TEE fellow) who was thrilled to learn he had colleagues interested and knowledgeable in POCUS.(Big community hospital here, non-tertiary)

    It takes time to build that trust but as with many things that do : the sweetness of the empowerment is even greater. Victory comes to those who wait indeed ! And for our patients, it just means being a better clinician and an advocate with better, visible arguments.

    Curious to know if some centers have general surg operate on a regular basis on their POCUS appy scans or even GB scans without confirmatory scans from radiology.

    Cheers from La Belle Province !


  2. Greg Hall says:

    Gen, that is an awesome story to hear. Really impressed with how far you have taken POCUS in your practice. I will be in contact with you very soon about some further opportunities to help out CEUS with improving POCUS skills nationally.

  3. Gen says:

    Will await further contact on that subject. I am quite interested in that topic as (preaching to the choir here, I know) being the first in an institution to do something takes patience and a lot of explaining and maintaining of quality. Good reputation is key. 🙂 Do you have a good QA system in place to review scans by fellow POCUS practionners in your ED? Trying to implement one here but budget is non-existent and we are moving our ED in a new next door facility in less than a year…

  4. Lloyd Gordon says:

    We’ve had patients taken to the OR with ectopics on POCUS (and no other imaging). Also one Urologist has taken patients to cysto on the basis of fever and findings of renal colic.

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