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Point if Care OB US compared to Radiology Studies
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


Does anyone have the details of this study?
 
Point-Of-Care Ultrasound Studies By ED Physicians May Have Discrepancies Compared To Those Performed, Interpreted By Radiologists.
Aunt Minnie (5/21, Ridley, 1K) reports that researchers conducting a “retrospective review...found that point-of-care ultrasound studies on first-trimester patients by” emergency department “physicians had a 24% discrepancy rate with exams performed in the radiology department and interpreted by radiologists,” according to an e-poster presentation at the American College of Radiology’s ACR 2015 meeting. The study authors suggested that such “patients should also receive radiology ultrasound studies to avoid potentially dangerous missed diagnoses.”
 
 
Sandra Schneider MD FACEP
Director, EM Practice
ACEP
sschneider@acep.org
1800 798 1822 x 3234
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


I agree with Darin and the others that echo the opinion that this "research" is completely petty and has no merit other than to be inflammatory.  To me, the findings actually suggest that ED physicians at Santa Barbara Cottage Hospital are pretty adept at knowing when their bedside study is inadequate and requires more advanced imaging/machinery. 

To produce a response for this at this point would only add legitimacy to it, which would probably be the only legitimacy it would have.  If it gains any real steam beyond Aunt Minnie then I agree with attacking it "officially", but otherwise, leave this garbage on the side of the road.

Sean


Sean P. Stickles, MD
Director of the Division of Emergency Ultrasound
Department of Emergency Medicine
University of Missouri
Columbia, MO
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


I will also echo the reply that no response is the best response as this is currently no more than a retrospectively generated “hypothesis” by a resident with no prospective validation to give any opinion derived from the results of this sample any scientific weight.  A response to this may inadvertently open a door for our Radiology and Gynecology colleagues to walk through and initiate a “discussion” on the use of bedside ultrasound in the Emergency Department to rule out ectopic pregnancy.  This is a dying fish flopping on the sand, I say leave it alone and let it die, and don’t bite it because at best it will just make us all sick for who knows how long.

Craig Sisson, MD, RDMS, FACEP
Associate Professor/Clinical
Director, Division of Ultrasound
Co-Director, Medical School Ultrasound Curriculum
UTHSCSA Department of Emergency Medicine
sisson@uthscsa.edu
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


Seems to be a resident project like we have all commented on with some bias and misinterpretation of the data. However, we have all had resident and student projects that are flawed and limited but satisfy the RRC scholarly requirements, which radiology also has.

This is likely a combination of design issues for the study and the journalist going for a sensationalist headline to increase readership. It did work and was picked up by the newsfeed systems as likely intended. This may be more of a reflection of the journalist than the resident

I agree unless there is a manuscript (highly doubtful) better to leave it alone. That way we have taken the high road rather than picking apart the resident, unless of course our hand is forced by another journalist or entity.

 

Jason Nomura, MD


pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


My personal bias is that we all keep getting better at and doing our own endocavitary studies and completely own 1st trimester US.

 

Joseph Minardi, MD


pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


If the ePoster methods or results are significantly flawed, a response might be in order.  There is a "comment" section on the Aunt Minnie website.
For instance, the one case of a "discrepancy" illustrated in the article is an ED-US showing "no IUP."  The radiology-US showed a left adenexal ectopic pregnancy.  This is entirely appropriate ordering sequence after the ED-US for this clinical circumstance -- correct use of ED-US, not a discrepancy.  
Who know how many of the other discrepancies are similarly flawed?  It reflects a basic misunderstanding of the role of ED-US.
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


From article:  "The reviewers determined if there was significant concordance or discordance in a yes/no fashion, and a majority vote was used to make the final ruling; discrepancies were considered significant if they included disagreement over the presence of intrauterine pregnancy, gestational sac, fetal demise, and ectopic pregnancy in the presence of a positive pregnancy exam."


I just finished my Xanax and Zofran while reading it quickly this morning.  The discrepancies were not broken down so we don't know what the majority discrepancy was.  Fetal demise?  The author mentions the majority of " Emergency Room Doctor" (hate that) scans were TAS with compact machines.   

I definitely think we need to advocate being more aggressive with TVS if unclear picture while keeping very ! focused on the goal directed question : IUP yes / no?  I personally never make the call on fetal demise even if 100% sure.  Too much risk for me to swallow.

This radiology resident also takes a stab at ACEP guidelines recommendation of 150 scans stating the average radiologist does that in one week.

I'm sure we will come up with a group response to this article!  


Rajesh Geria MD FACEP
Past Chair, ACEP Ultrasound Sectio
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


It was an e-poster at the ACR meeting (which I wasn't able to access, but I read the AuntMinnie article). My favorite part from the AuntMinnie article:
The study included 75 cases.
The authors note that ACEP requires only 150 scans for credentialing

"I think any radiologist who does ultrasounds can tell you they do that amount in a week," Wallace-Severa said.

So.... They studied half a week worth of ultrasounds?

At my shop we evaluate over 1000 r/o ectopics annually, and I'm sure there are plenty of places busier than us. A retrospective review of 75 cases can't begin to address the issue of ED vs. Radiology accuracy. Hard to say more without the actual abstract, though.

Does anyone have a way to access the ACR e-posters?

Bret Nelson
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


 Try this link


http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=111025&wf=6524

Raj Geria, MD


pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


Matt makes an excellent point; this seems more like a case of the media (AuntMinnie) jumping the shark to make a story out of nothing. We see the news reporting nonsense on new wonder-drugs, trials that go nowhere, etc. Like our recent experience with the New York Times article about stroke care in the ED, our response, if any, should be couched in terms of appropriate specialty collaboration (lots of data already in print on safety, efficiency of ED POCUS in ectopic eval so no need to bash) and appropriate reporting (a resident collecting 75 cases is not a headline any more than a new green drink that cures cancer).

Bret Nelson
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


All very good points.  I get infuriated as I read stuff published online by aunt minnie as they have a long history of bashing emergency ultrasound and posting everything and anything against emergency physicians.  I assumed as steam was blowing out of my ears that this was a manuscript and when I read everyone’s comments and went back I realize that this is just a ridiculous poster at a single site with very flawed science.  And that is evident without seeing all the data.  
I hope that any credible, respectable journal wouldn’t even consider this.

Jerry



Gerardo Chiricolo, MD, FACEP
Vice Chairman, Department of Emergency Medicine
Past Chair, ACEP Ultrasound Section
Chief, Division of Clinical Ultrasound
Director, Division of Emergency Ultrasound
Assistant Professor, Weill Cornell Medical College
NY Methodist Hospital
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


I don't disagree that a well-crafted response is in order.

However, if this is just an e-poster by a resident at a radiology conference is there any risk of drawing more attention to the bogus abstract by a formal response from ACEP EUS section?

Not saying that's the case......just wondering.  Will this just disappear if ignored?  Have response ready if it gets bigger or is published in actual journal?  

People with more experience than me with these things should make that call of course.

Matt Dawson
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


Can't seem to send the pdf of the slides through the Listserv . The link is

https://www.aievolution.com/acr1501/files/content/abstracts/4351/0077_WallaceSevera.pdf


The disagreement breakdown is unclear from the abstract or slides.  The first example in the slides is a scan where the ED called no IUP and sent to radiology for finding of the ectopic.  This is not a wrong diagnosis but rather staged imaging and evaluation.  The 2nd example is an error of no IUP vs IUP.

It does not break down how many were staged imaging such as no IUP, sent to rads for ectopic finding to guide intervention vs errors or limited scans.  They also do note (rightly so) that this only based on patients that were sent for US with radiology which involves the premise that these are patients were additional information was needed or the ED provider did not feel they were able to obtain adequate images for a definitive diagnosis.

A conclusion of a 76% accuracy rate is somewhat misleading if many of them are like the first example where the ED diagnosis is correct and an example of staged imaging.  It is also misleading that it is only referral cases only rather than an actual evaluation of all cases.

Based on the references it does not appear the original information was published.  Does anyone know someone from the group/hospital that can weigh in on the details?




Jason T Nomura
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


This slide says it all:

Screen Shot 2015-05-21 at 10.32.46 AM.png

The funny thing is that example 1 is a correct interpretation by the EM physician: no IUP. So, they sent it along for a better evaluation of the adnexa, where US tech found the ectopic. Bottom line: appropriate use of point of care ultrasound.
Example 2: Transabdominal study where a sac like structure is seen with TAUS but no definitive GS or YS seen. So the EM physician sent along for a TVUS to be done by the US tech where a small FP that measure less tham 3mm is seen. Bottom line: appropriate use of point of care ultrasound.  

I love the line: "why subject patients to two transvaginal studies?" I think we (and all of our patients) would all agree that a speculum and bimanual exam is much more invasive than an ergonomically shaped endocavitary probe.

This is a great example of spectrum bias. This study probably really illustrates that our teaching of IUP vs no IUP with using discriminatory beta quant HCG is appropriate, allows for more efficient care of patients in the ED and doesn't sacrifice accuracy.

It's up to us to tell that story…

Rob

Robinson M. Ferre, MD, FACEP
Director, Emergency Ultrasound Division
Program Director, Emergency Ultrasound Fellowship
Assistant Professor, Department of Emergency Medicine
Vanderbilt University
File Attachment(s):
Screen Shot 2015-05-21 at 10.32.46 AM.jpg (40985 bytes)

pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


I agree with Darin and the others that echo the opinion that this "research" is completely petty and has no merit other than to be inflammatory.  To me, the findings actually suggest that ED physicians at Santa Barbara Cottage Hospital are pretty adept at knowing when their bedside study is inadequate and requires more advanced imaging/machinery.  

To produce a response for this at this point would only add legitimacy to it, which would probably be the only legitimacy it would have.  If it gains any real steam beyond Aunt Minnie then I agree with attacking it "officially", but otherwise, leave this garbage on the side of the road.

Sean


Sean P. Stickles, MD
Director of the Division of Emergency Ultrasound
Department of Emergency Medicine
University of Missouri
Columbia, MO
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


I found the e-Poster:

https://www.aievolution.com/acr1501/files/content/abstracts/4351/0077_WallaceSevera.pdf

I agree with Matt, Sean, et al, that generating a response to an e-poster, of a poorly interpreted study, by junior radiology residents, from a community hospital, may only serve to generate more controversy. Now if it is published in a journal, that’s another issue.

One of our faculty does part-time shifts there, so I will also reach out for more information.

Also, (in a somewhat shameless plug) we published a recent observational study that supports the safe and efficient use of ED pelvic US for all indications where a pelvic US is considered. In it, we describe 25 cases where patients received both ED and Rad pelvic US, of which 2/25 had disagreement.

http://www.ncbi.nlm.nih.gov/pubmed/25440231

Alan

Alan Chiem, MD MPH FACEP
Director of ED Ultrasound | Olive View-UCLA Medical Center
Assistant Clinical Professor | Emergency Medicine
David Geffen School of Medicine at UCLA
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


I will also echo the reply that no response is the best response as this is currently no more than a retrospectively generated “hypothesis” by a resident with no prospective validation to give any opinion derived from the results of this sample any scientific weight.  A response to this may inadvertently open a door for our Radiology and Gynecology colleagues to walk through and initiate a “discussion” on the use of bedside ultrasound in the Emergency Department to rule out ectopic pregnancy.  This is a dying fish flopping on the sand, I say leave it alone and let it die, and don’t bite it because at best it will just make us all sick for who knows how long.

Craig Sisson, MD, RDMS, FACEP
Associate Professor/Clinical
Director, Division of Ultrasound
Co-Director, Medical School Ultrasound Curriculum
UTHSCSA Department of Emergency Medicine
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


A thank you to the entire US section for the feedback and support....

I am the Emergency Ultrasound Director at the Cottage One Health System, which is a medium sized community hospital in Santa Barbara, California.
I was both shocked and insulted upon learning about this study that was produced without my knowledge in our institution. I am very disappointed in my Radiology colleagues with whom I have gone out of my way to be completely open and collegial.

Our department has worked diligently over the past 10 years to develop an US program that has steadily progressed in the areas of image acquisition, saving to PACS, interpretation, EMR documentation and QA. We have developed conservative protocols that rely on a staged approach to the management of first trimester pregnancy and have a low threshold to refer patients to radiology for comprehensive studies in the cases where an IUP cannot be confirmed, or acquired images are sufficient to diagnose.

I am offering the following points to take away from this scenario......

1. This is a tiny retrospective study with little power and huge selection bias.....it proves nothing.....except how irritating and underhanded our colleagues can become.

2. Consultative radiology studies will frequently find more information than ED studies: they are by definition more detailed and comprehensive. We should not hold ourselves to achieve the same goals as radiology. We are scanning to answer a goal directed question: is there an IUP?  I think my department is doing this and appropriately recognizing their limitations. The " discrepancy" examples even prove this. We are unfortunately getting dissed for doing the right thing for our patients.

3. Our scanning is providing a great service to out patients! We have provided hundreds and hundreds of patients (excluded from the study) with first trimester pain or bleeding, the comfort of knowing their pregnancy is alive and has a good change for continued success. We have also saved each patient over an hour and a half of time that would be wasted waiting for comprehensive studies.

4. Agree we should NOT dignify this study with a formal response from the Section....... Unless our ACEP colleagues call for a response, this should be allowed to wither and die out. On a local level....I am meeting with the Radiology Chair today to call them out on this type of behavior.

5. As much as they want to make claims about accuracy and image quality, bedside ultrasound is a fundamental part of the Emergency Department. Just be wary of sharing a PACS.

Guy Tarleton MD, FACEP
Emergency Ultrasound Director
Cottage One Health
Santa Barbara, California
pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


 22 May 2015

Dear colleague friends

I am encouraged and proud of the section discussion.
This means we care and this means we believe in the quality and integrity of Point-of-Care Ultrasound.

We will be moving forward with the following:

- Crafting a brief response to Aunt Minnie on behalf of the section; this will be shared with the section
- Archiving this e-conversation on the website forum

Much thanks.

 
Resa Lewiss


pererap
Posted: Sunday, August 2, 2015
Joined: 8/31/2011
Posts: 231


This is great conversation.  It does give me a chance now to discuss my  study data. Here is my study that I am having problems getting published.

“Accuracy and disposition time of emergency physician completed bedside ultrasound compared to radiologist interpreted controls between 5pm and 9am at a rural hospital, a randomized study.”

Our goal was to compare accuracy and disposition time of emergency physician completed limited bedside ultrasounds (pretty much any ultrasound) vs radiologist interpreted, technologist completed ultrasounds at our more rural hospitals. It is a multi center study in Twin Falls and Jerome, Idaho. We may be able to throw in Gooding, Idaho as well but it is calving season.  

We randomized the patients in to each group (ER vs RAD) but the study had to be terminated after three or four hours.  We had problems with the randomization process.  When we  informed people in the RAD arm that they needed to come back tomorrow and see if ultrasound could squeeze them into their schedule they refused and wanted to be in the ER arm.  I could put some of the patient feedback comments in about the study but my spellchecker had some problems with the words.  A lot of bleeping and something about not having time tomorrow some more bleeping and “it is not like those calves will stop just because I have to go to the bleeping doctor.”  

I’ll never get this thing published because I’m too busy scanning. If ‘Aunt Minnie’ came in to our ER with a swollen leg I am sure she would much rather have an ultrasound done by a credentialed EP and be discharged with or without a DVT rather than a Lovenox shot and get an ultrasound done the next day or so.

This ‘study’ will be no news as fast as it takes for you to hit the little trashcan on your email program and delete my silly email.  

If you made it this far, thanks for reading and scan on!  Also, we are looking to fill one position!  Let me know if you’re interested! scott


R. Scott Holliday, DO, FACEP
Emergency Physician
St. Lukes Magic Valley Regional Medical Center
 
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