By Peter Kumasaka, MD
To ultrasound or not ultrasound? Do you feel pressured to ultrasound patients yourself because you have the ability to do so? Do you feel you are less of an emergency physician for not doing the ultrasound?
Administrators are pushing many of us for a No Wait ED. They want faster throughput and urge physicians to quickly see, treat, and disposition patients. Some systems are advertising their short wait times. The “suits” are tracking metrics, which they use to push the docs. Dr. Sandra Scott Simons recently lamented about her hospital’s claim of 10 minutes to see a doctor, and how it may be unreasonable and unsafe.1 Remember the Hippocratic Oath? Primum non nocere - first, do no harm. Don’t sacrifice good care for a timestamp.
In our hospital, newly roomed patients show up on the EMR with a red background, indicating that they are waiting for a provider to see them. “3 new ‘Reds’ on the board!” But wait, the patient in room 4 is tachypneic, tachycardic and hypotensive. Do you go in to see a newly roomed patient or go do the US? I’m sure the choice is obvious to all of us. But what about that young woman with right upper quadrant pain and stable vitals?
At times, it feels like there is another pressure on us. There are so many POCUS applications and protocols out there, and we feel the need to use them. Meanwhile, there seems to be a novel application being described every day. POCUS has been shown to expedite care and shorten ED stays in many of these less than critical cases, but we don’t have to perform an US on every patient that we think would benefit from it. It can feel disheartening to move the patient through faster, only to be rewarded with another red on the board, and you still haven’t seen the other two patients roomed 10 minutes ago. The clock is ticking. If there are a lot of patients waiting to be seen, it may be better to see these patients first. If time allows, come back and perform the indicated POCUS. Otherwise, some of these ultrasounds can actually be done in radiology and may improve throughput for the whole department, rather than just that specific patient. You will not be a lesser EP because you did not perform the ultrasound yourself.
Part of the art of emergency medicine is triaging your own time in caring for each patient. We can balance POCUS use and deliver both short Door to Doc time and excellent care by thoughtfully choosing when we use it.
1. Simons, SS. ER goddess: slaves to the billboards. Emer Med News. 2017 Feb;39(2):8. doi: 10.1097/01.EEM.0000512768.23377.fe
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