By Peter Kumasaka, MD
A 22 year-old healthy female with abdominal pain presents to your ED at 3 am. Her pain began periumbilical yesterday evening and has gotten worse, localizing to the right lower quadrant. The ride over was “rough.” Each bump sending a shockwave of pain that also made her nausea worse. She is not pregnant and has no vaginal bleeding or discharge.
Her physical exam is unremarkable, except for the guarding and rebound tenderness of her RLQ. Even her pelvic exam is unconcerning for TOA, PID, torsion or other gynecologic pathology. The CT scanner is backed up and your radiologist still believes in needing a full oral contrast prep, so you wheel in the ultrasound machine, ask her to point to where it hurts the most. and see a tubular structure, without peristalsis, measuring 1.2cm in diameter. She tenses and winces as you push the probe on her abdomen and note that the structure is non-compressible.
The surgeon answers the page, but requests that you get a CT to “prove” that she has an acute appendicitis. While POCUS may not be a perfect tool in acute appendicitis, given the findings in this patient, it is difficult to justify spending a couple thousand dollars in order to expose a healthy young patient to a big dose of radiation to confirm a known diagnosis. T 101. WBC 18. UPT negative. UA completely normal. How can we get our consultants to buy in on our POC =US?
If the clinical picture fits and the US shows us an acute appendicitis or evidence of a bowel obstruction, do we need to convince our consultants or admitting team with yet another study? Why are we in this situation? Possibly from our specialty’s own variability of US skills. But often because our colleagues might not be aware or convinced of the sensitivities and specificities of these exams. We might have to educate them about the POCUS exams.
The key would be in discussing the strengths and weaknesses of a POCUS protocol with our colleagues when these situations arise. But that means understanding these things ourselves as well. As an example, we can’t blindly rely on a negative FAST examination alone to rule out intra-abdominal injury, without understanding that it misses solid organ, diaphragmatic, bowel and retroperitoneal injuries. Yet not infrequently, I hear that the patient “doesn’t have any injury” because the FAST was negative and therefore he/she doesn’t need a CT scan. This, in spite of the patient having significant RUQ abdominal pain after a MVC at highway speeds.
WE need to know the benefits AND pitfalls of POCUS (not to mention how to perform it well) to work with our colleagues to deliver better care for our patients.