Direct Evidence

I became more comfortable with nasal laryngoscopy when I was stationed at the Naval Hospital at Twentynine Palms, CA. We ran a satellite ENT telemedicine clinic, where an ENT in San Diego would watch us nasolaryngoscope patients 3 hours away. Last night, it was instrumental for me in diagnosing an airway emergency. An evaluation the day before by another provider had shown a normal lateral neck XRay.

I cannot stop thinking about direct vs indirect findings in clinical evaluation. Nasolaryngoscopy vs lateral neck xray. stethoscope vs echocardiogram.

I have fallen for the bedside ultrasound. I flirted with Ultrasound throughout my days of doing prenatal care and deliveries: head position, AFI measurements or a quick first trimester look. But my ultrasound view changed last year. After attending a great 4 day ED US course at Gulf-Coast Ultrasound as well as several shorter courses, videos, I put together about 30 ultrasound-related topics on the fpnotebook.com site. I started this year trying to get at least 2 ultrasounds done per shift to build my skill set. These do not replace formal ultrasound by the techs/read by radiology. However they can and have helped me direct care.

Relatively simple ultrasounds with great impacts: Fluid status with IVC measurement and FAST Exam.

I’m getting closer to better renal ultrasound for hydronephrosis and abdominal aorta ultrasound.

More difficult ultrasounds I’d like to master: Echocardiogram, RUQ Ultrasound, and DVT ultrasound.

There are also ones that are regularly employed in some places with great efficacy in place of standard imaging: Blue Protocol for Dyspnea (Europe) and Appendicitis Ultrasound (pediatric hospitals). Musculoskeletal ultrasound has an entire certification (RMSK).

How limited my stethoscope (indirect) is compared with the ultrasound (direct). Outside of a gestalt “sick or not sick” and focused musculoskeletal exam, my examination overall is fairly limited. I worship Degowin and Degowin for their artful exams, but over 15 years or practice, my exam skills have become less nuanced – not more – a factor of available time. Ultrasound changes that.

Interesting that the Tricorder of Start Trek of the late 1960s coincided with the first medical uses of the ultrasound at the same time. With superb bedside ultrasounds available for <$40,000 (e.g Sonosite Edge) I am suprised this has not been more of a fixture in primary care. It is now a fixture in most EDs. 15-20 minute clinic appts are short, but how much money could be saved, how much expedited/focused the care if bedside ultrasound could direct care.

At times during busy clinic days, I felt like a referral machine; We are so much better trained than that. I propose that a good history and direct physical evidence leads to better decisions. Try ultrasound. Take a CME.

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