Prehospital Ultrasound

[VinBin]

So using this reasoning, any female of childbearing age who has abdominal pain should automatically go to an OB center?
You are missing the point here, too. It's not about ruling out bleeds in patients with a good history, it's about raising your index of suspicion in someone who doesn't meet obvious criteria.

If you have belly pain and a high suspicion for pregnancy related issue in your differential, you should go to a hospital which has capacities of managing an OB emergency. I don't understand what is confusing about that statement? My question is how would an ultrasound dictate your decision making in the field? Are you stating that a field ultrasound would be so accurate in picking up an ectopic pregnancy, ovarian cyst, etc that a medic would be using it to dictate a destination?

And regarding the trauma situation, the role of the ED is to triage patients who don't meet obvious criteria. It is difficult in many situations to differentiate this in the ER itself, why are you guys so confident that this is a role that EMS should be taking on?

 

[VentMonkey]

why are you guys so confident that this is a role that EMS should be taking on?

Why are you so confident it isn't?...

 

[usalsfyre]

I'm gonna take a guess that VinBin has never worked more than 30 minutes from a tertiary center.

 

[VinBin]

Why are you so confident it isn't?...

It opens up a host of liability that I don't think EMS is structured to take on.

We should have a RULE OUT method to not taking a patient to a higher level of care instead of a RULE IN method. Having a young female with "classical abdominal pain" with a "negative" field ultrasound who then ends up having a massive bleed due to ectopic with delayed transport to a hospital with OB capacities is not a responsibility that many systems should be taking on.

 

[VinBin]

I'm gonna take a guess that VinBin has never worked more than 30 minutes from a tertiary center.

I have actually worked in rural EMS. What statements have I made that make you think that?

 

[Carlos Danger]

If you have belly pain and a high suspicion for pregnancy related issue in your differential, you should go to a hospital which has capacities of managing an OB emergency. I don't understand what is confusing about that statement? My question is how would an ultrasound dictate your decision making in the field? Are you stating that a field ultrasound would be so accurate in picking up an ectopic pregnancy, ovarian cyst, etc that a medic would be using it to dictate a destination?

And regarding the trauma situation, the role of the ED is to triage patients who don't meet obvious criteria. It is difficult in many situations to differentiate this in the ER itself, why are you guys so confident that this is a role that EMS should be taking on?

I am very much one of the skeptics. I just don't think a good argument against it is that we should always assume the worst-case scenario when we make transport decisions.

 

[VentMonkey]

It opens up a host of liability that I don't think EMS is structured to take on.

We should have a RULE OUT method to not taking a patient to a higher level of care instead of a RULE IN method. Having a young female with "classical abdominal pain" with a "negative" field ultrasound who then ends up having a massive bleed due to ectopic with delayed transport to a hospital with OB capacities is not a responsibility that many systems should be taking on.

Honestly? I think your thought process is in line with mine, and even some of the others in this thread.

Perhaps a few things were lost in translation, but I certainly don't think it should be used as a clear cut R/O tool in the field.

Like many tools in our kit, the diagnostics they offer may provide guidelines to our treatments, and/ or hospital decisions.

I don't think having a questionable U/S in the field means that it stops there. Think 12-lead, do ED's not repeat them on EMS arrival regardless if the field 12-lead reads AMI***?

The same would apply, in my mind here, it would merely get the ball rolling, and have the patient headed in the right direction.

Personally, I think were quite aways from that, or even iSTAT being implemented; the latter being one I would prefer over the former, but cost-effectiveness pollutes most aspects of healthcare, IMO.

 

[luke_31]

Honestly? I think your thought process is in line with mine, and even some of the others in this thread.

Perhaps a few things were lost in translation, but I certainly don't think it should be used as a clear cut R/O tool in the field.

Like many tools in our kit, the diagnostics they offer may provide guidelines to our treatments, and/ or hospital decisions.

I don't think having a questionable U/S in the field means that it stops there. Think 12-lead, do ED's not repeat them on EMS arrival regardless if the field 12-lead reads AMI***?

The same would apply, in my mind here, it would merely get the ball rolling, and have the patient headed in the right direction.

Personally, I think were quite aways from that, or even iSTAT being implemented; the latter being one I would prefer over the former, but cost-effectiveness pollutes most aspects of healthcare, IMO.

Working on getting Istats out here at my place, but I don't expect to see them till next summer with how slow things move here. We are still waiting on supplies we ordered over a month ago.

 

[ERDoc]

If you have belly pain and a high suspicion for pregnancy related issue in your differential, you should go to a hospital which has capacities of managing an OB emergency. I don't understand what is confusing about that statement? My question is how would an ultrasound dictate your decision making in the field? Are you stating that a field ultrasound would be so accurate in picking up an ectopic pregnancy, ovarian cyst, etc that a medic would be using it to dictate a destination?

And regarding the trauma situation, the role of the ED is to triage patients who don't meet obvious criteria. It is difficult in many situations to differentiate this in the ER itself, why are you guys so confident that this is a role that EMS should be taking on?

First, most OB issues before 20 weeks don't need an OB. Second, there are a lot of things that can cause pelvic pain in a female of childbearing age, almost none of which require an OB (including ovarian cysts). Prehospital US has a very limited role, which would be only in those women who know they are pregnant. You would not be ruling anything in or out in the field, just determining the most appropriate hospital based on the available info. Pelvic pain in a pregnant woman with no fetus or free fluid on US, go to OB hospital. Intrauterine fetus with no free fluid, go to local hospital. Is it fool proof? No, but nothing in medicine is.

It opens up a host of liability that I don't think EMS is structured to take on.

We should have a RULE OUT method to not taking a patient to a higher level of care instead of a RULE IN method. Having a young female with "classical abdominal pain" with a "negative" field ultrasound who then ends up having a massive bleed due to ectopic with delayed transport to a hospital with OB capacities is not a responsibility that many systems should be taking on.

What is "classical abdominal pain"? If she has a massive bleed you are going to see fluid in the pelvis. The same applies for trauma. Most trauma pts don't need a trauma center. But a prehospital FAST with fluid would definitely warrant transfer to a trauma center or activation of HEMS.

 

[VinBin]

I think you're still missing the point. It is a liability that should not be placed on EMS to document they used a field ultrasound and made a decision based on that (if it turns out to be incorrect). You are definitely right that the vast majority of trauma patients do not need a trauma center, but they do need a full eval from a physician to rule out occult trauma. It is all based on mechanism, if someone has minor trauma, they can easily go to a level 2 or 3 center. If someone has mechanism to warrant a level 1 but have a negative prehospital FAST and minimal symptoms, I don't suggest encouraging EMS to take them to a level 2/3 based on the negative US. The mentality that to sit around on scene and do an ultrasound will improve outcomes is tenuous. The role of EMS is quick stabilization and transport, that has always been shown to improve outcomes in the vast majority of pathology/trauma that is seen.

And I was under the assumption that severe abdominal pain from suspected ovarian cyst has to be evaluated for a rupture, don't OB docs get consulted for that eval/management?

 

[Carlos Danger]

I think you're still missing the point. It is a liability that should not be placed on EMS to document they used a field ultrasound and made a decision based on that (if it turns out to be incorrect). You are definitely right that the vast majority of trauma patients do not need a trauma center, but they do need a full eval from a physician to rule out occult trauma. It is all based on mechanism, if someone has minor trauma, they can easily go to a level 2 or 3 center. If someone has mechanism to warrant a level 1 but have a negative prehospital FAST and minimal symptoms, I don't suggest encouraging EMS to take them to a level 2/3 based on the negative US. The mentality that to sit around on scene and do an ultrasound will improve outcomes is tenuous. The role of EMS is quick stabilization and transport, that has always been shown to improve outcomes in the vast majority of pathology/trauma that is seen.

And I was under the assumption that severe abdominal pain from suspected ovarian cyst has to be evaluated for a rupture, don't OB docs get consulted for that eval/management?

Personally, I do not think US has much practical role in most EMS settings. There are smarter folks than me who feel differently though, so who knows. Theoretically, it is a great idea - all sorts of potential uses. Realistically though, using it to make accurately diagnoses takes much more training and experience than most paramedics will get with it. If I understand your posts, we basically agree on this.

That said, I think you are making the wrong arguments against prehospital US.

First, how is a poor transport decision based on US findings any more of a liability than a poor transport decision based on any other assessment findings? With US you have another tool for gathering information. What you do with that information can be either good or bad. One could turn around your very argument and say "it is a liability for EMS to not use all available technology to accurately assess their patients".

Second, mechanism of injury correlates poorly to both injury patterns and outcomes. I'd go so far as to say that using MOI in any type of decision making algorithm should be completely struck from our educational curricula and our policies/protocols. For the sake of credibility, I would never use the term MOI if your goal is to convince other clinicians.

Lastly, there is no practical difference between a ACOS-verified level 1 and level 2 trauma centers. Participation in educational and research programs are the only real differences. Clinical capabilities and resources are virtually identical. Even a level 3 has the resources to properly manage all but the subspecialty cases. So along with MOI, I would avoid relying on this terminology in your argument.

Theoretically, ultrasound is nothing but a good thing. Where it falls apart is in the nuts of bolts of having everyday paramedics learn anatomy and imaging well enough to use it accurately on all types of patients for all types scans, and then integrate those findings into a treatment plan that they likely would not have developed without the information gleaned from the scan. I think that is a very tall order, especially when compared to the risk of misdiagnosis. But it has to be about more than transport destination to be worth using it.

 

[ERDoc]

The mentality that to sit around on scene and do an ultrasound will improve outcomes is tenuous. The role of EMS is quick stabilization and transport, that has always been shown to improve outcomes in the vast majority of pathology/trauma that is seen.

And I was under the assumption that severe abdominal pain from suspected ovarian cyst has to be evaluated for a rupture, don't OB docs get consulted for that eval/management?

1. It only takes a few seconds to do a FAST exam. No one has said that it will improve outcomes, because no one has studied it yet. No one would expect EMS to perform at the level of an ultrasonographer, just enough to be able to say, yes fluid or no fluid.

2. You assume wrong. The only time an OB/Gyn sees an ovarian cyst is when they are causing torsion. Ruptured cysts are painful because the cause inflammation in the peritoneum, which is painful but not dangerous. Occasionally you can have a hemorrhagic cyst which are also not serious, the only caveat is that a rare hemorrhagic cyst can continue to bleed and cause hemodynamic instability. This would need a Gyn, but I have seen maybe 2 of these in 15 years. These pts are pretty obvious because, well, they're hemodynamically unstable. Ob/Gyn rarely sees ER pts. Most of them we deal with and send home. The ones over 20 weeks with possible pregnancy related issues skip the ER and head to L&D.

 

[medicsb]

I'm in the group that thinks US has an extremely limited role, if any.

I use it all the time in the ED and it is useful. I'm not as into it as some of my other colleagues, but it does have uses. As far as the prehospital setting and use by paramedics, as deployed and trained in the US, I do not think it has much if any role. Not even in rural settings.

Hemoperitoneum can take time to accumulate to the point that you can see something. I have seen more than a few GSWs to the abdomen in patients who have had negative FAST exams... and still went to the OR for ex-lap and in many cases had bowel resected, etc. (I'm at an institution that sees over 2000 trauma activations with ~50% being penetrating; to be honest I could probably count on my fingers the number of times I've seen a positive FAST.) The patients where it was positive usually had a good mechanism, a peritoneal exam, or some degree of instability, but sure, there were some that were totally stable with nonperitoneal exams. The usual trauma center criteria is pretty sensitive and definitely allows for significant "over triage" to trauma centers, so I don't think US is going to change that.

I don't care much for US in cardiac arrest. I have yet to find it useful and whether there is "cardiac activity" or not is of little value to me as I'm not going to do anything different. Even in the ED setting, there is little evidence showing that US actually changes anything in a meaningful way, but there is plenty of anecdote, so I don't want to discount it completely and will assess early for a blown RV w/ R heart strain or pericardial effusion because I can potentially treat that. I'm giving fluids no matter the size of the IVC and fluid in the abd won't change how I run the code. If its from ascities - they have poor protoplasm and will die no matter what. If its from a ruptured AAA, they're dead dead dead. No lung sliding... yeah I'll put a needle in and maybe a chest tube, but if they're easy to bag and the breath sounds aren't unilaterally diminished, it's probably a simple pneumo and unlikely to affect outcome even if decompressed.

Gallbladder? Few get rushed to the OR anymore, they're more likely to go to IR the next day for drainage if its really bad. Appendix? Good luck seeing it, but even if your do, no one is getting rushed to the OR and I bet you surgery will still want a CT unless its a kid. Even then its often ABx until inflammation subsides, then an appendectomy.

Preggers and with abd pain - to a place with OB all day everyday and twice on Sunday. You'd probably get more milage from pricking the finger and putting a drop of blood on a bedside urine preg test (yeah, it can work), which would probably be more useful than an US.

 

[DesertMedic66]

I think you're still missing the point. It is a liability that should not be placed on EMS to document they used a field ultrasound and made a decision based on that (if it turns out to be incorrect). You are definitely right that the vast majority of trauma patients do not need a trauma center, but they do need a full eval from a physician to rule out occult trauma. It is all based on mechanism, if someone has minor trauma, they can easily go to a level 2 or 3 center. If someone has mechanism to warrant a level 1 but have a negative prehospital FAST and minimal symptoms, I don't suggest encouraging EMS to take them to a level 2/3 based on the negative US. The mentality that to sit around on scene and do an ultrasound will improve outcomes is tenuous. The role of EMS is quick stabilization and transport, that has always been shown to improve outcomes in the vast majority of pathology/trauma that is seen.

And I was under the assumption that severe abdominal pain from suspected ovarian cyst has to be evaluated for a rupture, don't OB docs get consulted for that eval/management?

Why shouldn't we be able to make a transport decision based on what results we get from the FAST exam? We make the decision to transport to a STEMI center vs non STEMI center frequently based off of the 12-lead.

Mechanism is a very poor indicator for how critical a patient is. A patient who has minor trauma can usually be seen and treated at a general hospital with zero issues.

Level 1 and level 2 trauma centers are pretty identical. We only ever transport our patients to the level 2 because that is our closest center.

OB patients (confirmed pregnancy) out here are not seen in the OB department until <20 weeks. So even if it's a pregnant female with ABD pain at 16 weeks she is seen and treated in the ED.

 

[medicsb]

Why shouldn't we be able to make a transport decision based on what results we get from the FAST exam? We make the decision to transport to a STEMI center vs non STEMI center frequently based off of the 12-lead.

Mechanism is a very poor indicator for how critical a patient is. A patient who has minor trauma can usually be seen and treated at a general hospital with zero issues.

Level 1 and level 2 trauma centers are pretty identical. We only ever transport our patients to the level 2 because that is our closest center.

OB patients (confirmed pregnancy) out here are not seen in the OB department until <20 weeks. So even if it's a pregnant female with ABD pain at 16 weeks she is seen and treated in the ED.

Mechanism may be a poor predictor, but mechanism is still important for consideration especially when trying to interpret physical exam findings in a stable patient. I may only be a resident, but in my few years of evaluating patients with trauma complaints, I have seen enough patients with "low" mechanisms have bad things happen. Should mechanism alone be enough to make someone a trauma? I'd say in certain cases, yes.

Abd pain in 1st trimester preg patient is ectopic until proven otherwise. You're right that OB does not have to see the patient initially. But, if ectopic is found or cannot be excluded (e.g. an indeterminate US), OB should be consulted if for no other reason than trending of HCG and close follow-up until an IUP or ectopic is confirmed.