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The Speed of Sound

The Speed of Sound

A Day in the Life of Ultrasound

Butts, Christine MD

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doi: 10.1097/01.EEM.0000473169.85227.9b
    Image 1. Soft tissue ultrasound demonstrating large area of edema with irregular-appearing fluid collection. Color flow within the collection demonstrates the location of the vein.
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    I am a big believer in using ultrasound at the bedside in the ED (obviously!), and I clearly don't need any convincing that ultrasound is a valuable tool. Sometimes, however, I get comments from my colleagues (and even some of my more senior residents) that ultrasound is nice but not practical for regular use in a busy community ED. Those comments got me thinking about my own day-to-day use, and I thought I'd let you spend a typical day with me and my ultrasound device to show how practical it really is.

    It was a typical busy Tuesday day shift. I was working with a lower level resident and trying to help him clear the rapidly growing patient list on our computer tracking board.

    The first patient I evaluated that morning was a man in his 40s complaining of swelling to his antecubital fossa that developed after he attempted to shoot up in that site a few days earlier. His physical exam was consistent with cellulitis and possible abscess, but given the anatomic location, we were concerned with avoiding the vasculature. A quick ultrasound at the bedside documented a large fluid collection and the location of the thrombosed vein, allowing us to complete the procedure easily without complication. (Image 1.)

    A few minutes later, the resident filled me in on a patient in her 20s complaining of epigastric pain. Her presentation seemed most consistent with GERD. My astute resident was thinking about gallstones as well because the patient noted post-prandial pain and nausea, and she was obese. Together, we evaluated her gallbladder at the bedside, confirmed that it was normal, and gave her a GI cocktail. She was discharged shortly after her symptoms improved.

    My next three patients were young women with complaints of abdominal pain and positive pregnancy tests at triage (because that is just the way things tend to happen in the ED). Quick ultrasounds of two of them revealed intrauterine pregnancies (IUP), and they were discharged after finding other causes of their abdominal pain. The third patient, however, proved to be a bit more complex. Our bedside ultrasound revealed a lack of intrauterine pregnancy, with an odd-appearing fluid collection within the endometrium. Evaluation of her adnexa showed a solid-appearing mass to the left with some questionable free fluid nearby. (Image 2.)

    Image 3. Soft tissue ultrasound demonstrating a small fluid collection (arrow) close to the surface, appearing to communicate with a larger, more solid area on the left of the image.

    Feeling somewhat flummoxed, we ordered a radiology-performed ultrasound to get an expert opinion. A little while later, the radiologist called me to report that they were concerned that the solid mass represented a clot from a possible ruptured ectopic pregnancy, particularly given the lack of clear IUP. The patient had developed severe lower abdominal pain in the interim. A quick call to the obstetric service, and the patient was taken to the operating room, where a ruptured ectopic pregnancy and large amount of bleeding was noted. The last time I checked, she was doing well following a left salpingectomy.

    Image 2. Transvaginal image of the left adnexa demonstrating a large, solid-appearing, circular mass adjacent to the uterus (U). The arrow highlights an area of suspected free fluid.

    The rest of the morning passed in an ultrasound-free haze of seizures, alcohol intoxication, and chest pain, but we pulled the ultrasound machine to the bedside twice more by the time the afternoon rolled around — once to evaluate another gall bladder (this one with stones) and the second time to check on a patient with a recent diagnosis of renal stones and continued pain. She had no hydronephrosis, and was discharged after changes to her pain management.

    My last case of the day was the most interesting and challenging. A woman in her 50s presented for a “wound infection” that had not improved after a week of oral antibiotics. Her case was complicated by a known diagnosis of melanoma that had recently been identified as metastatic based on a CT scan done the week before. The scan had identified metastasis to her bowel and a suspicious mass to her right axilla. Incidentally, the site of the suspected “wound infection” was where she had had a surgery of some type many months earlier. She complained that the incision site had become swollen, red, and painful.

    Her oncologist had evaluated her and, concerned for cellulitis, had placed her on antibiotics, but her symptoms had not improved. Exam of the area appeared consistent with possible cellulitis, with induration palpable surrounding the site. We reviewed her CT scan, and again were concerned about opening the area without knowing what was underneath. A bedside ultrasound revealed a small fluid collection connected to a deeper, more complex, and solid-appearing mass. (Image 3.) We decided to avoid opening the area and discussed the case with her oncologist, who agreed that the collection was most likely related to her underlying mass. Close follow-up was arranged for biopsy, and the patient was discharged.

    I probably pulled the ultrasound to the bedside about 10 times that day, which would make it a pretty typical day for me. I certainly didn't do any fancy calculations or diagnose any esoteric conditions, but I changed a few workups, streamlined a few more, and made a procedure safer. All in all, not a bad day.

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