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The Speed of Sound

The Speed of Sound

Canadian Radiologists Flex at EPs' Expense

Butts, Christine MD

doi: 10.1097/01.EEM.0000604520.54413.a8

    When I saw the hubbub online regarding the recent statement on POCUS published by the Canadian Association of Radiologists, I thought the publication date must have been a typo: It was listed as August 2019 when surely it must have been August 1999. (Can Assoc Radiol J. 2019;70[3]:219;

    This paper makes multiple statements that are lacking appropriate references or lacking references altogether. The association stated that “inappropriate use of ultrasound by undertrained physicians has resulted in increased patient harm” with no citation at all. The radiologists also didn't mention hundreds of studies that have demonstrated the benefits of POCUS and the abilities of non-radiologists to use it.

    The underlying problem of this statement, however, is that an ultrasound is an ultrasound to the association. In other words, POCUS should be viewed as any other ultrasound and subjected to the same standards as radiology-performed scans. This is wishfully simplistic. POCUS cannot be viewed this way, and one only has to look at its history to see why.

    The earliest application of POCUS was the FAST exam. As anyone old enough to remember the 1990s knows, assessing trauma patients at that time was limited. Diagnostic peritoneal lavage was the best option for a rapid(ish) assessment of intra-abdominal hemorrhage, but there was no quick and easy way to assess for pericardial effusion. No offense to Beck, but everyone's heart tones are muffled in a loud resuscitation room. Thanks to some trauma surgeons and EPs, the FAST was born.

    As any physician who evaluates patients in real time can appreciate, obtaining the perfect image is irrelevant when someone is crashing in front of you. Figuring out whether he is hemorrhaging is relevant, and is what led to the development of the FAST and what sets it apart from standard imaging. To this day, if I try to order a FAST exam by radiology, it doesn't exist.

    EPs then started to realize the potential of POCUS to answer other questions at the bedside. The E-FAST was a direct answer to the (many) limitations of the supine chest x-ray. The RUSH protocol combined echo and body imaging to evaluate patients in shock. A lines and B lines exist thanks to POCUS, not to a radiologist.

    Do we need radiologist-performed ultrasound? Of course, we do. Radiologists are experts in their field, and are invaluable in diagnosis and treatment. But the horse has left the barn when it comes to POCUS. Just like other skills that used to “belong” to other specialties (e.g., intubation), we've demonstrated that we can use it to save lives. Ultrasound at the bedside has become an invaluable tool, and we won't go back.

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    Dr. Buttsis the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her on Twitter@EMNSpeedofSound, and read her past columns at

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