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Bedside Ultrasound: Part of the Physical Examination
LETTER
Bedside Ultrasound: Part of the Physical Examination To the Editor: I have read with interest the articles1-3 published over the past year in The American Journal of Medicine with regard to the use of the bedside ultrasound machine as an adjunct to the physical examination. I started using a bedside ultrasound machine for central line placement during my last year of residency and quickly realized the value of this new technology. I now think that all standard internal medicine procedures, including paracentesis, thoracentesis, and central line placement, should be performed with bedside ultrasound guidance for patient safety. As I have grown more comfortable with the use of a bedside ultrasound machine, it has become clear to me that the potential for this new technology to improve the sensitivity of the physical examination is significant. I believe that in the future, a shared bedside ultrasound machine will be found in all internal medicine offices. A recent clinical experience illustrates the utility of this valuable new technology. This past summer, one of my relatively new patients, an 85-year-old man, visited me in the office for a blood pressure check. He was a thin white man who did not have any particular symptom. On abdominal examination, I palpated a pulsatile abdominal mass that I believed to be an abdominal aortic aneurysm. I hesitated to schedule a confirmatory ultrasound for a moment, thinking that he may be best served through immediate referral to a vascular surgeon. However, in the end, I scheduled the ultrasound to confirm my examination findings. To my horror, 2 weeks after the patient missed his scheduled ultrasound appointment, I learned that he had presented to our local emergency department with abdominal pain. His aneurysm had ruptured. Remarkably, after 2 major surgeries, a 2-week intensive
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
care unit stay, a 3-week hospital stay, and 3 weeks of rehabilitation, he survived. I saw him last week for the first time since his hospitalization; he was pale but otherwise looked well. I discussed this case with several of my partners, and no one faulted me for my course of action. However, I cannot stop thinking about what may have happened if I had been able to confirm my physical examination finding with a bedside ultrasound. I strongly believe that a basic understanding of ultrasound physics and image interpretation should be a part of a medical student’s education, and I am obligated as a practicing physician to become facile at this powerful new bedside tool. I wonder what study could be done to provide the necessary evidence that a bedside ultrasound can be safely used at the bedside and cost-effective? What studies were initially performed to prove the usefulness of the stethoscope? As for the cost, the cost of a laptop-sized ultrasound machine with 2 probes is approximately $35,000-$40,000. The cost of my patient’s 3-week emergency hospital stay was $110,152.06. I believe that the time is now for the use of the bedside ultrasound machine as an adjunct to the physical examination. Donald Medd, MD Maine Medical Center Portland, Me
doi:10.1016/j.amjmed.2009.11.016
References 1. Alpert JS. Should a hand-carried ultrasound machine become a standard equipment for every internist? Am J Med. 2009;122:1-3. 2. Martin LD. Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination? Am J Med. 2009;122:35-41. 3. Martin LD. Hospitalist performance of cardiac hand-carried ultrasound after focused training. Am J Med. 2007;120:1000-1004.
Bedside Ultrasound: Part of the Physical Examination To the Editor: I have read with interest the articles1-3 published over the past year in The American Journal of Medicine with regard to the use of the bedside ultrasound machine as an adjunct to the physical examination. I started using a bedside ultrasound machine for central line placement during my last year of residency and quickly realized the value of this new technology. I now think that all standard internal medicine procedures, including paracentesis, thoracentesis, and central line placement, should be performed with bedside ultrasound guidance for patient safety. As I have grown more comfortable with the use of a bedside ultrasound machine, it has become clear to me that the potential for this new technology to improve the sensitivity of the physical examination is significant. I believe that in the future, a shared bedside ultrasound machine will be found in all internal medicine offices. A recent clinical experience illustrates the utility of this valuable new technology. This past summer, one of my relatively new patients, an 85-year-old man, visited me in the office for a blood pressure check. He was a thin white man who did not have any particular symptom. On abdominal examination, I palpated a pulsatile abdominal mass that I believed to be an abdominal aortic aneurysm. I hesitated to schedule a confirmatory ultrasound for a moment, thinking that he may be best served through immediate referral to a vascular surgeon. However, in the end, I scheduled the ultrasound to confirm my examination findings. To my horror, 2 weeks after the patient missed his scheduled ultrasound appointment, I learned that he had presented to our local emergency department with abdominal pain. His aneurysm had ruptured. Remarkably, after 2 major surgeries, a 2-week intensive
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
care unit stay, a 3-week hospital stay, and 3 weeks of rehabilitation, he survived. I saw him last week for the first time since his hospitalization; he was pale but otherwise looked well. I discussed this case with several of my partners, and no one faulted me for my course of action. However, I cannot stop thinking about what may have happened if I had been able to confirm my physical examination finding with a bedside ultrasound. I strongly believe that a basic understanding of ultrasound physics and image interpretation should be a part of a medical student’s education, and I am obligated as a practicing physician to become facile at this powerful new bedside tool. I wonder what study could be done to provide the necessary evidence that a bedside ultrasound can be safely used at the bedside and cost-effective? What studies were initially performed to prove the usefulness of the stethoscope? As for the cost, the cost of a laptop-sized ultrasound machine with 2 probes is approximately $35,000-$40,000. The cost of my patient’s 3-week emergency hospital stay was $110,152.06. I believe that the time is now for the use of the bedside ultrasound machine as an adjunct to the physical examination. Donald Medd, MD Maine Medical Center Portland, Me
doi:10.1016/j.amjmed.2009.11.016
References 1. Alpert JS. Should a hand-carried ultrasound machine become a standard equipment for every internist? Am J Med. 2009;122:1-3. 2. Martin LD. Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination? Am J Med. 2009;122:35-41. 3. Martin LD. Hospitalist performance of cardiac hand-carried ultrasound after focused training. Am J Med. 2007;120:1000-1004.