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Ultrasonography and missed ectopic pregnancies
Correspondence Ultrasonography and Missed Ectopic Pregnancies Timothy Jang, MD Sanford Sineff, MD Chandra Aubin, MD Rosanne Naunheim, MD Reply Douglas S. Binder, MD Evaluating the Reconstitution of Intramuscular Ziprasidone (Geodon) Into Solution John D. Ewing, BA Douglas A. Rund, MD Nicholas A. Votolato, RPh Osteopathic Emergency Medicine Gail V. Anderson, Jr., MD, MBA Fellowship Training in Critical Care May Not Be Helpful for Emergency Physicians Rajesh Gupta, MD Rhett H. Butler, MD Reply Tiffany M. Osborn, MD Thomas M. Scalea, MD Out-of-Hospital Ultrasonographic Diagnosis of a Left Ventricular Wound After Penetrating Thoracic Trauma Frédéric Lapostolle, MD Tomislav Pétrovic, MD Jean Catineau, MD Sylvia Garcia, MD Frédéric Adnet, MD, PhD
Ultrasonography and Missed Ectopic Pregnancies To the Editor:
In a recent issue of Annals, Binder1 (May 2003; article #167) referred to a case report of a missed interstitial ectopic pregnancy and suggested that “undoubtedly many cases” of ectopic pregnancies were missed by
0196-0644/$30.00
emergency physician–performed ultrasonography. However, because interstitial ectopic pregnancies account for less than 0.15% of patients presenting with symptomatic first-trimester pregnancy, it may be that the difficulty in diagnosis had as much to do with the epidemiology of the disease and limitations of ultrasonography as it did the skill of the emergency physician. The diagnosis of ectopic pregnancy is difficult, even for radiologists.2 Before emergency physician–performed ultrasonography became accepted practice, 40% to 50% of women with ectopic pregnancies were missed on initial medical evaluation.3 However, after implementation of an emergency physician–performed ultrasonography protocol, Mateer et al4 found a reduction of almost 50% in the number of missed ectopic pregnancies. Likewise, Durham et al5 had an initial misdiagnosis rate of only 10% after implementation of a protocol involving emergency physician–performed ultrasonography. Contrary to Binder’s1 conjecture, the literature demonstrates a drastic reduction in the rate of missed ectopic pregnancies when emergency physician– performed ultrasonography is used in clinical evaluation. Binder states that “most of us will probably never be good enough at ultrasonography to justify our incursions into this field,”1 but the evidence seems to suggest otherwise. In addition to the aforementioned literature, data relating to focused abdominal sonography for trauma examinations have shown that inexperienced clinicians Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager™ (http://AnnEmergMed.editorialmanager.com). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A manuscript submission agreement, signed by all authors, must be faxed to the Annals office at the time of submission. Financial associations or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
Copyright © 2004 by the American College of Emergency Physicians.
MARCH 2004
43:3
ANNALS OF EMERGENCY MEDICINE
4 1 7
CORRESPONDENCE
can quickly obtain the skills necessary to perform accurate examinations. Likewise, in a study of our residents who had undergone 2 to 6 hours of didactic training, we found that an appreciable learning curve was reached after 20 examinations for both focused abdominal sonography for trauma and right upper quadrant examinations—well within a reasonable amount of training for emergency physicians. He goes on to state, “Given the choice, I would much rather concentrate my efforts at making sure that I have ready access to the technologists and radiologists who are specifically trained to perform and interpret ultrasonographic images rather than engage in interpretation of ultrasonographic images myself.” Unfortunately, many emergency departments do not have access to both ultrasonography technicians and interpreting radiologists 24 hours a day, 7 days a week, making this an untenable option for some. Likewise, given the ability of bedside ultrasonography by emergency physicians to rule in lifethreatening illness (eg, hemoperitoneum in blunt abdominal trauma and ruptured abdominal aortic aneurysms) quickly and without removing patients from the clinical area, it would be hard to justify refusing to learn or use such readily available diagnostic tools. We appreciate the reminder that emergency physician–performed ultrasonography should be used with clinical guidelines in appropriate settings. Although far from perfect, emergency physician–performed bedside ultrasonography has saved lives and advanced the care of patients, not only with ectopic pregnancies, but also with other life-threatening illnesses. For the sake of our patients, we hope that more emergency physicians will seek facility and competence in the use of this important tool rather than avoiding it. Timothy Jang, MD Sanford Sineff, MD Chandra Aubin, MD Rosanne Naunheim, MD Division of Emergency Medicine Barnes-Jewish Hospital Washington University School of Medicine St. Louis, MO doi:10.1016/j.annemergmed.2003.07.008 1. Binder DS. Use of ultrasonography in the emergency department: time for a reappraisal [letter]. Ann Emerg Med. 2003;41:755-756. 2. Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a US criterion of an early intrauterine pregnancy. Radiology. 1986;161:463-467. 3. Carson SA, Buster JE. Ectopic pregnancy. N Engl J Med. 1993;329:1174-1181. 4. Mateer JR, Valley VT, Aiman EJ, et al. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med. 1996;27:283-289. 5. Durham B, Lane B, Burbridge L, et al. Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Ann Emerg Med. 1997;29:338-347.
4 1 8
ANNALS OF EMERGENCY MEDICINE
43:3
MARCH 2004
Ultrasonography and Missed Ectopic Pregnancies To the Editor:
In a recent issue of Annals, Binder1 (May 2003; article #167) referred to a case report of a missed interstitial ectopic pregnancy and suggested that “undoubtedly many cases” of ectopic pregnancies were missed by
0196-0644/$30.00
emergency physician–performed ultrasonography. However, because interstitial ectopic pregnancies account for less than 0.15% of patients presenting with symptomatic first-trimester pregnancy, it may be that the difficulty in diagnosis had as much to do with the epidemiology of the disease and limitations of ultrasonography as it did the skill of the emergency physician. The diagnosis of ectopic pregnancy is difficult, even for radiologists.2 Before emergency physician–performed ultrasonography became accepted practice, 40% to 50% of women with ectopic pregnancies were missed on initial medical evaluation.3 However, after implementation of an emergency physician–performed ultrasonography protocol, Mateer et al4 found a reduction of almost 50% in the number of missed ectopic pregnancies. Likewise, Durham et al5 had an initial misdiagnosis rate of only 10% after implementation of a protocol involving emergency physician–performed ultrasonography. Contrary to Binder’s1 conjecture, the literature demonstrates a drastic reduction in the rate of missed ectopic pregnancies when emergency physician– performed ultrasonography is used in clinical evaluation. Binder states that “most of us will probably never be good enough at ultrasonography to justify our incursions into this field,”1 but the evidence seems to suggest otherwise. In addition to the aforementioned literature, data relating to focused abdominal sonography for trauma examinations have shown that inexperienced clinicians Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager™ (http://AnnEmergMed.editorialmanager.com). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A manuscript submission agreement, signed by all authors, must be faxed to the Annals office at the time of submission. Financial associations or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisement for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
Copyright © 2004 by the American College of Emergency Physicians.
MARCH 2004
43:3
ANNALS OF EMERGENCY MEDICINE
4 1 7
CORRESPONDENCE
can quickly obtain the skills necessary to perform accurate examinations. Likewise, in a study of our residents who had undergone 2 to 6 hours of didactic training, we found that an appreciable learning curve was reached after 20 examinations for both focused abdominal sonography for trauma and right upper quadrant examinations—well within a reasonable amount of training for emergency physicians. He goes on to state, “Given the choice, I would much rather concentrate my efforts at making sure that I have ready access to the technologists and radiologists who are specifically trained to perform and interpret ultrasonographic images rather than engage in interpretation of ultrasonographic images myself.” Unfortunately, many emergency departments do not have access to both ultrasonography technicians and interpreting radiologists 24 hours a day, 7 days a week, making this an untenable option for some. Likewise, given the ability of bedside ultrasonography by emergency physicians to rule in lifethreatening illness (eg, hemoperitoneum in blunt abdominal trauma and ruptured abdominal aortic aneurysms) quickly and without removing patients from the clinical area, it would be hard to justify refusing to learn or use such readily available diagnostic tools. We appreciate the reminder that emergency physician–performed ultrasonography should be used with clinical guidelines in appropriate settings. Although far from perfect, emergency physician–performed bedside ultrasonography has saved lives and advanced the care of patients, not only with ectopic pregnancies, but also with other life-threatening illnesses. For the sake of our patients, we hope that more emergency physicians will seek facility and competence in the use of this important tool rather than avoiding it. Timothy Jang, MD Sanford Sineff, MD Chandra Aubin, MD Rosanne Naunheim, MD Division of Emergency Medicine Barnes-Jewish Hospital Washington University School of Medicine St. Louis, MO doi:10.1016/j.annemergmed.2003.07.008 1. Binder DS. Use of ultrasonography in the emergency department: time for a reappraisal [letter]. Ann Emerg Med. 2003;41:755-756. 2. Yeh HC, Goodman JD, Carr L, et al. Intradecidual sign: a US criterion of an early intrauterine pregnancy. Radiology. 1986;161:463-467. 3. Carson SA, Buster JE. Ectopic pregnancy. N Engl J Med. 1993;329:1174-1181. 4. Mateer JR, Valley VT, Aiman EJ, et al. Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med. 1996;27:283-289. 5. Durham B, Lane B, Burbridge L, et al. Pelvic ultrasound performed by emergency physicians for the detection of ectopic pregnancy in complicated first-trimester pregnancies. Ann Emerg Med. 1997;29:338-347.
4 1 8
ANNALS OF EMERGENCY MEDICINE
43:3
MARCH 2004