Could ultrasound replace the stethoscope?
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Regardless, the stethoscope has (for better or worse) already been replaced for a while, at least for in-hospital care at larger US/Canadian community/academic settings, by chest x-ray and/or the increasing straight jump to CT pulmonary angiography.
The amount of patients with respiratory complaints presenting acutely that leave hospital without radiology department imaging is probably <10% today.
Physical exam skills as a whole are dying, abdominal pain is similarly a straight jump to CT or US these days, often before a physical exam is even documented (was it even done?). Even more true for gynaecological concerns (not debating whether or not this more ethical, but it's very rare to see ER physicians perform a vaginal exam these days before ordering ultrasound).
In terms of the utility of POCUS, the heterogeneity in training has been a barrier to adoption by clinicians in Canada (I imagine similarly in the US). While POCUS is performed by ER/internal medicine, patients are still being sent to radiology for formal imaging before definitive management takes place, even for more straightforward cases like gallstones and kidney stones. Presently, very few POCUS studies are formally uploaded to a patient's record in my current hospital (largest institution in Canada) although that is increasing and clinician competence at POCUS is slowly rising.
The FAST exam in trauma settings is probably one of the only reliable POCUS uses at the moment, and echocardiography.
I would say biliary, echo, ocular, peritonsillar, procedural (CVC, paracentesis, thora), soft tissue, early obstetric all highly reliable in my practice environment. Then again, our small department is almost all recently trained and we have very limited radiology options so we get a lot of practice.
1. Regarding FAST
There is a certain amount of variation by centre, but it is definitely not true that every trauma goes to CT first, most do but it’s not infrequent (forgive my usage of this) to go straight to OR for damage control lap and CT after, particularly with penetrating trauma or non-responding hemodynamically unstable patients. At my hospital (level 1 trauma) a positive FAST + instability generally goes straight to OR, you may argue the FAST is noncontributory and these patients should go straight to OR anyway but it’s certainly routinely performed.
2. Procedural - completely agree, should be highly reliable for all physicians. It’s arguably malpractice to do procedures blind these days.
3. Early OB - are you performing TVUS? This is uncommon, and if you are that’s phenomenal. Are you just doing r/o ectopic or formal dating US? CRL and MSD can be challenging to measure accurately, but if you’re doing a lot and getting followup from rads/OB it’s certainly possible to be reliable at this.
4. Soft tissue - as in abscess or MSK? MSK ultrasound is very challenging and I would be enormously impressed if you are doing tendon tears reliably (other than full thickness) as many radiologists are uncomfortable with these today. Do you have MR or formal radiology follow up reads to assess your sens/spec?
5. Biliary - Assuming you mean cholecystitis and gross bil dil, glad to hear this is becoming comfortable for POCUS practitioners. My centre has a formal POCUS fellowship but the surgeons don’t rely on their reads, they will see in consult based on POCUS but always demand a radiology examination prior to operating. I hope that this will change in the near future for chole. I’d be hesitant as a patient getting scanned for focal bil dil (aka ?cholangio) or PSC by POCUS, but I doubt that’s a common indication for you.
6. Echo - Assuming you mean for ER indications? Are you still sending for formal echos or comfortable ruling out all valvular disease? Our cardiology fellows who do bedside echo in CCU still seem to get formal reads.
7. Peritonsillar - I can’t even remember the last time I’ve reported one of these, we have dedicated ER CT scanners 24/7 so they always go straight to CT. Is this an accurate test?
Overall happy to hear POCUS is more reliable in some places, I dream of the day I can stop reporting acute care US.
> One of the issues to keep in mind with POCUS is monitoring outcomes / comparing with gold standards
Yes, establishing a QA process has been challenging.
> There is a certain amount of variation by centre, but it is definitely not true that every trauma goes to CT first
I'm sure it's very institution dependent. I trained at L1TS where the OR was much, much farther away than CT. CT was basically in the trauma bay, multiple scanners so almost always 1 open, so I don't recall a single case going straight to OR. CT usually only took a few minutes longer than an intern's FAST honestly. I'm sure there were a few that went without CT, but I don't remember any.
In my current L4TS our surgeons won't take trauma, so it's usually a multi-hour process just to get the patient accepted for transfer somewhere, during which they also always get scanned (or die if they're never stable enough).
> 3. Early OB - are you performing TVUS?
Yes, frequently. My wife is the chair of our Ob/Gyn department, so I have a bit of a leg up. Yes mostly eval for IUP / rule-in ectopic. Tremendous number of patients presenting late for prenatal care so will occasionally estimate a CRL / BPD / femur length, but only as a ballpark when communicating with colleagues -- rarely much time pressure on these so can be formalized as outpatient.
> Soft tissue - as in abscess or MSK?
Not MSK. Abscess, cellulitis (high burden of NSTI but don't want to scan them all). MSK mostly limited to joint effusions / shoulder dislocations in the obese. Occasionally for fracture reductions -- we have no C-ARM).
> 5. Biliary - Assuming you mean cholecystitis and gross bil dil
Yes, this. Lots of these, very high burden of alcoholism and gallbladder disease here (as many as 5 acute choles in 1 morning between 8 AM and noon, all confirmed in the OR), so lots of abnormal LFTs, belly pain, and vomiting. POCUS critical here! Many of our surgeons hesitant, but the sensitivity seems to be pretty good and helpful for making overnight dispos in people with clearly normal studies (esp in the context of labs, vitals, exam -- which admittedly bias our interpretation of the study).
> 6. Echo - Assuming you mean for ER indications?
Yes -- mostly wall motion, severe acute CHF, gross RV dilation, large effusion, gross valvular incompetence. Can get formal studies later for the details, this is mostly for "does this seem to be a likely cause of this patient's critical illness?"
> 7. Peritonsillar
Tons of PTAs here. Yes, useful -- both for Dx as well as "where to aim the needle / scalpel."
I forgot to add DVT -- we do lots of those.
Yes, and that's also not supposed to work like that. ATLS says FAST+ -> OR without donut. As an anesthesiologist, I can tell you it's very frustrating to lose patients because you spent an hour and a half in the ER because the trauma surgeon doesn't have the balls to open the patient without a CT. Lost a 20 yo, probably in good part due to that.
> you spent an hour and a half in the ER because the trauma surgeon doesn't have the balls to open the patient without a CT. Lost a 20 yo, probably in good part due to that.
Rough case, sorry to hear about that. I imagine the logic of blindly following ATLS probably depends on circumstances; where I trained the CT scanners were basically in the trauma bay, whereas the OR might as well have been a mile away. I imagine estimating the cumulative harms of opening a patient for a false-positive FAST (ascites, physiologic pelvic fluid in a reproductive age female) every once in a while vs the harm of spending an extra 5-10 minutes for CT (when it takes longer than that to get to the OR) is some complex math. Of course the farther away the OR is, it would taken even longer to get CT and then get there...
To the extent that there are regulatory hurdles to buying and operating a CT suite (and there are such hurdles in many states), there should be regulation that ensures that the billing is reasonable. Instead, you pay like a whole number percentage of the cost of running the damn thing for a year.
1. A lot of ED centres are financially rewarded if they keep time to disposition within target (either directly in Canada or for throughput in US). If the CT identifies a cause for admission and a service is consulted that patient is officially “discharged” from ED even if they are physically still there waiting for the specialty consultation / admission.
2. Generally unjustified malpractice fears in both US/CAN, the theoretical risk of cancer down the line is impossible to tie to an individual imaging study, but there is a lot of fear for missed diagnosis. Despite risk scoring systems for things like pulmonary embolism I see a lot of patients with pneumonia on X-ray (I.e. an explainable cause for chest pain) getting these studies “just to be safe”. Overalll positivity rates on these studies is 1-2%, despite how much this imaging has become utilized (something like 10-20x increase over the last 10 years) we have not seen corresponding reductions in mortality suggesting overimaging, but research is ongoing.
As a radiologist I try my best to reject unnecessary scans, but it’s difficult to do so when a clinician is telling you “I’m scared about deadly condition x”. When they’re younger I can apply the radiation risk consideration and suggest shared decision making, in some outlandish requests (I was asked to CT an 18 year old male with a fever, negative blood work and zero risk factors for PE, so likely viral illness or asthma) I outright refuse but those cases are few unfortunately as most presentations are elderly patients.
It was just a sinus infection that was irritating a cavity, which was making my whole jaw ache to where I couldn't sleep (overnight Saturday), and I went in out of some combination of panic and concern that it was escalating.
It rankles me to no end that they up charged the visit because of the consult, where what really happened is the doctor ordered a test that allowed someone else to do a definitive diagnosis and more or less completely removed their liability (both by removing uncertainty and by shifting it). I also can't begin to reconcile the cost of the scan itself (but don't really have any information about their actual costs). I dunno, maybe it did actually cost them a bunch of money to wheel me over to the CT room and back.
Given that an average ER scanner does something like 80 studies a day, sounds like they’re depreciating over a week…
It's a small town hospital, so I wouldn't be surprised if their volume is quite a bit lower than that. Which still doesn't get to the cost being reasonable. 35,000 people in the county, with some of those people being closer or equal distance to other facilities.
In hospitals, sure, but GPs don't have access to those. At least in my experience "is this a bad cold or is it bronchitis" gets answered with a stethoscope.
- POCUS = Point Of Care Ultrasound
1: Thanks to https://news.ycombinator.com/item?id=34464971
I have literally never had an inpatient colleague -- from rural to academics -- admit a patient for eg pneumonia without an X-ray, no matter how young and otherwise healthy or how convincingly the history and vitals match my carefully documented auscultation, egophony, and percussion. It's a waste of everyone's time to even try. As a result, many of my colleagues skip the middle man and don't bother with much exam. Some don't even bring a stethoscope to work anymore.
Which makes me sad.
Good for you though, I haven’t seen these exams performed done since the clinical skills course during preclerkship of medical school. It’s honestly a running joke in my medical friend group, when we used to teach the medical students we’d have to pull out a copy of Bates and remind ourselves how to do those and whispered pectoriloquy haha.
Not until a ultrasound can easily and quickly identify a heart murmur or crackle of lungs indicating the type of lung infection. (as in put it on, wait for 10 seconds)
Look, ultrasounds are slow, narrow, high resolution tools. Scanning your lungs with an ultrasound takes a fucking age, and requires a lot of training to get good results and interpret them. if you at the GP/family doctor, and you want to eliminate symptoms quickly, the stethoscope is super quick.
sure, if you are looking for fluids to drain, ultrasound is great. But you are looking for something and you need to be precise so you can shove the drain in the right place.
my doctor friend says: "ultrasounds are great, but they are really hard to understand. I used to do brainscans on newborns, and I fucking hated it" (the inference being that getting a good image was tricky and fatiguing)
US reports are so heavily based on what the sonographers saw, and documented, so there is huge operator dependency/variability.
I’m not sure how old your friend is, but as a recently trained rad I have little confidence in my own skills for neonatal brains to be honest, older rads had more time to develop their skills while we are much more exposed/comfortable with cross-sectional imaging these days and dependent on sonographers. I feel a lot better reporting a rapid MR protocol with the neonate in bundle and wrap (no anesthesia).
take a 5 year old, its coughing like a 5 year old does when it has a nasty cold. Is it crackling, if so where? ok something to worry about, lets think about antibiotics. If not done. off you go home tell us if it doesn't improve in 5 days. (steps shortened etc, etc etc)
xray? seems excessive, ultrasound? also expensive and trying to get the kid to stay still for it. faff.
For actual confirming diagnosis, yes, but its already done that way. The article specifically says replacing the 'scope with an ultrasound.
Can a slicing machine replace a knive ? Yes but it is too heavy to carry around.
It's one instance among many of the same.
They were also part of AMD' CES keynote on health with their chips. https://youtu.be/OMxU4BDIm4M?t=3831
Great story highlighted how having mobile ultrasound has helped this rural community doctor
Surprised to hear that they have separate USB-C and lightning offerings in 2022/2023, seems archaic.
In the western world, isn't it preferable if ultrasounds are left to specialists? I'm wondering if the use of cheap portable devices is part of a trend of improving healthcare, or just making it cheaper (or both).
There’s the idea that clinicians can use this tool to aid in diagnosis as an extension of the physical exam (e.g. I’m worried this patient might have a kidney stone, let me slap the ultrasound on their back and check).
The pitch has been that it would increase throughout and alleviate the strain on radiology departments giving us and our sonographers more time to do more complex imaging studies.
In practice, the training and skill of clinicians ranges from borderline negligent to amazing, leaning more towards the lower end. Given this heterogeneity, it is still yet to be accepted as a true diagnostic test in many places where a radiology department exists so the purported benefits aren’t being realized.
Ultrasound is harder than it looks, and unfortunately a lot of physicians just took a weekend course to get certified. In the hands of an adequately trained physician, I feel it’s very safe for clinicians to perform basic scans and that it would safely expedite patient care while alleviating burden on radiology so overall benefiting the system more than a cost thing.
Yes, if you happen to be in a country with money and technology sure. for some cases.
I hope they will still train doctors how to use a Stethoscope and drill it into them.
Years ago I read that BillyG got a full MR once a year That way the billionaires' doctors could look for changes. growths, and whatever else may show up in a delta. Sounds like a good idea.
If everyone had a full MRI every 6 months, a lot of issues would be resolved earlier, I think. (I am not a doctor). So a lot of doctors visits and exams could be eliminated.
We would just need a sh*tload of MRI machines everywhere.
On that note could you just make a conveyor belt? One person at a time, 0.5 m between each person? I mean to make the process efficient. Maybe add a few XR or CTs on the path, some blood. sprinkle AI and we will have a Silicon Valley sensation. Someone write me a check now.
If you had an ileus (non moving bowel) for 2 weeks you would know without auscultating. If you’re passing gas or having bowel movements, the presence or absence of bowel sounds means nothing.
If you’re not passing gas or having bowel movements after 2 weeks the auscultation findings are similarly meaningless as this is a very concerning presentation.
At the time I was unfamiliar with this term (which means a rumbling or gurgling sound in the belly) and did not for a moment consider that a nephrologist was listening to someone’s belly in the middle of the night. Given how scary the word sounded I performed a stat CT.
I googled it after the scan was completely normal. One of the most embarrassing and angering moments of my medical career so far. I swore since that day I would die fighting the crusade against those demons who auscultate bowel sounds.
An inordinate amount of time is spent teaching auscultation (using a stethoscope) to doctors. The diagnostic performance isn’t that great even under ideal conditions. Having bedside ultrasound would really improve things for patients, and save money on unnecessary tests and treatments.
Irrespective of their findings, clinicians are not yet confident enough to discharge their patient on the basis of their negative POCUS nor are surgeons confident enough in the clinician skills to operate on positive POCUS findings (except FAST). Hopefully this will slowly improve over time, particularly if AI can play a role in procuring adequate images, but ultrasound is a hard skill to master (sonographers do this day in and day out, a lot more skillful than myself as a radiologist let alone a clinician with an underpowered POCUS).
Conversely, there is a non-trivial amount of unnecessary imaging generated as a result of POCUS findings (perhaps most significantly for aortic dissection which is a high dose CT scan). Out of ~100 CT studies I've reported that come with the history 'dissection/intimal flap on POCUS' 0 have been positive, and had the clinician gone purely on the clinical picture + labs they would have probably not ordered the CT in most of these cases.
Also ultrasound can't penetrate lungs.
Yeah exactly. Apologies I use them inconsistently and interchangeably, Epic’s electronic medical record system changed it to ED for some reason.
I thought POCUS was useful for pleural effusion and consolidation, but you’d know better than I do.
Pulmonary edema is presently still X-ray preferred as it’s easier to compare cardiomegaly and pulmonary vasculature with priors, as opposed to US images which are operator dependent and likely not saved. There is increasing research on cardiac/caval measurements as surrogates for CHF but the standard measurements haven’t been fully developed to be clinically ready as the sole investigation, I expect one day in the not too distant future this will change.
Pleural effusions go either way, as an initial investigation you’ll usually still want the X-ray to evaluate for parenchymal disease and CHF so why do two tests. With that said we drain effusions under US guidance so if that’s your only clinical question for sure POCUS is great, I would say that’s an uncommon scenario though unless the patient is known for chronic/malignant effusions and you may only be assessing for reaccumulation and planning drainage.
Pneumothoraces on US still need X-ray confirmation and to accurately assess size as the sliding sign isn’t that reliable yet.
Given how broad most differentials are for dyspnea it’s hard to find a patient where US (either in radiology or POCUS) is satisfactory as a single investigation when concerned about lung/pleural disease. It’s awesome for cardiac stuff like wall motion abnormalities and gross dilatation/dysfunction in the acute setting, but you’ll still want a formal echo for accurate size measurements. At my institution we still have echocardiographers on backup call for the cardiology fellows, although they’re being called in less and less.
Abdominal imaging is way more of a crapshoot. Acutely presenting patients are often unwell, have large body habitus, and acquiring adequate images is hard even for us. If you’re in a place without emergent/urgent US access it’s certainly better than nothing. You would certainly never diagnose malignancy or workup a mass based on POCUS, this can be really hard even for radiologists + sonographers.
Personally, I hope clinician skills reach the point where I don’t do (or do significantly less) acute US studies so this isn’t gatekeeping at all. I would gladly give up the work. A lot of the issues stem from how POCUS was implemented, currently it is very unstandardized and you can get certified after a weekend course in some places and are being taught by other clinicians. It would be better if they rotated with our sonographers to learn the skills in my opinion.
Edit: I don’t disagree re: stethoscope but it’s already been replaced by X-ray in any facility with one (which is most places), chest imaging is a bad example of where POCUS will be useful for the above reasons. Increased skills at biliary, renal and testicular pathology as well as echo are way better examples and instances where stethoscopes are already outdated. When I was an intern 5 years ago we had already moved past auscultating murmurs, which are generally not acute, and you would still get a formal outpatient echo for accurate measurements (these take a while and you need to be really good at measuring, slight obliquely can significantly alter values).
My unpopular opinion is that point of care ultrasound is a fad and will eventually be phased out of physician workflows. This is because I haven't seen it actually change someone's medical decision making. More often, people use it as a means to justify why they haven't actually made a treatment decision yet.
The only way I could see it have adoption is if actual radiologists (which as of now are the only physicians that went through standardized examination confirming competency in reading ultrasound studies) started doing rounds in the ER and on the wards.
Volumes are getting insane, in some places I’ve worked I’ve had to keep up with 80+ CTs and 100 x-rays on an 8 hour evening ER/inpatient shift (never leave at 8 hours).
Convenience is no longer a significant differentiator.
https://en.wikipedia.org/wiki/Tricorder_X_Prize
Ultrasound goes to other industries like helping the true poor with smallholder animal husbandry to the billion dollar construction industry.
The sensors just need to be made cheap and attachable to cell phones.