Community Hospitals: Ultrasound Free Zones by William Mallon, M.D.
Monday, September 7, 2009 
William Mallon, M.D.Why is it that every EM resident training in the USA learns Bedside Ultrasonography (BSU) during residency, and then upon graduation goes out into the cold ultrasound-less world of the community hospital ED? Is rapid ultrasound so available in these hospitals that their skills in BSU are really not necessary? Hint; NO, THAT IS NOT IT! Well if that isn’t the explanation, then what is?
Some possible explanations are:
1) You can’t teach an old dog (AKA the ED Director) new tricks. These senior representatives and ED Directors can always get an ultrasound when they work. Usually they work on Tuesday between 10AM and 3PM (because they don’t work nights anymore, and can’t be left alone in the ED for much more than 4 hours because the wheels will fall off). Their reality just doesn’t overlap with the pit docs they hire to work weekend nights when the ultrasound tech is over an hour out and won’t come in. That trained EP could be diagnosing ectopics, ruptured spleens, retinal detachments and more if “the management” would just get over it and demand a machine. And brace yourself, they could bill for it too!
2) Previously identified old dog, does not want to challenge radiology on behalf of his docs or their patients. BSU done in the ED will no doubt cause concerns in the shadowy reading rooms where the radiologists are fraudulently billing for plain films they didn’t read contemporaneously to care. “Live and let live”, is how you keep your ED contract, so the old dogs don’t want to rock the boat by getting an ultrasound machine, let alone ask them to stop the billing fraud.
3) The decision-makers really don’t believe BSU works or is of any clinical value. When faced with that magnitude of ignorance what can you do? The evidence for BSU is compelling and substantial, but clinical reality is mired in delay at the community hospitals that still lack BSU capability. I always wonder how something with really weak evidence becomes a new EM standard of care (say amiodarone as an antiarrythmic for example), whereas something like BSU with compelling study after compelling study just never happens in the community.
Another blogger (Jan Shoenberger) on this site noted the disconnect between academic environments and the “real world” noting that many new grads are unprepared for the realities of practice. One example of this is that they know how to do BSU but will likely never have a chance to use that skill. Yet another blogger (Tom Mailhot) demonstrated bilateral peritonsillar abscesses and drained them with ultrasound guidance (no CT needed). Even the big “quality” gurus nationwide have called for ultrasound assisted procedures, which is something radiology is never going to do regardless of the time of day.
As for the “old dogs” reading this and responsible for the status quo…... Shame on you.
ED Directors, Mallon, Ultrasound in ED Operations, Ultrasound
Reader Comments (10)
I am saddend by Dr Mallon's comments denegrating community emergency medicine. As an " old dog" with well over 20 years in community emergency medicine ( and having trained in the days long before ED ultrasound), I can say that there are many suburban EDs where it is the standard of care to use BSU. The department where I work has two machines that are in near constant use. Many years ago, I went to the radiology department and fought the fight for ED ultrasound. I then went to multiple courses to learn its use. I have even taught some of the new grades ultrasound tricks. I agree that we should use every skill and part of our training to provide the best care possible. Oh, and I still work nights, weekends and holidays ( just finished working all of Labor Day weekend).
My ED in a poor rural community has had BSU for 2 years so it might not be as rare as you think. One of our arguments to administration was that we could use it as a tool to recruit RT physicians.
That high whining sound from the ivory tower might help spread the technology but I’ll bet that encouraging your graduating residents to make the availability of ultrasound an issue in their job searches would be more effective.
Tom Kearns, MD
I'm not sure Billy really meant to denegrate anyone, but i DO think a lot of community hospitals do lack it. Ithink its great the 2 responders have BUS bc it is indeed becoming (became??) standard of care, but i tend to agree it more the exception than rule. Hopefully those reading out there who don't have it, will get it soon. Also as noted, it is billable, and as an incomplete exam which is what we usually do, doesn't conflict with the radiologist bill, thereby avoiding the "double-billing" issue we see with EKGs and reg plain films or even CTs.
Its funny to me about the underlying tone of comparisons of acedemic centers and community hospitals here too bc i also agree most community docs work VERY, VERY hard......i don't dare say harder! But for those that work just in academic centers, SOME really don't realize the sometimes limited resources available to community guys. Some academia, and ONLY SOME, kinda like to hold their heads high like they're better docs than their community brethern when in reality SOME would have a very difficult time making the transition to that kind of work.
Nice read, I'm surprised to read that ultrasound is not readily available in the community. I wonder what the prevalence is nationwide.
Here is a pdf I found from ACEP on how to get reimubrsed for ultrasound:
http://www.acep.org/workarea/downloadasset.aspx?id=33270
I am an ER doc from a small community ED in PEI, Canada, and I also am an instructor for BSU. BSU is set to become a necessary component to our residency programs in 2010, and it is just over the last 7 years steadily spreading across our country's ED's. We in Canada are still a bit behind the US with respect to integrating BSU into our practice, especially in our community ED's, but this is very quickly changing.
With respect to Dr. Mallon's comments on possible reasons why BSU isn't widely available in smaller ED's, perhaps they are true (although I agree they aren't generalizable to all community ED's) but his first point "misses the point" of BSU, with all due respect, and perhaps that is also part of the problem.
When physicians equate BSU with formal ultrasound, and argue that they have no problem getting an ultrasound so why bother doing BSU, they are missing the point. In Canada, we call it EDE (pronounced "Eddie" after the first and most popular introductory course offered nationwide). EDE stands for Emergency Department ECHOSONOGRAPHY precisely to make the distinction between formal ULTRASOUND, and our bedside exam. While it is true, some centers can have a radiologist / resident do a bedside ultrasound (probably better than we can in some indications), this takes time to arrange and usually takes a very clear indication. We, on the other hand, can roll the machine to the bedside immediately and do the exam in less than one minute in most cases, and most importantly our threshold for doing the exam is MUCH LOWER than that for doing a formal. We get our answer faster, and in any patient in whom the question enters our head. This is important, since often the question we are asking involves a diagnosis with a real potential for sudden instability. Posterior hip pain COULD BE a ruptured AAA, but try and argue for a formal ultrasound! The person with a benign belly exam after that minor fall COULD still have free fluid, but good luck getting a radiologist to agree to a formal for that! The real power of EDE is for ruling out disease in the moderate to low risk (but not zero risk -- ie the patient that doesn't meet the threshold to obtain a formal ultrasound but who still potentially could have the disease). This allows for safer discharge. Yes, occasionally when an elderly man with all the risk factors who has a pulsatile mass and just fainted at home with belly pain presents, the EDE showing the 10cm AAA confirms the diagnosis and you feel like a hero. I don't think this happens as often as the negatives, and in this example you probably didn't need the EDE to tell you what was going on anyway. You will also occasionally, using EDE, make a diagnosis that you wouldn't normally have made simply because you did the exam in a patient that normally you wouldn't have thought met the criteria for a formal -- it is then that EDE has really made you a "hero." EDE should be considered like an extension of our physical exam, just like using the stethoscope, otoscope, or slit lamp, and not in diagnostic terms like more formal ultrasonography. These are totally different entities, done for very different indications and often for different reasons.
One could even argue that EDE / BSU has indications and uses beyond what formal ultrasound has. Guiding procedures (eg fracture reduction), for example, or using it to rule out pneumothorax in trauma. At least in Canada, neither of these are available through our radiology department.
Perhaps finding these "old dogs" -- we all know they still exist in some areas -- and arguing more appropriately about EDE's effect on patient care and making the distinction between formal ultrasound and bedside echo, you may be able to bring them over to your side.
thanks for your time, and sorry if this rambles.
Some have misunderstood this rant. It was in NO WAY a denegration of the community ER or its docs or the work they do. I have worked many hours in that environment and have the utmost respect. The blog was a comment to highlight the delayed emergence of BSU in community hospitals.
I didn't say NONE HAD IT (so if you do, great), but it is certainly true the majority do not. I have worked at 6 community hospitals in the LA area (with 3 city based EM residencies all teaching BSU) and NONE of those community hospitals had BSU when I worked there.
The "Old Dog" comments directly reflect the responses and reality impeding BSUs emergence in the community setting. If you are an "old dog" and still work weekends and nights great, but most ED Directors do not, and getting BSU into their EDs does fall on them.
The semantics comments are cetainly true and how we say what we are doing with BSU does matter, and I agree with that response.
The ivory tower whining (if you heard it) was probably tinnitus, because I don't live in an ivory tower, and I was not whining. I was simply identifying a widespread issue encountered by new EM grads when they start working in the community.
In any event, I appreciate the feedback, so thank you to all responders. Billy.
When I read Dr. Mallon's 3 comments I thought they were dead on. I have a company that has taught over 200 ultrasound courses to community EDs. In speaking with these community docs who are now on the other side of the fight (ie, I wouldn't be there teaching if they hadn't already won these battles) it seems the success lies in taking the high road and always doing whats best for patient care. One needs to prove this point through evidence based medicine and the latest ACEP guidelines outline these steps quite nicely.
There are many barriers for the community EP to not only get the machines, to get the training, get credentialed, create reports, archive images, perform QA, and submit charges - but in the end its worth all the hassles.
Nice post.
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