Search This Blog

Follow by Email

Thursday, July 12, 2012

More on ultrasound use at the bedside: this short week in review

This week I was supposed to work 7 days at a busy hospital as a hospitalist. I am, however, done today, after only 3 days because the company that hired me found someone cheaper to work for 4 of the 7 days I was scheduled. I found out about this too late to refuse, but it is really not a good thing and I am moderately annoyed. It is, of course, nice to not work 7 straight very difficult days and to be headed home on a beautiful Thursday to spend some unexpected free time with my family, but the disruptions involved in working in shifts, as hospitalists do, are bad enough when we change every 7 days. The reason I'm more expensive and therefore at a disadvantage in my present job is that I am represented by a locum tenens company that is particularly nice to me and therefore costs the client hospital more money. I'm just learning this.

Nevertheless, it was a very good 3 days for learning. There were patients with mysterious illnesses that I got to discover and almost figure out, which was truly delightful. And I got to do many many bedside ultrasounds.

The best thing about working at a hospital where the patients are really sick and I am seeing lots of them is that there are so many good stories and so much interesting pathology and I get to meet so many people, patients, families and consulting doctors. The drawbacks involve my increasing wrinkles and gray hair.

Having bought my little pocket ultrasound machine, I now ultrasound everybody at least once and many of them I do repeated ultrasounds to followup abnormal findings. Other than the actual radiologists in this hospital and the occasional ER doctor, the only people who use ultrasound in patient care are me and the intensive care physicians who work in the Intensive Care Unit. Those of us who use ultrasound at the bedside are at a distinct advantage. That is putting it very mildly. With bedside ultrasound we can see, in minutes, what everyone else is simply guessing about. Some examples with details changed so as to be discrete:

I met a woman who was transferred from her regular doctor's office to the hospital because she had gained 30 pounds of fluid weight in a month and was starting to exude it from blisters on her legs. Very disconcerting! She was diabetic and had not had heart problems before. The possible causes could have been liver failure, kidney failure, failure of one or both sides of her heart or a host of other rare conditions. We met, talked, and I looked at her heart, lungs and abdominal cavity with my little machine and was able to see and show her what was wrong. Her heart had ceased to pump well, which had put liters of fluid into her lung and abdominal cavities and had backed up into her legs. After starting several medicines for heart failure she felt a tad better and I could show her that her heart, though still very tired, was getting a little more perky. This was very useful because, though she had a "real" echocardiogram done after I made the diagnosis, it would have been expensive and impractical to repeat that daily, and with my little machine I could show the patient exactly what I was looking at.

An elderly man who had a hip fracture did fine after surgery but then was unable to maintain a normal blood pressure an hour later and was not waking up. IV fluids helped only a little. A bedside echo at 11 at night showed his heart to be thickened, noncompliant and not a very strong pump (couldn't fill, couldn't empty). Ultrasound of his lungs showed that they were not yet wet, which was good. He could get more fluids, and probably what had happened was that his small firm heart had lost pressure due to dilated blood vessels with anesthesia and was temporarily out of service. No heart attack, not occult blood loss, not severe infection.

The very most interesting thing for me, though, was in the Intensive Care Unit where I sometimes hang out after my shift to learn things from the truly awe inspiring docs who work there. When I walked in, the patient, a 60 year old woman with severe lung disease, morbid obesity and a really bad pneumonia was getting a central venous catheter put in to her subclavian vein for infusion of the various potions that she would need for surviving, were she to do that. Ultrasound was, of course, used to put the line in, which was great, because there was a lot of tissue covering the landmarks usually used to put in such lines and the ultrasound made sure that the needle went into a vein rather than an artery and avoided the lung. As we sat talking, the patient's blood pressure started to fall. The ultrasound said that there was no pneumothorax, but it wasn't quite as good a picture as would be ideal, so we looked at the x-ray too, which took forever to be processed (it seemed like forever, but was probably 15 minutes, which is forever when someone is dying.) So the blood pressure problem was not a complication of the line placement. She then had no blood pressure, requiring cardiopulmonary resuscitation, chest compressions, the whole thing. Definitely bad news. There was a rhythm on the monitor but no blood pressure, electromechanical dissociation, a very bad prognosis. What was going on? Bedside echo shows that the heart is hardly pumping. Blood gas shows severe acidemia. Appropriate treatment is to correct the acid base balance and support the heart's pumping function artificially with epinephrine. Repeat echo in 5 minutes: heart is working fine. This only lasted about 20 minutes, then her pressure dropped again, CPR started again, echo shows heart is pumping fine, so the patient now needs more fluid due to the effects of septicemia from the pneumonia. The resuscitation went on intermittently for hours, and as such things go, did not end well, though the patient was stabilized as far as blood pressure and heart function went.

Quite the week. I think I'll go outside now and see what the sun looks like.

No comments: