Saving Brainspace with POCUS

Here is a cool case that Lloyd Gordon recently sent us…

“A 60 year-old woman had a fever of 39.6C and vomiting. The triage note mentioned abdominal pain but she didn’t have any pain when I saw her and she never asked for analgesics. Her abdomen was completely benign and she looked well. Not much to go on, especially with roughly another patients with influenza and gastroenteritis in the ED at the same time. I POCUS’ed all over, of course.

Here is her IVC:

Somewhat underfilled.

Here is her right kidney:

The right kidney showed a very prominent medulla, looking like nephrocalcinosis.

And her left kidney:

The left kidney had moderate hydronephrosis. [Ed. note: One wonders about a stone in the renal pelvis where there seems to be calcification (see circle). But there is no shadowing.]

Here is the CT scan:

A big stone at the UPJ.

So from an initial non-specific fever/vomiting/?abdomen pain, an immediate diagnosis of a urological emergency: renal colic with sepsis. Her lactate was 4.0. IV bolus/antibiotics and referral to urology.”

Ed. note: Think about what would have happened before POCUS in such a patient. 60 years old. Fever and vomiting. Abdo pain but non-tender. Flu season. Here’s your IV fluids and anti-emetics. Feeling better? Perfect! Because we don’t have any beds so you can go. If you are more concerned about her, maybe you do more tests and admit her, and you or the admitting MD falls upon the diagnosis…eventually. POCUS saves Brainspace on shift. The diagnosis is made up front. Treatment is started sooner. No diagnostic dilemma. Disposition from the get-go. The chart is off the EP’s clipboard and the case is off the brain of the EP, which is now clearer and ready to tackle the other patients, without the details of this case clouding their cortex.

Lloyd brings up nephrocalcinosis. Rather than blabbing on about it, here are some links regarding that entity from the good folks at Sonoworld and Radiopaedia.

EM Update in Toronto, Week of April 23

Lots of POCUS stuff will be happening at EMU this year. EDE and EDE 2 take place prior to the conference. EDE Master Instructors Jordan Chenkin and Rob Simard from Sunnybrook/U of T as well as Greg Hall (EDE 3/Brantford/McMaster) and myself will be running POCUS workshops during the conference. POCUS will even be on the main stage! The conference is happening a bit earlier this year, during the week of April 23rd. Mark your calendars and head over to www.emupdate.ca to register.

Foreign bodies in genitalia – Time for POCUS!

How’s that for a title! Books, lectures and plenty of other resources on foreign bodies would not be complete without at least one eye-catching image of a foreign body in an orifice where it clearly does not belong :). And there is often a bizarre story to go along with it. Admit it! Everyone has a grin on their face when such a pic flashes across the screen. Well, these next 2 cases are not that bizarre. But they do show how POCUS can be used to make small improvements in care and make our jobs just a bit easier.

This elderly man with dementia was seen by one of my colleagues recently, Dr Christine Pun. This gentleman was tired of having a Foley catheter. [Ed. note: Can’t say as I blame him!] He took it upon himself to cut the catheter off. No one was sure where the rest of the catheter was. Was it still in him? Did the rest of it snake up into his bladder. Presuming that the balloon was rendered dysfunctional, did he fully rid himself of the catheter with his next micturition? The emergency physician felt that part of the catheter was still in his penis. Urology was not convinced. Enter POCUS…

No need for labels on that image! Alligator forceps and away we go.

Next case…

100% of women feel sheepish and embarrassed when they present with the good old tampon in the vagina. Understandable that they would feel that way. But if given the same anatomy, guys would store all sorts of stuff up there. Just sayin’! But I digress…

Most of the time, these are simple cases. Do a bimanual exam, remove the tampon, and you’re done. Unfortunately, in a significant minority, no tampon is found on bimanual. But the patient is pretty convinced that it must be there, so the always uncomfortable speculum exam is often performed with the result usually being the same – no tampon. Maybe if POCUS can see a tampon, we could at least avoid the speculum exam?

A girl in her mid-teens presented with this exact complaint. She was a virgin and had never had a pelvic exam. For sure, that is a case where you would really want to avoid a speculum exam. I was training one of our EM residents when this patient was in the ED…he was doing his CPOCUS Core IP certification. He did a pelvic scan on her, with the imaging in longitudinal shown here…

Do you see the FB? This scan combines EDE 1 and EDE 2 topics, the image generation of Obstetrical EDE and the image interpretation of FB EDE. The tampon is the horizontal, linear area of echogenicity in the vagina on screen right. As the probe is swept towards the end of the video, shadowing into the far field becomes more apparent and is the giveaway. The emergency physician removed the tampon without difficulty. No one will ever study the utility and patient outcomes in these specific cases. But the argument could be made that if there is no FB on POCUS, then anything more than a bimanual exam may not be indicated.