The C Word & POCUS

Is cancer an emergency medical diagnosis? Technically, it’s not. The primary diagnosis of cancer does not show up in any emergency medicine textbooks. And rightly so. Although the complications of cancer can kill quickly, cancer itself develops relatively slowly. As such, the responsibility for the initial diagnosis of cancer falls largely to family physicians and our specialist colleagues. But try telling that to a patient and the public at large. If cancer is not a medical emergency, it sure is a personal emergency for our patients and their families. After all, it’s “The C Word”. Despite the above, it sure seems like the diagnosis is falling in our lap more and more. Maybe it’s just the way health care is going, but I have diagnosed more cancers in the last few years than I did in the first ten years of my career. In any case, if we can pick up some cancers earlier, so much the better for the patient. Here are some cases from Dr Lloyd Gordon that illustrate how POCUS can make it easier.

“How quickly can you make a difficult diagnosis? Would I have missed the diagnosis in these cases without POCUS?

Case 1

The first patient used a scooter because of a CVA. Two weeks before I saw him, the battery on the scooter died and he had to wrestle the scooter back to his place. His lower mid back had been aching with movement since then. He thought he had strained his back. So did I. Certainly the history and physical was otherwise not helpful. Probably a waste of time to POCUS. Still….

When I got to the left kidney, I saw something unexpected, a big cortical mass.

Compare to the normal R kidney? The R Kidney had a mass too, although smaller.

Bilateral renal cell ca (Papillary Type 1, Renal Cell Ca. on biopsy).

Case 2

The second patient had aches and pains all over. That was it for the history. Would POCUS help with this very non-specific history? Well….

Liver Metastases?

POCUS didn’t find a primary, so I did a rectal, which revealed a large rectal cancer.

Case 3

The third patient had just come from Southeast Asia, with a history of fever (not documented) as well as dizziness and generalized weakness. By now you know that POCUS is going to make the diagnosis. Liver metastases again.

This time POCUS found the primary in the GB.

3-4 minutes of POCUS to a definitive diagnosis for each of the 3 patients. Plus I might have missed the diagnosis without a little bedside imaging.”

Ed note: Who knows how long it would have taken to make these diagnoses if Lloyd had not used POCUS. In some cases, sure, the diagnosis may have been made in follow-up in the next week or 2. But, in other cases, the patient may not have bothered seeing another physician for months and his or her only contact with the health-care system may have been the ED visit with Lloyd.

Another abdo pain…just my 6th case today!

Every ED across the planet has its own demographic. Some EDs may see more of this, and other EDs may see more of that. But I bet we all see lots of cases of abdominal pain. Often enough, it can be difficult and time-consuming to make the diagnosis, especially in the older patient. Order blood and urine tests…maybe an x-ray…wait for the results…get an elective ultrasound…wait for that to get done…order a CT (if you can win that argument!)…wait for the result 🙁 An entire shift or more can go by in working up these patients before you get down to a diagnosis. Can POCUS always make the diagnosis in these cases? No, of course not. But it can in many. When it does, it will cut your diagnosis and disposition time from many hours to just a few minutes.

A 49 year-old man presented with a 3-day history of LLQ pain. It was constant and mild in intensity, with jabbing-type pain when it got worse. No fever, anorexia, or nausea/vomiting. He was constipated but had no other stool changes. PMH included diabetes. Normal vitals except for a HR of 106. Exam negative except for mild-moderate tenderness in his LLQ. No peritoneal signs and a NT prostate.

POCUS showed no AAA and no hydronephrosis. The probe was placed on the point of maximal tenderness and the following was seen.

 

 

Any ideas? Feel free to play the video again or look below for the answer.

 

The colon is outlined by the green arrows. A sizable diverticulum with a fecolith is indicated by the red circle. The blue arrow points to another smaller diverticulum. The tenderness was at its max when this area was in the centre of the screen and pressure was applied with the probe.

The patient was seen about an hour into their ED stay. The diagnosis of diverticulitis was made at first contact. Labs ordered at triage were still pending when the patient was seen. Those results ended up being non-concerning. With no red flags, the patient was discharged with treatment and did fine.

Diverticulitis and a whole bunch of other GI topics are presented at EDE 3 by Dr Andrew Skinner of St Paul’s Hospital in Vancouver.

Stroke patient…order CT…admit patient…no role for POCUS :( Ho hum…

What is the role of the acute-care clinician in strokes? In large part, it’s really unexciting. We all know that. All need a CT which is usually normal. Most get admitted. Whether they are devastating or trivial, there’s not much that we can do about it (if this makes you think about lytics, go to EM Cases for an update on that literature).

Is there a role for POCUS? Actually, there is! You knew I was going to say that 🙂 One use is looking at the middle cerebral artery. That’s a bit tricky so we’ll save that for another day and a discussion of EDE 4 topics! Here is a case from Dr Lloyd Gordon from Humber that illustrates something you can look for that is pretty straightforward. Here’s Lloyd:

“We were just discussing this topic at rounds a few days ago. On my very next shift, my 2nd patient was a man in his late 50s with mild DM who woke up with a left sided CVA. It started with left arm and leg weakness and progressed to a dense hemiplegia and facial nerve paresis. After doing a POCUS of his heart which was negative, I scanned his carotids in the longitudinal and transverse planes.

Longitudinal

Transverse

 

Sure enough the right carotid had what looked like an intimal flap, presumably a carotid dissection. The point was made at rounds a few days prior that CVAs due to carotid dissections tends to occur in younger patients.”

Ed. note: This scan is really quick to do. Note that Lloyd also scanned the heart. While not all stroke patients need their heart scanned, the A-fibbers and those with bad hearts are worth scanning. You will find the occasional clot suggesting an embolic source. And you will find the clot WAY sooner than an elective echo, even when admitted.