by Cindy Soon MD and edited by Lorraine Ng MD and Sonny Tat MD MPH
Many new start-ups are promoting themselves as the Uber Something these days. There is the Uber of Dog Walking, The Uber of Snow Plows, and even The Uber of Dental Hygiene. Being the Uber of Something means disrupting existing approaches and instant gratification. In this way, The Uber of Pediatric Emergency Medicine may be Point of Care Ultrasound. It took one case to convince me.
She was a 12-year old girl with abdominal pain and no other symptoms. She was afebrile, tachycardic, had normal blood pressure, and an oxygen saturation of 91%. Her abdomen was diffusely tender but did not have rebound or guarding. Aside from the tachycardia, the rest of her exam was reassuring. We initially thought her abdominal pain may have been constipation, so we ordered an abdominal x-ray. While the abdominal part of the x-ray was unremarkable, the x-ray caught the bottom of the heart and it looked borderline enlarged.
At that point, it seemed like there were more questions than answers. We needed more information but what were our options in a busy ED?
Fortunately, Dr. Russ Horowitz was the attending that night and also the department’s director of ultrasound. He performed a bedside echo that showed severely depressed cardiac function and a fractional shortening of 11%.
Her BNP was elevated at 600 and EKG showed sinus tachycardia. Cardiology confirmed the echo findings and the patient was admitted to the cardiac intensive care unit. She did well on milrinone and was eventually discharged home a week later having recovered from a significant case of viral myocarditis.
The point-of-care (POC) ultrasound led to a timely diagnosis by zeroing in on poor cardiac function as the cause of abdominal pain. Without ultrasound, her evaluation would have been delayed and we could even imagine that if she had improved with pain medications, she may have even been discharged home.
Apical four views of the heart showing a severely depressed cardiac function.
Now widely accepting in emergency medicine, POC ultrasound has started gaining traction in pediatric emergency medicine. In 2011, 88% of pediatric emergency medicine programs provided training in POC ultrasound and 95% endorsed using POC ultrasound in their emergency department. In 2015, The American Academy of Pediatrics recommended that PEM physicians should receive POC ultrasound training, an acknowledgement of ultrasound’s potential.
Medicine is evolving, and physicians have to keep up with both the latest guidelines and the latest technological advances that help us become better, more effective clinicians. For example, instead of waiting for an x-ray to diagnose cases of questionable pneumonia, we can now place an ultrasound probe on the patient’s chest and make the diagnosis immediately. In addition to expediting clinical decision-making, POC ultrasound improves procedural success and can decrease patient lengths of stay.
One day in the near future, every clinician may have their own affordable and portable ultrasound device. POC ultrasound will move being from an optional skill to a basic clinical tool. Your Uber of pediatric emergency medicine will be arriving shortly.
We are hosting a 2-day hands-on pediatric ultrasound conference this May 19th and 20th in Denver, CO. Click to register or get more information.