Emergency physician–performed (EP) pelvic ultrasound has been shown to save lives, expedite patient care, and improve patient satisfaction. The 2001 and 2008 ACEP Emergency Ultrasound Guidelines define pelvic ultrasound as a core application for the assessment of the first-trimester patient presenting with vaginal bleeding or abdominal pain. Despite this, AuntMinnie.com, an imaging website, recently published an interview questioning the utility of EP pelvic ultrasound.¹

The news article highlighted a fundamentally flawed research abstract presented at a national radiology meeting. The study was a retrospective review of 75 patients at Santa Barbara Cottage Hospital in Santa Barbara, California, who received an EP pelvic ultrasound followed by a consultative ultrasound in radiology. When study results were dichotomized into positive or negative, the EP pelvic ultrasound was reported to be 74 percent sensitive and 90 percent specific compared to the consultative ultrasound in radiology. As expected, 24 percent of the focused EP pelvic ultrasound diagnoses did not match those reported in the comprehensive radiology reports. Examples included studies that were diagnosed in the ED as “no intrauterine pregnancy (IUP),” followed by a radiology ultrasound that diagnosed the presence of an ectopic pregnancy.

“I am proud of our program and have commended my physicians for embracing the amazing potential of POCUS. I am disappointed the program was cast into a disparaging light but have learned that evolution and change will always be scrutinized by the status quo.”
—Guy Tarleton, MD

The emergency ultrasound director at the institution, Guy Tarleton, MD, commented, “I interviewed the principal investigator of the study, and l learned there was little knowledge or appreciation of the goals of point-of-care ultrasound [POCUS] in the ED. The studies were judged against radiology department–specific standards set by the American College of Radiology [ACR]. Those standards mandate a comprehensive and detailed sonography of a given organ system or body part. The ED studies were lumped into a ‘misclassification’ category when they fell short of ACR comprehensive standards but clearly met or exceeded our goals for first-trimester ED POCUS. I am proud of our program and have commended my physicians for embracing the amazing potential of POCUS. I am disappointed the program was cast into a disparaging light but have learned that evolution and change will always be scrutinized by the status quo.”

The study investigators failed to acknowledge that staged imaging with an EP pelvic ultrasound followed by a radiology ultrasound is actually the appropriate use of both tests.

In a stable pregnant patient, if the focused EP pelvic ultrasound with a compact system reveals a viable IUP, no radiology ultrasound is necessary. The more complete examination must be performed by an appropriately trained individual, be it an emergency physician, ultrasonographer, or an ob-gyn consultant, if the EP pelvic ultrasound does not reveal a viable IUP. A comprehensive consultative ultrasound in radiology with a cart-based system would be indicated. In the unstable pregnant patient, if the EP pelvic ultrasound reveals significant free fluid in the abdomen in the absence of an IUP, emergent OB intervention is required.

Dr. Bailitz is ACEP Ultrasound Section Chair Elect, director of the division of emergency ultrasound at Cook County Hospital in Chicago, and associate professor of emergency medicine at Rush University Medical School in Chicago. Dr. Ferre is director of the emergency ultrasound division, program director of the emergency ultrasound fellowship, and assistant professor in the department of emergency medicine at Vanderbilt University in Nashville, Tennessee. Dr. Geria is clinical assistant professor of emergency medicine at Rutgers Robert Wood Johnson Medical School and faculty and ultrasound director at Brunswick Urgent Care in East Brunswick, New Jersey. Dr. Lewiss is director of point-of-care ultrasound and associate professor of emergency medicine at the University of Colorado Hospital in Aurora. Dr. Nomura is director of the emergency ultrasound fellowship at Christiana Care Health System in Newark, Delaware. Dr. Raio is chairman of the department of emergency medicine at Good Samaritan Hospital Medical Center in West Islip, New York, and past chair of the ACEP Ultrasound Section. Dr. Tarleton is emergency ultrasound director at Santa Barbara Cottage Hospital in Santa Barbara, California. Dr. Tayal is chief of the division of emergency ultrasound in the department of emergency medicine at Carolinas Medical Center in Charlotte, North Carolina.

Reference

1. Ridley EL. ACR 2015: Bedside US may not capture whole picture in ER. AuntMinnie.com website. Accessed Oct. 9, 2015.