Re: Protocols for ER Pelvics
From: Scotia Phillips, RT, RDMS (scotia@bellsouth.net)
Thu Aug 27 04:56:35 1998
At Wed, 26 Aug 1998, Scotia Phillips, RT, RDMS wrote:
OOPS! Intended to say difference between real Sonographer/Sonologists
and OTHERS (you supply the others).
>
>I have to jump in here! The difference between a real
>Sonographer/Sonologist is the ability to make informed judgements by
>performing whatever is needed to answer the clinical question. I do not
>believe that a limited exam is of real value except in very limited
>circumstances. Many times, these limited exams in the hands on
>non-sonographers cause delays in diagnosis as well as additional
>expense.
>
>Almost always, we do transabdominal scanning with whatever bladder is
>available and follow with transvaginal. Yes, TVS can miss some lesions
>out of the field of view vaginally, but the reverse has been true as
>well. IMHO, it is cruel to subject a patient who is already sick and in
>great pain to extreme bladder filling if the question can be answered (
>and it usually can) without this extreme.
>Of, course, we always fill the bladder of virgins, preferably without a
>catheter.
>The ability and desire to perform the neede exam is a mark of
>professionalism. All sonographers should be willing to do TVS when
>needed and adapt the exam within the standards of care to provide this
>service.
>
>Unfortunately, it also can require that we sacrifice our valuable time
>to fullfill our commitment to quality care.
>
>At Tue, 25 Aug 1998, June Standley and William Neubert wrote:
>>
>>I learned some interesting facts from you. Thanks. I don't like the idea
>>of inserting the catheter myself, but I certainly wouldn't mind if the ER
>>doc (OB specialist) looked with an EV probe in the ER and made the
>>determination before calling me in. That brings up the entire issue of
>>ultrasound being performed by the ER docs. I'm not against it, as long as
>>they know what they're doing. Ours will soon have an EV probe, and I'll be
>>instructing them (a couple short sessions !). A deal has been cut with the
>>hospital Radiologists; the ER docs are allowed to do about 5 things only -
>>extremely limited. As a sonographer, I'm happy not to get called in in the
>>middle of the night as long as I know the patient is getting adequate care.
>>June, RDMS,RVT,PHD
>>-----Original Message-----
>>From: James S Smeltzer MD <gaperina@mindspring.com>
>>To: Multiple recipients of list <ultrasound@talk.obgyn.net>
>>Date: Tuesday, August 25, 1998 3:06 PM
>>Subject: Re: Protocols for ER Pelvics
>>
>>>June,
>>>
>>>Then there is the one patient in twelve cathed who will have a UTI she
>>>didn't need, ruling out the ectopic she didn't have. Then she will develop
>>>pyelo (as happens with 25-40% of pregnant women with bacteriuria) and the
>>>fever will cause a lethal heart anomaly.
>>>
>>>One alternative would be to determine if she NEEDS a foley before inserting
>>>one, and inserting it yourself. She could be hydrated IV for the
>>>procedure, and asked not to void while waiting for the sonographer to come
>>>in. An alternative that would eliminate over half of the ER call-ins would
>>>be for the trained OB consultant to do the sonogram with their ER exam.
>>>Almost all masses not visible on TVS are palpable on abdominal exam or
>>>bimanual, so that person could make that call. That is how we worked it in
>>>2 of the 4 medical centers I have worked in, and it worked just fine with
>>>fewer hassles for the patient and
>>>as good or better results.
>>>
>>>Jim SMeltzer MD (gaperina@mindspring.com) (:^}>
>>>
>>>At 01:28 PM 8/25/1998 -0500, you wrote:
>>>>I agree with Terry. Also, remember the poor sonographer in all this. For
>>>>example, it's 2:30 AM and we get called in to do a case, EV only, then
>>find
>>>>out we have to do a full bladder scan, too. The patient has to go back to
>>>>the ER for the foley insertion, and we have to WAIT. By the time we crawl
>>>>home, it's looking like 4:00 AM ...... IF the ER hasn't added on another
>>>>case "since we were already there" ... and IF we don't get called back
>>again
>>>>before our 8 AM shift begins. We try to take everyone into consideration.
>>>>Our radiologists do whatever the ER doc wants and are NEVER rigid in
>>>>requiring a foley and full bladder if they feel the EV exam is adequate.
>>>>However, we always start on the premise that a foley will be inserted
>>before
>>>>we get there and that both techniques will be used unless the ER doc, the
>>>>patient, or the radiologist says otherwise. June
>>>>-----Original Message-----
>>>>From: DuBose, Terry <DuboseTerryJ@exchange.uams.edu>
>>>>To: Multiple recipients of list <ultrasound@talk.obgyn.net>
>>>>Date: Tuesday, August 25, 1998 9:27 AM
>>>>Subject: RE: Protocols for ER Pelvics
>>>>
>>>>>Donna, Victoria, et al. I agree in principle, but not in absolutes. The
>>>>>point I would draw the line is with those who may say that endovaginal is
>>>>>ALL that is EVER needed. I can't forget a case we were referred after
>>>>>having an exam in a lab where they only did EV for GYN and early OB.
>>They
>>>>>had called fluid in the uterine cavum a 4 week IUP. The physician didn't
>>>>>buy it and sent her to us for a 2nd. Transabdominally I found an 8 week
>>>>>abdominal fetus with a beating heart well above the uterine fundus... out
>>>>of
>>>>>the field of view of the EV.
>>>>>
>>>>>I think if you can document a normal IUP by EV, that may be all that is
>>>>>needed. But we also need to be flexible, very case is not the same.
>>>>>--
>>>>>Peace, Terry J. DuBose, M.S., RDMS
>>>>>
>>>>> I agree with Donna K.
>>>>>
>>>>> I have a strong bias toward doing transvaginal sonography. I believe
>>>>>that my bias may
>>>>> come from working in an OB/GYN office setting for several years.
>>>>>Whenever we have
>>>>> a patient with a possible spontaneous abortion, ectopic pregnancy or
>>>>>with acute pelvic
>>>>> pain...the FIRST thing we do is a transvaginal sonogram. It takes
>>>>>such a short time to
>>>>> verify a viable first trimester IUP with transvaginal sonography.
>>>>>I've never understood
>>>>> why I was required to have a patinet fill via Foley when I could
>>>>>usually answer the
>>>>> diagnostic question with a quick, realtively painless transvaginal
>>>>>exam.
>>>>>
>>>>> To my mind, for first trimester pregnancies and acute pelvic pain in
>>>>>an ER setting,
>>>>> transvaginal scanning should be the first thing done. Then, if more
>>>>>information is
>>>>> needed...a transabdominal scan could be performed with bladder
>>>>>distension via Foley.
>>>>>
>>>>> I have actually stood between an obstetrician and radiologist on an
>>>>>ER call with a
>>>>> patient on the table who had a positive HCG, acute pain and
>>>>>bleeding.
>>>>> The radiologist was insisting on a Foley and transabdominal scan.
>>>>>The OB said "WHY? Just
>>>>> do a transvaginal scan." In the end, the radiologist said that
>>>>>he/she was reading the
>>>>> exam...and they wanted the Foley and transab. scan. I did the
>>>>>transvag. first with the
>>>>> OB...viable IUP. Then, we had to cath the poor lady and take
>>>>>transab. images for the
>>>>> radiologist. WHY?
>>>>>
>>>>> It seems to me that the most cost effective, efficient and patient
>>>>>friendly thing we can
>>>>> do is use the transvaginal scan as a first scan.
>>>>>
>>>>> What do ya'll think?
>>>>>
>>>>> Donna Kepple wrote:
>>>>> >
>>>>> > Hold on! it is 1998!!! Transvaginal sonography IS pelvic
>>>>>sonography. I think
>>>>> > this argument should have been over years age. We routinely take a
>>>>>look
>>>>> > transabdominally only for masses that extend out of the focal zone
>>>>>of the
>>>>> > transducer. You don't have to have the bladder full for this at
>>>>>all. The PELVIC
>>>>> > sonogram is then done TRANSVAGINALLY.
>>>>> >
>>>>> > ______________________________ Reply Separator
>>>>>_________________________________
>>>>> > ______________________________ Reply Separator
>>>>> > ______________________________ Reply Separator
>>>>> > ______________________________ Reply Separator
>>>>> > Subject: Re: [Fwd: Protocols for ER Pelvics]
>>>>> > Author: buddy@redrose.net (JT or JL Tomko) at +INET
>>>>> > Date: 8/23/98 5:13 PM
>>>>> >
>>>>> > >
>>>>> > >Hello All,
>>>>> > > I need to know policies from those of you who have an ER and
>>>>> > >perform pelvics and first trimester pregnancies. In an effort to
>>>>>reduce
>>>>> > >nosocomial infections and pt. discomfort, my ER has started
>>>>>refusing to
>>>>> > >cathetrize and electing to oral fill instead. While I can
>>>>>understand the
>>>>> > >motives, when a sonographer is being called out to perform a
>>>>>study I
>>>>> > >personally feel that we should not have to wait while the patient
>>>>>fills
>>>>> > >by mouth. Doesn't this method defeat the "emergency" nature of
>>>>>the
>>>>> > >procedure? Also, these patients have probably already had an "in
>>>>>and
>>>>> > >out" cath for a U/A. Most of the other hospitals in town have
>>>>>standing
>>>>> > >orders for catheterization. What do you do? I need to know either
>>>>>way.
>>>>> > >Thanks for your help. Rene' Davis RDMS,RVT
>>>>> >
>>>>> > Rene',
>>>>> >
>>>>> > Our institution will place a foley catheter for ALL emergency
>>>>>examinations.
>>>>> > When the ER doesn't want to do so the argument/discussion is
>>>>>raised to the
>>>>> > emergency of the procedure. Our Rads argue if the patient is P.O.
>>>>> > hydradtion the surgeons will have our heads with anesthesia not
>>>>>too far
>>>>> > behind! If the patient is not a potential for surgery the case is
>>>>>not an
>>>>> > emergency. Occasionally we have a patient refuse the foley and
>>>>>the
>>>>> > examination is scheduled for a specific time as the patient fills
>>>>>via the IV
>>>>> > route or chooses to come back the next morning with a full
>>>>>bladder.
>>>>> >
>>>>> > Good luck on this issue.
>>>>> >
>>>>> > Janet
>>>
>--
>Scot
>
--
Scot
|
|
