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Editor,—We were interested to read the “for debate” articles on ultrasound performed by accident and emergency (A&E) physicians. There seemed to be more support from the radiologists than from the A&E authors for this potential service development.1, 2
As advocates of beside emergency ultrasound, we suggest the case for or against ultrasound examinations by A&E staff should take both a hospital and an A&E perspective. The primary step in any evaluation is to show an investigation such as ultrasound can be performed safely and appropriately in our departments. Once this had been done, studies can be conducted to determine its contribution to clinical practice.
A&E indications for focused ultrasound include: free abdominal fluid following blunt trauma, cardiac tamponade, confirmation of intrauterine pregnancy in the first trimester, sonographic Murphy's sign in gallbladder disease, hydronephrosis in renal colic and abdominal aortic aneurysm. At King's, trained A&E physicians perform a limited scan to answer specific questions. The use of ultrasound in this regard is as an extension of the clinical examination to reach a diagnosis and initiate appropriate management. If a comprehensive scan is required, the patient is referred to the radiology department.
Radiological support for A&E ultrasound reflects the findings of a recent survey (unpublished) in which 25% of radiology clinical directors supported the concept of ultrasound performed by A&E doctors. This early endorsement is encouraging. The requirement for adequate training, skill maintenance and audit is common to many areas of clinical practice.
In a recent introductory two day ultrasound course at King's for emergency physicians, we found that interpretation skills are learned rapidly with pre-course and post-course testing indicating an improvement from 42% (SD 17.3) to 71% (SD 13.3). This is only the beginning of the learning process, but it supports the clinical findings that emergency physicians can be trained to perform bedside ultrasonography. A recent publication3 has confirmed the view that emergency physicians have a particularly steep learning curve when using ultrasound for a specific finding. It is suggested that as few as 10 scans may be sufficient to become competent at detecting free fluid following blunt abdominal trauma.
With regard to skill maintenance the actual number of scans performed per physician per day has not been established, but neither has the number of trauma resuscitations per physician per day. At King's in a department with 80 000 new patients per year, we could be performing 10 ultrasound scans per day. Each scan takes 5–10 minutes and assists in determining the management plan for the patient with perceived benefit with regard to time in the department and further investigations. Early impressions in patients with blunt abdominal trauma are that A&E ultrasound reduces the time for patients to proceed to theatre and also reduces the number of CT scans requested. This is currently being quantified.
The cost of a suitable ultrasound machine to perform these tasks is approximately £20 000. The longevity of such a machine is approximately 10 years. With very low maintenance costs, the principal revenue expense relates to training. Any service development involving acquisition of new skills requires an investment in training.
The question facing our specialty in the UK is whether limited ultrasound examination performed by A&E physicians has net benefits for patient care and service efficiency. We need to increase the understanding within the specialty of the limited nature of the study we are encouraging. Once it is in use in several units it will be possible to attempt to unravel the more complicated issues regarding health economics and patient versus hospital value. It may not be possible yet to quantify the benefits from ultrasound performed by A&E physicians in the UK, but there can be little doubt about the enthusiastic interest from colleagues.
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