1/14
The hallway SOBs
Twas a busy evening in the ED. I was coming out of the ressusc bay and I see 3 patients with the CC of "shortness of breath" all placed in hallway beds. X-rays were ordered already but X-ray is backed up. A resident has already seen 2 of the patients.
The hallway SOBs
Twas a busy evening in the ED. I was coming out of the ressusc bay and I see 3 patients with the CC of "shortness of breath" all placed in hallway beds. X-rays were ordered already but X-ray is backed up. A resident has already seen 2 of the patients.
2/14
"These 2 patients are quick ones with similar stories," he says, "Both in their 50s. The first pt has COPD, ran out of his meds a few months ago, coming in SOB. The 2nd pt is the same except he has asthma and ran out 1 week ago. I'll refill their meds then we can dc them"
"These 2 patients are quick ones with similar stories," he says, "Both in their 50s. The first pt has COPD, ran out of his meds a few months ago, coming in SOB. The 2nd pt is the same except he has asthma and ran out 1 week ago. I'll refill their meds then we can dc them"
3/14
"I typically get a CXR on COPD patients," I said "But let's go see them. Xray is backed up so let's take the ultrasound to look at their lungs."
"I typically get a CXR on COPD patients," I said "But let's go see them. Xray is backed up so let's take the ultrasound to look at their lungs."
4/14
While taking my history from patient 1, I scan his lungs. While scanning he remarks that he's mostly SOB at night. Here's his right side
While taking my history from patient 1, I scan his lungs. While scanning he remarks that he's mostly SOB at night. Here's his right side
5/14
These diffuse B-lines are not consistent with a COPD exacerbation. The diffuse B-lines on his left lung confirm pulmonary edema. He then tells me he has no history of CHF.
These diffuse B-lines are not consistent with a COPD exacerbation. The diffuse B-lines on his left lung confirm pulmonary edema. He then tells me he has no history of CHF.
6/14
With findings of pulmonary edema, I move to a cardiac #POCUS and confirm a diagnosis of new onset CHF. He gets Furosemide IV and we admit him for diuresis.
With findings of pulmonary edema, I move to a cardiac #POCUS and confirm a diagnosis of new onset CHF. He gets Furosemide IV and we admit him for diuresis.
7/14
After that patient, I was somewhat skeptical of patient 2 being straightforward asthma. This patient is wheezy throughout but is in no respiratory distress. I'm relieved to see A-lines on his right lung
After that patient, I was somewhat skeptical of patient 2 being straightforward asthma. This patient is wheezy throughout but is in no respiratory distress. I'm relieved to see A-lines on his right lung
8/14
His left lung also appears normal, with A-profile throughout. This time I agree with the resident's plan. After a nebulizer treatment he improves and is discharged with a new prescription. CXR was cancelled.
His left lung also appears normal, with A-profile throughout. This time I agree with the resident's plan. After a nebulizer treatment he improves and is discharged with a new prescription. CXR was cancelled.
9/14
Continuing on with my #POCUS in tow, I see patient 3 myself. He's an elderly male who says he's "sick". Reports left sided chest pain, SOB and malaise. He doesn't look toxic. He is a little tachy but otherwise normal VS. I take a look at his lungs. Right side has A-profile.
Continuing on with my #POCUS in tow, I see patient 3 myself. He's an elderly male who says he's "sick". Reports left sided chest pain, SOB and malaise. He doesn't look toxic. He is a little tachy but otherwise normal VS. I take a look at his lungs. Right side has A-profile.
10/14
Left anterior lung with A-profile too. So far so good.
Left anterior lung with A-profile too. So far so good.
11/14
I move to the left base and see pleural shred and focal B-profile. Uh-oh.
I move to the left base and see pleural shred and focal B-profile. Uh-oh.
12/14
Moving posteriorly I see the consolidation. Note lung hepatization (lung looks like liver) with dynamic air bronchograms (white shimmery lines in the consolidation). These are diagnostic of pneumonia.
Moving posteriorly I see the consolidation. Note lung hepatization (lung looks like liver) with dynamic air bronchograms (white shimmery lines in the consolidation). These are diagnostic of pneumonia.
13/14
I return to my computer to place orders. Labs are coming in and his WBC count is 16. Of course, I already know he has pneumonia and likely sepsis so I order IVF and CAP coverage. I admit him to the hospital. CXR is eventually done and reads "left atelectasis vs pna"
I return to my computer to place orders. Labs are coming in and his WBC count is 16. Of course, I already know he has pneumonia and likely sepsis so I order IVF and CAP coverage. I admit him to the hospital. CXR is eventually done and reads "left atelectasis vs pna"
14/14
This sequence demonstrates how #POCUS improves:
-diagnostic accuracy
-efficiency
-Time to diagnosis
-Time to treatment
and my favorite
-cognitive offloading. Making a dx at the bedside so didn't think too deeply. Allows me to focus my limited brain energy on other patients
This sequence demonstrates how #POCUS improves:
-diagnostic accuracy
-efficiency
-Time to diagnosis
-Time to treatment
and my favorite
-cognitive offloading. Making a dx at the bedside so didn't think too deeply. Allows me to focus my limited brain energy on other patients
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