In another 10 years, emergency ultrasound machines will replace the stethoscope as the physician's principal diagnostic instrument, and every medical student in Canada will be trained to use it, predicts Dr. Ray Wiss, an emergency physician at Sudbury Regional Hospital.
Wiss and his colleague, Dr. Steve Socransky, spearheaded the introduction of the portable ultrasound machines into emergency departments across Canada and gave Sudbury a reputation as a centre of expertise for the technology.
Socransky was exposed to emergency ultrasound, also called EDEs (short for emergency department echo) during his residency in the United States prior to arriving in Sudbury in 1997.
"Then, as I started to work here, I realized that there was a tremendous need for it because of the limited availability of ultrasound in our hospital."
Socransky lobbied to acquire the technology for Sudbury Regional's emergency department, but ran into stiff resistance from radiologists.
Wiss joined the department in 2001 fresh from a month of training in emergency ultrasound in Chicago and, together, he and Socransky succeeded in getting approval to buy a machine. That same year, Wiss started an introductory EDE course.
At the time, there were only three emergency departments across Canada that had emergency ultrasound machines, but they were using them "in a semi-professional manner," said Wiss. "When we came up with the EDE course here (in Sudbury), we introduced a much higher level of professionalism and a very methodical approach to the technology." Today, there are 300 emergency departments across the country with emergency ultrasound machines.
Course
The one-day introductory course was taught 20 times in 2002, 50 times in 2003 and between 50 and 70 times every year since then. Wiss serves as the director or the introductory EDE course, and Socransky is the director of a more advanced, two-day course introduced in 2009, all of which are taught by Sudbury emergency physicians in hospitals and at medical conferences across Canada. To date, the Sudbury ER docs have trained more than 5,000 physicians worldwide.
Sudbury Regional's Emergency Department also serves as an important training site for the Canadian Emergency Ultrasound Society's four-day certification course, and hosts Canada's only emergency ultrasound fellowship.
Socransky and Wiss were flattered when a graduate of the one-year fellowship program was recently recruited by St. Paul's Hospital in Vancouver and encouraged to make "Vancouver the Sudbury of Western Canada."
Emergency ultrasound took off somewhat earlier in the U.S., but "the Americans have a hodgepodge of training programs," said Wiss. "In Canada, we're united under one stream. The Americans look at this with great envy because we've been able to make sure that everybody who is using emergency ultrasound in Canada is using it at a very high level."
According to Wiss, emergency ultrasound can pick up tubal pregnancies or abdominal aortic aneurysms right in the Emergency Department and send patients suffering from these and other life-threatening conditions to the operating room without having to wait for an ultrasound in the diagnostic imaging department.
"These are people who literally would have died 10 years ago and now they're surviving," said Socransky.
"At the other extreme are patients where we have just a niggling doubt that they might have something," said Wiss. "It could be a woman who comes in with a bit of first trimester bleeding. She's in no pain and looks perfect. We look in the uterus and see her baby is in the right place. This woman can leave the department right away. She doesn't have to wait for the radiology department to come in the morning.
"Finally, there's the patient who falls in-between and causes the emergency physician tremendous anxiety. This is probably where the impact of the technology is greatest. Take, for example, an older person, over 50 who comes in with abdominal pain. Using emergency ultrasound, we can look into the belly and make sure he doesn't have any internal bleeding and doesn't have an abdominal aortic aneurysm. You can take down the risk to the point where you can sit on him overnight until your specialists come in the morning.
Grey hairs
"What gives us grey hairs as emergency docs is not so much the big cases. It's the times we worry about someone who might have something. These just kill us because our choice at two in the morning is to wait until 8 a.m. and sweat for six hours or to wake up a specialist at 2 a.m., which is not the most agreeable thing to do. Your choice is between two equally unpalatable options. Instead of that, you can take a look with ultrasound and assure yourself that the really bad things aren't there and it's not a problem to sit on the patient and do their workup in more congenial hours."
Emergency physicians are expanding the use of ultrasound and taking it to a whole new level, said Socransky.
"At least three-quarters of the scans that we do aren't done by radiology. We're using it on our patients at the bedside and because we have all the patient information about what's wrong with them, we're looking for new ways to use it."
"We can look for a pneumothorax (collapsed lung) which can kill someone within minutes or seconds. We can diagnose that at the bedside much more accurately and quickly than any other test. We can also look for retinal detachments. Radiologists aren't trained for that, so this isn't just about making traditional ultrasound services available 24/7 by bringing it to the bedside. We're actually expanding what ultrasound can be used for."
Afghanistan
Wiss, who grew up in Sudbury, has won national prominence for two books,
FOB Doc and A Line in the Sand that he wrote about his two tours of duty with the Canadian Armed Forces in Afghanistan. "There are a couple of Afghan soldiers who are walking around now who'd be in the ground if I hadn't brought my ultrasound machine with me on my first tour of duty," said Wiss. "It had a dramatic effect on the Canadian Forces, such that by the time I went on my second tour of duty, they had trained all their docs, physician assistants and battlefield medics."
Sudbury docs have trained emergency physicians across Northern Ontario, and emergency departments in Timmins, North Bay, Sault Ste. Marie and Thunder Bay are all equipped with EDEs.
As the technology gets smaller and prices go down, said Socransky, emergency ultrasound will proliferate through the health-care system and will be used by intensivists, anesthetists, surgeons, obstetricians and even paramedics.
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