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It's not about what comes next, it's about what comes first...

It’s not about what comes next, it’s about what comes first!

A week into my 4 month stay in London I am given the opportunity to assist with one of London’s Thoracic U/S courses. The venue is impressive: large sky-lit rooms, plenty of room for the audience and scanning stations, multiple flat screens displaying real time scans performed by the speakers.

The audience, a little different than I’m used to, is made up of all varieties of physicians: internists, respirologists, GPs, surgeons, & emergency physicians. The course speakers come from a range of specialities as well: here we have radiologists, respirologists, & surgeons.

Late into the course, a speaker initiates a case-based review of some of the material just covered. Case 2: a young male with history of fall from scaffold. He puts up a CXR showing a substantial hemopneumothorax. The speaker goes on to ask the audience about the next best test. It’s clear that he’s looking to make a point: despite everything he had just taught, the next best test would not be ultrasound, it would be CT.

He was right, the next best test would have been CT. And yet, in my mind, as I sat there doing my best to not blurt out my frustration, all I could think was that he had asked the wrong question.

It’s not about what comes next, it’s about what comes first!

Now, I know very well I do not own this idea. The “Ultrasound First” movement has been gaining ground for some time ( Top that with this year being “the Year of Ultrasound” and you’d think maybe I should calm down. After all, we’ll get there eventually, right?

Well, I’m not so sure. First of all, I wasn’t in some backroom rounds, I was at a dedicated point-of-care thoracic ultrasound course. Of all the places, the role of POCUS should be clearest here. And yet it’s not. Part of the message is coming through, but there’s a lot being lost. Time to turn up the gain.

Sure, POCUS has a tremendous role to play in the outpatient setting. The British Thoracic Society now strongly recommends (if not mandates) that whenever applicable thoracic procedures should be done under u/s guidance. Great, I get that. But what concerns me is that we are failing to illustrate to our colleagues the broader utility that can be found in this remarkable technology.

That brings me to the second point: in medicine we are used to thinking about what comes next, and not so much about what should have come first. In a sound world, that young fall victim would have had his hemopneumothorax identified within minutes of presentation to the ED (if not prehospital even as some may have it). Had he been unstable, that chest would have been decompressed right then and there with chest drain in place soon after. No CXR for diagnosis needed, the significant pathology would have been suspected through a combination of history & physical exam and then solidified by POCUS performed by the attending care team. All within minutes, all at the bedside. For the stable fall patient, the same approach would have exposed somewhat occult pathology to the benefit of the entire care team and most importantly the patient who would now be identified as having (not suspected of having) a large hemopneumothorax.

But for us to get there, we actually have to go back. We have to hit ‘rewind’ in our clinical skill-set back to the point of the bedside examination. There we have to insert our newly acquired bedside ultrasound assessments. It is there that we have to teach ourselves to think “Ultrasound First.”

As physicians, we are going to have to spend some serious time unlearning our first steps. Let’s be clear and honest about this: It is very difficult to unlearn anything!

And so maybe that is why the process has been slow going. Perhaps we need to be more explicit about the fact that we’re not just talking about adding the next test. What we’re talking about now is the first, and in some cases most important, test of all.

Cheers from London,

Paul Olszynski

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