Real World POCUS
POCUS = point-of-care ultrasound (for the uninitiated). I’ve spent the better part of the last year trying to learn how to image different organs with ultrasound and incorporate those findings into management decisions. To take better care of my patients. And to see their guts. Anyway my co-fellows and our faculty talk a lot about ‘real world POCUS’. That’s dirty, sheisty, unscrupulous, sullied POCUS. The images you see in presentations, case reports, at conferences and on Twitter - that’s a fantasy. Most of the time the images are grainy, the axis is off, you’re too deep or too shallow, there’s lung or bowel or Godknowswhat in the way, or they won’t stop moving/talking/laughing/crying/etc. So you do what you can with what you have. A while back I saw a patient with about a half dozen personality disorders and a failing ticker. They’d been hospitalized about a week prior to our appointment and I was meant to check in, see how things were going. I wound up asking to perform an ultrasound to assess whether or not they were retaining fluid, as one’s wont to when their ticker’s amiss. Hand over my heart they stood up right in front of me, unbuttoned their shirt, and regaled me with operatic German and tales of our constitution’s framing. “Um, it would be a bit easier with you on the exam table.” “You know I knew Jimmy Madison before he made it big with the Federalist Papers” “Oh sure, those essays were bangers - tell ya what I’ll just scan ya standing up.”
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I’m going through my archive from the year and came across this case, got me thinking about how we’re all just doing our best with what we’ve got. Being a doctor, and more generally a person at all, is about making decisions with imperfect information. And owning those decisions, taking responsibility for the fallout - accountability. We do our best with what we’ve got - sometimes all we’ve got in front of us is a delusional narcissist who may or may not almost certainly couldn’t possibly be old enough to witness the framing of the constitution. And you scan em standing up and maybe you learned enough to help. Then you ratchet up their diuretic and schedule em for follow up, but not with you - with your co-fellow, Paul. He loves personality disorders and busted hearts.