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It’s busy. There are twenty-eight patients in the waiting room with the longest waiting 4 hours. The queue for CT scans is over 2 hours and the one for ultrasounds is even longer; a staggering 4 hours, plus another hour to get results. Lots of people are frustrated. Your next two patients are both pregnant females in their first trimester with vaginal bleeding. As you perform your H & P, you encounter more similarities between the two. Both have midline crampy pain like a period, with no fever, no vomiting, and no syncope. Both recently had ultrasounds done, one in your ED 3 days ago, and one with her obstetrician four days ago. You know why they are here. One reason – they want to see if their baby still has a heartbeat. You also know that repeating the ultrasound is not really medically indicated using the strict sense of the word. Sure it’s reasonable, even customary, but will it change management tonight? Can’t they just see their OB tomorrow? Is it really the right way to practice medicine to clog up your department even worse while simultaneously adding one more straw to the camel carrying the national healthcare budget? Who are you going to listen to? Press and Ganey? Barack Obama? Your conscience? What will the parents think and how will they react if you tell them, “Sorry, we can’t do an ultrasound tonight. You have to go home and make an appointment tomorrow to see your doctor.”?
Vaginal bleeding in pregnancy, like many things in medicine, is both common and controversial. Do you really need to do a pelvic exam? Do you need to do another ultrasound if they already had one in this pregnancy that showed an IUP and they are not on fertility meds? Few patients will be disappointed if the pelvic exam is skipped, especially if is unlikely to have any important impact on their care, but if you don’t do the ultrasound it may require some explaining if you don’t want them to feel disappointed. But maybe there is a third option. Do a quick bedside ultrasound and show the mom the heartbeat (hopefully). She gets what she wants, you feel like you are doing the right thing, your ED throughput doesn’t take another hit, and you get to improve your ultrasound skills. If sold correctly to the patient and/or her husband, this can truly be a win-win approach.
As long as you know the patient has an IUP, unless they are on fertility meds, for all intents and purposes, you have ruled out an ectopic pregnancy unless the presentation is particularly concerning for a heterotopic pregnancy. It’s even better if someone else has already documented an IUP on a recent scan. Take a look at the two images below. What do they show? Can you quickly and efficiently send the patient on her way home?
What do the images show? Can you quickly and efficiently send the patient on her way home? Conclusion on next page