Blog | Thursday, April 26, 2018

How the best of care can be terrible without bedside ultrasound


I read a “Clinical Problem Solving” case from the New England Journal of Medicine (NEJM) titled “Stream of Consciousness,” and it told the story of a 65 year old man who was a patient at the Brigham and Women's Hospital of Harvard Medical School, arguably one of the finest medical institutions in the world.

These cases are presented in single paragraphs to a clinical expert physician who then comments about his or her thought processes and discusses how he or she would have handled the situation. In this narrative the patient presented to a different hospital in New England with kidney failure and a gradual onset of confusion in the setting of very high blood pressure. He was then transferred to the Brigham and Women's Hospital for further evaluation and treatment. He had lab tests of all color and stripe along with MRI and CT scans of his brain which showed some disconcerting spots. He had a lumbar puncture and his high blood pressure was treated. Eventually, after 2 or 3 days in the hospital (I can't tell from the narrative), an ultrasound was done which showed that his bladder had not been emptying properly, which had caused the kidney failure and probably the high blood pressure. A Foley catheter was placed, which drained nearly 3 liters(!) of urine, after which his blood pressure was much more easily controlled.

The exciting diagnosis was posterior reversible encephalopathic syndrome (PRES), which was first described in a case series in 1996. It is closely related to eclampsia. The cause is thought to be leakiness of the blood vessels in the brain related to high blood pressure. It is very important to recognize PRES because prompt treatment to lower the blood pressure can prevent long term brain damage.

This guy had the best of treatment by the best of doctors, but what he really needed was a bedside ultrasound at the first hospital or on arrival at the Brigham. People who read this blog will have noticed that I am a strong proponent (nerd perhaps) of ultrasound performed by a treating physician as part of a physical exam in just about everyone with a significant medical concern. If he had a bedside ultrasound the doctor performing it would have seen that the collecting systems in his kidneys were dilated and that the cause was a massively over-full bladder, likely due to an enlarged prostate. The bladder would have been drained immediately, resulting in correction of his blood pressure and improvement in his kidney function. He might not have needed to be transferred to the larger hospital at all.

Perhaps his physicians at the community hospital did not know how to perform an ultrasound. Still, he would have benefited mightily from prompt point of care ultrasound once he arrived at the Brigham. Head scratching about the cause of his kidney failure might have been curtailed. Blood pressure control would have been more rapidly achieved, benefiting his spotty brain. His very complete and likely very costly evaluation might have been briefer and less expensive. Physicians might have been able to discharge him to home more quickly.

The impact of bedside ultrasound could have been even more profound had it been done even earlier in his course. This fellow's problem emptying his bladder did not happen all of a sudden 3 weeks before he came to the hospital. It is likely that he had mentioned to his primary care doctor some slowness passing urine or a feeling that he hadn't emptied completely. If that physician had performed an ultrasound of the bladder in the office he would have seen that it wasn't emptying properly and would have initiated some kind of treatment before it got to be the size of a large honeydew melon. It is possible, even likely, that this whole near-tragedy could have been prevented.

Bedside ultrasound is not yet the standard of care among internal medicine physicians. It should be, and in the fullness of time, it probably will be.

Janice Boughton, MD, FACP, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.