Ultrasound horror stories

I am looking for tales of patient care gone wrong with POCUS.  Please send me your cases, (or cases you “heard happened to someone else”) where the use of ultrasound at the bedside led to less than ideal outcomes.

POCUS is just like any other tool in medicine:  it has its limitations, it can generate false positives and negatives, and the data points it generates can be used badly.

The first issue is that POCUS is a operator dependent modality.  It takes practice and skill to generate quality images.

The second issue is that the clinician must have the cognitive ability and experience to effectively integrate the data generated into the overall clinical picture.

For example, vascular access has been greatly improved by ultrasound guidance.  However, guiding a needle to the target is not always easy and the inexperienced operator can have a false sense of security as they visualize their target but lose track of the needle tip and miss the target.  “Residents can feel invulnerable with a probe in their hands,”  a supervisor once observed.

I have heard complaints from vascular surgeons that they were initially seeing higher numbers of carotid cannulations after the introduction of POCUS.  In part that was due to physicians attempting IJ insertions using the old “see one, do one” training approach.  There were also attempts were being made on extremely challenging patients that would never have been attempted in the past, some with good reason.

I have watched learners see a collapsing IVC while training on a normal patient and comment that the patient must be hypotensive.  They failed to understand the limitations of IVC measurement and did not correlate this finding with cardiac echo, lung scan, or clinical history and physical.

So have you or someone you know done an ultrasound guided carotid biopsy?  Aspirated a nonexistent abscess?  Declared a pericardial effusion when there was just a big epicardial fat pad?  Or have you been led down the garden path to the wrong diagnosis thanks to ultrasound?

Send me your cases!  I will be creating a presentation and blog post with the best stories along with the hard lessons learned!

The Dunce- Harold Coping

Greg