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The C Word & POCUS

December 29, 2017

Is cancer an emergency medical diagnosis? Technically, it’s not. The primary diagnosis of cancer does not show up in any emergency medicine textbooks. And rightly so. Although the complications of cancer can kill quickly, cancer itself develops relatively slowly. As such, the responsibility for the initial diagnosis of cancer falls largely to family physicians and our specialist colleagues. But try telling that to a patient and the public at large. If cancer is not a medical emergency, it sure is a personal emergency for our patients and their families. After all, it’s “The C Word”. Despite the above, it sure seems like the diagnosis is falling in our lap more and more. Maybe it’s just the way health care is going, but I have diagnosed more cancers in the last few years than I did in the first ten years of my career. In any case, if we can pick up some cancers earlier, so much the better for the patient. Here are some cases from Dr Lloyd Gordon that illustrate how POCUS can make it easier.

“How quickly can you make a difficult diagnosis? Would I have missed the diagnosis in these cases without POCUS?

Case 1

The first patient used a scooter because of a CVA. Two weeks before I saw him, the battery on the scooter died and he had to wrestle the scooter back to his place. His lower mid back had been aching with movement since then. He thought he had strained his back. So did I. Certainly the history and physical was otherwise not helpful. Probably a waste of time to POCUS. Still….

When I got to the left kidney, I saw something unexpected, a big cortical mass.

Compare to the normal R kidney? The R Kidney had a mass too, although smaller.

Bilateral renal cell ca (Papillary Type 1, Renal Cell Ca. on biopsy).

Case 2

The second patient had aches and pains all over. That was it for the history. Would POCUS help with this very non-specific history? Well….

Liver Metastases?

POCUS didn’t find a primary, so I did a rectal, which revealed a large rectal cancer.

Case 3

The third patient had just come from Southeast Asia, with a history of fever (not documented) as well as dizziness and generalized weakness. By now you know that POCUS is going to make the diagnosis. Liver metastases again.

This time POCUS found the primary in the GB.

3-4 minutes of POCUS to a definitive diagnosis for each of the 3 patients. Plus I might have missed the diagnosis without a little bedside imaging.”

Ed note: Who knows how long it would have taken to make these diagnoses if Lloyd had not used POCUS. In some cases, sure, the diagnosis may have been made in follow-up in the next week or 2. But, in other cases, the patient may not have bothered seeing another physician for months and his or her only contact with the health-care system may have been the ED visit with Lloyd.

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