[greg c]

Counterpoint: The use of technology enables safer patient management.

In my training I have seen a few procedures go from "blind" to "guided." The two that first come to mind are the the use of ultrasound (US) guidance for thoracentesis and US guidance for central venous catheter placement. In the first case, US does not replace physical diagnostic techniques of pecussion of the thorax or auscultation of breath sounds, but simply ensures a margin of safety when needles are being placed into cavities that contain vital organs. In the second case, US guidance does not replace visualization of landmarks, or palpation of pulses, but again can help guide needles and help avoid accidental needlesticks to vital arteries.

The above said, I rarely use US guidance for central line placement- my comfort level with the procedure allows me to believe that it does not add much in the way of safety given that I have a significant number of that particular procedure under my belt, and an almost nil personal complication rate bears that out. But I see a lot of new guys and gals erroneously poking arteries and lungs and whatnot because they eschew the available technology and don't have the talent/experience to make it safe to do so.

On the flip side, I use ultrasound for nearly every thoracentesis I do. It makes it safer given that I cannot palpate or percuss the depth of a given effusion. And within effusions you may have areas of thick or thin layers, making one area for needlestick safe where an area not less then a few centimeters away might be dangerous.

I suppose is that at some point an operator gains a level of skill which may perhaps relegate technology to not be as necessary, but in the sometimes suboptimal situations that arise (obese patients, distorted anatomy, coagulopathies) judicious use of technology has been proven to reduce complications.

Some case studies:

What if your blunt trauma patient has a slowly increasing pneumothorax? Would your exam reveal this as well as a chest film before it got big enough to cause obvious dyspnea and decreased breath sounds? Or would you triage the patient as "ok" only to find him blue an hour later?

What if your patient had an abd wound that was slowly internally bleeding? Would your exam detect this as well a peritoneal lavage- or would you find him dead hours later?

What if your patient had whacked his head and had no neuro signs but a headache (and a subdural hematoma)? Would your initally normal exam make you feel better about his death a hours later?

I don't deny that the physical diagnosis is a powerful thing, but I can't fool myself into thinking that practicing without technology is a good thing either. Best combination is to do your thorough exam, make your best guess, then do the studies and see if you are right. If not, then figure out why you blew it, and do better next time.

Respectfully submitted.
-G

PS. I Googled Wenkebach because I had in my head a picture of the man leaning over a pulse with his head bowed in deep concentration but it appears that he used a sphygmograph to diagnose his now famous arrythmia. And he first diagnosed it via experiments with frogs.

Def: Sphymograph: instrument which, when applied over an artery, indicates graphically the movements or character of the pulse.