An Education in Ultrasound


Early Days

In 1991 I was a newly minted attending physician starting my first job in a community hospital in New England. Emergency Medicine (EM) as a specialty was relatively young and not widely accepted as legitimate by the rest of the medical specialties. Most EM training programs, like the one I graduated from, were in the Midwest. There were none in staunchly traditional New England and certainly none were at any of the hoary Ivy League medical schools, which only accepted EM thirty years after the rest of the country. I later helped start an EM residency at Yale, but that is a whole other story. The hospital ER I worked at was busy and well-staffed, but I was the only ER doc who had any training in EM. I was viewed with a great deal of suspicion and skepticism by most of the medical staff of the hospital. My insistence on imposing my wisdom on the unenlightened community docs probably wasn’t helpful either.

One evening that first year I saw a young woman with low abdominal pain and a small amount of vaginal bleeding. Her pregnancy test was positive, which was a surprise to her. Those of you who have read my accounts of my experiences in Ob will recall how well versed I am in all things obstetrics, so I called a local obstetrician to admit her to the hospital for close observation.

A quick biology primer for those who haven’t had health class in a while: human eggs are released from the ovary once a month and fertilized by sperm in the fallopian tubes. Normally after fertilization they continue down the fallopian tube and after about a week they implant in the uterus. Occasionally though the new baby hangs up in the fallopian tube and starts to grow there, recruiting its own blood supply from the mother to grow in the tube. This is called an ectopic pregnancy. This is fine for a while but unlike the uterus, the fallopian tube cannot expand as the baby grows and sooner or later it ruptures. Because of the newly grown blood supply the mother can hemorrhage massively when the tube ruptures and often will rapidly die.

The classic presentation for ectopic pregnancy is low abdominal pain, vaginal bleeding and a positive pregnancy test, which is why I thought this lady needed to be admitted until an ultrasound could be performed the next day. Ultrasound was a new technology then and wasn’t easily available, certainly not after hours.

The obstetrician was very nice and assured me over the phone that many normal pregnancies bleed a little in the first trimester (three months). This is true, but without an ultrasound I had no way of knowing that this was a normal pregnancy, and I pressed him to come in to see the patient and admit her. We went back and forth, but eventually he convinced me to discharge the patient with the assurance that he would see her first thing in the morning in his office. It was clear if I was going to practice in the community, I was going to have to practice to the community standard, not the ivory tower standards I was taught. Keep in mind also that ruptured ectopics are quite rare and were even more rare back then, before the widespread use of fertility drugs.

Well, she did see him the next morning and he ordered an ultrasound. Unlike today, ultrasound was not an office ob procedure, it was performed by radiologists in the hospital. Ironically, I was well trained in ultrasound in residency 22 years ago but had no authorized access to a machine in this ED. She left his office to return to the hospital for her ultrasound. She collapsed in the parking lot and was rushed into the ER actively dying of a ruptured ectopic pregnancy. She was transfused with ten units of blood and went directly to the operating room for an emergency hysterectomy as they could not localize the bleeding site to just the tube, which they removed as well. So, she lived but lost her fertility.


You can’t swing a dead cat in our ER without hitting an ultrasound machine. They are everywhere.

Recently a colleague loaned me “the stethoscope of the future,” a pocket sized ultrasound. He wanted me to trial it for a day. It is a marvel of technology and I used on a pregnant lady who was having vaginal bleeding and low abdominal pain. A perfectly healthyv baby was growing in her uterus, right where it was supposed to be. It was her first pregnancy. I congratulated her.

“It wasn’t planned,” she said, some ambivalence in her tone.

“Oh,” was all I had to say in reply. I paused and held her hand in support for a few moments.

Which brings me to the point of my column this month, an education in ultrasound and its role in the doctor patient relationship for all the Virginia legislators mandating ultrasounds before elective abortions under the cover of providing informed consent. For those who didn’t follow the discussion, the Virginia State House and Senate passed a bill February 10th mandating that all women undergo an ultrasound prior to having an abortion. During the debate phase on the Senate floor, the senators were advised that most of these ultrasounds would necessarily be transvaginally performed, something even the sponsors of the bill were not aware of. Apparently very few actually understood what the term meant and they voted to pass the bill. The Virginia senators who voted for this ought to be ashamed of themselves. They are such champions of informed consent that they did not even bother to inform themselves of the very procedure they would force on patients. A one-minute conversation with any EM intern would have sufficed to show them what they were proposing, an invasive procedure driven by the politics of abortion.

By the time the bill came to the House for a vote it was increasingly clear what was being proposed, but they passed it anyway.

Undeterred by the subsequent exposure on a national stage of their complete ignorance, they simply modified the bill slightly to leave out the mandated transvaginal probe and resubmitted it. It still stinks. The issue is not the probe. The issue is that mandating these ultrasounds serves no valid medical purpose. The lawmakers are still trying to legislate medical practice in order to advance a political agenda, without the slightest glimmer of medical knowledge. If they knew at all what they were talking about, they would know that almost all abortions are preceded by ultrasounds already, mostly transvaginally, to determine dates and ensure that an ectopic is not present.

Happy legislating. I’ll get back to doctoring now, thanks. Now where did I leave that darn stethoscope of the future?