Connor Glair, MS4
The Article: Panebianco, Nova, Frances Shofer, Katie Oconor, Tristan Wihbey, Lakeisha Mulugeta, Cameron M. Baston, Evan Suzuki, Adel Alghamdi, and Anthony Dean. "Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy." Journal of Ultrasound in Medicine 37, no. 8 (2018): 1965-975. doi:10.1002/jum.14546.
The Idea:
In emergency medicine there are many beliefs and practices that are based on anecdotes and have never been studied. These beliefs and practices are particularly vulnerable to implicit biases that physicians may hold. Additionally, there exists a great amount of anxiety with performing intimate genital physical examinations in the medical community. Presently transvaginal ultrasound (TVUS) is under utilized by emergency medicine physicians despite its well-studied efficacy in the assessment of obstetric and gynecological conditions. Prior to this journal article no known study has assessed the perceived pain, anxiety, and embarrassment in women who receive emergency department TVUS as part of their care. This study aimed explore patient and provider perceptions of emergency department TVUS.
The Study: This study was a single-center prospective survey of consecutive women undergoing ultrasound evaluations for complications of first-trimester pregnancy and their emergency medicine providers. Data was collected from January 2013 to December 2013 from 7am to midnight. The study participants were surveyed before and after any ultrasound in the emergency department or before/after any TVUS in the radiology department. Patients’ and physicians’ assessment of pain, embarrassment, and anxiety were measured using 0-100 visual analog scales.
Inclusion/Exclusion Criteria: Female patients aged 18-50 years of age with the conditions of “pregnant and bleeding, “pregnant and cramping”, “pregnant and vomiting”, “abdominal pain”, “pelvic pain”, and “nausea and vomiting” were screened. To be included the patient must have been hemodynamically stable, older than 17 years of age, fluent in English, had a positive pregnancy test result, were known or estimated to be in the first trimester of pregnancy, and the treating team must be planning to perform an ultrasound of some form in the emergency department.
Primary Endpoint: Assessment of attitudes about emergency department TVUS among pregnant patients in terms of pain, embarrassment, anxiety, and willingness to receive a TVUS as part of their diagnostic workup.
Secondary Endpoint: Physician perception of patents’ experiences in terms of pain, embarrassment, and pain/embarrassment related to TVUS in comparison with pelvic examination.
Results:
398 patients participated in the survey. In the pre-ultrasound survey the median anxiety score of the participants was 14 out of 100, with 96% of patients responding that they would be willing to undergo TVUS if necessary. Of the patients who had TVUS performed in the emergency department, 96% reported that they would be willing to undergo the procedure again. The median pain score for emergency department TVUS was 17 and the median embarrassment score was 8. TVUS had a median pain score of 47 compared to pelvic examination. There was no statistically significant difference in pain or embarrassment scores when comparing the emergency department and radiology department as exam settings. Physicians were able to accurately assess patient’s embarrassment and pain with TVUS however they overestimated these values when comparing TVUS to pelvic examination (mean difference for embarrassment 12.8, P<0.0001; pain, 8.0; P=0.01).
The Takeaway: Overall pregnant patients in the emergency department report low levels of anxiety, pain, and embarrassment with TVUS with 96% of these patients agreeing to undergo the procedure again if necessary. There was no difference found in embarrassment or pain scores based on the setting of the TVUS. Many physicians do not perform TVUS in the emergency department based on implicit biases and assumptions they make about their patients. The results of this study seem to reinforce the idea that TVUS is underutilized in the emergency department given how well tolerated it is by patients. Many physicians are more willing to perform a pelvic examination in the emergency department than a TVUS, however the results of this survey indicate that patients find pelvic examination more painful and embarrassing. With ultrasound training and equipment becoming more universal and accessible to physicians and with the well established reduction in length of hospital stay associated with TVUS in the emergency department for 1st trimester pregnancy issues there is a growing momentum for more frequent TVUS examinations in the emergency department.