Concluding Remarks
years the situation has progressively improved.
One can now note the emergence of another para- dox: »ultrasound in the ICU« is often understood as meaning »cardiac ultrasound in the ICU«. An increasing number of cumbersome specialized devices can be observed, while the lungs, the veins and other organs and tissues still have little access to the wide-ranging applications permitted by lighter ultrasound equipment. If one is prepared to do without Doppler – a remarkable tool but one which can, as we have seen, backfire against the patient – a simple, unsophisticated device provides a valuable whole-body approach, heart included.
Clearly, the results yielded by ultrasound depend on the skill of the operator. However, let us return to the time when, for instance, auscultation was not part of clinical routine. The situation did not change overnight, but nowadays one can hardly imagine any physician calling in a specialist in aus- cultation to detect rales and then write a report on which subsequent treatment could be based. Ultra- sound is nothing more than a stethoscope, slightly heavier than Laënnec’s device and powered by electricity. Plainly some years will pass before ultrasound becomes part of the armory of every physician. However, one can observe that institu- tions which tentatively begin to apply ultrasound soon integrate it into their daily routine and never go back.
Ultrasound is progressively spreading over the medical landscape. First cardiologists and gyne- cologists, then some gastroenterologists, derma- tologists, and surgeons, e.g. urologists – not forget- ting veterinarians, who were by no means slow to appreciate ultrasound’s potential. All of these specialties have adopted ultrasound as a daily tool. Ultrasound is now beginning to be used by general practitioners, and some voices – including our own! – speak in favor of its introduction into medical studies. It certainly merits use where it has the most potential for benefit, namely in the critically ill.
Our object in writing this book was to depict all the ways in which a simple ultrasound approach can assist the intensive care physician. Indeed, the title could have been »The 1001 Reasons to Perform General Ultrasound in the Critically Ill Patient«.
Ultrasound is increasingly attracting interest in the field of emergency medicine. However, it has to earn its place with respect to CT and MRI, which provide easy-to-read images and will remain indispensable for some indications. First, one can- not just compare the accuracy of ultrasound with these two heavyweights of modern imaging: one must also consider the risks, the expected benefits and the constraints for the patient. Referral for CT or MRI requires reflection, whereas ultrasound can be ordered without hesitation. Second, ultra- sound neatly resolves the paradox that the most severely ill patients are those who might benefit most from CT or MRI but often cannot reach the examination suite. Ultrasound is a bedside proce- dure and in trained hands yields respectable results.
In our setting, even more so than elsewhere, rapid and accurate decisions are crucial. A judi- cious ultrasound scan will reinforce the physical examination and outclass radiography and, in most cases, CT. Ultrasound is not just a rough test carried out to decide which allegedly more sophis- ticated investigation is most appropriate. On the contrary, prompt therapeutic decisions can be taken according to ultrasound findings alone. This is of great import in situations where, previously, one had to rely on clinical experience and basic tools such as a stethoscope, perhaps supplemented by an ill-defined radiograph. To the well-known advantages of ultrasound (low cost, etc.) can be added bedside use and an increasing spectrum of indications, e.g., examination of the lungs.
In the first French edition of this book, pub- lished in 1992, we wrote that the place of ultra- sound in the ICU was modest. In the intervening CHAPTER 31
The ICU of the 21st century thus has to have a suitable structure, i.e., full-time presence of an operator or, better still, progressive training of one or more members of the intensive care team. This concept will not only discharge our ethical obliga- tions but also, above all, lend a new dimension to our duties. With permanent whole-body scanning at our disposal, the patient will be rendered »trans- parent« directly after admission. Ultrasound will become our daily tool, since it allows nothing but
»visual-based medicine«.
Ultrasound has been plagued by widespread misconceptions that have cast a long shadow
over its development – and have certainly not helped to save lives. One simple example is the mistaken belief that air is an enemy of ultra- sound, whereas in fact the very opposite is true.
The existence of a whole lung semiology can be considered a chance for ultrasound to become a genuine stethoscope. A salutary trend considers ultrasound as tomorrow’s stethoscope. Let us just note here that ultrasound is today’s stethoscope, if we recall the etymology of this word coined by Laënnec in 1819: a means of looking (scopein, to observe) through the lung (stethos, the chest wall).
Concluding Remarks 189
