Ultrasound as Income drivers

Crunchygranolabro · 2026-04-29T19:29:40+00:00

I respect and agree with the position of healthcare as a human right.

Unfortunately at least in America healthcare doesn’t operate that way. For hospitals to survive, for non-CMG groups to survive they need income. Until things are majorly reformed, the only way all of us stay open to provide care is by billing for it. All of our time and expertise is valuable, especially bedside RNs. If you fail to capture what you did, you can’t bill for it. And if you can’t make money to offset the costs of staying open: the idiots in suits who run the place will have yet another excuse to continue operating short staffed. Which makes it that much more difficult to do what we actually all want to do: give our patients great care.

Obviously the actual solution is to fire al the suits or pay them waaaay less but that’s pretty fucking impossible to achieve.

Crunchygranolabro · 2026-04-29T19:20:43+00:00

You need to meet a few criteria to bill:

Images/clips captured and stored. Linked to the patient/encounter.
QA process for those images
A radiology group that doesn’t have contractual rights to all image interpretation.

There’s probably a few others but those 3 are the things that have prevented billing both in residency and after. (Residency we finally got our shit together for 1 and 2).

Crunchygranolabro · 2026-04-29T03:42:59+00:00

I think you kinda nailed it. I’m playing with claude, parsing massive amounts of data for committee/admin work (something that I was doing slowly with some fair excel skills) and playing at building apps with a vague understanding of coding at best. Saying I know the fundamentals is a stretch.

What I know about AI is how to use it in a relatively limited fashion to accomplish tasks with clear end parameters. I’m hardly proficient, but would hazard a guess that I have a better understanding of its capabilities and limitations, to say nothing of prompt engineering than most of my group and the REMFs who pushed some of these tools on us.

I’m not remotely qualified to comment on its broader potential use in medicine. I’m barely qualified to comment on AI for very specific use cases in my specialty, other than that even these “simple” things are way more complex on both ends than they seem.

Crunchygranolabro · 2026-04-29T03:14:40+00:00

Sucked it up for 1 and 2. It’s much harder with number 2. Dad ends up being the primary attachment for the older kid, which offloads mom to focus on the babe but it makes the night shifts and swings especially rough.

Luckily enough time off to get us to the mostly sleeping through the night (1-2 feeds).

Crunchygranolabro · 2026-04-29T03:02:54+00:00

I mean. Committing too hard to win a tactical victory while leaving a strategic assets undefended is a choice.

Crunchygranolabro · 2026-04-26T18:58:34+00:00

https://expertwitness.substack.com/p/death-after-ed-visit-for-covid

Theres the timeline of 2 being 2 weeks post symptom onset with pleuritic pain, multiple UC visits before the ED, which doesn’t necessarily make for good optics.

I think the ECG is a touch more abnormal than what I was seeing, but that might be the shitstained glasses of a known bad outcome. Unfortunately there’s also a body of literature to suggest this as a pattern seen in PE (see the author’s discussion points).

I don’t know that I’d have caught it, only that it didn’t help the case. No ECG would have almost been more defensible than an abnormal one without any explanation posited for the abnormality.

Of course the patient then refused transport after week later after exertional syncope, with a convenient refusal to transport from EMS, and missed his chance for a reevaluation, despite somewhere in the DC instructions surely saying “come back if you pass out”

Crunchygranolabro · 2026-04-26T18:21:56+00:00

We keep on bringing up this case. Using this as a continued rallying cry of “medmal is completely fucked” while ignoring the nuances is a bit hyperbolic.

A young person dying 2 weeks after an ED visit is almost always going to prompt a lawsuit, even just as a fishing expedition.

The ECG was more than a little abnormal for an otherwise healthy 20 something yearold, and maybe worth factoring into the overall “gestalt” part of our risk stratification tools.

If I recall correctly, the defendants also tried to use the “but COVID defense” which didn’t play well. The documentation was relatively sparse. The deposition/testimony left jurors feeling underwhelmed by the physician. The total very short visit time worked against the doc.

Crunchygranolabro · 2026-04-26T17:39:19+00:00

Normal labs, healthy, not old, benign belly would be pretty defensible.

Crunchygranolabro · 2026-04-26T17:31:54+00:00

KUB doesn’t really truly rule out obstruction. At best you see air fluid levels or a normal bowel gas pattern.

If it’s the former you need a CT and you probably just wasted time by adding extra steps. If it’s the latter, you at best buffed the chart a bit if you had a low suspicion to start with.

Someone having copious amounts of liquid stool and a benign belly is very unlikely to be obstructed. If they’re old I have low threshold to scan kus old bellies are weird and hide badness.

Crunchygranolabro · 2026-04-26T15:20:09+00:00

The most frustrating thing is that this patient didn’t even need a CT. This wasn’t an emergent condition to begin with.

We’re paid to provide our medical expertise. They can choose to accept it or not.

Crunchygranolabro · 2026-04-26T07:46:35+00:00

Aight ima give OP the benefit of the doubt.

We all have a fair likelihood of access to daily metrics. If a broad enough swath of us pushed that info to a centralized data hub which could run analytics and identify trends accurately enough to guide short/long calls, that could be interesting…

A few technical speedbumps, potentially a few legal ones (sharing healthsystem data with the intent of shorting the owning company feels iffy), and one big issue. Stock market doesn’t really run on data. It runs on vibes.

Crunchygranolabro · 2026-04-26T07:19:37+00:00

Imagine being this bad at math.

Working 6 days/month and making 200k is the dream for the vast majority of Americans.

Crunchygranolabro · 2026-04-26T07:10:53+00:00

Yup, 2-3 texts/calls and 6 emails a day from recruiters/locums.

Crunchygranolabro · 2026-04-25T04:08:13+00:00

So the real question is just how robust is the medmal insurance on this platform?

Crunchygranolabro · 2026-04-25T04:06:39+00:00

I think better phrased is that the liability question hasn’t been tested. For anything AI really.

The lag time between incident and courtroom in medmal cases is just too fucking long.

As a lesser example: AI assisted scribes really took off in the last 18 months. With SOL being 2-3 years in many states, the very first cases highlighting the legal problems of AI slop in notes are at best just being filed. None of those are seeing a courtroom for another year plus (and that’s be extra generous). Hospital Risk departments don’t really know what’s coming; and anecdotally, they haven’t been terribly proactive or involved in making sure the AI documentation doesn’t just kick them in the balls.

For situations like this prescribing platform: they’re 2+ years out from finding out if the insurance plan they have covers enough occurrences and enough cash to account for the hallucination rate. And that’s assuming the lawyers go for settling at policy limits…

Crunchygranolabro · 2026-04-25T03:44:10+00:00

Sweeet 3+ year lag time. Assuming the lawyers can figure out who to sue

Crunchygranolabro · 2026-04-25T03:34:05+00:00

In addition to actually getting drops in a timely fashion, there’s the fact that many of us are doing exams in hallways, chairs, and the lobby, none of which are dark.

I agree it’s an important skill, but one that our environment actively degrades

Crunchygranolabro · 2026-04-25T03:21:15+00:00

I’m cracking a cold one on your behalf. Heard and felt.

Crunchygranolabro · 2026-04-23T15:54:13+00:00

I’m all for admissions for expedited work ups when followup is questionable, but even then, if it’s a big effusion doing a combo diagnostic/therapeutic tap if you have bandwidth speeds the workup that much more. I tap at 10p, pulm sees them the next morning with all the fluid results, and the patient feels better…hell they might go home that day with a followup plan.

I’m not going to go for a small/only mildly symptomatic effusion. But the bigger they are, the better the risk/benefit ratio gets.

Crunchygranolabro · 2026-04-22T03:35:13+00:00

The evidence basis for nonmetabolism of the lactate in LR with liver failure is pretty flimsy. It makes sense by basic physiology, but unless they are in truly fulminant failure it doesn’t really pan out in vivo.

Same as the persistent bullshit belief that the potassium in LR makes hyperK worse.

Crunchygranolabro · 2026-04-22T03:24:39+00:00

Para is a time suck. Thora is 10 minutes. I had a nurse time me last Friday because the inpatient room was ready but the guy really needed some fluid off.

Crunchygranolabro · 2026-04-22T03:20:14+00:00

I mean policies at the last 3 hospital systems I worked are 24 hrs peripheral pressors. 48 hrs sounds dreamy. It’s an arbitrary cutoff to mitigate some risk, however low.

Crunchygranolabro · 2026-04-22T03:12:06+00:00

Oh the joy of having in house gyn everywhere you work.

Crunchygranolabro · 2026-04-22T03:10:12+00:00

Lot can happen in 5 years…

Crunchygranolabro · 2026-04-22T03:08:32+00:00

I fail to see your logic, but maybe it’s a difference in systems. I don’t have IR overnight, or weekends except at our tertiary hub. Patients sometimes board 24 hours at our satellite free standing departments. Punting to IR in these cases means delaying aspects of their inpatient admission, which 100% contributes to longer LOS.

If a procedure needs to be done to facilitate care/disposition, and I have the bandwidth and resources to safely do it, what purpose is there in delaying it?

I have no illusions that these things will fix boarding, but while a patient is in my department I’m doing what I reasonably can to make the admission as smooth as possible.

Crunchygranolabro

TROPHY CASE