Today’s Medical Shows Depiction on TV

A Medical Professional's Critique of FAST Ultrasound Imaging Techniques in Television's "PITT"

Michael Paul Cyll

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Today's Medical Shows: A Sonographer's Perspective on Television Medicine

By Michael P. Cyll, M.A., B.A., (RET), RDCS, (Ret.) RCCS, (Ret.) FASE, CTT+

Medical television shows have certainly come a long way since the days of Marcus Welby, M.D. One of the best current examples is The Pitt, an exceptionally well-produced medical drama that portrays a 12-hour shift in a Pittsburgh hospital's emergency department trauma unit.

The skills displayed by the entire medical staff—from medical students and interns to first-, second-, and third-year residents, as well as attending physicians—reflect a strong understanding of medical knowledge and clinical decision-making. Their technical skills are also impressive, although there are a few areas where realism could be improved.

Having spent multiple decades in clinical medicine within the technical services division of cardiovascular ultrasound imaging, I have earned professional certifications and credentials in specialized areas including adult, pediatric, neonatal, and micro-preemie echocardiography, as well as fetal echocardiography. My experience also includes transesophageal echocardiography (TEE), invasive procedures, and ultrasound guidance during interventional medical device placement.

In addition to my clinical work, I have served as a community college instructor, a clinical education specialist with Philips Healthcare, an assistant university professor, and a Certified Technical Trainer (CTT+). These experiences have given me a unique perspective as both a clinician and educator.

With that background, I feel qualified to comment on the ultrasound imaging techniques portrayed during the FAST examinations on The Pitt. These examinations are performed by medical students, interns, residents, and attending physicians to evaluate the liver, kidneys, abdomen, aorta, lungs, and heart.

What Is a FAST Examination?

FAST stands for Focused Assessment with Sonography for Trauma. It is a rapid bedside ultrasound examination performed in the emergency department, trauma bay, or critical care setting to quickly detect internal bleeding or fluid accumulation following traumatic injury.

The four traditional FAST views include:

1. Right Upper Quadrant (RUQ) – Hepatorenal (Morrison's Pouch) View

This view looks for free fluid between the liver and the right kidney (Morrison's pouch), around the tip of the liver, and within the right pleural space. It is often the most sensitive abdominal view for detecting hemoperitoneum.

2. Left Upper Quadrant (LUQ) – Splenorenal View

This view evaluates for free fluid between the spleen and the left kidney, around the splenic tip, and within the left pleural space.

3. Pelvic (Suprapubic) View

Performed in both longitudinal and transverse planes, this examination looks for fluid posterior to the bladder.

• In males, fluid collects within the rectovesical pouch.
• In females, fluid commonly accumulates in the pouch of Douglas (rectouterine pouch).

4. Subxiphoid Pericardial View

This view evaluates for pericardial effusion and cardiac tamponade—blood surrounding the heart following penetrating or blunt chest trauma.

The Extended FAST (eFAST)

Many trauma centers now perform the Extended FAST (eFAST) examination, which adds evaluation of the lungs for:

• Pneumothorax
• Absence of lung sliding
• Absence of comet-tail (B-line) artifacts
• Presence of a lung point
• Hemothorax
• Fluid within the pleural space
• Collections in the costophrenic recesses

The FAST examination is designed to answer several critical questions:

1. Is there blood in the abdomen?
2. Is there blood around the heart?
3. Is there blood in the chest? (eFAST)
4. Is there a pneumothorax? (eFAST)

Typical Findings

A positive FAST examination demonstrates anechoic (black) free fluid within dependent spaces. In trauma patients, free fluid is generally presumed to represent blood until proven otherwise.

A negative FAST examination shows no visible free fluid. However, it does not completely rule out injury, particularly early after trauma.

Advantages

• Can be completed in approximately two to five minutes.
• Portable bedside examination.
• No radiation exposure.
• Can be repeated serially.
• Especially valuable in unstable trauma patients.

Limitations

• Small amounts of blood may be missed.
• Obesity and bowel gas can limit image quality.
• It is not ideal for identifying specific organ injuries.
• CT imaging remains the gold standard for stable trauma patients.

For cardiovascular sonographers, the cardiac portion of the FAST examination is especially important because it can rapidly identify life-threatening pericardial tamponade, allowing immediate intervention in the trauma bay.

Where Hollywood Differs from Reality

As an experienced sonographer, I have a few observations regarding the ultrasound imaging portrayed in the series.

First, I rarely see anyone operating the ultrasound machine adjusting the controls necessary to obtain high-quality diagnostic images. In reality, producing an accurate examination requires continual adjustments to image depth, gain, focus, probe angle, and scanning plane. Ultrasound is far more than simply placing the probe on the patient.

This is where Hollywood understandably simplifies the process. Actors place the transducer on the patient, and perfectly optimized diagnostic images instantly appear on the screen.

In my opinion, productions such as The Pitt would benefit from having a professional sonographer serve as an on-set consultant. Such a consultant could help train the actors in realistic scanning techniques while ensuring that the images displayed accurately reflect proper anatomy, pathology, and scanning methodology.

A Color Doppler Inaccuracy

One scene particularly caught my attention.

While Dr. Santos was evaluating vascular blood flow in a patient's legs, she explained:

"The blue is your veins, and the red is your arteries."

From an ultrasound physics standpoint, this explanation is incorrect.

In Color Doppler imaging, the colors do not represent arteries versus veins. Instead, they represent the direction of blood flow relative to the ultrasound transducer.

• Red indicates blood flow toward the transducer.
• Blue indicates blood flow away from the transducer.

Depending on probe orientation, either arteries or veins may appear red or blue.

Interestingly, many patients have made this same assumption during clinical examinations. Whenever that happened, I enjoyed giving them a brief explanation of the underlying Doppler physics.

Conclusion

Overall, I believe The Pitt is one of the most realistic medical dramas currently on television. The writing, acting, and medical decision-making are exceptionally well done.

However, I believe the production could achieve an even higher level of authenticity by consulting experienced sonographers to ensure that ultrasound imaging techniques, anatomy, pathology, and ultrasound physics are portrayed accurately.

I would welcome the opportunity to contribute to such a production by helping train the cast and production team in realistic ultrasound imaging techniques.

In fact, I already have an interesting case that would make an excellent storyline for Season 4.

Michael P. Cyll, M.A., B.A., (RET), RDCS, (Ret.) RCCS, (Ret.) FASE, CTT+

Email: mpcyll@gmail.com