5 Echo Mistakes That Cost Lives On-Call – An expert guide for the 3 a.m. clinician

  “The scan looked fine. The patient wasn’t.”
— Every clinician who learned this the hard way

This is not another echo tutorial.

You already know the views.
You’ve done the courses.
You can recite PLAX, PSAX, A4C, subcostal in your sleep.

And yet — patients still deteriorate after a “reassuring” scan.

Not because the echo was technically wrong.
But because the thinking was.

In my experience across hundreds of on-call shifts, critical care reviews, cath lab emergencies, and post-procedure collapses, the most dangerous errors in echocardiography are not technical.

They are interpretive.

Patients rarely die because an EF was estimated at 45% instead of 50%.
They die because clinicians see what they expect to see, not what is actually happening.

This article is about those moments.

Read it in five minutes.
It may change how you think at 03:00.

Mistake #1

“The parasternal view looks normal — so the heart is fine”

The scenario
You’re called to a crashing patient. You get a PLAX view.
The LV is contracting well — symmetrical, vigorous. Relief washes over you.

The trap
“Good LV function. It’s not cardiac.”

The reality
While you were staring at the LV, you missed the killer.

In massive pulmonary embolism, the LV often looks normal — or hyperdynamic — because preload has collapsed. Meanwhile, the RV is dilating and failing.

The canary died while you were watching the wrong bird.

Key fact
A normal-looking LV does not rule out cardiac catastrophe.
In acute PE, a normal LV with a dilated, hypokinetic RV is PE until proven otherwise.

Pro tip
In A4C, the RV should be ~⅔ the size of the LV.
If the RV equals or dominates the LV — stop everything and think PE.

The rule
👉 A normal LV does not mean a normal heart.

Mistake #2

“The heart is hyperdynamic — so function is good”

The scenario
Post-operative patient. BP 80/50.
The heart is thrashing. Walls almost touching. It looks powerful.

The trap
“Good biventricular function. Heart is strong.”

The reality
A hyperdynamic heart in a hypotensive patient is not healthy — it’s desperate.

It’s screaming for volume.
Or fighting against near-zero afterload in distributive shock.

By calling this “good function,” you falsely reassure the team and delay the real treatment.

Key fact
EF tells you what the heart is doing, not whether it’s coping.
In hypovolaemia or sepsis, EF can be 70%+ while cardiac output is critically low.

Pro tip
Stop saying “good function” in shocked patients.
Instead ask: Is this level of contractility appropriate for the blood pressure?

The rule
👉 A hyperdynamic heart in shock is a red flag, not a green light.

Mistake #3

“The valve looks abnormal — but that’s not why I’m scanning”

The scenario
You’re asked to assess LV function in a breathless patient.
You notice a heavily calcified aortic valve with barely any opening.

You note it mentally — but the LV looks fine.

The trap
“LV function preserved.”
You don’t mention the valve because “that’s not what they asked for”.

The reality
The valve was the entire problem.

You don’t need to quantify valve disease to save a life.
You need to recognise danger and escalate.

A valve that barely opens.
A flail leaflet.
An oscillating mass.

These are visual diagnoses.

Key fact
Focused echo does not mean blind echo.
If you see pathology that explains deterioration, it becomes your responsibility to communicate it.

Pro tip
Valve red flags that require no Doppler expertise:

• Calcified valve that barely moves → think severe AS

• Leaflet flipping the wrong way → think flail

• Oscillating mass → vegetation until proven otherwise

The rule
👉 If the valve looks wrong, say so. Don’t wait until you can quantify it.

Mistake #4

“The effusion is small — so it’s not tamponade”

The scenario
Post-PCI patient deteriorates.
You see ~1 cm of pericardial fluid.

You write: “Small effusion. No tamponade.”

The trap
Low volume = low pressure = low risk.

The reality
Tamponade is a haemodynamic diagnosis, not a volume measurement.

Chronic effusions can reach litres.
Acute bleeds can kill with 50–100 ml.

Key fact
The pericardial pressure–volume curve is J-shaped.
Acute bleeds hit the wall fast.

Pro tip
Forget size. Look for interaction:

• RA indentation

• RV diastolic collapse

• Plethoric, fixed IVC

Hypotension + any new effusion post-procedure = tamponade until proven otherwise.

The rule
👉 In acute bleeds, small effusions kill.

Mistake #5

“I’ve done the views — the echo is complete”

The scenario
You’ve acquired PLAX, PSAX, A4C, subcostal.
You’ve measured what you can.

The scan is “done”.

The trap
Echo becomes a task, not a question.

The reality
A completed dataset is not the same as an answered clinical problem.

If the question was “Why is this patient in shock?”
and your echo doesn’t help answer that — you’re not finished.

Key fact
Echo is not an imaging test.
It is a clinical decision tool.

Pro tip
Have the courage to say:

• “Non-diagnostic”

• “Unable to exclude”

• “Formal echo urgently required”

A safe escalation beats a confident guess.

The rule
👉 The scan starts with the question, not the probe.

The Reframe

On-call echocardiography is not report writing.

It is risk recognition under pressure.

The probe doesn’t save lives.
Your thinking does.

The 30-Second On-Call Echo Sanity Check

Question: What am I trying to rule in or out?

• LEFT: LV size, function, regional abnormality

• RIGHT: RV size vs LV, septal shape, free wall motion

• VALVES: Any obvious restriction, flail, or mass

• FLUID: Effusion? Chamber interaction?

• FILLING: IVC size and respiratory variation

• CONTEXT: Does the echo match the patient?

👉 If in doubt: escalate. Don’t guess.

Want to build real on-call confidence?

The EchoMasters Foundation Course doesn’t just teach views.

It teaches clinical reasoning under pressure —
the kind that keeps patients safe at 03:00.

👉 echomasters.co.uk

Dr Mohamed Mansour

Consultant Cardiologist & Cardiac Imaging Specialist

ECHO UNDER PRESSURE — Critical Care Echo That Saves Lives

A practical series for ICU/ED clinicians & cardiac sonographers.

Master Echocardiography. Lead with Confidence.