Point-of-Care Ultrasound: An Emergency Physician’s Perspective on the Portable Clinical Tool

Point-of-care ultrasound (POCUS) devices have undergone a revolution in the past 5 years in terms of cost and portability. A device that cost over $50k years ago can now be purchased for about $2,000, making it more accessible to frontline clinicians. In 2020, the Food and Drug Administration cleared for use a handheld ultrasound system that has full-spectrum Doppler capability, which had not previously been available in any handheld system. Now we are seeing an explosion of interest in POCUS across the entire healthcare industry.

In the same way that VisualDx provides meaningful guidance at the point of care but does not take the place of a clinician, a bedside ultrasound device can be a great tool to help with medical decision making.

Emergency physician Jeremy Boyd, MD, answers our questions about POCUS, an emerging technology that is changing the way care is given.

 

How is POCUS Disrupting the Paradigm?

Typically, a healthcare provider with a clinical question that needs to be answered by ultrasound orders the study, which often requires transferring the patient to a sonography “lab” where a trained sonographer or echocardiographer performs the study that would provide a comprehensive survey of the organ or area of concern. That study is then read or interpreted by a trained radiologist who writes up a report and in turn, that diagnostic report is integrated into the patient’s clinical care by the clinician.

With POCUS, the same provider sees the patient, performs the POCUS exam, interprets the exam, and then integrates that diagnostic information into the patient’s clinical care.

POCUS causes additional disruption by focusing the question. For example: in a hypotensive trauma patient, I want to know whether there is fluid in their peritoneum, because I’m worried their hypotension is secondary to hemorrhagic shock. My question is a focused one: is there fluid in the peritoneum? This is what is referred to as a focused assessment with sonography in trauma, or FAST exam. I’m not concerned about the size of the liver and/or spleen, whether there are cysts on the kidney, or their bladder volume. Sure, that information can be very important information in the right clinical context, but when I’ve got a sick trauma patient in front of me who might need an emergent surgery—answering that simple yes or no question allows me to make an expedited decision in a situation where I don’t often have the luxury of time.

In what situations is POCUS most useful?

POCUS really developed in the acute care setting—in the ED and ICU—but now we’re seeing its adoption in many different outpatient clinical settings. It’s tremendously useful in dyspneic patients in the ED and has been shown to be highly sensitive for the detection of COVID-19 lung findings.

It shines in time-limited decision-making situations where more comprehensive studies, such as a CT or even an x-ray, may not be available. It’s also very useful for procedural guidance, improving the safety and precision of all kinds of procedures, from paracentesis to central venous catheter placement to regional anesthesia.

It’s been incorporated into advanced trauma life support (ATLS) and is utilized in our Emergency Department for everything from ruling out ectopic pregnancies (by detecting an intrauterine one), to detecting abdominal aortic aneurysms, looking for signs of obstructive urolithiasis in patients with kidney stones, identifying pneumonias, cholecystitis, DVTs, retinal detachments, cardiac tamponade, and more.

As an emergency physician, I see it mostly used in acute care situations involving cardiopulmonary complaints, as these are some of the most common in the ED.

What are the downsides to POCUS? 

The most important thing about POCUS as a provider is knowing what you don’t know. This can be one of the hardest things for new and enthusiastic POCUS users.

But it’s important to recognize that everything in medicine has limits, and POCUS is a diagnostic tool with its own limits. It is not a substitute for clinical judgment and using it well requires practice and training.

The tremendous expansion of POCUS interest due to the change in affordability has led to challenges in terms of ensuring competency across many healthcare providers, rather than just a few highly trained ones. It has also led to the need for IT imaging and documentation workflows that aren’t necessarily the same as traditional radiology ones. In addition, there are potential legal concerns if physicians are purchasing their own personal devices and billing for ultrasound use without following CMS guidelines and possibly even self-referral or Stark Law violations.

Who should be trained on POCUS and what does that training look like?

I think every physician should be trained in POCUS. However, it’s not just something one can easily pick up; like any skill in clinical medicine—particularly ones that involve some level of dexterity—in order to be proficient at it one must practice. In addition to the manual dexterity, one must also practice learning to interpret the study, and lastly you need to know what to do with the answer when you get it.

Many medical schools have incorporated POCUS into their curricula, and it’s a required part of residency training in multiple subspecialties. It’s ideal to learn it while you’re developing your own clinical practice patterns in residency, but certainly, any time is better than no time and there are many programs and courses available. Practicing clinicians can and have learned POCUS with the right combination of dedication and practice.

When not obtained during residency, most often it involves some kind of intensive introductory course of 2-3 days in length. After this, a period of training is needed where the provider develops a portfolio of some kind, demonstrating that they have performed anywhere from 25-50 ultrasound studies of a particular application (eg, cardiac, FAST, early pregnancy) that have been reviewed by a POCUS expert. In general, at least 150-300 studies are recommended to develop a solid foundation in the skill. Fortunately, many of the physical skills needed to effectively manipulate a POCUS transducer crossover between applications.

POCUS is a complex diagnostic tool that requires practice and dedication to master. I like to say that it can be a clinical “amplifier” but is NOT a substitute for clinical judgment.

As a friend once said, a fool with a tool is still a fool.

 

About Dr. Boyd

Jeremy Boyd, MD, FACEP, is an emergency medicine physician at Vanderbilt University Medical Center. Additionally, as the emergency ultrasound director, he oversees the Department’s clinical, educational, and research endeavors with emergency ultrasound. This involves working with a core group of fellowship-trained faculty to perform undergraduate, graduate, and continuing medical education in the performance, interpretation, and clinical integration of POCUS studies.

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