Point-of-Care-Ultrasound tech expands non-invasive imaging capabilities across diverse dettings
Joanne is brought into the emergency department by an ambulance at her local community hospital in Oklahoma City. She is having serious trouble breathing. While the attending physician is unsure what’s causing this, it’s clear that a quick decision needs to be made to stabilize her condition.
With limited resources available, the physician turns to a powerful tool that was recently purchased by the hospital to gain a better understanding of the situation. She uses Point-of-care ultrasound (POCUS) technology, where the ultrasound images are presented on the screen of a common tablet. The physician arrows down possible diagnoses and indicates a likely cause — Joanne has acute cardiac dyspnea. She quickly implements an intervention that effectively manages theses dangerous symptoms so that Joanne can be transferred to the cardiology wing of the hospital.
POCUS is a risk reduction tool
Utilization of POCUS is a relatively new risk reduction tool in the physician toolbox that can be used in diverse settings to assess patients at their bedside. It represents a technological advance by improving portability due to the miniaturization of equipment. Point-of-care ultrasound provides extensive and immediate data that is cost-effective, safe, and non-invasive. While POCUS can be used in a single exam, it is also completely harmless to the patient, which means a medical team can use it to conduct multiple exams or for monitoring.
Point-of-care ultrasound provides clinically significant data not obtainable by inspection, palpation, auscultation, or components of the physical examination. In the case of cardiac ultrasound, POCUS enables the ability to answer many diagnostic questions such as: to what extent is there cardiac activity? Is the left ventricle function normal or severe? Is there fluid surrounding the heart?
In essence, POCUS is a tool that offers increased diagnostic certainty, shortens time to definitive therapy, and decreases complications from procedures that carry inherent risks.
The use of ultrasound has quickly made its way into clinical guidelines such as the American College of Physicians (ACP) – becoming a standard for the clinical evaluation of emergency department patients. ACP recently released the Appropriate Use of POCUS in Patients with Acute Dyspnea in the Emergency Department or Inpatient Settings, stating:
“Emergency physicians have taken the leadership role for the establishment and education of bedside, clinical, point-of-care ultrasound use by clinicians in the United States and around the world. Ultrasonography has spread throughout all levels of medical education, integrated into medical school curricula through residency to postgraduate education of physicians, and extended to other providers such as nursing, advanced practice professionals, and prehospital providers.”
Use of POCUS in diverse settings
Point-of-care ultrasound is increasingly being used in out-of-hospital emergency settings, or pre-hospital care settings as well. It can be used in doctor’s offices, remotely in rural areas, during global health and disaster situations, military, and battlefield assessments – even in outer space.
A prospective study with 202 patients was conducted in the pre-hospital
setting comparing a Focused Assessment with Sonography in Trauma (FAST) examination with a physical examination. FAST is a rapid bedside ultrasound exam used to screen for blood around the heart or abdominal organs after trauma. POCUS was found to be highly effective across the measures of sensitivity, specificity, and accuracy. The use of pre-hospital ultrasound led to a change in management of 30 percent of patient cases, and a 22 percent change in which hospital the patient was transferred to.
In the trauma care setting, another prospective study with 262 randomized patients was conducted using a protocol that included point-of-care, limited ultrasound (PLUS) versus usual care. Researchers discovered that PLUS provided more rapid management of patients in the operating room, fewer CT scans, shorter hospitalizations, and fewer complications.
Overcoming barriers for use
Although there are clear benefits of POCUS, and ultrasound generally, there are limitations to physician use that inhibit more widespread adoption. Any application of ultrasound is both operator- and-patient dependent; the process of acquiring ultrasound images requires hand-eye coordination. The sonographer moves the ultrasound probe on a patient’s body and looks at the monitor to determine in which direction to move. This process is difficult for the inexperienced or occasional user. Additionally individual patient characteristics, such as a high rib cage, can make image acquisition challenging.
These factors contribute to inconsistent quality of the ultrasound image and may hinder confidence and adoption. Without proper mentorship and oversight, an inexperienced user’s implementation may also lead to risk of causing harm by missing critical findings, delaying diagnoses and the potential misinterpretation the data.
Proper training is essential. In a study surveying 170 practicing internists caring for hospitalized patients, the physicians reiterated this point. They expressed that they would use POCUS more frequently if they had better training and emphasized the need for greater direct supervision to apply to patient care. The internist’s concerns regarding use of POCUS with limited training are based on many potential factors. Primarily, they worry about inappropriate care such as false positive or false negative findings, and how these unintentional mistakes could lead to problems downstream in the treatment journey.
A glimpse into the future
Is there a potential solution for variability across users and for shorter learning curve and higher adoption? One idea is use of artificial intelligence (AI) to guide users through the process of imaging. It is well known that AI is making its way into the healthcare space, especially in radiology, where it is used to analyze visual data. One could imagine that use of AI could be leveraged to guide the capturing of images and to assess the quality of the image that is identified.
While there can be risks associated with inexperienced users of POCUS, physicians with the right training can extend the capability of physicians to assess, diagnose, and treat cardiac patients under different circumstances. The functionality of POCUS is especially relevant for decisions that need to be made quickly in the face of acutely ill patients. For patients like Joanne, this capability can be critical to stabilizing an escalating problem.
Point-of-care ultrasound can be used successfully to address medical unmet needs in diverse settings at different stages of diagnosis and treatment. Ultimately, the idea is to provide access to cardiac monitoring and diagnostic information because the space environment can create challenges to the cardiovascular system for astronauts and citizen space travelers. If this could be achieved in space, it could also benefit rural and underserved communities on earth.
The sky is clearly the limit when it comes to use of POCUS. The future holds great promise for its implementation in diverse settings once the challenges of proper training and oversight are effectively addressed.
Photo: DjelicS, Getty Images