Basics

TL;DR (summary of this page)

Using ultrasound for bedside diagnosis and intervention makes for better doctors and faster, safer patient care. POCUS can drastically improve the workup of almost any presenting complaint, as well as making invasive procedures safer. Pocket-sized ultrasound is already a reality: in the near future we could be using it like a stethoscope. Getting good at POCUS takes a long time: the earlier you start the better. The literature is clear that students can easily learn this skill. NZ medical schools are not yet teaching POCUS, but why wait for them to catch up with the rest of the world? Start learning here.

What is POCUS?

Point-of-care ultrasound (POCUS) refers to the use of ultrasound at the bedside by the clinician for:

  • diagnosis/prognosis
  • assessing response to treatment
  • imaging guidance for invasive procedures

other names include clinician-performed ultrasound (CPU) and bedside ultrasound. Emergency ultrasound (EUS) refers to the use of POCUS in ED, which was one of the first clinical settings where clinicians began to use ultrasound at the bedside. Since then POCUS has expanded to most other specialties and even to primary care.

POCUS differs from traditional uses of ultrasound in important ways:

POCUSTraditional ultrasound
Performed by you, at the beside.Requested by you, performed by sonographer in radiology department, then reported by radiologist.
Do scan, act immediately. Repeat scan, adjust treatment (seconds-minutes)Request scan, wait for it to be done, then act on report (hours-days)
Answers a focused clinical question (e.g. does the patient have a AAA?)More exhaustive imaging of the requested area (e.g. abdomen)
Controversial: an extension of the physical exam? A semi-diagnostic study?A formal diagnostic imaging study.
You interpret images, in clinical context of patient. It may not be possible to store images.Radiologist interprets images based on the clinical information provided in the request (typically 2 sentences). Report and images stored forever.

POCUS is absolutely not intended to replace traditional ultrasound. Rather, it allows clinicians to take better care of patients by making faster, more accurate decisions. A POCUS examination may be followed up with a more exhaustive, sonographer-performed ultrasound exam, or more advanced imaging; in some cases, it may be the only imaging required for the patient’s workup.

Common uses of POCUS

The earliest use of POCUS in the emergency department was the FAST exam – assessing for abdominal organ injury in trauma [1]. Since then, there has been an explosion in the use of POCUS, supported by clinical research into its efficacy and limitations. The adaptability of ultrasound as a technique means that new applications are constantly being explored.

POCUS can be used in the workup of:

  • Shock or hypotension
  • Trauma
  • Abdominal pain
  • Chest pain or respiratory symptoms
  • Syncope and cardiac arrest
  • Fever/sepsis of unknown cause
  • Fracture assessment and reduction
  • Joint pain
  • Threatened miscarriage
  • Sudden vision loss
  • Swollen leg
  • Cellulitis/abscess

POCUS can also be used for real-time guidance to make invasive procedures safer: common examples include venous or arterial cannulation, peripheral nerve blocks, and drainage of fluid (e.g. thoracentesis, joint aspiration).

See cases for examples of clinical ultrasound cases from students/TIs and junior RMOs. There are heaps of blogs/podcasts out there demonstrating the amazing scope of POCUS.

Why should I care about this?

POCUS allows you to go beyond the guesswork of “inspection, palpation, percussion and auscultation” to actually see what is going on inside the patient’s body, in real time. Not surprisingly, this improves diagnostic accuracy and patient outcomes [2,3].

Technology has been improving quickly. Scanners have become so small and cheap, it will soon be feasible for individual doctors to carry their own ultrasound machine in their pocket (or around the neck!). We may be entering a revolution in patient care.

The catch is that ultrasound is extremely operator-dependent. You need to learn to orient and control the probe, use the machine, and differentiate normal, abnormal, and unexpected findings. This all takes time, training and practice.

POCUS and med students

In the USA, med schools are teaching POCUS from the first year. The idea is to produce graduates with a solid foundation in POCUS who can immediately put their skills to use. Medical school represents a unique opportunity for extended teaching and practice. Time is limited after graduation and education has to be squeezed in around work.

There is excellent evidence in the literature that med students can easily learn POCUS [4,5,6]. In one study, students performing echocardiography (after 18 hours of training) outperformed consultant cardiologists (using traditional clinical examination) in diagnosing valvular and non-valvular cardiac disease [7].

Using ultrasound is also a fantastic way to reinforce clinically relevant anatomy and physiology. Several studies have demonstrated the utility of ultrasound for teaching anatomy and physiology to junior medical students [8,9]. Drawings in textbooks cannot compare to watching organs do their thing in real time!

Join the revolution

Need more convincing? See cases that demonstrate the utility of POCUS performed by students/junior RMOs

If you’re sold, start your journey with these resources and courses.

References

  1. Tso P, et al. Sonography in blunt abdominal trauma: a preliminary progress report. J Trauma. 1992;33(1):39–43; discussion 43–44
  2. Diprose W, et al. Re-examining physical findings with point-of-care ultrasound: a narrative review. New Zealand Med J. 2017;130:1449.
  3. Reynolds TA, et al. Impact of point-of-care ultrasound on clinical decision-making at an urban emergency department in Tanzania. PLOS ONE 2018;13(4):e0194774.
  4. Wilson SP, et al. Implementation of a 4-Year Point-of-Care Ultrasound Curriculum in a Liaison Committee on Medical Education-Accredited US Medical School.  Journal of Ultrasound in Medicine. 2017;36(2):321-325.
  5. Olszynski P, et al. Point-of-Care Ultrasound in Undergraduate Urology Education: A Prospective Control-Intervention Study. Journal of Ultrasound in Medicine. 2018;37(9):2209-2213.
  6. Steinmetz P, et al. Acquisition and Long-term Retention of Bedside Ultrasound Skills in First-Year Medical Students. Journal of Ultrasound in Medicine. 2016;35(9):1967-75.
  7. Kobal SL, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005;96(7):1002–6
  8. Parikh T, et al. Novel Use of Ultrasound to Teach Reproductive System Physical Examination Skills and Pelvic Anatomy. Journal of Ultrasound in Medicine. 2018;37(3):709-715.
  9. Ahn JS, et al. Using Ultrasound to Enhance Medical Students’ Femoral Vascular Physical Examination Skills. Journal of Ultrasound in Medicine. 2015;34(10):1771-6.

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