The subtle sound of a distant explosion rang out. We barely flinched, numb to the sound that was a near-daily occurrence at our remote outpost in war-torn Afghanistan in 2005. Minutes later, a fast-approaching Humvee suggested that this time, something was amiss. The sight of a bloodied soldier draped over the vehicle’s hood provided confirmation.
As we scrambled to prepare our dusty, sparsely equipped treatment tent, casualties poured through the door. A young Afghan man, triaged as minimally injured, lay in front of me, peppered from head to toe with small shrapnel wounds. His wounds were indeed benign-appearing, as his triage category suggested, but penetrating wounds can be deceptive. I struggled to gauge whether his lack of responsiveness to my questions was due to our language barrier, or something more sinister like blunt or penetrating head trauma. His primary survey was otherwise unremarkable…nosignificant external hemorrhage, airway intact without labored breathing. His blood pressure was borderline low, not an uncommon finding in the thin/healthy.
I dusted off the nearby SonoSite 180, now widely considered to be the first portable ultrasound device of its kind. Most of its knobs were still foreign to me, and my inexperienced eyes struggled to interpret the grainy images. His belly and lungs appeared unremarkable, but scanning through his subxiphoid region, the black stripe encircling his heart jumped out at me, inconsistent with my already-anchoring bias of a traumatic brain injury, but consistent with the images I had only seen in Ma and Mateer’s landmark text.
I quickly called the surgeon, whose experience with the device barely surpassed my own. After a quick look at both the machine and text, he commanded his team to prep the operating suite, an equally dusty, adjacent tent. Minutes later, the surgeon’s skillful incision of the patient’s pericardium evacuated the now-tamponading bloody effusion, revealing the tiny piece of shrapnel embedded within the patient’s right ventricular wall and saving the patient’s life.
On that day, the humbling and lifesaving power of point-of-care ultrasound (POCUS) was revealed to me. As a junior clinician with limited trauma experience, I had no formal ultrasound training, mentorship, or experience. Yet this machine, when coupled with only a book, and the desire to learn, allowed me the opportunity to overcome the shortcomings of my physical exam skills, my resource constraints, and my cognitive bias, and the mistriage of another, to ensure a patient received the timely and definitive care he deserved. In the decade or so since, I have been fortunate to serve my patients while under the tutelage of several POCUS experts whose altruistic and thoughtful mentorship allowed me the opportunity to cultivate my passion for this powerful tool, while also imparting the nuances and limitations of POCUS, frequently leading me back to a common question:
“How can we best harness the full power of POCUS?”
There is a rapidly growing body of evidence that suggests that clinicians of various skill levels can effectively employ focused POCUS applications with minimal training. Though not without risk, POCUS is no different from other clinical skills; performed with variable competency regardless of profession, specialty, or scope of practice. Some will evoke the mantra of “a fool with a tool is still a fool,” which may certainly be true, but it is unfair to assume that foolhardiness is necessarily bound by profession, experience, or even breadth/depth of training.
The notion that POCUS can/should only be monolithically employed by a limited number of broadly/extensively trained physicians may be yet another example of the monoculture of thought that continues to plague our healthcare system. Certainly, any diagnostic testing should be performed thoughtfully; but do we limit who can use the stethoscope, or order a CBC, based upon title or his/her knowledge of Bayesian principles, Fagan’s nomogram, or pre/post-test probabilities and test-characteristics? Do all successful clinicians adhere to these principles with each and every test they order? Are there other factors to consider when ordering diagnostic testing, particularly in the resource-constrained areas where POCUS can have the greatest impact?
Until POCUS is adaptably and appropriately employed by all those who provide care, regardless of practice setting and scope, its full benefit and potential, especially to those living in medically underserved areas, cannot be realized. Some will inevitably oppose this concept, citing concerns with expertise, patient safety, documentation, reimbursement, etc. Ironically, it is these same arguments that emergency physicians faced 2 decades ago before successfully overcoming significant resistance to fully integrate POCUS into emergency medicine practice.
POCUS leaders are uniquely poised to best mitigate the risks associated with POCUS use through the provision of expanded training opportunities that are well-crafted, appropriately focused, and variably commensurate with clinicians’ skills, cognition, practice setting, and scope. Some of our most innovative POCUS educators are already doing so, whether by incorporating POCUS into the physical exam, or training nurses to perform diagnostic ultrasound, or training medics to employ ultrasound in austere locations. The rise of artificial intelligence/machine learning is already reducing the training burden traditionally associated with POCUS.
POCUS is a rare technological tool; one that is portable, versatile, and liked by both patients and clinicians alike. It can expedite diagnosis and care, improve the accuracy of our physical exam, and help us overcome our own anchoring bias while reducing the risk of procedural error, healthcare cost, and iatrogenic radiation exposure. Though it may not impact a majority of patients, for those it does, that impact is often significant. But the most uniquely promising characteristic of POCUS that we should all embrace is its ability to bring better-informed clinicians of any ilk, back to the bedside where they belong, wherever those in need of care may be.
Do you believe the democratization of point-of-care ultrasound can enhance patient care? Share with us your thoughts or your efforts to do so: comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.
Dedicated to the memory of CPT Jeremy A. Chandler, 1st BN, 3rd Special Forces Group, whose life was lost while bravely serving his country on that fateful day, August11th, 2005, in Tarin Kowt, Afghanistan.
Jonathan Monti, PA-C, RDMS, is an Associate Professor of Emergency Medicine PA Studies at Baylor University and president of the Society of Point-of-Care Ultrasound (SPOCUS). He is currently conducting research on the unconventional employment of ultrasound in the U.S. Armed Forces as an employee of the Henry M. Jackson Foundation for the Advancement of Military Medicine.