POCUS, Point-of-Care Ultrasound: A New Paradigm in Clinical Medicine
If you haven't heard about POCUS (point-of-care ultrasound) by now you must have been stranded on a deserted island, but if you're just now back home and starting to get your wits about you, it’s time to get your knowledge base up to speed on this important technology. POCUS is revolutionizing the practice of medicine.
Just what is POCUS?
The first thing you need to know about POCUS 0r point-of-care ultrasound is that it is not the same or a substitute for consultative ultrasound.
POCUS or Point-of-care ultrasound is used by clinicians at the bedside to answer focused questions. For example, in a trauma patient clinicians will use POCUS to assess for the presence of fluid indicating hemorrhage. This application attempts to simply answer the question of whether or not hemorrhage is present and does not look for other pathologies that may be detected on a consultative abdominal ultrasound.
Clinicians will still be ordering consultative studies-echocardiograms, liver ultrasounds, obstetrical ultrasounds-that are performed by professional ultrasound technologist and interpreted by the appropriate specialist.
It is best to think of POCUS as an extension of the physical exam. Now, instead of merely listening to the heart one can apply an ultrasound probe and visualize the beating heart and in many cases estimate the patient's ejection fraction.
POCUS in Emergency Medicine: How it all started
The POCUS paradigm began in emergency medicine where the need for real-time imaging and the lack of resources left emergency medicine clinicians to their own devices. As the cost of point-of-care ultrasound devices came down, ultrasound units became more common in emergency departments.
With probes in hand, EM clinicians began expanding the scope of their applications. Emergency medicine practitioners found that they were able to safely and effectively perform focused assessments. Early on, emergency medicine providers were using ultrasound to identify intrauterine pregnancies and to perform fast exams (focused abdominal sonography and trauma).
Over time, experimentation led to ever-increasing applications which include the extended FAST exam (looking for lung slide to rule out pneumothorax), estimation of ejection fraction, assessing 4B lines, point-of-care deep venous thrombosis studies and many more. With time and experience EM practitioners were able to refine and extend the range of applications until the new ultrasound based paradigm of emergency medicine emerged.
One of the best Emergency Ultrasound courses online was created by Drs. Mark Deutchman and Mark Kendall at the University of Colorado. Using ultrasonographic recordings and interactive controls it was the first true course in Emergency Medicine Ultrasound (EMUS) with lessons from ultrasound physics through point-of-care applications for traumatic injuries, guided procedures and more. The course (example of Doppler ultrasound below) is still a valuable asset today and can be found in the Med-Challenger online medical education library, here.
Today, emergency medicine residencies are required to have a formal POCUS training. POCUS is now a formal element at over half of all medical schools throughout the four years of training.
POCUS and today's Physician Assistant
At least five PA programs have integrated POCUS into their curriculum including the University of Oklahoma (Tulsa) where students learn POCUS throughout the didactic and clinical curriculum.
If you're practicing PA unfamiliar with the sonographic arts you may be asking yourself, "Do I need to be trained in POCUS?"
The short answer is yes but let's be more specific...
I'm in emergency medicine PA, do I need to be trained in POCUS?
Uh, Yeah. Emergency medicine PAs always want to be upgrading our skills and practice patterns to effectively complement our physician counterparts. When it comes to POCUS in emergency medicine, the future is now.
I'm a family practice PA, do I need to be trained in POCUS?
You bet. I know it seems daunting at first but in addition to the applications noted above consider the ability to actually visualize and measure a patient's spleen, thyroid.
Abscess or cellulitis in a pediatric patient? You don't have to stab it to make sure you can now scan it and if abscess is present you can proceed with the parents knowing that you have sonographic confirmation of abscess and you're not just stabbing it blindly.
As time and experience goes by, these POCUS applications are going to continue to grow in many POCUS practitioners believe that it's just a matter of time before the ultrasound probe effectively replaces the stethoscope.
I'm a rheumatology PA, do I need to be trained in POCUS?
Interestingly, yes, you would very much benefit from learning the musculoskeletal applications of ultrasound in rheumatology. This is a new and important component of rheumatologic practice where clinicians can more effectively identify responses to treatment by ultrasound in a patient's joints.
So what is the next step?
The first step is obtaining access to an ultrasound probe. There are now devices on the market selling for around $2,500 but there is a good chance that your hospital or ED has a unit that you can access.
The next step is POCUS skill acquisition, you know, training.
In addition to the instructive online EMUS course mentioned earlier, there are a number of great CME outfits that have hands on training as part of their conference. I started with 3rd Rock and it was excellent.
The last thing you will need to get started is guided experience. If you have a colleague or collaborating physician that are trained in POCUS, they will be glad to help you learn the ropes.
Another great resource is the Society for Point of Care Ultrasound at www.spocus.org. Check out their website for resources on getting started with POCUS. Welcome to the new paradigm in clinical medicine!
Everyone should get to know POCUS, especially physician assistants where these skills are primed to become more and more a part of the PA's practice wheelhouse and provider value.
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