Knowledge, wisdom, and passion were key players in my pursuit of a career in medicine. As point-of-care ultrasound (POCUS) incorporates both the science and the art of medicine, it has rekindled my passion for medicine, greatly expanding my clinical knowledge.
A few weeks ago, a young man presented complaining of 24 hours of shortness of breath and chest pain. His triage painted the picture of a panic attack. After completing the history and physical exam, I rolled the small ultrasound cart into his room. Within 90 seconds evidence of focal pneumonia was seen on the ultrasound image, despite a clear chest x-ray.
Talk about a game changer.
The Knowledge
Ultrasound has been used to promote informed medical decision-making for over 7 decades. Dr. John Wild, regarded as the father of medical ultrasound, was driven to advance diagnostic imaging as he sought a different approach to evaluate bomb victims with suspected bowel injury. At the time, the military was interpreting sound wave patterns to identify armor defects on battle tanks. He transposed this technology to collect information from high-frequency sound waves hitting the small bowel and echoing back to the device.
By the 1950s, Wild was implementing his sonographic device to distinguish normal from abnormal soft tissue in cancer diagnostics.
Now fast forward to 7 years ago, when the World Health Organization [WHO] published its second edition of the Manual of Diagnostic Ultrasound. It states, “Ultrasound is a core technology for diagnostics and remains one of the safest. Clinical effectiveness is enhanced when used properly.”
The focused assessment with sonography in trauma (FAST) was one of the first widespread applications of bedside ultrasound; today its utilization is saving lives worldwide. Since the innovation of the FAST exam in the 1990s, emergency clinicians have been using ultrasound for safe and immediate diagnostic information when evaluating for conditions ranging from retinal detachment to renal colic.
There is power in having this knowledge. As urgent care clinicians, we know when a patient is checking in complaining of shortness of breath, there is a broad differential. A few of the potentially critical differential diagnoses include pneumonia, pneumothorax, and congestive heart failure, just to name a few. And ultrasound offers yes or no answers to each of these specific diagnoses.
The Wisdom
It is rewarding to have the wisdom to embrace innovations in science and apply them within an appropriate clinical context. Adopting bedside ultrasound in the urgent care environment affords answers to daily questions like: Is there an abscess? Is there a foreign body? Knowing the presence or absence of these conditions offers considerable guidance toward the next step in care. It is a relief for both clinicians and patients alike to avoid attempting I&D on cellulitis. The gratification is high when a nonpalpable splinter is visualized on ultrasound. This provides clarity regarding the utility of pursuing procedural removal ourselves vs referral to a specialist or watchful waiting.
The Passion
I can only speak for myself, but after a decade of urgent care life, I feel the need to learn new techniques to feed my clinical passions. Ultrasound fosters this by bringing me back to the patient’s bedside and expands the diagnostics I can offer in urgent care. Three core concepts can encapsulate my journey of learning, incorporating, and teaching bedside ultrasound: Innovation. Perseverance. Integrity.
- Ironically, ultrasound, though long-established technology, is actually modernizing medicine. Rationing ionizing radiation as a value is on the rise. As medicine changes, I too must change. It is quite possible that as the electronic medical record has reformed medicine in the last decade, ultrasound will prove to be a transformative force in this decade. The growing proficiency among first year medical students in the use of ultrasound was my initial inspiration to put a focus on POCUS.
- Ultrasound is not like learning a new language; it is a new language. In essence, supersonic sound waves, the thickness of a razor blade, zoom into the three-dimensional, full-color human body. These sound waves come in contact with tissues and bounce back to the probe where they are measured and reformatted to create a two-dimensional image out of 256 shades of gray. The interpretation of these images and elucidation of patterns can become quite sophisticated with practice.
- Ultrasound provides images of what is within our patients. With these pictures comes tremendous information. Information invites interpretation. Our interpretation then adds nuance to the care plan. The reality is, although I am passionate about ultrasound and teach it to medical students, residents, and colleagues, and use it in clinical care most shifts, it is not always the right tool. It is equipment-, operator-, and patient-dependent. The utility of POCUS is limited and not designed to replace a comprehensive radiology tech ultrasound with radiologist interpretation. Two clinical examples of natural limitations of ultrasound in general: it will not differentiate cellulitis from soft tissue edema, nor will it decipher pulmonary edema from a nonfocal pneumonia. The limitations of POCUS must be kept in mind when deciding in which clinical contexts it should be applied.
The gestalt I apply to determining if ultrasound has clinical utility involves asking the following questions: 1) Is the question answerable by ultrasound? 2) Do I understand the medical literature for this ultrasound application? 3) Can I capture quality images and interpret them? 4) Will I be able to responsibly integrate these findings into patient management?
In conclusion, the versatility and clinical utility account for the recent rise in bedside ultrasound, especially in acute care settings. Bedside ultrasound has become an extension of my physical exam as a UC clinician. It is incredibly gratifying to ultrasound patients; it offers an opportunity to spend more time at the patient’s bedside, and consequently improves patient experience.
As my knowledge, wisdom, and passion grow toward the utility of POCUS in urgent care, I am compelled to share my experience with fellow providers. It is my hope that this issue of JUCM will demystify POCUS for the uninitiated and that you will begin to understand better my enthusiasm for new applications of this old technology.
Chelsea Burgin MD is the Medical Director of MD360 Boiling Springs and the Director of MD360 Ultrasound, Prisma Health and Assistant Clinical Professor , University of South Carolina School of Medicine Greenville.
