Hocus PoCUS: introducing point-of-care ultrasound

It seems strange that in an age of technological gadgets and smart phones, clinicians are still tapping on patients' chests and listening with a rubber tube to the sounds that they generate. The medical profession has a reputation for being sceptical of new advances until they have proven their worth. An example of a device that was resisted for many years is highlighted by the following quote:

That it will ever come into general use, notwithstanding its value, I am extremely doubtful; because its beneficial application requires much time, and gives a great deal of trouble both to the patient and to the practitioner …

J Forbes, of course, wrote this in 1820 about the stethoscope. ¹ There is, however, a realization that clinical practice needs to advance with contemporary developments and ultrasound is one modality that is now firmly established. The American College of Emergency Physicians wrote:

Throughout medicine, the increasing emphasis on patient safety, quality care, efficiency, less invasive treatment and non-ionizing imaging has found a natural fit with the advantages of ultrasound. ²

Ultrasound technology is not new: case reports of its use in trauma were published many years ago. However, the technology and quality have been improving, becoming more compact and portable as well as, more importantly, reducing in cost. ³

However, concerns from traditional specialties, with regard to quality and governance of practice, did ensure that the use of ultrasound by non-radiologists and non-sonographers was initially highly regulated and only accessible to users after significant training and practice. ⁴ This created a situation where only a few progressed to accredited status, leaving the rest to either abandon hope or ‘tinker’. Fortunately, with time and multidisciplinary collaboration, such constraints were lifted and more realistic training and practice solutions were established. ⁵ One example of how ultrasound has been embraced by non-traditional specialties is with the College of Emergency Medicine. Point-of-care ultrasound (PoCUS) will be a mandatory part of the curriculum for higher specialty training in emergency medicine from 2013. ⁶ These core skills encompass four scanning modalities: focused assessment with sonography in trauma (FAST); detection of abdominal aortic aneurysms; focused echocardiography in cardiac arrest (ELS); and ultrasound guidance for insertion of central venous lines. ⁷

What is important for all users of PoCUS to appreciate are the following golden rules:

PoCUS is an adjunct to clinical evaluation or procedures and not a stand-alone investigation, e.g. it may give further information to the clinician in addition to what is already known from clinical examination;