POCUS is everywhere

Abstract

POCUS, or point-of-care ultrasound, is everywhere and is not going away. Enthusiasts are plentiful as are detractors. Enthusiasts claim that POCUS augments clinical examination to expedite diagnosis, thus improving management. Detractors claim that POCUS is an inadequate substitute for comprehensive diagnostic ultrasound that leads to misdiagnosis. Both are true. This issue of AJUM is all about POCUS.

Wong et al.¹ present data on the role of focussed cardiac and lung ultrasound performed by a junior doctor as part of the pre-operative assessment in patients undergoing non-cardiac surgery. They found that the rate of pathology picked up rose from 28% based on clinical examination to 72% after the POCUS examination. Point-of-care ultrasound led to changes in patient management, predominantly in fluid administration. Interestingly, on retrospective review, there was poor agreement between the junior doctor and POCUS expert reviewer on the interpretation of haemodynamic status, which had guided these management changes. Point-of-care ultrasound will change management regardless of its accuracy, highlighting the importance of adequate training and quality assurance structures for novice users, particularly for identifying when image quality is too poor to allow meaningful interpretation.

Using ultrasound to augment clinical examination is an important part of POCUS, and Pettit et al.² present a study showing that, after brief training, medical students and junior doctors improved their diagnosis of elevated jugular venous pressure (JVP) using ultrasound and that ultrasound resulted in similar clinical estimations as experienced cardiologists using physical examination. This is an important clinical adjunct as novices often find the measurement of JVP difficult to do.

Expanding training opportunities to meet the demand from a growing pool of interested novice POCUS users is an ongoing challenge. Zhao et al.³ present a study where they employed both telemedicine and peer-assisted learning. After didactic lessons, a cohort of second-year medical students were randomised to 1:1 instruction from a peer (second-year medical students with an interest in POCUS) in person or through telemedicine. There was no difference in their ability, or improvement in ultrasound skills, whether the training was in person or not. They concluded that, to be effective, POCUS training may not need to be in person, nor delivered by experts.

In some areas, such as lung ultrasound, POCUS users have created a new application for diagnostic ultrasound and are leading the way into areas unexplored by traditional ultrasound. In this issue of AJUM, Zadeh et al.⁴ present a review and pictorial essay on the assessment of pneumonia using contrast-enhanced ultrasound and B-mode imaging, correlating lung ultrasound with CT. The portability and repeatability of the ultrasound examination, as well as its correlation with CT findings, suggest untapped clinical application.

And finally, two case studies show the impact on clinical care achieved through POCUS. Adorno et al.⁵ present a series of three cases who were being worked up for renal colic, in which emergency room POCUS resulted in the detection of malignant tumours. And Yasuda et al.⁶ present a case where POCUS revealed free fluid in the abdomen which expedited a CT scan and diagnosis of spontaneous intraperitoneal haemorrhage secondary to gastric vessel rupture in a young patient presenting with chest pain.

This AJUM issue reminds us that POCUS is everywhere. It is evolving into an essential adjunct for many clinicians, but we need evidence to show it is efficacious; we need evidence to understand the best ways to teach and support POCUS users; and we need evidence to understand how POCUS and diagnostic skills should be integrated together. Most importantly, we need evidence with patient-oriented outcomes to understand how POCUS is impacting the patients we serve.