Perhaps the most important aspect of a physician’s role is our diagnostic capabilities. Truly, if we cannot identify and diagnose a patient’s pathology with reasonable accuracy, we cannot effectively treat them and may even cause greater harm.
Let’s look back. The year is 1816, and you are a physician evaluating a patient with shortness of breath. The common practice of the time was direct auscultation by placement of the practitioner’s ear on the patient’s chest. At the time, many criticized this technique as providing little insight into the patient’s condition as well being out of normal social standards. Secondary to these pressures that year a French physician named Dr. Rene Laennec invented the stethoscope, which dramatically improved the clarity of the auscultation exam. He spent the remainder of his career correlating how the stethoscope could detect various chest pathologies, and educating on the utility of this technology The accumulation of his works resides in his text De l’Auscultation Médiate, which is one of the most widely translated medical texts in history.
Now, just over 200 years later, it is incredible to think that this technology has not been disrupted — especially when you compare the advances humankind has made in other areas. We have gone from the horse and carriage to cars that can practically drive themselves, from the notepad to the iPad, and can now communicate anywhere on the globe irrespective of language or distance. In health care as well, we have drastically altered our ability to monitor as well as treat our patients.
Yet despite all of our technological advances, the stethoscope remains the primary tool used at the bedside for the physical exam. This is in spite of the widely known inaccuracies produced by the stethoscope guided physical exam. For example, a recent study demonstrated dismal results regarding the ability of the stethoscope to detect common cardiac events with a reported accuracy of 20 to 40 percent. Even amongst cardiologists, the accuracy of the stethoscope is poor.
Acceptance of this concept is key for us to innovate. One simply needs to ask themselves: how do you tell the difference between rhonchi or rales? What section of the lung did you hear diminished breath sounds? Or where is that heart murmur emitting from and what pathology does it represent to realize the severe limitations of the stethoscope? Moreover, when you compare the scrutiny that we require all modern medical monitors to achieve for their accuracy (no one would use a pulse oximeter that had only a 40 percent accuracy rate), why do we not seek a similar level of accuracy when we discuss the tools we use for our physical exam? Fortunately, technological advances have recently allowed for a new technology to be evaluated as an adjunct for our physical exam: point-of-care ultrasound (POCUS).
The utility of POCUS has been demonstrated for nearly every type of physical exam including cardiac, pulmonary, neurologic, pulmonary and abdominal. How often have you wondered: what is the ventricular function, how severe is that aortic stenosis, how bad is the COPD, is there a pneumothorax, what is the amount gastric volume or what is the patient’s volume status? These are all questions that have proven to be answered “real-time” by POCUS.
Sadly, the utility for POCUS to facilitate acute care management has mostly been shown in emergency medicine (EM). This has been viewed with some criticism given the fact that patients have the same comorbidities and acute care events in multiple patient care settings (intensive care unit, perioperative setting, step-down units, etc.). Truly, from a patient care standpoint, why should the skillset for bedside evaluation change simply because they transition from the emergency room to a different acute care setting?
Fortunately, the utility of POCUS to improve patient care in non-EM environments is starting to emerge rapidly. Recent research has demonstrated a positive clinical impact in these new environments as well. While it is encouraging to see the growth of POCUS, there is much more that can be developed. Currently, the certification and educational processes for the non-ED setting are limited. But the concept is growing.
A collaboration of academic programs including Loma Linda University Medical Center, UCI Medical Center and UCLA Medical Center are working together to help address the need for education and training on this topic. One such curriculum termed F.O.R.E.S.I.G.H.T. (Focused perioperative Risk Evaluation Sonography Involving Gastro abdominal Hemodynamic and Transthoracic ultrasound ) has been published as an effective strategy for education. This curriculum incorporates the topics of 1. Cardiac, 2. Pulmonary, 3. Hemodynamic, 4. Gastro-Abdominal 5. Airway, 6. Vascular access and 7. Intracranial pressure assessment. This curriculum is now online and is free to access. Additionally, training workshops on this curriculum are now available as well.
Importantly, this is just one initiative to further the development of POCUS. Additional online resources available for education on POCUS include those from the Society of Critical Care Medicine and American Institute of Ultrasound. Finally, a recent review article highlighted the current CME training programs available on this topic.
While these resources serve a key role, the impetus is on all acute care specialties to develop structured guidelines, endorsed educational pathways, and credentialing processes to incorporate this new assessment tool into everyday practice.
To draw back to the works of Dr. Laennec, in 1834 (18 years after his innovation), the Times of London reported that the medical profession was unlikely ever to start using the stethoscope, “because its beneficial application requires much time and gives a good bit of trouble.” Clearly, Dr. Laennec efforts have proven this statement to be false. Now, we are at the same crossroads with the stethoscope and point of care ultrasound.
Davinder Ramsingh is an anesthesiologist.
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