You will frequently see posts on social media attempting to crowd-source information from others in the industry regarding protocols/guideline implementation. Within the last few years, I have seen an uptick in individuals asking about the steps needed to implement ultrasound successfully within their organization. This blog will serve as an attempt to create a "one-stop shop" and summarize what you need to get started!
I did a webinar on implementing ultrasound for Philips Lumify a few years ago. I started with this disclaimer:
This is not to say that the providers of specific programs are not "smart enough" to learn ultrasound, but rather that the key to successfully implementing ANYTHING, especially ultrasound, relies on a solid foundation. I believe the yellow brick road to POCUS should look something like this.
With point-of-care ultrasound devices becoming increasingly affordable, there has been an increase in well-intentioned providers purchasing their own probes and taking implementation into their own hands. Some may argue that it is "just a fancy stethoscope," but any tool without proper training and reliable feedback can be misleading and ultimately dangerous. While I do not discourage providers from purchasing their own device for learning purposes, systemic implementation and training is best when it comes to training and sustainability.
If you are thinking about implementing ultrasound within your program, ask yourself these three questions:
What resources are available to my program for initial and ongoing training and competency?
What specific clinical questions are we trying to answer with point-of-care ultrasound?
How will the ultrasound clips be reviewed and critiqued while maintaining patient privacy after the call?
What resources are available to my program for initial and ongoing training and competency?
A survey in 2014 asked EMS Medical directors in North America what their biggest barriers to implementing ultrasound were. The results were honestly not that surprising.
Training providers to become competent with a new piece of equipment is not cheap and the time commitment is obviously a barrier that can't be ignored. I believe the best training model for implementing ultrasound involves an initial and ongoing component. I redid and flipped the Blooms Taxonomy and created a POCUS taxonony for the heirachy of learning ultrasound.
Identifying Specific Views
A clinician new to ultrasound will start with identifying specific views. These are the approved views that your program has decided to use for answering common clinical questions.
"Put the probe here, aim the probe marker in this direction, and this is what the view should look like."
While there are special manikins you can use to train this step, many of them lack the ability to teach the amount of pressure needed to get a good view. I recommend using humans for this initial step if possible. It is important to note that this step should not be taught online and requires intimate coaching to ensure the clinician is applying appropriate technique.
Normal vs. Abnormal
Once a mental model has trained the eye to know what a "good view" looks like for a specific scan, the student can move on to identifying abnormal pathology. This component of learning is difficult when scanning humans in the classroom due to the majority of your co-workers being pretty healthy lol. Learning normal vs. abnormal can totally be done online or in the classroom, with videos of abnormal scans for the clinicians to analyze and discuss.
The internet is full of abnormal scans for instructors to use for teaching. Some of my go-to sites are:
Applying Ultrasound To Physical Assessment
At this point, the clinician is starting to become more proficient with identifying specific views and modeling their perception for normal vs abnormal. The hardest part now ( and the one commonly missed) is putting it into practice. Utilizing ultrasound as an extension of your physical assessment can initially feel clunky or unnatural. It feels strange to approach an undifferentiated hypotensive patient and train your brain to take out a piece of equipment that alone will not increase blood pressure. The only way to cultivate a smooth workflow is to practice this in simulation. Just like a 12 lead does nothing to fix the MI your patient is having, ultrasound is a detection tool that helps us avoid broad blanket treatments that might not be beneficial or may even cause harm. Actively working ultrasound into your assessment also means this device should be readily accessible to the clinicians on their truck. Buying a few probes and putting them on a supervisor is a great way for probes to collect dust.
The flight program I work for is fantastic at incorporating ultrasound into our quarterly sim lab. Our scenarios are not always based on ultrasound, but ultrasound is commonly used to answer clinical questions throughout the simulation. Here are just a few examples:
Lung Ultrasound
Does my patient have a pneumo?
Does my patient have pulmonary edema?
Cardiac Views
Is this tachycardia compensating for poor contractility?
Is this inferior wall MI actually an ascending aortic dissection?
Is this PEA arrest just a profound shock?
Does my patient have pericardial tamponade?
Is my patient's ejection fraction likely to improve with a fluid bolus?
Abdominal Views
Does my patient have free fluid within the peritoneal cavity?
OB Views
What is my pregnant patient's fetal heart rate?
It is important to realize that even though ultrasound can be used for a million different clinical questions, the number that are actually useful to EMS and aid in decision-making is few.
Before I get beat up for not including ocular nerve sheath and vascular access, I will say that my umbrella is simplified to the most common clinical questions you can answer with a reasonable amount of training (and yes I group fetal heart rate in with cardiac motion).
QI & Peer Review
The top tier of my POCUS taxonomy is clinical decision-making, peer review, and teaching. Like any other skill, absense of practice degrades mental models and ultrasound is no different. In addition to quarterly simulation, a peer review system can help expose more clinicians to scans taken by colleagues.
Let's say that I go on a flight and end up doing a cardiac scan on a cardiac arrest patient. When I come back to the base, I will do my chart and upload my ultrasound to some sort of post-debrief system that is attached to my chart (for me that is a software called Protean). Once uploaded the form will ask what clinical question I was trying to answer and whether or not I was able to answer that clinical question with the quality of my scan. This is an important assessment and metric to evaluate because there is nothing wrong with saying "hey, I just could not get a good view on that patient." The key is knowing that the view you obtained was subpar and could not be used for clinical decision-making. After I upload/finish my ultrasound assessment and lock my chart, a colleague within the company will get an alert on their next shift that they have been assigned a peer review. The chart and any attachments, such as the ultrasound I obtained, will be included in that peer review. This system allows my partner and I to evaluate the ultrasound from that assignment and exposes my colleagues to the clip for further evaluation and discussion on clinical decision-making. In addition to colleagues, your medical director should also evaluate ultrasound images and provide feedback to fine-tune your sonography and clinical assessment skills.
Summary
EMS has historically used external signs and symptoms with incredibly low sensitivity to make clinical decisions (i.e tracheal deviation, JVD, muffled heart tones). Ultrasound provides a tool that allows clinicians to actually look into the body and know what is wrong instead of guessing. The fact that any medical director would argue that this tool is not useful in EMS is ludicrous. However, the fact that some programs do not have the systems in place for ultrasound to be used appropriately to answer clinical questions is very common and a legitimate concern. I hope this blog provides some insight and framework into successfully implementing ultrasound within your program.
References:
Amaral CB, Ralston DC, Becker TK. Prehospital point-of-care ultrasound: A transformative technology. SAGE Open Med. 2020 Jul 26;8:2050312120932706. doi: 10.1177/2050312120932706. PMID: 32782792; PMCID: PMC7383635.
Schoeneck JH, Coughlin RF, Baloescu C, Cone DC, Liu RB, Kalam S, Medoro AK, Medoro I, Joseph D, Burns K, Bohrer-Clancy JI, Moore CL. Paramedic-performed Prehospital Point-of-care Ultrasound for Patients with Undifferentiated Dyspnea: A Pilot Study. West J Emerg Med. 2021 Mar 24;22(3):750-755. doi: 10.5811/westjem.2020.12.49254. PMID: 34125056; PMCID: PMC8203026.
Taylor J, McLaughlin K, McRae A, Lang E, Anton A. Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors. BMC Emerg Med. 2014 Mar 1;14:6. doi: 10.1186/1471-227X-14-6. PMID: 24580744; PMCID: PMC3941255.
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