Letter to the Editor: POCUS is a Privilege Requiring… : Emergency Medicine News – LWW Journals

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I have not been involved in emergency ultrasound as long as Christine Butts, MD, having completed my emergency ultrasound fellowship in 2020, but reading the article, “Defending POCUS (and Quashing a New Turf War),” I was disheartened to see certain comments regarding the use of emergency ultrasound. (EMN. 2022;44[9]:18; https://bityl.co/ESnN.)
I strongly value using POCUS in the emergency department; I will not argue with that. I encourage all my co-attendings, residents, and students to utilize POCUS appropriately in caring for their patients. Yet I do agree in some ways with the radiologist who made the statement that POCUS/emergency ultrasound is not a stethoscope; however, it is a not scalpel either.
ACEP’s own policy statement states: “[Emergency ultrasound] is a separate entity distinct from the physical examination that adds anatomic, functional, and physiologic information to the care of the acutely-ill patient. It provides clinically significant data not obtainable by inspection, palpation, auscultation, or other components of the physical examination. US used in this clinical context is also not equivalent to use in the training of medical students and other clinicians in training looking to improve their understanding of anatomic and physiologic relationships of organ systems.” (Ultrasound Guidelines: Emergency, Point-of-care, and Clinical Ultrasound Guidelines in Medicine. June 2016; https://bit.ly/3L6TTGg.)
We certainly should not give up POCUS, but emergency ultrasound is a skill that needs to be learned, with numerous caveats and pathologies. There needs to be a process for educating, credentialing, documenting, and ensuring quality improvement that is controlled.
Already in my experience as an ultrasound director, I have seen issues with the careless use of POCUS. From physicians who perform POCUS without saving any images and making medical decisions based on scans no one can review leading to potential liability, to physicians not mentioning or reporting incidental findings such as cholelithiasis, to entirely missed diagnoses such as pleural effusions. Even medical students, who can purchase their own portable ultrasound devices, have provided information to patients that was simply not accurate based on scans they performed without supervision. Furthermore, I have seen confidence in POCUS skills in those were not adequately trained lead to complications such as not accurately visualizing needle position during central line placement.
Yes, democratize POCUS, but keep in place protocols that ensure patient safety and encourage training, appropriate use, and appropriate diagnostic decision-making. Dr. Butts asks, “Is using ultrasound a right or a necessity?” I argue that it is a privilege that requires adequate training and credentialing. Sure, teach medical students anatomy and physiology using ultrasound, but don’t extrapolate that to using POCUS for medical decision-making, as noted in ACEP’s statement.
After all, if the comparison of POCUS with a stethoscope holds, then what is the purpose of obtaining a fellowship in emergency ultrasound? Perhaps the suspicion around POCUS comes from other specialties that have had similar experiences—questionable POCUS performed by those who have not been adequately trained or vetted by POCUS-trained physicians.
I agree that POCUS should not be within the realm of radiology, but even under the auspices of emergency medicine, critical care, or whoever else utilizes it, POCUS’s use should be considered a skill and a privilege. In these aspects, I agree that we must be careful in how we use our instruments and ensure we are maintaining high quality, lest we lead to inadvertent patient harm.
Yash Chavda, DO
New York City
Dr. Butts responds: Thank you so much for your thoughtful response to my column. I agree with a lot of your points. I think the issue lies in the idea that anyone who can purchase an ultrasound device can suddenly become an expert sonographic diagnostician. Just like any skill in medicine, from palpation to ECG interpretation, none of us was an expert the first day. We practiced, with guidance and supervision, learning from interesting cases and those more skilled than we were as we went. I still learn new ECG points from my colleagues even after almost 20 years!
Training is absolutely essential, and nowhere did I state or suggest that training is not needed. It’s a huge jump to go from being a medical student learning the spaces of the abdomen with ultrasound to being that same medical student diagnosing conditions independently. In fact, I would suggest that to understand free fluid in the abdomen, you have to first understand why it accumulates there to even look for it in the FAST exam.
The point of my article was not to say that anyone and everyone should perform ultrasound on anyone who sits still for it. My point was that ultrasound is a powerful tool that doesn’t belong to anyone, just as a stethoscope or tuning fork doesn’t belong to cardiology or neurology. We realized long ago that these tools would make us better doctors and those turf wars (such as they ever were) ended long ago. It’s high time the same turf battles over ultrasound ended and we focused on your very good point, which is to make sure we are adequately training and supervising those who want to learn. But that’s a column for another month.
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