So a few weeks ago I got into some twitter debates after I – not uncharacteristically – stated that, in my opinion, practicing acute care today without using/learning POCUS is unethical. Now I was hasty, and, in my wording did not exclude those docs who simply do not have access to the technology, and I apologize for that. For the rest, however, I totally stand by my words.
So there was a bunch of smart people who exhibited the monosynaptic reflex of asking for the evidence, the studies, or else brandishing some that showed that some aspect or other of POCUS is flawed, or some anecdote about misdiagnoses, bla, bla, bla…
Now this time, I’m going to start the discussion with the bottom line, in a sense, and leave the nitty gritty for later (which is actually the most important part, tho). But here it is:
Unless you think that the addition of ultrasonography cannot perform more accurate and rapid diagnoses than you can with your inspection/palpation/percussion/auscultation, you cannot rule against POCUS.
Now if you actually believe that, the corollary would be to never ask for an echocardiogram, abdo-pelvic ultrasound, etc… Not too many takers. Thats what I thought.
What you can challenge, however, is the process of POCUS, meaning how do you get Dr. John Doe competent enough to make a call of pathology X (for the diagnostic aspect) and how do we clinically integrate and act on the POCUS findings, many of them being “new” from increased sensitivity, what do they mean, what does their evolution mean? Many good questions there.
That’s why I lament the entire debate around POCUS. These smart people should focus their neurons on helping us fine-tune POCUS instead. POCUS is a huge, exploding field. I’m pretty POCUS-comfortable, but don’t ask me to start looking at bones and tendons and ligaments and a myriad of other applications. There’s not much in the body we can’t get some ultrasound into, so all those represent areas of additional information to be assessed.
The education process is also clearly in need. I’m on a panel of the Quebec College of Physicians whose mission is to put some parameters around POCUS. There’s no holding it back, it’s just about getting it going in the right direction.
It’s like anything else in medicine. We have no perfect tools, because we are working with a hypercomplex system with many variables.
And speed. Anyone interested can scan thru the POCUS cases on my blog, and what you see every time is the speed and accuracy that POCUS brings. Studies are hard, and complex. POCUS is not a single intervention, so measuring impact is difficult. Let’s say we have a septic patient with an obstructed kidney. POCUS will assess the hemodynamics, guide fluid resuscitation and inotrope use, but also find the probable source quickly, then perhaps make sure there is no gastric distension prior to intubation, confirm ETT and CVC placement, and more as the evolution goes. How do you make an RCT around that? It is, however, a good idea to validate every aspect (which has essentially been done already, but certainly there is more to do).
Sadly, most of the naysayers, in my experience, are not echo-competent and likely don’t want to feel like med students all over again, learning a complex skill from scratch, and instead are crossing their fingers hoping that somehow, ultrasonography will be discredited… Yup, it’s not just a river in Egypt.
POCUS is a work in progress. It won’t go away. Hop on and give us a hand. Your patients will benefit.