Trending: Expanded use of prehospital point of care ultrasound (P-POCUS)
How far has prehospital point of care ultrasound come in the past year and, more importantly, where is it going next?
If emerging tools and technology trends continue, prehospital point of care ultrasound (P-POCUS) is the assessment and skills adjunct that might be right around the corner for your EMS service.
Ultrasound devices as medical tools have been around since 1942 when neurologist Dr. Karl Theodore Dussik first used sound waves to detect brain tumors. Ultrasound systems have been mainstream medical devices since the mid-1960s, with significant imaging improvements occurring with each decade.
Over the past 20 years, portable machines have brought point of care ultrasound capabilities to physicians in emergency departments, introducing improving rapid diagnostic capabilities and improving skills performance. The question then arises, can and should paramedics be using these devices outside of the hospital? In the past year, the answer from experts in the field is a resounding, “Yes!”
Rapid diagnosis in the prehospital setting
A 2018 systematic review of literature on prehospital point of care ultrasound (P-POCUS) concluded, “Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome.” Clearly more research is required, but the introduction of new smaller, lighter, more EMS-friendly devices coincides with positive experiences of EMS services already successfully using P-POCUS to rapidly diagnose and treat challenging patient presentations.
In 2018, EMS services in virtually every state are using P-POCUS tools in a variety of ways, including:
- Assessing heart rhythm and blood flow during cardiac arrest
- Rapid ultrasound in shock and hypotension (RUSH)
- Focused assessment with sonography for trauma (FAST) exams
- Endotracheal tube placement confirmation
- Guiding difficult IV access
“Diagnostic ultrasound is widely used in medicine but its clinical relevance continues to expand at the point-of-care. In particular, the growth of pre-hospital ultrasound has been fueled by greater portability and affordability of ultrasound equipment. Equally as important, numerous emergency medical societies and thought-leaders are educating new ultrasound users at conferences, workshops, and on social media,” says Andy Lippman, Philips Ultrasound Marketing Manager.
Lippman goes on to say, “In recent years, ultrasound has been called “the stethoscope of the future.” While this is buzzworthy, it’s a bit of an overstatement. Ultrasound, and imaging in general, is innately complex and requires substantial training to use accurately and efficiently. Automation technology (often called A.I.) and continued user education will advance pre-hospital ultrasound in the years to come.
PPOCUS in the EMS scope of practice
The 2018 draft of the National Association of State EMS Officials (NASEMSO) EMS Scope of Practice Model is the first to address the inclusion of P-POCUS as being within the scope of EMS providers, stating, “non-invasive diagnostic equipment (e.g. ultrasound)” not be limited to any specific levels of qualification of EMS personnel.
Thomas Hudson, NRP, CCP-C, a flight paramedic with Guardian Flight in Fairbanks, Alaska, agrees. “I think that we are seeing POCUS evolving more rapidly than any other EMS technology in the past, at least in the last 18 years I’ve been practicing. As recently as four years ago, the number of agencies that had deployed POCUS in the field was minuscule.”
Hudson recognizes the need for research showing the connection between the use of P-POCUS and improved patient outcome and/or EMS service safety and efficiency. “Unfortunately, there isn’t more recent data regarding field utilization, at least that I’m aware of. Anecdotally however, there seems to be an ongoing surge in interest across both air medical and ground EMS providers, as seen by both the recent development of paramedic-specific education programs, as well as manufacturers beginning to market their ultrasound products specifically to the EMS market.”
Hudson sees this evolution being precipitated by a number of factors. “First and foremost is the continuing development of paramedics as competent clinicians delivering high-quality medicine, rather than algorithmic technicians working in a ‘see A, do B’ fashion. In order to practice at this level, more advanced diagnostics are necessary; we’re beginning to see this through the proliferation of POCUS, as well as other technologies like portable laboratory testing. Not far behind that has been the ongoing democratization of medical education.”
Innovation fuels prehospital point of care ultrasound applications
Hudson sees big changes as the industry moves to deliver products designed better for P-POCUS applications. “The final precipitating factor has been the hardware itself. The miniaturization of ultrasound equipment is a relatively new development, and it being at a price point within reach of EMS agencies is even more so. With the perpetually limited budgets of EMS agencies, I think we’re beginning to see a “if you build it, they will come” situation beginning to unfold.”
Dave Willis, co-founder at Clarius Mobile Health, agrees. “We have seen a lot of interest in hand carried ultrasound in the last few years. This trend has expanded the use of ultrasound to many clinical practices outside of the typical ultrasound departments. These systems have also expanded the use of ultrasound as a diagnostic tool in locations that have very little health care equipment available to them.”
What trends do these experts see coming for P-POCUS in 2019? “Ultrasound will gradually see more acceptance among the EMS community in 2019. Early adopters in physician-led and aeromedical EMS are quantifying the benefits of pre-hospital ultrasound and are developing protocols for widespread use. In 2018, we saw some of the first public EMS agencies adopt ultrasound with much excitement and this trend should continue into 2019,” Lippman noted.
Willis sees potential for expanded use of P-POCUS in areas served by rural and frontier EMS services. “Wireless imaging using smart devices makes imaging available to anyone using smart devices with different operating systems.”
Hudson believes that there are big changes ahead when it comes to prehospital point of care ultrasound. “I think that the next year or two is going to be extraordinarily interesting when it comes to prehospital POCUS in this country. There have only been a small handful of us that have been willing to ‘figure it out as we go’ when it came to procurement, training and QA. Now that there have been several proof-of-concept cases, we’re starting to see the industry realize that this is a large, untapped market. As soon as commercial interests put the tools and technology out to make POCUS convenient and cost effective to deploy, I believe that we are going to see an explosion of programs across the country.”