Hocus POCUS: the magic and progress of pre-hospital ultrasound use by EMS

A portable ultrasound machine enabled eFAST exam can identify free fluid, a pneumothorax or signs of dissection from the back of an ambulance


Ever wish you could just see inside your patient’s body to find where they’re bleeding from? Or, find that buried vein that you just can’t feel from the outside? Well, the introduction and progress of point-of-care ultrasound in EMS can help you with just that!

Prehospital use of point-of-care ultrasound (POCUS) isn’t an entirely new assessment tool within our industry, but recent technological and financial improvements have changed its game for feasibility.

EMS agencies in Texas, Nevada, North Carolina and other parts of the country have jumped on the band wagon by implementing POCUS into their clinical assessment repertoire, and now Colorado is joining them.

Pre-hospital portable ultrasound can provide diagnostic evidence to inform transport decisions. (Photo/courtesy Rommie Duckworth)
Pre-hospital portable ultrasound can provide diagnostic evidence to inform transport decisions. (Photo/courtesy Rommie Duckworth)

Dr. Gary Witt, an EMS medical director serving from Castle Rock (Colorado) Adventist Hospital, outlines that “prehospital ultrasound allows us to identify potentially life-threatening conditions in the field, and often expedite emergency department diagnosis and management of these conditions.”

He and one of his colleagues, Dr. John Riccio, have brought Colorado into the spotlight as a growing example of prehospital ultrasound use. Both are active medical directors within the South Denver-metro area with Centura Health, and have helped to resurrect this project, which was once determined not feasible for EMS use.

Years ago, another colleague, Dr. Eugene Eby supported Littleton Fire Department with a prehospital ultrasound project, but the portable technology of today just wasn’t available yet. Now, an active agency is the first to bring this updated technology back to the area.

So, how can POCUS have an impact in the field – on patient care and in determining transport destinations?

Thinking FAST

We’ve all been on this call a dozen (or hundred) times before: a motor vehicle collision involving a patient that wants to get transported to the hospital for evaluation. The patient, a restrained passenger, is complaining of abdominal pain and has seemingly normal vital signs. The patient’s pain, however, seems higher in acuity than what other past patients have presented with.

Palpating the abdomen results in guarding and the patient’s pain level doubles. Is this muscle-related, or is there a bleed?

Assessing the liver, spleen, kidneys, bladder and pericardium for free fluid (or blood) can all be accomplished through a FAST exam. No, not a stroke assessment; a focused assessment with sonography for trauma.

Noticing fluid around one of these organs could upgrade your call from a non-emergent transport to the closest hospital, to an emergent transport to a higher-level trauma center.

Extending to the lungs

Adding the lungs to the FAST exam allows evaluating for a pneumothorax. This addition is often referred to as an EFAST (eFAST or E-FAST) exam – one that is extended.

Take a patient that was kicked in the chest by a horse on a ranch or farm. Not only is there a high likelihood this patient has broken a rib, but that could also put them at a higher risk for a pneumothorax (which could develop into a tension pneumothorax).

Your response to this rural scene is 15 minutes, where you find your patient with a high degree of pain, signs of severe, progressive dyspnea and jugular vein distention present. Shortly after loading her into the ambulance, she begins to experience periods of altered mentation and then becomes unresponsive.

Your gut instinct tells you she’s got a tension pneumothorax (and you’re right!). Your ultrasound screen shows a marked difference between the lung views of the affected and unaffected sides. One shows a seashore with waves crashing in and ants marching, while the other looks like a barcode.

Now, imagine watching your needle insert into her skin, then into the pleural space to relieve the tension. Performing a needle decompression would otherwise be performed as a blind procedure, but not with ultrasound. You can watch your progress in real time.

Finding the hidden vessel

Whether it’s finding that deep vein that we know has got to be there, or assessing the aorta for signs of dissection, ultrasound can allow us to look inside the body to see structures that otherwise can only be viewed with advanced imaging technology or visually through surgery.

If you’re debating between making a third attempt at an IV and inserting an IO needle on a stable patient, why not get an inside look via ultrasound?

“This must cost a lot,” you might ask?

Not nearly as much as it has in the past, and not even as much as your cardiac monitors. Advancements in technology have improved this technology to be accessible with one single probe and a device like your tablet (or smartphone).

Some argue that ultrasound is the wave of the future, even potentially replacing the stethoscope as we know it. Regardless of the degree of truth in this, ultrasound surely is a progressive technology that EMS should keep its eye on (and embrace) moving forward.

“Analogous to the 12-lead ECG, POCUS allows for a continuous and seamless transition of care,” Dr. Witt pointed out. “As the technology and our experience grows, the potential to use ultrasound directly in the prehospital setting for applications such as identifying pulmonary edema, evaluating volume status and facilitating peripheral intravenous access is exciting as well.”

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