Point-of-Care Ultrasound and Me

Hello there,

I am a pulmonary and critical care physician in the United States and an associate professor of medicine at the Warren Alpert Medical School of Brown University, teaching Point-of-Care Ultrasound (POCUS) to medical students, medical residents, and fellows. For some reasons, I - all of a sudden, not sure how or why - thought of writing about POCUS - more or less for my personal memorandum. I teach POCUS in the US more than a decade at American College of Chest Physicians (ACCP - CHEST) and have been teaching at my medical school as well. I have also started teaching it in Japan as well since 2017. Again, this article is more or less for my personal memo, but hope you also find it helpful. Note also I may keep editing each article, so you may notice some changes when you come back to read the "same" article.

(1) Point-of-Care Ultrasound in General
(1-a) Paper
Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011 Feb 24;364(8):749-57. doi: 10.1056/NEJMra0909487. Review. PubMed PMID: 21345104.

So, what exactly is this "Point-of-Care Ultrasound"? How different is it from a conventional ultrasound examination? Any special technique? This article defines POCUS as follows: "Point-of-care ultrasonography is defined as ultrasonography brought to the patient and performed by the provider in real time. "

For those who use ultrasound for your daily practice, like in Japan where you can find ultrasound machines on every medicine floor, you might be puzzled to learn this concept. "So what is this POCUS thing? How is it different from my everyday practice? I perform ultrasound examinations for my patients at the bedside every day". Well, you are performing POCUS. No difference.

But for those who practice in the US, you may understand this concept better, since ultrasound was traditionally NOT performed by physicians at the bedside, and the results were NOT interpreted and applied to the patients in front of you in real-time. We order an ultrasound, then the technicians may come at the bedside, perform ultrasound examinations, then, later on, radiologists read the findings stored in the machines or servers, then upload the reports. Most often we only read the reports, and not the images or least, movies. Sometimes we receive the reports on the same day hours later, and sometimes we do not and may wait for them for days. For those of us, POCUS is indeed a new and brilliant concept. This article explains the concept very nicely. A nice introductory paper I recommend you all read to get the grasp of this concept.

(1-b) Textbook
Point-of-Care ULTRASOUND by Nilam Soni (Second edition)
If I choose one textbook for point-of-care ultrasound, I have no doubt to pick up this one. The first edition is truly a fantastic textbook written by my dear friend Nilam (I started the program in Japan with him and Dr. Toru Yamada at Tokyo Medical and Dental Univ, so every year we work together), and please note 2nd edition is now out!

Ultrasound in the Intensive Care Unit

I wrote a few chapters including diaphragm ultrasound and abdominal ultrasound. While I still recommend Nilam's amazing textbook, this unique textbook might be still the only textbook published in English which explains diaphragm ultrasound in one chapter. A good read.

For those who can read Japanese fluently, I highly recommend this book.
レジデントノート 2018年8月 Vol.20 No.7 エコーを聴診器のように使おう! POCUS〜ここまでできれば大丈夫! ベッドサイドのエコー検査

I have edited this book with Dr. Toru Yamada at TMDU and Dr. Hiromizu Takahashi at Juntendo University. I hate to recommend something I wrote, but I believe this is quite a good one as long as you can read Japanese!

(2) Focused Cardiac Ultrasound (FoCUS)
Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013 Jun;26(6):567-81. doi:10.1016/j.echo.2013.04.001. PubMed PMID: 23711341.

I believe one of the significances of FoCUS comes from the fact it is written by the group of cardiologists, and Dr. Kirk Spencer is indeed the pioneer of this field.

Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble VE, Tsung JW, Neskovic AN, Price S, Oren-Grinberg A, Liteplo A, Cordioli R, Naqvi N, Rola P, Poelaert J, Guliĉ TG, Sloth E, Labovitz A, Kimura B, Breitkreutz R, Masani N, Bowra J, Talmor D, Guarracino F, Goudie A, Xiaoting W, Chawla R, Galderisi M, Blaivas M, Petrovic T, Storti E, Neri L, Melniker L; International Liaison Committee on Focused Cardiac UltraSound (ILC-FoCUS); International Conference on Focused Cardiac UltraSound (IC-FoCUS). International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014 Jul; 7(7):683.e1-683.e33. doi: 10.1016/j.echo.2014.05.001. Review. PubMed PMID: 24951446.

International guideline for FoCUS: a very nice summary of FoCUS (and I like how they define FoCUS, which embodies the spirit of POCUS).

(3) Lung Ultrasound
Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25. doi:10.1378/chest.07-2800. Epub 2008 Apr 10. Erratum in: Chest. 2013 Aug;144(2):721. PubMed PMID: 18403664; PubMed Central PMCID: PMC3734893.

Lichtenstein is a genius who has founded this field of lung ultrasound almost all by himself - my dear mentor and I am so fortunate to learn this directly from him.

(4) Abdominal Ultrasound
Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma. 1999 Mar;46(3):466-72. Review. PubMed PMID: 10088853.

(5) DVT
Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011 Mar;139(3):538-542. doi: 10.1378/chest.10-1479. Epub 2010 Oct 28. PubMed PMID: 21030490.

My then senior fellow Pierre wrote this excellent article.

(6) POCUS in the evaluation of Shock
Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll. Emerg Med Clin North Am. 2010 Feb;28(1):29-56, vii. doi: 10.1016/j.emc.2009.09.010. PubMed PMID: 19945597.

There are SO many protocols to assess hemodynamic instability by POCUS, such as RUSH, FALLS, or FEEL. I think as long as you stick to keep four major differential diagnosis of shock (hypovolemic, cardiogenic, obstructive, and distributive) in mind and figure out how you rule them in or out, you should not miss too much. I believe they have almost the same or similar content with different faces. Pick one of your preference, and we teach RUSH at the medical school.