EMERGENCY ULTRASOUND SECTION
Is POCUS a Procedure or an Extension of the Physical Exam? Experts Debate Joshua Guttman, MD FRCPC FAAEM and Yash Chavda, DO FAAEM
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OCUS is not a part of the physical examination - Yash Chavda, DO FAAEM There is nothing more irksome to an ultrasound director than to hear people equivocate point-of-care ultrasound (POCUS) to physical examination or a stethoscope of the future. A stethoscope enhances our already existing senses such as hearing, they do not give us an internal view of a person as ultrasound does. This false equivalence is becoming even more prominent with the advent of portable ultrasound devices. I urge extreme caution to patient care facilities to ensure that POCUS remains what is supposed to be—a diagnostic procedure like other imaging studies.
Obviously, the convenience of POCUS in trained and responsible hands is undeniable, but there needs to be a process for educating, credentialing, image retention, quality assurance, and remediation. All emergency physicians should be able to perform POCUS, if they go through the process of being credentialed and perform it appropriately. Just as physicians train for intubation, tube thoracostomies, and other procedures, they must be trained in POCUS and recognize its value as a procedure. Additionally, POCUS is case-specific as opposed to the physical exam which is performed on every patient. POCUS should be limited to specific applications for the identification of limited pathology, often with yes/ no answers. Hospitals also benefit as they can be reimbursed for procedures separately performed from history and physical examination if they choose to, thus increasing revenue. If the physician took the time to perform POCUS and interpret the findings, it should be reimbursed. We must stop this false equivalence of POCUS as a component of physical examination to reduce risk, improve patient, safety, and ensure a high level of quality.
POCUS is a procedure that needs to be learned, with risks, benefits, POCUS can be an extension of the physical exam and alternatives just as any diagnostic procedure. Careless use of - Joshua Guttman, MD FRCPC FAAEM POCUS can lead to worse patient care and resource utilization. These In a 2018 special communication in JAMA Cardiology, Narula et al. include misinterpreted images and of finding or missing incidentalomas. argued that “insonation” should be added as the fith pillar of the physical Examples observed are false negative FAST exams, false negative examination. The authors state that there has been a diminishing focus exams for lung sliding, and false positive cardiac ultrasounds for pericaron physical examination, given the understanding of its limitations in the dial effusions. Other examples include missed complex renal cysts recontext of modern diagnostic imaging. Adding POCUS as a pillar of the quiring patient follow-up and bowel misidentified as gallstones prompting physical examination both modernizes bedside clinical examination and unnecessary surgical consultation. I have also seen physicians carrying would spur more enthusiasm in bedside clinical diagnosis. Specialties their own pocket devices to perform such as internal medicine, critical care, POCUS, never save any images, and anesthesiology are increasingly briefly document their findings, and embracing POCUS as a useful bedmake medical decisions off those side diagnostic and procedural tool. findings. Who verifies those images? Arguments for POCUS to be considWhat happens when there is a comered a separate procedure note how plication? Furthermore, I have seen Adding POCUS as a pillar of it is a distinct skill that is done apart confidence in POCUS skills in those the physical examination both from history and physical exam as who were not adequately trained opposed to concurrently with it. Other modernizes bedside clinical lead to complications such as not arguments include that this is a proexamination and would spur visualizing needle position leading cedure done by those with specialized to a pneumothorax during central more enthusiasm in bedside training using specialized equipment line placement. Yes, findings can be clinical diagnosis. and not taught as part of the physical missed on physical examination as exam taught to all medical students. well, but the risk is significantly greatHowever, this is not always the case. er for POCUS. The use of handheld doppler to check >>
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COMMON SENSE JANUARY/FEBRUARY 2023