Ultrasound

I was drawn to point of care ultrasound since medical school. The ability to visualize the dynamics of a patient's internal structures without releasing even a particle of radiation was better than having x-ray vision superpower. I ultrasounded every-part of every-one, particularly myself whilst fasting, feasting, exercising, and passive leg raising. Motivated by the ever growing literature surrounding POCUS, I was convinced that this would replace traditional clinical practices. Today, I remain an aficionado. But I've become more cautious regarding its use. This website humbly attempts to teach POCUS: how-to, critical thinking, and careful interpretation.


Understanding Physiology

POCUS is an incredibly rich tool understanding an individual's physiology. However, it's also chicken-egg. Proper interpretation and use of ultrasound (particularly echos) relies on a strong mastery of physiology to begin with. Echo education cannot occur without physiology education. So I apologize in advance if some of the material seems dense and not immediately "practical" to clinical care. But echo was never meant to be simplified down to "this measurement means more fluids". It is meant to help you think; whereas the above tries to take away the thinking.

Clinical Care

Then how to use ultrasound in clinical care? Depends on the clinical situation and the provider's confidence in their POCUS findings. Only in the most dire circumstances does an abnormal finding lead to immediate action. For most situations, an abnormal finding spurs re-evaluation and corroboration with another test. For example:

In the coding or near-coding patient (rare),

a large pericardial effusion prompts me to perform emergent bedside pericardial drain placement

lack of lung sliding prompts me to perform finger thoracostomy

small cardiac chambers prompts me to administer volume expansion, Hg checks, with possible massive transfusion

RV overload prompts me to administer intropic support and empiric lytics if this is a new finding

For everyone else (common),

a large pericardial effusion prompts me to corroborate with pulsus paradoxus

lack of lung sliding prompts me to corroborate with CXR

low EF prompts me to corroborate with SvO2, clinical measures, thermodilution

RV overload prompts me to corroborate with history, previous echos, CXR, and possibly CTA-PE

hydronephrosis with AKI prompts me to corroborate with CT-renal colic

As you see from above, POCUS is not necessary for clinical care of most patients. Thank god! It's hard for the best of us to get a good view ~30-40% of the time! But it can be a useful tool to trigger a more focused and advanced workup.

However, ultrasound can completely change our approach to procedures after the initial learning curve is overcome.

Research

There is infinite potential for research in POCUS. Research on new maneuvers, clinical applicability, and educational pedagogy arise everyday. It is as important to contribute to this body of literature as it is to critique it. All new science follow the trend of an initial bloom of positive findings followed by a wave of rebuttal findings before settling on an equilibrium closer to the truth. Especially since POCUS has evolved separately from the older body of echo literature, there is much opportunity for cross-specialty research/learning.