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Friday Sep 21, 2018

POCUS: A Small Tool With Big Benefits for Primary Care

Point-of-care ultrasound (POCUS) is a tool that is increasingly being incorporated into the family physician's toolbox. In 20 years, a pocket ultrasound device may be as a ubiquitous for physicians as a stethoscope is today.

[diagnostic tools in red toolbox]

Not only can POCUS complement the history and physical exam -- providing more detail to inform our clinical decisions -- it also is an effective tool that can reduce costs of advanced imaging, improve patient care and patient safety, and increase face-to-face interactions between doctor and patient, thus increasing patient satisfaction. That list sounds a lot like something that meets the quadruple aim of providing higher-quality care and lower costs while improving patient and physician satisfaction.

Many family physicians have used ultrasound in maternity care. As ultrasound devices get smaller, more powerful and, most importantly, more affordable, they are increasingly being used for other modalities, such as to assess fluid status and perform limited cardiac and pulmonary evaluations, as well as for some procedural indications, to name a few.

Here are two examples of ways that POCUS has improved the care I provided in the past year.

I saw a young woman, whom I will call Jackie, who presented for an urgent appointment with vaginal bleeding and lower abdominal pain and cramping. Jackie thought she was five weeks pregnant based on the timing of her last menstrual period. A pregnancy test confirmed her suspicion. Her pelvic exam revealed bleeding from the cervix with no other abnormality.

Without POCUS, the differential diagnosis was broad -- ranging from miscarriage or fibroid or endocervical polyp to a life-threatening ectopic pregnancy.

I could have performed blood work and ordered a formal ultrasound, but that would have taken hours and Jackie would have been waiting all day. Instead, I performed a bedside endocavitary ultrasound and saw two things that made me nervous and changed my management. One, there was no intrauterine gestational sac, which I would have expected to see at five weeks' gestation; two, there was free fluid in the abdomen. A potentially life-threatening ectopic pregnancy shot to the top of my differential.

I immediately called my OB/Gyn and radiology colleagues and arranged for a stat formal ultrasound and had my nurse draw blood work. Within a few hours, Jackie was in the operating room and successfully had her fallopian tube removed to resolve an ectopic pregnancy.

Utilizing POCUS did not change Jackie's ultimate care plan. However, it enabled a faster and more accurate diagnosis. In one 15-minute office visit, we avoided a potentially life-threatening delay in care.

Another, less dramatic, example of how POCUS improves care involved a patient I will call Roger, a pleasant, 85-year-old man I had been treating for COPD, congestive heart failure (CHF), obesity, gastroesophageal reflux disease (GERD) and type 2 diabetes. He presented with a chief complaint of mild shortness of breath, cough, fatigue and sore throat. This was in January, and our medical center had seen many cases of influenza.

Roger's exam and history were relatively unremarkable and unchanged from prior exams. His lung exam revealed mild, coarse breath sounds in both lower lungs with possible rales (although I couldn't be sure), mild bilateral lower-extremity edema, nasal congestion, obese abdomen and unchanged II/VI systolic heart murmur. The differential diagnosis again was broad: a viral upper respiratory tract infection, influenza, CHF exacerbation, COPD exacerbation, pneumonia or worsening of his GERD resulting in pulmonary symptoms.

I grabbed my ultrasound, looked at both lungs and found no evidence of pleural effusion and no obvious infection. I did see some mild pulmonary edema and fluid within the lung parenchyma. I also looked at his inferior vena cava and saw that it was slightly enlarged at 2.5 centimeters and did not collapse with inspiration, which indicated he was fluid overloaded. Lastly, I saw a trace amount of peritoneal fluid in his abdomen.

With this additional clinical information, CHF exacerbation quickly became my leading diagnosis.

I gave Roger a dose of IV Lasix and drew some stat labs, but I did not wait to initiate treatment. I also ordered a chest X-ray and confirmed my suspicion that there was no pneumonia. After a dose of IV Lasix, some time and several trips to the bathroom, Roger's shortness of breath was slightly improved. I increased his home Lasix dose for a few days, arranged for him to return for subsequent doses of IV Lasix and labs and scheduled to see him back in clinic the following week to follow up. I also arranged for him to attend a heart failure class to learn more about how to avoid CHF exacerbations.

Roger felt much better the following week. Utilizing POCUS, I was able to improve and expedite my clinical decision-making, improve Roger's treatment plan and possibly avoid a hospital admission for his CHF exacerbation.

There are countless similar examples.

Let me tell you what POCUS is not. It is not always a replacement for formal imaging. It is not as complete an evaluation as a formal ultrasound. POCUS can, however, reduce expensive stat or after-hours radiology exams and reading.

Primary care POCUS is not a turf war with radiology, it is a complementary tool and can help improve radiology usage. Clinical decisions are not based solely on the result of a bedside ultrasound. You treat a patient and a constellation of findings, not a single lab value.

POCUS is not new, but its popularity has increased recently due to improved technology, lower cost and the increased portability of new handheld machines.

In fact, according to a 2012 survey, 62 percent of U.S. medical schools had formal POCUS education incorporated into their curriculum(journals.lww.com) on either a required or optional basis. Among family medicine residencies, just 2.2 percent had a formal POCUS curriculum component in 2014.(www.stfm.org) However, 29 percent had just added it to their curriculum, and an additional 11 percent were planning to start formal training.

Researchers from the original study have indicated they plan to repeat it to track the proliferation of formal POCUS curriculum. It's also worth noting that the AAFP has published a residency curriculum guideline for POCUS.(175 KB PDF)  

There are many opportunities to learn POCUS. The American Institute of Ultrasound in Medicine(www.aium.org) has a myriad of online resources. Hands-on POCUS courses are popping up throughout the country, including sessions at the AAFP Family Medicine Experience, Oct. 9-13 in New Orleans. I will help facilitate discussion and learning during two informal lunch meetings at the conference on Oct. 10 and 11.

The AAFP also has a POCUS member interest group (MIG), which will meet Oct. 9 in New Orleans. The MIG allows family physicians to access a collective wealth of knowledge and information from peers across the country who are using POCUS in a variety of practice settings.

POCUS is an extension of the physical exam that adds to clinical decision-making and can reduce delays in care and treatment. It is an aid in diagnosis, just like an EKG or X-ray. POCUS can also reduce the burden on radiology or emergency departments -- particularly that associated with expensive stat exams -- freeing up resources and improving access for those who truly need urgent or more formal exams.

Lastly, POCUS can provide quick answers to direct and focused clinical questions at the bedside -- and it's coming soon to a location near you.

Alex Mroszczyk-McDonald, M.D., practices comprehensive family medicine and sports medicine in Southern California, with a focus on health policy, physical activity and advocacy. You can follow him on Twitter @alexmmtri.(twitter.com)

Posted at 10:19AM Sep 21, 2018 by Alex Mroszczyk-McDonald, M.D.

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