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Point-of-Care Ultrasound: The Best Thing Since Stethoscopes?

A bit of good news for a change: a “Perspective” article in the New England Journal of Medicine describes how point-of-care ultrasound devices are being integrated into medical education. The wonders of modern medical technology are akin to science fiction. We don’t yet have a tricorder like “Bones” McCoy uses on Star Trek, but we are heading in that direction, and the new handheld ultrasound devices are a promising development.

The stethoscope has become iconic, a symbol of medical expertise draped proudly around the neck by doctors and other medical personnel. Before it was invented, doctors could only try to listen to a patient’s heart by direct application of ear to chest. In 1816, Laennec interposed a tube of rolled paper between ear and chest, and the stethoscope was born. It quickly became an essential tool, allowing us to hear the distinctive murmurs produced by different heart valve abnormalities, to take blood pressures, to detect the wheezing of asthma or the collapse of a lung , to hear the bruits caused by atherosclerotic narrowing of blood vessels, to detect intestinal obstructions by listening for borborygmi (I love that onomatopoeic word!).

The stethoscope allows us to hear sounds produced by the body, but sound also allows us to see inside the body. Diagnostic ultrasound has a multitude of uses. With prenatal sonograms, we can determine the sex of a fetus, watch it suck its thumb, and even take its picture for the family album. With echocardiography we can evaluate heart valves, see fluid accumulation in the pericardium, observe the thickness and motion of the heart wall, and even quantify the efficiency of the pumping process. Ultrasound lets us see clots in blood vessels and stones in the gallbladder, evaluate abdominal organs, detect cysts, screen for carotid artery narrowing and abdominal aortic aneurysms, and guide needles into the body for therapeutic and diagnostic purposes.

Modern imaging methods allow us to see abnormalities in the living patient that were once only detectable on autopsy. Because of this, medical autopsies are no longer so useful and their rates have declined drastically although forensic autopsies are still required by law. It’s really amazing what we can see with CT scans, MRIs and ultrasound. I recently had an echocardiogram and my mind was boggled as I looked into my own heart and watched the valves open and close. I developed a new respect for my heart as I watched the organ pumping away, working assiduously to keep me alive, with never a moment’s rest. The visual experience was impressive, but perhaps even more impressive was the way the technician was able to precisely measure the thickness of the ventricular wall and quantify the ejection fraction, measuring the amount of blood that was being pushed out of the ventricle with every heartbeat.

Instead of writing an order for technicians to do these tests, doctors now have the option of using ultrasound technology themselves as part of the physical exam at the bedside or in the office. Several US medical schools are offering ultrasound training as early as the first year, even in orientation programs. Ultrasound is used in classes of anatomy, physiology, and physical diagnosis, and eventually on clinical rotations. Harvard has students performing ultrasounds on each other. Mt. Sinai is issuing hand-held ultrasound units to all internal medicine interns.

Studies have shown that first year medical students using these devices are better at detecting cardiac abnormalities than cardiologists (75% vs. 49%) and better at judging liver size than specialists palpating the liver. In the future, ultrasound may well become a standard part of the physical exam. The stethoscope was an extension of the doctor’s sense of hearing, and ultrasound extends the doctor’s senses in far more versatile ways.

Providing these devices to students may not be an unalloyed good. Proper use requires extensive training. False positives and negatives will occur. Students will rely on technology and neglect other diagnostic skills like palpation and auscultation. Full conventional ultrasound studies will still be needed for confirmation and further detail.

Consider this criticism:

Notwithstanding its value, I am extremely doubtful because its beneficial application requires much time, and gives a good deal of trouble both to the patient and the practitioner.

No, that wasn’t criticism of ultrasound, it was an 1829 comment about the stethoscope. Old dogs (and old docs) are slow to learn new tricks, and any new-fangled technology is bound to meet with some resistance. The real question is whether its use will improve medical practice and patient outcomes. It seems logical that it will, but that premise, like any other, will have to be evaluated by controlled scientific testing. I am optimistic.

Developments in scientific medicine are far more awe-inspiring than anything alternative medicine has to offer. Invisible acupuncture meridians and chiropractic subluxations can’t compete with watching your own heart valves open and close.

Reality is a lot more satisfying than fantasy.

Posted in: Medical Academia, technology

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31 thoughts on “Point-of-Care Ultrasound: The Best Thing Since Stethoscopes?

  1. Dr Mick says:

    Our point-of-care ultrasound has become an extension of our routine examination, especially for shoulders and cases of suspected bursitis. I’m a pain specialist with a musculoskeletal bent by trade. I can now accurately inject structures in the office I used to have to send ppl to the radiologist for. It takes some effort to get good at but it’s transformed our practice!

  2. irenegoodnight says:

    Oh dear– I can just see the acupuncturist with his handheld ultrasound device to guide his needles to just the right meridian. And Santa will get a GPS for the sleigh, and the Tooth Fairy will start sending text messages to tell you where to find your money (or bit coin).

  3. Andrey Pavlov says:

    I think US is an excellent tool. People are indeed slow to adopt it though, just like anything. I have also noticed some instances where the push back is explicitly because they feel it will dull other physical exam skills. Not an unwarranted concern, but to me the solution is not to not adopt the technology.

    At my institution using US for the placement of central lines is standard of care. If you don’t use the US you have to document why. Well, conceivably you could be in that situation. So every time a different attending has supervised me placing a line, they have asked me to describe precisely how I would do it without the ultrasound. Seems like a reasonable balance to me.

    But in the ICU I especially love the US. I would run around with it all day. Using it to see IVC collapse is a much better way to judge fluid responsiveness. A quick check of the chest for a suspected pneumonia (based on auscultatory findings) can save a chest xray. I even learned some basic windows for echocardiography which is handy for a quick assessment of how the heart is doing in response to a fluid challenge. It can even be used for checking for small pneumothorax also potentially saving a chest xray.

    When I had down time I would run around the hospital with it to do difficult peripheral lines for nurse by finding deep veins for good access. Checking for weak peripheral pulses, spot checks of lymph nodes, etc… the list goes on.

    All around, I think it will indeed be something we carry with us like a stethoscope. A small Bluetooth enabled device that can interface directly with the smart phone we all carry anyways. I certainly would.

    1. WilliamLawrenceUtridge says:

      What would work to preserve palpative diagnostic skills? First palpation followed by confirmation through US? Or would that create problems?

      It’ll be neat to see the research when it eventually comes out, as Dr. Hall says.

      1. MadisonMD says:

        Tradition, pooh. Why is it necessary to maintain old exam skills that are superseded by ultrasound?

        The only reasons I could imagine are:
        (1) If inspection, palpation, percussion, auscultation additionally add sensitivity or specificity.
        (2) In case ultrasound is not ubiquitous among places one might practice.

        1. Windriven says:

          There was a case report many years ago – I think it was in Anesthesiology – that described an attempt to wean a CABG off bypass. As I remember the story, BP was crap and remained crap despite a garbage can of pressors and stimulants. At some point somebody checked the carotid pulse and it was pounding. The BP transducer had failed.

          The moral, of course, was that technology is great – except when it gives false data. Sometimes you have to go back to basics to know.

        2. MadisonMD says:

          @Windriven.
          Point taken (and actually I feel better b/c I to have the nostalgia too). It’s a backup. But I think the ultrasound will mostly replace parts of the exam that were not very sensitive nor specific to begin with, unlike pulse.

          1. Andrey Pavlov says:

            I think your #2 is the most compelling reason. However, I also agree that it is important to know how to do it “the old fashioned way” even if crudely, just as a way to independently check. That is also why it is important to know what is likely to be expected, so that when you get a result that is wildly out of expectation you can pause and be prompted to do said independent check.

  4. Cory says:

    Speaking as an old-time doc, I don’t think there is any question the US will give more and better information than the stethoscope. Many of us cold see that coming forty years ago. In theory, a wonderful thing.
    But the critical question is what will the clinicians do with this information?
    That learning curve, if done right, might take a practitioner 10 years.
    So you can see ventricular thickness and measure ejection fraction, so what?
    What does that actually mean to the patient? We will find that many of our current beliefs about that information are incomplete or mistaken all together.
    If you have ever been lost using a GPS with no other available information, you will understand what I mean.
    If anything, I think it will require a better understanding of clinical medicine.

  5. Young CC Prof says:

    Ultrasounds are amazingly detailed these days! What might be even more amazing than watching an adult’s heart move is watching the heart of a 20-week fetus, the tiny tiny heart of a one-pound child, fast and perfect. You can see the valve that will become the septum, wiggling independent of the outer heart muscle. That was my favorite part of my son’s anatomy scan.

    They can count and measure the organs, estimate the baby’s size with remarkable precision, and diagnose problems with the cord or placenta. The ultrasound that told my doctor to deliver him three weeks early almost certainly saved my son’s life when his placenta began to fail. The one that diagnosed my cousin’s heart defect probably saved his life.

    Of course, like any test, it takes expertise to put the results into perspective, to know when a false positive is likely and when a false negative is possible. And, as with everything, advancing technology causes the loss of old skills. The question is, which skills are worth fighting to keep, and which should we let go? (I certainly don’t think doctors should ever lose the skills of diagnosing with their own senses, but it’s a question.)

  6. mouse says:

    I’m enjoying the lyrical odes to ultrasound from doctors! Personally, I’m not sure that we’ve experience a point of care ultrasound yet in our family healthcare. Is it an entirely handheld device?

    When my son was almost four he was diagnoses with profound unilateral hearing loss. Because he was also born with a cleft lip and palate there was a reasonable amount of concern from doctors that this additional congenital difference might indicate other mid line* defects could be present so they recommend a series of tests/imaging to check his heart, kidneys, etc(?). My son is a bit of a medical champ, so the testing was more of a curiosity for him than a problem.

    For me, it was a kinda scary time until it was all done, but I will say the highlight of the testing was the ultrasound, So lovely and intriguing seeing that heart pumping away.

    Just as an aside – Almost all the testing was normal (yeah!) except the EKG had a small abnormality. My doctor said it was probably fine, but sent us to a pediatric cardiologist just to double check (cleft is sometimes associated with heart defects). How did the very experienced pediatric cardiologist rule out any areas of concern? Stethoscope!

    Okay, I don’t actually have any opinion of the superiority (or lack) of the stethoscope. I just got caught up in the narrative.

    *Not sure if I’m right on the terminology there

    1. Andrey Pavlov says:

      How did the very experienced pediatric cardiologist rule out any areas of concern?

      US can detect heart defects that are smaller than can be detected by a trained auscultologist (i.e. anyone skilled at listening to such sounds, not just a cardiologist). However, if you can’t hear them they are unlikely to be of any concern. The only exception I can think of off the top of my head is a ventricular septal defect. Those tend to get softer as they get larger (they love pimping us on that because it is contrary to ALL other heart murmurs). But there would be other signs and reasons to be concerned for those (VSDs).

      In general though, one wouldn’t use US to diagnose heart murmurs, but to confirm them and have a more objective way of quantifying and tracking them in cases where that is necessary. (also various parameters of the heart to track those as they change through the course of a murmur… watchful waiting)

      1. mouse says:

        Not sure that I remember what exactly they were looking for AP. The EKG showed – some slight axis offset (?) that can indicate something wrong, but also is often just normal variation. Oy it’s been years and once I decide I don’t have to worry about something I tend to drop it from my memory banks.

  7. Joan says:

    When I had down time I would run around the hospital with it to do difficult peripheral lines for nurse by finding deep veins for good access. Checking for weak peripheral pulses, spot checks of lymph nodes, etc… the list goes on.

  8. LindaRosaRN says:

    What, I wonder, will this do to the profession of US technologists?

    1. Harriet Hall says:

      Not much. The hand-held units are not as precise and detailed, and conventional studies will still be needed. Also, some of the uses like locating veins for venipuncture are new uses, added ones that don’t replace anything. And the US technologists will have a role in training doctors.

  9. Frederick says:

    I like How the greatest tool for medicine can from the physics department :-)
    Nuclear physics inclued of course, Nothing cooler than some super-cooled superconductors magnet for MRI hehe. The be able to “see” inside the body much also be “fun” for Doctors, i mean afterall, you guys must like you human biology after all.

    1. Frederick says:

      First phrase, it should be “came from”.

    2. @ Frederick
      “I like How the greatest tool for medicine can from the physics department”

      In my experience the greatest tools in medicine are a thin filamentous stainless steel needle (acupuncture needle) and the hypodermic needle counterpart. Both can be used to palpate, diagnose and are therapeutic, all for a few pennies.

      1. WilliamLawrenceUtridge says:

        Nobody cares and nobody believes you, Bozo the clown.

      2. Frederick says:

        LOL yeah… who cares about you illusion of knowledge.

      3. mouse says:

        SSR “In my experience the greatest tools in medicine are a thin filamentous stainless steel needle (acupuncture needle) and the hypodermic needle counterpart.”

        Oh? I guess that’s why I take my son to better doctors, then. He wouldn’t be eating, speaking or hearing well today without modern technology.

  10. irenegoodnight
    ” Invisible acupuncture meridians and chiropractic subluxations can’t compete with watching your own heart valves open and close.”

    FYI, acupuncture meridians do not exist as discernible absolute points, the diagrams on the models are only a guide. IMO, subluxation is a term used to describe a “misalignment, corrupted, tense tight bundle of muscles and nerves” which cause pain and limited motion with no solid radiologic findings. You need only the proper instruction and lots of practice because each unique case will determine the therapy.

    In the world of clinical practice where the hands-on art of palpation takes years or decades to develop, this high-technical doohickey will only add data points and probably no added clarity and slow the mastery of clinical medicine.

    1. WilliamLawrenceUtridge says:

      FYI, acupuncture meridians do not exist as discernible absolute points, the diagrams on the models are only a guide.

      Can you prove that they exist at all?

      IMO, subluxation is a term used to describe a “misalignment, corrupted, tense tight bundle of muscles and nerves” which cause pain and limited motion with no solid radiologic findings.

      Wow, that doesn’t even match up with the chiropractor’s bullshit, made-up definition. So, essentially what you are saying here is “this nonsense CAM term makes total sense as long as you completely redefine it to mean something different.” Great. And even your “different” term is a bundle of unproven assertion.

      How do nerves and muscles “bundle”? How do they “misalign”? What do you mean by “corruption”?

      You’re not doing science, you’re not operationalizing terms, you’re just adopting some of the surface features of science and ignoring what makes it so powerful and useful. Once again, you’re doing it wrong and just proving that you’re not really interested in science, what is “sciencey” enough to fool your customers.

      You need only the proper instruction and lots of practice because each unique case will determine the therapy.

      …which conveniently gives you an excuse for every patient that isn’t helped, and an excuse to ignore ever dissenting study that confronts you with your own erroneous beliefs.

      In the world of clinical practice where the hands-on art of palpation takes years or decades to develop, this high-technical doohickey will only add data points and probably no added clarity and slow the mastery of clinical medicine.

      See…doctors had, for millennia, the time and experience to develop their hands-on palpation skills. It didn’t help. Hands-on palpation lead traditional Chinese medical practitioners to imagine 12 kinds of pulses and illusory correlations between stars and bodies (real traditional acupuncture is astrology with needles, 365 points, one for each day of the year).

      Objective tests and instruments, reference to empirical data, that is what increased life expectancies and reduced suffering. That is what makes babies dying a tragedy rather than an inconvenience.

  11. Scubadoc says:

    In 1969 when I was a junior hospital doctor in New Zealand, our neurologist produced the first ultrasound machine in the hospital. This was a small wooden box with a probe that was pressed to one side of the head. It was designed to tell if there was a midline brain shift from eg an extradural bleed, and an attached Polaroid camera produced the result, and that was all it did.
    I think most of us are in awe of the technological and other advances that occur over our working lifetimes, resulting in many previously common diseases becoming increasingly rare – I can’t remember the last time I saw a peptic ulcer for example.
    Of course this occurs in many walks of life. I sometimes watch “The Amazing Race” on TV and have to smile at a young person trying to figure out how to work a manual gear lever.
    It’s also true that this has had an impact on clinical skills. Does anyone now listen for whispering pectoriloquy or feel for vocal fremitus, or do we just order the chest Xray?

  12. MadisonMD says:

    I have not seen ultrasound at POC. My clinical team has discussed this but there certainly is some resistance on the part of radiology. So there is an interesting angle to this story about billing / reimbursement / and territory among medical specialties. If it becomes part of a physical exam, hospitals and radiology departments have a lot to lose. (Another argument to change the fee-for-service medical model in US)

    Reminds me of the old story (in reverse) of the neurologist who taught in med school. He said back in the day, MRI was done by neurologists, and they actually called in NMR. He quipped that this meant “No More Radiologists,” but radiologists subsumed the imaging modality anyway and managed to rename it “More Radiological Income.”

    Disclosure: I have friends in radiology (or did until right now).

  13. Cloudskimmer says:

    While ultrasounds can enhance medical practice, what is your opinion on legislatures requiring their use, including mandating that the Doctor describe the image, prior to performing an abortion? (See, for example: http://www.npr.org/templates/story/story.php?storyId=128212951 )
    Is there any medical reason for requiring patients to have an ultrasound prior to every abortion, even very early in the pregnancy? And what would be seen on such an ultrasound? Who should pay for mandated testing if it is not medically indicated?

    1. Young CC Prof says:

      It actually is important to be sure how far along the pregnancy is, because that affects the choice of abortion techniques (pill vs surgical) and the level of complication of a surgical abortion, so a quick look with abdominal ultrasound may be a reasonable precaution, especially if the woman herself isn’t sure of the due date. Or, it may be necessary to confirm that it IS normal pregnancy rather than some pathological condition that would require a different treatment.

      However, the requirement to describe the image in detail or show it to the mother obviously has no medical benefit and is intended only to discourage abortions. Transvaginal is usually unnecessary, also.

      1. Andrey Pavlov says:

        Precisely.

        The legislation is question is nothing more than the coercive tactic of slut-shaming to try and dissuade women from abortion veiled as a medical procedure.

  14. Donna B. says:

    I’m old enough that I got an ultrasound only with my youngest child. And while I was thrilled that the doctor said everything was just as it should be, I thought I was mentally impaired because I could just barely discern there was something there in the photo they gave me. No take home videos back then.

    Now, I’ve seen ultrasounds of my grandchildren in utero. Oh Wow! And I’ve experienced the ‘miracle’ of ultrasound therapy for bursitis. It was so… simple, I halfway convinced myself that it was a placebo and the pain/lack of mobility I’d experienced with that shoulder was just in my head.

    Now, I’m going through the experience of doctors knowing what caused some problems and having settled that, seeming to be uninterested in helping with the symptoms.

    So, purely from the patient perspective, I would advise doctors to not get so caught up in the diagnostic goodies and take time to recognize that there are still symptoms to treat. Though I can see how years of being accused by SCAMmers of only treating the symptoms that there might be some unconscious resistance to doing so.

    On the other hand, a handy diagnosis might not be the one that’s ultimately needed even if it does account for a great majority of the symptoms presented.

    And, maybe y’all should just ignore me because right now I’m really frustrated with one specific doctor of one specialty (of which there are few in this area) that has locked onto a treatment for a disease which she has said out loud to us numerous times doesn’t match the symptoms we keep coming to see her about. That’s a problem because the other possible diagnoses are also within the purview of her specialty… so we’re feeling stuck.

    The reason ultrasound brings this frustration up front, is that one of the diagnostic tests that points to another (perhaps additional) disease is an ultrasound one.

    So yeah, ignore me. But thanks for the opportunity to anecdotally vent.

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