POCUS: Which Path Will You Take?

“Yes, there are two paths you can go by, but in the long run, There's still time to change the road you're on.”1971; Robert Plant/James Patrick Page (Led Zeppelin) The fundamental harmony for point of care ultrasound, generically referred to as POCUS, can be roughly divided into those who recognize its current value with enormous un-tapped potential or those who see its current limitations as overwhelming with the potential to negatively impact conventional echocardiographic reputation. The former group generally consists of non-cardiology-trained clinicians who perform POCUS as part of their daily clinical practice. The latter group commonly includes radiologists, cardiologists, or non-cardiologists with advanced training in ultrasound/echocardiography who frequently perform complementary comprehensive studies subsequent to the POCUS exams. Importantly, this historic grouping is undergoing a dynamic realignment, and you can now find ultrasound experts using POCUS in daily practice and non-ultrasound experts emphasizing POCUS limitations. For many reasons, there will continue to be discrepancies between POCUS and complete studies, and this should not be the only metric for a quality POCUS program. Anticipating that these dichotomous viewpoints may arise from isolated observations–unique to the clinical environment in which the individual practices–we proposed an open request to submit POCUS CASEs to the Journal to be included in a Special Issue dedicated to this topic. It was our belief that a CASE Special Issue on POCUS, including multiple perspectives available in one location, would serve to improve the multidisciplinary communication gap which currently exists. Thanks to your spectacular response to this invitation, more than 100 contributing authors provided us with ample educational material to consider. With the help of more than 50 expert peer reviewers, the CASE Special Issue on POCUS quickly evolved from a good idea to a final product that we are certain you will enjoy. We received submissions from cardiologists and sonographers; cardiac anesthesiologists and critical care echocardiography practitioners; pediatric and neonatal experts; emergency room physicians, hospitalists, intensivists, and others. During my review of these phenomenal CASEs, I quickly learned that the definition of POCUS is as unique and varied as there are flavors of ice cream. POCUS is a widely applied term that encompasses physician-performed cardiac and non-cardiac ultrasound exams that vary in their complexity based upon individual acquisition and interpretation skills, clinical circumstances, ultrasound devices, and institutional operations. Where some would refer to a stat echocardiogram performed by a cardiologist-in-training to exclude a catastrophic finding as a POCUS study, others might simply refer to this as a stat TTE without considering the POCUS label. Where some might become disillusioned when POCUS misses an acutely ruptured papillary muscle with severe MR, others might recognize that this finding is outside the scope of POCUS. Where some are cardio-centric and ignore non-cardiac findings, others consider a heart POCUS alone as incomplete. This CASE Special Issue on POCUS presented us with a diverse list of indications, widely variable scopes of practice, and a number of limitations including unspoken errors and voiced concerns, which in their entirety provided an impressive representative list of the full extent and prevalent use across the globe. I want to thank the authors from the United States, Canada, Australia, Rwanda, China, England, and Malaysia who provided us with these educational reports. It was hard not to be reminded of this quote: “Spock stared hard at his POCUS, as if by sheer will he might force it to tell him the answer to his questions.”1Kagan, J. (2000). Uhura's Song (Star Trek: The Original Series Book 21). Pocket Books/Star Trek.Google Scholar NOTE: EIC poetic license replaced “tricorder” with “POCUS.” This special issue was not without controversy as some authors were highly concerned with entirely focusing on the potential problems associated with POCUS. This remains a point of emphasis to this Editor, who often reminds those willing to listen that simply because echo is a “non-invasive tool” that is not the same as being a “tool without risk.” Although it may be easier to connect the dots to an iatrogenic complication from an invasive procedure, it should not come as a surprise to any CASE reader that a poorly performed or misinterpreted echocardiogram may similarly lead to complications. Important omissions of pathology that are free to progress unabated; incorrect interpretations that lead to unnecessary downstream invasive testing; and premature recommendations for surgical interventions that could have safely waited are some examples emphasizing that echo should not live in a risk-free “echo” zone. How do echo-experts avoid these potential echo-risks? We should employ multiple safety nets. These include performing studies with appropriate indications and understanding what the clinical questions are. Simple Bayes theorem reflection reminds us that false-positive and false-negative results will more likely occur when this concept is not applied. It is also critically important to use a standardized approach to imaging protocols so as not to overlook any cardiac structures; to have the training and skills necessary to match your scope of practice so that your reported findings reflect those boundaries; and to continue to improve your knowledge through quality oversight and dedicated self-education. CASE was specifically created with this mission in mind and now is prepared monthly as an imaging-based source of education. Given the fact that POCUS is so widely available, pocket-sized, low-cost, and seemingly without risk, I suspect the number of POCUS users may now exceed the number of conventional echo users. Maintaining an institutional structure for oversight will be important to accentuate the value of POCUS, which offers advantages over conventional echo since it is performed with greater patient information from the clinicians who have direct bedside contact. Another issue that was highlighted through the cumulative review of these POCUS submissions was that many of the listed concerns with POCUS can and should be similarly applied to all comprehensive TTE programs: variable training environments resulting in a heterogeneous range of competencies; importance of recognizing scope of clinical practice and limitations when deviating from this; need to carefully integrate TTE findings with the clinical picture; and a need to embrace ongoing quality assurance practices. The critical appraisal and discussion of near-misses is an integral part of the safety culture and quality improvement efforts in clinical medicine. In total, this CASE Special Issue on POCUS represents a reflection of the diversity of POCUS currently in practice across the globe–from large university hospitals in some of the biggest cities in North America to individual practitioners in rural Africa innovating clever ideas using cloud-based archiving practices to enhance oversight and quality assurance. We have examples of cardiac masses detected by POCUS in both the left and right heart (Lane et al, Ezzeddine et al); there are many patients with unexplained hypotension where POCUS helped identify the etiology and assist in the subsequent management (Shariff et al, Pandompatam et al); and we get a glimpse into the unique value of POCUS in developing nations where it guides the clinical management of patients presenting with heart failure (Klassen et al). We had numerous submissions for patients with cardiac tamponade diagnosed by bedside POCUS (Wharton et al, Knuf et al, Ng et al), one of which was recognized as a byproduct of an acute aortic dissection (Saeid et al); uniquely, there is a report of an interesting vascular pattern seen with color Doppler using POCUS for line placement that helped the clinical team better understand the etiology of respiratory failure in an infant (Su et al). Although typically considered outside the scope of conventional POCUS, there was a report of acute prosthetic valve failure (Naing et al). Finally, there are two CASE series emphasizing the ‘definitive advantages’ (Lanspa et al) and the ‘potential pitfalls’ (Douflé et al) of POCUS. With this collection of reports, the readers have an opportunity to better understand both the value and limitations of POCUS. As demonstrated at the recent ASE Scientific Sessions, where there were 25 separate lectures dedicated to POCUS and focused on a wide spectrum of cardiovascular ultrasound applications by practitioners from diverse training backgrounds, there is boundless interest in improving our inter-disciplinary communication with a goal toward greater collaboration. We hope that this collection of CASE reports helps achieve that goal and guide us on the correct path. Remember, there's still time to change the road you're on.

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