Post on 10-Oct-2020
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Update in IM Bedside Ultrasound: Are We Being Left Behind?
Keith Barron, MDMichael Wagner, MD, FACP, RDMS
Bedside Medicine: Slow to Change
Laennec invents stethoscope: 1816
Stethoscope: 1860
Stethoscope:2019
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A True Stethoscope
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Adoption of Ultrasound Across Specialties
• Subspecialty use
• Procedural Guidance
• Point-of-Care Ultrasound
Adoption of Ultrasound into Internal Medicine
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Updates on Procedural Guidance
Ultrasound for Procedural Guidance: Now Standard of Care
• US guidance improves safety and efficiency for most procedures
• Arterial catheterization• Arthrocentesis/joint injection• Paracentesis• Peripheral vein catheterization • Thoracentesis
• Can reduce bleeding, infection, improve success, reduce attempts
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• “The use of ultrasound guidance for paracentesis has been associated with higher success rates and lower complication rates.”
• “We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax”
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• “We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for CVC insertion, regardless of the provider’s level of experience”
Updates on POCUS
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Point-of-care ultrasound (POCUS): Beyond Procedures
• At bedside to guide patient management in real-time
• Does NOT replace radiology-performed ultrasound
• Usually binary decisions: “yes” or “no”
Soni and Lucas. J of Hosp Med. 2014.
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• “Seeing pathology through imaging might improve interest in physical examination among trainees, and permit appropriate downstream testing and possibly superior decision making”
• “Recent studies have found that clinical management involving the early use of POCUS accurately guides diagnosis, significantly reduces physicians’ diagnostic uncertainty, and also changes management and resource utilization”
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Figure 1
Mayo Clinic Proceedings 2016 91, 1811-1827DOI: (10.1016/j.mayocp.2016.08.023)
Copyright © 2016 Mayo Foundation for Medical Education and Research Terms and Conditions
• POCUS for hospitalists: DVT, pericardial effusion
• Reviews previously reported data about lung ultrasound, more accurate than CXR for:
• Pleural Effusions
• Pneumonia
• Pneumothorax
• Pulmonary Edema
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• “The results of this study suggest that bedside lung ultrasonography has excellent accuracy for the diagnosis of pneumonia in adults.”
• “Th e implementation of LUS with the clinical evaluation may improve accuracy of ADHF diagnosis in patients presenting to the ED.”
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LV
• “Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease”
• “Ultrasonography with HHU clearly has the potential to be the fifth pillar of the physical examination and to improve the accuracy of bedside diagnosis”
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d
• “One of the real utilities of ultrasound augmented clinical diagnosis is in evaluating patients efficiently and selecting patients for appropriate downstream diagnostic testing including comprehensive echocardiography”
• Even Cardiologists now recognizing value
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• “The doctors of tomorrow may still listen with a stethoscope to their patient’s lung, but they will certainly be seeing it with ultrasound.”
Where is IM POCUS Heading?
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Full Webinar: “ultrasound PEARLS”
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Starting Off Right
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Barriers/Concerns
•Equipment Portability/Availability•Equipment Costs•Billing•Quality Assurance/Image Archive•Litigation•Broad Applications/Scope of Practice•Time•Training
Can Ido “ultrasound”?
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Privileging in POCUS?
PRIVILEGING is NOT REQUIRED
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Pertinent Guidelines
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Active ACP Initiatives
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SHM
• “Given the many advantages of POCUS over traditional tools, we anticipate its increasing implementation among hospitalists in the future.”
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AAIM
Point of Care Ultrasound for Internal Medicine Residency Training: A Position Statement from the Alliance of Academic Internal Medicine
• “The Alliance recognizes and supports the integration of POCUS . . . POCUS has demonstrated broad utility within internal medicine”
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SGIM
JGIM Editorial
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Can Ibillfor POCUS exams?
But SHOULD you?
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“Mo’ Money Mo’ Problems…”
• Archiving
• Reporting
• Credentialing
• Impact on Other Departments/Local Politics
Won’t *they* come after me?(I don’t want to be sued!)
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Lawsuits (in EM)
NOT performing US may soon carry MORE liability
How do I get “certified”?(privileges, credentials, *training*)
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Next Steps
•Get connected! •www.sonointernist.com•www.twitter.com - #pocus, #IMPOCUS, #FOAMus
@sonointernist; @IMSonoSC#FOAMed, #IMpocus and #ultrasound
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In Summary
• POCUS ≠ Traditional Ultrasound
• Pocket-sized devices are well suited to hospitalist workflow
• The potential applications are numerous and broad in scope• Start small with simple POCUS physical (e.g. PEARLS, CLUE, FAST)• PRACTICE, find mentors or form peer support groups• Layer additional applications over time
• Numerous barriers exist to POCUS utilization by hospitalists
• Innovation, collaboration, and hard work will be essential
• But well worth it!
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