#108: Point-of-care Ultrasound for the Internist

August 13, 2018 | By Matthew Watto, MD

Point-of-care Ultrasound AKA POCUS ain’t no hocus. Dr. Renee Dversdal (@ReneeDversdal) Director of the Oregon Health & Science University Point of Care Ultrasound and General Medicine Ultrasound Fellowship Director, joins The Curbsiders to discuss her craft. Topics include: Defining POCUS, the value POCUS adds to the physical exam, training pathways and the appropriateness of billing. This episode is sponsored for CME-MOC credit by the American College of Physicians. ACP members can claim free credit at acponline.org/curbsiders (goes live at 9am on release date). Follow this link to read the ACP’s statement in support of POCUS in Internal Medicine.

Credits:
Written by: Christopher Chiu MD and Renee Dversdal MD
Produced and CME questions by: Christopher Chiu MD
Edited by: Matthew “Mike” Watto MD
Hosts: Matthew Watto MD, Stuart Brigham MD, Christopher Chiu MD
Guest Expert: Renee Dversdal MD

Clinical Pearls

1. POCUS is different from formal ultrasound because the POCUS user has a focused question that they are trying to answer versus a sonographer/radiologist/cardiologist who is doing a comprehensive assessment.
2. POCUS should not be thought of as another test that you can bill for, but an adjunct to your physical exam (like a stethoscope). It can enhance time spent at the bedside with the patient, patient satisfaction and provider satisfaction.
3. There is no perfect or ideal ultrasound machine as it is dependant on the user and the circumstances in which the machine will be used.
4. Don’t be afraid to practice with the ultrasound machine as it is a skill that needs to be developed and kept sharp.
5. There are two main Ultrasound Training Pathways: a “Residency-based Pathway” and a “Practice-based Pathway”.

In-depth Show Notes

• POCUS is known by many synonyms and abbreviations. The big picture is that the clinician with the patient is actively acquiring, interpreting & clinically integrating focused ultrasound images in real time.  This is different than “consultative” or “formal” ultrasound. In those situations, a POCUS user has a question as a clinician. Is this new systolic heart failure? Or is this ascites? When a test is ordered, a sonographer will acquire the images, a radiologist or cardiologist will interpret them, and the ordering provider will eventually get back a report (hours to days later), that will be clinically integrated and acted upon.  Those tests are also usually comprehensive assessments, whereas POCUS is more more focused.
• Society of Ultrasound in Medical Education (SUSME) promotes the use of ultrasound in medical education through development of educational experiences, research on outcomes, and distribution of results.
• Ultrasound machines range from large and expensive to small pocket-sized devices. An upcoming device (not yet on the market) is advertised to be less than $2000 but many pocket-sized devices are closer to $5000-$10000.
• Competency assessment is currently difficult to establish as there are no training guidelines (yet) in Internal Medicine. The American College of Physicians just released a statement in support of the use of POCUS and will be developing training and clinical practice guidelines in partnership with other medical societies. Data is currently extrapolated from our Emergency Medicine colleagues. For training, there is a residency-based pathway and for faculty there is a “practice-based” pathway that includes didactics and hands-on time.

Clinical Case 1: At Kashlak Memorial, a 64 year old man with history of severe aortic stenosis status post recent transaortic valve replacement, with course complicated by pneumonia/empyema requiring decortication, and chronic diastolic heart failure presents to ED with dyspnea/generalized fatigue & pre-syncope, found to have lactic acidosis, acute hepatitis and acute renal failure.

•  The dilemma: It’s hard to appreciate a jugular venous pressure (JVP) due to body habitus, and the lung exam was difficult to interpret given a persistent left sided pleural effusion. Chest xray showed low lung volumes. Heart failure exacerbation with volume overload, congestive hepatopathy & cardiorenal syndrome is highest on the differential with this constellation of symptoms.
• How can POCUS help?  Can use Cardiac Limited Ultrasound Examination (CLUE) created by Dr. Bruce Kimora (see links below).
• Findings on POCUS: In this case, while he did have profound lower extremity edema, POCUS noted a grossly normal EF, a collapsible inferior vena cava (indicator of fluid tolerance), a non-distended internal jugular vein with US above clavicle at 45 degrees, and no findings of pulmonary edema. He was also found to have small ascites.  
• Conclusion: This patient ended up getting fluids instead of diuresis. His lactic acid resolved. Final diagnosis was hypovolemia and hypotension/shock liver/pre-renal AKI from home diuretic regimen in the setting of poor PO intake.

Dr Dversdal speaking to the consent process for POCUS
[There is not] a formal consent process, as ultrasound is generally thought to be harmless (exceptions to every rule of course, wouldn’t use power doppler on a fetus or eyeball for example)…. However, we do complete a verbal consent of sorts, so that everyone is on the same page. [When] learning/practicing, we… explain that we are practicing ultrasound, and [are] looking for nice patients to scan, so their attending, RN, resident, someone, sent us their way (flattery goes a long way)!  We are not sonographers, radiologists, cardiologists, any of those things. We are clinicians trying to learn or teach or practice ultrasound at the bedside, with the future hope of improving clinical decision making. I explicitly tell them that this is 100% optional and not related to their medical care. But, if we find something abnormal we will let their medical team know and they can work-up as needed.

Billing and Documentation

• POCUS brings high-value care. Dr. Dversdal will bill when using for some procedures like placing central lines as she considers this standard of care but she considers POCUS an adjunct to her physical exam and will document in the appropriate sections of her physical exam.

Bedside teaching

• POCUS can aid in anatomy and physical exam skills education. It can help learners visualize the parts of the physical exam that they either observe from the outside (elevated JVP) or on auscultation (reduced breath sounds are from pleural effusions).
• Learning POCUS isn’t about being able to identify “everything” but “how to know normal” and knowing when to get further testing or interventions.

Practical Applications

• In the outpatient primary care and urgent care settings, POCUS can be used for volume assessments, musculoskeletal assessments (joints), skin/soft tissues assessment, joint taps/injections.

Dr Dversdal’s Top 5 POCUS Exams

1. No one should ever die of pericardial tamponade.
2. Free abdominal fluid should be able to be ruled out. AKA the FAST exam for Internal Medicine AKA Fluid Assessment Sans Trauma.
3. Hydronephrosis and genitourinary exam.
4. Reduced Ejection Fraction.
5. Pleural Effusions.

Take Home Points: POCUS is not scary. You can’t hurt them with the machine. (Dr Brigham notes we shouldn’t hit people with the probes). There is an incredible amount that it can add to your clinical care. You need to keep practicing or you will lose your skills.

Dr. Dversdal’s POCUS Resources

•     POCUS Resource Handout 
•     Cardiac Limited Ultrasound Examination (CLUE) Webinar: https://www.youtube.com/watch?v=Hv-I9T1dVCg
•     Basic abdomen for internist by Irene Ma: https://www.youtube.com/watch?v=H9vIokcQMo8
•     PEARLS physical exam with pocket size US by Janice Boughton & Mike Wagner: https://www.youtube.com/watch?v=ywuIeoEfG1I&t=33s
•     IMpocus: a weekend on the wards: https://www.youtube.com/watch?v=jvtBufD-2og
•     Primary Care US including FAQ about billing & credentialing by Paul Bornemann (FM at Univ of S Carolina): https://www.youtube.com/watch?v=HHRZvqlXBU4&t=975s
•  The Evidence Atlas (subset of POCUS atlas): Fantastic compilation of evidence including brief synopsis of journal articles, tables with sensitivity/specificity, positive/negative likelihood ratios, and PMID with link to pubmed for article: http://www.thepocusatlas.com/ea-home
•  5 minute Sono: Very well composed & concise “just in time” videos to review before you go practice! http://5minsono.com
•  Ultrasound of the week Tools page: Includes amazing stuff programmed by Dr. Ben Smith including sonogif (can de-identify, trim & convert to gif all in 1 program), clipdeidentifier, and several tutorials to make your US presentations better: https://www.ultrasoundoftheweek.com/tools/
•  Ultrasound Podcast: “Making horrible doctors decent and good doctors GREAT”: http://www.ultrasoundpodcast.com
•  Ultrasound Training Solutions famous site in general: includes weekly wrap of everything found on social media, links, etc. https://www.ultrasoundtraining.com.au/foamus/foamus

Disclosures: Dr. Dversdal reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 Announcements
• 01:00 Disclaimer, show intro and guest bio
• 06:00 Guest one liner, book recommendation, rapid fire Q & A
• 12:00 Dr Dversdal shares a story about failure/struggle
• 16:00 POCUS defined
• 20:00 Uptake of POCUS in Internal Medicine
• 23:45 Getting into the game. Cost, choice of device and how to get training
• 27:40 Dr Dversdal shares her journey into POCUS
• 32:00 Clinical case of indeterminate volume status and how POCUS helped
• 36:00 IVC and IJ POCUS exam discussed in detail
• 38:55 How to choose a machine and bring US to your institution
• 42:00 How to troll the wards and introduce yourself to patients for practice of POCUS
• 44:00 Billing and documentation for POCUS
• 47:43 How POCUS can improve physical exam
• 52:27 Uses for POCUS in the primary care clinic
• 54:40 Dr Dversdal’s top 5 POCUS exam findings
• 57:27 Patients love POCUS
• 59:30 Outro

Goal: Listeners will be able to contrast point of care ultrasound with “formal” or consultative ultrasound, describe use case scenarios which can be useful for a practicing internist and lastly know where to find resources and pathways for further education.

Learning objectives:
After listening to this episode listeners will be able to:

1. Contrast POCUS with consultative (aka “formal”) ultrasound
2. Describe at least three uses where POCUS can be used to teach learners at the bedside
3. Recognize that there are several components to POCUS competency
4. List several resources for future POCUS education for use in Internal Medicine

Links from the show and further reading:

1. Let’s Pretend This Never Happened by Jenny Lawson
2. Bhagra, Anjali, et al. “Point-of-care ultrasonography for primary care physicians and general internists.” Mayo Clinic Proceedings. Vol. 91. No. 12. Elsevier, 2016. https://www.sciencedirect.com/science/article/pii/S0025619616305390
3. Liu, Rachel B., et al. “Point‐of‐Care Ultrasound: Does it Affect Scores on Standardized Assessment Tests Used Within the Preclinical Curriculum?.” Journal of Ultrasound in Medicine (2018). https://doi.org/10.1002/jum.14709
4. Nardi, Melissa, et al. “Creating a Novel Cardiac Limited Ultrasound Exam Curriculum for Internal Medical Residency: Four Unanticipated Tasks.” Journal of Medical Education and Curricular Development 3 (2016): JMECD-S18932. http://journals.sagepub.com/doi/abs/10.4137/JMECD.S18932
5. Kimura, Bruce J., et al. “Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination.” Journal of hospital medicine 7.7 (2012): 537-542. https://onlinelibrary.wiley.com/doi/abs/10.1002/jhm.1944
6. Kimura, Bruce J., et al. “Cardiac limited ultrasound examination techniques to augment the bedside cardiac physical examination.” Journal of Ultrasound in Medicine 34.9 (2015): 1683-1690. https://onlinelibrary.wiley.com/doi/abs/10.7863/ultra.15.14.09002
7. Mathews, B. K., et al. “The Design and Evaluation of the Comprehensive Hospitalist Assessment and Mentorship with Portfolios (CHAMP) Ultrasound Program.” Journal of hospital medicine (2018). https://europepmc.org/abstract/med/29489924
8. Ma, Irene WY, et al. “Internal medicine point-of-care ultrasound curriculum: consensus recommendations from the canadian internal medicine ultrasound (CIMUS) group.” Journal of general internal medicine 32.9 (2017): 1052-1057. https://link.springer.com/article/10.1007/s11606-017-4071-5
9. Liu, Rachel B., et al. “The Practice and Implications of Finding Fluid During Point-of-Care Ultrasonography: A Review.” JAMA internal medicine 177.12 (2017): 1818-1825. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2659327
10. Platz, Elke, et al. “Dynamic changes and prognostic value of pulmonary congestion by lung ultrasound in acute and chronic heart failure: a systematic review.” European journal of heart failure 19.9 (2017): 1154-1163. https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.839