Making Waves With Point-of-Care Ultrasound; Investment Begets Impact at the ICU Bedside?*

In the late 1800s, North American medical education was inexpensive and plentiful (1). Proprietary 2-year trade schools churned out physicians for profit and asked little in qualifications. In addition to the wonders of chocolate and saffron, radioactive water was a miracle cure (2), and you could treat migraines in a mildly electrified bathtub (3). A fundamental change came with the new century with the advent of automobiles and telephones and therefore increased patient access leading to questions of medical competency across the field. A group was convened in first decade of the 20th century led by a William Welch, MD, a founding dean at Johns Hopkins and Sir William Osler, Bt MD FRS FRCP, the chief of medicine also at that institution and was called the Hopkins Circle (4). The Circle questioned why North American medicine seemed so unscientific while world-renowned academic European clinics catapulted the healthcare forward in understanding the fields of infectious diseases, endocrinology, and radiology among others. Enter Abraham Flexner, a 42-year-old private school teacher named who had published on concerns about North American universities in comparison to European counterparts. Two years later in 1910 and 155 medical school visits later, The Flexner Report was published as a book-length evaluation of medical education in his day. Based primarily on his expert opinion, institutions poured in resources toward achieving the new recommendations and formed the foundation of North American medical education. At that time, this massive effort significantly reduced the broad heterogeneity of physician training, defined expectations for the profession, and provided indices of institutional success in training to meet the needs of medicine and society at the time. Today, it is seen as a major event that led to allopathic medical education becoming the primary means for physician training in modern medicine. The clinical application of point-of-care ultrasound (POCUS) is at a crossroads. Ultrasound in the hands of bedside clinicians as a tool for rapid decision-making is increasingly ubiquitous throughout healthcare. It is being deployed every day in critical care as well as perioperative, emergency, urgent, and outpatient clinical settings driven by clinical demand, educational regulation, and efficiencies of medicine (5). On one hand, its use in ICU procedures is directly tied to decreases in complications and increased survival of devices. Its use is increasingly mandated, not just for procedural applications but also in diagnosis in adult surgical critical care, pulmonary critical care, and neurocritical care as well as appearing in good practice recommendations in neonatal critical care (6–9). The use of POCUS is becoming well established in fundamental training requirements across medicine and will increasingly influence workflow as its practice expands. In this evolving field establishing its clinical effect, standards for education, and standards for its practice are a moving target in a heterogeneous field not unlike the medical education of yesteryear. As POCUS use at large scale is not completely blindable, proof of effect is difficult and complicated by implementation bias. The Focused Assessment with Sonography in Trauma scan, one of the most fundamental POCUS examinations of abdominal fluid (10) is not an adequate test for intra-abdominal injury after blunt trauma in large meta-analyses. Hemodynamic POCUS (11) in a large multicenter international trial failed to demonstrate a clinical benefit in assessing shock. Beguiling is that many POCUS educators can identify cases where ultrasound made a difference for a pediatric patient, although the field struggles with determining the cutoff between signal and noise in implementing the technology. In this issue of Pediatric Critical Care Medicine, Baker et al (12) present a report on the clinical effect of a supported and established POCUS program in a PICU. In a critical care department seeing 4,200 admissions a year 7,201 diagnostic POCUS studies were performed over 5 years with adequately completed quality assurance (QA) records in 1,930 of cases (26.8%). POCUS influenced clinician understanding of pathophysiology in 563 of 1930 cases (29.2%) and changed management in roughly half of these 563 cases. Furthermore, cardiac POCUS was found to influence clinical decision-making more frequently than other forms of POCUS. This lends to a body of evidence that demonstrates POCUS changes minds on management (13,14) and influences patient care (15,16). A gap remains in knowing how outcomes are affected by care, however, as large prospective studies in POCUS have not replicated the success of smaller positive studies. The work also illustrates that not all POCUS is equal, as noncardiac POCUS does not yield the same changes in management authors noted in hemodynamic POCUS. Was it a function of the illnesses and are typical cardiac and lung POCUS findings differ in what can be done to address them? For instance, hemodynamic findings may tailor shock management; however, we would not use POCUS to titrate a ventilator necessarily. Or are POCUS management protocols too ill defined at this time to know when to intervene on findings and the examinations are not diagnostically equivalent? This is an area for further analysis. Additionally, the reader receives a glimpse at the infrastructure necessary for this endeavor in terms of resources and total revenue generated. A recordkeeping system was initiated with a formal review process involving cardiology and radiology, and training and practice expectations were enacted at the bedside. In crafting a POCUS practice paradigm, there are no experimental trials proving efficacy, and one relies on expert opinion. A first step is considering that POCUS as imaging integrated into the physical examination is perhaps akin to having other tools at the bedside such as an ophthalmoscope or pupillometer. These tools are used at the point of care and can spur expert consultation, and their inferiority is understood compared with more complex diagnostic modalities, such as a brain MRI. However, an ultrasound is not an ophthalmoscope, it is a computer that records images that are readily archived in the medical record. Images are an important part of the durable medical record and practical standards for the practice of storage and recordkeeping in POCUS can likely benefit patients and clinicians alike in supporting equitable and consistent care. The QA experience at the Children’s Hospital of Philadelphia, the authors’ institution, illustrates important lessons. Although the QA information survey provided appears robust, QA targets in POCUS nationally remain undefined. Information identifying the types of management changes clinicians initiated using POCUS findings and their effects is not available, leaving both the nature of the clinical decisions and the outcome impact unknown. Even though clinician impressions changed, and decisions were made, research in POCUS on what these changes mean for patients and outcomes is lacking. The neonatal American Academy of Pediatrics statement on POCUS describes a collaborative approach to POCUS program administration and interspecialty partnerships are endorsed in the POCUS literature (9). Notably in this work, 3 years after POCUS program inception, cardiology, and radiology no longer remained involved in QA. This appears to be a reality of mature POCUS collaboration as one cannot expect it to equate working together with oversight, and interspecialty partnerships can persist as independent imaging workflows develop within Pediatric Critical Care Medicine itself. A routine image review process remained that does not involve reevaluation of every study, and this is not unlike International Accreditation Council on Echocardiography Laboratory standards for echocardiography laboratories, where two studies per quarter are reviewed for quality, interpretation, and reporting in addition to additional criteria for clinical correlation (17). The benefit and necessity of POCUS in the ICU is known in some applications and prompts needs for consistent education and practice. Investment in practicing it well is clearly necessary and was demonstrated at the authors’ institution with the provision of sufficient equipment, a documentation structure, fiscal resources, and a full faculty position supporting the endeavor. The work by Baker et al (12) highlights the importance of characterizing POCUS practice is, how challenging it is, and how incredibly necessary it is to establish ideals so that a child receiving POCUS in an ICU in one part of the country can have a reasonably similar experience in another. The Flexner Report teaches us another important lesson from history. It was credited for promoting rigor in medicine and promoting its scientific basis, but by 1936 half of American medical schools shut down. Consistent with Flexner’s focus on allopathic academic medicine, schools that taught osteopathic medicine, homeopathy, and other nonallopathic medicine were pressured to close. Among these were schools that had demonstrated higher enrollment among women and Black Americans, for both of which Flexner mentioned less enthusiasm and contributed to iniquities in medicine seen to this day (18,19). In defining practice in POCUS, the needs are becoming increasingly clear for supported programs that reinforce good practice, support clinical benefit, and incorporate appropriate imaging and documentation. Rather than looking to an outside consultancy, the voices to define POCUS should come from those practicing it. In summary the work by Baker et al (12) is important, it reinforces that evolution of POCUS toward sustainability beyond clandestine nighttime scans at the ICU bedside followed up in the morning by the statement, “I did a POCUS to manage the patient’s ventilator and infusions, now let’s get an echo.” We exist in a world with POCUS where mechanisms for durable and responsible practice are needed and the practices of Baker et al et al (12) are demonstrating that building an imaging practice in the ICU around accountable scanning is important, evolving, and possible.