Point of Care Ultrasound (POCUS) in Clinical Medicine

Point-of-care ultrasound (POCUS) is an ultrasound exam performed by the clinician at the bedside to answer focused clinical questions that can assist in patient care. POCUS exam findings are integrated with the patient’s history, physical exam, and investigation results. For example, in evaluating patients with dyspnea (shortness of breath), POCUS can provide valuable additional information about volume status, degree of pulmonary congestion, as well as findings which may change management.

When used to guide bedside procedures, POCUS increases success and decreases complication rates. While POCUS is not new to practitioners in emergency medicine or critical care, its use in internal medicine has only just begun in the last 5-10 years.

The Department of Medicine Leads the way in POCUS in Canada

Members of the General Internal Medicine Division have led the way in national curriculum development¹, standard setting², and curriculum implementation³. 

Our program offers one of the first internal medicine POCUS fellowships in Canada, having trained 7 experts since 2017. With one of the largest trained faculty group in the country (10 active members), at RGH and FMC, we implemented a novel POCUS consult service for patients admitted to the medical teaching unit , assisting with clinical decision making and bedside procedures.

Members of the DOM are also working with the Medicine Strategic Clinical Network to develop training resources and best practice recommendations to maximize the safe use of POCUS for the province.

Requirements and barriers for intergrating POCUS into Clinical Medicine

The use of POCUS is recommended in settings of diagnostic uncertainty as it has higher accuracy than chest radiographs for some findings, such as pleural effusions and pneumothorax, and can increase the proportion of and reduce the time to correct diagnoses. While POCUS does not replace physical exams or indicated comprehensive diagnostic imaging, its use does represent a significant departure from traditional practice.

Proper use of POCUS requires both sufficient quality as well as quantity of training, not just in image acquisition and interpretation, but also in the limits and nuances of clinical integration. Such training requires time, trained faculty, access to machines, as well as infrastructure such as secure image archival systems so that images are reviewed by trained practitioners.

How POCUS can help in assessing medical patients

Common focused clinical questions that can be answered by POCUS include:

1. Has my patient with pneumonia developed a pleural effusion?
2. My patient with alcohol use disorder but no known cirrhosis has abdominal pain. Is there ascites (do I need to rule out spontaneous bacterial peritonitis)?
3. My patient is short of breath - how likely is pneumothorax, tamponade, and/or heart failure to be accounting for her symptoms?
4. In performing a paracentesis, are there any collateral blood vessels present within the needle path?
5. Does my patient with knee pain have a knee effusion?

<sub>References: 
1.Ma IWY, Arishenkoff S, Wiseman J, et al. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. Journal of General Internal Medicine 2017;32:1052-7.
2. Desy J, Noble VE,L iteplo AS, et al. Minimal criteria for lung ultrasonography in internal medicine. Can J Gen Intern Med 2021;16:6-13.
2. Ambasta A, Balan M, Mayette M, et al. Education Indicators for Interna lMedicine PointofCare Ultrasound: a Consensus Report from the Canadian Internal Medicine Ultrasound (CIMUS) Group. Journal of General Internal Medicine 2019:1-7.</sub>