Is a Portable Ultrasound the future for EMS

Kavsuvb

Forum Lieutenant
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Saw this in the JEMS article and I am wondering, is the Stethoscope dying and being replaced with portable Ultrasounds

 

hometownmedic5

Forum Asst. Chief
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Way, way down the road when we’re all independently licensed, degree conferred professionals, maybe. While the majority of us are still counting hours and working for low rent privates(regardless of how things look from the upside, internally their all the same) or good enough fire departments, no. Basically the same argument as for iStats.

BTW, I just read your post footer resume. Aside from the fact that posting your full name on the internet is incredibly astronomically stupid, I get that you're proud and all, but none of that is really relevant here. You do you, it just comes off as aggressively ostentatious.
 

Peak

ED/Prehospital Registered Nurse
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POCUS will never replace a stethoscope, whether in hospital, the clinic, or EMS.

An ultrasound does not auscultate lung sounds, friction rubs, bowel sounds et cetera.

They also require a great deal of skill to use, even for basic exams. You have to have a good understanding of the relevant anatomy in order to even begin to learn how to perform or interpret the exam.

Further like any other test you have to actually have a purpose to what you are doing. For example if you find a pericardial effusion what you will be doing different in your care? The same for a small hemothorax, portal hypertension, hydronephrosis, trivial mitral regurg, and so on. Even on an fast exam will you take the patient to a different center because you see a bleed, our would you have been going to a high level center anyway?

Personally I have a butterfly and one of our PEMs has a lumify. I think the real market for these are in third would countries with limited medical resources (being used by Docs, LIPs, etc).

I knew of a few HEMS programs that had VSCANs, but beyond HEMS/CCT I just don't see it anywhere in the near future.
 

NPO

Forum Deputy Chief
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Is it the future of EMS? No. But I do see a future where it's not uncommon to see POCUS deployed prehospital. My agency has a butterfly we are setting up before we deploy one on every ambulance.

Does POCUS change the game? No. But it offers an opportunity to be better for those agencies who want to.
 

ffemt8978

Forum Vice-Principal
Community Leader
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One thing to keep in mind, unfortunate as it is, is who's going to pay for these in the field? Would your service allow you to perform ultrasounds if insurance or Medicare is not going to reimburse for it? There is still a business side to EMS at this time, and ignoring it doesn't always advance EMS. It's great to say everything should be about the patient, but at the end of the day somebody has to pay for it.
 

VFlutter

Flight Nurse
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I have a fascination with POCUS and would love to have it on the helicopter but having said that I think it has limited utility in most EMS environments and the required education and skill to obtain and accurately interpret anything other than blatantly obvious findings is more than most systems could realistically accomplish outside of a small group of clinicians.

The Butterfly looks like an awesome device. Since we carry an iPad Pro that would be a good combination. The Vscan I have used is pretty much trash but the new models look like an improvement.
 

Bullets

Forum Knucklehead
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I think its use for EMS is a FAST exam. While it doesnt change our destination, it speeds up the process and steps the patient up a level. Perhaps i think its a trauma alert and suspect a abdominal bleed, i can confirm and make it a trauma code. We have a MD fly car that carries the butterfly and if the have a positive FAST they will make the patient a Level 0 and go straight up to the OR and bypass the trauma bay. They do their basic overview in the elevator vestibule and go up. I think it has potential to speed up the trauma process.

I also think the ability to place ultrasound guided IVs would be nice to reduce placing IOs on conscious patients.
 

VFlutter

Flight Nurse
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I think its use for EMS is a FAST exam. While it doesnt change our destination, it speeds up the process and steps the patient up a level. Perhaps i think its a trauma alert and suspect a abdominal bleed, i can confirm and make it a trauma code. We have a MD fly car that carries the butterfly and if the have a positive FAST they will make the patient a Level 0 and go straight up to the OR and bypass the trauma bay. They do their basic overview in the elevator vestibule and go up. I think it has potential to speed up the trauma process.

I also think the ability to place ultrasound guided IVs would be nice to reduce placing IOs on conscious patients.
To play devils adovcate I doubt any trauma center will be taking patients directly to the OR based off EMS FAST exams. It will assuredly be redone in the ER before. Even progressive HEMS services who do POCUS frequently are verified by a physician on arrival. Obviously having a pre-hospital physician make that call is a different situation. Also most of these patients will likely meet trauma activation criteria regardless of the positive FAST and/or be upgrade quickly on arrival . Not sure there is going to be a huge time savings in most level one trauma centers as the process is already pretty fast.

US for IV access is a great tool to have
 

NPO

Forum Deputy Chief
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I think its use for EMS is a FAST exam. While it doesnt change our destination, it speeds up the process and steps the patient up a level. Perhaps i think its a trauma alert and suspect a abdominal bleed, i can confirm and make it a trauma code. We have a MD fly car that carries the butterfly and if the have a positive FAST they will make the patient a Level 0 and go straight up to the OR and bypass the trauma bay. They do their basic overview in the elevator vestibule and go up. I think it has potential to speed up the trauma process.

I also think the ability to place ultrasound guided IVs would be nice to reduce placing IOs on conscious patients.
I will also counter this and say EMS FAST exams absolutely can change a destination. I work in a rural county with no trauma services. Most of our residents prefer not to be transported 2 counties away "just in case." So we often take low acuity traumas to our local hospital, and inevitably some get sent out emegently for trauma.

We are also working on a prehospital blood program, and a positive FAST exam is one of the indications we've written into our protocol.
 

NPO

Forum Deputy Chief
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A FAST exam really shouldn't be used there to help you decide if you are safe taking the patient to your local ED, because the sensitivity isn't really that high to rule out intra-abd pathology.
Right, but in the absence of other indicators for a trauma center, it could help. You're never going to catch them all, unless you over triage everyone
 

NomadicMedic

EMS Edumacator
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I'd like it to use for US guided IV access and to confirm ventricular standstill in an arrest.

Other than that, it's of limited value to EMS right now.

However, if you read the FOAMed EMS blogs, those guys are all fired up about it. It's a little off-putting, that they're preaching POCUS and high level vent strategies to new medics when I have medics that can't identify VT and what do do about it.
 

hometownmedic5

Forum Asst. Chief
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I'd like it to use for US guided IV access and to confirm ventricular standstill in an arrest.

Other than that, it's of limited value to EMS right now.

However, if you read the FOAMed EMS blogs, those guys are all fired up about it. It's a little off-putting, that they're preaching POCUS and high level vent strategies to new medics when I have medics that can't identify VT and what do do about it.
This is why I only see this as a way down the road idea, when we have degrees and, for want of a more delicate way to phrase it, they’ll have more class time to fill. The training involved will be a non starter for most agencies, and most of the more.....experienced medics. When we transitioned to the FAST-ED stroke assessment from the Mass Stroke Scale, I tried to explain it to one of our.....experienced medics And was met with an impenetrable wall of resistance, and all we were talking about was changing the questions some and maybe use an app to help you.

The two things paramedics hate are change and status quo....
 

Peak

ED/Prehospital Registered Nurse
521
280
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Adults can have about 200 mL of blood in the abdomen and still have a negative FAST, so it really isn't a great tool to exclude intra-abdominal process. A 64+ slice helical CT is still the gold standard in ED (pre-OR) imaging. Ultrasound should only be used in lieu of CT if the patient is too unstable for CT. The always is a bit of a weird balance as a true trauma resuscitation should not be moved out of the trauma room, and a modern CT can do a trauma pan scan with contrast in under five minutes. Skipping imaging for damage control resuscitation is very risky, and really if a trauma center wants to go that high speed they need to have an OR in the ED type setup.

USGPIVs are a great tool, but are more difficult that many people think. The technique takes a lot of practice to become good at, especially for kids or adults who are truly difficult access. It also takes more time than normal, for a patient that has a good peripheral vein and only requires one attempt it may add about 5 minutes. If you really have to hunt down a good vein or make multiple attempts it is not uncommon to spend 20 or more minutes trying to put the IV in. Some patients still won't have appropriate body habitus or vasculature and will still require a midline, PICC, or central line.

The butterfly isn't very appropriate for USGPIVs as the probe is so large that you can't really use standoff technique and are essentially forced to use fully sterile technique, which adds more time and cost.

For the lumify you would need to purchase a linear probe, which is different from the curvilinear or phased probe you would use for an EFAST. If I remember correctly the outright purchase price varies on probe cost but they are all over 5k, so that adds up quick.

For the VSCAN you would need to purchase the dual probe, which is also quite pricey. It used to be well over 10k but when the butterfly was coming out they pushed marketing hard and I think the email I got offered it for around 8K.
 

Remi

Forum Deputy Chief
Premium Member
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I don't see US really having any place in EMS at this time. It's harder to learn than people think, for one. More importantly, like all diagnostic tests, a US scan only has utility insofar as the results are going to guide management decisions. I can't think of any way to use US in the field that is going to change treatment at this point in time.

Of course the FOAMed community is all about "POCUS", but those guys think that almost everything done anywhere in a hospital should be available in the field. And of course some EMS agencies are going to buy US and "train" their medics in a few scans because being "progressive" is more important than actually improving patient care, only to realize after a couple of years that they are prolonging scene times with sick patients yet not improving outcomes at all.

In the future? Maybe. Who knows?
 
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RocketMedic

By Kaepernic’s Wheelchair!
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Agree with Remi here. Would much rather see investments on basic educational opportunities, improved shift schedules and things of utility. Ultrasound is sort of like the TXA or blood of diagnosis for us- it’s cool and has potential uses, but also sort of self-defeating in that it’s most likely beneficiaries are people who need a Team of Good Doctors Quickly, not Two Dudes and a Van.
 

VentMonkey

k’uhul ajaw
Premium Member
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There was an overdramatized show about the Memorial Hermann flight program years back, they were doing POCUS.

It seemed like it led to a lot more overtriage of trauma patients brought in by them from their POCUS assessments.

Also, not to be too crude, but OP how come you always bring things up that have been talked about for at least a decade already?
 

VentMonkey

k’uhul ajaw
Premium Member
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it’s most likely beneficiaries are people who need a Team of Good Doctors Quickly, not Two Dudes and a Van.
Or one dude and his wheelchair van? Activate hyper speed!...

You do know you will never live that down on here, right?
 

RocketMedic

By Kaepernic’s Wheelchair!
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Or one dude and his wheelchair van? Activate hyper speed!...

You do know you will never live that down on here, right?
I don’t want to live it down. I keep it as a memory. A reminder of my shame. Like how Batman kept Bane’s mask after his spine was snapped. It makes me stronger and smarter to never compromise again. Like the vomit of redemption from team America world police.
 

MackTheKnife

BSN, RN-BC, NREMT, EMT-P, TCRN
509
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Way, way down the road when we’re all independently licensed, degree conferred professionals, maybe. While the majority of us are still counting hours and working for low rent privates(regardless of how things look from the upside, internally their all the same) or good enough fire departments, no. Basically the same argument as for iStats.

BTW, I just read your post footer resume. Aside from the fact that posting your full name on the internet is incredibly astronomically stupid, I get that you're proud and all, but none of that is really relevant here. You do you, it just comes off as aggressively ostentatious.
Perhaps he is demonstrating his professional credibility by posting his name and resume. You "astronomically stupid" comment is "astronomically wrong". Or are you just jealous?
 
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