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Patient Care

Case Study: Implementing POCUS

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In July 2015, I became the EMS medical director for the Iredell County (NC) EMS service. Working with the service’s director, Blair Richey, and assistant director, Ryan Wilmoth, we performed a needs analysis to identify any areas of opportunity to better serve the citizens of our county. As a result of that analysis, Iredell County EMS is in the midst of a complete overhaul of its trauma protocols. These changes, and early outcomes from our efforts, will be discussed at EMS World Expo in New Orleans, LA, October 3–7.

A cornerstone of these new protocols is the introduction of point-of-care ultrasound (POCUS) to our EMS units. Three ultrasounds have been deployed with EMS supervisors and one is held in reserve by the training division. Each machine has linear and phased array probes.

We chose the Terason uSmart 3200T for a number of reasons. The units are extremely portable, being the size of a large tablet computer, and are surrounded by a large rubberized case for durability. They are full-function units, capable of accepting a variety of probes, allowing providers to eventually increase the use of POCUS into newer and more varied indications. They have a touch screen and a very intuitive user interface. The units have a Windows-based architecture, which can be updated remotely via WiFi. Additionally, the solid state hard drives on the machines make preserving images for review—both in real time on patient arrival in the ED and later for QI/QA—a breeze. Lastly, the support Terason has provided in terms of training has been nothing short of incredible.

We currently use ultrasound in three roles:

  • For the traumatically injured patient, we perform an extended focused assessment with sonography for trauma (eFAST) exam. The results of the study, either indeterminate or positive, are radioed to the receiving trauma center. While the result may not directly change our care of the patient, the positive eFAST exam functions like a positive 12-lead ECG in ST-elevation myocardial infarctions: The information allows the receiving center to better prepare to rapidly treat the patient.
  • Our second POCUS indication is to assess for the presence of pregnancy in obtunded trauma patients. Again, the idea is to provide the receiving facility as much information as possible so the patient’s needs can be rapidly met.
  • Our third POCUS study is to assess cardiac motion to guide cardiopulmonary resuscitation efforts in both traumatic and medical cardiac arrest scenarios.

A group of senior paramedics and paramedic supervisors underwent 12 hours of training, both in classroom and with live models, in the performance of the POCUS studies above.

At the end of training, a 50-image test, with 10 “positive” studies hidden among 40 “normal” pictures/video clips, was administered. With one positive image thrown out of the test because of poor inter-rater agreement among the instructor cadre, every member of the class scored 91% or better.

Use for trauma in the field thus far has yielded three positive studies (one hemoperitoneum and two spontaneous pneumothoraces), each later confirmed in the ED. One potential “miss” (defined as a positive eFAST in the trauma center not detected by EMS) was also identified during QI/QA. We are moving forward with plans to expand POCUS use into our active shooter triage protocols, to aid in establishing peripheral IV access, and into our care of the non-traumatic patient who is in shock of undetermined origin. Overall we consider the project a resounding success and look forward to the future and expanding our use of POCUS in prehospital care.

Howard K. Mell, MD, MPH, CPE, FACEP, is EMS medical director for Iredell County in North Carolina. He is a featured speaker at EMS World Expo, October 3–7 in New Orleans, LA. Register at EMSWorldExpo.com.

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