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Back to the bedside: Using point-of-care ultrasound

Reed, Harrison MMSc, PA-C

Journal of the American Academy of Physician Assistants: December 2017 - Volume 30 - Issue 12 - p 9
doi: 10.1097/01.JAA.0000526784.19401.48
Editorial

Harrison Reed practices critical care medicine at the University of Maryland Medical Center's R. Adams Cowley Shock Trauma Center in Baltimore, Md., is an adjunct instructor in the School of Medicine and Health Sciences at George Washington University in Washington, D.C., and is associate editor of JAAPA. The author has disclosed no potential conflicts of interest, financial or otherwise.

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Like many fields driven by science and industry, medicine has benefited from frequent, momentous leaps in technological advancement. The tools of our trade have transformed the clinician from a passive bedside observer to one who can bend the very laws of biology. From mechanical ventilation to dialysis to cardiac bypass, we can override nearly any failure of nature with the brawn of machinery. But like so many accomplishments of humankind, the pace of these achievements has often surged past our understanding of their consequences.

Radiography was such a wonder at its inception that the fallout became an afterthought. Radioactive shoe-fitting machines found themselves on the aisles of department stores as amusing sales gimmicks, snatched away only years after we appreciated the harms of radiation exposure.1

Mechanical ventilation ushered in an era of critical care medicine, a specialty that now practices some of the most dramatic—and expensive—nonsurgical interventions in healthcare. But long after we could keep the human body alive without meaningful brain function, debate about the moral, ethical, and legal implications rages on.

We seem to have made a habit of thrusting an innovation into service before we fully consider its effects, even if the consequences conflict with our own collective conscience. Primum non nocere long ago became “first, press the button.”

But there may be a technology that, for once, does not put us at odds with our own principles. The emergence of widespread use of point-of-care ultrasound offers a marriage of technology and medicine that may let us keep our vows.

As illustrated in the article by Fuller and Norman in this issue (page 48), point-of-care ultrasound has a wide range of clinical applications. It is no longer a technology chaperoned by sonographers and interpreted by radiologists; it is the bedside tool of the generalist and specialist alike, the pragmatic, new-age stethoscope.

But the rise of ubiquitous ultrasound supports a trend in medicine more important than any shiny new toy. It aligns with a philosophy that focuses not on the prestige of the individual clinician but the information at his or her fingertips. It supports evidence over eminence. It puts empiric data within arm's reach. It places patient safety back on the cutting edge.

Point-of-care ultrasound can answer questions that once required a dose of radiation—and the risk and price tag that comes with it. Now we can rule out a pneumothorax in a harmless instant.2 We can differentiate cellulitis from abscess without IV contrast—and without piercing the skin.3

Point-of-care ultrasound removes our reliance on the periodic mythology and dogma of fickle physical examination findings. We can assess cardiac function at the bedside with more than a vague search for crackles and a sage stroke of our chins.4

For perhaps the first time in the history of medicine, the newest and most effective applications of technology are safer and cheaper than their predecessors. The feather-light weight of ultrasound has—ever so slightly—tipped the scales of risk and benefit in favor of the patient.

Of course, this power also comes with an added responsibility. In an era of splintered, ultraspecialized medicine, point-of-care ultrasound demands that we embrace our generalist roots and cultivate a broad skillset. To maximize the benefit of bedside ultrasound, we must invest the time and energy to become competent, self-sufficient operators—technician, clinician, and diagnostician all at once.

In a strange way, the forward march of technology has come full circle. The ultrasound machine places the focus of medicine back where it began: in the hands of a single, caring individual standing at the patient's bedside.

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REFERENCES

1. Dyson ED. Shoe-fitting X-ray fluoroscopes: radiation measurements and hazards. Br Med J. 1956;2(4987):269–272.
2. Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med. 2005;12(9):844–849.
3. Subramaniam S, Bober J, Chao J, Zehtabchi S. Point-of-care ultrasound for diagnosis of abscess in skin and soft tissue infections. Acad Emerg Med. 2016;23(11):1298–1306.
4. Levitov A, Frankel HL, Blaivas M, et al Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part II: cardiac ultrasonography. Crit Care Med. 2016;44(6):1206–1227.
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