The 11th Commandment: Thou Shalt Use Ultrasound in the ICU

November 24, 2014

By Seth Koenig, MD, FCCP

I have never written a blog before and in fact have never read one. So I was intrigued when I was asked to write one relating to point of care ultrasound (also known as POCUS). Since I write without poetic ease when working on peer-reviewed journal articles, I thought this would be an opportune time to lay out my feelings toward POCUS as it relates to critical care medicine.

Three main groups have surfaced over recent years regarding the use of point of care ultrasound in critical care medicine:

• There are those who drank the Kool-Aid, watched the waters part, visited the promised land, adopted POCUS into practice and feel as though they could not practice critical care medicine without it.
• Another group of intensivists understand the benefits and embrace point of care ultrasound but have not yet been able to integrate it fully into their practice because they lack experience and the training in the field.
• And then there are physicians who hold tight to tradition and continue to practice critical care medicine with a compartmentalized approach. They rely on the radiology and cardiology departments to perform diagnostic and potentially therapeutic procedures on patients that are not their own.

I'm sure I will face criticism from the last group, and I’ve heard many reasons why they believe that they can do without point of care ultrasound. But let us first speak about the overwhelming data supporting its use.

Time after time, well-designed and controlled studies have shown that those who are not radiologists and cardiologists can become both accurate and proficient at performing point of care ultrasound. More studies have shown the benefits of the treating clinician in making a timely diagnosis and in ensuring the accuracy and safety of performing diagnostic and therapeutic procedures. It is hard to find a critical care journal that does not have an article each month supporting the use of point of care ultrasound. Even the American College for Graduate Medical Education has mandated education for all pulmonary and critical care fellows to become competent in both pleural and vascular point of care ultrasound.

The unoriginal, the naysayers, and those stuck with tradition may state that their intensive care units can get these tests done almost instantaneously and may ask themselves why should they take the time and assume the risk of performing these tests themselves. As if one test at one time sums up the whole of the patient’s critical care journey. As if left ventricular and right ventricular function remain the same throughout the patient’s septic shock state. As if when a deep venous compression study is performed and no thrombosis is found, that the patient is obliged not to develop one later. As if when the patient who is on high levels of ventilatory support develops hypotension and tachycardia, the chest radiologists will magically appear to perform lung ultrasound to diagnoses a tension pneumothorax.

Let's also not forget the reduction in costs and radiation exposure that is achieved by performing ultrasound instead of using ionizing radiation technology. The ultrasound seeds were planted years ago, and cultivated in a soil of experimentation and thoughtful educational design. I am certainly heavily biased in my use of ultrasound in the intensive care unit because I have received extensive training in my pulmonary and critical care fellowship and use it each day, just as I use a stethoscope in diagnosing and treating critically ill patients. And I understand our time constraints, especially when learning a potentially new paradigm in critical care rounding. But old dogs can learn new tricks, and I have watched seasoned but ultrasound-naïve veterans of the critical care wars embrace, learn and integrate this modality into their practices. They all say the same thing—once you go ultrasound, you never go back.

Seth Koenig, MD, FCCP, is Associate Professor of Medicine, Hofstra North Shore-LIJ School of Medicine, and Section Editor of Ultrasound Corner, CHEST. Dr. Koenig is an avid user of ultrasound, is co-chair of the CHEST course Ultrasonography: Essentials in Critical Care, and loves Belgian ale.