POCUS and the Sceptics

"As I was saying at the odd conference before we were so all so rudely interrupted, Point of Care Ultrasound is finally coming of age in the UK.  It has taken a while – the first diagnostic use of ultrasound was in the 1940s by a neurologist, a comparatively rapid pickup from the first demonstrations of Non-Destructive Testing for metals using ultrasound in 1928. 

By the 1990s the technology had moved to the bedside, expanded to take in the pleura and the lung alongside traditionally ultrasound-transmitting structures, and then benefitted from miniaturisation, phenomenal increases in computing power including Artificial Intelligence, cloud computing and rapid dissemination of information through novel media. 

The attitude to using ultrasound for vascular access for example have changed dramatically over the years, from it being deemed unnecessary and over-complicated, to it now being a standard of care.  The same may be said for the development of POCUS within critical care.  The service is incredibly varied across the country; some units may do no POCUS or have a solitary local expert with a machine that gathers dust except for their ICU weeks, to units with POCUS completely embedded and FICE being a stepping-stone to BSE echo accreditation.  So how do you encourage and embed the practice? And how do you win over the sceptics? 

I have encountered three main groups and objections when bringing this or other technologies to a unit. 

Group 1: The enthusiasts – they are vital lest you be plodding along on your own.  However, this is not the group with whom you will have to work hardest – they’re keen and involved, and always developing their skills.  Being there to mentor them through accreditation is a genuine pleasure. 

Group 2: The Sceptics – willing to be influenced but needing information and demonstration of benefit. This group is vital to success and may be some of the most listened-to people in an organisation.  They have probably seen a parade of technologies, interventions and trials come and go.  The default position of a lot of intensivists should be scepticism – every intervention should be thoroughly assessed before we let it near a patient.   

Group 3: The Hard No – everyone has areas of their professional lives which they have no intention of developing, no matter how generally enthusiastic they are.   This may be related to other pressures and interests inside and outside work, it may be a temporary stance or a permanent resolve.  Any attempt to overcome this definite resistance is actively harmful. 

So, what are the objections? Just as an automatic insistence on “retraining” does not work for anything but knowledge-based errors, addressing the concerns through only one tactic, evidence, is not going to work.  Yes, you need to know the evidence and be able to summarise it on demand, present it to your colleagues and apply it daily, but that won’t be enough to persuade everyone.  It answers only the first objection of “Does this work?”.  

The second objection is usually cost.  There is no getting around that a fully featured, modern machine will be a large number on a spreadsheet.  There are several ways of addressing this: First that GPICS v2 has helpfully made this a standard and really a “must-do”.  However, budgets remain tight and other priorities can take precedence.  I take the argument that the first quality binaural stethoscope by Hewlett-Packard was the equivalent of £5000 in modern money, that just the portering for a CT in some hospitals can cost over £100 billed to the department, and a fully-featured, human-approved portable ultrasound is now available for £1800.  Combined with the evidence used to overcome the “Does this work?” objection, you can make it clear that your unit really can’t afford not to invest in POCUS. 

The final objection is the hardest to deal with.  Bringing POCUS into everyday practice should really serve one purpose; to improve the diagnostic and procedural accuracy for the benefit of patients.  I have been astonished at the number of cardiac tamponades I have detected using cardiac ultrasound, having only ever diagnosed one clinically.  I have then asked myself “What else have I been missing?” To bring a practice-changing technology to a unit risks causing considerable distress, which in turn can lead to further objections that may seem irrational.  Effectively, you are posing the question to your team, “What have we all been missing, and maybe for years?” The reactions to that will vary greatly, but can include aggression, defensiveness or rejection of the entire idea.  This shouldn’t be mistaken for the “Hard No” group – but you can easily turn someone from scepticism to permanent rejection with an unkind or forceful approach. 

The evidence, the kit and the will are all there.  We have the chance to build on our momentum as a speciality to make POCUS a service improvement for the whole of UK practice.  I already see trainees for whom this has been part of their practice from day one, and who I will have to learn from as their skills progress much faster than mine.  I hope that UK ICM POCUS becomes so established that my role is reduced to just trying to keep up."