POCUS-Enhanced Physical Examination Is the Future, and the Future Is Now

Harini Bejjanki                            Abhilash Koratala

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What is POCUS?

POCUS, or point-of-care ultrasonography, is a limited ultrasound examination performed by the clinician at the patient’s bedside. As opposed to a radiographic examination of an anatomic area, POCUS is intended to answer focused questions, mostly “yes” or “no” questions, and is performed by the same physician examining the patient. It is a valuable adjunct to physical examination, and some authors describe POCUS as a fifth pillar to bedside physical examination in addition to inspection, palpation, percussion, and auscultation (1). In specialties such as emergency medicine, POCUS training has been well established, and the Accreditation Council for Graduate Medical Education recognizes bedside ultrasonography as one of the key index procedures essential for independent practice. More recently, POCUS has spread throughout all levels of medical education and is being integrated into medical school and postgraduate training curricula (24).

Why should nephrologists perform POCUS?

Once confined to procedural guidance, the scope of POCUS in nephrology practice is quickly expanding. There are several clinical scenarios where it can guide patient management (Figure 1). For example, one can quickly exclude hydronephrosis using POCUS at the time of history taking, which reduces fragmentation of care and enhances the treatment of patients with acute kidney injury. Determination of volume status is another challenging area of nephrology practice. POCUS, being noninvasive and a dynamic parameter, not only guides therapy but also allows monitoring of response to an intervention such as ultrafiltration or diuretic therapy.

Figure 1.

Infographic demonstrating common diagnostic point-of-care ultrasonography applications and clinical questions and pathologic conditions pertinent to nephrology practice

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Similarly, maturation of the arteriovenous fistula can be assessed at the time of regular nephrology clinic visits, thereby avoiding the trip to vascular surgery. Moreover, it can enhance our interactions with patients by showing them the imaging findings in real time. In addition to improving clinical care, it enhances the attractiveness of the nephrology fellowship training. Last but not least, if we do not learn this skill, we will soon lag behind other specialties and may be looked upon as not having an essential physical examination skill such as auscultation.

We need to wake up, and the time to do so is now.

Where do we start?

The scope of nephrology-oriented POCUS is still emerging, and there are no well-defined training guidelines or educational approaches. Only a handful of nephrology fellowship programs offer formal training in POCUS (3).

For practicing physicians and trainees from other programs, short-term training opportunities exist in the form of workshops and courses such as those offered by the Emory University Renal Division. Emory is the only ultrasound program accredited by the American Society of Diagnostic and Interventional Nephrology (5). Nonetheless, it is focused on comprehensive kidney and bladder imaging and does not cover other POCUS applications pertinent to nephrology.

POCUS workshops, typically offered as a “pre-course” before national meetings, are a good starting point for novice users to learn the basics of image acquisition and “get a feel” for the technique. However, residency-based or fellowship-based longitudinal training provides an opportunity for long-term skill retention. Nobody masters the skill of auscultation in 1 day, and the same is true with POCUS; we cannot expect to learn everything about it from a half-day workshop.

The best way to gain competence and confidence is to scan at every possible opportunity and to review ultrasound technician–performed formal studies while trying to interpret your own. Until every nephrology fellowship program has a faculty “champion” who leads the POCUS training, a multidisciplinary approach in collaboration with other specialties such as emergency and critical care medicine can be greatly beneficial. In addition, teaching colleagues and students is the best way to learn and practice further. Apart from the ultrasound machine, no expensive resources are required to establish a training room, and at the University of Florida, we use a regular office room with a computer and a foldable bed to scan faculty and trainee volunteers (Figure 2).

Figure 2.

POCUS training room for nephrology fellows at the University of Florida

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What is our POCUS video curriculum?

Recognizing the gaps in training and the scarcity of nephrology-oriented POCUS teaching resources, Dr. Koratala has designed and developed a series of instructional videos covering the common diagnostic POCUS applications relevant to nephrology practice, which fellows and residents at our institution have found immensely helpful (Table 1, Figure 3). The curriculum is a set of 10 videos available for free on YouTube by typing in the key words “nephrology ultrasound Florida.”

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Figure 3.

Representative slides from the University of Florida video curriculum

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The advantage of having a video curriculum is that trainees can review the online material at their own pace, in a low-stress environment that is not impeded by patient care obligations. This flipped classroom model allows more time for interactive demonstrations and hands-on learning. Moreover, with more medical students being trained in POCUS, it is likely that we will have trainees with varying levels of knowledge and skill sets in the future. The availability of a structured video curriculum gives them the opportunity for targeted review of the topics they are less familiar with.

Are there any additional online resources?

In addition to several POCUS educational websites and videos primarily intended for emergency physicians (6), the “Focus on POCUN” series on the Renal Fellow Network authored by Dr. Koratala addresses key concepts in renal-relevant POCUS (7). He also contributes to a POCUS gallery on the Renal Fellow Network, along with hosting the blog nephropocus.com. Those who use Twitter can follow Dr. Koratala’s POCUS-specific handle @NephroP for interesting images and discussions. As more programs start incorporating POCUS, more educational material will become available. Until then, do not stop practicing, and do not hesitate to request a formal scan when you are not sure about the diagnosis.

September 2019 (Vol. 11, Number 9)

References

1. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside physical examination: Inspection, palpation, percussion, auscultation, and insonation. JAMA Cardiol 2018; 3:346–350.

2. Rempell JS, et al. Pilot point-of-care ultrasound curriculum at Harvard Medical School: Early experience. West J Emerg Med 2016; 17:734–740.

3. Koratala A, Segal MS, Kazory A. Integrating point-of-care ultrasonography into nephrology fellowship training: A model curriculum. Am J Kidney Dis. doi: 10.1053/j.ajkd.2019.02.002.

4. Koratala A, Bhattacharya D, Kazory A. Helping patients and the profession: Nephrology-oriented point-of-care ultrasound program for internal medicine residents. Clin Nephrol 2019; 91:321–322.

5. ASDIN ultrasound accredited programs https://www.asdin.org/page/279 Last accessed: 5/11/2019.

6. The Society of Point of Care Ultrasound POCUS resources https://spocus.org/FOAMED Last accessed: 5/11/2019.

7. Renal Fellow Network Focus on POCUN. https://www.renalfellow.org/tag/pocun/ Last accessed: 5/11/2019.