Intro: Expert Insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode's post-test.

This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host, Melanie Cole.

Melanie Cole, MS (Host): Welcome to Expert Insights with The Carle Foundation Hospital. I'm Melanie Cole. And today, we're highlighting the role of POCUS, point-of-care ultrasound in modern clinical practice. We have a panel for you today with two program leads for POCUS. Joining me is Dr. Harshal Swaminarayan, he's a specialist in Adult Hospital Medicine at The Carle Foundation Hospital; and Dr. Jose Ochoa, he's an emergency medicine physician at The Carle Foundation Hospital.

Doctors, thank you so much for joining us today. And Dr. Ochoa, I'd like to start with you. Tell us a little bit about point-of-care ultrasound and how it complements the physical examination, traditional diagnostic testing, and can improve the quality of care.

Dr. Jose Ochoa: First, I'd like to thank you guys for having us here today. This is an exciting opportunity for us to share POCUS with you and the passion that we have for this modality as well. The way I can explain POCUS is, as it is, is point-of-care ultrasound. It's a bedside ultrasound that is being performed by a clinician with the goal of answering a specific question.

That could be as simple as, is there something here positive or not? And then, using that, integrating that into our bedside examination, any adjunct labs, imaging studies that might still need to be performed. It's not replacing your traditional radiology imaging modalities. It's an adjunct, and it's something that you can perform rapidly to obtain an answer that you might have on a patient.

The best way I can explain this is by giving you an example more than just talking about what POCUS is. I have a lot of examples over the years, but I'm going to talk about one that's more recent in my mind from a few weeks ago. I had a patient in the emergency department, it was around midnight, who came in with visual disturbances. Performing my typical exam, external eye exam, eye pressures. And then, I decided to use POCUS at that time. You know, what is this going to answer for me? And in this case, it was going to be internal globe findings. Is there a retinal issue, a vitreous problem? And in this specific case from a few weeks ago, I found that the individual that was having visual disturbances was having a retinal detachment, which is an urgent eye emergency that has to be addressed in some instances.

What I did after finding the detachment was I had to contact the transfer center to transfer the patient to a hospital that had capability to handle the detachment at that time of the night. When I got a hold of the physician at the other facility, they told me that I needed to contact my ophthalmologist at Carle, have them come to the bedside, do their assessment before I could ever transfer the patient.

Instead of doing that, I asked them if I could share the image through a secure network with them. And as soon as I shared the image, they told me I could go ahead and transfer the patient. Now, in this example alone, it shows you how performing POCUS, you know, it saved time for the patient. They didn't have to wait for a ophthalmologist to come from home at midnight. It also allowed me to use a consultant in a better way. I didn't have to have a consultant come in at midnight, one o'clock in the morning, and then have to come back the next morning to their clinic or surgery. It prevented me from having to do unnecessary tests. I didn't have to then expand my differential to central processes, strokes. But once I had the diagnosis, I could act on it more efficiently. And that's kind of how we can use POCUS for examples like this.

Now, you might say, "Well, I'm not in the emergency department. I'm at a clinic. I'm at the inpatient setting." But imagine the same patient that comes to you. You have a clinic patient that you're seeing, and they tell you they're having visual disturbances. This is not dependent to just the emergency department. You could perform an ultrasound there, try and rule out certain things, and then contact the appropriate services that you might need.

Let's say you're rounding on a patient on the floor and your hypertensive patient is having visual disturbances. You can perform an ultrasound at that time as well. So, it's not just dependent on specific specialties.

Melanie Cole, MS: So Dr. Swaminarayan, let's explore the high-yield clinical applications of POCUS. Tell us some of the common clinical scenarios where POCUS can really enhance diagnostic assessment and expedite patient management, sort of expanding on what Dr. Ochoa was just saying.

Dr. Harshil Swaminarayan: Yeah, no, thank you so much, Melanie, for the opportunity to be on this panel. And thank you so much, Dr. Ochoa, for sharing your insights on your clinical case. So, in terms of the general applications of point-of-view ultrasound, there are a variety of different applications of POCUS.

And the opportunity to perform POCUS begins with a clinical question in mind, which then triggers a POCUS assessment using the ultrasound. So, I come from a hospitalist background, and the Society of Hospital Medicine literature has proposed a series of clinical applications including cardiac, pulmonary, abdominal, vascular, musculoskeletal, procedural, and then there's other multi-system studies as well. Going over cardiac, some of the examples I could give would be if a clinician is curious about the growth ejection fraction of the patient, if they want to evaluate for pericardial effusion, if they want to compare the two sides of the heart, is the right heart greater than the left heart? Meaning could it be a strain on the right heart? We look at IVC measurements to then evaluate for volume status. We look for gross valvular abnormalities.

When scanning the lungs, we look for pleural effusion, interstitial syndromes, alveolar syndromes, and look for pneumothorax. For abdomen, there are applications to rule out free fluid in the abdomen and trauma, to rule out hydronephrosis, to look at liver, spleen, and so on and so forth. In terms of the vascular evaluation, a key application is to rule out DVTs and also to look at the abdominal aortic aneurysms. For musculoskeletal, we could evaluate for fractures, tendon ruptures, and so on and so forth.

And for procedural ultrasound, that has shown to improve the safety of procedures and increase the yield of the procedures. And it's the standard of care in performing a variety of different procedures, including thoracentesis, paracentesis, arthrocentesis, and I could just go on and on. But the highest yield of the focused application comes when the clinician is trying to diagnose a clinical uncertainty rapidly. For example, if a patient is in shock or if they're having a cardiac arrest or if they're dyspneic and have hypoxia, the clinician could perform multi-system evaluation using point-of-care ultrasound to evaluate the heart, evaluate the lungs, evaluate DVTs, and abdomen to come up with the etiological diagnosis in the patient.

Whereas contrasting that in a scenario where POCUS is not available, the clinician would have to order several different studies like an echo. They would have to get an echo tech to come in and see the patient. They would have to get a vascular tech to come in and see the patient. They might have to send the patient for a CAT scan of the belly to rule out free fluid in the belly and so on and so forth. So, POCUS really improves the efficiency and the timeliness of the diagnosis.

Dr. Jose Ochoa: If I can expand on that as well, Dr. Swaminarayan, I don't want people also to hear all these modalities and feel that it's maybe outside of their scope of practice. POCUS can be as simple as I want to learn what's pertinent to my practice. do I want to learn how to just do ultrasound-guided IVs? And that's perfectly fine. Do I want to do abdominal for FAST on trauma? Do I want to be focused on orthopedic issues and only that? You could pick what you want to learn. It doesn't have to be all or nothing. You can specialize it and that's the beauty of POCUS. it's something that you can pick based on your specialty and what you use it for.

Melanie Cole, MS: Well, I'm glad you made that point, Dr. Ochoa, because that is really important to separate that out so that it is for individual practice and can save so much time. This is really fascinating technology. And Dr. Ochoa, what are some of the more important benefits, limitations, and the best practices for POCUS?

So, tell us about the strengths and limitations, but also those best practices, which include operator dependence and image quality, appropriate indications as you were just mentioning. Give us a summary here.

Dr. Jose Ochoa: The thing I can tell you is when it comes to POCUS, especially in the emergency department, but anywhere else, it's speed and wanting to do things and find answers. So, speed is very important. If I give you another example, over the years, I've had a few patients that come in with scrotal or testicular pain. And you kind of know what the differential for the most part is going to be. I have been able to perform ultrasounds, POCUS, find the evidence of torsion, and contact the urologist. Now, there have been times where they tell me, "Can you please order the confirmation study?" But for the most part, they're already on their way. You know, but there's been times where I've been back in the room, the technician is there, and the surgeons are already doing the consent forms. So, the most important thing is patient care and providing the best care for them with the tools that we have, which POCUS is one of them.

Another thing is repeatability. You can repeat the study. You have a patient that comes in, maybe they're hypotensive. You perform a POCUS exam, cardiac, pulmonary, you know, whatever you might be focusing on, and then the patient improves. And then, half an hour later, they're hypotensive again. You can go and repeat it. You can go back and see has anything changed. Can I gather any information from this and use it clinically?

One of the drawbacks, the main one that I've encountered over the years is the ability for people to get through the track and to want to learn because they might see it as something that's—like I mentioned earlier—maybe it's not something that I'm going to perform. And I usually tell new learners that over the years, some of the best clinicians have come through these POCUS tracks. They haven't always been physicians. You know, I've had advanced practice providers, PAs, NPs. There's been so many different trainees that have become so proficient at POCUS that they even become better than the physicians at times.

I have a good friend who is currently now working in a different hospital out of state. He's an APP. He took some of these skills. Within a month of being at the other hospital, he called me and said, "Hey, the providers at this hospital are asking me to do ultrasound-guided procedures, paracentesis, lumbar punctures with ultrasound, cardiac ultrasounds." And that's exactly what I had told him. You know, once you learn, you have the passion, you have the go-ahead and I'm going to go learn this, you can become very proficient at the POCUS skill. But that is one of those things where we want to guide you. Especially, we'll give you more information later today about how do we go through that track, and how do we actually start to get these skills

Dr. Harshil Swaminarayan: No. Thank you so much, Dr. Ochoa, for making those very important points. If I may add some of the other benefits of POCUS that we come across is quality of care. Now, that is the North Star that we look to provide the best quality of care for our patients. And POCUS has been shown in a variety of applications to improve the quality of care.

For example, in a study published in 2025, POCUS showed length of stay reduction in hospitalized patients with dyspnea by about 30%. It also has shown to reduce the cost of care in hospitalized patients. POCUS has also been demonstrated to reduce readmission rates in congestive heart failure patients, which is a huge clinical burden. And it also improves the clinician's ability to predict outcomes at discharge.

On the other hand, when we look at the emergency room literature, POCUS is also shown to improve patient satisfaction and reduce the return visit rate in the ER patients. So essentially, quality of care, it would be one of the key contributions of POCUS to the medical fraternity.

Now, when we talk about the benefits of POCUS, we should also talk about some guardrails to implementing while we are performing POCUS. So, one of them could be that if you're performing a point-of-care ultrasound study and if you're not sure about what you're looking at or if you are tentative about some of the findings, then go ahead and order a confirmatory study. Only comment on structures that are adequately evaluated. And once you're credentialed, you want to go off of institutional policies for documentation, for billing and recording your study. And whenever there is a technically limited or discordant exam, that should trigger a confirmatory study and not just falsely reassure us.

Melanie Cole, MS: All good points. And Dr. Swaminarayan, do you have some strategies for integrating POCUS for other providers into their everyday practice? Take us from bench to bedside and show us how we can really integrate this into everyday practice.

Dr. Harshil Swaminarayan: So as we know, POCUS is no longer an emerging modality. It is an established modality when it comes to the emergency room and critical care practices. And specialties like internal medicine, hospital medicine, family medicine, anesthesiology, sports medicine, and so on and so forth, have been rapidly integrating a lot of POCUS modalities into their clinical practice. POCUS is a standard of care, as we discussed, for a lot of procedural applications and now increasingly becoming used for diagnostic applications.

And as you may all know, POCUS is being integrated in medical school and internal medicine residency programs. And studies showed over 50% of these programs already have some POCUS training available for their trainees. So when they're going to be graduating, they're going to be coming out with POCUS skills. Now, if a clinician today has decided to embark on this journey, I would suggest that they start with looking into training options, which we'll review later on during our chat today. And then, that facility would want to have a credentialing policy and set up for maintenance of a quality analysis process.

Melanie Cole, MS: So Dr. Ochoa, I'd love to give you each a chance for final thoughts here. Dr. Ochoa, as we think of the exciting emerging innovations in the future of POCUS, speak a little bit about some handheld ultrasound devices, artificial intelligence-assisted imaging acquisition, interpretation, tele-ultrasound, cloud-based image management. I mean, there's so many exciting things in this realm right now.

Dr. Jose Ochoa: That's for sure. You know, just like everything else in our society, technology is just advancing so rapidly. When I was in residency many years ago now in Phoenix, we used to practice on this ultrasound machine that to me, looking back, it felt like it was the size of a small car almost. We had to have two residents, you know, wheel that squeaky wheels and everything into the room, and it almost made you not want to do it, perform this study based on just how big that thing was.

And even from then to now, you have handheld devices which have become a big advance over the last 10 years, 15 years where these handheld devices have decreased the cost at times for entry into doing POCUS. It's one less barrier to be able to have a machine. It's more portable. You can have it in your clinic, go from room to room. You can be rounding on patients and have in your white coat. And it's something that can definitely assist with portability. That's the big thing with handhelds there.

Quality is not as good usually as the cart-based ones, but cart-based usually is better for some settings compared to the portable. We even have pre-hospital teams, EMS flight teams that are using portable ultrasounds when they're flying to make decisions and change managements. Some of them are also training through Carle at the moment. So for sure, handheld is one of those big advances. And with handheld comes AI.

Now, I know a lot of times we hear AI and we sometimes will cringe or think AI, you know, what, what's going to happen here? But AI, the applications that they're using with AI are to try and assist probe positioning, image quality. Sometimes it'll auto-adjust your image. They're working on allowing you to see. You know, you put the ultrasound probe on the abdomen and the AI will tell you, "This is the liver. This is a gallbladder. This is a kidney," which is a great application for learners when they're trying to learn the structures and what they're looking at. Some of them are giving you the measurements, what's the IVC size? What's my TAPSE score? What's my MAPSE? What's my ejection fraction? So, saving you time on that.

But AI, there are some safeguards. You can turn it off. Any AI is also reviewed by IT, biomed before anything gets allowed into the hospital system. But AI, even though it's helpful you still need to know what you're looking at. You need to know how to interpret these findings. It might tell you numbers and what you're looking at. But if you don't understand what you're using it for, then it's just going to give you more unnecessary information.

To go along with AI, we also have middleware options in software where you can scan a patient and the software will give you image quality. It can tell you if you have a grade almost on your scanning. It allows for QA for someone that's reviewing your credentials or giving you feedback to be able to do it through software as well. There's a lot more applications with software. But mostly imaging, archiving, portfolios, education and continuing education as well for privileges.

So, these are one of many advances, but those are the main ones I can discuss today when it comes to POCUS and technology.

Melanie Cole, MS: Thank you for that. And Dr. Swaminarayan, last word to you. Talk a little bit about the learning curve and about education, so I'd like you to tell us some of the resources and education that's available through the Carle Foundation Hospital and Carle Health, and how other providers can find out about this amazing technology.

Dr. Harshil Swaminarayan: Now, when we look at the training curve of point-of-care ultrasound, we often describe trying to attain clinical images first. So, it's image acquisition. The second step is interpretation, and the third is integrating these findings into the clinical practice. Now, the goal of the POCUS program is to encourage evidence-based use of POCUS modalities to improve the quality of care.

And in order to do this, the POCUS program includes components of training, standardization of documentation, credentialing, billing, and QA. The Carle Illinois College of Medicine already has a POCUS curriculum for their first and second year medical students. The Carle Internal Medicine Residency program has a robust three-year-long, which the residents are awarded a certificate of completion. And our aim is to expand this POCUS training to the cardiology fellowship and other GME programs, namely the family medicine residency program in Peoria, which we have partnered to support.

Now, a lot of these programs may already have existing POCUS training and our collaboration with them would be to assist with any component of their program. There are also several sessions that are currently being conducted for attendings and for APPs. There are specific tracks for POCUS training for residents, attendings, for new learners versus advanced learners. If somebody wants to focus on a particular modality of POCUS, say, for example cardiac or pulmonary DVT or gallbladder and so on and so forth. A lot of these sessions are underway at Carle Foundation Hospital. On the other hand, there are other classes that are being scheduled at BroMenn and Methodist at Peoria and Richland. Now, if you are a physician or APP or a clinician interested in learning more about POCUS or if your department's leader, we kindly encourage you to reach out to us via email if we haven't already communicated, connected. You could also reach out to us via Epic chat to inquire about our offerings.

Dr. Jose Ochoa: There's a lot of other training modules, databases, archived images online, a lot of different websites that if you feel you want additional training that way before you meet with us even. You can reach out to us. There's national conferences that I know some providers have gone to including next month. There's the ASEP conference in Chicago, actually. So, this year, it's going to be close by to us. And within that, they have workshops. They also have ultrasound-focused training. You don't have to be a member of ASEP to go to those. You can select that. It'll be early October. There's CME options as well. So if you come to our sessions, most of them have CME credit attached with them.

But anything that you're interested in, you can reach out to both of us, or if you prefer one or the other, you know, if you're internal medicine or ER That's what we're here for. We're here to help and provide you guys resources and and just be support.

Melanie Cole, MS: Thank you both so much for joining us today and sharing your expertise with this exciting new technology, and it really is such an exciting time. Thank you again for joining us. For more information and to get connected with one of our providers, you can always visit carle.org. Or for a listing of Carle providers and to view Carle-sponsored educational activities, head on over to our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole.