Point-of-care ultrasound (POCUS) is often taught to answer binary questions, like, “Is there free fluid in the abdomen?” However, when we combine POCUS images with clinical documentation, we are telling a story — and every good story has a beginning, middle, and end. The key is simplicity: focus on answering one clear question with each scan. If the scan doesn’t provide an answer, don’t start filling in the gaps with speculation.

Tell Me Why – Ain’t Nothing But A Heartbreak

 

Your ultrasound images are part of the medical-legal record. Therefore, it is essential that you adhere to documentation rules and save the appropriate images for each type of scan you perform. If you encounter technical difficulties (e.g., body habitus, patient discomfort, etc.) that prevent you from obtaining ideal images, it’s okay to acknowledge that. For instance, in a hypotensive patient where you perform a RUSH exam and identify a fever with consolidation on lung POCUS, you might note:

“Although the aorta was not fully visualized due to body habitus, given the clinical picture, an abdominal aortic aneurysm (AAA) is unlikely the cause of this patient’s shock.”

Don’t Tell Me You Don’t Love Me

It’s crucial to stay within your scope when interpreting POCUS findings. As every ultrasound textbook will remind you, “ultrasound is user-dependent.” Our comfort levels will vary based on training and experience. The Canadian Medical Protective Association (CMPA) has reviewed several POCUS-related cases, and while ultrasound often helps in court, it can hurt when interpretations are incorrect or poorly documented.

For example, avoid commenting on complex findings, like regional wall motion abnormalities or ovarian cysts, if they fall outside your training. If you do encounter an unfamiliar or unusual finding (e.g., a strange mass in the heart of a septic IV drug user), document your observations carefully and conservatively. You could note something like:

“While I am not qualified to formally diagnose this, I suspect that what I’m seeing could be [describe finding]. Therefore, I’m ordering [additional test] or consulting [appropriate specialist] for further evaluation.”

 

Elevating Your Game: Taking The Next Step

 

Rarely is one POCUS exam enough. Just like assessing an elbow injury requires examining both the shoulder and wrist, a POCUS finding should prompt further investigation. For example, a positive pregnancy test with no definitive intrauterine pregnancy should lead you to check for intra-abdominal free fluid, as ectopic pregnancy becomes a concern. Similarly, if a patient has flank pain without hydronephrosis and no previous history of kidney stones, pivot to scan the aorta to rule out AAA. Always be ready to shift gears based on the evolving clinical picture.

 

PoCUS Pearls: “Relationship Advice”

  • You don’t have to capture the perfect image, but you do have to capture every piece you need. If you can’t see the liver tip when looking at the hepatorenal interface all in a single image, that’s okay. Get the images piece by piece, but make sure you meet all your requirements.

  • Similarly, you can create a reasonable reconstruction of the aorta by tilting down, skipping over the area obstructed by gas, then tilting back up to ensure you’ve seen every piece.

  • If you’re not getting the images you want, try different probes. The tradeoff between frequency and resolution may work in your favor.

  • Experiment with different patient positions, balancing the ideal position against the anatomical tradeoff (e.g., rolling the patient onto their side into a lateral decubitus position).

  • Sneak between the ribs if the shadow is too big. It’s a tradeoff between better image clarity and a better anatomical cross-section.

  • For the gallbladder: if you can’t see it from the front, try looking at it from the free-fluid scan position.

  • More pressure doesn’t mean better images when you’re scanning over the ribcage (e.g., cardiac, lung, RUQ/LUQ views for free fluid). You’re likely just pressing harder on bone. When you’re over soft tissue only (e.g., anteriorly, like the abdomen or pelvis/uterus), varying degrees of pressure may help.

  • Get comfortable—adjust the height of the bed, sit on the bed if needed, etc. If you’re not comfortable as the operator, your images will suffer.

  • If your hand is unstable, your images will be too. Keep at least one more point of contact (e.g., the hypothenar area or at least your fifth finger) on the patient, or even the bed.

 

Authors

  • Nathaniel Murray

    Nathaniel is an RCPSC Emergency Medicine Physician, having completed his residency at the University of Ottawa.

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  • Dr. Eusang Ahn is a RCPSC Emergency Medicine Physician who completed his residency at the University of Ottawa.

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