Dr. Will Duffin – Joint Medical Director & GP
Will is a jobbing Devon based GP, educator and adventure addict. He has provided medical cover for dozens of very different expeditions and projects; including commercial high-altitude treks in The Himalayas and The Andes, a luxury Trans-Siberian private train, a reality TV show in the South Pacific and he has worked with UNICEF out in forgotten corners of Myanmar.
Welcome to the third and final instalment in our article series on WEM’s media work. If you missed the first two on
We have been providing on-site emergency and primary care for the major US TV production ‘Survivor’ in the South Pacific, caring for around 500 crew and 36 contestants.
The show is filmed on a remote Island in Fiji and therefore we have limited access to investigations. Any bloods or imaging require a boat trip back to the mainland. Therefore, we were keen to trial this fancy new piece of kit: a handheld, wireless Point of Care Ultrasound (POCUS) scanner that pairs with a smartphone. [non affiliate link]
Read on to find out what POCUS is all about, and our teams reflections on piloting this device in our clinic.
Dr Joe Rowles, ED doc, Joint Medical Director and WEM Media Lead.
‘’Point of care ultrasound (POCUS) has increased in popularity in recent years, particularly in Emergency Medicine. As technology improves, pocket sized, relatively inexpensive scanners are now available and may be a useful addition to the remote medic’s toolkit.
The utility of POCUS is generally dependent on user skill and experience. There is potential for a clinician with minimal training to livestream images to an experienced US user who may be able to provide a degree of interpretation. However, most of us will be interpreting our own views.
With this in mind, how might POCUS be used in the remote environment? Generally speaking POCUS can be split into diagnostics and procedures.
Diagnoses that can potentially be made with POCUS include pneumothorax, haemothorax, pneumonia, cardiac tamponade, gallstones, urinary retention, limb fractures, DVT and raised ICP. Assuming the user has the skills to make these diagnoses accurately, they have to be considered in context. On a trekking trip someone who has sustained injury severe enough for you to scan for pneumo/haemothroax is probably going to be evacuated regardless of POCUS findings, ditto cardiac tamponade or raised ICP so POCUS is unlikely to change your patient management in this setting.
It may be more useful in the small clinic/remote hospital setting. Confirming intrauterine pregnancy, aortic aneurism, finding a large pleural effusion in a breathless patient or confirming a DVT may lead to a change the patient management or destination.
Procedures that may be useful include vascular access, nerve blocks, haematoma blocks and suprapubic aspiration. Again, these are dependent on user skill but have the potential to bring benefit to the patient. If procedural sedation is unavailable or contraindicated nerve blocks and intra articular injections can be very useful in the right hands.
As with all interventions the risks and benefits of using POCUS in the remote environment should be carefully considered. The user should be aware of the risks of false negative findings, their own skills and experience as well as the impact findings will have on the patient’s care.’’
Dr Laura McArthur, rural GP, Location Medic and WEM faculty.
‘’Who’d have thought a catch-up chat at the World Extreme Medicine Conference in November 2022 would result in the esteemed POCUS-guru Chris Yap liaising with GE Healthcare and them kindly allowing us to trial one of their Vscan Air ultrasound probes on this years filming of USA Survivor in Fiji!
I’ve practised rurally for most of my career, and I was interested to see what an USS would add. There was no debate, that if it added something then the Vscan Air is the way to go. It’s compact, light and can be used without internet, (as long as you already have the app downloaded on your phone or tablet), and can still be used without reliable electricity, once already charged; perfect for remote location work and countries where amenities are not a given.
Some Clinical Cases
In a hot, tropical environment we see so many abscesses! USS was really useful in confirming or showing us where and how deep tracking extended. This helped to decide whether to continue to manage cases in our relatively resource-light clinic to start with, or to send someone for an incision and drainage (I&D) on the mainland. Bear in mind, most of the local GPs will carry out fairly extensive I&Ds in Fiji, so your threshold to have something done in hospital has to be fairly high. This patient had an extensive upper thoracic/cervical abscess which extended deeply and widely, close to the spine. We sent her early on for hospital I&D.
Another useful application was assessing vascular status for vasculopaths with infected ulcers. One patient came to us a couple of times a week for 5 months to have his bilateral leg wounds managed and dressed. Initially, the USS helped us to identify the blood supply to both limbs, which we were concerned may need a vascular surgery referral.
Other potential applications of POCUS
From a rural GP perspective, I can see myself coming across cases where this really does change management for remote populations. Let’s take a palliative care example, where you are treating pain from bone metastases in the chest, or asbestosis invading the chest wall and have limited stocks of analgesics. With POCUS you could perform an intercostal nerve block that could offer effective and immediate pain relief, stopping someone needing to leave their home/island and travel extensively for a straightforward procedure.
Again, either for palliative analgesia, or whilst waiting for retrieval, fascia-iliaca blocks for hip fractures or metastases are a useful tool in a remote GP’s armoury. These can be done by landmark, but in larger, or older patients where skin is not taught, the accuracy is likely to be improved by ultasound-guided delivery. Most centres encourage the use of USS-guided blocks over the landmark method.
Joint injections, or aspirations of effusions; us GPs tend to do them based on landmarks. But again, in the rural population, a difficult injection or aspiration that requires an USS-guided procedure involves a 4-hour ferry, then driving to a hospital that provides this. It would be nice to be able to save those patients this trip, or provide them with a management option they may decline otherwise, because of the journey, and again we could render them pain-free.
With some training, the scope of handheld USS in remote medicine grows to include diagnosing retinal detachments or deep vein thrombosis (DVT). Spotting joint effusions in small -hand joints can identify early acute inflammatory arthritis. Testicular torsion is another example of where another timely medevac is required, but if the ultrasound can reassure us it’s epididymo-orchitis then we could save someone hours of travel whilst in pain, or aircraft crew risking poor-weather medevacs unnecessarily. There are also applications in early pregnancy scanning, such as identifying intrauterine pregnancy, ectopics and free fluid in the pelvis. Of course, this is a highly specialised area that requires extensive training and skills, but It’s a tool that could add to your clinical reasoning scales.”
Dr Will Duffin, GP, Joint Medical Director.
I love a good gadget, and I have to say I was impressed by the quality of images such a small device could produce on a tiny smartphone screen. I always wondered when the day might come where we’d all have portable ultrasounds hanging around our necks instead of stethoscopes. That old plastic tubing now seems antiquated in comparison. However I don’t think that day is finally here, because ultrasound is only intended to be an adjunct to our other clinical tools and is certainly not a panacea.
I’m still in the early stages of learning POCUS, so for me our pilot with the V Scan Air was more a case of playing aroundrather than using it to ‘nail’ the diagnosis. I’m also at a stage where it’s uncommon for the scan result to change my management. For example, whilst we were able to confirm full rupture of an Achilles tendon using the scanner, I must confess, this was clinically obvious from a palpable step in the tendon and a complete lack of dorsiflexion on the calf squeeze test.
I think ultrasound is a valuable tool for the remote medic, in both assisting with a primary and secondary trauma survey (looking for pneumothorax, focused echo, FAST scanning of the abdomen etc) as well as vascular access, guided nerve blocks and soft tissue imaging and much more. The potential applications are vast. The key caveat is that it takes a lot of time to build the skills and competency required and you need to be scanning often to maintain these. If you’d like to get started, we run two comprehensive, hands-on POCUS workshops at the annual World Extreme Medicine conference.