Explore how point-of-care ultrasound expands diagnostic capabilities and enhances patient care in modern practice.
In 2005, at a U.S. Army clinic in Afghanistan, a seemingly stable soldier injured in a training exercise presented with only superficial wounds. “Externally, it appeared quite benign,” recounted Jonathan Monti, DSc, PA-C, RDMS, then a captain on duty. “Initial triage assessed his injuries as relatively minor.”
However, a crucial secondary examination, utilizing a point-of-care ultrasound diagnostic tool, revealed a perilous accumulation of blood around the soldier’s heart. Swiftly moved to surgery, a pericardial window procedure drained the blood, uncovering shrapnel that had pierced the chest and heart. The successful removal of the shrapnel saved the soldier’s life.
This pivotal moment marked Monti’s first hands-on experience with point-of-care ultrasound. His self-education with the device during base downtime transformed his perspective. “My viewpoint on point-of-care ultrasound shifted dramatically,” said Monti, now retired as a major and affiliated with the Henry M. Jackson Foundation for the Advancement of Military Medicine in Seattle. “It became clear that specialized radiology training wasn’t necessarily a prerequisite for effective ultrasound application.”
Today, the adoption of point-of-care ultrasound by Physician Assistants (PAs) is experiencing significant growth. The Society of Point-of-Care Ultrasound (SPOCUS), a special interest group within the AAPA co-founded by Monti and Frank Norman, a PA practicing near Orlando, Florida, estimates that approximately 15% of PA programs now incorporate some level of ultrasound instruction into their curricula.
The Genesis of Point-of-Care Ultrasound Advocacy
Monti and Norman’s commitment to advancing point-of-care ultrasound led them to establish the Society of PAs in Clinical Ultrasound in 2015. The overwhelming interest from physicians, nurse practitioners, medical students, and other healthcare professionals prompted the organization’s expansion and rebranding in 2017 as the Society of Point-of-Care Ultrasound (SPOCUS). SPOCUS currently boasts 275 members and features a dedicated Student Ultrasound Interest Section to support students in PA programs lacking ultrasound components.
SPOCUS is proactively working towards a significant goal: the integration of ultrasound training into the curriculum of every PA program by 2031.
Establishing Standards for Point-of-Care Ultrasound Proficiency
Norman and Monti have taken a leading role in defining competency standards for PAs utilizing point-of-care ultrasound. Their 2017 guidelines emphasize that “clinical ultrasound training should commence at the earliest stage of PA education to facilitate progressive skill development throughout didactic and clinical phases.” These guidelines further recommend that instruction “should begin with fundamental ultrasound physics and instrumentation, followed by a concise introduction to the clinical applications of bedside ultrasound.”
The upcoming AAPA conference in New Orleans will feature “Yes I Scan,” an interactive question-and-answer session involving students from 15 PA programs, alongside practical demonstrations of ultrasound scans, including aortic ultrasounds. Miranda Ghali, a June graduate from Nova Southeastern University PA Program’s Orlando campus and an organizer of the session, highlights its aim to underscore the advantages and diverse applications of point-of-care ultrasound.
Point-of-Care Ultrasound: A Compact and Powerful Diagnostic Tool
Point-of-care ultrasound systems are characterized by their portability. Monti likens the size of these machines to that of a laptop. They are equipped with a transducer connected by a cord, which emits sound waves when placed on the patient’s skin. These sound waves penetrate the body, reflect back, and are rapidly converted into digital images, providing real-time visualization within seconds.
This technology empowers clinicians to efficiently assess various conditions: identifying internal bleeding in the chest or abdomen due to trauma, conducting cardiac ultrasounds to detect fluid around the heart, performing lung ultrasounds to diagnose pneumonia, and examining acute fractures and tendon injuries.
Monti emphasizes that point-of-care ultrasound “can accelerate and direct your patient management strategies.”
Rachel Krackov, a PA and adjunct faculty member at Nova Southeastern, views this technology as indispensable as an otoscope or stethoscope in a clinician’s toolkit.
Frank Norman further explains that the device significantly reduces delays in diagnosis and treatment by providing immediate answers to focused clinical questions, eliminating the need for time-consuming procedures like CT scans in many cases. “It enhances provider effectiveness and is considerably more cost-effective. An additional advantage is the absence of radiation exposure,” he adds.
Overcoming Barriers to Wider Adoption
Historically, the integration of point-of-care ultrasound training into PA programs has been hindered by cost and time constraints. While traditional ultrasound machines, often used in obstetrics, can cost upwards of $30,000, point-of-care ultrasound systems are available for as little as $2,000. The Butterfly Network’s model, which Krackov describes as a potential “game changer” for PA programs, connects to a smartphone and includes curvilinear, linear, and phased array probes within a single device.
Nova Southeastern addressed the training gap by renting a dozen machines for a four-week, 16-hour course led by Krackov last summer. The curriculum combined lectures, assigned readings, and hands-on scanning practice. All 62 students in the PA program voluntarily participated in this course.
Lorilee Butler, PA-C, the program director, underscored the importance of equipping students with “additional skills increasingly utilized in clinics and hospitals.” Krackov’s involvement began as a guest speaker in Butler’s medical imaging class.
Krackov was inspired by the enthusiastic response from her students during the summer course. “They would excitedly identify organs like the gallbladder and share their findings with each other,” she recounted. “They were truly engaged and eager to learn through clinical scenarios.”
Rachel Johnson, a Nova Southeastern student who, along with Ghali, proposed the summer course, recognized the technology’s direct relevance to her career aspirations in emergency medicine, where point-of-care ultrasound is poised to become widely accessible. However, she also acknowledged a challenge: “If I take a position where ultrasound isn’t used, it will be difficult to accumulate the necessary hours for certification.”
Johnson believes that hands-on experience with point-of-care ultrasound will cultivate a deeper understanding of patient anatomy and disease processes, facilitating a stronger “clinical connection with my patients and a better grasp of their experiences.” She also recognizes the career advantages: “Professionally, this expertise will unlock more opportunities.”
Norman shares this forward-looking perspective: “We believe PAs are ideally positioned to lead clinical ultrasound programs within their practices. Whether it’s family practice or dermatology, any clinic can benefit from an ultrasound program, and PAs are a natural fit to spearhead these initiatives.”
He illustrates the practical benefits with an example: “Consider a patient presenting with abdominal pain. Traditionally, a doctor might order a CT scan to rule out kidney stones. Point-of-care ultrasound can provide a rapid answer, informing the provider and guiding immediate treatment decisions. In a healthcare landscape often characterized by barriers between providers and patients, ultrasound serves as a powerful tool to reconnect the provider directly to the patient’s bedside.”
Several interviewees emphasized the growing prevalence of point-of-care ultrasound training in medical schools, urging PA programs to ensure their students remain competitive and possess comparable skills.
Krackov states, “As physician colleagues, PAs should be equipped to perform any task within their scope of practice. We can better support physicians by possessing the same fundamental skills. We utilize point-of-care ultrasound to address specific clinical questions: Is a gallstone present? Is there a blood clot? Is there a bowel obstruction?”
Krackov, who also founded Practical Point of Care Ultrasound Consultants in the Tampa area, developed her passion for the technology while working in interventional radiology. A radiologist encouraged her to pursue ultrasound credentialing, which she achieved as a registered vascular specialist.
Credentialing for point-of-care ultrasound users remains a “hot topic.” While Krackov believes credentialing was beneficial for her, she advocates for optional credentialing for PAs in point-of-care ultrasound, stating, “It’s about providing options so PAs can deliver the best possible patient care.”
A patient encounter in 2007 at Rhode Island’s Roger Williams Medical Center solidified the value of point-of-care ultrasound for Krackov.
A patient presented in respiratory distress. A chest x-ray suggested pneumonia due to lung opacity. However, a point-of-care ultrasound revealed a large pleural effusion causing lung collapse. Krackov then performed a thoracentesis, using ultrasound guidance to precisely position a needle to drain the fluid safely.
“It was remarkably safe, whereas performing the procedure without ultrasound guidance would have been considerably risky. We successfully stabilized her, re-expanded her lung—all thanks to ultrasound,” she explained. “This experience made me realize the vast potential of ultrasound in comprehensive patient assessment.”
Monti’s dedication extended to doctoral research focused on ultrasound and training diverse personnel, including medics and even food-service inspectors, in its basic applications. He found that fundamental training could be delivered in as little as 10 minutes.
His current work at the Jackson Foundation centers on evaluating the optimal training methodologies for PAs, military medics, and nurses in point-of-care ultrasound utilization.
While point-of-care ultrasound technology has advanced significantly – machines are more compact, images are clearer, and costs are lower – Monti identifies the primary obstacle today as “the availability of training opportunities. We still need to effectively address how to widely implement and utilize these invaluable diagnostic tools.”
Hillel Kuttler, freelance writer, contributed to this article.
