HOCUS POCUS — the Magic of Point of Care Ultrasound in Remote and Rural Medicine. Just get one already.

Rogers et all wrote in their 2016 article “Barriers to point-of-care ultrasound use in rural emergency departments” that there are numerous barriers to normalization of the use of POCUS (Point of Care UltraSound) in the field and in remote/rural emergency medicine. Some of the barriers include difficulty maintaining skills, slow uptake/evolution, lack of equipment, funding, quality assurance etc. Over the last 20 years POCUS has come to play a role in larger emergency medicine centers. Most residencies offer ultrasound electives. Some medical schools require it like they require a stethoscope. The benefits of POCUS include early diagnosis of pneumonia or pleural effusion that is not large or dense enough to show up on xray or for abdominal imaging — specifically the gallbladder is a star on POCUS imaging. In time, we will likely continue to expand emergency medicine residency training in ultrasound, some medical schools are already handing out Butterfly Ultrasounds on day one of class to start familiarizing their students with “playing” with it. The profound potential for benefit when access to advanced imaging is not readily available is immeasurable.

I “bit the bullet” and paid for part of it myself and fundraised to purchase the rest of a $2,000 Butterfly Ultrasound Device. I have never done a fundraiser before. But as the news of the coronavirus grew and the promise of pulmonary ultrasound imaging was heralded…I felt I needed this tool in my remote location — the island of Unalaska — in the middle of The Bering Sea-1000 miles from a “real hospital”. The training membership is $500 a year.

Day one with the Butterfly POCUS device someone came in complaining of shortness of breath, left lower chest pain, and fever- they looked quite ill-but their chest xray was read as negative on wet read and on radiologist overread and they had no WBC elevation — no “white count” indicative of infection. I put the Butterfly POCUS device on the point of maximal tenderness and this is what I saw on its maiden voyage:

This was my first attempt with this device but I was quite certain this was a developing pneumonia. We started IV antibiotics and the patient felt dramatically better the next day. Within three days everything was back to normal.

I had no more training than the videos on the Butterfly Inc website — if you pay for their subscription — and the desire to “play” with my new “toy”. The more I played with the device the more I loved it. I was able to see a fibula fracture and what I thought was decreased wall motion in the heart in a patient with a…drum roll please….troponin of 15. A massive heart attack. I used that video of their heart to help convince them to take the medevac to tertiary care to the cath lab. The cath lab that saved their life.

What about that right upper quadrant abdominal pain? In a patient with a WBC count of 14 and bili of 1.6. Their gallbladder looked like this:

For anyone who is not familiar this is a thickened wall. The beautiful thing is I can text or email a video of the exam directly to the patient, another tertiary ER, or to a specialist. I am 1000 miles away from the nearest specialist. This tool has become invaluable.

The next day that right upper quadrant abdominal pain patient returned with a white count of 19,000 — a sign of worsening infection likely due to cholecystitis seen on POCUS. This helped convince the patient to travel and they had their gallbladder removed almost immediately.

Sepsis can kill people even in a high end tertiary care facility and a medevac can cost 90,000. We need to have every tool at our disposal before we take risks medically or financially in this way. Can they fly commercial? Or do we have to medevac them?

The Butterfly Inc POCUS device is easy to use even for a novice like me. The online trainings are clear with video you can follow, and, if I can do it — so can you. Before I felt comfortable using the device — I would tell patients about it and advise them that we would not charge them for the service but that I wanted to take a look. They were usually curious too. I didn’t start charging for the service until I felt secure in my ability. I still sometimes just take a look with it for my own curiosity off the books — not unlike grabbing my stethoscope — it has a home in my right thigh cargo pocket. I just wish I could find a way to see the brain with it…