During my early career as an Urgent Care Physician, I worked in busy, under-served, and rural Urgent Care Centers (UCCs). At that time, Point-of-Care Ultrasound (POCUS) was not popular. I practiced in high acuity UC settings, where we would often have US machine and US tech during business hours with an on-call tech after hours, as well as CT scan, STAT labs, and IV placement capabilities. However, I was interested in learning more about POCUS – so I attended a few CME courses that taught MSK and soft tissue, led by companies like Sonosite.
After these courses, I returned to work excited and attempted to convince my medical director to incorporate POCUS into our UC workflow. My idea was rejected. As time passed and I moved to other jobs, I would again ask at each new urgent care clinic and would be met with the same response. They claimed it is cost-prohibitive and that training providers would be cumbersome.
The basic skills I learned from these courses withered away from lack of practice shortly after finishing these 2-day seminars. Years passed by, and I forgot about POCUS, having felt discouraged following many unsuccessful attempts to integrate it into my practice.
Yet, over the past 5 years, I have noticed a shift in the operation of UCCs nationwide. There has been a tendency to eliminate US and CT from UC, reserving it for emergency department (ED) patients and scheduled outpatient orders. Our UCC still maintained STAT labs and IV placement capabilities, but this shift created bigger problems. Mainly, it led to increases in unnecessary ED transfers, which led to longer ED wait times, unsatisfied patients, more UC bounce-backs, and delayed patient care. At the same time, the shortage of primary care providers (PCPs) continued to grow, and the wait to get timely appointments with their PCP remained difficult, resulting in many patients not receiving the care they needed.
When I first started practicing UC Medicine, the goal of many UCCs was to reduce ED burden through managing stable patients while at the same time reducing primary care burnout by offering primary care services to bridge the gap in access to care. Nonetheless, the lack of imaging in the UCCs has caused the urgent care world to fall short of these goals – including duplicate and incomplete workups and increased costs to patients (particularly when labs are ordered only to discover the need to go to the ED to finish the workup). Add on top of this the fact that many insurance companies will not pay for 2 visits on the same day and the lack of consistent X-ray staffing due to shortages, and it becomes clear that there is a dire need for POCUS and POCUS-trained providers in our UCCs.
Two years ago, I decided to dedicate my time to learning and practicing POCUS. Recently, I decided to do a fellowship in POCUS. I wanted to refine my skills to provide the best care for my patients. Many patients come in with presentations such as undifferentiated dyspnea. Is it CHF? Pneumonia? COPD? POCUS can help with medical decision-making and finalize safe disposition to the ED or home.
What about that popliteal DVT that you strongly suspect on your shift? It is 7:00 pm on a Friday night, and outpatient imaging will not be able to get your patient in until the following week. How would you handle this situation? Unfortunately, many times patients must go to the ED and sit for many hours to get a DVT study done. Or what about the early-pregnancy patient that comes in with some vaginal bleeding and pelvic pain? Is it an intrauterine pregnancy (IUP) or a miscarriage?
POCUS helps you treat each of these patients with clinical accuracy and speed. For example, one day in our clinic, we had no x-ray tech on shift. I didn’t want to ask the patient to travel, as they, like many in our patient population, have difficulty finding affordable and timely transport. Instead, I was able to diagnose a fracture and treat it using my hand-held ultrasound.
Another time, I was able to diagnose a shoulder dislocation and do postreduction imaging to confirm placement. I’ve been able to rule out cardiac tamponade on a young patient with chest pain and pericarditis on EKG and send him home safely. POCUS enabled me to see a foreign body inside an abscess I would have missed. The list of what POCUS has enabled me to diagnose and treat goes on: a right lower quadrant mass on a patient with suspected appendicitis, with expedited care as the ED saw these images and took him straight to CT scan; several Pneumonias on the ultrasound that were missed on chest x-ray; the ability to differentiate between biliary colic and acute cholecystitis while doing a right upper quadrant scan.
One day, a colleague came and asked me if I could do a Renal Ultrasound on her patient, an elderly female who had been seen in the ED the day before with flank pain and hematuria. She received a CT scan in the ED showing moderate hydronephrosis and a partially obstructed ureteric stone. She came to the UC 24 hours later with worsening flank pain and vomiting. My bedside POCUS showed severe hydronephrosis and a completely obstructed ureteric calculus, with the added advantage of ruling out abdominal aortic aneurysm (AAA) at the same time. We were able to transfer her to the ED and expedite her care.
I offer all of these examples to showcase POCUS’s diverse breadth and depth in urgent care medicine. Undoubtedly, it saves lives, improves patient outcomes, and reduces costs. It is time to take a step back and consider the long-term benefits of POCUS.
The money spent now on machines and training will pay dividends in the future. While it seems like a longer-term investment, it will be recouped quickly, and the benefits will continue year after year.
Amera Gaballa, MD, is an Advanced Primary Care Ultrasound Fellow at the University of Michigan in Ann Arbor.
