Predicting Risk of 30-Day Readmission in Heart Failure Patients

Pulmonary congestion is the most frequent cause of heart failure hospitalizations and readmissions. In addition, approximately 20%–25% of heart failure patients aged 65 years and older in the United States are readmitted within 30-days after hospital discharge,1–5 despite efforts to identify predictors of readmission for acute decompensated heart failure (ADHF), such as laboratory markers, the readmission rates remain high. Lung ultrasound (LUS), however, has been shown to be a valuable tool for assessing pulmonary congestion, providing a reliable assessment based on the presence of B-lines.

A recent study by Cohen et al7 evaluated the association between lung ultrasound findings and the risk of 30-day readmission among HF patients, hypothesizing that a higher number of positive B-line lung fields on LUS will indicate an increased risk of readmission. Using a log-binomial regression model in an 8-zone LUS exam from the day of discharge, the researchers assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines, considering a zone positive when ≥3 B-lines were present. According to the results from 200 patients, the risk of 30-day readmission in patients with 2–3 positive lung zones was 1.25 times higher (95% CI: 1.08–1.45), and in patients with 4–8 positive lung zones was 1.50 times higher (95% CI: 1.23–1.82), compared with patients with 0–1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin.

Ultrasound image of a lung
Ultrasound image of a lung with B-lines. The pleural line is indicated by the arrow. Emanating from the pleural line are hyperechoic reverberation artifacts, which are B-lines (indicated by the star), indicating the presence of fluid within the interstitium of the lung.

A recent study by Cohen et al7 evaluated the association between lung ultrasound findings and the risk of 30-day readmission among HF patients, hypothesizing that a higher number of positive B-line lung fields on LUS will indicate an increased risk of readmission. Using a log-binomial regression model in an 8-zone LUS exam from the day of discharge, the researchers assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines, considering a zone positive when ≥3 B-lines were present. According to the results from 200 patients, the risk of 30-day readmission in patients with 2–3 positive lung zones was 1.25 times higher (95% CI: 1.08–1.45), and in patients with 4–8 positive lung zones was 1.50 times higher (95% CI: 1.23–1.82), compared with patients with 0–1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin.

This study adds to the research on LUS in patients with HF in inpatient or intensive care units and emergency departments, including studies on identifying pulmonary congestion to reduce decompensation in heart failure patients,7 the risk of hospitalization or all-cause death was greater in patients with more B-lines at discharge,8 and the prognostic value of LUS as an independent predictor of 90-day readmission.9,10

The study by Cohen et al7 expands on the prior research and demonstrates the prognostic importance of more B-lines at discharge for HF patients. Failure to relieve congestion before discharge is associated with increased morbidity and mortality and is a strong predictor of poor outcomes in patients with acute decompensated HF.

By evaluating HF patients with LUS, we may be better able to risk-stratify the severity of asymptomatic pulmonary congestion on discharge and identify patients at higher risk of readmission.


  1. Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation 2012; 126:501–506.
  2. Suter LG, Li SX, Grady JN, et al. National patterns of risk-standardized mortality and readmission after hospitalization for acute myocardial infarction, heart failure, and pneumonia: update on publicly reported outcomes measures based on the 2013 release. J Gen Intern Med 2014; 29:1333–1340.
  3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240–e327.
  4. Tavares LR, Victer H, Linhares JM, et al. Epidemiology of decompensated heart failure in the city of Niter_oi: EPICA -Niter_oi Project. Arq Bras Cardiol 2004; 82:125–128.
  5. Cleland JG, Swedberg K, Cohen-Solal A, et al. The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe. The study group on diagnosis of the working group on heart failure of the European Society of Cardiology. The medicines evaluation Group Centre for Health Economics University of York. Eur J Heart Fail 2000; 2:123–132.
  6. Cohen A, Li T, Maybaum S, et al. Pulmonary congestion on lung ultrasound predicts increased risk of 30-day readmission in heart failure patients [published online ahead of print February 25, 2023]. J Ultrasound Med. doi: 10.1002/jum.16202.
  7. Araiza-Garaygordobil D, Gopar-Nieto R, Martinez-Amezcua P, et al. A randomized controlled trial of lung ultrasound-guided therapy in heart failure (CLUSTER-HF study). Am Heart J 2020; 227:31–39.
  8. Platz E, Lewis EF, Uno H, et al. Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients. Eur Heart J 2016; 37:1244–1251.
  9. Gargani L, Pang PS, Frassi F, et al. Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study. Cardiovasc Ultrasound 2015; 13:40.
  10. Coiro S, Rossignol P, Ambrosio G, et al. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail 2015; 17:1172–1181.

To read more about this study, download the Journal of Ultrasound in Medicine article, “Pulmonary Congestion on Lung Ultrasound Predicts Increased Risk of 30-Day Readmission in Heart Failure Patients” by Allison Cohen, MD, et al. Members of the American Institute of Ultrasound in Medicine (AIUM) can access it for free after logging in to the AIUMJoin the AIUM today!

Interested in reading more about ultrasound? Check out these posts from the Scan:

Join the POCUS Revolution: Unlock the Power of Point-of-Care Ultrasound

A Hand-held ultrasound device scanning a patient

If you’re a fan of the AIUM (American Institute of Ultrasound in Medicine), then you already understand the importance of ultrasound technology in revolutionizing patient care. However, the emergence of Point-of-Care Ultrasound (POCUS) has taken this technology to new heights. POCUS is transforming the medical landscape, offering a sleek, affordable, and user-friendly solution that brings ultrasound imaging directly to the bedside. In this blog post, we’ll explore the advantages of POCUS over other imaging fields, share statistical data, discuss key POCUS techniques, and invite you to join us at the AIUM’s POCUS Course in Portland, Oregon, sponsored by AIUM and OHSU (Oregon Health & Science University), where you’ll discover the top 5 reasons to attend.

POCUS: Your Trusty Sidekick
POCUS is designed to be there for you when you need it the most, acting as a trusty sidekick to clinicians. With its ability to be performed at the bedside, POCUS delivers real-time answers, confirming diagnoses and guiding procedures without the need for additional appointments or waiting for results.

The Power of POCUS 

Let’s explore some statistical data that demonstrates the effectiveness and widespread adoption of POCUS:

  • Improved Diagnosis Accuracy
    According to a study published in a Royal College of Physicians journal, POCUS improved the accuracy of initial diagnoses compared to physical examination alone in various medical specialties, including emergency medicine, critical care, and primary care.
    Reduced Supplemental Exams
    A research article published in the Journal of Ultrasound in Medicine found that POCUS reduced the need for additional imaging studies and can reduce length of stay and imaging costs in various cases leading to significant cost savings and streamlined patient care pathways.
    Enhanced Patient Outcomes
    A systematic review and meta-analysis published in the Ultrasound Journal demonstrated that POCUS-guided interventions in cardiac patients resulted in improved outcomes, including reduced mortality rates and shorter hospital stays.

Key POCUS Techniques

POCUS encompasses various techniques that aid in diagnosing and guiding procedures. Some of the key techniques include:

  • Focused Cardiac Ultrasound (FOCUS)
    FOCUS allows clinicians to rapidly assess cardiac function, detect pericardial effusions, and evaluate for cardiac abnormalities such as wall motion abnormalities or valvular dysfunction.
  • Lung Ultrasound (LUS)
    LUS is valuable in the assessment of pulmonary conditions, including pneumothorax, pleural effusions, and pulmonary edema. It provides real-time visualization of lung sliding, B-lines, and consolidations.
  • Abdominal Ultrasound
    Abdominal POCUS aids in the evaluation of acute abdominal pain, gallbladder disease, kidney stones, and abdominal aortic aneurysms, among other conditions. It enables quick assessment and intervention in critical situations.
  • Musculoskeletal Ultrasound
    Musculoskeletal POCUS allows for an accurate evaluation of joint effusions, tendon injuries, muscle tears, and other soft tissue abnormalities. It assists in guiding interventions such as joint aspirations and injections.

POCUS is a game-changer, offering real-time answers that confirm diagnoses and guide procedures at the bedside. The statistical data highlights its effectiveness in improving diagnosis accuracy, reducing the need for supplemental exams, and enhancing patient outcomes. Don’t miss your chance to join the POCUS revolution and become a superhero in your own right. Register today for the AIUM’s POCUS Course in Portland, Oregon, and unlock the power of Point-of-Care Ultrasound. It’s time to level up your medical game and make a lasting impact on patient care. Sign up today!

Smallwood N, Dachsel M. Point-of-care ultrasound (POCUS): unnecessary gadgetry or evidence-based medicine? Clin Med (Lond) 2018; 18(3):219–224. doi: 10.7861/clinmedicine.18-3-219. PMID: 29858431; PMCID: PMC6334078.

Amina Jaji, Rohit S. Loomba. Hocus POCUS! Parental quantification of left-ventricular ejection fraction using point of care ultrasound: Fiction or reality? [published online ahead of print December 30, 2022] Pediatr Cardiol. doi:10.1007/s00246-022-03090-w.

Kasmire KE and Davis J. Emergency department point-of-care ultrasonography can reduce length of stay in pediatric appendicitis: A retrospective review. J Ultrasound Med 2021; 40:2745–2750.

Ávila-Reyes D, Acevedo-Cardona AO, Gómez-González JF, Echeverry-Piedrahita DR, Aguirre-Flórez M, Giraldo-Diaconeasa A. Point-of-care ultrasound in cardiorespiratory arrest (POCUS-CA): narrative review article. Ultrasound J 2021; 13(1):46. doi: 10.1186/s13089-021-00248-0. PMID: 34855015; PMCID: PMC8639882.

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Why Have UltraCon FOMO When You Can Be a Part of the Transformation of Medical Ultrasound?

Are you still on the fence about deciding whether or not to attend UltraCon, a reimagined take on the American Institute of Ultrasound in Medicine’s annual meeting? The transformation of the AIUM’s annual ultrasound meeting into UltraCon is an exciting step forward for the field. It will provide a platform to connect professionals, share ideas, and learn from each other. 

Previously, we’ve highlighted the benefits of attending Day 1 and Day 2 of UltraCon, but what about Day 3? Just one look at the UltraCon schedule, and you can tell that this is going to be its busiest day yet! Despite the jam-packed program, there are a ton of amazing professional development opportunities ready for you to explore. On Tuesday, four new symposia will kick off, covering topics from 3D/4D imaging to musculoskeletal sonography. There’s also a shark tank competition, an e-poster kiosk hall, the annual AIUM Awards session, and don’t forget about the William J. Fry Memorial Lecture. 

Let’s dive into the first new symposia, Early Pregnancy Ultrasound: Implications and Impacts on Care. This TED-talk-style forum is a great resource for learning about critical issues in the first trimester, such as providing equitable care in the emergency department and managing life-threatening situations. It has not only valuable information for medical professionals but also provides important insight into how to support patients after Dobbs. Participants can earn up to 1.5 CMEs.

Next, we have Optimizing Outcomes in Prenatal Imaging. During this symposia, participants can increase the quality and patient experience in obstetric imaging with a multidisciplinary approach. A group of specialists will present TED talks on topics such as early trimester issues, health inequities, and maternal/fetal life-threatening situations. Improve imaging outcomes via a perception bias workshop, challenging cases, and using the 3D world to understand ultrasound. Plus, roundtables with industry on image optimization and a special session on understanding the lifecycle of prenatal imaging. Participants can earn up to 3.0 CMEs.

POCUS: Cutting-Edge Uses and Controversies is the third symposium of Day 3. Point-of-care ultrasound (POCUS) is revolutionizing the way clinicians diagnose and treat patients. By providing real-time insights, POCUS offers quick, accurate, and cost-effective diagnosis of clinical problems. From development to bedside, POCUS has changed the game for clinicians worldwide. Are you seeking an engaging and informative symposium to discuss current POCUS advancements in medical ultrasound? Look no further than POCUS: Cutting-Edge Uses and Controversies symposium, which discusses topics such as global health, first-trimester concerns, scan ownership, POCUS workflow, and more. With an array of activities, including lectures, panel discussions, and workshops, this is sure to be a stimulating symposium that will leave you informed and inspired.

Breaking the Sound Barrier: Shaping the Future of Ultrasound is the last symposium of the day. The highly interactive symposium on ultrasound technologies is a great opportunity for clinicians, technologists, researchers, industry, and other stakeholders to learn about the latest advancements in ultrasound technology. This symposium will provide an invaluable platform for experts to share their knowledge and insights on how to utilize ultrasound techniques in clinical settings effectively. Attendees will have a chance to interact with leading professionals from around the world and discuss potential solutions for existing challenges within this field.

Outside of attending the symposia, there are several other interactive activities for participants to engage in. Firstly, the AIUM supports an ePoster program every year where attendees can explore and learn at their own pace through self-guided exploration. Secondly, attendees who have a great ultrasound idea and want to pitch it to industry can submit an application to pitch their ideas to venture capitalists, leaders from the industry, and an IP attorney, for the chance to win a cash prize of $1,000. Lastly, don’t forget to attend the 2023 William J. Fry Lecture given by pioneer in gynecologic ultrasound, Dr. Steven R. Goldstein, entitled “Do You Do POCUS: Why reinvent the wheel?”.  

UltraCon will be the must-attend event of the year for medical professionals who want to stay up-to-date on the latest advancements in ultrasound technology. With a wide variety of engaging sessions and workshops, there’s something for everyone, so avoid getting caught with FOMO. All of this is just what is available on the third day of symposia at UltraCon. Check out the Full Schedule to start planning out your UltraCon journey.

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

Pick-Up-and-Go Block Bags for Fascia Ilaca Blocks

Ultrasound-guided regional anesthesia is a mainstay of multimodal pain control and is becoming an increasingly important part of emergency medical care. Regional anesthesia allows for maximal analgesia while minimizing the adverse effects of opioids, such as respiratory depression and sedation. The fascia iliaca block is one such procedure that provides regional anesthesia in the Emergency Department (ED) for proximal femur fractures and hip fractures.1 This plane block is performed by depositing a moderate volume of local anesthetic, usually bupivacaine, into the potential space between the fascia iliaca and the iliopsoas muscle. The procedure provides analgesia in the distribution of the femoral nerve, as well as the obturator nerve and lateral femoral cutaneous nerve. 1 Patients who receive this procedure experience improved pain scores and a reduction in the need for opioid medication.2–5 The use of preoperative regional nerve blocks, specifically including older patients with hip fractures, is supported by 2022 American Association of Orthopedic Surgeon guidelines.5,6

At Rutgers New Jersey Medical School, we developed a teaching paradigm for the fascia iliaca block, with an online didactic session followed by a hands-on simulated skills session offered to faculty and residents (Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model).

Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
Figure 1A
Figure 1, Rutgers NJMS Emergency Medicine residents learning to perform the fascia iliaca block on a porcine simulation model.
Figure 1B

Later in the year, we performed a quality assurance project in order to determine what barriers existed to performing this block, in order to maximize the number of eligible patients that received this valuable procedure. We found that the fascia iliaca block was performed about 16% of the time when indicated (Figure 2).

A bar graph indicating that, of those who received a nerve block, 87 were for hip/femur fractures (~3-4 per week), 16% (95CI: 10% to 25%) received the block, and 90% (95CI: 82% to 95%) completed the survey.
Figure 2. Percentage of eligible patients who received the block.

The most common reason for the block not being performed was the perceived lack of time during a busy clinical shift (Figure 3), which was a factor that was present in more than ¾ of missed opportunities.7 We theorized that this limitation came from a combination of the time required to obtain consent from the patient, gather supplies, coordinate with the admitting Orthopedics service, and ultimately perform the procedure.

A bar graph indicating the number and strength of each agreement for each response.
Figure 3. Reasons that the block was not performed.

To address this barrier, we created ready-made pick-up-and-go nerve block kits containing all the necessary materials for performing ultrasound-guided nerve blocks in the ED (Figure 4). These kits include sterile gloves, ultrasound probe covers, sterile drapes, spinal needles, syringes, IV tubing, nerve block reference materials, and a consent form. We placed the kits in a centralized location in the ED for ease of access.

Figure 4A. A collection of nerve block kits ready for use.
Figure 4B. Contents of a nerve block kit.

As a result of this intervention, we have anecdotally noted an increased number of procedures performed, with a complete analysis forthcoming. As our program increases the scope and scale of regional anesthesia procedures offered to patients, the nerve block kits will hopefully eliminate a barrier to performing nerve blocks and thus facilitate the deliverance of high-quality patient-centered analgesia to the largest number of patients possible.


  1. Chesters A, Atkinson P. Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Emerg Med J 2014; 31(e1):e84–e87. doi:10.1136/emermed-2013-203073.
  2. Groot L, Dijksman LM, Simons MP, Zwartsenburg MM, Rebel JR. Single fascia iliaca compartment block is safe and effective for emergency pain relief in hip-fracture patients. West J Emerg Med 2015; 16:1188–1193. doi:10.5811/westjem.2015.10.28270.
  3. Ritcey B, Pageau P, Woo MY, Perry JJ. Regional nerve blocks for hip and femoral neck fractures in the emergency department: A systematic review. CJEM 2016; 18:37–47. doi:10.1017/cem.2015.75.
  4. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med 2012; 43:692–697. doi:10.1016/j.jemermed.2012.01.050.
  5. Kolodychuk N, Krebs JC, Stenberg R, Talmage L, Meehan A, DiNicola N. Fascia iliaca blocks performed in the emergency department decrease opioid consumption and length of stay in patients with hip fracture. J Orthop Trauma 2022; 36:142–146. doi:10.1097/BOT.0000000000002220.
  6. O’Connor M, Switzer J. AAOS Clinical practice guideline summary: Management of hip fractures in older adults. J Am Acad Orthop Surg 2022; 30(20):e1291–e1296. doi: 10.5435/JAAOS-D-22-00125.
  7. Alsharif P, Muckey E, Lu H, et al. Emergency department workflow limits the utilization of fascia iliaca blocks for hip and femur fractures. Academic Emergency Medicine 2022; 29(S1).

Peter Alsharif MD, Marwa Ali MD, Helen Lu MD, Robert James Adrian MD, Annette Mueller MD MBA, Ilya Ostrovsky MD, and Stephen Alerhand MD, are from the Department of Emergency Medicine at Rutgers New Jersey Medical School in Newark, New York.

What if Ultraportable Ultrasound Devices Were the Future of Healthcare in Africa?

The improvement and miniaturization of ultrasound devices is a result of the need to make ultrasound devices quickly accessible regardless of location. The right diagnosis at the right time in the right place can take you a step ahead in this race for point-of-care diagnosis.

Developed countries have experienced very significant direct and indirect impacts on the quality of care for patients in acute care and those who are hospitalized. However, if in these countries, ultrasound has made it possible to bypass certain additional examinations (standard radiography, CT, MRI, etc) for certain precise indications despite the latter being nevertheless available, it can be deduced logically that under certain conditions, point-of-care ultrasound (POCUS) would have an even greater impact in settings where other modalities are simply not available.

Indeed, developing countries and areas with limited resources often have in common a lack of diagnostic imaging means: old, non-mobile X-ray machines with little or no function at all and you’ll rarely find CT or MRI, and when you do, it is inefficient except in concentrated, large cities.

Add to this an extremely limited electricity supply, which significantly reduces the effectiveness of the existing means even further. It directly results in the impossibility of full-time operation due to power cuts, and indirectly through breakdowns and the gradual deterioration of the equipment related to variations in electrical voltage.

These various problems make Africa extremely fertile ground for the use of clinical ultrasound (POCUS) with exactly the same benefits as those obtained in other better-developed regions, but better still the absence of other means of diagnosis, which could lead clinical ultrasound to become the “gold standard” for clinical diagnosis in African.

The problem, however, is the availability of the devices, especially the type of device. Indeed, the devices currently present in Africa are either static or relatively portable (more than 10kg), which poses a real problem of mobility for an imaging modality that could otherwise be performed at the patient’s bedside.

Ultraportable devices with their small size, their resistance, their autonomy, and their low energy requirement could be a valuable diagnostic aid in Africa. However, there remains the problem of their availability (most manufacturers limit their network to developed countries) and their cost (due to the low purchasing power of practitioners in developing countries), the very idea of ​​obtaining one at its actual cost is completely illusory.

What if the manufacturers of ultraportables developed strategies to support doctors who want to equip themselves and the educated societies with POCUS, set up conventional classroom-based training courses and E-learning free or at a reduced price for all doctors wishing to learn?

Yannick Ndefo, MD, is a general practitioner in Cameroon and a POCUS ambassador for POCUS Certification Academy.

Interested in learning more about ultrasound in global health? Check out these posts from the Scan:

        Where it Matters Most

        The infant, carried by her father, had been vomiting for several days. The patient’s history was consistent with pyloric stenosis, but there were still other differential diagnoses to consider. The surgeon caring for the patient was trained in Morocco and France. He was an excellent physician who returned to his community in the small coastal country of The Gambia in West Africa. The physician needed diagnostic ultrasound to confirm or refute the presumed diagnosis. He was plagued by indecision at the prospect of performing unnecessary surgery on the infant. The patient had traveled at great cost and distance to arrive at the only tertiary care center in the country. Her family needed help and if they could not find it here, they were out of options.

        At the invitation of the surgeon, I was taking the entire attending physician group from every specialty available through a point-of-care ultrasound (POCUS) course. The course was tailor-made for surgeons, despite having representatives present from internal medicine and pediatrics. It was reasoned that the largest immediate gains would be from trauma care, ultrasound-guided procedures, and confirmation of surgical diagnoses and complications. The amount of blunt trauma and blind procedures including liver biopsies was staggering.

        Each day focused on problem-based and group learning, with gamification and competition built it. The goal was to keep the learners engaged and follow up with deliberate practice every afternoon. The surgeon would bring patients from the hospital who required diagnostics, which were unavailable until now. Patients made the trek up 2 flights of stairs, where we were teaching in the only air-conditioned space. Conditions that would be identified early in high-resource regions are often elusive without the necessary diagnostics. With POCUS, we identified patients with heart failure, pneumonia, bowel obstructions, appendicitis, and complications of pregnancy. We also identified conditions that are less readily seen in high-resource health systems such as rheumatic heart disease and hepatic abscesses.

        Each day focused on problem-based and group learning, with gamification and competition built it. The goal was to keep the learners engaged and follow up with deliberate practice every afternoon. The surgeon would bring patients from the hospital who required diagnostics, which were unavailable until now. Patients made the trek up 2 flights of stairs, where we were teaching in the only air-conditioned space. Conditions that would be identified early in high-resource regions are often elusive without the necessary diagnostics. With POCUS, we identified patients with heart failure, pneumonia, bowel obstructions, appendicitis, and complications of pregnancy. We also identified conditions that are less readily seen in high-resource health systems such as rheumatic heart disease and hepatic abscesses.

        The surgeon confirmed the diagnosis of pyloric stenosis during our POCUS course. He took his patient to the operating theater with confidence and she did well postoperatively. Ultrasound continues to make a lasting impact in The Gambia. Together, we are building a sustainable program that will incorporate POCUS into all graduate medical education. POCUS impacts care wherever it is used by trained professionals, but in my experience, it is the single most important diagnostic tool in low-resource health systems.

        Michael Schick, DO, MA, MIH, FACEP, is an Assistant Professor of Emergency Medicine and Director of International Ultrasound at UC Davis Medical Center.

        Interested in reading more about POCUS medical education? Check out these posts from the Scan:

        I Lost My Stethoscope…on Purpose

        In July of 2016, my medical school gave me my first, only, and likely, last stethoscope. Since its adoption by clinicians, it has become so iconic to the physician identity. I wanted to hear murmurs and rales—and sometimes prank my classmates and yell into the diaphragm. Since the start of my clinical rotations, it has been my constant companion, tucked away in my bag until I drape it behind my neck at the start of shift. I felt naked without it. Not in my bag? Might as well show up to work without my scrub top. But here I am, almost 3 years into residency: it’s somewhere at the bottom of my bag…I think.

        Throughout the years, emergency clinicians have continued to adapt and evolve in parallel to the rapidly expanding medical device industry, such as portable ultrasounds. The term “portable”, when describing ultrasounds, has evolved beyond most of our wildest imaginations. The once bulky, immobile machines that were only seen in the “ultrasound suite or room” are now stowed away in backpacks and physicians’ back pockets. The ubiquitous nature of ultrasound has encouraged even physicians that did not train with it to adapt and learn to utilize it for almost any chief complaint. 

        I posit the adoption of point-of-care ultrasound (POCUS) as part of the routine physical exam in the emergency department. Except in the case of an asthmatic assessment for wheezing, confirmation of breath sounds after rapid sequence induction (RSI), or in a patient with penetrating chest trauma, the stethoscope has become obsolete.

        Transthoracic echocardiograms are often the most interesting studies due to the dynamic nature of the exam and the potential for performing various advanced studies. Everyone gets excited seeing a pericardial effusion and making a determination if the patient has early signs of tamponade or the visualization of a transvenous pacemaker wire’s capturing. However, I am arguing for the complete replacement of the stethoscope with point-of-care ultrasound. So, unless you believe in the existence of an I/VI systolic murmur in the patient’s upper left sternal border, you’re probably already convinced of its utility for the cardiac exam. So, let’s talk lungs.

        A 32-year-old male presented after a mountain bike accident complaining of shoulder and back pain since he had fallen onto the dirt mound after overestimating a jump. He had been diverted from the trauma bay and moved to the back of the department after having been triaged with an Emergency Severity Index (ESI) of 3. I entered the room and introduced myself. He was tachypneic but easily spoke in full sentences. I placed him on the monitor and found this otherwise healthy, active, and fit male was hypoxic to 90% on room air.

        Pneumothorax, right? I just needed to prove it. I set his nasal cannula to 5 liters and continued my physical exam. Breath sounds were normal, trachea was midline, no paradoxical chest wall movement or obvious deformities. On repeat vitals the patient was normotensive, but the pulse oximetry was dipping from 96%, then 94%, then holding at 90%. The nurse immediately called the x-ray technician, however, they were busy with various other trauma patients. My attending brought an ultrasound to the bedside, which revealed no lung sliding on his left. Clearly, he needed a tube thoracostomy performed. Using POCUS, we expedited treatment; the kit was brought to bedside, and by the time the technician had arrived, I had already consented the patient, prepped for the procedure, and anesthetized the site. The tube was placed successfully, and vitals immediately improved. Ultimately, the patient was weaned to 2 liters of oxygen via nasal cannula and admitted to the hospital.

        Fast forward to the fall. It was the middle of my second year, and COVID-19 was rearing its head again. But physicians were wiser this time: we ought not to rush to intubate, lest the patient never come off the ventilator. It was mid-afternoon, and the ED staff was pushing through their post-prandial drowsiness. A 64-year-old male with a history of hypertension and medication noncompliance was rushed to the resuscitation bay in respiratory distress. He was in extremis, fluctuating between 80–85%. We put on a non-rebreather and cranked up the oxygen. Using an Egyptian translator, he responded in 2- to 3-word sentences: he reported a recent COVID-19 exposure in his family in Egypt just before returning to the United States and reported the only symptom of shortness of breath.

        We listened to his lung fields. We all had differing opinions as to what we were hearing. I reported rales, another reported rhonchi, and the first year medical student said, “[The lungs] sound really bad.” I could not appreciate jugular vein distention (JVD) due to body habitus. He had no lower extremity edema. Blood gas demonstrated no acid-base imbalance. COVID screening was pending. The X-ray technician was on the way. The respiratory technician had put him on a bilevel positive airway pressure machine (BiPAP), but he continued to deteriorate, though more slowly. I was pushed to set up for intubation. But I asked to mix a bag of nitroglycerin first while I took the time to perform an ultrasound. While others argued this was COVID pneumonia, I thought it was due to his hypertension or sympathetic crashing acute pulmonary edema (SCAPE). If I intubate, he codes.

        The first blood pressure was taken while I looked at his lungs. B-lines everywhere, systolic greater than 230 and diastolic in the low 100s. While giving myself a pat on the back, I asked the nurse to go ahead and hang the nitroglycerin while keeping him on BiPAP. He stabilized, then headed upstairs to the ICU.

        Still not convinced? One more case. A woman in her 70s with a history of congestive heart failure and paroxysmal atrial fibrillation presented complaining of shortness of breath. She had been taking her medications, including her diuretic, as prescribed. She was hypoxic in the mid-80s. After improving her saturations with a nasal cannula, I looked at her monitor and confirmed with an electrocardiogram (EKG): she was also in atrial fibrillation with rapid ventricular response (RVR) in the 130s. She insisted it was due to her fast heart rate. She had been adamant the last time this happened, she was simply given a medication to slow her heart, which caused complete resolution of her symptoms.

        Next best step? Is it merely rate control then? Is tachycardia the etiology or symptom? I heard rales bilaterally, measured JVD to the angle of her mandible, and noted 3+ pitting edema to her legs. Ultrasound demonstrated a severely depressed ejection fraction with any pericardial effusion. Her inferior vena cava was plethoric. She had diffuse B lines bilaterally with small pleural effusions. The temptation is simply to rate control. Yet, in taking a step back to further assess, I chose, rather, to drop her preload with noninvasive positive pressure ventilation (NIPPV) and IV diuretics.

        In multiple cases, the utilization of POCUS has proven an invaluable tool. I believe it is a vital skill. The emergency physician ought to become comfortable with this tool so readily at our disposal. The next time you feel the need to listen for the difference between rhonchi and rales, pick up a probe to settle the argument.

        Author, Aaron Alindogan, MD, is a second year resident at the Department of Emergency Medicine at UT Health San Antonio. Editor, Ryan Joseph, DO, DTM&H, is an assistant professor of emergency medicine at UT Health San Antonio.

        Growing a POCUS Program in a Large Academic Institution: a guide and some lessons learned

        Point-of-care ultrasound (POCUS) has quickly become an area of interest within medical education. As of 2020, a total of 57% of medical schools have incorporated POCUS training within their curricula.1 Integration of ultrasound into undergraduate medical education (UME) has been shown to help students learn anatomy, physiology, and pathology in a more effective and dynamic way.2

        Indiana University School of Medicine (IUSM), which has more than 1400 medical students spread across 9 campuses throughout the state, began the process of implementing a longitudinal UME POCUS curriculum in 2018. Their journey is outlined below—for a more detailed review, see Russell et al.2

        Step 1:  Create a POCUS committee.  A POCUS committee was created to identify and coordinate with key stakeholders throughout the institution. This committee was composed of a program manager, student representatives, and faculty from the departments of radiology and emergency medicine. Under the direction of the Executive Associate Dean for Educational Affairs, the committee worked with the regional deans, course directors, key educators, and sponsors to identify space within the existing curriculum for POCUS.
        Lesson learned: Engagement at multiple levels was key to the simultaneous integration of the curriculum across all campuses and ensuring an equitable learning experience for all.

        Step 2. Consider physical space and POCUS equipment. With many learners and multiple sites, the decision was made to use handheld ultrasound devices. While imaging parameters from these devices may be suboptimal at times, decreased cost and increased portability compared to cart-based ultrasound systems proved advantageous. A check-out system was created to allow learners to easily borrow the devices for self-driven education.
        Lesson learned: Handheld devices allowed for easy to stand-up educational sessions, smaller educational groups, more hands-on time, and overall greater program flexibility.

        Step 3. Instructional material and modules. Because of limited classroom time, the didactic portion of the curriculum was delivered asynchronously. The curriculum was divided into a series of 16 modules designed to complement and augment the existing medical school curriculum (Figure 1). The POCUS modules paralleled the curriculum as it advanced from basic science to bedside care (Figure 2). Modules were divided into diagnostic, procedural, and symptom-based categories.
        Lesson learned: Take advantage of online, self-paced learning modules. Completing modules prior to hands-on instruction minimized classroom time and maximized scanning opportunity.

        Figure 1. The 16 learning modules, included in the IUSM POCUS program, divided categorically (originally published in Ultrasound J2).
        Figure 2. An approach to structuring a curriculum and progressively building upon concepts throughout the UME curriculum.

        Step 4. Phased implementation. POCUS was initially integrated into anatomy and targeted clerkships. These areas were ideal starting points as they had existing POCUS champions and already had some POCUS elements (obstetrics, emergency medicine, etc).
        Lesson learned: Identify and leverage existing POCUS opportunities, then expand.

        Step 5. Development of an ultrasound learning website. A POCUS website was created using an institutional learning management system (LMS) where all relevant information was stored. This also allowed for easy and rapid dissemination of course materials such as modules, lab facilitator guides, equipment check-out procedures, open lab times, and consent forms.
        Lesson learned: Keep critical information centralized for quick access and easy updates.

        Step 6. Interprofessional collaboration. Having an adequate number of proctors was a barrier to implementing the hands-on elements of the curriculum. The team increased its number of available instructors by using a train-the-trainer approach for non-POCUS-trained faculty.3  The pool of available instructors expanded to include senior sonography students, senior medical students who had previously completed an elective in POCUS, residents (emergency medicine, family medicine, and radiology), ultrasound fellows, as well as POCUS-trained faculty.
        Lesson learned: Interdepartmental and interprofessional collaboration multiplies your efforts and reduces the workload.

        Step 7. Continue to build upon the foundation. The team recently launched a combined graduate medical education POCUS curriculum that started with 3 targeted residency programs and will soon include more than 10 residency and fellowship programs for the upcoming academic year. The experience gained and the connections made in building the UME curriculum have made this effort within the graduate medical education (GME) realm equally successful.
        Lesson learned: The success of the UME program was dependent upon effective collaboration, support from executive leadership, and strong student interest in learning POCUS.


        1. Russell FM, Zakeri B, Herbert A, et al. The state of point-of-care ultrasound training in undergraduate medical education: findings from a national survey. Acad Med 2021 Nov 16. doi: 10.1097/ACM.0000000000004512.
        1. Russell FM, Herbert A, Ferre RM, et al. Development and implementation of a point of care ultrasound curriculum at a multi-site institution. Ultrasound J 2021; 13:9. doi: 10.1186/s13089-021-00214-w.
        1. Russell FM, Herbert A, Zakeri B, et al. Training the trainer: faculty from across multiple specialties show improved confidence, knowledge and skill in point of care ultrasound after a short intervention. Cureus 2020; 12:e11821.

        Daniela Lobo, MD, FAAFP, is an Assistant Professor of Family Medicine and POCUS Fellow at Indiana University School of Medicine.
        Josh Kaine, MD, is an Emergency Medicine POCUS Fellow at Indiana University School of Medicine and future ultrasound faculty at IUSM.

        We invite you to comment below or on Twitter (@IUEM_ultrasound) and share with us what challenges or successes you’ve faced while trying to implement a POCUS curriculum at your institutions, residencies, student clerkships, or electives.

        End-of-Residency Perspective on Early Ultrasound Education

        I remember clearly the first day I ever held an ultrasound probe. It was my second week of medical school, I knew next to nothing about medicine, and my faculty member turns to me and enthusiastically says “oh look, you have a few thyroid cysts.” I, of course, immediately thought a few things. First, how many are there, how big are they, what do I need to do, could it be cancer, and why is the faculty member so nonchalant about this.

        The next thing I thought was “what is a thyroid”.

        After the initial and very clearly unnecessary panic was over, I thought to myself that it was very interesting we were scanning things before we were taught about them in class. Throughout my training, I have come to realize how lucky I was to get such early exposure to ultrasound training and teaching. At Eastern Virginia Medical School, ultrasound was integrated into all aspects of the curriculum. This started in anatomy lab, continued into our second-year courses in pathology, and was a crucial part of 3rd year rotations where each rotation had several portable ultrasounds for students to use to scan. In the Family Medicine clerkship, we were tasked with scanning multiple people for AAA, and on surgery, we had to get 5 images of cholelithiasis. By the 4th year, faculty were using ultrasound to do procedural training and students were in the trauma bay performing FAST exams for the team. Although I thought this was the norm, I quickly found out on the interview trail that this experience separated me from a lot of my peers.

        A selfie of a very young David sent to his clerkship director as proof he did his scans for the rotation.

        In residency, we had a point-of-care or POCUS-centered curriculum. Although we all got the same instruction, I felt like my previous experience, and most of all my comfort with the probe, made me into the “ultrasound guy” of my program. While the immense clinical utility is not lost on any of my peers, the amount of time it takes to become comfortable just did not fit into the time constraints of residency.

        While I do not think ultrasound can be filed under “you can’t teach an old dog new tricks,” I do strongly believe that integrating it into medical education early on is crucial for the future of medicine. Based on my conversations with colleagues at different schools and institutions, often, ultrasound training is saved for residents and fellows, and it really shouldn’t be. Although, this surely is based on several factors including class size, cost, requirement for specialization (eg, prenatal ultrasound for OB/GYN, MSK ultrasound for Sports Medicine and Orthopedics), and availability of sufficient machines.

        One of the most frustrating things for me is the train of thought that imaging is ruining the art of the physical exam. While yes, many people will get a CT of their abdomen and pelvis in the ED, the dynamic and live view that ultrasound provides is invaluable in learning about anatomy. Multiple studies, including one that I have worked on, have shown that a longitudinal and integrated ultrasound curriculum improves procedural and physical exam skills. Many of these studies show that the biggest effect is when it is started early in training.

        After being the confused MS1 who was freaking out about his thyroid cysts (which since have gone away by the way), and being slightly frustrated at the time that more work and learning was on my plate, it’s abundantly clear to me now that this is the direction that medical education needs to go. Every first-year medical student at every institution should have their hands on probes throughout their first year, especially while learning anatomy. My challenge to medical school leadership is to find a way to incorporate or expand on ultrasound in their curriculum. At first, your students will not be confident, and they will feel like they don’t know what they are doing, but it CAN and it WILL help in the long run. It certainly did for me.

        David Neuberger, MD, is currently a 3rd year Family Medicine Resident at Emory University in Atlanta, GA. He will be pursuing a Primary Care Sports Medicine fellowship at the University of Louisville this upcoming year and has a special interest in ultrasound and ultrasound education.

        How I Brought Point-of-Care Ultrasound (POCUS) to My Family Medicine Department

        As I demonstrate a handheld ultrasound (US) machine to the eager medical students in our clinical simulation laboratory today, I am struck by a vivid recollection of my own first time seeing a handheld US machine. I was a 4th year medical student on an away rotation at a rural hospital in my home country of Peru. A visiting foreign obstetrician produced an amazing small machine, detecting fetal malposition when unsatisfied with palpation with Leopold’s maneuvers alone.

        My fascination with the clinical utility of bedside US began that day and has continued through my move to US postgraduate training in family medicine, a geriatric medicine fellowship, academic faculty roles, the completion of an accredited POCUS fellowship, and right through to my current passion for growing POCUS use within family medicine practice.

        I have learned so much along the way, have been helped by so many mentors and colleagues, that I write today to share my POCUS journey in the hopes that my story may be useful to others.

        In 2018, I joined the department of Family Medicine at the University of Michigan in Ann Arbor (AAFP). The AAFP had recently released its novel POCUS curriculum guidelines for family medicine physicians, and the department was in search of a champion to lead the development of a POCUS program for our department. I was fortunate to be chosen for this role and over the intervening 3 years have had the privilege of working with several wonderful, enthusiastic colleagues across our department, our institution, and on a national scale through the AAFP’s POCUS interest group.

        Early on in my role as POCUS champion, I realized that to be successful with this project, I was going to need a lot of help from a lot of people! My first stop (along a long journey) was to ask my department chair for time and resources. He readily obliged, providing me with the protected time to do an established accredited POCUS fellowship (which luckily was available through our emergency medicine department) and important administrative resources, which were also vital as we developed our program.

        During my yearlong fellowship, I worked hard to become a clinical sonographer, educator, academic leader, and administrator in US. These newly acquired skills have been invaluable since assuming the role of Clinical US director for my department. There have been many challenges and administrative headaches—who knew that selecting and purchasing ultrasound machines could be so complicated?!?—but countless successes.

        In terms of successes, we have defined minimum credentialing requirements for POCUS use, defined pathways for faculty interested in training in POCUS, and obtained hospital privileges for the same from our department. We have developed billing for our clinical POCUS use in ambulatory care as well as electronic health record order sets and templates for easy documentation. With regard to the POCUS curriculum that we initially set out to create, we now have a formal POCUS curriculum for family medicine residents as well as an intensive US track for residents interested in a more in-depth POCUS educational experience. Additionally, I am so excited that we will be welcoming our first Advanced Primary Care US fellow for a one-year fellowship this July.

        It has not always been easy, but I have been so fortunate with wonderful supportive departmental leadership and fantastic emergency medicine colleagues who are always eager to help with advice on regulatory or administrative requirements. Developing the POCUS program for our department has taken a lot more time than I initially anticipated, and at times, the process has proved tedious. There certainly have been times when I have doubted if it has been worth the time and effort and doubted that colleagues share my vision for the potential POCUS offers for improving our patient care in family medicine or whether they see it as a burden, yet another thing to learn. However, the excitement I felt the first time I saw the handheld US those (many!) years ago in Peru, is reflected in the excitement I see in the faces of the medical students here in the clinical simulation lab today. This shared enthusiasm and passion for POCUS tells me that in the end, it truly will have been worth it.

        An US track resident in training.
        An US track resident performing US as part of training.

        Juana Nicoll Capizzano, MD, is a Clinical Assistant Professor and Clinical US Director of Family Medicine at Michigan University.

        Interested in learning more about developing ultrasound education? Check out the following posts from the Scan:

        Getting Sonography Students Hands-on Experience

        Ultrasound Education in the Post-COVID Era

        Sink or Swim? Modifying POCUS Medical Education Curriculum During Coronavirus Pandemic

        Teaching Point-of-Care Ultrasound