Patricia A. Pellikka, MD, FASE

It has been estimated that more than 50,000 handheld ultrasound units are now in use globally. Since their release several years ago, these devices have become even smaller, from handheld to pocket-sized. These affordable, small devices could change the paradigm of performing echocardiography.

Indeed, the paradigm is already changing. The tremendous utility of using ultrasound at the bedside to immediately guide management decisions has been recognized by many, including not only echocardiographers, but interventional cardiologists, critical care physicians, emergency department physicians, trauma teams, and primary care providers, who are now using this technology.

In parallel with this trend, training, and education of users is evolving. Presently, it is not only cardiology fellowship programs that offer training in cardiac ultrasound. Anesthesiology residency and fellowships include training in echocardiography. Critical care physicians receive training in both transthoracic and transesophageal echocardiography. Emergency department and family medicine residency curriculums now include training in ultrasound. Medical students and internal medicine residents are using ultrasound to understand cardiac anatomy, physiology, and pathology. Obviously, the goals, depth, and scope of training differ in these programs.

In addition to training offered as curriculum in medical training programs, courses are now offered by various organizations. Instruction may be provided by board-certified cardiologists or by other experts in echocardiography. Handheld devices offer much simpler “knobology” for the new or less frequent user. Both handheld and mannequin simulation devices are increasingly being used in educational programs.

Does cardiac ultrasound performed with handheld devices fall within the mission of ASE? Yes. According to our mission statement, “ASE is committed to excellence in cardiovascular ultrasound and its application to patient care through education, advocacy, research, innovation, and service to our members and the public.” Although practitioners of cardiovascular ultrasound and users of handheld devices generally include cardiologists, increasing numbers of anesthesiologists, emergency department physicians, critical care physicians, as well as internists and family practitioners have also honed their skills and have passed the National Board of Echocardiography examination. Because training in limited point-of-care ultrasound is now required in critical care and emergency department training programs, there is a need for further training and educational materials. The ASE membership includes many superb teachers who would be passionate about such an undertaking. ASE’s mission should include helping others to use point-of-care ultrasound effectively to serve the public.

Aligned with this mission, ASE’s new course, Echo Florida, which will take place in Orlando in October, includes a full day pre-conference on point-of-care ultrasound. This section of the course will provide training and education not only in how to operate the system, but in its application. Brief lectures will focus on the use of handheld echo for bedside assessment of ventricular function and volume status and recognition of pericardial effusion and cardiac tamponade, as well as for noncardiac applications such as pulmonary edema. The faculty, including cardiologists, emergency department physicians, and cardiac sonographers, will guide students with hands-on training with multiple types of portable devices. This pre-course program is intended not only for cardiologists and sonographers, but for other physicians, nurse practitioners, physician assistants and those in any practice setting in which hand-held cardiac ultrasound is utilized.

Is it advantageous for ASE to collaborate with new users of handheld devices? Yes. As the experts in cardiovascular ultrasound, we strive to improve quality and disseminate education. Developing educational materials and improving quality of practice of echocardiography everywhere is a laudable goal. An advantage to ASE in including and welcoming members of other groups is that there is, indeed, strength in numbers. We are the largest cardiac imaging group; nevertheless, more members would increase our voice, whether we are lobbying for reimbursement or for research funding from the National Institutes of Health. Various professional societies are organizing ultrasound interest groups. We should work together instead of in parallel.

Research is needed to document the training required to use handheld technology and the scope of practice for which it is appropriate. We also need to demonstrate its cost effectiveness and document its impact on outcome in various settings. These focused, goal-directed exams do not replace the need for comprehensive echo-Doppler examinations which accurately delineate cardiac structure, quantify cardiac function and predict outcome. However, use of handheld devices to provide immediate information on volume status and ventricular function and to guide line placement will be life-saving and will enhance safety and quality of care.

The possibilities for application of handheld ultrasound are vast. Last January, the ASE conducted an echocardiography project in northwest India. Over 1,000 very limited transthoracic echocardiograms were performed over a two day period. Patients who may never have had access to this technology had brief echocardiograms and received reports, and complex cases were referred for more comprehensive echo imaging, as indicated. The availability of small, inexpensive portable echocardiographic devices made the project feasible and affordable. Point-of-care ultrasound may also be widely applicable outside of clinic and hospital settings for utilization by ambulance personnel and critical care teams who need immediate information to guide treatment, as well as free screening in inner city medical clinics and on other medical outreach trips.

Of course, there are plenty of complex issues to be resolved with the expansion of users of point-of-care and focused cardiac ultrasound, including scope of practice, training requirements, reimbursement, reporting and storage of data, quality, and accreditation. However, as healthcare reimbursement shifts from a model of fee for service to one with emphasis on quality, and possibly even capitated payment, increased utilization of low cost devices may become less controversial.

∗“Here, There and Everywhere” written by Paul McCartney, was recorded by the Beatles in their 1966 album, Revolver . Their song can be modified to apply to echocardiography. “To lead a better life, [we] need [echo] to be here…changing a life with a wave of the hand…[echo] is to share…to be there and everywhere…” Let us keep an open mind to the possibilities!