critical questions that might otherwise take
hours to decipher.
2 In the hands of a trained
provider, ultrasound allows one to see inside the
patient and use that data to guide resuscitation.
The speed at which point-of-care ultrasound (POCUS) technology has become a
standard in the ED suggests its potential to
improve patient outcomes in the prehospital
arena. Whether or not this efficiently translates to our prehospital environment can’t be
assumed, and must be explored further.
Although there are many innovations in
prehospital care, three overarching categories remain paramount and warrant attention:
1) practice improvements and infrastructure
upgrades that facilitate patient care; 2) programs that reduce harm and risk for the
provider, thus creating a safer practice environment; and 3) tools, tactics and strategies which ultimately combine to result in
improved patient outcomes.
Some would argue that more technology
would solve problems in the EMS sphere.
These same individuals would argue that technology is the panacea to prehospital problems.
A controversial, yet relevant example
is mechanical CPR. Adoption of this new
technology is supported by prospective EMS
research indicating tremendous variability in
the quality of manual CPR (rate, depth and
adequacy of recoil during compressions).
Further post-hoc analysis of data gathered
by the Resuscitation Outcomes Consortium
demonstrates that only 45% of cases, using
available data meeting a predefined definition,
show “acceptable quality CPR.”
However, some are quick to dismiss
mechanical CPR, citing research that current
use fails to show patient outcome improvement
when studied prospectively and compared to
Let’s put technology aside for a moment.
The most valuable resuscitation tool in the
ambulance isn’t technology, but rather the
medical decision-making ability of the prehospital providers.
Before attempting to integrate advanced
technology (proven or unproven) in efforts
to improve patient outcomes, EMS systems
should aggressively coordinate care and sys-
tematically go after “low hanging fruit.”
Technology in itself isn’t a blanket solution.
It should be tightly integrated with providers
and the system’s response algorithms to offer a
benefit. For example, an important early step
in improving cardiac arrest outcomes in a par-
ticular community may be to invest in inter-
agency training and ensure all providers are
well versed in high-performance CPR. This
should include integration that consistently
demonstrates a chest compression fraction
rate of greater than 80%.
To parallel this example to prehospital
ultrasound, one must be able to walk before
running. Ultrasound is a tool for the advanced
practitioner and system (BLS providers can
be advanced in regard to their medical decision-making and select skills depending on
their area of operation).
Being well-versed in ultrasound indications, understanding how it can help refine
medical decision-making, incorporating it
algorithmically and directly into protocols,
and ultimately having a longitudinal quality
assurance program for continued practice and
onboarding of new personnel are precursors
to a successful program.
The indications for prehospital ultrasound
parallel the increasing utility of point-of-care testing seen broadly in the ED. (See
Table 1.) Some have hypothesized that ultrasound can be applicable in up to one-sixth of
EMS patients, while not delaying treatment
or transport to receiving centers given relatively short exam times.
In a review of the current use of prehospital
ultrasound, the authors suggest that, “Ultra-
sound with rugged, portable technology could
be used to augment physical examination and
has the potential to increase diagnostic capa-
bility for prehospital providers.”
Prehospital medicine relies on making an
operational differential diagnosis to begin tri-
age and treatment for patients with limited
history and a narrow exam.
7 Field trials sug-
gest paramedics can adequately obtain and
interpret images gathered in the prehospital
environment, striking an important first step
in delivering this modality from the in-hos-
Table 1: Indications for point-of-care ultrasound
Out-of-hospital cardiac arrest Pericardiocentesis (e.g., cardiac tamponade)
Termination of resuscitation Nerve blocks
Pulseless electrical activity Needle decompression (e.g., tension pneumothorax)
Shock states Endotracheal tube placement
Pericardial effusion Transcranial sonography (e.g., stroke)
Aortic dissection Extracorporeal membrane oxygenation (ECMO) cannulation
Aortic aneurysm Resuscitative endovascular balloon occlusion of the aorta (REBOA)
Acute pulmonary embolus
Estimating ejection fraction
Elevated intracranial pressure
Obstetric (e.g., ruptured ectopic
Acute dyspnea (e.g., COPD vs. CHF)
Assessing volume status/
Deep vein thrombosis