Shaping the Path Forward:
The Evolution of POCUS in Acute Cardiac Care

Luke Baldwin: Many people, especially in the early 2000s, were diving into ultrasound training. Your expertise is in critical care medicine, right?

Hatem Soliman-Aboumarie, MD: My primary training is in critical care, but I also did a post-graduate Diploma in Cardiology and the American National Board of Adult Echocardiography as I was aspiring to become a cardiac intensivist. 

Luke Baldwin: So, when you come across people learning ultrasound today, how do you find it? Convincing them of the value of ultrasound nowadays is easier. When students approach you for ultrasound learning, is it generally accepted, or do you still have to make a case for its value in your teaching role?

Hatem Soliman-Aboumarie, MD: It’s becoming less emphasized than before. The cultural shift is gradual. A decade ago, I had to advocate extensively for the importance of ultrasound. Now, I discuss it less, focusing more on governance, regulations, training, and accreditation. Most people I talk to understand ultrasound’s significance. However, challenges persist, primarily in regulations and the ongoing cultural shift. This extends to other specialties like nephrology, with a growing advocacy for ultrasound. I advocate for multi-specialty and multidisciplinary integration, acknowledging the inevitability of technological advancement. Miniaturized devices, now capable of complex functions, are changing the landscape. I emphasize supporting learners from non-cardiology backgrounds to prevent unstructured learning avenues like YouTube and other online resources without proper structured training. Viewing this as a positive wave for the betterment of patients, teaching provides clarity and structure.

The perception of point-of-care ultrasound has evolved from a basic exam performed by beginners to a complex assessment by experienced practitioners performed in a targeted manner in a short period. This shift is driving a change in the accreditation paradigm. I’m committed to advocating for structured training, recognizing that the journey is not easy but a collaborative process that we must embrace to improve patient care.

Luke Baldwin: That’s a fascinating distinction. I never considered it that way. In the early days of point-of-care ultrasound, it focused on specialized basic exams, addressing specific questions. However, as time progressed, it became more advanced. For instance, transesophageal (TEE) ultrasound-guided resuscitations was traditionally not an emergency medicine device. The power of ultrasound unleashed creativity, leading to new and more specialized use.

Hatem Soliman-Aboumarie, MD: Absolutely. Patients are now dealing with more complex issues, requiring beyond the binary classic point-of-care ultrasound. We need calculations and measurements—a more intricate approach. I perform complex focused assessments, especially in mechanical circulatory support. We recently published a book, “The Cardiopulmonary Point-of-Care Ultrasound,” highlighting these various aspects. The book’s concept underscores that POCUS can be basic, intermediate, or advanced. Ultrasound means you are assessing at the bedside in a targeted manner to answer specific clinical questions, ranging from very basic to very advanced.

Luke Baldwin: You mentioned calculations and specificity, moving beyond a simple yes or no. Is it safe to say that basic POCUS might be sufficient in specific patient populations, but in complex cases like the ones you handle, a more comprehensive approach is necessary?

Hatem Soliman-Aboumarie, MD: Absolutely. Different patient cohorts present unique challenges. In general intensive care units, sometimes basic POCUS might suffice. While in cardiac intensive care units, complex assessments are often required. In our unit, I often aim for complex assessments—looking at perfusion, cardiac output, congestion and pulmonary vascular resistance. This requires advanced technology and specialized devices for accurate measurements, emphasizing the evolution and adaptability of point-of-care ultrasound.

Luke Baldwin: It’s fascinating to see the evolution of technology and the acceptance of point-of-care ultrasound in diverse ways. However, on the flip side, there’s a growing sicker population with complex cases. In your experience, is the shortage of cardiac sonographers contributing to the rise of point-of-care ultrasound in acute care settings?

Hatem Soliman-Aboumarie, MD: It’s crucial to distinguish between diagnostic echocardiograms performed by cardiac sonographers and the point-of-care assessments performed by the bedside clinician. They serve different purposes. POCUS is never a replacement for comprehensive echocardiograms. Point-of-care ultrasound is an extension of bedside physical examination, providing immediate information for clinical management decisions.

Luke Baldwin: I appreciate the clarification. The focus is on targeted exams to enhance bedside examinations and guide clinical decision-making. How does ultrasound fit into the larger picture of medical advancements and innovation, and what should ultrasound manufacturers keep in mind to support this growth?

Hatem Soliman-Aboumarie, MD: The concept of point-of-care ultrasound is about targeting to enhance bedside physical examination. Ultrasound should be viewed as the true stethoscope, not just a new technology. It is crucial in triaging patients, deciding on care levels, and providing information during critical times like the COVID pandemic. As technology evolves, ultrasound manufacturers should focus on creating systems that address real-world problems, making assessments more accurate, faster, and user-friendly. Listening to clinicians’ needs and challenges will be driving advancements that positively impact patient care.

A few weeks ago, I read the biography of Professor Magdi Yacoub, the renowned surgeon who worked at Harefield Hospital, establishing it as the largest heart transplant center in the world in the 1990s. In his biography, he emphasized that the ability to innovate and push boundaries back then was due to less governance compared to what we are having today, which led them to pursue groundbreaking procedures like the first combined heart-lung transplantation in Europe. Therefore, he acknowledged that such innovations might face more obstacles today due to increased regulations, which are indeed crucial for patient safety but they are potentially stifling progress. Reflecting on this, I see point-of-care ultrasound, particularly Kosmos, as a revolution in bringing advanced concepts to the bedside. It’s a safe and powerful way to improve patient care without invasive interventions. While regulations are essential, we should balance them for meaningful progress.

Luke Baldwin: It’s fascinating to consider the historical context and the potential impact of point-of-care ultrasound. It seems like a crucial tool in advancing patient care, and you’ve mentioned the importance of training other clinicians. Could you elaborate on how you train nurses, physiotherapists, and other team members in point-of-care ultrasound?

Hatem Soliman-Aboumarie, MD Absolutely. I’m very proud of my team, and my aim is to train all of the team in point-of-care ultrasound as the enhanced modern version of the stethoscope. We’ve started a training program for junior doctors, physiotherapists, nursing staff, advanced critical care practitioners and critical care outreach. We’ve also established governance frameworks and standard operating procedures for our physiotherapy lung ultrasound to ensure safe practices and the data we collected so far showed that lung ultrasound has a strong positive impact on guiding decision-making by physiotherapy in cardiothoracic critical care.

Luke Baldwin: So, you had this trip to Kazakhstan, and I was reading something you had posted on it, and you were talking about integrated POCUS in your post when you were talking about your trip to Kazakhstan. Could you share what that trip was about and what you mean by integrated POCUS?

Hatem Soliman-Aboumarie, MD: Yeah. So, we were invited to deliver a workshop to a university hospital in Astana. Later, we got another invite to provide another workshop at another cardiac center in Almaty, one of the two main cities in Kazakhstan.

It was our first trip to Central Asia. It was terrific, not only because we were impressed by the culture and the hospitality but also because we had a fantastic setup, and they needed more similar kinds of contributions, especially point-of-care ultrasound. The workshops were very successful. We trained over 80 doctors from both cities. We even performed bedside assessments in the intensive care unit in one of the hospitals they asked us to go to, which was a critical moment because you’re not just giving a lecture, you’re applying what you do at the bedside for rea patients. I had the same feeling in my unit when I applied this every day. It is fundamental. It changes the management; it gives important insights. We applied the integrated approach, which is not only cardiac ultrasound but also the pyramid of point-of-care ultrasound. It combines cardiac, lung, and systemic venous ultrasound. So, you bring the three main pillars of point-of-care ultrasound together to assess patients’ hemodynamics, fluid status, and filling pressures. And that’s what I do in my patient cohort every day. I apply this as a protocol, and it takes around 10 to 15 minutes to perform the targeted protocol. It adds much to my information, knowing more about my patients and guiding fluid management, inotropes, and vasopressors. And that’s why I’m advocating for the integrated approach, combining cardiac, lung, and systemic venous ultrasound.