Unveiling the Truth: Debunking Medicolegal Myths Surrounding Point-of-Care Ultrasound

Using point-of-care ultrasound (POCUS), clinicians can rapidly diagnose patients at bedside and expedite care with accuracy and precision. This tool has been adopted by multiple specialties, including emergency medicine, family medicine, and internal medicine. However, providers and administrators may remain hesitant to use it due to medicolegal concerns. Here, we review the evidence and guidelines surrounding common medicolegal myths in the application of POCUS in your clinical practice. With the correct systems and checks in place, POCUS can become an asset for providers in a range of practice settings.

“I’m going to get sued for misinterpreting images and misdiagnosing my patients”

Clinicians may be apprehensive about their clinical ability to make accurate diagnoses despite completing recommended training in POCUS. However, the retrospective review of lawsuits does not show a prevalence of cases due to misdiagnosis or misinterpretation. Retrospective reviews of 25 emergency medicine malpractice lawsuits related to POCUS show a predominance of cases centered on the failure to perform POCUS or a delay in performing the study within a timely manner.[1-4] None of the reviewed lawsuits involved failure in interpretation, or a misdiagnosis of the images by a non-radiology provider. Even expanded to internal medicine, pediatrics, family medicine, and critical care, retrospective reviews show no adverse legal action for diagnostic use of point-of-care ultrasounds.[5] Importantly, the majority of the lawsuits were not directly attributed to POCUS but rather to broader issues in diagnostic errors, including comprehensive ultrasound done by ultrasound technicians and interpreted by radiologists. This suggests that not using POCUS can pose a greater risk in terms of legal implications.

 “I don’t have enough experience in ultrasound”

Before making clinical decisions, it is important to achieve competency in specific applications of POCUS. Many organizations, with American College of Emergency Physicians (ACEP) being the leader, now have guidelines outlining the best way to achieve competency using asynchronous learning, hands-on training, and longitudinal preceptorship. While it is not mandatory for every emergency medicine clinician to be an expert in every core application of clinical ultrasound, ACEP emphasizes basic education in understanding ultrasound, instrumentation, procedural guidance, and Focused Assessment with Sonography in Trauma (FAST).[6-7] Limited competency in performing diagnostic or symptom/sign-based clinical ultrasound will vary based on training.

The American Academy of Family Physicians (AAFP) has similar recommendations for POCUS, including diagnosis, procedural guidance, and multi-organ scans.[8] The American College of Radiology is currently working on guidelines for POCUS.[9] POCUS is becoming integrated into many aspects of medicine, given it is an effective and affordable adjunct in medical care.

Many organizations have developed free open-access medical (FOAM) education, such as the Academy of Emergency Ultrasound or ACEP’s Sonoguide. [10 - 11] These curriculums have demonstrated efficacy in teaching POCUS to pre-medical students.[12] Continued practice will improve confidence in performing and analyzing images. Providers should focus on honing a handful of applications within their scopes of practice, and having these skills readily available for patients.

 What’s the final medicolegal conclusion on POCUS?

Multiple studies have demonstrated the accuracy and reliability of POCUS in various medical specialties. For example, a meta-analysis published in the Journal of Clinical Ultrasound examined the use of POCUS for detecting acute appendicitis in the ED and found high sensitivity (81%) and specificity (87%), indicating its potential as a valuable diagnostic tool.[13] Clinicians can accurately assess left ventricular function, identify wall motion abnormalities, and detect pericardial effusions.[14] A review of 177 P POCUS  exams performed in a rural Ugandan mobile clinic showed that it changed management in 53% of the patients.[15] Facilitating rapid assessment of trauma patients or life-threatening conditions improves patient outcomes, which is particularly imperative in the emergency setting. Outside of diagnosis, POCUS can help guide and improve safety of various procedures, such as central line and peripheral intravenous line placements, joint injections, thoracentesis, and nerve blocks.

POCUS is a powerful tool that is becoming an integral part of clinical practice, as outlined by professional organizations and in our prior post. It can augment our current practice to delivery real-time, bedside assessments of our patients and improve safety of procedures we perform. With the appropriate training and competency, providers and administrators should feel safe integrating POCUS into many practice settings.

Authored by Jason Wang DO, MBS

Edited by Tatiana Havryliuk, MD

References 

1. A. Gupta. “Emergency providers don’t face much legal risk from POCUS use,” Medical Buyer. Accessed: Nov. 11, 2023. [Online]. Available: https://www.medicalbuyer.co.in/emergency-providers-dont-face-much-legal-risk-from-pocus-use/

2. B. Russ, J. Arthur, Z. Lewis, and G. Snead, “A REVIEW OF LAWSUITS RELATED TO POINT-OF-CARE EMERGENCY ULTRASOUND APPLICATIONS,” J. Emerg. Med., vol. 63, no. 5, pp. 661–672, Nov. 2022, doi: 10.1016/j.jemermed.2022.04.020.

3. L. Stolz, K. M. O’Brien, M. L. Miller, N. D. Winters-Brown, M. Blaivas, and S. Adhikari, “A review of lawsuits related to point-of-care emergency ultrasound applications,” West. J. Emerg. Med., vol. 16, no. 1, pp. 1–4, Jan. 2015, doi: 10.5811/westjem.2014.11.23592.

4. M. Blaivas and R. Pawl, “Analysis of lawsuits filed against emergency physicians for point-of-care emergency ultrasound examination performance and interpretation over a 20-year period,” Am. J. Emerg. Med., vol. 30, no. 2, pp. 338–341, Feb. 2012, doi: 10.1016/j.ajem.2010.12.016.

5. M. Reaume, M. Farishta, J. A. Costello, T. Gibb, and T. A. Melgar, “Analysis of lawsuits related to diagnostic errors from point-of-care ultrasound in internal medicine, paediatrics, family medicine and critical care in the USA,” Postgrad. Med. J., vol. 97, no. 1143, pp. 55–58, Jan. 2021, doi: 10.1136/postgradmedj-2020-137832.

6. “Ultrasound Guidelines: Emergency, Point-of -care, and Clinical Ultrasound Guidelines in Medicine.” Accessed: Nov. 11, 2023. [Online]. Available: https://www.acep.org/patient-care/policy-statements/ultrasound-guidelines-emergency-point-of--care-and-clinical-ultrasound-guidelines-in-medicine

7. “Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine,” Ann. Emerg. Med., vol. 82, no. 3, pp. e115–e155, Sep. 2023, doi: 10.1016/j.annemergmed.2023.06.005.

8. “Point-of-Care Ultrasonography | AAFP.” Accessed: Dec. 06, 2023. [Online]. Available: https://www.aafp.org/pubs/afp/issues/2020/0301/p275.html

9. “POCUS Workgroup Now Underway.” Accessed: Dec. 06, 2023. [Online]. Available: https://www.acr.org/Practice-Management-Quality-Informatics/Quality-Care-News/Newsletter/Quality-and-Safety-eNews-March-2022/POCUS-Taskforce-Now-Underway

10. “Sonoguide.” Accessed: Nov. 11, 2023. [Online]. Available: https://www.acep.org/sonoguide

11. “AEUS Asynchronous Ultrasound Curriculum,” Default. Accessed: Nov. 11, 2023. [Online]. Available: https://www.saem.org/about-saem/academies-interest-groups-affiliates2/aeus/education/aeus-off-the-shelf-asynchronous-ultrasound-curriculum

12. C. M. Smalley, V. Browne, B. Kaplan, B. Russ, J. Wilson, and R. E. Lewiss, “Early Innovative Immersion: A Course for Pre-Medical Professions Students Using Point-of-Care Ultrasound,” J. Ultrasound Med. Off. J. Am. Inst. Ultrasound Med., vol. 35, no. 12, pp. 2681–2686, Dec. 2016, doi: 10.7863/ultra.16.01050.

13. S. U. Cho and S. K. Oh, “Accuracy of ultrasound for the diagnosis of acute appendicitis in the emergency department: A systematic review,” Medicine (Baltimore), vol. 102, no. 13, p. e33397, Mar. 2023, doi: 10.1097/MD.0000000000033397.

14. “Point-of-Care Ultrasonography | NEJM.” Accessed: Nov. 09, 2023. [Online]. Available: https://www.nejm.org/doi/full/10.1056/NEJMra1916062

15. “Impact of point-of-care ultrasound on the diagnosis and treatment of patients in rural Uganda - Daniel E Baker, Laura Nolting, Heather A Brown, 2021.” Accessed: Dec. 06, 2023. [Online]. Available: https://journals.sagepub.com/doi/10.1177/0049475520986425