In their first clinical application about 70 years ago, ultrasound machines were the size of automobiles and required water immersion of the patient to obtain shadowy suggestions of internal anatomy [1]. The physics involved were the same as those used to track icebergs and submarines, adapted by innovators to the delicate task of finding a tumor or looking for a gallstone [2, 3]. Within 20 years of its initial clinical use, scientists had advanced the technology to a point where ultrasound machines were much more compact and offered image quality sufficient to evaluate the fetus in obstetrics care [4]. Since then, diagnostic applications of sonography have incrementally increased to encompass literally every field of health care, from physical medicine and rehabilitation to obstetrics and gynecology, emergency medicine to pulmonology, critical care to disaster management, oncology to trauma and emergency surgery, and pediatrics to gastroenterology [5–10].
As clinical applications of ultrasound have expanded and image resolution has improved, the actual sizes of machines and probes have progressively become smaller [11–13]. This portability has allowed ultrasound studies to occur at a patient’s bedside, largely eliminating the need for patient transport in the new point-of-care testing paradigm [14]. From simple diagnostics and interventions, sonography has blossomed into more advanced applications, such as real-time guidance for bedside procedures (e.g., venous catheter placement, thoracentesis, lumbar puncture, and even endotracheal intubation) [15–18]. By facilitating a procedure that results in fewer unsuccessful interventional attempts and increases patient safety [19, 20], sonography actively enhances the overall value of health-care services offered. Moreover, the marriage of miniaturization and minimally invasive techniques has also allowed for high-resolution endocavitary studies, such as transesophageal echocardiography, endovascular ultrasound, endoscopic ultrasound, or transvaginal studies, giving medical providers detailed visualization of structures not previously seen outside of the operative theater [21–26]. This includes minimally invasive interventional applications [25–27]. Indeed, the increasing portability and affordability of this technology has allowed for its ever-expanding and evolving use, both within and outside the hospital’s walls [28, 29]. Now, ultrasound is finding a role even earlier in the care of the patient, including the pre-hospital arena where studies are performed by emergency medical providers to assist in decisions regarding triage and resource allocation [29]. Point-of-care sonography has been used successfully in developing countries, resource-poor areas, and mass casualty/disaster settings [6, 30].
Supporters of ultrasound technology have touted it to be the “new stethoscope” of the twenty-first century, moving it conceptually from its traditional role as a diagnostic modality to a necessary and central part of a good physical examination performed by a medical practitioner [31, 32]. This moniker illustrates the ubiquitous nature of ultrasound application. Much like the basic use of the stethoscope, ultrasound technology can be effectively employed by technicians, students, nurses, mid-level practitioners, primary care physicians, and subspecialists [28, 33–37]. However, how sonography is practically implemented and used is somewhat different from the traditional “stethoscope” concept, with key differences related to image acquisition, interpretation, and the subsequent generation of a professional report [38, 39]. Consequently, future growth of sonography will require significant educational and system-based coordination efforts among health care’s various providers.
Our patients are the focus of a continuous quest to provide the best care, in a sustainable manner, at optimal quality and value points. For each individual provider, this process starts with solid educational background. Ultrasound in health care and medical education has a rich history, with ultrasound education being an important cornerstone for future advances in the area of clinician-driven diagnostics. Sonography has always had the stigma of being operator dependent. In this respect, the technology seems to have outpaced the education. Consequently, starting ultrasound didactics early in the education of students and residents will help enhance subsequent physician education and the overall level of sonography expertise and acceptance. Integrating ultrasound into existing curricula can be useful, as can starting afresh with ultrasound as a main focus [40, 41]. Collaborating between specialties seems to be the long-term answer to educational challenges faced by both medical schools and medical centers. One must also remember that educating the various learners who have different levels of pre-existing knowledge (e.g., medical school, residency, fellowship, practicing physician) demands different approaches. No matter where diagnostic ultrasound is used, the key components must be taught to produce minimally competent practitioners who understand the indications, acquisition, and interpretation nuances of point-of-care ultrasound [5]. Interlacing ultrasound didactics with other knowledge a student is exposed to during his or her standard medical education seems to be the most optimal manner in which sonography can achieve the desired level of enmeshment.
Ultrasound is “the future” and, although one could easily accuse the authors of being too forward looking, we must remember that humanity’s progress will result in increasing the number of ventures into interplanetary (and perhaps even interstellar) space. Various disease states are likely to follow humans on this quest, necessitating the presence of reliable diagnostic (and therapeutic) tools. Ultrasound is one tool that can identify normal and abnormal fluid or air, help visualize structural characteristics of healthy and inflamed tissues, and provide information on key physiology and hemodynamics of our organs and tissues, regardless of the location of the patient [42–45]. Early experiences with sonography on the International Space Station provide a glimpse of what space medicine might look like on our voyages to other planets and stars [42–44, 46].
Future clinicians will be well served to have a scaffold of vision and clear outcomes for each part of their ultrasound education. Even though the impact of sonography in clinical practice is evidence-based, commonly deployed general and trauma surgeons are reluctant to embrace the ultrasound probe as a daily tool for clinical problem solving. Fully aware of this problem, of the particular needs of adult learning, and even the need to optimize the on-site “hands-on” part of learning for time-constrained acute care surgeons, a novel educational format was developed by the European Society for Trauma and Emergency Surgery (ESTES) [47]. Modular UltraSound ESTES Course (MUSEC) was designed a priori as a blended educational format tailored to the surgeons’ requirements and centered on ultrasound-driven surgical decision-making. The results of this novel approach, both in terms of learning gain and of overall satisfaction, fully support this educational initiative. Modularity, flexibility, continuous correlation with clinical practice, and hands-on training utilizing realistic original phantoms and healthy models are intended to narrow the gap between the ultrasound as a clinical tool and the acute care surgeon as the operator.
As the Guest Editors of the second “Focus on Ultrasound” issue of the European Journal of Trauma & Emergency Surgery, we hope that you find the current contributions educational, practical, and thought provoking. From a basic review on FAST and E-FAST sonography for the injured, through an overview of ultrasound-guided bedside procedures, a focused review of sonography in disaster settings, to the latest trends from MUSEC, we hope to captivate your attention and enhance your knowledge on this topic of growing importance for all practitioners of trauma, critical care, and emergency surgery. As ultrasound use in clinical practice continues to expand, let us work together to identify best educational practices and implementation pathways. Let us also make this a global affair, no longer confined to countries or continents. Patients around the world are listening.
References
Goldberg BB, Gramiak R, Freimanis AK. Early history of diagnostic ultrasound: the role of American radiologists. AJR Am J Roentgenol. 1993;160(1):189–94.
Kane D, et al. A brief history of musculoskeletal ultrasound: ‘from bats and ships to babies and hips’. Rheumatology (Oxford). 2004;43(7):931–3.
Arshadi R, Cobbold RS. A pioneer in the development of modern ultrasound: Robert William Boyle (1883–1955). Ultrasound Med Biol. 2007;33(1):3–14.
Brown TG. An explanation of the principles of ultrasonic echo sounding [summary]. Proc R Soc Med. 1962;55(8):637.
Stawicki SP, Bahner DP. Modern sonology and the bedside practitioner: evolution of ultrasound from curious novelty to essential clinical tool. Eur J Trauma Emerg Surg. 2015;41(5):457–60.
Stawicki SP, et al. Portable ultrasonography in mass casualty incidents: the CAVEAT examination. World J Orthop. 2010;1(1):10–9.
Lane N, et al. Ultrasound in medical education: listening to the echoes of the past to shape a vision for the future. Eur J Trauma Emerg Surg. 2015;41(5):461–7.
Benacerraf BR, et al. Three-and 4-dimensional ultrasound in obstetrics and gynecology proceedings of the American Institute of Ultrasound in Medicine consensus conference. J Ultrasound Med. 2005;24(12):1587–97.
Stawicki SP, et al. Dynamic behavior of venous collapsibility and central venous pressure during standardized crystalloid bolus: a prospective, observational, pilot study. Int J Crit Illn Inj Sci. 2015;5(2):80–4.
Stawicki SP, et al. Prospective evaluation of intravascular volume status in critically ill patients: does inferior vena cava collapsibility correlate with central venous pressure? J Trauma Acute Care Surg. 2014;76(4):956–63 (discussion 963–4).
Scholten C, et al. Hand-held miniaturized cardiac ultrasound instruments for rapid and effective bedside diagnosis and patient screening. J Evaluation Clin Pract. 2005;11(1):67–72.
Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, part I: feasibility of field deployment. Journal Emerg Med. 2011;40(2):190–7.
Huang C-C, et al. Design and implementation of a smartphone-based portable ultrasound pulsed-wave doppler device for blood flow measurement. Ultrason Ferroelectr Freq Control IEEE Trans. 2012;59(1):182–8.
Stawicki SP, et al. Academic College of Emergency Experts in India’s INDO-US Joint Working Group and OPUS12 Foundation Consensus Statement on Creating A Coordinated, Multi-Disciplinary, Patient-Centered, Global Point-of-Care Biomarker Discovery Network. Int J Crit Illn Inj Sci. 2014;4(3):200–8.
Charboneau JW, Reading CC, Welch TJ. CT and sonographically guided needle biopsy: current techniques and new innovations. AJR Am J Roentgenol. 1990;154(1):1–10.
Kanai M, Sekiguchi H. Avoiding vessel laceration in thoracentesis: a role of vascular ultrasound with color Doppler. Chest. 2015;147(1):e5–7.
Ozdamar E et al. Ultrasound-Assisted Lumbar Puncture in Pediatric Emergency Department. Pediatr Emerg Care 2015. doi:10.1097/PEC.0000000000000593
Bahner DP, et al. What’s new in critical illness and injury science? The challenge of verifying tracheal airway placement: solving the puzzle one piece at a time. Int J Crit Illn Inj Sci. 2013;3(2):105–7.
Chan VW, et al. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg. 2003;97(5):1514–7.
Dogu O, et al. Ultrasound-guided versus ‘blind’intraparotid injections of botulinum toxin-A for the treatment of sialorrhoea in patients with Parkinson’s disease. Clin Neurol Neurosurg. 2004;106(2):93–6.
Kelly N, et al. Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of current indications and limitations. Eur J Trauma Emerg Surg. 2015;41(5):469–80.
Karakitsos D, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162.
Haji DL, Royse A, Royse CF. Review article: clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia. Emerg Med Australas. 2013;25(1):4–12.
Stawicki SP, et al. Use of non-invasive esophageal echo-Doppler system in the ICU: a practical experience. J Trauma. 2005;59(2):506–7.
DeWitt JM, Chappo J, Sherman S. Endoscopic ultrasound-guided fine-needle aspiration of melanoma metastatic to the pancreas: report of two cases and review. Endoscopy. 2003;35(3):219–22.
Mariani J Jr, et al. Intravascular ultrasound guidance to minimize the use of iodine contrast in percutaneous coronary intervention: the MOZART (Minimizing cOntrast utiliZation With IVUS Guidance in coRonary angioplasTy) randomized controlled trial. JACC Cardiovasc Interv. 2014;7(11):1287–93.
Gussenhoven EJ, et al. Intravascular ultrasound and vascular intervention. J Interv Cardiol. 1991;4(1):41–8.
Melanson SW, et al. Aeromedical trauma sonography by flight crews with a miniature ultrasound unit. Prehosp Emerg Care. 2001;5(4):399–402.
El Sayed MJ, Zaghrini E. Prehospital emergency ultrasound: a review of current clinical applications, challenges, and future implications. Emerg Med Int. 2013;2013:531674.
Becker DM et al. The use of portable ultrasound devices in low- and middle-income countries: a systematic review of the literature. Trop Med Int Health 2015. doi:10.1111/tmi.12657
Gillman LM, Kirkpatrick AW. Portable bedside ultrasound: the visual stethoscope of the 21st century. Scand J Trauma Resusc Emerg Med. 2012;20:18.
Lichtenstein D, et al. Ten good reasons to practice ultrasound in critical care. Anaesthesiol Intensive Ther. 2014;46(5):323–35.
Cook T, Hunt P, Hoppman R. Emergency medicine leads the way for training medical students in clinician-based ultrasound: a radical paradigm shift in patient imaging. Acad Emerg Med. 2007;14(6):558–61.
Siqueira VN, et al. Training program for cardiology residents to perform focused cardiac ultrasound examination with portable device. Echocardiography. 2015;32(10):1455–62.
Atkinson P, et al. Detection of soft tissue foreign bodies by nurse practitioner-performed ultrasound. Crit Ultrasound J. 2014;6(1):2.
Weiner SG, et al. Single-operator ultrasound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in patients with difficult-to-establish intravenous access. J Emerg Med. 2013;44(3):653–60.
Herrmann G, Woermann U, Schlegel C. Interprofessional education in anatomy: learning together in medical and nursing training. Anat Sci Educ. 2015;8(4):324–30.
Filly RA. Ultrasound: the stethoscope of the future, alas. Radiology. 1988;167(2):400.
Geria RN, Raio CC, Tayal V. Point-of-care ultrasound: not a stethoscope—a separate clinical entity. J Ultrasound Med. 2015;34(1):172–3.
Bahner DP, et al. The state of ultrasound education in U.S. medical schools: results of a national survey. Acad Med. 2014;89(12):1681–6.
Bahner DP, et al. The ultrasound challenge: a novel approach to medical student ultrasound education. J Ultrasound Med. 2012;31(12):2013–6.
Marshburn TH, et al. New heights in ultrasound: first report of spinal ultrasound from the international space station. J Emerg Med. 2014;46(1):61–70.
Sargsyan AE, et al. FAST at MACH 20: clinical ultrasound aboard the international space station. J Trauma. 2005;58(1):35–9.
Reddick V. Ultrasound aboard the international space station. Radiol Manage. 2001;23(3):22–4.
Stawicki S, et al. Incidental findings on intensivist bedside ultrasonographic (INBU) examinations: why should we care. OPUS 12. Scientist. 2008;2(3):11–4.
Ultrasound to be aboard International Space Station. Telemed Virtual Real 1998, 3(3):p 28.
Zago M, et al. Tailored ultrasound learning for acute care surgeons: a review of the MUSEC (Modular UltraSound ESTES Course) project. Eur J Trauma Emerg Surg. 2016;42(1):2016. doi:10.1007/s00068-016-0651-z
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
Rebecca Jeanmonod, Stanislaw P. Stawicki, David P. Bahner, and Mauro Zago declare no conflicts of interest in relation to this work.
Ethics statement
The authors declare that this manuscript conforms to the established guidelines for ethical conduct of research.
Rights and permissions
About this article
Cite this article
Jeanmonod, R., Stawicki, S.P., Bahner, D.P. et al. Advancing clinician-performed sonography in the twenty-first century: building on the rich legacy of the twentieth century pioneers. Eur J Trauma Emerg Surg 42, 115–118 (2016). https://doi.org/10.1007/s00068-016-0652-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00068-016-0652-y