Ultrasound – the future of rural diagnostic medicine?

Back in October, a chance Twitter dialogue resulted in some interesting discussion about the prospect of developing ultrasound (US) training for rural GPs – mainly in Scotland but with interest from further afield too.  As a safe, immediate, easily-transmissible and potentially game-changing imaging modality, I sometimes wonder why it isn’t in mainstream use in our community hospitals already.  I can’t help but think that in ten or so years time, medical students will be graduating with an ultrasound unit round their necks instead of a stethoscope.

It turns out that at the University of California, Irvine (USA), this is already happening…

A responsibility to innovate

For rural practice, ultrasound offers lots of possibilities.  This is not news.  In fact, one of my GP predecessors Dr Alastair Grassie was innovative in using ultrasound on Arran back in the late 1990s/early 2000s.  As well as its use in acute presentations, he offered abdominal aortic aneurysm screening long before the national aneurysm screening programme was in place in Scotland. The service was continued by my colleague Dr Greg Hamill until it gradually became too difficult to adhere to increasing competency requirements in order to continue routine scanning sessions.

However, recent developments in PoCUS (Point of Care Ultrasound) – spurred on by its exponential use in emergency and prehospital medicine settings – has opened the gates once again to the case for rural GP ultrasound.  In the context of undifferentiated presentations, being able to speed up diagnosis helps to either prioritise or indeed avoid the need for transfer – with all the potential risks and expense that transfers involve.  On Arran we are frequently in situations whereby information from ultrasound would allow us to decide whether a patient needs air transfer urgently, or if they could wait until a later ferry. There are – like any clinical test – limitations, but any aid to whittling down a differential diagnosis – particularly if more significant pathology can be ruled out – will have an absolute impact on patient safety and effective use of transfer and secondary care services.  This observation is potentiated by the escalating growth in elderly, comorbid and complex undifferentiated medical presentations.

It’s easy to look abroad to see what everyone else is doing, and a simple Google search shows some very relevant work going on in Australia.  But we don’t have to go as far as that, as in Scotland there have been some very successful ultrasound schemes set up to allow GPs to offer US in community hospitals in Grampian.  Such was the success of this, that the programme has been presented to other countries and there is current work ongoing to link Scottish work with the development of rural ultrasound in Sweden.  Hamish Greig, a Brechin GP (North East Scotland) has been particularly involved in this work and you can view one of his presentations here.

We were delighted to welcome Hamish to our annual RGPAS conference in November, and along with some wise advice and a demonstration of ultrasound, he had many of us convinced (or more convinced) that this is something we need to develop further in Scotland.

The UK’s Royal College of Emergency Medicine has an established ultrasound curriculum, and this would seem a useful basis on which to develop competences pertinent to the rural/community hospital setting.

What are the hot topics?

There are a number of hot topics in the world of ultrasound.  There is increasing work being carried out into remote US interpretation – even to the extent that a ‘lay person’ operator can be mentored quickly over Skype, and the resulting scan interpreted by centralised expertise located many miles away.  Prof James Ferguson has worked on this concept using oil rig workers, and there is a report on the success of this here.  The Centre for Rural Health in Scotland has ongoing research into the provision of satellite-facilitated remote ultrasound in ambulances, as well as looking at the possibility of trans-sphenoidal ultrasound to aid differentiation between haemorrhagic or embolic stroke – which could potentially allow stroke thrombolysis to be given before the patient reaches a stroke unit/CT scanner.  This has clear benefits for rural patients in particular.

Concerns exist regarding appropriate governance, and indeed whether rural sites have the turnover of patients to maintain skills & competence.  However these concerns can now be mediated by the fact that technology exists to allow either a first or second opinion in real-time, by a mainland-based expert e.g. consultant radiologist.  Decay of competence can also be mitigated by a well-functioning and supportive clinical governance network whereby cases can be compared, exposure maintained and quality assured.

Learning about the work above has made me reflect on the need – as always – for rural GPs to advocate for our communities. In the context of rural acute medical care, it seems that we are at a critical yet ideal point to realise the evolving possibilities of rural GP-led ultrasound.

basicsIt was a recent BASICS call for me that focussed my interest.  In the summer I was called to a young cyclist who took a different path to his bike, at high speed.  After we instigated initial treatment, the EMRS trauma team arrived by helicopter.  I was struck that their ultrasound unit was the size of an old-style flip mobile phone… and they were able to check for significant chest and abdominal injury at the roadside.  I wrote about the experience here.

I’m not suggesting here that rural GPs need to be doing prehospital trauma ultrasound – the majority of these infrequent patients need immediate medical intervention and speedy transfer to secondary/major trauma care; roadside ultrasound brings the risk of distraction by gadgets.  However if ultrasound technology can exist easily at the roadside, it shows that the technology exists for ultrasound to be easily available at the community hospital bedside.

The Future

Island and rural medicine brings occasions when helicopters are not immediately available.  Even when they are, there is a plentiful supply of clinically undifferentiated cases, where the need for transfer and/or intervention is difficult to ascertain without further imaging.  The potential exists for point of care ultrasound (whether remotely interpreted or not) offers ‘game changing’ opportunities in the provision of advanced rural medical care.

Of course, PoCUS is not the exclusive domain of the attending physician; indeed in rural areas where radiographer teams provide 24/7 cover, it may be more beneficial to train a smaller number of radiographers to be available to provide this service.  The feasibility of remote interpretation has been demonstrated in the above projects and this could potentially alleviate the challenges that presently exist in US training in accessing regular mentoring/supervision.

So what have we done?  As a result of our initial Twitter conversation, we have set up an informal Google Group to discuss the options further.  Any UK rural clinician who wants to take part in this is welcome to join (we may be focussed on development in Scotland, but that is to be clarified with time).  We may decide to meet up sometime in 2016 to take things further.

Please do join if you are interested in being involved.

Featured image (ultrasound) under Creative Commons © Nevit Dilman

Here’s a video to reflect on how ultrasound actually originated… and the fact that Prof Ian Donald of Glasgow University is attributed as one of the pioneers of ultrasound.

And finally, here’s a video all about rollout of PoCUS to Rural Primary Care Physicians in South Carolina (2011)

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