Using Point-of-Care Ultrasound: A Hospitalist’s HM17 Checklist

Point-of-care ultrasound (POCUS) has become a practical extension of the hospitalist’s examination. It can answer focused bedside questions about volume status, lung pathology, cardiac function, urinary obstruction and procedural safety within minutes. The scan does not replace a formal radiology or cardiology study; it helps the treating team decide what to do next.

The Hospital Medicine 2017 programme in Las Vegas placed strong emphasis on usable clinical knowledge, bedside decision-making and innovations that could be taken back to daily practice. The conference’s HM17 learning resources remain a useful reference point for clinicians reviewing the meeting’s educational themes, including the disciplined use of focused imaging in acute care.

Define The Clinical Question

A reliable POCUS examination begins with a narrow question. “Is this patient wet or dry?” is more useful than “Do a cardiac scan.” “Is there a pleural effusion?” gives the operator a clear target, while “Look at the lungs” may encourage unfocused image collection and overinterpretation.

Hospitalists should state the question before placing the probe: Is hypotension related to poor left ventricular contraction, right-heart strain, tamponade or likely hypovolaemia? Is breathlessness caused by pulmonary oedema, consolidation, pneumothorax or fluid? Is the bladder distended in a patient with acute kidney injury?

The answer should change management. If the scan will not affect fluids, diuretics, escalation, drainage, anticoagulation or further imaging, it may be better to request a formal study or continue with standard assessment.

Prepare The Patient And Equipment

Patient positioning matters. A semi-recumbent patient may provide better lung views, while a left lateral position can improve cardiac windows when tolerated. In a crowded Australian emergency department or a busy general medical ward, explain the examination briefly, preserve dignity and expose only the area required.

Use the correct transducer and preset. A phased-array probe is generally useful for cardiac imaging, a curvilinear probe for abdominal and lung views, and a linear probe for vascular access, pleural sliding and superficial structures. Check depth, gain, focus and orientation before interpreting the image.

Equipment logistics are part of safe practice. Wipe the machine and probe according to local infection-control policy, use gel appropriately and protect the keyboard and cables. Australian hospitals may have shared devices moving between wards, intensive care and emergency areas, so cleaning and battery checks should be routine rather than an afterthought.

Run A Focused Cardiorespiratory Sweep

A basic undifferentiated shock or dyspnoea assessment can combine several views. Cardiac windows may identify grossly reduced systolic function, a large pericardial effusion or a markedly enlarged right ventricle. Inferior vena cava appearance can add context, but it should not be treated as a standalone measure of fluid responsiveness.

For the lungs, scan anterior and lateral zones on both sides. Pleural sliding, A-lines, B-lines, consolidation and pleural fluid can help distinguish common causes of respiratory deterioration. Scan through more than one interspace and compare sides rather than relying on a single attractive image.

Interpret findings with the clinical story. B-lines may reflect pulmonary oedema, but they can also occur with interstitial disease, infection or fibrosis. A small pericardial effusion may be incidental; tamponade is a physiological diagnosis supported by chamber collapse, venous congestion and the patient’s haemodynamic state.

Use POCUS For Procedures

Ultrasound guidance can improve safety for vascular access, thoracentesis, paracentesis and selected peripheral procedures. Before puncture, identify the target, assess depth, distinguish vein from artery and look for nearby structures. Keep the needle tip visible when using an in-plane approach, and avoid assuming that seeing the shaft means the tip is in the intended location.

For pleural and abdominal procedures, confirm a safe fluid pocket and consider respiratory movement, organ position and the expected needle path. In a patient with a small effusion, a portable scan may show that bedside drainage is unsafe or unlikely to help. That is a valuable decision even when no procedure follows.

Local credentialing and supervision vary across Australia. A metropolitan teaching hospital may have a structured POCUS curriculum, image review and credentialing pathway, while a rural or remote service may rely on tele-education, visiting specialists and a smaller pool of trained clinicians. The standard should remain consistent: supervised learning, documented competence and clear escalation when the scan is limited.

Recognise Limits And Dangerous Errors

POCUS is operator-dependent. Poor windows, obesity, dressings, subcutaneous emphysema, agitation and mechanical ventilation can all reduce image quality. Record the limitation rather than forcing a confident diagnosis from a technically inadequate view.

Avoid common cognitive traps. A visually “empty” ventricle does not automatically prove that more fluid is needed. A normal-looking ejection fraction does not exclude myocardial ischaemia, pulmonary embolism or severe valvular disease. A negative lung scan does not rule out every cause of breathlessness.

If the result is discordant with the patient’s condition, stop and reassess. Seek a second operator, repeat the examination after treatment, or arrange formal imaging. This is particularly important for suspected pulmonary embolism, aortic pathology, endocarditis, complex valve disease and subtle abdominal emergencies.

Build Documentation And Team Communication

A useful record includes the indication, views obtained, key findings, limitations and clinical action. “POCUS performed” is too vague. A stronger entry might state that bilateral anterior and lateral lung views showed diffuse B-lines, no large pleural effusion was seen, and the finding supported treatment for suspected pulmonary oedema alongside the examination and chest radiograph.

Save representative clips or still images according to hospital policy. Image archiving supports quality assurance, teaching and review when a patient’s condition changes. It also helps distinguish a repeatable examination from an undocumented impression.

Communicate the result in plain clinical language during handover. For example, “The scan suggests a large left pleural effusion with compressive atelectasis; oxygen needs are rising, so I have discussed formal imaging and respiratory review.” This is more useful than announcing that “the ultrasound is positive.”

The HM17 educational archive also sits alongside wider conference material, including these clinical updates, which can help place bedside ultrasound within broader changes in inpatient medicine.

Keep A Repeatable Bedside Routine

A checklist reduces variation when the ward is noisy, time is short and several clinicians share responsibility. It should guide thinking without turning POCUS into a box-ticking exercise.

Before And During The Scan

• State the clinical question and expected management change
• Confirm patient identity, consent, position and infection-control precautions
• Select the probe, preset and depth suited to the target
• Save representative images and note technical limitations

These steps are particularly valuable during after-hours cover, when a registrar may be assessing a deteriorating patient in a regional Queensland hospital or a metropolitan ward in Melbourne. A consistent sequence makes it easier for another clinician to understand what was examined and what remains uncertain.

After The Scan

• Reconcile the findings with vital signs, examination and laboratory results
• Escalate discordant, severe or technically limited findings
• Document the indication, views, interpretation and action
• Arrange formal imaging or specialist review when the question exceeds POCUS

Training should reflect the local service. Australian clinicians may work across public hospitals, private facilities, community settings and retrieval networks, with different machines and governance arrangements. A practical programme can include supervised scans, image review, a logbook and periodic reassessment rather than assuming that attending a single course establishes competence.

Match The Scan To The Next Decision

The value of focused ultrasound is clearest when its role is compared with other investigations. It is fast and repeatable, but it has a narrower scope and depends heavily on operator skill.

For an Australian hospitalist, the practical test is simple: can the scan produce a timely, defensible decision while the patient is being assessed? If yes, POCUS may shorten uncertainty. If no, it should not delay radiology, echocardiography, senior review or transfer.

The most durable lesson from a hospital medicine conference is disciplined integration. Use the probe to sharpen the bedside examination, document what it shows, acknowledge what it cannot show and connect every finding to a clinical action. The practical takeaway is to ask one focused question, obtain interpretable images and let the patient’s response determine the next step.