The burden of trauma and medical diseases in South Africa is high.^1,2 Public hospital emergency departments (EDs) are the first point of contact for various medical and trauma emergencies, with many of these healthcare facilities limited to plain radiography services. Although resource limitations persist, there has been an increase in the number of emergency medicine specialists in the EDs since the introduction of the specialty in 2003 and an advance in accredited level 1 emergency point-of-care ultrasound (POCUS) providers in the country.

Ultrasound is a safe, repeatable, non-invasive and cost-effective diagnostic tool. Point-of-care ultrasound is practiced in austere environments for applications related, but not limited, to battlefield triage, in-flight examination of critically ill transfers and screening at high altitudes for high-altitude emergencies; additionally, in-hospital facilities such as the operating theatre (OT) and EDs use POCUS.³ In the ED, POCUS has shown to be quick, focused, goal-directed with minimal delay or need for specialised technical personnel. Point-of-care ultrasound has been well-established, validated protocols for use in acute emergencies.

The integration of the extended-focused assessment with sonography for trauma (e-FAST) in the initial assessment for suspected thoraco-abdominal injury has shown to have a therapeutic impact in patients with severe trauma, and the accuracy of lung ultrasound has also shown to be superior to that of chest radiography in the detection of a pneumothorax.^4,5 The use of focused cardiac ultrasound (FOCUS) has aided in diagnostic assessments, monitoring, therapy titration and procedural guidance in critically ill patients at the bedside.⁶ While studies have emerged noting potential harm of POCUS in prolonging cardiopulmonary resuscitation (CPR) pause duration, advances in resuscitation strategies during cardiac arrest and following return of spontaneous circulation (ROSC) have incorporated POCUS as a tool for detection of reversible causes of pulseless electrical activity (PEA).^7,8,9

Retrospective analyses have demonstrated the ability of emergency physicians to perform colour Doppler ultrasound and reduce time-to-disposition of patients while also maintaining good correlation in results during screening for deep vein thrombosis (DVT)^10,11; additionally, a bedside abdominal aortic aneurysm ultrasound performed by an emergency physician has shown to be accurate and fast.¹² Emergency physicians have also demonstrated proficiency in evaluating patients at risk of ectopic pregnancy, detecting hydronephrosis in suspected ureteral colic and diagnosing ocular pathology in ED.^13,14,15,16

The traditional paradigm of ultrasonography being performed by radiologists may become replaced by the POCUS paradigm in the ED as more methods of POCUS utility are described and published for acute critical care.

During the study period, there was a total of 964 study participants who met the inclusion criteria. One hundred and eighty of those participants only had a record of time and date saved. These participants were subsequently excluded because they had no record of POCUS type(s), images, video clips or PDF data saved. Therefore, most of the data on POCUS were based on 784 study participants (Figure 1).

The mean age of the studied population was 42.89 with a standard deviation of ±20.62 years. The male population had more POCUS exams (54.04%) than that of the opposite gender (45.96% were female).

From 01 September 2019 to 31 March 2020, a total of 978 POCUS exams were performed using the Mindray M6 ultrasound machine (Figure 2). The findings were normal in 17% of POCUS exams, positive in 31% of exams, 9% of exams were unspecified in terms of POCUS type and 43% of POCUS exams were inconclusive.

Different types of POCUS were performed at variable frequencies (Figure 3). Point-of-care ultrasound was utilised more often for focused emergency echocardiography in resuscitation (FEER) exams and eFAST exams with the month of October having the highest number of POCUS exams performed (Figure 4).

Positive findings were detected with POCUS exams (Table 1). Pleural free fluid was the most common finding with positive eFAST exams. Mitral valve disease, dysrhythmia, dilated cardiomyopathy and congenital heart anomaly were some of the additional abnormalities detected with FEER POCUS. Hydronephrosis, cholecystitis and enlarged optic nerve sheath diameter were noted on POCUS; additionally, POCUS was utilised for DVT and abdominal aortic aneurysm (AAA) screening.

The ultrasound machine was utilised more frequently during day-shift hours as opposed to after-hour use (Figure 5).

Eight percent of POCUS data had sonographer credentials saved (Figure 6).

The advantages of using POCUS in the ED make it a useful tool for resuscitative and diagnostic measures, procedure guidance, therapeutic and monitoring purposes. Although 12 emergency POCUS applications have been identified as essential for practice in the ED by the ACEP, proficiency and accreditation in the five level 1 emergency POCUS exams is the minimal recommended requirement by the College of Emergency Medicine of South Africa (CEMSA) for POCUS practice within our EDs.^18,19

Our study showed that the scope of practice of POCUS by doctors working in the ED at GJGMRH included trauma and cardiac assessment, AAA and DVT screening, first trimester pregnancy assessment, urinary and biliary tract assessment, ocular and soft tissue applications, procedure guidance and post-intubation thoracic assessment.

Focused emergency echocardiography in resuscitation and eFAST exams were the most frequent POCUS applications performed. A retrospective study by Stolz et al. reported similar indications for POCUS use in a rural ED in Uganda.²⁰ In their analysis, the FAST exam was the most utilised application for POCUS (n = 53.3%). Interestingly, nurses were the emergency care providers performing POCUS. Potentially, task shifting of clinical skills such as POCUS may be a means of improving service delivery in rural areas where doctors and resources are very limited.

Despite the numerous benefits of POCUS, it is an operator-dependent tool that relies on the information gathered in real time during the investigation in order to aid the clinical assessment and decision-making process. Emergency ultrasound guidelines recommend POCUS documentation to include image corroboration as part of medical record.¹⁸ In our study, 43% of POCUS exams had incomplete imaging data to conclude, 9% had insufficient documentation of POCUS categories and 180 study participants were excluded because of absent of POCUS image data. A survey conducted by Graglia et al., identified their barriers to POCUS utility-included time constraints and discomfort with machine operation, such as storing patient data and images.²¹ A different finding was observed in a multicentre study in Malawi, Tanzania and Uganda. Shokoohi et al. identified that lack of ultrasound knowledge was the most common barrier to POCUS utility rather than time and equipment issues.²² Given the abrupt nature of trauma and medical presentations in the ED, delivery of emergency care takes precedence over saving ultrasound data.

The ED at GJGMRH is one of the academic sites for rotating EM registrars. To date, the department has three emergency medicine specialists. This may have contributed to the peak in POCUS utility during day-shift hours noted in our study. Multiple factors may have played a role in the decline in ultrasound use in March including the declaration of a national state of disaster as a result of the COVID-19 pandemic.

The results of our study showed that the ED at GJGMRH integrated POCUS core applications for various emergency care scenarios. Further studies are needed to assess POCUS use, barriers and challenges with adopting POCUS practice by associated acute care medical specialties such as paediatric and adult intensive care units.