Implementing Ultrasound in Emergency Medical Services: Assessing Physician Proficiency and Training Requirements

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Modern technology makes ultrasound available in a mobile and portable form, so it can be used even in prehospital emergency care with several interventional and diagnostic applications. This also raises the question of what kind of education and training is necessary for EMS (emergency medical services) physicians to be able to use Point-of-Care Ultrasound (POCUS) in the prehospital setting. Aims : This observational study investigates the use of prehospital POCUS in a rural EMS area. It focuses the question of what level of competence is needed for EMS physicians to use POCUS adequately in the prehospital emergency setting for correct application and interpretation of the findings. Method: This was a quality assurance measure designed as a prospective cohort study. We investigated POCUS examinations performed by EMS physicians in the EMS Service Area of Nuremberg City, Germany between June 2021 and July 2022. Patients transported to three specific hospitals in Nuremberg city after care were followed up and the prehospital findings were compared with the in-hospital radiological results. The number of correct findings was correlated with the level of competence in POCUS examinations of the performing EMS physicians. Various classifications of competence were used to assess the influence of training and education on the safe application of prehospital POCUS. Results: 258 prehospital POCUS examinations were documented, with 108 followed up, including 268 sonographic findings. There was a wide range of indications for POCUS use. In 79.5% of cases the prehospital findings correspond with those in-hospital. By correlating the correct findings with the participants level of competence, there was no significant difference between POCUS-experienced and -inexperienced EMS physicians, even when divided into different categories. Conclusion: POCUS can be used in prehospital emergency care for a wide range of indications safely, with a high number of correct diagnoses and findings. Our results suggest that emergency POCUS is easy to learn and EMS physicians do not need intensive training to perform POCUS adequately in the prehospital setting. Emergency medical services POCUS sonography prehospital training Figures Figure 1 Figure 2 Take home messages Mobile ultrasound appears to be useful in the prehospital setting It can be used by EMS physicians even without extensive prior experience and expertise POCUS is able to find important findings for prehospital patient’s care with a high level of certainty Introduction Bedside ultrasound is an integral part of modern patient care and plays an important role in diagnosing and monitoring various diseases and traumatic injuries. In emergency medicine in particular it is essential to respond quickly to identify the patient’s acute problem for optimal care. Using bedside targeted ultrasound examinations (POCUS – Point-of-Care Ultrasound) is a crucial component of clinical diagnostics. The continuous development of technology of mobile ultrasound devices enables their use in prehospital care as well. More than 10 years ago, prehospital POCUS was cited as one of the top five research topics in emergency medicine (1). Since then, ultrasound diagnostic in prehospital emergency medicine has been increasingly mentioned, discussed and a variety of research on different aspects of its use has been published. A large number of publications addressed the implementation and use of ultrasound in the prehospital setting, not only for diagnostic purposes but also for assisting interventional procedures, such as vascular access (2–7). One particular focus of interest is the need for education and training (8–10). Across this research, participants typically received intensive training in prehospital POCUS examinations, either at the beginning or repeatedly during data collection. The question of what is necessary to gain competence in POCUS examination has been analyzed, and different concepts and training courses have been published. One of these, named pPOCUS (prehospital Point-of-Care Ultrasound), is currently published as a training concept for EMS physicians in Germany (11). Despite a series of reported experiences, the organization and intensity of training required to enable the use of emergency ultrasound in patient care remains an open question. Some publications name a certain number (e.g. 50–100) of examinations to be performed during training (12). However, in addition to the question of acquiring skills, there is also the question of how to maintain these skills over time. A large part of EMS physicians in Germany do not necessarily perform emergency ultrasound examinations regularly during their work in-hospital. The mere availability of mobile ultrasound in the prehospital setting does not necessarily ensure that sufficient conclusions can be obtained from the investigation. As the use of POCUS is not yet part of EMS physicians medical training programs and considering the wide spectrum of physicians working in emergency medicine in Germany, it seems important to know how POCUS competence can be achieved and sustained over time, especially regarding the fact that mobile ultrasound devices are rolled out extensively. This prospective observational study investigated the implementation of POCUS examinations in prehospital emergency care with regard to the question about what expertise and training EMS physicians need for appropriate utilization. Methods This study was a quality assurance measure designed as an observational prospective clinical trial. It adhered to the principles outlined in the Declaration of Helsinki, and its conduct was reviewed and approved by the institutional review board of PMU – Paracelsus Medical University, Nuremberg, Germany (IRB-2021-036). In May 2021, the four EMS physician ambulance cars of the Nuremberg City Ambulance Services were equipped with mobile ultrasound devices (GE Vscan Extend, GE Healthcare). Between June 2021 and July 2022, prehospital POCUS examinations performed by EMS physicians were recorded on a documentation form (Fig. 1 ) for prospective exploratory data collection. All patients who underwent ultrasound examination and were transported to one of the three sites of Nuremberg City Hospital - Campus South (Level III care), Campus North (Level II care) and Hospital Lauf/Pegnitz (Level I care) - for further treatment were followed up regarding the radiological and sonographic findings obtained there. If a patient was left on site after emergency care or transported to another Nuremberg hospital, data were not available and not followed up. Ultrasound diagnostics in prehospital emergency care The indication for performing POCUS on site was left to the attending EMS physician. There was no randomization or blinding. In addition, we asked the indication for POCUS use on scene and the time spent on the patient’s investigation (less than 3min, 3-5min or more than 5min). Table 1 shows the overview of type and characteristics of prehospital POCUS findings on the documentation form, which was created by the research group and displayed on each rescue station on paper (Fig. 1 ). POCUS competence of participating EMS physicians To compare the different levels of competence in emergency POCUS examinations, a scoring system was developed to categorize the participating emergency physicians. This scoring was based on the consensus of five independent experts in emergency medicine. None was involved in data collection or implementation of this study. The following aspects were included: I) Frequency of use of ultrasound in daily clinical practice : Less than 1/month − 1/month - several times/month − 1/week - several times/week - daily use - several times/day II) Proportion of emergency POCUS examinations (estimated) 0% − 1–25% − 26–50% − 51–75% − 76–100% III) Number of attended POCUS courses and training concepts (such as FAST, FATE, FEEL, RUSH…) 0–1/2 - >2 Based on this categorization, a total of three different classifications of participants were made according to their ultrasound competence (Table 2). All prehospital ultrasound findings were compared with regard to the radiological findings obtained in-hospital (ultrasound examination, X-ray or CT scan during emergency room treatment). It was documented whether the in-hospital findings corresponded with those from prehospital assessments and whether these were therefore correctly recorded during the prehospital POCUS examination. Statistical methods Data was checked for consistency. Fisher’s Exact test or Pearson’s Chi-Squared test were used to analyze cross tabulations. All reported tests were two-sided, and p-values < 0.05 were considered statistically significant. All statistical analyses in this report were performed by use of STATISTICA 13 (Hill, T. & Lewicki, P. Statistics: Methods and Applications. StatSoft, Tulsa, OK). Results Cohort: A total of 32 EMS physicians participated in data collection. The physician’s epidemiological data is shown in Table 2. A total number of 258 prehospital POCUS examinations were documented during the observation period. In 108 (41.5%) of these, the in-hospital findings were available and followed up. All other documented patients (n = 140) were either left at home after treatment or admitted to a hospital where in-hospital data was not available. The median age of the examined and followed up patients (n = 108) was 66.4 years (1;90), 44.9% were female (n = 59). Ultrasound diagnostics in prehospital emergency care A total number of 268 POCUS findings were recorded during the 108 sonographic examinations. The comparison with in-hospital radiological examinations showed a high degree of correct findings in the performed prehospital ultrasound. In 79.5% of the POCUS examinations (n = 210), the documented prehospital findings corresponded to those in-hospital. In 65.7% (n = 71) of all cases, less than 3 minutes were required to perform the POCUS examination, in 28.7% (n = 31) it took 3–5 minutes, none was more than 5min, 5.6% (n = 6) of cases time was not documented. The distribution of indications for POCUS use is shown in Fig. 2 (n = 108) A listing of all prehospital POCUS findings and the number of identical results in in-hospital diagnostics is shown in Table 3 . POCUS competence of participating EMS physicians Data about attended training courses and the usage of ultrasound was available from 28 EMS physicians. As shown in Table 1 scoring system, the participants were rated according to their level of competence in the use of ultrasound. When divided into two levels of competence (named High2 and Low2), we had n = 7 (25%) in Low2 and n = 21 (75%) in High2. By dividing into three levels of competence (Low3, Medium3 and High3), we found n = 4 (14%) in Low3, n = 12 (43%) in Medium3 and n = 12 (43%) in High3. By dividing into two categories (named no use and use ), we found n = 2 (7%) in no use group and n = 26 (93%) in use categorized. Number of correct POCUS findings compared with level of competence Table 4 a shows the results of comparing the number of correct prehospital POCUS findings and the level of competence of performing EMS physicians (three competence levels: Low3 - Medium3 - High3 and two competence levels: no use - use ). 4b shows these relations graphically as an Alluvial diagram. In none of the different categorizations we found any significant differences in comparison, the same result was observed when divided into two categories Low2 - High2. Discussion In recent years, mobile ultrasound has increasingly found its way into emergency medicine as a useful and important tool for detecting serious problems bed-side respectively on scene. The work presented here examines POCUS use in prehospital care in Germany and the need for EMS physician’s education to perform adequately. Our data shows a wide range of indications for POCUS examinations in various leading symptoms relevant to emergency medicine. Already established in trauma patients (13), ultrasound also appears to be able to provide findings for prehospital care in many internal medical conditions too, especially by examining the heart and lungs. Participants used mobile hand-held ultrasound devices focused on answering certain questions on scene. All examinations took less than 5 minutes. This time span was also demonstrated in other studies, so time on scene was not significantly extended in operations in which ultrasound examinations were performed prehospital (14). This alleviates concerns about delays in patient care when using prehospital emergency POCUS. Regarding all this, our results are comparable to those from recent years (1;3;5; 15–22). A research group from Switzerland investigated the distraction caused by ultrasound examinations of critically ill patients. They found a significant decrease in oxygen saturation went unnoticed in 75% of cases when ultrasound was used caused by focusing on POCUS examination during patient’s care. This result should be taken into account when considering whether ultrasound provides an advantage in treatment (23). Despite the fact that on scene time is not significantly affected, ultrasound examination can distract the emergency physician`s focus, especially the inexperienced, from upcoming serious patient’s problems and immediate treatment. Looking at the course of the patient, it was found that in addition to early diagnosis and thus more targeted therapy, the length of hospital stay of patients who have undergone prehospital sonography is shorter than that of patients who have not had an ultrasound examination which demonstrates a clear advantage of prehospital ultrasound (23). From the author’s point of view, these data underline the important role POCUS has found in becoming an integral part of prehospital care, so it should be used universally. We also addressed the question of what intensity of POCUS training is needed for safe use in prehospital patient care. We found a high agree of agreement when comparing our cohort’s prehospital POCUS findings with in-hospital results (79.5% in total). A high level of safety was observed, particularly in the search for critical life-threatening pathologies such as pneumothorax (correctly diagnosed in 91.7% of cases), pericardial effusion (correct in 89.2%) or free abdominal fluid after trauma (86.9%). Even in examining the left ventricular function of the heart (LV-EF) which requires a higher level of expertise than e.g. the assessment of B-lines over the lungs, a high level of agreement between the findings was observed (correct in 60%). In the vast majority of other prehospital POCUS publications, participants have had special training in POCUS examinations before or further education during data collection (2;3;5;6). Most EMS physicians in Germany are not necessarily well-trained and specialized in using ultrasound. We compared the prehospital ultrasound findings with the results of in-hospital radiological diagnostics during emergency department care. Participating EMS physicians were divided into different levels of competence in emergency ultrasound examinations using a developed scoring system. Unfortunately, no statistically significant difference was found between groups with different levels of expertise. This raises the question of whether, conversely, practical experience plays no role in the correct use of emergency ultrasound. The experience gained from the application and logic say no. What we found is that even EMS physicians with a low level of expertise in ultrasound examinations seem to be able to perform POCUS correctly at the prehospital scene. It must be taken into account that the number of examinations carried out by inexperienced emergency physicians was very low compared to the number of (very) experienced physicians and only a few examination results were documented for the respective findings. Findings were correct in a high number of cases and remain in good correlation with those obtained in-hospital. Of course, safe use requires training and regular practice. However, data suggests that one does not need to be a highly trained specialist in ultrasound diagnostics to perform prehospital POCUS savely. With attended training courses (like pPOCUS - prehospital Point of Care Ultrasound) and consistent use of ultrasound (e.g. several times/month), reliable findings for patient’s care can be obtained safely. It is essential to remember that competence and training in emergency POCUS are necessary. It is not sufficient to simply roll out mobile ultrasound devices area wide. Educational training concepts like pPOCUS, focusing prehospital ultrasound use are needed. Limitations When considering the results, several limitations must be taken into account. This study was a prospective observational trial. For obvious reasons no randomization or blinding was conducted. There were no guidelines for the participating EMS physicians regarding whether or which symptoms POCUS examinations should be performed prehospital. The decision was left to the respective EMS physician. The same applied to the documentation of the examinations. It cannot be ruled out that not all examinations were documented. Follow up in-hospital data was available in only 108 cases. There was a high number of „lost cases“ due to no transport to a hospital or the inability to obtain the in-hospital findings. The four emergency ambulances in Nuremberg city complete around 23,000 missions per year (data from the rescue control center of the City of Nuremberg). Only a number of 258 POCUS examinations were documented as part of our study. Of the approximately 100 EMS physicians in the Nuremberg City ambulance service, only 32 participated in the study. Regarding this, a possibility of selection bias must be taken into account. Emergency POCUS was mostly performed by (very) experienced providers. There was just a small number of POCUS inexperienced EMS physicians. So we had limited data available for comparison between EMS physicians with different levels of competence. Additionally, from a medical point of view, sonographic findings may already will change during prehospital treatment. The examination results in the ED may already be different, even though the ultrasound findings were correctly recorded prehospital. For example, the extent of heart failure may improve rapidly as a result of initial treatment, leading to an increased LV-EF over time, or no B-lines may be visualized over the lungs as treatment progresses. The question of whether the study’s POCUS findings had an influence on prehospital treatment, therapeutical or organizational questions during prehospital care is part of an additional study, results are not discussed in this manuscript. Conclusions The indications for the use of prehospital ultrasound extend beyond those for (poly)trauma or cardiopulmonary resuscitation. There is no significant time delay in patient care when performing prehospital POCUS on scene. Education and training are needed, but data suggest that prehospital POCUS use can be learned quickly, with a high level of quality in obtaining the findings. Prehospital POCUS does not require a complete sonographic examination. The decisive factor is the possibility of focused diagnostics in order to identify life-threatening pathologies quickly or to rule out with a high degree of certainty. Further studies are needed to assess POCUS influence on outcomes and mortality. In view of the experience from ultrasound use in anesthesiology, intensive care and in-hospital emergency care, we support the call for widespread mobile ultrasound for prehospital use. Declarations Conflict of interest statement There is no conflict of interest in conducting this study, and there was no financial support from industry or other interest groups. The four ultrasound devices on Nuremberg City EMS cars were purchased solely through donations from the public. Author Contribution J.H. and C.E. wrote the main manuscript in equal parts, D.L. was involved in data acquisition, W.H. processed data for statistical analysis, T.H., A.K. and J.K. were responsible for participitating physicians competence level scoring. References Bøtker MT, Jacobsen L, Rudolph SS et al. The role of point of care ultrasound in prehospital critical care: a systematic review. Scand J Trauma Resusc Emerg Med. 2018 Jun 26;26(1):51. doi: 10.1186/s13049-018-0518-x. Breitkreutz R, Campo Delľ Orto M, Hamm C et al. Does the integration of personalized ultrasound change patient management in critical care medicine? Observational trials. Emerg Med Int. 2013;2013:946059. doi: 10.1155/2013/946059 Weilbach C, Kobiella A, Rahe-Meyer N et al. Introduction of Prehospital Emergency Ultrasound into an Emergency Medical Service Area. Anaesthesist. 2017 Jan;66(1):21-27. German. doi: 10.1007/s00101-016-0248-2. Scharonow M, Weilbach C. Prehospital point-of-care emergency ultrasound: a cohort study. Scand J Trauma Resusc Emerg Med. 2018 Jun 18;26:49. doi: 10.1186/s13049-018-0519-9. Mandavia DP, Hoffner RJ, Mahaney K et al. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001 Oct;38:377-82. doi: 10.1067/mem.2001.118224. Ienghong K, Cheung LW, Tiamkao S et al.. The Utilization of Handheld Ultrasound Devices in a Prehospital Setting. Prehosp Disaster Med. 2022 Jun; 37:355-359. doi: 10.1017/S1049023X22000644. Imbriaco G. The Expanding Role of Ultrasound Vascular Access Procedures in Prehospital Emergency Medical Services. Prehosp Disaster Med. 2022 Jun;37(3):424-425. doi:10.1017/S1049023X22000589. Naeem S, Edmunds C, Hirst T et al. A National Survey of Prehospital Care Services of United Kingdom for Use, Governance and Perception of Prehospital Point of Care Ultrasound. POCUS J. 2022 Nov 21;7:232-238. doi: 10.24908/pocus.v7i2.15739. Meadley B, Olaussen A, Delorenzo A et al. Educational standards for training paramedics in ultrasound: a scoping review. BMC Emerg Med. 2017 Jun 17;17:18. doi: 10.1186/s12873-017-0131-8. Eimer C, Lorenzen U, Reifferscheid F et al. Ultrasound diagnostics in prehospital emergency care-do we need a standardized educational approach?. Med Klin Intensivmed Notfmed. 2023 Aug 14. German. doi: 10.1007/s00063-023-01045-4. Michels G, Greim CA, Krohn A et al. Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN. Med Klin Intensivmed Notfmed. 2023 Dec;118(Suppl 1):39-46. doi: 10.1007/s00063-023-01054-3. Hempel D, Michels G. Sonography in intensive care and emergency medicine : A new training concept. Med Klin Intensivmed Notfmed. 2021 May;116:301-306. German. doi: 10.1007/s00063-020-00688-x. Walcher F, Weinlich M, Conrad G et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg. 2006 Feb;93:238-42. doi: 10.1002/bjs.5213. Ienghong K, Cheung LW et al. The Impact of Prehospital Point of Care Ultrasounds on Emergency Patients Length of Stay in Thailand. Journal of Multidisciplinary Healthcare 2023: https://www.dovepress.com/the-impact-of-prehospital-point-of-care-ultrasounds-on-emergency-patie-peer-reviewed-fulltext-article-JMDH#cit0003 Canakci ME, Ozakin E, Acar N. POCUS in Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med. 2022 Jun;37:423. doi: 10.1017/S1049023X22000577. Atkinson P, Bowra J, Milne J et al. International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. CJEM. 2017 Nov;19:459-470. doi: 10.1017/cem.2016.394. Kjesbu IE, Laursen CB, Graven T et al. Feasibility and Diagnostic Accuracy of Point-of-Care Abdominal Sonography by Pocket-Sized Imaging Devices, Performed by Medical Residents. J Ultrasound Med. 2017 Jun;36:1195-1202. doi: 10.7863/ultra.16.05077. Laursen CB, Hänselmann A, Posth S et al. Prehospital lung ultrasound for the diagnosis of cardiogenic pulmonary oedema: a pilot study. Scand J Trauma Resusc Emerg Med. 2016 Aug;24:96. doi: 10.1186/s13049-016-0288-2. Hagendorff A, Tiemann K, Simonis G et al. Recommendations on emergency echocardiography. Kardiologe 2014: 8, 45–64. https://doi.org/10.1007/s12181-013-0531-2 Estoos E, Nakitende D. Diagnostic Ultrasound Use in Undifferentiated Hypotension. 2023 Apr 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29763130. Soyuncu S, Cete Y, Bozan H et al. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury. 2007 May;38:564-9. doi: 10.1016/j.injury.2007.01.010. Betz1 R, Gilbert A, Moens D et al. Prehospital point of care ultrasound in Helicopter Emergency Medical Services: a 5-year experience study in Belgium. Front. Disaster Emerg. Med., 28 October 2024: https://www.frontiersin.org/journals/disaster-and-emergency-medicine/articles/10.3389/femer.2024.1440545/full van der Geest Y, Marengo L, Albrecht R et al. Prehospital ultrasound constitutes a potential distraction from the observation of critically ill patients: a prospective simulation study. Scandinavian Journal of Trauma 2024: https://sjtrem.biomedcentral.com/articles/10.1186/s13049-024-01280-4#citeas Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 20 May, 2025 Read the published version in Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine → Version 1 posted Editorial decision: Accepted 14 Apr, 2025 Reviews received at journal 03 Apr, 2025 Reviewers agreed at journal 28 Mar, 2025 Reviewers invited by journal 28 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 23 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5875169","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435513755,"identity":"44813078-4950-4f7e-b6d1-b99f0d33915b","order_by":0,"name":"Johanna Haack","email":"","orcid":"","institution":"Paracelsus Medical University","correspondingAuthor":false,"prefix":"","firstName":"Johanna","middleName":"","lastName":"Haack","suffix":""},{"id":435513756,"identity":"107e3806-8547-4e7b-8fee-9cafe8db83b9","order_by":1,"name":"Daniel Lämmermann","email":"","orcid":"","institution":"Paracelsus Medical 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Engelen","email":"data:image/png;base64,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","orcid":"","institution":"Paracelsus Medical University","correspondingAuthor":true,"prefix":"","firstName":"Christian","middleName":"","lastName":"Engelen","suffix":""}],"badges":[],"createdAt":"2025-01-21 17:40:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5875169/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5875169/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13049-025-01391-6","type":"published","date":"2025-05-20T15:57:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79819613,"identity":"7691bd62-948c-4cc6-9725-2a318c96cc96","added_by":"auto","created_at":"2025-04-03 08:33:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":136159,"visible":true,"origin":"","legend":"\u003cp\u003eDocumentation form used for documenting POCUS findings\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5875169/v1/fca2dada6d9cbf973b800950.jpg"},{"id":79819614,"identity":"3c8a978f-e620-419c-837a-5244844e4b44","added_by":"auto","created_at":"2025-04-03 08:33:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92266,"visible":true,"origin":"","legend":"\u003cp\u003eIndications for use of prehospital ultrasound diagnostics\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5875169/v1/b335b96f77a3cd957c888993.png"},{"id":83459958,"identity":"538c7420-a6eb-4c95-9317-182bf109b81b","added_by":"auto","created_at":"2025-05-26 16:05:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":752031,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5875169/v1/aced4c5a-4b44-4afa-992c-315b718559ff.pdf"},{"id":79819615,"identity":"97b653c1-c70e-4bd2-8be3-ffdc564bb540","added_by":"auto","created_at":"2025-04-03 08:33:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":845469,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5875169/v1/bdb33384a13ab1a24f27048c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing Ultrasound in Emergency Medical Services: Assessing Physician Proficiency and Training Requirements","fulltext":[{"header":"Take home messages","content":"\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eMobile ultrasound appears to be useful in the prehospital setting\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIt can be used by EMS physicians even without extensive prior experience and expertise\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePOCUS is able to find important findings for prehospital patient’s care with a high level of certainty\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eBedside ultrasound is an integral part of modern patient care and plays an important role in diagnosing and monitoring various diseases and traumatic injuries. In emergency medicine in particular it is essential to respond quickly to identify the patient\u0026rsquo;s acute problem for optimal care. Using bedside targeted ultrasound examinations (POCUS \u0026ndash; Point-of-Care Ultrasound) is a crucial component of clinical diagnostics.\u003c/p\u003e \u003cp\u003eThe continuous development of technology of mobile ultrasound devices enables their use in prehospital care as well. More than 10 years ago, prehospital POCUS was cited as one of the top five research topics in emergency medicine (1). Since then, ultrasound diagnostic in prehospital emergency medicine has been increasingly mentioned, discussed and a variety of research on different aspects of its use has been published. A large number of publications addressed the implementation and use of ultrasound in the prehospital setting, not only for diagnostic purposes but also for assisting interventional procedures, such as vascular access (2\u0026ndash;7). One particular focus of interest is the need for education and training (8\u0026ndash;10). Across this research, participants typically received intensive training in prehospital POCUS examinations, either at the beginning or repeatedly during data collection. The question of what is necessary to gain competence in POCUS examination has been analyzed, and different concepts and training courses have been published. One of these, named pPOCUS (prehospital Point-of-Care Ultrasound), is currently published as a training concept for EMS physicians in Germany (11).\u003c/p\u003e \u003cp\u003eDespite a series of reported experiences, the organization and intensity of training required to enable the use of emergency ultrasound in patient care remains an open question. Some publications name a certain number (e.g. 50\u0026ndash;100) of examinations to be performed during training (12). However, in addition to the question of acquiring skills, there is also the question of how to maintain these skills over time. A large part of EMS physicians in Germany do not necessarily perform emergency ultrasound examinations regularly during their work in-hospital. The mere availability of mobile ultrasound in the prehospital setting does not necessarily ensure that sufficient conclusions can be obtained from the investigation.\u003c/p\u003e \u003cp\u003eAs the use of POCUS is not yet part of EMS physicians medical training programs and considering the wide spectrum of physicians working in emergency medicine in Germany, it seems important to know how POCUS competence can be achieved and sustained over time, especially regarding the fact that mobile ultrasound devices are rolled out extensively.\u003c/p\u003e \u003cp\u003eThis prospective observational study investigated the implementation of POCUS examinations in prehospital emergency care with regard to the question about what expertise and training EMS physicians need for appropriate utilization.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was a quality assurance measure designed as an observational prospective clinical trial. It adhered to the principles outlined in the Declaration of Helsinki, and its conduct was reviewed and approved by the institutional review board of PMU \u0026ndash; Paracelsus Medical University, Nuremberg, Germany (IRB-2021-036).\u003c/p\u003e\n\u003cp\u003eIn May 2021, the four EMS physician ambulance cars of the Nuremberg City Ambulance Services were equipped with mobile ultrasound devices (GE Vscan Extend, GE Healthcare). Between June 2021 and July 2022, prehospital POCUS examinations performed by EMS physicians were recorded on a documentation form (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) for prospective exploratory data collection. All patients who underwent ultrasound examination and were transported to one of the three sites of Nuremberg City Hospital - Campus South (Level III care), Campus North (Level II care) and Hospital Lauf/Pegnitz (Level I care) - for further treatment were followed up regarding the radiological and sonographic findings obtained there. If a patient was left on site after emergency care or transported to another Nuremberg hospital, data were not available and not followed up.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eUltrasound diagnostics in prehospital emergency care\u003c/h2\u003e\n \u003cp\u003eThe indication for performing POCUS on site was left to the attending EMS physician. There was no randomization or blinding. In addition, we asked the indication for POCUS use on scene and the time spent on the patient\u0026rsquo;s investigation (less than 3min, 3-5min or more than 5min).\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the overview of type and characteristics of prehospital POCUS findings on the documentation form, which was created by the research group and displayed on each rescue station on paper (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePOCUS competence of participating EMS physicians\u003c/h3\u003e\n\u003cp\u003eTo compare the different levels of competence in emergency POCUS examinations, a scoring system was developed to categorize the participating emergency physicians. This scoring was based on the consensus of five independent experts in emergency medicine. None was involved in data collection or implementation of this study. The following aspects were included:\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003eI) Frequency of use of ultrasound in daily clinical practice\u003c/em\u003e:\u003c/div\u003e\n\u003cp\u003eLess than 1/month \u0026minus;\u0026thinsp;1/month - several times/month \u0026minus;\u0026thinsp;1/week - several times/week - daily use - several times/day\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003eII) Proportion of emergency POCUS examinations (estimated)\u003c/em\u003e\u003c/div\u003e\n\u003cp class=\"Heading\"\u003e0% \u0026minus;\u0026thinsp;1\u0026ndash;25% \u0026minus;\u0026thinsp;26\u0026ndash;50% \u0026minus;\u0026thinsp;51\u0026ndash;75% \u0026minus;\u0026thinsp;76\u0026ndash;100%\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003cp\u003e\u003cem\u003eIII) Number of attended POCUS courses and training concepts\u003c/em\u003e (such as FAST, FATE, FEEL, RUSH\u0026hellip;) 0\u0026ndash;1/2 - \u0026gt;2\u003c/p\u003e\n \u003cp\u003eBased on this categorization, a total of three different classifications of participants were made according to their ultrasound competence (Table 2).\u003c/p\u003e\n \u003cp\u003eAll prehospital ultrasound findings were compared with regard to the radiological findings obtained in-hospital (ultrasound examination, X-ray or CT scan during emergency room treatment). It was documented whether the in-hospital findings corresponded with those from prehospital assessments and whether these were therefore correctly recorded during the prehospital POCUS examination.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical methods\u003c/h2\u003e\n \u003cp\u003eData was checked for consistency. Fisher\u0026rsquo;s Exact test or Pearson\u0026rsquo;s Chi-Squared test were used to analyze cross tabulations. All reported tests were two-sided, and p-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. All statistical analyses in this report were performed by use of STATISTICA 13 (Hill, T. \u0026amp; Lewicki, P. Statistics: Methods and Applications. StatSoft, Tulsa, OK).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eCohort:\u003c/h2\u003e\n\u003cp\u003eA total of 32 EMS physicians participated in data collection. The physician\u0026rsquo;s epidemiological data is shown in Table\u0026nbsp;2.\u003c/p\u003e\n\u003cp\u003eA total number of 258 prehospital POCUS examinations were documented during the observation period. In 108 (41.5%) of these, the in-hospital findings were available and followed up. All other documented patients (n\u0026thinsp;=\u0026thinsp;140) were either left at home after treatment or admitted to a hospital where in-hospital data was not available.\u003c/p\u003e\n\u003cp\u003eThe median age of the examined and followed up patients (n\u0026thinsp;=\u0026thinsp;108) was 66.4 years (1;90), 44.9% were female (n\u0026thinsp;=\u0026thinsp;59).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eUltrasound diagnostics in prehospital emergency care\u003c/h2\u003e\n\u003cp\u003eA total number of 268 POCUS findings were recorded during the 108 sonographic examinations. The comparison with in-hospital radiological examinations showed a high degree of correct findings in the performed prehospital ultrasound. In 79.5% of the POCUS examinations (n\u0026thinsp;=\u0026thinsp;210), the documented prehospital findings corresponded to those in-hospital.\u003c/p\u003e\n\u003cp\u003eIn 65.7% (n\u0026thinsp;=\u0026thinsp;71) of all cases, less than 3 minutes were required to perform the POCUS examination, in 28.7% (n\u0026thinsp;=\u0026thinsp;31) it took 3\u0026ndash;5 minutes, none was more than 5min, 5.6% (n\u0026thinsp;=\u0026thinsp;6) of cases time was not documented.\u003c/p\u003e\n\u003cp\u003eThe distribution of indications for POCUS use is shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e (n\u0026thinsp;=\u0026thinsp;108)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA listing of all prehospital POCUS findings and the number of identical results in in-hospital diagnostics is shown in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cp\u003ePOCUS competence of participating EMS physicians\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003cp\u003eData about attended training courses and the usage of ultrasound was available from 28 EMS physicians. As shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e scoring system, the participants were rated according to their level of competence in the use of ultrasound.\u003c/p\u003e\n\u003cp\u003eWhen divided into two levels of competence (named High2 and Low2), we had n\u0026thinsp;=\u0026thinsp;7 (25%) in Low2 and n\u0026thinsp;=\u0026thinsp;21 (75%) in\u003c/p\u003e\n\u003cp\u003eHigh2. By dividing into three levels of competence (Low3, Medium3 and High3), we found n\u0026thinsp;=\u0026thinsp;4 (14%) in Low3, n\u0026thinsp;=\u0026thinsp;12 (43%) in Medium3 and n\u0026thinsp;=\u0026thinsp;12 (43%) in High3.\u003c/p\u003e\n\u003cp\u003eBy dividing into two categories (named \u003cem\u003eno use\u003c/em\u003e and \u003cem\u003euse\u003c/em\u003e), we found n\u0026thinsp;=\u0026thinsp;2 (7%) in \u003cem\u003eno use\u003c/em\u003e group and n\u0026thinsp;=\u0026thinsp;26 (93%) in \u003cem\u003euse\u003c/em\u003e categorized.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003eNumber of correct POCUS findings compared with level of competence\u003c/h2\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003ea shows the results of comparing the number of correct prehospital POCUS findings and the level of competence of performing EMS physicians (three competence levels: Low3 - Medium3 - High3 and two competence levels: \u003cem\u003eno use\u003c/em\u003e - \u003cem\u003euse\u003c/em\u003e). 4b shows these relations graphically as an Alluvial diagram.\u003c/p\u003e\n\u003cp\u003eIn none of the different categorizations we found any significant differences in comparison, the same result was observed when divided into two categories Low2 - High2.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn recent years, mobile ultrasound has increasingly found its way into emergency medicine as a useful and important tool for detecting serious problems bed-side respectively on scene. The work presented here examines POCUS use in prehospital care in Germany and the need for EMS physician’s education to perform adequately.\u003c/p\u003e \u003cp\u003eOur data shows a wide range of indications for POCUS examinations in various leading symptoms relevant to emergency medicine. Already established in trauma patients (13), ultrasound also appears to be able to provide findings for prehospital care in many internal medical conditions too, especially by examining the heart and lungs.\u003c/p\u003e \u003cp\u003eParticipants used mobile hand-held ultrasound devices focused on answering certain questions on scene. All examinations took less than 5 minutes. This time span was also demonstrated in other studies, so time on scene was not significantly extended in operations in which ultrasound examinations were performed prehospital (14). This alleviates concerns about delays in patient care when using prehospital emergency POCUS. Regarding all this, our results are comparable to those from recent years (1;3;5; 15–22).\u003c/p\u003e \u003cp\u003eA research group from Switzerland investigated the distraction caused by ultrasound examinations of critically ill patients. They found a significant decrease in oxygen saturation went unnoticed in 75% of cases when ultrasound was used caused by focusing on POCUS examination during patient’s care. This result should be taken into account when considering whether ultrasound provides an advantage in treatment (23). Despite the fact that on scene time is not significantly affected, ultrasound examination can distract the emergency physician`s focus, especially the inexperienced, from upcoming serious patient’s problems and immediate treatment.\u003c/p\u003e \u003cp\u003eLooking at the course of the patient, it was found that in addition to early diagnosis and thus more targeted therapy, the length of hospital stay of patients who have undergone prehospital sonography is shorter than that of patients who have not had an ultrasound examination which demonstrates a clear advantage of prehospital ultrasound (23).\u003c/p\u003e \u003cp\u003eFrom the author’s point of view, these data underline the important role POCUS has found in becoming an integral part of prehospital care, so it should be used universally.\u003c/p\u003e \u003cp\u003eWe also addressed the question of what intensity of POCUS training is needed for safe use in prehospital patient care. We found a high agree of agreement when comparing our cohort’s prehospital POCUS findings with in-hospital results (79.5% in total). A high level of safety was observed, particularly in the search for critical life-threatening pathologies such as pneumothorax (correctly diagnosed in 91.7% of cases), pericardial effusion (correct in 89.2%) or free abdominal fluid after trauma (86.9%). Even in examining the left ventricular function of the heart (LV-EF) which requires a higher level of expertise than e.g. the assessment of B-lines over the lungs, a high level of agreement between the findings was observed (correct in 60%).\u003c/p\u003e \u003cp\u003eIn the vast majority of other prehospital POCUS publications, participants have had special training in POCUS examinations before or further education during data collection (2;3;5;6). Most EMS physicians in Germany are not necessarily well-trained and specialized in using ultrasound. We compared the prehospital ultrasound findings with the results of in-hospital radiological diagnostics during emergency department care. Participating EMS physicians were divided into different levels of competence in emergency ultrasound examinations using a developed scoring system.\u003c/p\u003e \u003cp\u003eUnfortunately, no statistically significant difference was found between groups with different levels of expertise.\u003c/p\u003e \u003cp\u003eThis raises the question of whether, conversely, practical experience plays no role in the correct use of emergency ultrasound. The experience gained from the application and logic say no. What we found is that even EMS physicians with a low level of expertise in ultrasound examinations seem to be able to perform POCUS correctly at the prehospital scene. It must be taken into account that the number of examinations carried out by inexperienced emergency physicians was very low compared to the number of (very) experienced physicians and only a few examination results were documented for the respective findings. Findings were correct in a high number of cases and remain in good correlation with those obtained in-hospital. Of course, safe use requires training and regular practice. However, data suggests that one does not need to be a highly trained specialist in ultrasound diagnostics to perform prehospital POCUS savely. With attended training courses (like pPOCUS - prehospital Point of Care Ultrasound) and consistent use of ultrasound (e.g. several times/month), reliable findings for patient’s care can be obtained safely. It is essential to remember that competence and training in emergency POCUS are necessary. It is not sufficient to simply roll out mobile ultrasound devices area wide. Educational training concepts like pPOCUS, focusing prehospital ultrasound use are needed.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eWhen considering the results, several limitations must be taken into account. This study was a prospective observational trial. For obvious reasons no randomization or blinding was conducted. There were no guidelines for the participating EMS physicians regarding whether or which symptoms POCUS examinations should be performed prehospital. The decision was left to the respective EMS physician. The same applied to the documentation of the examinations. It cannot be ruled out that not all examinations were documented.\u003c/p\u003e\u003cp\u003eFollow up in-hospital data was available in only 108 cases. There was a high number of „lost cases“ due to no transport to a hospital or the inability to obtain the in-hospital findings. The four emergency ambulances in Nuremberg city complete around 23,000 missions per year (data from the rescue control center of the City of Nuremberg). Only a number of 258 POCUS examinations were documented as part of our study. Of the approximately 100 EMS physicians in the Nuremberg City ambulance service, only 32 participated in the study. Regarding this, a possibility of selection bias must be taken into account. Emergency POCUS was mostly performed by (very) experienced providers. There was just a small number of POCUS inexperienced EMS physicians. So we had limited data available for comparison between EMS physicians with different levels of competence.\u003c/p\u003e\u003cp\u003eAdditionally, from a medical point of view, sonographic findings may already will change during prehospital treatment. The examination results in the ED may already be different, even though the ultrasound findings were correctly recorded prehospital. For example, the extent of heart failure may improve rapidly as a result of initial treatment, leading to an increased LV-EF over time, or no B-lines may be visualized over the lungs as treatment progresses.\u003c/p\u003e\u003cp\u003eThe question of whether the study’s POCUS findings had an influence on prehospital treatment, therapeutical or organizational questions during prehospital care is part of an additional study, results are not discussed in this manuscript.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe indications for the use of prehospital ultrasound extend beyond those for (poly)trauma or cardiopulmonary resuscitation. There is no significant time delay in patient care when performing prehospital POCUS on scene.\u003c/p\u003e \u003cp\u003eEducation and training are needed, but data suggest that prehospital POCUS use can be learned quickly, with a high level of quality in obtaining the findings. Prehospital POCUS does not require a complete sonographic examination. The decisive factor is the possibility of focused diagnostics in order to identify life-threatening pathologies quickly or to rule out with a high degree of certainty.\u003c/p\u003e \u003cp\u003eFurther studies are needed to assess POCUS influence on outcomes and mortality. In view of the experience from ultrasound use in anesthesiology, intensive care and in-hospital emergency care, we support the call for widespread mobile ultrasound for prehospital use.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of interest statement\u003c/h2\u003e \u003cp\u003eThere is no conflict of interest in conducting this study, and there was no financial support from industry or other interest groups. The four ultrasound devices on Nuremberg City EMS cars were purchased solely through donations from the public.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.H. and C.E. wrote the main manuscript in equal parts, D.L. was involved in data acquisition, W.H. processed data for statistical analysis, T.H., A.K. and J.K. were responsible for participitating physicians competence level scoring.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eB\u0026oslash;tker MT, Jacobsen L, Rudolph SS et al. The role of point of care ultrasound in prehospital critical care: a systematic review. Scand J Trauma Resusc Emerg Med. 2018 Jun 26;26(1):51. doi: 10.1186/s13049-018-0518-x.\u003c/li\u003e\n\u003cli\u003eBreitkreutz R, Campo Delľ Orto M, Hamm C et al. Does the integration of personalized ultrasound change patient management in critical care medicine? Observational trials. Emerg Med Int. 2013;2013:946059. doi: 10.1155/2013/946059\u003c/li\u003e\n\u003cli\u003eWeilbach C, Kobiella A, Rahe-Meyer N et al. Introduction of Prehospital Emergency Ultrasound into an Emergency Medical Service Area. Anaesthesist. 2017 Jan;66(1):21-27. German. doi: 10.1007/s00101-016-0248-2.\u003c/li\u003e\n\u003cli\u003eScharonow M, Weilbach C. Prehospital point-of-care emergency ultrasound: a cohort study. Scand J Trauma Resusc Emerg Med. 2018 Jun 18;26:49. doi: 10.1186/s13049-018-0519-9.\u003c/li\u003e\n\u003cli\u003eMandavia DP, Hoffner RJ, Mahaney K et al. Bedside echocardiography by emergency physicians. Ann Emerg Med. 2001 Oct;38:377-82. doi: 10.1067/mem.2001.118224.\u003c/li\u003e\n\u003cli\u003eIenghong K, Cheung LW, Tiamkao S et al.. The Utilization of Handheld Ultrasound Devices in a Prehospital Setting. Prehosp Disaster Med. 2022 Jun; 37:355-359. doi: 10.1017/S1049023X22000644.\u003c/li\u003e\n\u003cli\u003eImbriaco G. The Expanding Role of Ultrasound Vascular Access Procedures in Prehospital Emergency Medical Services. Prehosp Disaster Med. 2022 Jun;37(3):424-425. doi:10.1017/S1049023X22000589.\u003c/li\u003e\n\u003cli\u003eNaeem S, Edmunds C, Hirst T et al. A National Survey of Prehospital Care Services of United Kingdom for Use, Governance and Perception of Prehospital Point of Care Ultrasound. POCUS J. 2022 Nov 21;7:232-238. doi: 10.24908/pocus.v7i2.15739.\u003c/li\u003e\n\u003cli\u003eMeadley B, Olaussen A, Delorenzo A et al. Educational standards for training paramedics in ultrasound: a scoping review. BMC Emerg Med. 2017 Jun 17;17:18. doi: 10.1186/s12873-017-0131-8.\u003c/li\u003e\n\u003cli\u003eEimer C, Lorenzen U, Reifferscheid F et al. Ultrasound diagnostics in prehospital emergency care-do we need a standardized educational approach?. Med Klin Intensivmed Notfmed. 2023 Aug 14. German. doi: 10.1007/s00063-023-01045-4.\u003c/li\u003e\n\u003cli\u003eMichels G, Greim CA, Krohn A et al. Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-\u0026Auml;LRD, DGU, DIVI and DGIIN. Med Klin Intensivmed Notfmed. 2023 Dec;118(Suppl 1):39-46. doi: 10.1007/s00063-023-01054-3.\u003c/li\u003e\n\u003cli\u003eHempel D, Michels G. Sonography in intensive care and emergency medicine : A new training concept. Med Klin Intensivmed Notfmed. 2021 May;116:301-306. German. doi: 10.1007/s00063-020-00688-x.\u003c/li\u003e\n\u003cli\u003eWalcher F, Weinlich M, Conrad G et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg. 2006 Feb;93:238-42. doi: 10.1002/bjs.5213.\u003c/li\u003e\n\u003cli\u003eIenghong K, Cheung LW et al. The Impact of Prehospital Point of Care Ultrasounds on Emergency Patients Length of Stay in Thailand. Journal of Multidisciplinary Healthcare 2023: https://www.dovepress.com/the-impact-of-prehospital-point-of-care-ultrasounds-on-emergency-patie-peer-reviewed-fulltext-article-JMDH#cit0003\u003c/li\u003e\n\u003cli\u003eCanakci ME, Ozakin E, Acar N. POCUS in Out-of-Hospital Cardiac Arrest. Prehosp Disaster Med. 2022 Jun;37:423. doi: 10.1017/S1049023X22000577.\u003c/li\u003e\n\u003cli\u003eAtkinson P, Bowra J, Milne J et al. International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest. CJEM. 2017 Nov;19:459-470. doi: 10.1017/cem.2016.394.\u003c/li\u003e\n\u003cli\u003eKjesbu IE, Laursen CB, Graven T et al. Feasibility and Diagnostic Accuracy of Point-of-Care Abdominal Sonography by Pocket-Sized Imaging Devices, Performed by Medical Residents. J Ultrasound Med. 2017 Jun;36:1195-1202. doi: 10.7863/ultra.16.05077.\u003c/li\u003e\n\u003cli\u003eLaursen CB, H\u0026auml;nselmann A, Posth S et al. Prehospital lung ultrasound for the diagnosis of cardiogenic pulmonary oedema: a pilot study. Scand J Trauma Resusc Emerg Med. 2016 Aug;24:96. doi: 10.1186/s13049-016-0288-2.\u003c/li\u003e\n\u003cli\u003eHagendorff A, Tiemann K, Simonis G et al. Recommendations on emergency echocardiography. Kardiologe 2014: 8, 45\u0026ndash;64. https://doi.org/10.1007/s12181-013-0531-2\u003c/li\u003e\n\u003cli\u003eEstoos E, Nakitende D. Diagnostic Ultrasound Use in Undifferentiated Hypotension. 2023 Apr 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan\u0026ndash;. PMID: 29763130.\u003c/li\u003e\n\u003cli\u003eSoyuncu S, Cete Y, Bozan H et al. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury. 2007 May;38:564-9. doi: 10.1016/j.injury.2007.01.010.\u003c/li\u003e\n\u003cli\u003eBetz1 R, Gilbert A, Moens D et al. Prehospital point of care ultrasound in Helicopter Emergency Medical Services: a 5-year experience study in Belgium. Front. Disaster Emerg. Med., 28 October 2024: https://www.frontiersin.org/journals/disaster-and-emergency-medicine/articles/10.3389/femer.2024.1440545/full\u003c/li\u003e\n\u003cli\u003evan der Geest Y, Marengo L, Albrecht R et al. Prehospital ultrasound constitutes a potential distraction from the observation of critically ill patients: a prospective simulation study. Scandinavian Journal of Trauma 2024: https://sjtrem.biomedcentral.com/articles/10.1186/s13049-024-01280-4#citeas\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency medical services, POCUS, sonography, prehospital, training","lastPublishedDoi":"10.21203/rs.3.rs-5875169/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5875169/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Bedside ultrasound plays an important role in diagnostics and monitoring, especially in emergency medicine. Modern technology makes ultrasound available in a mobile and portable form, so it can be used even in prehospital emergency care with several interventional and diagnostic applications. This also raises the question of what kind of education and training is necessary for EMS (emergency medical services) physicians to be able to use Point-of-Care Ultrasound (POCUS) in the prehospital setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e: This observational study investigates the use of prehospital POCUS in a rural EMS area. It focuses the question of what level of competence is needed for EMS physicians to use POCUS adequately in the prehospital emergency setting for correct application and interpretation of the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eThis was a\u003cstrong\u003e \u003c/strong\u003equality assurance measure designed as a prospective cohort study. We investigated POCUS examinations performed by EMS physicians in the EMS Service Area of Nuremberg City, Germany between June 2021 and July 2022. Patients transported to three specific hospitals in Nuremberg city after care were followed up and the prehospital findings were compared with the in-hospital radiological results. The number of correct findings was correlated with the level of competence in POCUS examinations of the performing EMS physicians. Various classifications of competence were used to assess the influence of training and education on the safe application of prehospital POCUS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e 258 prehospital POCUS examinations were documented, with 108 followed up, including 268 sonographic findings. There was a wide range of indications for POCUS use. In 79.5% of cases the prehospital findings correspond with those in-hospital. By correlating the correct findings with the participants level of competence, there was no significant difference between POCUS-experienced and -inexperienced EMS physicians, even when divided into different categories.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePOCUS can be used in prehospital emergency care for a wide range of indications safely, with a high number of correct diagnoses and findings. Our results suggest that emergency POCUS is easy to learn and EMS physicians do not need intensive training to perform POCUS adequately in the prehospital setting.\u003c/p\u003e","manuscriptTitle":"Implementing Ultrasound in Emergency Medical Services: Assessing Physician Proficiency and Training Requirements","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 08:32:55","doi":"10.21203/rs.3.rs-5875169/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-04-14T08:17:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T07:51:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147156039148621038077239020028782435768","date":"2025-03-28T19:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-28T17:16:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T08:11:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","date":"2025-03-23T10:31:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"stre","sideBox":"Learn more about [Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine](http://sjtrem.biomedcentral.com)","snPcode":"13049","submissionUrl":"https://submission.nature.com/new-submission/13049/3","title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine","twitterHandle":"@SJTREM","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5aae3fb9-f799-420b-965e-63e2e4170063","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T15:59:31+00:00","versionOfRecord":{"articleIdentity":"rs-5875169","link":"https://doi.org/10.1186/s13049-025-01391-6","journal":{"identity":"scandinavian-journal-of-trauma-resuscitation-and-emergency-medicine","isVorOnly":false,"title":"Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine"},"publishedOn":"2025-05-20 15:57:02","publishedOnDateReadable":"May 20th, 2025"},"versionCreatedAt":"2025-04-03 08:32:55","video":"","vorDoi":"10.1186/s13049-025-01391-6","vorDoiUrl":"https://doi.org/10.1186/s13049-025-01391-6","workflowStages":[]},"version":"v1","identity":"rs-5875169","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5875169","identity":"rs-5875169","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}