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Role of POCUS in Advanced Medical Care in Executive Protection

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Michael Guirguis and Adrian Dang
Michael Guirguis and Adrian Dang
Michael Guirguis, MD, is an Emergency Room Physician and Reserve Sheriff Deputy for San Bernardino Sheriff Air Rescue, with extensive experience in pre-hospital care. Adrian Dang, is a Team Leader Pararescueman with the U.S. Air Force. He specializes in emergent and non-emergent patient treatment and extraction in austere locations across the globe. He provides EP medical and security services for clients, whose unique lifestyles require extraordinary attention.

As a security professional, you’re working a maritime detail off the coast of France. Your principal and his family are riding personal watercraft. One of the teenage members of the family hits another watercraft and gets launched and contacts the water hitting the right side of his torso. You get him back on board the yacht and your initial assessment is he did not lose consciousness but is complaining of right-sided lateral chest and abdominal pain.

The patient’s airway is intact, and the patient is breathing but in some pain, as you visualize his inspiration. The patient has strong pulses and you move on to your secondary survey. You notice he isn’t having that much pain but continue your thorough exam. Everything is looking good, vitals are stable, and has minimal pain to the right chest wall and some right-sided abdominal pain on palpation. This is the time our point-of-care ultrasound comes in handy.

You’re able to place the ultrasound probe and check the thoracic cavity, there is no evidence of pneumothorax, and no evidence of fluid which would be indicative of hemothorax in this situation. You move to your FAST Scan (Focused Assessment with Sonography for Trauma) and notice blood in Morrisons Pouch, the hepatorenal recess which is the subhepatic space that separates the liver from the right kidney. Your previous inclination that the patient is looking good has now become an emergent need to get the patient to a trauma center because the patient has intra-abdominal bleeding. 

Although his vitals are stable now if he continues to bleed he will become hypotensive and could possibly bleed out internally. The yacht crew facilitates transport to the local trauma center that you’ve chosen for trauma during your medical advance, while you stabilize and package the patient. This is one example where POCUS is invaluable while in austere conditions.

What is Point of Care Ultrasound (POCUS)?

It’s a medical imaging technique that involves using portable ultrasound devices at the patient’s bedside or point of care. It allows healthcare providers to obtain real-time images and information about various anatomical structures and physiological processes. POCUS has gained popularity in medicine due to its versatility, convenience, and ability to aid in rapid diagnosis and treatment decisions.

Here are some of the common conditions that POCUS is helpful in identifying: 

  • Intrabdominal Bleeding: Identify internal bleeding via FAST scan.
  • Pneumothorax: Identify the presence of air in the pleural space, indicating a pneumothorax (collapsed lung).
  • Pleural Effusion: Visualize fluid accumulation in the pleural space, helping to diagnose pleural effusion, and guide thoracentesis or chest tube insertions.
  • Cardiac Abnormalities: Evaluate cardiac function, detect conditions like pericardial effusion, and assess valve abnormalities and aid in interventions such as pericardiocentesis or central line placements.
  • Abdominal Aortic Aneurysm (AAA): Measure the abdominal aorta and detect an AAA, a potentially life-threatening condition.
  • Gallstones: Visualize gallstones in the gallbladder, aiding in the diagnosis of cholecystitis and other gallbladder disorders.
  • Kidney Stones: Detect kidney stones (renal calculi) in the urinary system.
  • Deep Vein Thrombosis (DVT): Identify blood clots in deep veins, assisting in the diagnosis of DVT.
  • Ectopic Pregnancy: Visualize the location of the pregnancy and detect ectopic pregnancies outside the uterus.
  • Fetal Evaluation: Assess fetal well-being, position, and development during pregnancy.
  • Soft Tissue Infections and Abscesses: Aid in diagnosing soft tissue infections, abscesses, and guide drainage procedures.
  • Musculoskeletal Injuries: Help diagnose musculoskeletal injuries, such as ligament tears, tendon injuries, and fractures, joint effusions, foreign body location. Can 
  • Thyroid Nodules: Can evaluate thyroid nodules for size, characteristics, and potential malignancy.
  • Testicular Torsion: Assist in diagnosing testicular torsion, a medical emergency causing testicular blood flow obstruction.
  • Peripheral Nerve Entrapment: Help identify peripheral nerve entrapment syndromes.
  • Ascites: Detect fluid accumulation in the abdominal cavity, indicating conditions like ascites.
  • Vascular Access: Help clinicians visualize veins and arteries to facilitate vascular access for procedures such as IV catheter placement, arterial line insertion, or difficult peripheral venous access.

Why is POCUS important in EP?

It’s important because it can quickly aid in diagnosing and facilitate life-saving interventions. The faster that we can determine the pathology in an injured or sick person, the faster we can provide proper care. With rapid response to proper care, we can reduce morbidity and have a more favorable outcome for the client. 

But you might think “Hey, I’m not a Doctor”, but you just might find yourself to be the most capable person on a yacht to use this device. Not only is it very simple to use, in conjunction with a medical doctor via a telemedicine consult, it can be a game-changing piece of equipment. Using the example above, you will be able to identify the injury and exfil your client immediately to a higher level of care, due to an internal bleed, which you would not have known about without POCUS. Counter to this, your ultrasound assessment findings with your Medical Director might prove to be minor in nature, in which case your client can finish the trip they had originally planned.

The Butterfly iQ+ Ultrasound device is one of the favorites for mobile ultrasound imaging in the field for good reason. The compact size of the probe makes for an easy travel companion. It measures about the size of a regular 16 oz water bottle which plugs right into your phone for ease of use. Then, all you have to do is open up the app, apply ultrasound gel, and perform your assessment. Easily enough, with wifi or a cellular connection, you can perform the assessment while a Doctor observes the Ultrasound screen in real-time. In this method, you move the probe into the appropriate positions, while an experienced set of eyes helps make sound conclusions about your patient.

That being said, it is advised you have at least one Paramedic certified agent on your detail who is well-trained in POCUS when on a maritime detail or any other austere location. Not only are Medics able to perform life-threatening assessments and treatments, but being able to utilize these devices quickly and efficiently will enable a more fluid experience of client care. Not all Protective Details have caught on to augment their teams with Paramedics, but the most cutting-edge have. 

Conclusion

Point of Care Ultrasound (POCUS) is another tool that should be utilized on all EP Details that deal with travel to remote locations across the globe.  With the proper training by Security, Medical Teams it is a valuable tool to improve patient outcomes by enabling faster and more accurate diagnoses and treating underlying pathology before the situation worsens. 

Ideally, a Paramedic is part of your EP team, but if not, it’s still possible you can still use Ultrasound with your on-call medical director.  However, it is important to remember that POCUS is an adjunct to clinical assessment and should be used by trained and experienced healthcare professionals, with previous training in ultrasound to get the most out of the technology. 

This is not a diagnostic technique you want to be learning on the fly. 

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