Neonatal Hocus POCUS: When Did We Become Laggards in Using Point-Of-Care Ultrasound Magic?
Jae Kim, MD, PhD / October 2018
When I was first attracted to neonatology, I was told some great stories of its birth by many of my mentors who witnessed the beginning.
Those early pioneers were working desperately to break new ground to save lives, as preterm infants were routinely dying from respiratory illness, sepsis, and other morbidities. They experimented with whatever they could to save those immature babies with the hopes that outcomes would be better for both survival and disabilities. They were unafraid to push the limits of technology to figure out better ways to breathe for them, treat their infections, and provide optimal nutrition.
A deep knowledge of physiology led to alternative modes of ventilation, including high frequency oscillation and jet ventilation. Those pioneers utilized many different drugs and treatments that made sense at the time. Great barriers were broken with many of those daring trials.
A flurry of studies gave us access to life-altering surfactant to save those that were previously often subject to multiple chest tubes used to valiantly save them. Imagine a routine of putting in chest tubes every day!
The result was a tremendous change in practices. Barriers were broken. We saw steady improvement to survival and outcomes. Even though some morbidities were slow to change, the severe forms became much less common over time. We saw less overt blindness and fewer wheelchair-bound graduates than decades past.
Neonatology is a progressive field that has a history of early adopters. History shows that neonatologists gravitated toward new devices, explored new treatments, and took risks. Also, our neonatal market was small compared to adult medicine, so efforts had to be made to solve newborn problems with creativity and insightful innovation. Neonatal caregivers had to be the “MacGyvers” of medicine.
I could always trust an experienced neonatal nurse or respiratory therapist to jury-rig something up in a pinch to cover equipment problems or gaps due to our small-sized babies. Everything from goal posting for umbilical lines, and other myriad taping jobs, to developmental position, to configuring tubing for exchange transfusion… Great ideas have been proposed to help our infants.
Neonatal caregivers retiring today have seen the growth of our field, and experienced so many novel attempts to improve the lives of the most vulnerable patient population. Fortunately we now we have a few more companies dedicated to our cause.
Hocus POCUS: It’s like magic
Over a decade ago, I entered the world of bedside point of care ultrasound (POCUS) and participated in a bowel project, resulting from my interest in bowel injury when a few of my radiology colleagues noted significant improvement in detection of pneumatosis (air in bowel wall) using ultrasound. That led me to a deeper exploration of the use of ultrasound to bowel as well as other areas.
Our dependence on the outdated stethoscope pales in front of the information that can come from using an ultrasound probe. With POCUS, one can see different stages of necrotizing enterocolitis. Besides pneumatosis, we can see peristalsis much better than trusting our listening skills for bowel sounds. With such direct visualization, I fully expected us by now to diagnose NEC in that manner, but it has been over a decade since the raw data was published. What perplexes me, often to a level of deep frustration, is that there are numerous opportunities to use POCUS to make a serious difference in workflow, as well as infant outcomes.
What is taking us so long to embrace potentially beneficial new techniques? Why do we resist this change? What is slowing us down? Yes, it is true too that times have changed. There are more rules around practice, and the ethical constraints are tighter and more transparent. Overall, compared to the past, we need to be more cautious and slower in clearing all the rules and regulations, putting into policy, creating credentialing, defining competency, etc. Perhaps we are also gun-shy, seeing the immense amount of clinical research dollars that were put forth with many that have generated negative results. Added to this, there are less federal resources than in the past to conduct some of the research to prove worth of the newer ideas.
I am also reminded of the shifting conservatism that occurred with Baby Boomers who were once the radical social change factors of the sixties. At my age, I sit sandwiched between the Baby Boomers and Generation X. Sometimes I feel torn by the comfort of establishment, and embracing newer and exciting changes coming up the pipeline. How do we make some sense of the reasons for being so behind? Why are we one of the last specialties to embrace POCUS? Have we simply run out of space or time to fit new technical practices or trade?
Traditional… and innovative
The lessons learned in technology innovation suggest that many of us disperse into innovators, early adopters, medium adopters, and laggards. An early adopter in one area is not always such in other areas. It is not uncommon for me to see someone be a laggard in nutrition, but a maverick in ventilator management. We all have different perspectives and comfort zones.
We may seem to move backwards first in other areas of embracing new technology. The original rush to electronic medical records (EMR) brought technology that was not quite ready for prime time. I still have nightmares from the first integration in the 90’s where I was taught to use the “best in technology” with a tethered light wand that pointed to a now considerably low tech cathode ray tube screen with ALL CAP text on the screen. Ordering an antibiotic required at least seven to eight screens to flash through in large size font before the printout killed a few trees and was practically illegible in ALL CAPS.
The EMR is much smoother now. But after efforts to build the perfect progress note and see so much copy-paste errors, I lament the time when all we carried was a stethoscope, a pile of papers, and several handbooks in our white coats. Rounds consisted of real bedside experiences. We looked at the patients, examined the patients, discussed the clinical findings and differential diagnosis. Today our team moves as a slow caravan of mobile computer carts. We all hide behind our screens trying to keep up with the documentation (P.S. I still refuse to walk around with mine). Sometimes I wonder if this is really progress… or regress.
Most of my energy on POCUS these days is spent finding ways to build it into the curriculum of our neonatal fellows who are training. There has been such an inversion in pediatric critical care where fellows are universally trained in vascular access, while many faculty have not learned. I see this coming in neonatology. The future is very bright. Perhaps, however, it will be carried as with many things by the next generation, our junior staff and fellows who feel more inclined to take risks.
We need a new generation of neonatal caregivers that are willing to change how we do things in order to make things better for babies of the future. POCUS has us on the edge of a world where we may not need to do so many x-rays. The device is now even less complicated, and some devices are less complicated than your own smartphone. The image quality is outrageously good compared to the past. When I check for an endotracheal tube I feel like I am seeing a sectioned slice of the chest of an infant. The images are that good.
Let’s not be afraid of taking risk and changing the framework that we have grown used to. I just attended a retirement party of a series of caregivers in our NICU: a manger, an echo tech, and a nurse, who collectively walk away with over 100 years of experience. I felt the same loss of experience five years ago when four senior faculty retired en mass – losing at least 150 years of experience in one fell swoop.
Albeit painful, there is hope that as our bimodal population is aging, we will have lots of new caregivers taking interest in changing the future. The needs are clearly many, and present every day. Here’s to hoping that we work seamlessly together, and embrace the magical rush of a rapidly adapting culture. It won’t require any special mysterious spells; just focused work and collaboration. We can do this together.
About the Author
Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, spinprogram.ucsd.edu). He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela LLC.