My journey to lung ultrasound accreditation during COVID-19

The use of Point of Care Ultrasound (POCUS) is growing in popularity and usefulness. Until last year, my awareness of this and particularly its potential relevance to physiotherapists had been limited until I embarked upon a MSc in Advanced Clinical Practice. We were encouraged to start thinking about our vision for our own roles and where it could fit within advanced practice. I knew then that the use of Lung Ultrasound (LUS) by physiotherapists and the positive benefits to clinical decision-making, treatment, management and patient outcomes would be an essential skill and something for me to attain.

I had the fortune of getting in touch with Simon Hayward (Blackpool Teaching Hospital NHS Trust), who has been and continues to be the inspiration and pioneer for LUS in the physio community. He spent time explaining how he and his team have been using the tool and what they have been able to achieve as a result of its use. After attending his course in January 2020, I was very motivated and excited about the tool and the potential benefits it could offer me, my team (working as respiratory physios in intensive care) and my patients. I recall multiple conversations with others on the course around mentors and felt very lucky that I had access and had already organised a mentor within my Trust. Unfortunately, this mentorship was unable to continue as my mentor moved to another Trust.

I did however start completing scans immediately after the course with some guidance from a couple of my Consultant colleagues who have POCUS experience but whilst they were accredited in Focused Intensive care ECHO (FICE), they were not accredited in Focused Ultrasound in Intensive Care (FUSIC) LUS so this created a barrier in obtaining my supervised scans initially. One of our Locum Consultants acted as a mentor for a few scans to get me going and I was really lucky to be offered a space on an additional course run within my Trust – Ultrasound At The Front Door (USATFD) during which I was able to complete my supervised scans. Innovatively, the team had arranged a mix of normal models and models with pathology which was key in picking up signs as well as reporting.

I swiftly moved forward with my scans when mentorship was offered to me remotely by two colleagues Dr Chris Duncan (ICU registrar and original mentor) and Dr Sarb Clare (Acute Medical Consultant). We used the sharing platform www.sonoclipshare.com as a way to communicate and this ensured safety and standards were maintained. Feedback on getting better images to challenging reports was critical in my development and confidence.

By the time COVID-19 arrived at our doors, I had managed to complete just over 20 scans including my supervised ones. It was clear from international colleagues that POCUS LUS is critical in diagnosis and management decisions in Covid-19, being comparable to CT. In addition LUS is safe, portable with easy access and reduces cross contamination which was critical in this very virulent disease.

When it was suggested that I may have to pause my scanning due to infection control and availability of educational support, a sentiment shared by the ICS, my heart sank. This led to arrangements for a 3-month extension to the accreditation process. However, Covid-19 opened an opportunity for me to continue to scan and I was probably able to scan more patients than I probably would have done. This empowered me to educate colleagues and guide management and treatment plans. I received full support from my team, mentors and ITU colleagues.

Despite the support I received, I still seemed to face personal and situational barriers and needed to find a way to overcome these. I found at times access to a machine difficult especially when we expanded and were located on 4 rather than 2 units. Whilst I don’t consider myself the biggest techno-phobe I did have challenges saving scans to our machine. Additionally, at times I felt like a bit of a fraud, walking up to a patient with an ultrasound machine repeatedly having to explain why I (a physio) was using it and why I was going near some of the sickest patients with it. With COVID-19, all the patients I saw were ‘very sick’ and dealing with young patients and often members of the same family was mentally challenging. Wearing full PPE due to the pandemic actually made carrying out scans physically tough on top of the normal rehabilitation being provided. In addition, within the multidisciplinary team I was the most experienced lung scanner on the unit and that felt strange and I was aware of a different dynamic, therefore. However, I overcame these barriers and I was driven by the fact that I was fully supported by my colleagues in addition to the notion that I could make a difference to our sickest patients and that my scan could be critical in their management. My mind set changed from scanning for my logbook to giving management advice which naturally increased my confidence and competence.

During this time, I watched much YouTube footage and read papers from international colleagues to further increase my knowledge. One thing I did on a regular basis was remind myself of what a normal scan looked like so that my interpretation did not become blurred.

I wanted to share just a few examples of scans that resonated with me which demonstrate that by having this tool we can really make a difference. This is just a snapshot of my experience:

- A patient who had required re-admission and re-intubation due to deterioration on the ward. Presented as unstable cardiovascularly and requiring high FiO2. I had scanned this patient a few weeks previous so had a frame of reference. On re-scanning I discovered a complete absence of pleural sliding on the right in keeping with pneumothorax. An urgent CXR was ordered given the high levels of Positive End Expiratory Pressure (PEEP) the patient was requiring to determine the need for an inter-costal drain (ICD). An ICD was subsequently sited and the patient went on to be extubated.

- A patient who had gone home was re-admitted with a massive PE and right heart strain. She was thrombolised and having scanned her on the previous admission I opted to re-scan. I picked up significant consolidation but in the absence of a pyrexia and raised inflammatory markers this presentation was in keeping with a pulmonary infarct from the PE. As an educator, I regularly remind staff to remember that all assessment tools need to be pieced together to complete the jigsaw and full clinical picture. This case also highlighted the benefits of serial scanning to my physio assessment in terms of monitoring for change – whether that be improvement or deterioration.

- The third example for me was the most empowering. A patient who I had scanned previously at the height of her deterioration and recommended proning due to widespread areas of sub-pleural consolidation was then in the weaning phase of her recovery. Anxiety was huge as it has been with so many patients affected by the virus. I repeated her scan and saw the previous irregular pleural line was now beautifully regular, A-lines dominated and only the odd residual area of abnormality was seen. I explained this to the patient as well as my colleagues. This then gave the patient and my colleagues huge confidence and reassurance and allowed me to push her wean. She was ventilator free and decannulated within 48 hours and didn’t look back. This was incredibly gratifying.

After 3 months I passed my triggered assessment and achieved accreditation at the end of April. It was exhilarating and I was very proud. Achieving this accreditation was a challenge but very important and absolutely essential for us physios who can make a difference to our patients.

I am acutely aware that this is a new skill to me and I will continue to learn and develop.
One of the greatest challenges I foresee, but hope as the use of POCUS grows, will become less of an issue, is how familiar LUS is amongst the wider team. I am currently the only person with FUSIC LUS accreditation on our ICU although not the only person who uses ultrasound in practice. I regularly offer to show my medical colleagues if they would like to take a look at the scan but the offer is not always accepted. One of the registrars voiced that he is not familiar with LUS and I wonder whether this explains this response. It is not the same as reviewing our ‘old friend’ the CXR together, in this case both parties are familiar with what they are looking at and discussion can occur more easily. Perseverance will be required to ensure findings are acknowledged, particularly being a member of a non-medical profession.

I’m relieved to say I’ve scanned some non-COVID chests over the last couple of weeks and it’s quite refreshing. I believe this is just the start. I recognise that I have been more than fortunate with the support I have received and the contacts I have had the fortune to make, but I’d urge everyone to keep plugging away at this as this skill is invaluable for our community…it is a game changer and it is absolutely possible even in a pandemic!

Please contact me on email for any advice or words of encouragement
Nicki Heys (e-mail: nheys@nhs.net)
Advanced Physiotherapist
Clinical Lead Physio for Critical Care
Sandwell and West Birmingham NHS Trust

With thanks to:
Dr Chris Duncan (USATFD) Dr Pradeep Madhivathanan
Dr Sarb Clare (USATFD) Respiratory Physio Team at Sandwell and West Birmingham’s NHS Trust
Simon Hayward Dr Khalid Haiba
Dr Nick Sherwood

Mentors Perspective:
As an Acute physician who has been practising and championing POCUS for around 16 years it is incredibly rewarding to see Nicki flourish, develop her skills and use them in an invaluable manner. I teach many grades from undergraduates to Consultants colleagues and more recently have started opening my courses and teaching sessions to nurse practitioners but Nicki is the first physio and I hope the first of many to come. What was refreshing about Nicki was that she not only had a desire to learn but also keen to receive feedback on how she could improve her skills which takes solid insight and self-awareness.

As the first Acute physician who received British Society Of Echocardiography Transthoracic accreditation in a cardiology department where no one was accredited I fully understand and appreciate the challenges that Nicki would have faced when working with medical colleagues. I applaud her for her resilience, persistence and determination as well as humility.

Physiotherapists are core team members providing high quality care to our patients and it is a natural course that they should acquire this fundamental skill to empower themselves and their teams with knowledge to determine patient management. Nicki demonstrated this beautifully.
Lung Ultrasound out of all the scanning domains is the easiest to acquire and report upon and as Nicki has demonstrated an achievable accreditation even during a pandemic. Mentoring and supervising can be relatively easy in a department that regularly scans and has a clear governance procedure. Pre pandemic I traditionally carry out regular sessions with hands on teaching by scanning patients with pathology on the unit. During the pandemic we used a virtual platform (Sonoclip share) to review scans and give feedback. I would encourage all those who do not have a mentor on site to use this system as I mentor many colleagues outside the West Midlands in this manner.

I strongly advocate this core skill is acquired not just by physiotherapists but other AHPS including paramedics, district and community nurses just to name a few!
Feel free to contact me: Dr Sarb Clare (USATFD) e-mail: sclare@nhs.net
Visit www.ultrasoundatthefrontdoor.com