What if there was a critical medical device sitting unused in an emergency department because no doctor on the shift knew how to operate it?
That's the predicament in many hospitals when a point-of-care ultrasound (POCUS) offers patients faster and more accurate care, but not all junior emergency physicians know how to use them.
Senior consultants are skilled in POCUS for time-critical presentations involving seriously injured or sick patients. But when no consultant is on a shift, emergency departments are manned by registrars who may not be appropriately trained, emergency physicians say.
"There's a machine, but as to whether that machine gets used depends on the skill of the staff that's available," said emergency physician at the Prince of Wales Hospital Bruce Way, who ran a POCUS training program for junior doctors at the hospital.
Ultrasound was used exclusively by radiologists and sonographers but, over the past two decades, emergency physicians have been increasingly using mobile ultrasounds at the patient's bedside with a limited amount of training.
"It means patients can avoid unnecessary, invasive tests and dangerous procedures and allows us to make decisions a lot quicker and be a lot safer," Dr Way said.
The Austrasian College of Emergency Medicine recommends emergency physicians be trained to investigate abdominal and lung trauma, abdominal aortic aneurysms and the heart and learn to insert devices, including intravenous lines into the circulatory system.
No emergency physician training in Australia should be without basic POCUS instruction, Dr Way said.
POCUS was about answering very specific clinical questions, for instance assessing abdominal trauma, guiding a specific procedures such as inserting intravenous lines. Formal ultrasound services in the hospital (usually available Monday to Friday during daytime working hours) were still critical for more comprehensive scans.
"It's about time-critical stuff," said acting director of the Prince of Wales Hospital emergency department Matt Davis. "We don't have time to muck around.
Dr Way said: "If we have a patient who is in shock from trauma, we don't know what is causing that shock, whether it's bleeding into their abdominal cavity or blood around their heart.
"We can put an ultrasound on them and find out immediately what the source of that shock is and perform the procedure they need under ultrasound.
"Without it we have to do other things like stick needles into their belly, all sorts of other dangerous things."
"[Registrars] would have to look for alternative tests that would take longer."
Broken down machines and staffing shortages
Emergency physicians said the state government needed to step up its support for POCUS programs, including more funding for ultrasound equipment, staffing and training.
Patients had come to expect this level of care from their hospitals around the clock, an expectation the government had promised to deliver, Dr Davis said.
"You've got a whole bunch of machines breaking down ??? the technology changes to the point that it becomes obsolete, but we don't have the recurrent funding to address that.
"It's the 21st century ... If NSW Health is fair dinkum about investing in the future, we need more resourcing," he said, adding POCUS would improve the state's heavily scrutinised emergency department waiting times.
Chair of the ACEM ultrasound committee Alistair Murray said there was much to improve upon nationally when it came to resourcing POCUS.
"The use of bedside ultrasound has a highly positive impact upon patient care in almost every clinical shift that I work," Dr Murray said.
"The challenge lies in striking the right balance between access to POCUS and access to POCUS with clinicians who have achieved minimum training standards in order to maximise benefit and minimise error," Dr Murray said.
Chitrita Mukerjee's gallstone obstruction was eventually picked up by POCUS. Photo: Ben Rushton
Expanding POCUS to detect more complex presentations
As more doctors were trained in POCUS basics, more complex investigations could be added to their training in the future, including biliary investigations, emergency physicians said.
That is one application that may have helped Chitrita Mukerjee.
The 53-year-old presented at the Prince of Wales emergency department in February with an "awful burning sensation" in her abdomen.
She was given a chest X-ray, an ECG and urine and blood tests, which all came back negative.
"I pleaded for an ultrasound, but I was told it would not be possible or necessary," Ms Mukerjee said, and she was sent home with a prescription for antacids.
"By this stage I could feel almost a protrusion towards the right area of my abdomen and an intense, localised pain," she said.
A day later her family took her to Blacktown hospital where emergency physicians used POCUS and found stones in her gall bladder. One gallstone had become lodged in the neck of a duct, causing considerable pressure and infection.
She had surgery two days later.
"Luckily mine was not a life-threatening condition," Mrs Mukerjee said. "But I find it appalling that ultrasound is not available for every patient with a life-threatening condition, depending on what time of day they come in and who's on shift," she said.
A spokesperson for NSW Health said funding for POCUS machines had been rolled out twice, most recently in 2013/2014, and local Health Districts had also invested in mobile ultrasound machines.
More than 160 clinicians have started the Emergency Care Institute's emergency ultrasound training program supported by NSW emergency departments, the spokesperson said in a statement.
"Although access to POCUS services have vastly improved across the state over the past decade, NSW Health recognises the need to continue to support upskilling of clinicians in POCUS and is actively collaborating with the specialty groups involved to ensure that this is occurring," the statement read.