By Dr. Frances M. Russell, Department of Emergency Medicine, Indiana University School of Medicine
Emergency departments (EDs) across the country face critical challenges1 that threaten patient safety and care. By empowering emergency responders with advanced diagnostic tools, we may improve patient outcomes and alleviate the mounting pressures on our healthcare system. Recent research published2 in Academic Emergency Medicine demonstrates a promising path forward leveraging portable ultrasound in the prehospital setting.
Acute heart failure (AHF) is a silent predator that often eludes detection in its critical early stages. Each year, over one million patients3 in the United States are hospitalized with this life-threatening condition, but what if the journey to diagnosis and treatment could begin before they reach the emergency department doors?
In the field, paramedics must accurately identify AHF among patients struggling to breathe. The symptoms of AHF—shortness of breath, fatigue and fluid retention—can mimic other common conditions like chronic obstructive pulmonary disease (COPD), pneumonia or asthma. This diagnostic ambiguity, combined with limited tools and time constraints, has led to a troubling trend4 of misdiagnosis and undertreatment in the field.
Our study revealed that without advanced diagnostic tools, paramedics correctly identified AHF in only 23% of cases. This low rate translates to missed opportunities for early intervention—a critical factor in improving patient outcomes. The consequences of these missed diagnoses are stark: delays in treatment initiation, prolonged hospital stays and increased mortality rates.
This narrative must be changed. One opportunity: equipping our first responders with a tool that dramatically improves their ability to recognize and treat AHF in those crucial moments before they reach a hospital.
The Effectiveness of Lung Ultrasound Used by Paramedics
Lung ultrasound (LUS) is a simple yet powerful imaging technique that’s proving to be a game-changer through new innovations making it accessible and easy to use by trained paramedics. This innovative approach improves diagnosis and revolutionizes emergency cardiac care from the moment help arrives.
Our study, conducted over six months in 2022 and released last year, followed 264 patients with difficulty breathing who were transported by ambulance (emergency medical services). Of these, 94 were ultimately diagnosed with AHF.
When paramedics were armed with a handheld Butterfly iQ point-of-care ultrasound device from Butterfly Network, Inc., their diagnostic accuracy skyrocketed to 85%. This improvement didn’t come at the cost of misdiagnosing other conditions–the specificity remained high at 96%, meaning false positives were rare.
The benefits of LUS in the prehospital setting extend beyond improved diagnosis. The study revealed a significant impact on treatment initiation. Without LUS, only 14% of AHF patients received appropriate heart failure therapy before reaching the hospital. With LUS, this number jumped to 53% – a nearly 4x increase in early intervention.
Perhaps most crucially, prehospital LUS slashed the time to treatment. The median time from first patient contact to the start of heart failure therapy dropped from 169 minutes to just 21 minutes when LUS was used. In the world of AHF, every minute counts, and this reduction could mean improved patient comfort and decreased hospital stays and mortality.
Our study employed a methodical and practical approach. Paramedics underwent a focused training program, including 30 minutes of instructor-led classroom training, 30 minutes of hands-on scanning practice and a comprehensive assessment. We used a simplified four-view LUS protocol, looking for the presence of B-lines5–telltale signs of fluid in the lungs often associated with heart failure.
Interestingly, the study revealed no significant differences in age, gender or vital signs between patients who received LUS and those who didn’t. This suggests the improved outcomes resulted from the ultrasound technology and not due to patient selection bias.
Prehospital Ultrasound and the Future of Emergency Healthcare
The implications of this study extend beyond the immediate improvement in AHF care. It opens the door to a new era of prehospital diagnostics and treatment, where advanced, user-friendly tools like handheld POCUS devices can be used to enhance patient care before they reach the hospital.
The success of LUS in diagnosing AHF suggests that other prehospital diagnostic tools could similarly revolutionize emergency medical services. This aligns with the trend6 of prehospital ultrasound use, which has increased from just 4% of North American EMS agencies in 2014 to wider adoption today, with 21.7% of agencies considering implementation.
Critics might argue that implementing LUS across all emergency medical services would be costly and logistically challenging. However, the opportunity for savings in terms of reduced hospital stays, decreased complications and improved long-term outcomes could far outweigh the investment. Moreover, as new single probe, whole-body ultrasound devices become more affordable and higher quality, and hospitals continue to adopt enterprise imaging platforms to streamline billing and governance, the financial barriers to implementation diminish.
Our study demonstrated paramedics could be effectively trained in Butterfly iQ LUS use with a brief, focused program. This suggests that widespread implementation is not only beneficial but feasible. Other studies have shown that paramedics and emergency medical technicians (EMTs) can accurately perform assessments with sonography for trauma (FAST) exams, indicating the potential for broader ultrasound applications in prehospital care.
We are planning follow-up studies to address the questions raised by this initial investigation. They will explore the long-term outcomes of patients who receive early LUS-guided treatment and refine the training protocols.
Integrating technologies like LUS into prehospital care could transform emergency medicine. For patients with AHF, every breath is precious. This study shows us a path forward where those critical early moments can be used more effectively.
The medical community faces an exciting challenge: translating these findings into widespread practice. To ensure this life-saving technology becomes standard equipment on ambulances, collaboration among EDs, EMS agencies and policymakers is required.
This study reminds us of technology’s impact on patient care. By bringing advanced diagnostics out of the hospital and into the field, we’re not just changing where care begins—we’re potentially rewriting the outcomes for thousands of patients each year.
So, the question is no longer whether we should implement prehospital LUS for AHF diagnosis and treatment but how quickly we can make it happen. The answer can’t come soon enough for those short of breath, waiting for answers.
About the Author
Frances Russell, MD, is a tenured professor of emergency medicine and the ultrasound research director in the division of ultrasound at the Indiana University School of Medicine. Dr. Russell’s research interests include point of care ultrasound for acute heart failure, undifferentiated shortness of breath and ultrasound medical education. Dr. Russell serves as an American College of Emergency Physician ultrasound research subcommittee co-leader.
References
1 Mallory Locklear, Yale News, Sept. 30, 2022, “Emergency Department Crowding Hits Crisis Levels, Risking Patient Safety,” https://news.yale.edu/2022/09/30/emergency-department-crowding-hits-crisis-levels-risking-patient-safety
2. Frances M Russell, MD; Michael Supples, MD; Omkar Tamhankar, BSc; Mark Liao, MD; Patrick Finnegan, MD, Academic Emergency Medicine, Sept. 29, 2023, “Prehospital Lung Ultrasound in Acute Heart Failure: Impact on Diagnosis and Treatment,” Prehospital lung ultrasound in acute heart failure: Impact on diagnosis and treatment – Russell – 2024 – Academic Emergency Medicine – Wiley Online Library
3. Akshay S. Desai, MD, MPH; Lynne W. Stevenson, MD, American Heart Association Journals, “Rehospitalization for Heart Failure – Predict or Prevent?” Rehospitalization for Heart Failure (ahajournals.org)
4. William F. Peacock, Chad M. Cannon, Adam J. Singer, Brian C. Hiestand, Critical Care, Dec. 1, 2015, “Considerations for Initial Therapy in the Treatment of Acute Heart Failure,” Considerations for initial therapy in the treatment of acute heart failure | Critical Care | Full Text (biomedcentral.com)
5. Victor V. Rao MBBS, DMRD, RDMS (APCA), Point-of-Care Ultrasound Certification Academy, Nov. 16, 2022, “POCUS Lung – Introduction to A-lines and B-lines,” POCUS Lung – Introduction to A-lines and B-lines | Point-of-Care Ultrasound Certification Academy
6. John Taylor, Kyle McLaughlin, Andrew McRae, Eddy Lang, Andrew Anton, BMC Emergency Medicine, March 1, 2014, “Use of Prehospital Ultrasound in North America: A Survey of Emergency Medical Services Medical Directors,” Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors | BMC Emergency Medicine | Full Text (biomedcentral.com)
