Regional barriers in POCUS training

Abstract

Point-of-Care Ultrasonography (POCUS) has become part of the daily clinical practice of physicians dealing with emergencies in almost all European countries. This involves intensivists, emergency physicians, anesthesiologists, and generally physicians treating patients who require immediate clinical decision making, emergency care and proper monitoring improving safety of critically ill patients.

In Greece, instead of rewarding physicians who use POCUS—and even strive to pass on their knowledge and experience to younger colleagues—on the contrary, obstacles are created by physician associations (such as the Radiology Society) that attempt to block any effort for POCUS training and modernization in Intensive Care Units (ICUs). The objections are based on outdated Greek laws and the mistaken belief that their professional rights are being undermined. It should be noted that a significant part of POCUS (brain, transcranial Doppler, thorax: lung and diaphragm) is not included in the training of Radiologists in Greece, while there is resistance from Radiologists in providing basic training in POCUS to physicians outside their specialty. These barriers were met around 20 years previously in Europe and North America, when POCUS was being introduced in the ICUs; intensivists had to develop informal working and teaching relationships in a non-competitive and low-keyed manner with other frontline intensivists who understood the value and utility of POCUS. The obstacles were overcome with the publications of landmark papers [1, 2] that defined the competencies in POCUS and the operationalization of recommendations into the curriculum and training programmes by the national societies [3].

Point-of-care ultrasonography is defined as the acquisition, interpretation and immediate clinical integration of ultrasonographic imaging performed by a treating clinician at the patient’s bedside rather than by a radiologist or cardiologist. POCUS is an inclusive term not limited to any specialty, protocol, or organ system [4]. Sound evidence supports that non-radiologists and non-cardiologists can become competent in the performance of POCUS. This has resulted in the expanded use in many practice settings and in all phases of care—from screening and diagnosis to procedural guidance and monitoring. POCUS use has been associated with changes in clinical decision making in medical practice [5, 6].

Especially in the ICU, POCUS complements clinical examination as a new “functional stethoscope”. Lung Ultrasonography (LUS) is more accurate than X-rays in distinguishing atelectasis, consolidation, or pleural effusion, pneumothorax and interstitial syndrome in ICU patients [7]. Additionally, LUS criteria fulfill the imaging requirements for ARDS diagnosis [8], and diaphragm ultrasonography can guide and monitor patient-ventilator interaction, preventing asynchrony and ventilator-induced diaphragmatic dysfunction [9, 10]. Brain ultrasonography aids the monitoring of patients with acute brain injury [6], while abdominal ultrasonography is mandated in the initial and re-evaluation of trauma patients, source of infection evaluation in septic patients and is a standard examination in every hypotensive patient [11]. Echocardiography facilitates hemodynamic monitoring, while it represents the “reflexive” examination picked by every intensivist facing a patient with hemodynamic instability [11]. Based on echocardiography advancements, the Swan-Ganz catheter, has largely been replaced. Moreover, cardiac ultrasonography is used to guide mechanical ventilation, procedures and weaning protocols [12, 13]. Finally, ultrasonography-directed central line catheterization has increased the safety and minimized complication rates [14]. Thus, POCUS examinations are performed at least once daily in every ICU patient to answer different clinical questions or during procedural guidance. In our ICU, POCUS is used 24/7 by all our physicians—and by nurses under physician guidance—who have been trained by senior colleagues with European training certificates. Naturally, all central lines are inserted with us-guidance, a polytrauma patient with hemodynamic instability undergoes a complete-head to toe POCUS examinationupon ICU admission. This approach has practically eliminated complications, ensuring rapid diagnosis, immediate intervention, and continuous monitoring.

Structured training programs are of paramount importance to ensure the proper use of POCUS. Recently, an international consensus of experts, commissioned by the European Society of Intensive Care Medicine (ESICM), provided a list of experts’ recommendations regarding the basic skills and competences that each intensivist should acquire for a basic, “head to toes” ultrasound-based evaluation of ICU patients, [2]. This framework is used in the masterclass on Ultrasonography of the ESICM. Moreover, ESICM offers national certification, open to international physiciansin advanced critical care echocardiography, while European Respiratory Society offers a Pan-European Diploma in Lung Ultrasound [4]. In Greece, there is no national certification for POCUS and this is the main obstacle raised by the Radiology Society in the implementation of regional training programs. Therefore, Greek intensivists cannot be accredited in POCUS, despite holding European diplomas in echocardiography and lung ultrasonography and despite the daily use of POCUS in the ICU, which has been proven to enhance the safety of our patients.

The expanding acknowledgement that POCUS is an essential skill, has raised the need for implementation from specialties not traditionally (in Greece) known to be in need for ultrasonography: Intensivists, Emergency Medicine Physicians, Respiratory Physicians, Anesthesiologists, Internists, General Surgeons. National accreditation in Greece is provided to specialties for focused ultrasonography limited to the scope of their specialty, such as Gynecologists, Urologists, Vascular Surgeons. Recently, it was elegantly demonstrated that procedural and diagnostic POCUS use is not yet universal in ICUs, even for applications that would be considered standard of care, and the main recognized obstacle was the lack of POCUS training [15]. It should be noted that Intensive Care is a supra-specialty in Greece (two years of additional ICU training beyond the primary specialty). However, the legislation concerning Intensive Care supra-specialty in Greece is outdated and, unfortunately, does not include POCUS in the core training curriculum. Does this mean that Intensivists are not allowed, or even illegal (!) in using/training POCUS in everyday clinical practice?

In the years of artificial intelligence and technological improvements we think that it is a rather retrograde belief that non-radiologists accredited with international certifications are not qualified to train their colleagues in ultrasonography or even should not perform POCUS, needed in everyday clinical practice at the bedside. Should Intensivists not use mechanical ventilation, renal replacement therapies, transvenous pacemakers, bronchoscopy, perform tracheostomies, gastrostomies or insert chest tubes, as all these are domains dealt from other specialties? How can training in the ICU be harmonized according to the Competency Based Training programme in Intensive Care Medicine for Europe (CoBaTrICE) and other world regions if these obstacles are not overcome?

No datasets were generated or analysed during the current study.

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Authors and Affiliations

1. Intensive Care Medicine, Intensive Care Unit, Faculty of Medicine, General University Hospital of Larissa, University of Thessaly, Mezourlo, 41110, Larissa, Greece

   Vasiliki Tsolaki & Epaminondas Zakynthinos

2. Intensive Care Unit, General Hospital of Athens “KAT”, Athens, Greece

   Maria Theodorakopoulou

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VT and EZ wrote the main manuscript text. All authors reviewed the manuscript.

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Correspondence to Vasiliki Tsolaki.

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Tsolaki, V., Theodorakopoulou, M. & Zakynthinos, E. Regional barriers in POCUS training. Crit Care 29, 169 (2025). https://doi.org/10.1186/s13054-025-05394-8

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• Received: 16 March 2025

• Accepted: 28 March 2025

• Published: 28 April 2025

• DOI: https://doi.org/10.1186/s13054-025-05394-8

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