Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors
© Taylor et al.; licensee BioMed Central Ltd. 2014
Received: 12 July 2013
Accepted: 25 February 2014
Published: 1 March 2014
Advances in ultrasound imaging technology have made it more accessible to prehospital providers. Little is known about how ultrasound is being used in the prehospital environment and we suspect that it is not widely used in North America at this time. We believe that EMS system characteristics such as provider training, system size, population served, and type of transport will be associated with use or non-use of ultrasound. Our study objective was to describe the current use of prehospital ultrasound in North America.
This study was a cross-sectional survey distributed to EMS directors on the National Association of EMS Physicians (NAEMSP) mailing list. Respondents had the option to complete a paper or electronic survey.
Of the 755 deliverable surveys we received 255 responses from across Canada and the United states for an overall response rate of 30%. Of respondents, 4.1% of EMS systems (95% CI 1.9, 6.3) reported currently using ultrasound and an additional 21.7% (95% CI 17, 26.4) are considering implementing ultrasound. EMS services using ultrasound have a higher proportion of physicians (p < 0.001) as their highest trained prehospital providers when compared to the survey group as a whole. The most commonly cited current and projected applications are Focused Abdominal Sonography for Trauma (FAST) and assessment of pulseless electrical activity (PEA) arrest. The cost of equipment and training are the most significant barriers to implementation of ultrasound. Most medical directors want evidence that prehospital ultrasound improves patient outcomes prior to implementation.
Prehospital ultrasound is infrequently used in North America and there are a number of barriers to its implementation, including costs of equipment and training and limited evidence demonstrating improved outcomes. A research agenda for prehospital ultrasound should focus on patient-important outcomes such as morbidity and mortality. Two commonly used indications that could be a focus of standardized training programs are the FAST exam, and assessment of PEA arrest.
KeywordsUltrasonography Emergency medical services
Ultrasound is a form of medical imaging that is portable, non-invasive and does not expose the patient to ionizing radiation. Healthcare providers that use ultrasound are able to obtain immediate anatomical, diagnostic and functional information on their patients. In recent years, ultrasound machines have decreased in size and cost while producing images of enhanced quality. These advances have made ultrasound more accessible to prehospital care providers.
There is evidence that prehospital ultrasound may be beneficial in diagnosis and management of critically ill patients [1, 2] and may be useful in as many as one sixth of medical and trauma EMS missions . EMS providers can be trained to interpret ultrasound scans with a high degree of accuracy in a relatively short period of time [4–6]. For example, prehospital focused abdominal sonography for trauma (FAST) exams have the potential to provide valuable information in abdominal trauma with specificity of 97.5 - 99% and sensitivity of 93 - 100% [2, 7] leading to more appropriate transport destination decisions. However, the use of prehospital ultrasound may result in a time delay to hospital by 0–6 min . There is currently insufficient evidence that prehospital ultrasound improves morbidity or mortality in critically ill or injured patients [8, 9].
An extensive literature review describes the potential ultrasound indications for prehospital EMS providers . The review concluded that many potential applications exist for prehospital ultrasound but more prospective, outcome-based studies were needed to determine if ultrasound should be implemented more widely. Potential indications for prehospital ultrasound described to date include: FAST [4, 11]; echocardiography and assessment of pulseless electrical activity (PEA) arrest [12–14]; cardiac tamponade [15, 16]; pneumothorax ; assessment of volume status through jugular venous pressure (JVP) or inferior vena cava diameter (IVC) ; abdominal aortic aneurysm (AAA) [18, 19]; vascular access and intraosseus line placement ; endotracheal tube placement [21, 22]; fracture identification [23, 24]; and identification of pulmonary edema [17, 25]. Transmission of ultrasound images to the emergency department has also been described as a possible advantage of prehospital ultrasound [26–28].
While these indications for prehospital ultrasound have been described in the literature, little is known about how EMS services are actually using this technology in the field. We suspect there is significant variation in the adoption of prehospital ultrasound and the perception of indications for its use. We expect that rural services, those with long transport times, and those utilizing air-transport, will be the most common users of prehospital ultrasound. The objective of our study is to describe in detail how ultrasound is currently being used by EMS services in North America.
This study was a cross-sectional convenience survey distributed via mail to EMS directors in Canada and the United States. Recipients were identified using the National Association of EMS Physicians (NAEMSP) mailing list and we obtained permission to distribute the survey to NAEMSP members. The University of Calgary Conjoint Health Research Ethics Board approved this study (Ethics ID 24183). The survey consisted of a single mail out and respondents had the option to complete the enclosed paper-based survey or an on-line version of the survey for which the link was provided.
The inclusion criteria for the study were: the survey was to be completed by a medical director of an EMS system, and the EMS system provided prehospital care in Canada or the United States of America.
The main survey consisted of two sections. The first section of the survey consisted of questions that focused on describing the EMS systems of each organization. In the second section, we asked targeted questions based on whether or not the EMS service is using ultrasound.
We calculated proportions of respondents that gave a specific answer to each question and their 95% confidence interval based on a population size of EMS medical directors of 755, the number of NAEMSP medical directors receiving the survey. This number was calculated by subtracting the undeliverable surveys from the total number of surveys sent out. We analyzed each question of the survey independently based on the number of respondents to the question. We compared the characteristics of EMS systems using ultrasound to all responding EMS systems using Fisher’s Exact Test for categorical and binary variables.
Characteristics of EMS services
Percent (95% CI)
Country n = 225
95.1% (92.7, 97.5)
4.9% (2.5, 7.3)
Funding n = 209
50.7% (44.9, 56.5)
24.4% (19.4, 29.4)
Mixture of public and private
24.9% (19.9, 29.9)
Urban vs rural population n = 222
30.2% (25.1, 35.3)
15.3% (11.3, 19.3)
Mixture of urban and rural
54.5% (49, 60)
Population n = 222
0 – 9 999
3.2% (1.2, 5.2)
10 000 – 99 999
23.9% (19.2, 28.6)
100 000 – 999 999
47.3% (41.8, 52.8)
>1 000 000
25.7% (20.9, 30.5)
Type of transport n = 222
95% (92.6, 97.4)
Helicopter air transport
36.5% (31.2, 41.8)
Fixed, wing air transport
8.6% (5.5, 8.6)
Transport time to nearest hospital n = 221
29.4% (24.3, 34.5)
52% (46.5, 57.5)
11.3% (7.8, 14.8)
7.2% (4.3, 10.1)
Transport time to nearest tertiary care hospital n = 221
13.6% (9.8, 17.4)
38.5% (33.1, 43.9)
19.9% (15.5, 24.3)
16.7% (12.6, 16.7)
11.3% (7.8, 14.8)
Level of training n = 221
NREMT Basic or equivalent
3.6% (1.5, 5.7)
NREMT Intermediate or equivalent
1.4% (0.1, 2.9)
NREMT Paramedic or equivalent
67.9% (62.7, 73.1)
NREMT Paramedic with additional training in critical care or registered nurses with critical care training
24.9% (20.1, 29.7)
Among the 8 EMS providers using ultrasound who commented on the level of training of their providers, 4 (50%) are paramedics, 5 (62.5%) are physicians, 1 (12.5%) are rescue medics, and 1 (12.5%) are paramedics or registered nurses with additional training in critical care. Of the 8 EMS services that commented on their ultrasound usage, 7 (87.5%) use it for FAST, 7 (87.5%) assess PEA arrest, 6 (75%) examine for cardiac tamponade, 5 (62.5%) use it to detect AAA, 4 (50%) examine for pneumothorax, 2 (25%) use it for vascular access, 2 (25%) assess volume status through JVP or IVC diameter, and 1 (12.5%) use it to identify fractures. None of the services that responded used ultrasound to confirm intraosseous line placement, endotracheal tube placement, identification of pulmonary edema, or used telemetry of ultrasound images to the emergency department. Among 5 EMS medical directors using ultrasound who commented on the perceived benefits, all 5 (100%) stated that it improves patient management in the field and patient triage, 4 (80%) stated may change disposition upon arrival to definitive care and 3 (60%) stated that it helps expedite care of critically ill patients.
EMS services currently using ultrasound are more likely to have physicians as their highest trained prehospital providers when compared to the survey group as a whole (p < 0.001). Characteristics that were not different between EMS services using ultrasound and the whole survey group included: funding model (public vs private); urban or rural population; size of population base; type of transport (air vs ground); or transport time. All respondents using ultrasound were from the USA, however, this was not a statistically significant association with ultrasound use (p = 0.724) as the majority of survey respondents were American.
The barriers EMS Medical directors perceive to implementing prehospital ultrasound n = 198
Number of respondents
Percentage (95% CI)
Challenges in training
Concerns about delaying time to definitive care
Ultrasound is beyond the scope of practice of providers
Lack of evidence
Approval by EMS administration
Buy-in by other EMS medical directors
Factors that would facilitate implementation of prehospital ultrasound among to EMS medical directors not currently using ultrasound
Research n = 174
Number of respondents
Percentage (95% CI)
Studies demonstrating improvement in patient mortality
Studies demonstrating improvement in patient morbidity
Studies on sensitivity and specificity of ultrasound used by paramedic operators
Studies on the effect of prehospital ultrasound on transport time
Studies about the potential indications for prehospital ultrasound
Case studies demonstrating examples of prehospital ultrasound and patient outcomes
Other facilitating factors n = 165
Practice guidelines including prehospital ultrasound
Standardized training available for EMS staff
Policy statements endorsing ultrasound
The results of our study indicate that prehospital ultrasound is infrequently used in North America. Prehospital physician providers are associated with increased use of ultrasound. While EMS services commonly use physicians as primary care providers in Europe, in North America physicians have a smaller role in direct patient care and act more often as EMS Medical directors . This difference may explain the low utilization of ultrasound in prehospital care in North America while it may be more feasible in Europe.
Medical directors of EMS systems that are not currently using ultrasound identified a number of barriers to implementation of prehospital ultrasound. The most commonly cited barriers were related to cost of ultrasound equipment and training. Even some EMS services currently using ultrasound identified cost as an ongoing challenge for them.
EMS medical directors identified challenges in training as an important barrier to implementation of ultrasound in their EMS systems. Our study identifies the most commonly used indications for prehospital ultrasound as the FAST exam and assessment of PEA arrest. These indications could be used to create initial prehospital ultrasound curricula. Training for other indications such as AAA screening, vascular access, cardiac tamponade, and pneumothorax imaging could follow a successful template used for FAST and PEA.
Before considering implementing ultrasound into their EMS systems, many directors would like to see additional evidence that prehospital ultrasound improves patient morbidity and mortality. Several EMS directors also specifically mentioned the need for cost-benefit analyses for prehospital ultrasound. The development of a research agenda for prehospital ultrasound could help provide direction for studies that are most likely to change practices. Our data notes that EMS medical directors believe that the objective of a research agenda should be to evaluate impact of prehospital ultrasound on morbidity and mortality.
This study has limitations that arise from using a survey for data collection. The survey is likely to have some degree of selection bias, with respondents that are using ultrasound more likely to respond to the survey because they are already invested in the survey topic (voluntary response bias). Therefore the low levels of use reported are likely are an overestimate of true usage rates and true prehospital ultrasound usage rate could be as low as 1.2% (9/755) if all non-responders represented EMS services not using ultrasound. Respondents were limited to those currently on mailing list of a professional organization, the National Association of EMS Physicians. Although we believe this mailing list is widely inclusive of our target population, it may not be all-inclusive. Our survey response rate of 30% is comparable to other surveys of EMS providers using this survey method . Another limitation arises because not all medical directors completed all sections of the survey. As a result these sections may have some bias in their responses. This phenomenon has previously been reported in surveys of EMS providers . To mitigate this, each question of the survey was analyzed independently based on the number of respondents to that particular question.
Currently, prehospital ultrasound is infrequently used in North America and EMS services identified a number of barriers to implementation. Current ultrasound use is associated with services with advanced trained providers. Decreased cost for equipment and training may make ultrasound a more feasible expenditure for EMS services. Two commonly used indications that could be a focus of standardized training programs are the FAST exam, and assessment of PEA arrest. A research agenda for prehospital ultrasound may be beneficial and should focus on the impact of prehospital ultrasound on patient outcomes.
Abdominal aortic aneurysm
Emergency medical services
Focused abdominal sonography for trauma
Inferior vena cava
Jugular venous pressure
National Association of EMS Physicians
National Registry of Emergency Medical Technicians
Pulseless electrical activity
United States of America.
We would like to thank the National Association of EMS Physicians for the use of their mailing list and its members who took part in our survey. We would also like to thank the Emergency Medicine Research Group at the University of Calgary for their support and the Emergency Medicine Research Advisory Committee for funding our study.
- Rognas LK, Christensen EF, Sloth E, Bendtsen TF: Prehospital ultrasound. Ugeskr Laeger. 2009, 171 (36): 2545-2547.PubMedGoogle Scholar
- Walcher F, Weinlich M, Conrad G, Schweigkofler U, Breitkreutz R, Kirschning T, Marzi I: Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg. 2006, 93 (2): 238-242. 10.1002/bjs.5213.View ArticlePubMedGoogle Scholar
- Hoyer HX, Vogl S, Schiemann U, Haug A, Stolpe E, Michalski T: Prehospital ultrasound in emergency medicine: Incidence, feasibility, indications and diagnoses. Eur J Emerg Med. 2010, 17 (5): 254-259. 10.1097/MEJ.0b013e328336ae9e.View ArticlePubMedGoogle Scholar
- Mazur SM, Pearce A, Alfred S, Goudie A, Sharley P: The F.A.S.T.E.R trial focused assessment by sonography in trauma during emergency retrieval: A feasibility study. Injury. 2008, 39 (5): 512-518. 10.1016/j.injury.2007.11.010.View ArticlePubMedGoogle Scholar
- Brooke M, Walton J, Scutt D, Connolly J, Jarman B: Acquisition and interpretation of focused diagnostic ultrasound images by ultrasound-naive advanced paramedics: trialling a PHUS education programme. Emerg Med J. 2011, 29 (4): 322-326.View ArticlePubMedGoogle Scholar
- Heegaard W, Hildebrandt D, Spear D, Chason K, Nelson B, Ho J: Prehospital ultrasound by paramedics: results of field trial. Acad Emerg Med. 2010, 17 (6): 624-630. 10.1111/j.1553-2712.2010.00755.x.View ArticlePubMedGoogle Scholar
- Walcher F, Kortum S, Kirschning T, Weihgold N, Marzi I: Optimized management of polytraumatized patients by prehospital ultrasound. Unfallchirurg. 2002, 105 (11): 986-994. 10.1007/s00113-002-0517-1.View ArticlePubMedGoogle Scholar
- Jorgensen H, Jensen CH, Dirks J: Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med. 2010, 17 (5): 249-253. 10.1097/MEJ.0b013e328336adce.View ArticlePubMedGoogle Scholar
- Brooke M, Walton J, Scutt D: Paramedic application of ultrasound in the management of patients in the prehospital setting: a review of the literature. Emerg Med J. 2010, 27 (9): 702-707. 10.1136/emj.2010.094219.View ArticlePubMedGoogle Scholar
- Nelson B, Chason K: Use of ultrasound by emergency medical services: a review. Int J Emerg Med. 2008, 1 (4): 253-259. 10.1007/s12245-008-0075-6.View ArticlePubMedPubMed CentralGoogle Scholar
- Price DD, Wilson SR, Murphy TG: Trauma ultrasound feasibility during helicopter transport. Air Med J. 2000, 19 (4): 144-146. 10.1016/S1067-991X(00)90008-7.View ArticlePubMedGoogle Scholar
- Grmec S, Prosen G, Kit B, Strnad M, Klemen P: Prehospital monitoring in resuscitation: today and the future. Signa Vitae. 2010, 5: 36-43.Google Scholar
- Aichinger G, Zechner PM, Prause G, Sacherer F, Wildner G, Anderson CL, Pocivalnik M, Wiesspeiner U, Fox JC: Cardiac movement identified on prehospital echocardiography predicts outcome in cardiac arrest patients. Prehosp Emerg Care. 2012, 16 (2): 251-255. 10.3109/10903127.2011.640414.View ArticlePubMedGoogle Scholar
- Backlund BH, Bonnett CJ, Faragher JP, Haukoos JS, Kendall JL: Pilot study to determine the feasibility of training army national guard medics to perform focused cardiac ultrasonography. Prehosp Emerg Care. 2010, 14 (1): 118-123. 10.3109/10903120903349770.View ArticlePubMedGoogle Scholar
- Byhahn C, Bingold TM, Zwissler B, Maier M, Walcher F: Prehospital ultrasound detects pericardial tamponade in a pregnant victim of stabbing assault. Resuscitation. 2008, 76 (1): 146-148. 10.1016/j.resuscitation.2007.07.020.View ArticlePubMedGoogle Scholar
- Heegaard W, Hildebrandt D, Reardon R, Plummer D, Clinton J, Ho J: Prehospital ultrasound diagnosis of traumatic pericardial effusion. Acad Emerg Med. 2009, 16 (4): 364-10.1111/j.1553-2712.2009.00379.x.View ArticlePubMedGoogle Scholar
- Noble VE, Lamhaut L, Capp R, Bosson N, Liteplo A, Marx JS, Carli P: Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. BMC Med Educ. 2009, 9: 3-10.1186/1472-6920-9-3.View ArticlePubMedPubMed CentralGoogle Scholar
- Ward DI: Prehospital point-of-care ultrasound use by the military. Emerg Med Australas. 2007, 19 (3): 282-10.1111/j.1742-6723.2007.00972.x.View ArticlePubMedGoogle Scholar
- Mazur SM, Sharley P: The use of point-of-care ultrasound by a critical care retrieval team to diagnose acute abdominal aortic aneurysm in the field. Emerg Med Australas. 2007, 19 (1): 71-75. 10.1111/j.1742-6723.2006.00932.x.View ArticlePubMedGoogle Scholar
- Tsung JW, Blaivas M, Stone MB: Feasibility of point-of-care colour doppler ultrasound confirmation of intraosseous needle placement during resuscitation. Resuscitation. 2009, 80 (6): 665-668. 10.1016/j.resuscitation.2009.03.009.View ArticlePubMedGoogle Scholar
- Chun R, Kirkpatrick AW, Sirois M, Sargasyn AE, Melton S, Hamilton DR, Dulchavsky S: Where’s the tube? Evaluation of hand-held ultrasound in confirming endotracheal tube placement. Prehosp Disaster Med. 2004, 19 (4): 366-369.PubMedGoogle Scholar
- Sim SS, Lien WC, Chou HC, Chong KM, Liu SH, Wang CH, Chen SY, Hsu CY, Yen ZS, Chang WT, Huang CH, Ma MH, Chen SC: Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency intubation. Resuscitation. 2012, 83 (3): 307-312. 10.1016/j.resuscitation.2011.11.010.View ArticlePubMedGoogle Scholar
- Heiner JD, McArthur TJ: The ultrasound identification of simulated long bone fractures by prehospital providers. Wilderness Environ Med. 2010, 21 (2): 137-140. 10.1016/j.wem.2009.12.028.View ArticlePubMedGoogle Scholar
- McNeil CR, McManus J, Mehta S: The accuracy of portable ultrasonography to diagnose fractures in an austere environment. Prehosp Emerg Care. 2009, 13 (1): 50-52. 10.1080/10903120802474513.View ArticlePubMedGoogle Scholar
- Zechner PM, Aichinger G, Rigaud M, Wildner G, Prause G: Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med. 2010, 28 (3): 389.e1-389.e2.View ArticleGoogle Scholar
- Sibert K, Ricci MA, Caputo M, Callas PW, Rogers FB, Charash W, Malone P, Leffler SM, Clark H, Salinas J, Wall J, Kocmoud C: The feasibility of using ultrasound and video laryngoscopy in a mobile telemedicine consult. Telemed J E Health. 2008, 14 (3): 266-272. 10.1089/tmj.2007.0050.View ArticlePubMedGoogle Scholar
- Strode CA, Rubal BJ, Gerhardt RT, Bulgrin JR, Boyd SY: Wireless and satellite transmission of prehospital focused abdominal sonography for trauma. Prehosp Emerg Care. 2003, 7 (3): 375-379. 10.1080/10903120390936608.View ArticlePubMedGoogle Scholar
- Takeuchi R, Harada H, Masuda K, Ota G, Yokoi M, Teramura N, Saito T: Field testing of a remote controlled robotic tele-echo system in an ambulance using broadband mobile communication technology. J Med Syst. 2008, 32 (3): 235-242. 10.1007/s10916-008-9128-x.View ArticlePubMedGoogle Scholar
- Benitez FL, Pepe PE: Role of the physician in prehospital management of trauma: North american perspective. Curr Opin Crit Care. 2002, 8 (6): 551-558. 10.1097/00075198-200212000-00012.View ArticlePubMedGoogle Scholar
- Schmuhl P, Van Duker H, Gurley KL, Webster A, Olson LM: Reaching emergency medical services providers: is one survey mode better than another?. Prehosp Emerg Care. 2010, 14 (3): 361-369. 10.3109/10903121003760184.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-227X/14/6/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.