A family physician from a remote northern BC community who got hooked on point of care ultrasound (PoCUS) during the COVID-19 pandemic was able to save a patient from a heart attack thanks to online learning and a visionary project. 

Dr. Ioana Lupu, one of only two physicians who cover the ER in the tiny community of Fort Nelson, 800 kms north of Prince George, said she believes that all rural physicians can benefit from learning PoCUS.  

Dr. Lupu took the HOUSE (Hands-on Ultrasound Education) course in 2020 and it didn’t take long for her to see the benefits of PoCUS. She said: “The course was absolutely amazing, and it got me hooked onto point of care ultrasound in the same way that first year medical students get hooked onto their stethoscope.”  

Prior to the pandemic, the HOUSE program was only available in person, but instructors pivoted to online learning in order to continue to serve rural providers and the patients in their care.  

While there were challenges with doing a hands-on course over the internet, there were also benefits – it made the course more accessible to those who could not easily leave their community.   

Dr. Lupu said: “We would be scanning patients while the instructor was more than 1000 kms away, guiding us through, with words only, while looking at our screen and our probe/hand position on the patient.  

“Prior to that, I was not an ultrasound user. I started scanning simple things like kidneys and bladders, and got ongoing help from one of the course instructors, Dr. Virginia Robinson, who graciously looked at scans that were initially clumsy, off-centre and not too clear, and slowly helped me improve them.” 

Dr. Robinson, who co-leads the Rural Coordination Centre of BC’s PoCUS work, is a big believer in the power of ultrasound as a diagnostic tool. She said: “Having the skills to properly use ultrasound provides a better standard of care to your patients. Every day I see patients who suffer with an incorrect diagnosis while they could be diagnosed and treated within minutes by using PoCUS.”  

Dr. Lupu said seeing a patient in Fort Nelson with a 10cm aortic aneurysm spurred her on to want to get an even better education in ultrasound – one that would allow her to diagnose heart conditions and see fluid in trauma cases.  

She said: “I got even more convinced of the importance of using point of care ultrasound after that.  I knew being able to scan people’s aortas for aneurysms would give me great comfort in the ER. Not to mention looking for free fluid in a trauma, which is pure gold in the absence of a CT scanner.”  

Last October, Dr. Lupu travelled to St Paul’s Hospital in Vancouver to learn how to acquire echocardiogram images at an echo “bootcamp” organized by the Rural Coordination Centre of BC (RCCbc) and UBC Rural Continuing Professional Development (UBC RCPD). 

“It was a long weekend, locked in the St Paul’s Hospital’s basement, scanning hearts until my hand turned into a prune marinated in ultrasound gel.  At the end of the blur, I made it home with a brand-new phased-array ultrasound probe on loan, waiting for some hearts to discover,” she said.   

Dr. Lupu said it was difficult to continue her learning journey on her own, so once she got back to Fort Nelson, she almost lost her motivation. “The pictures were not great, and it was hard to upload them, and after a few less than stellar attempts at acquiring echo images, I was ready to relegate the scanner back to its box out of frustration,” she explained.    

That is when a patient came into the emergency department complaining of heartburn.  

“Having worked in ER for around 15 years, I never trusted heartburn to be just that, so my antennae went up. We did an ECG and labs, and both were normal.  The patient wanted to go home as he felt fine, but I insisted we do the full workup, including serial troponin (repeated bloodwork at regular intervals), and sure enough, the next ECG showed STEMI in the lateral leads and the troponin was very slightly elevated – in other words he was having a ‘heart attack’.”  

At that stage Dr. Lupu did not know if this was a clear-cut case to prescribe fibrinolytic (clot buster), because the drug can have serious side effects, so she called for backup.  

The Patient Transfer Network put her in touch with Dr. Ken Gin at Vancouver General Hospital who reviewed the case and said it was a tough call. 

“Say, you don’t happen to have someone who can do an echo?” he had asked.    

“I said ‘Give me five minutes; I probably can acquire some images’,” Dr. Lupu recounted. “I said a quick prayer and I got some decent images, sent them to Dr. Gin.” 

Dr. Lupu said she expected him to laugh at her attempt but he told her that her images were beautiful. But he also revealed that she had accidentally inverted her probe so that what she had thought was the right ventricle was actually the left.  

“I nearly died of embarrassment, but once I got the pictures straightened out in my head, I could clearly see that my patient had a BIG problem, that he had had a large infarct and that he needed the clot buster, which he got promptly and without hesitation on my part.”   

“The patient immediately improved his ECG tracing, and was transferred out for angiogram 24 hours later.”   

The experience gave her the confidence to keep on going with the phased-array probe – which provides superior images of the heart compared with other probes. 

“I rekindled my love for the phased-array probe and it is now getting used every day.  It is a lot of work initially, but in our neck of the woods it can make a significant difference.”   

Dr. John Pawlovich, the lead of the Echo Project, which ran the echo bootcamp at St. Paul’s Hospital, said that Dr. Lupu built on her own successes.  “Her tenacity and resiliency in picking up a new skill and knowledge and moving forward in her really remote community is remarkable.”  

Dr. Lupu said she was grateful for the training that helped her acquire these skills. She said: “This project is truly visionary and I hope more physicians in isolated hospitals can learn to acquire and send images like this to specialists.”    

Anyone interested in getting started in PoCUS is welcome to sign up for the HOUSE course through the contact form.  

The next HOUSE course is Pediatrics-focused and will take place in Trail on September 23. The next HOUSE EM course takes place in Hope on October 14.  

Dr. Robinson is also encouraging communities to host a HOUSE OB course where participants will improve their management of patients in their first and third trimester through hands-on learning sessions with rural physicians who are experienced in PoCUS. 

Providers can get ongoing PoCUS training through Rural PoCUS Rounds, a partnership between RCCbc and UBC RCPD.