The POCUS Manifesto

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So, a book lands on POCUS! Of course, I’m interested! But, we’ve seen them all before….the ‘how to’ guides, the instructional references. There are plenty of them out there now. So, what’s special about this book then…..and it is very special, I hasten to add.

Take a look below to see what some of our well-known POCUS greats had to say.

The quote below from Larry, for me, embodies the ethos of why we POCUS enthusiasts are that and more:

POCUS enables a clinician to digitally peel back the skin and observe the ecosystem of internal organs functioning in real-time, an ability our forefathers, foremothers, and stethoscope-monogamous colleagues could infer only through skin changes, audible noises, or subjective symptoms. 

And another as to why some are sceptics perhaps:

Yet can we not expand upon this foundation two centuries later? Why must we continue to examine our patients in 2021 solely using the techniques of 1821? As the next leg of the race commences, the clinicians unwilling to accept the power and responsibility this baton carries will be left in the dust. 

This book is full of classic quotes from the very forefathers of medicine….Auerbrugger, Forbes and of course, the infamous Laennec (he of stethoscope fame – you know, that thing you use to listen in!). Each chapter begins with one of these quotes, gripping the reader to continue on and see what direction they will be taken in.  

We discover the very origins of the well known 4 pillars of clinical examination. From percussion of beer barrels to placing the head on the thorax to hear noises from within. The book almost instils humour in the reader, where we learn of what we now would consider ludicrous! The methods of minds eager to reach into the body….although rather remotely! How did we get from this to actually seeing with sound? And that’s exactly what this book explains.

I don’t want to ruin things, but there are some amazing historical pictures throughout the book, really making you feel like you are wandering around a medical museum of sorts.

Laennec using his stethoscope to examine a patient in front of students in the early C18th

Sorry to bang on about classic quotes, but this one below embodies how Laennec struggled to get people to listen to him and buy into the usage of his new discovery. We can empathise with this in the POCUS world, as I am sure we have all faced opposition to the results of our ‘enthusiasts’ scans’, by those who do not freely accept POCUS as a useful adjunct to the clinical examination profile.

He felt strongly that those who objected to the use of this device “like unjust judges, pronounce sentence without examining the merits of the case.” 

The book is an absolute treasure trove of history, reference and majestic prose…explaining how and why reticence to adopt new techniques and technology develops. It examines how, over time, new ways are eventually accepted from being foreign/apothecary, to unquestionably the norm within our regular practice.

Does this book kill Laennec’s livelihood then…..well, I would advise you to read it to see. What it does not do is go off on a tangent of stethoscope assassination as such, but it does provide the reader with some amazing information with which to assimilate opinion, backed by hard evidence. Discussion of anachronism is fruitful and it makes the reader consider the eras we are perhaps stuck in due to the time old teachings of our well-respected seniors….it’s what we knew, how we were taught ‘when I was a lad’, etc.

We start to discuss lung ultrasound in a little more detail; and enter Daniel Lichtenstein! The forefather of lung ultrasound himself is discussed in great narrative detail. How he plonked the ultrasound probe onto the chest of what we could consider being the index patient for lung ultrasound. We discover how he interpreted irritating artefacts on the screen and began to associate them with the well-known pathologies we literally see in front of us on ultrasound today. He took imagining to imaging and developed various methods, protocols and whimsical interpretations that have become lifesavers today. Not only this, it was soon apparent he was sparing most of his patients from unnecessary irradiation (CT/CXR) and trips from places of safety to areas of danger outside of the ICU.

I did say this book was not instructional on ultrasound, but as you read deeper into each chapter, it soon becomes apparent that within the steeps of medical history are some gemful teachings from Dr Istrail. He talks us through many of the fundamental basics of each ultrasound niche, and without you realising it, you are learning! What will be so useful, are the many tables within each chapter detailing the sensitivity and specificity profiling of each ultrasound modality. This is certainly data we can use as ammunition to back up the utility of POCUS as the 5th pillar of clinical examination.

POCUS profile for Pneumothorax detection
POCUS profile for pulmonary oedema detection


We have all read texts on ultrasound, mainly on the principles and the ‘how to’. But this alternative text, examining ultrasound’s very evolution and its metamorphosis from newbie light-weight to real heavyweight within the pillars of clinical examination, has to be one of the best reads of all time for me!

Larry Istrail…..I commend you and I urge you to buy it!

10/10 from JW

Buy it now!

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