Intro
Jeremy: Welcome back to another episode of the TIME podcast I'm still jeremy.
Hamish: and I’m still hamish. If you’re listening in between sessions or on the chairlift, this one’s for everyone who’s ever grabbed a probe in a resus bay and thought, “Am I actually using this well… or just using it a lot?”
Jeremy: Exactly. Today we’re talking point-of-care ultrasound — POCUS — and not the usual “Isn’t it great?” highlight reel. We’re asking a more uncomfortable question: Now that it’s everywhere… has our practice quietly drifted away from where the evidence and value live?
Hamish: Because in 2025, the debate is no longer “Should we use ultrasound in the ED or ICU?” That ship has sailed. It’s embedded: trauma, shock, respiratory failure, retrieval, procedural work — it’s in all of those
Jeremy: But with that ubiquity comes a "paradox.” The tool is so accessible that we can make two opposite mistakes: we can overuse it in low-yield scenarios, and underuse it when it would actually change lives
Hamish: We’re going to walk through how POCUS is used across emergency medicine, ICU, and prehospital care; where the overuse and underuse really sit; the human factors no one talks about; what different countries are getting right and wrong; and finally, where AI and tele-ultrasound are going to push us
Jeremy: And crucially, we’ll keep circling back to the same question: For senior clinicians and system leaders, what does high-value POCUS actually look like in practice?
Hamish: Alright, let’s start with where we are now — the paradox of modern POCUS
Hamish: So, let’s paint the picture. Twenty years ago, ultrasound was something that happened in a dark room down the corridor. Now, a registrar can pick up a handheld device and have a view of the heart, lungs, and IVC in under a minute
Jeremy: And the irony is: that’s both the best and worst thing about POCUS. The barrier to entry is so low that we’ve normalised scanning without always pausing to ask, “Why this scan, right now, for this patient?”
Hamish: I like the way the authors of the supplementary material frame it: the technology has reached “infrastructural maturity” — we’ve got machines, probes, training, pathways — but the governance, the appropriateness frameworks, the cultural discipline… those haven’t caught up in the same way
Jeremy: And we see that at the bedside. In shock resuscitation, you might have a patient where a 30-second cardiac view and a lung sweep early could completely change your trajectory — fluid versus pressor, inotrope choice, whether you’re thinking tamponade, massive PE, cardiogenic shock. But that scan might not happen until 40 minutes in, if at all
Hamish: Meanwhile, another patient with a totally clear diagnosis is getting their third “reassurance echo” that adds nothing new. So in the same department, maybe under the same consultant, you’ve got underuse in the high-leverage moment, and overuse in the low-leverage one
Jeremy: And it’s not just individual behaviour. The Australasian ecosystem — ACEM embedding ultrasound into training, ANZICS recognising it as core ICU practice, EMUGs pushing governance and QA — that’s all given us a high baseline of literacy
Hamish: But it’s also created a lot of local variation. Some departments have genuinely integrated POCUS into the cognitive workflow: it’s part of how they think about shock, respiratory failure, trauma. Others… it’s still personality-driven. You get “ultrasound weeks” depending on which consultant is on
Jeremy: If you zoom out internationally, that pattern repeats. The UK, Canada, Scandinavia, the US — they’ve all got their own flavour of the same problem: POCUS is mature as a technology but patchy as a system
Hamish: So that’s the paradox: we’re past the adoption curve, but not yet at the governance curve. And the key question we want listeners to sit with is: In your department, is the way you’re using POCUS aligned with value, or just with habit?
Jeremy: To answer that, we need to look at what’s actually happening in different environments — ED, ICU, retrieval. That’s our next stop
Jeremy: Let’s start in the ED, because that’s probably where most of our audience lives
Hamish: In Australasia, ED ultrasound is essentially “normal now.” Cardiac POCUS, eFAST, procedural guidance, early pregnancy — most departments have decent access, and most trainees have some exposure
Jeremy: But when you look carefully at utilisation, the gaps are stark. Lung ultrasound is the obvious underused modality. We know it outperforms chest X-ray for pleural effusion, pulmonary oedema, pneumonia, pneumothorax. We say that in teaching all the time
Hamish: Yet when someone rolls in with undifferentiated dyspnoea or they desaturate on the ward, a huge proportion of clinicians still default to a stat chest X-ray and a bit of clinical hand-waving while they wait
Jeremy: Exactly. And on the flip side, eFAST is frequently used in haemodynamically stable trauma where CT is readily available and definitive. Those scans rarely change management — they’re almost a cultural ritual
Hamish: And cardiac POCUS gets used for things like “just checking the EF” on people with long-established diagnoses. We’ve all seen the “Oh, let’s just have a look” echo that generates images, maybe a bit of anchoring, but doesn’t change anything material
Jeremy: Then there’s the documentation issue. A lot of audits suggest that somewhere between a third and a half of ED scans never get properly documented. They happen, the decision is influenced, but there’s no trace
Hamish: And that has two consequences. One: from a medico-legal perspective, the reasoning you actually used doesn’t exist. Two: from a system perspective, you can’t learn from something you can’t see. You can’t do meaningful QA, you can’t study your own utilisation, you can’t identify overuse or underuse
Jeremy: ICU is different again. There, ultrasound has become almost inseparable from complex haemodynamic thinking. You’ve got fluid responsiveness, dynamic lung assessments, daily cardiac reviews
Hamish: But it’s not universal. Some ICUs have embraced this deeply — echo is part of morning rounds, lung ultrasound is the default in ventilatory deterioration — and others still primarily rely on chest X-ray and gas interpretation, with ultrasound brought in late or sporadically
Jeremy: And the training pathways explain some of that. ICU in Australasia is a mix of training colleges and routes, not all of which mandate POCUS. So you can easily have one consultant who is essentially an echo-savvy intensivist, and another who is “POCUS-lite,” and the culture flips depending on who’s on service
Hamish: Then retrieval. This is where POCUS is at its highest value density. There’s no CT, radiology is minimal or nonexistent, and decisions are often time-critical
Jeremy: Exactly. In that environment, a single subcostal cardiac view can be the difference between diagnosing tamponade in the field versus missing it until arrival. A scan for pneumothorax in a ventilated patient halfway through a long-distance retrieval can be absolutely decisive
Hamish: Interestingly, the retrieval audits tend to show ultrasound being used more appropriately. People scan when the question is sharp: “Is there cardiac activity? Is there free fluid? Is there a pneumothorax?” The environment forces that discipline
Jeremy: But even there, image archiving and documentation can lag because the context is so chaotic. So again, practice may be good, but system learning lags behind reality
Hamish: If you put all three environments side by side — ED, ICU, retrieval — you don’t see a single pattern of overuse or underuse. You see local expressions of the same underlying pressures: training, workflow, culture, governance maturity
Jeremy: Which is why the article then zooms in from “where” ultrasound is used to “how” it’s used — modality by modality
Hamish: Let’s go modality by modality, because this is where the misalignment becomes really legible
Jeremy: Cardiac first. It’s the classic double-edged sword. In undifferentiated shock, peri-arrest, or the first minutes of cardiac arrest — cardiac POCUS is gold. It can immediately distinguish tamponade, severe LV failure, massive PE patterns, or profound hypovolaemia.
Hamish: But those are not always the moments when we reach for it. Time and again, we see underuse in that early phase — either because people feel technically unsure, or they’re worried about interrupting compressions, or they assume a formal echo will come “soon enough.”
Jeremy: Yet that same clinician might happily perform two or three follow-up echoes on a stable patient “just to see if the ventricles look better.” That’s the irony
Hamish: Then lung ultrasound. If we had invented it yesterday and showed its diagnostic performance compared with chest X-ray, we’d be screaming for it to be first-line in respiratory failure. But cultural inertia is strong
Jeremy: So we still see this pattern: saturations are dropping, chest X-ray ordered, someone vaguely palpates the chest wall, and ultrasound is an afterthought — if it’s used at all
Hamish: Trauma and eFAST are really illustrative of how practice norms lag behind system capability. In unstable trauma, eFAST is absolutely high-value. Time to surgery or angio is the whole game, and ultrasound gives you immediate direction
Jeremy: But in stable major trauma with rapid access to CT, eFAST often adds very little. Yet we still do it out of habit, because there was a time when CT wasn’t as available and eFAST really did carry more weight
Hamish: Early pregnancy ultrasound is almost the opposite story: huge potential value, still underused. After-hours, you might have a department full of patients with early pregnancy bleeding or pain, waiting hours for formal ultrasound. A quick POCUS to confirm an intrauterine pregnancy can massively streamline care
Jeremy: And that doesn’t mean we’re doing a full obstetric scan. We’re just answering a focused question: “Is there an intrauterine gestation I can see?” Yet the fear of “missing ectopics” sometimes paralyses clinicians from using POCUS at all, even for that narrow purpose
Hamish: Procedural ultrasound might be the lowest-hanging fruit in terms of correctable underuse. The evidence for vascular access, thoracentesis, paracentesis — it’s as strong as anything we do
Jeremy: But many of us were trained on landmark techniques, and you hear things like, “I don’t need ultrasound unless the patient is coagulopathic or the anatomy is weird.” That’s a cultural story, not an evidence-based one
Hamish: And then there are the “extra” modalities — gallbladder, MSK, ocular, hydronephrosis — which can be very helpful when driven by a clear clinical question, but can also create incidentalomas and scan cascades if used as a vague screening tool
Jeremy: The underlying message is: overuse and underuse aren’t opposites on a single line. They’re both symptoms of misalignment. Scanning too much and scanning too little can coexist in the same clinician, even in the same shift
Hamish: So the real question becomes: What’s driving that misalignment? That’s where the next section of the monograph goes, and it’s where the conversation gets very human
Jeremy: Let’s talk about the stuff under the waterline: training variation, governance, culture, and human factors
Hamish: Training first. POCUS has grown faster than our ability to standardise how we teach it. One registrar might have had structured ACEM-based ultrasound training, with supervised scans and formal logbooks. Another might have had a handful of ad hoc tutorials
Jeremy: And the behavioural consequences are predictable. High-confidence, highly skilled clinicians may “over-extend” the modality — using it everywhere because it’s become part of how they think. Low-confidence clinicians avoid scanning even when it would be clearly helpful
Hamish: Governance, or the lack of it, is the second big driver. We’ve got detailed appropriateness criteria for CT, MRI, formal echo. For POCUS, in many departments, it’s still personalised practice, governed by vibes and local heroes
Jeremy: And that extends to documentation and archiving. If there’s no expectation — or no easy mechanism — to store images and briefly document findings, then your POCUS practice becomes a kind of shadow medicine. It influences decisions, but the system has no way of seeing it
Hamish: Culture is the bit that we feel every day but rarely name. If you walk into a department where the senior consultants model targeted, high-value ultrasound — using it early in shock, routinely in respiratory failure, consistently for procedures — then that becomes the norm
Jeremy: In contrast, if the senior staff shrug and say, “Yeah, ultrasound is fine, but I don’t really use it much,” trainees learn that it’s optional, a hobby, not a system expectation
Hamish: Human factors is the part that often gets missed. Ultrasound is an attention magnet — it pulls your visual focus and your cognitive bandwidth onto the screen
Jeremy: Which is great when you’re the designated scanner. But if you’re the trauma team leader with your hands on the probe, your situational awareness can narrow. You stop seeing the room, the ventilator, the rhythm strip, the nurses exchanging glances
Hamish: And that’s where ultrasound can start to degrade performance instead of enhancing it. The same is true in cardiac arrest: a well-timed subcostal view during a pause can be invaluable, but if the team lets that pause drift while everyone stares at the screen… your compressions suffer
Jeremy: We also see cognitive biases. A novice might see a tiny pericardial effusion and anchor on tamponade, ignoring the fact that the clinical picture screams septic shock. Or they might see a moderately dilated RV and decide, “This must be PE,” when the context doesn’t fit
Hamish: So ultrasound doesn’t just add information — it changes which information your brain treats as salient
Jeremy: And then we layer system incentives on top: crowded EDs where POCUS is used as a rapid clarity tool because formal imaging is slow; other settings where CT is so fast that ultrasound is trivialised
Hamish: What that all adds up to is this: POCUS utilisation is a mirror. It reflects your training, your culture, your workflows, your cognitive ergonomics, and your governance maturity
Jeremy: Which is why comparing across systems is so revealing. Everyone thinks their pattern is “normal,” until you look over the fence
Hamish: Let’s take a quick tour abroad and see what that mirror shows us
Jeremy: The UK is fascinating. They’ve got strong top-down governance — clear training frameworks, documentation expectations, QA structures. On paper, it looks beautifully organised
Hamish: But audits still show underuse of lung ultrasound in respiratory failure, and habitual overuse of eFAST in stable trauma. So good governance doesn’t automatically rewrite culture
Jeremy: In Canada, there’s widespread POCUS adoption, especially in ED and ICU, but the “dark zone” problem is front and centre — inconsistent documentation and archiving. Lots of scans, not a lot of data about how, when, and why they were used
Hamish: Scandinavia is the opposite in some ways. They scan less overall, but what they do scan is highly purposeful. POCUS is tied tightly to specific protocols and shared mental models
Jeremy: In the US, you get the full spectrum: high-end academic centres with sophisticated ultrasound fellowships and exhaustive QA, and other environments where scanning is driven by defensive medicine or billing pressures. Plus rural hospitals where access to machines and training is still limited
Hamish: None of those systems are “right” or “wrong” in total — but the contrasts show us that POCUS behaviour is shaped more by local incentives and culture than by the technology itself
Jeremy: Then equity. Within Australasia, rural and remote clinicians rely on POCUS because the alternative is… nothing. No CT, no after-hours radiology. For them, not scanning when they could is a major risk
Hamish: But those same clinicians often have the least access to structured training, mentorship, and QA. It’s the classic paradox: highest need, least infrastructure
Jeremy: Tele-mentored ultrasound is a bright spot — remote clinicians guided in real time by tertiary specialists. That’s enormous for diagnosing ectopic pregnancy, tamponade, pneumothorax in communities that might be hours from a tertiary centre
Hamish: But it comes with its own questions: who carries liability, how do you document that shared decision-making, how do you build sustainable relationships rather than fly-in-fly-out advice?
Jeremy: Internationally, the message is consistent: no one has nailed it. Everyone has some mix of overuse, underuse, equity gaps, and governance gaps
Hamish: Which brings us to the constructive part: if you wanted to build high-value POCUS in your own system, what would that actually look like?
Jeremy: Let’s get practical. If you’re a head of department, an ultrasound lead, or a senior clinician, what are the levers you can pull?
Hamish: First is appropriateness. We need the same conceptual discipline we use for CT and MRI: clear indications, and just as importantly, clear non-indications
Jeremy: That doesn’t mean writing a 20-page document no one reads. It means articulating simple, high-yield rules of thumb, like “In undifferentiated shock, cardiac and lung ultrasound should be routine in the first 10-15 minutes,” or “In stable trauma with immediate CT, eFAST is optional, not mandatory.”
Hamish: And not in a punitive way — more as a shared standard: “In this department, this is how we think with ultrasound.”
Jeremy: Then governance: treating POCUS as a clinical service line, not a hobby. Clear training expectations, credentialing processes that are achievable but meaningful, and a named clinical lead or small leadership group
Hamish: Documentation is the next pillar, and it’s usually where everything falls apart. If the workflow is terrible — manual image transfer, clunky forms, multiple logins — people will not document unless they absolutely have to
Jeremy: So the design goal should be: documentation that takes less than 60 seconds for a focused scan. A couple of structured fields, a short impression, automatic linkage of images to the patient, and you’re done
Hamish: Once you have that, utilisation becomes visible. You can see how often lung ultrasound is used in hypoxaemia, how many central lines are ultrasound-guided, how often early pregnancy POCUS is performed. That gives you something to work with
Jeremy: Then QA. This shouldn’t be a witch hunt. It should be a normalised, routine part of practice: a sample of scans reviewed each month, with feedback on image quality, interpretation, and appropriateness
Hamish: And importantly, QA should look not just at “Did you interpret this correctly?”, but also “Should this scan have been done at all?” and “Was there a missed opportunity where a scan would have changed things?”
Jeremy: Finally, implementation. We all know how this goes: policy is written, sent by email, and nothing changes. Behaviour changes when respected clinicians model it at the bedside, when the workflow supports it, and when feedback loops reinforce it
Hamish: So high-value POCUS comes from aligning four things: clear appropriateness, sensible governance, frictionless documentation, and humane QA. You need all four. If one is weak, the system leaks
Jeremy: And then, just as we’re finally getting our heads around that, along comes AI and tele-ultrasound to change the game again
Hamish: Let’s talk about where this is heading, because it’s not hypothetical anymore. AI tools already exist that can tell you, in real time, whether your apical four-chamber view is adequate and give you a rough estimate of LV function
Jeremy: We’re seeing algorithms that can count B-lines, flag pneumothorax patterns, highlight pericardial effusions — essentially doing lower-order pattern recognition so humans can concentrate on clinical synthesis
Hamish: For trainees, that has real potential to shorten the learning curve. Instead of doing 200 marginal scans before you know what “good” looks like, the machine is giving you immediate feedback: “That view is non-diagnostic — adjust the probe.”
Jeremy: But the risk is that we slip into “AI autopilot,” especially at 3am. The temptation to trust the machine’s label — “No B-lines, normal LV” — without stepping back and asking, “Does this fit the rest of what I’m seeing?” is very real
Hamish: Which means governance around AI becomes critical. We need to be explicit: AI is an assistant, not an oracle. There have to be clear expectations about when you believe it, when you override it, and how you document that dynamic
Jeremy: Tele-ultrasound is the other big frontier. A remote clinician, guided in real time by an expert hundreds of kilometres away — that is game-changing for rural, remote, and resource-limited environments
Hamish: Imagine a small ED in rural Australia with a haemodynamically unstable pregnant patient. Being able to get a real-time scan guided and interpreted by a tertiary centre could completely change the outcome
Jeremy: But to normalise that, you need reliable connectivity, clear medico-legal frameworks, and workflows that don’t drown local clinicians in complexity. It should feel like an extension of the team, not a bureaucratic overhead
Hamish: Meanwhile, POCUS is diffusing outwards. Hospitalists, anaesthetists, obstetricians, surgeons — everyone is picking up probes. That’s great for patients, but it raises the stakes for coordinated standards
Jeremy: If each speciality has its own idiosyncratic training, documentation, and QA, the patient ends up moving through multiple ultrasound “micro-cultures” in the same hospital
Hamish: So one of the big future tasks is cross-disciplinary harmonisation. Not identical rules, but shared expectations: what “good ultrasound behaviour” looks like in a hospital
Jeremy: And through all of this, one thing doesn’t change: technology doesn’t decide when a scan is indicated. Humans do. AI won’t ask the clinical question for you. Tele-ultrasound won’t fix a culture that doesn’t value appropriateness
Hamish: So the future of POCUS is going to belong to systems that integrate these tools into mature governance, rather than using them as a shortcut to avoid doing the harder cultural work
Jeremy: Let’s land this. If you’re listening as a senior ED or ICU clinician, or a retrieval doc, what might you actually do when you go home?
Hamish: Maybe start with an honest audit of your own practice. In shock, do you use ultrasound early and deliberately… or late and reflexively? In respiratory failure, is lung ultrasound your default… or your afterthought? In procedures, are you using ultrasound consistently… or selectively “when things look tricky”?
Jeremy: At a departmental level, you might ask: “Do we have any shared view of appropriateness, or is it just individual style?” “Is our documentation usable, or does everyone quietly hate it?” “Do we do QA in a way that people find supportive, or do they hide from it?”
Hamish: And then the human factors piece. If you’re often the person with the probe and the team leader, could you deliberately delegate scanning more often? Could you structure resus roles so ultrasound doesn’t cannibalise situational awareness?
Jeremy: For those in leadership roles, maybe the bigger question is: “Are we treating ultrasound as a strategic capability?” Not just a tool we happen to have, but something that needs proper governance, resourcing, and cultural stewardship
Hamish: The article's closing line is really the key message: POCUS has matured. Now its oversight must mature with it. The probe is already in our hands. The next step is to bring our systems, cultures, and habits up to that same level
Jeremy: And there’s something hopeful in that. We don’t need new miracle machines to make ultrasound high-value. We need clearer intent, better design, and a bit of collective discipline
Hamish: So as you head back to your department after the TIME conference, maybe pick one thing: lung ultrasound in respiratory failure, procedural ultrasound uptake, documentation friction, or QA culture — and decide, “That’s the piece we’re going to move this year.”
Jeremy: Because if enough departments do that, the global picture of POCUS changes — not through another gadget, but through better use of what we already have
Hamish: Thanks for spending this time with us here at TIME. If you’re at the conference, there’s supplementary material linked to this episode available in the members’ section of Clintix.com. And if you can’t find it, just grab one of the friendly conference organisers and they’ll point you in the right direction
Jeremy: And a big thanks to our producers at Clintix — creators of Clintix Pro, the AI-powered study companion built for Australian critical care trainees. It helps you prep for your exams in a structured, efficient way. work smart, not hard
Hamish: Wherever you’re listening from — a busy ED, an ICU night shift, or a quiet rural hospital — keep asking the hard questions about how you use your tools
Jeremy: We’ll be back with more episodes from The TIME Podcast. Until then, stay curious
Hamish: and keep scanning with purpose.
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